BIOPHILIC DESIGN

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BIOPHILIC DESIGN
Does biophilic design have an impact on the recovery of
patients?
OZGE TASYURDU
BSc (Hons) Architectural Technology
April 2014-04-12
UNIVERSITY OF WESTMINSTER
Faculty of Architecture and the Built Environment
Department of Property & Construction

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Abstract
The aim of this dissertation was to investigate whether the application of
Biophilic Design strategies have an impact within healthcare institutions upon the
recovery of patients.
The objectives were set out accordingly to meet the research aim. Four main
objectives were outlined, which were to research the acknowledgement and use of
biophilic design elements in architectural practices that specialise in healthcare
design, to assess how nature can be incorporated in healthcare design projects, to
study patient and nature interactions in healthcare institutions and to compare the
difference in the recovery of patients in healthcare institutions influenced by
biophilic design and those that are not. The research of these objectives was
adequate to outline the impact of biophilic design elements upon patient well
being.
Both secondary and primary data was collected to satisfy the dissertation
objectives. There were limitations to this dissertation due to the lack of secondary
data available in regards to this topic. For this reason three methods of primary
data was collected; questionnaires, interviews and overt observations.
Additionally, case studies were analysed as a means of secondary data.
The findings of the dissertation outlined that the lack of data available in relation
to the biophilic design elements has prevented the construction industry to
acknowledge the benefits of these elements. However, the findings of the
secondary and primary data summarise that the use of biophilic design elements
have an impact on the well-being and recovery of patients.

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Table of Contents
List of Tables and Illustrations…………………………………..………….5
Declaration…………………………………………………………..………..6
Preface………………………………………………………………..……….7
Chapter One – Topic Selection & Research Goal………….…………...8-12
Introduction to the topic…………………………………………..……………8-10
Rationale for Topic Selection……………………………………..……….…10-12
Aim………………………………………………………………………..……..12
Objectives…………………………………………………………………..……12
Key questions…………………………………………………………………….12
Chapter Two - Literature Review.…………………………………...…13-30
Historical Evidence – Evolution………………………………………...……13-14
The Beginning – Biophilia Hypothesis……………………………………….14-15
Modern Day – Biophilic Design……………………………………………...15-22
Examples of how nature can be incorporated in healthcare buildings……….23-29
Case studies…………………………………………………………………..29-30
Chapter Three – Research Design & Methodology…………………...31-40
Possible Research Methods……………………………………………..……31-35
Chosen Primary Data…………………………………………………… …..35-37
Quantitative research…………………………………………………… ……38
Qualitative research………………………………………………… ……….38-39
Secondary Data……………………………………………………… ……….39
Table of chosen methods…………………………………………… …………40
Chapter Four – Investigation, Findings and Analysis………………...41-60
Primary Data………………………………………………………………….41-56
Questionnaires……………………………………………………………..…41-46
Interviews…………………………………………………………………….46-50
Over observations……………………………………………………….……50-56
Secondary Data……………………………………………………………….56-60
Case studies……………………………………………………………..……56-60

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Chapter Five – Conclusions & Recommendations…….………….… ..61-65
Limitations to this Research Study…………………….…………………...……61
Conclusion of Findings………………………………….………………...….61-65
Recommendations for Further Research…………………………………………65
References …………………………………………………………...…..66-69
Bibliography…………………………………………………………………70
Appendix A………………………………………………….……………….71
Appendix B……………………………………………….……………….…72

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List of Tables and Illustrations
Table 1. Table of Chosen Research Methods
Table 2. TMD Before and After HT Class and PEC
Table 3. HR Before and After HT Class and PEC
Table 4. Effect of HT and PEC On The Individual Mood Dimensions
Assessment By the POMs
Figure 1. Unknown. 2014. Edge Lane Hospital, Liverpool.
Figure 2. Unknown. 2014. Southmead Hospital, Bristol.
Figure 3. Unknown. 2013. St. Joseph River.
Figure 4. Baker, C. 2010. Horticultural Therapy.
Figure 5. Hernandez, J. 2009. Maggie’s Centre, Charing Cross.
Figure 6. Hernandez, J. 2009. Maggie’s Centre, Charing Cross.
Figure 7. Koolhaas, C. 2012. Maggie’s Centre, Glasgow.
Figure 8. Koolhaas, C. 2012. Maggie’s Centre, Glasgow.
Figure 9. Alice St. Clair. 2013. Metro Health Hospital.
Figure 10. Gerard Van Grinsven 2013. Henry Ford Hospital Atrium.
Figure 11. Gerard Van Grinsven 2013. Henry Ford Hospital Atrium.
Figure 12. Tasyurdu, O. 2014. Division of Qualitative and Quantitative
Research
Figure 13 Pie Chart Illustrating Answers for Question 1 of Questionnaire.
Figure 14. Pie Chart Illustrating Answers for Question 2 of Questionnaire.
Figure 17. Tasyurdu, O. 2014. Entrance to Sydenham Gardens
Figure 18. Tasyurdu, O. 2014. View from Garden to Main Building
Figure 19. Tasyurdu, O. 2014. Back Garden Entrance
Figure 20. Tasyurdu, O. 2014. Consulting Room
Figure 21. Tasyurdu, O. 2014. Sydenham Gardens
Figure 22. Tasyurdu, O. 2014. Dementia Patient at Sydenham Gardens
Figure 23. Tasyurdu, O. 2014. Garden Area for Planting

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Declaration
I hereby certify that all material in this dissertation, which is not my own words,
has been identified through proper use of citations and references. I also confirm
that I have fully acknowledged by name all of those individuals and organisations
that have contributed to the research for this dissertation.
I further declare that this dissertation has not been accepted in part or full for any
other degree, nor is it being submitted currently for any other degree.
This dissertation contains xxxxx words, exclusive of diagrams, tables,
bibliography and appendices.
I confirm that a digital copy of this dissertation may be made available to future
students of the University of Westminster.
Student’s name…………………………………………………………
Student’s signature……………………………………………………..
Date of declaration…………......……………………………………...

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Preface
Firstly, I would like to say a huge thank you to every staff member of the
Architecture and Built Environment department at the University of Westminster
for their support and wisdom during my time at the university.
I would like to take this opportunity to thank my dissertation supervisor Sean
Flynn for his endless support and motivation. His guidance through every step of
the dissertation has pushed me to produce a document at a higher standard than I
would have without his support and wisdom.
Eric Mackenzie has supported me through his dedication on assisting me to find
data on this research topic as it has been challenging to find relevant information.
I would like to thank him for his dedication and support.
This research has been very challenging and intense and the last two weeks of the
final dissertation has been very stressful due to the lost of a family friend. During
this time my family and friends have supported me hugely and I would like to say
a big thank you to all of them, especially my mother, father, my cousin Hazal
Seyitoglu and my two best friends Selma Tarim and Suzan Senpalit.
Finally, I would like to thank Lisa Cerasoli, the granddaughter of Nora Jo Cerasoli
for the video she has publicised of her grandmother. This video has inspired me to
investigate how we can improve the well-being of patients through their hardship.

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Chapter One - Topic Selection & Research Goal
Introduction to the topic
This dissertation will explore the impact of biophilic design upon patient recovery
when incorporated in healthcare design. Biophilia is the term used for the
interaction between human and nature and biophilic design is the expression used
for the integration of nature in building design.
The term biophilia was first expressed in Erich Fromm’s book The Anatomy of
Human Destructiveness in 1973 (Fromm, E. 1973). He is a German-born
American psychoanalyst and social philosopher. Fromm examines in his book
why individuals create destructiveness, in other words, evilness and negativity.
The two examples he refers to as human destructiveness are suicide and Adolph
Hitler’s evilness during the Holocaust. He explains the reasons for destructiveness
as “people have committed suicide because of their failure to realise the passions
for love, power, fame, revenge” (Fromm, E. 1973). He outlines that people fail to
be happy because they fail to embrace the positive sides to life. He emphasises
that biophillia is a way of loving life, which is a cure from the destructiveness. His
definition of biophilia is “the passionate love of life and of all that is alive” (Erich
Fromm Online. 2010).
Fromm’s theory is developed from Konrad Lorenz’ theory that destructiveness
has been passed on to humans from their animal ancestors. Lorenz’s instinctivist
theory 1930 (Lorenz, K. 1930), argues that human aggression is a natural drive in
which is a need for survival. Fromm goes beyond the controversy of instinctivists,
accepting that there is a kind of aggression which man shares with its ancestors.
Fromm expressed this through his book The Anatomy of Human Destructiveness
in 1973 (Fromm, E. 1973).
Edward O. Wilson developed the idea of Biophilia after Fromm’s publication of
The Anatomy of Human Destructiveness in 1973 (Fromm, E. 1973). The outcome
was the publication of Wilson’s book Biophilia in 1986 (Wilson, E. 1986). He

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expressed that human beings have depended on nature for many years and this
attraction may encourage the love to live. “For millions of years human beings
simply went at nature with everything they had, scrounging food and fighting off
predators across a known world of a few square miles” (Wilson, E. 1986).
Stephen Kellert worked with Wilson in which an outcome was the publication of
The Biophilia Hypothesis (Kellert, S & Wilson, E. 1995). This lead Kellert to
establish the idea of biophilic design and publish a book in 2008 named Biophilic
Design: The Architecture of Life. He referred to it as The Architecture of Life
(Kellert, S. 2008) through embracing its theory that nature gives life to the human
mind. Biophilic design incorporates nature within buildings to provide
psychological comfort. For example healing gardens are designed to undertake
gardening activities to exercise the brain and to have an impact on the patients’
self-esteem. Biophilic design does not aim to heal physical wounds; but seeks to
provide mental health and well-being. Its relevance with healthcare institutions is
that it provides a therapeutic environment. This type of design approach is new to
the industry and requires development.
Biophilic design is divided into six elements, which are defined by Kellert. These
elements are:
• Environmental features;
• Natural shapes and forms;
• Natural patterns and processes;
• Light and space;
• Place-based relationships;
• Evolved human-nature relationships.
The first biophilic design element is Environmental Features. This feature
encourages natural light, natural ventilation, natural materials and plants for the
well-being of people. “The mere insertion of plants into the built environment can
enhance comfort, satisfaction, well-being and performance” (Kellert, S. 2008)

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The second biophilic design element is Natural Shapes and Forms. This is the
representation of the natural world on the building façade. An example of this is
applying the appearance of fish scales to a cladding system for buildings. It is
believed that these natural shapes and forms enable individuals to feel territorial
control by familiarising with the buildings.
The third biophilic design element is Natural Patterns and Processes. An attribute
of this element is biomimicry where natural systems are mimicked. Termite
mounds are mimicked in buildings to provide natural ventilation. The termites
create holes into the mound to circulate air internally. This can be applied to
buildings to allow air circulation during the nighttime through the floor voids.
This has an impact on reducing emissions created for ventilation.
The next biophilic design attribute is Light and Space. This feature encourages
maximum natural light and systems that enhance reflective light. The aim is to
prevent the negative impact of dull rooms. The space feature of this element
enables spacious environments in the building design to create open spaces.
The fifth biophilic design element is the Place-Based Relationships. This feature
enables an individual to feel safe in an environment they are familiar with, as one
can feel intimated in a new place. “The connection of people to places reflects an
inherent human need to establish territorial control” (Kellert, S. 2008).
The final biophilic design element is the Evolved Human-Nature Relationship.
This is the only attribute that focuses on the inherent human relationship with
nature. An example of this feature is therapeutic gardens where gardening
activities are undertaken.
Rationale for Topic Selection:
Individuals spend most of their day within a building, whether it is their
workplace, home, or educational institution. Since buildings are a significant
element in people’s lives, it is essential that they are designed to satisfy visitor

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requirements. Architects design these buildings and to a certain extent the
experience of these individuals may be dependent on the architects.
Healthcare buildings aim to provide support and cure for patients. “For most
people, a hospital is a scary place, a hostile place, a place where bad things
happen” (Grey, M. 2006). The quotation suggests that visiting the hospital can be
intimidating. For this reason it could be recommended that hospitals should be
designed to ensure a better experience for patients. There are many informative
posters in healthcare buildings such as the one in The Neaman Practice in
London, England, “each year there is an increase in the number of patients
diagnosed with diabetes” (The Neaman Practice, 2014). Even though, this is an
informative poster, it potentially has the effect of intimidating patients, and
making them feel uncomfortable.
For this reason, this dissertation will investigate whether the application of
biophilic design elements can prevent patients feeling overwhelmed. The function
of the human brain is to control the body. “The brain stem is responsible for
regulating most of the automatic functions of the body that are essential for life”
(NHS. 2012). Psychology is a state of mind and it can have an impact on moods,
emotions and actions. “Individuals with illnesses who also feel sad may be less
likely to believe they can carry out illness-alleviating behaviours...whereas,
positive emotional states can offer people the opportunity to consider and plan for
future events.” (Wichrowski, M.,J. 2005).
It is acknowledged that if a patient feels isolated in an environment this will make
it challenging to adapt their minds to recovery. “Patients with Alzheimer’s
disease, the most common form of dementia, and their caregivers say the illness
leaves them feeling isolated” (Ostrow, N. 2012). Hence, Biophilic Design may
have the potential to provide this need of physical and psychological comfort..
Many people have negative experiences when visiting hospitals. These
experiences could be long waits or not enough individual care. Therefore, this is

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another reason to why it is essential to create tranquil and relaxing environments
in hospitals to motivate those patients for positive thoughts.
However, the theory of biophilic design is new to the construction industry and
requires development. There is a potential that biophilic design will have an
impact on the recovery and well being of patients. Therefore, this dissertation will
seek to explore whether biophilic design has an effect of improving the well-being
of patients.
Aim:
The aim of this dissertation is to investigate whether the application of Biophilic
Design strategies have an impact within healthcare institutions upon the recovery
of patients.
Objectives:
• To investigate whether biophilic design is acknowledged and used by
architectural practices that specialise in healthcare design
• To assess how nature can be incorporated in healthcare design projects
• To study patient and nature interactions in healthcare institutions
• To compare the difference in the recovery of patients in healthcare
institutions influenced by biophilic design and those that are not
Key questions:
• Which elements of biophilic design can be incorporated in the design of
healthcare institutions?
• To what extent has biophilic design been used in healthcare institutions?
• What is the difference in patient moral and motivation in a health
institution that influence the use of biophilic design and in a health
institution that does not?
• Is there a difference in the recovery time of a patient that visits or stays in
a health institution that has integrated nature within the building design?
• Do Government bodies encourage the use of biophilic design elements?

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Chapter Two - Literature Review
Historical Evidence – Evolution
In the past, humans were highly dependent upon nature for survival. Their
necessities such as food were satisfied by what nature provided them with.
“Bodies of water not only provided a physical necessity to individuals, but it is
likely they also provided a perimeter of defence from predators or other enemies.”
(Gullone, E. 2000).
Health problems were satisfied by natural medication consisting of herbs and
natural plants and shelter was provided by trees and plants. “The evolutionary
context for the development of the human mind and body was mainly world
dominated by critical environmental features such as light, odor, window,
weather, water, vegetation, animals, and landscapes” (Kellert, S. 2008). This
emphasises that human beings have been in contact with nature since the human
evolution, and that there has always been an attraction between them.
Nowadays individuals are highly dependent on technology to provide their daily
necessities. Over generations, societies have evolved and adapted in respect to
new technological development. It is evident to say that in the present day,
people around the world do not live the same way as they did before. However, it
is arguable that these technological developments are merely a curtain drawn over
humanity, distracting them from the reality and responsibilities of living. Albert
Einstein stated “Look deep into nature, and then you will understand everything
better” (Einstein, A. 1951). This suggests that nature can provide everything for
survival.
Nature has provided humanity with the five basic needs of life; food, water,
oxygen, living space and proper temperature. David J Buller states that “human
populations are characterized by evolved psychological variation…human minds
are continuously adapting to changing environments over evolutionary time”
(Buller, D.J. 2006) This can be linked to the Mesopotamian people, who could be

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considered as being one of the earliest civilizations formed. They were forced to
adapt to the surrounding warm environments of the Middle East, and were able to
develop water and shelter strategies.
In contrast, there are still ‘un-contacted tribes’ located in the Amazon Rainforest
in South America. José Carlos Mereilles described them, as being “the last free
people on earth” (Eede, J. 2011). These people and communities reflect that
nature is ultimately still a huge part of humanity.
The Beginning – Biophilia Hypothesis
The biologist Edward O Wilson established the biophilia hypothesis. His study
was influenced by Erich Fromm’s book, The Anatomy of Human Destructiveness
(Fromm, E 1973). In this book Fromm analyses the reasons for human
destructiveness and why they lack the love to live. He emphasised that biophilia is
“the passionate love of life and of all that is alive” (Erich Fromm Online. 2010).
Wilson developed Fromm’s theory of human aggression and biophilia. He studied
the attraction between human beings and the natural world and how this can
influence love to live. His study expressed his findings about biophilia and he
defined this term as “an innate and genetically determined affinity of human
beings with the natural world.” (Kellert, S & Wilson, E. 1995) Hence, biophilia
has been existence since human evolution, “because biophilia is rooted in human
biology and evolution, it represents an argument for conserving nature based on
long-term self-interest” (Kellert, S. 2005).
Wilson elaborated on the affinity of human beings with the natural world through
his investigation into how human beings are connected to the natural world. This
was expressed in his book Biophilia (Wilson, E. 1986). “For millions of years
human beings simply went at nature with everything they had, scrounging food
and fighting off predators across a known world of a few square miles.” (Wilson,
E. 1986). Here he expresses that human beings have been dependent on the
natural world for food and shelter since the human evolution.

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Stephen Kellert states that the relationship between the natural world and human
beings is part of a deep history, however, “cognitive psychologists have been
strangely slow to address its mental consequences” (Kellert, S & Wilson, E.
1995). This quotation emphasises the lack of data related to this subject although
there is historical evidence of the interaction between human beings and the
natural world. Hence, Wilson indicates the benefits of this interaction as, “the
more we know of other forms of life, the more we enjoy and respect ourselves”
(Kellert, S & Wilson, E. 1995).
On the other hand, Kellert and Wilson have also studied biophobia, which is the
term used to describe the fear or antipathy towards the natural world. “Biophobia
ranges from discomfort in natural places” (Kellert, S & Wilson, E. 1995). Kellert
emphasises that people brought up with television and technological devices are
prone to experience biophobia. This hypothesis will be satisfied by the end of this
dissertation through the collection of primary data.
The filmmaker Woody Allen is an example of biophobia. Kellert indicates, “Allen
is known to take extraordinary precautions to limit bodily and mental contact with
rural flora and fauna” (Kellert, S & Wilson, E. 1995). Allen refused to go into
lakes, as there were living things in them. He felt at comfort with manmade
devices and elements. Those that experience biophobia fear the natural world and
feel at comfort when they are surrounded with man-made elements. “The
manifestation of biophobia explicit in the urge to control nature has led to a world
in which it is becoming easier to be biophobic” (Kellert, S & Wilson, E. 1995).
Modern Day – Biophilic Design
The Department of Health (DoH) has been encouraging health and wellbeing
boards, which were established in April 2012 under the Health and Social Care
Act 2012. “Boards will bring together clinical commissioning groups and councils
to develop a shares understanding of the health and wellbeing needs of the
community” (Local Government Association. 2014). To ensure a democratic
system the patient representatives will be democratically elected. “The
Government wants NHS services to be more responsive to the needs of patients,

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carers and the wider public.” (NHS. 2010). The representatives will be responsible
for supporting patients and conveying their concerns to the Department of Health
for development.
The Health and Social Care Act 2012 outlines that any health care service
provider in England that is not exempt is required to have a licence. One of the
key legislative changes is the Healthwatch. “Healthwatch England will be a new
national body representing the views of users of health and social care services,
other members of the public and local Healthwatch organisations.” (Sillett, J.
2012). The scheme is a non-profit making body and aims to build the healthcare
sector with the feedback from patients, carers and the wider public.
The three main aims of the UK Green Building Council are; “influence
government policy, lead industry action and build industry knowledge and green
skills” (UK Green Building Council. 2014). The GBC has created task groups to
meet these aims. The task groups are the collaboration of experts within the GBC
membership that work together to develop the sustainability agenda. Additionally,
they organise events such as seminars, debates and tours of green buildings in
order to enlighten individuals about the importance of green building. In addition
to this, GBC influences biophilic elements for the wellbeing of individuals by
posting information about hospitals that have integrated these elements. An
example is the Mackenzie Health Sciences Centre in Canada that; “found that
depressed patients in sunny rooms recovered 15% faster than those in darker
rooms” (UK Green Building Council. 2014).
In order to influence patient well-being, GBC encourages people to:
• “Partner with your local healthcare facility to host a workshop for hospital
staff and local healthcare professionals;
• Meet with government or healthcare bodies to highlight the benefits and
encourage promotion of green healthcare facilities.” (UK Green Building
Council. 2014).

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Furthermore, under the BREEAM New Construction 2011 scheme, new
healthcare buildings are required to achieve an excellent rating and existing
healthcare buildings are required to achieve a very good BREEAM rating. This is
a funding requirement as BREEAM is a prerequisite under the UK Government
Sustainable Procurement Action Plan.
Medical Architecture and ARUP designed the Edge Lane Hospital located in
Liverpool. The hospital was rated excellent under the BREEAM standards. It
provides eighty-five inpatient beds and is one of the first developments under
TIME (To Improve Mental Health Environments). This hospital is super-insulated
with a mechanical ventilation system and high efficiency lighting system. One of
the features that enabled it to achieve an excellent rating was the “extensive soft
landscaping to improve health and well-being of particularly vulnerable building
occupants” (BRE Global. 2013), which is a biophilic design element.
Fig.
1.
Unknown.
2014.
Edge
Lane
Hospital,
Liverpool.

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The Southmead Hospital designed by BDP has also achieved a BREEAM
excellent rating for its sustainability credentials. The brief was to “maximise
natural light and ventilation both to key public routes and individual rooms” (BDP
Architects. 2014). The increase of natural light and ventilation is relevant to the
fourth biophilic design element; Light and Space.
Robin Guenther and Gail Vittori expressed in their book Sustainable Healthcare
Architecture (Guenther, R and Vittori, G. 2008) that “the public health challenges
of today, asthma, development disabilities, diabetes, obesity, reduced fertility,
cancer, have a significant linkage to the technological and environmental change
of the twentieth century.” (Guenther, R and Vittori, G. 2008). Hence, this
questions whether there is a correlation between the increase of health problems
and the increase of technological developments that have eradicated the natural
environment.
Health problems have increased from the twentieth century; cancer is one of the
stark examples. Hence, doctors inform patients diagnosed with cancer to ensure
they have high morale. The question is; if the interaction with nature increases
Fig.
2.

Unknown.
2014.
Southmead
Hospital,
Bristol.

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morale and positivity, does biophilic elements such as healing gardens have an
impact on patients with cancer?
Clare Cooper Marcus indicates in her book that there is a need for contact with
nature. “The actual provision of appropriate outdoor space in healthcare facilities
is often less than adequate, with limited ‘green nature’”. (Marcus, C. 2013).
Marcus describes examples of how healing gardens can be used in healthcare
institutions to embrace the ‘green nature’ through horticultural therapies. “The
horticultural therapist might engage recovering stroke victims in weeding,
watering, and repotting plants” (Marcus, C. 2013).
Most patients could feel useless and isolated due to their illness. “8,000, newly
diagnosed patients, an estimated 700 patients each year are left feeling isolated,
according to Macmillan Cancer Support.” (Monteverde, H. 2013) “Patients with
Alzheimer’s disease, the most common form of dementia, and their caregivers say
the illness leaves them feeling isolated” (Ostrow, N. 2012). It is clear from the
evidence above that patients feel isolated. People with health issues can
experience an intense treatment procedure that can be very draining. Therefore, it
is important to ensure patients do not feel isolated and this could be achievable
through incorporating biophilic design elements into healthcare buildings.
Additionally, activities undertaken in these biophilic hospitals would give patients
the opportunity to achieve something for their self-esteem.
Additionally, it is arguable that hospital environments are intimidating and
reminds patients of their illness. Hospitals and clinics contain posters such as the
one in the University College Hospital in London; “one in three of us have a
disease that could kill” (UCH. 2014). These are intended to be informative posters
however they affect the patients’ morale and positivity to recover. As explained in
the previous paragraph, patients feel isolated and most of the healthcare buildings
can have an impact on this.

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The elements of biophilic design are new to the industry but the importance of the
interaction between human beings and the natural world was previously
recognised. “At one time nature was seen as intrinsic to healing, but this important
connection was largely lost by the twentieth century.” (Marcus, C. 2013). During
the seventeenth century nature was accepted as an element for healing. However,
as technology developed, individuals disconnected with nature, which is
potentially one of the reasons why elements of biophilic design are not widely
known.
An example of a biophilic design element that Clare Cooper Marcus refers to is
the Lakeland hospital in Niles, Michigan that has a view of the St. Joseph River
(see fig. 3) in the waiting area for endoscopy and ambulatory surgery. This view
is deliberately designed to prepare the patients emotionally and mentally for the
waited treatment.
Fig. 3 Unknown. 2013. St. Joseph River.
Stephen Kellert wrote the Biophilic Design book to define what biophilic design
is and how it can be integrated in buildings. He states, “To investigate how
biophilia can be expressed in building design, we need to understand what it is
about nature that creates a sense of please, well-being, and engagement with

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place” (Kellert, S. 2008). The outcome of this investigation was the six biophilic
design elements. He concluded that the “contact with nature has been found to
enhance healing and recovery from illness and major surgical procedures,
including direct contact (e.g., natural lighting, vegetation)” (Kellert, S. 2008).
Kellert emphasises that there is lack of data available in regards to biophilic
design. “We need nature in a deep and fundamental fashion, but we have often
designed our cities and suburbs in ways that both degrade the environment and
alienate us from nature” (Kellert, S. 2011). This supports previous data that
underline that there is a lack of information available in relation to biophilic
design
Furthermore, Kellert expresses in his book that the view of a garden through a
window is an example of contact with nature. However, he questions this
interaction and indicates that the window is a barrier between the individual and
nature. “Does this attraction, this seeming instance of ‘biophilia’, indicate that we
are enjoying our control over, i.e., our dominion over and thus our secure
instantiation from the ‘prickle’ of nature; or do we imagine that we are truly
bonding with or engaging the world outside.” (Kellert, S. 2008). This suggests
that the satisfaction of this type of contact with nature could be due to territorial
control.
The current hot subject in the construction industry is sustainable design. There
have been various developments to provide sustainable construction methods.
However, Kellert states that, “Biophilic design is, thus, viewed as the largely
missing link in prevailing approaches to sustainable design” (Kellert, S. 2008). It
is evident from the research undertaken by this dissertation that there is a lack of
data available on biophilic design. This could be the reason to why Kellert
expresses that the construction industry has not come to realisation that biophilic
design elements can also enhance sustainable design. This can be achieved
through the encouragement of natural light and enhancement of landscape.

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Kellert indicates a feature of biophilic design, which is the integration of
maximum natural light in the building design. “When contact with nature involves
exposure to natural light or sunlight, yet another pain-reduction mechanism may
come into play”. (Kellert, S. 2008).
Horticultural therapy is a psychological therapy aimed to bring positivity to the
human mind by influencing patients to engage with gardening and activities that
involve the engagement with nature (see fig. 5). A professional horticultural
therapist assists these activities. An example of an element of horticultural therapy
is planting. “Although the therapeutic use of horticultural activities have been
practiced for hundreds of years, objective documentation of its benefits is
relatively recent.” (Wichrowski, M.,J. 2005).
Fig. 4. Baker, C. 2010. Horticultural Therapy.
Examples of how nature can be incorporated in healthcare buildings
Maggie centres are cancer caring centres for those patients with cancer or anyone
that has been affected by cancer. These cancer care centres are deliberately

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designed in a small footprint to create a homely environment. This allows those
visitors to feel at home and in their comfort zone. The director of the Maggie’s
Centre Professor Bob Leonard expressed “This gives patients somewhere to
emote and get different support than we can provide in the hospital” (BBC News.
2008).
All Maggie centres have integrated nature within their designs. (See fig. 5, 6, 7 &
8). This has created a therapeutic environment where patients are in contact with
and surrounded by nature.
Fig. 5. Hernandez, J. 2009. Maggie’s Centre, Charing Cross.
Figure 5 illustrates the roof design of the Maggie’s Centre in Charing Cross,
London, which has integrated the fourth biophilic element, Light and Space. The
stepped back roof allows maximum light into the kitchen area where the patients
socialise the most. This is to create a spacious atmosphere, which prevents the
patients feeling intimidated by a closed dull room.

24

Fig. 6. Hernandez, J. 2009. Maggie’s Centre, Charing Cross.
The image above illustrates the landscape, which could be considered to meet the
requirements of the following two biophilic design elements; environmental
features and evolved human-nature relationships.
Fig. 7. Koolhaas, C. 2012. Maggie’s Centre, Glasgow.
The photograph illustrated in figure 7, is the Maggie’s Centre in Glasgow,
Scotland. The centre was built on a green field and has a court yard in the centre

25

of the building. The courtyard includes vegetation, which creates a space for the
visitors to interact with nature. This meets the sixth element of biophilic design,
which is the evolved human-nature relationship.
Fig. 8. Koolhaas, C. 2012. Maggie’s Centre, Glasgow.
The photograph in figure 8, illustrates the view from the building into the
courtyard. The sofa’s located at far right hand side of the photograph is the
consultation area, where visitors are exposed to nature and light when they are
having a consultation session. This is a feature of the fourth biophilic design
element; Light and Space.
The designs of Maggie’s Centres ensure a therapeutic environment is created for
stress relief. The councillor at the Maggie’s centre in London has stated;
“Especially those which include contact with nature have been shown to enhance
quality of life and a person’s ability to cope with stress” (Forestry Commission.
2013).
Furthermore, the MacMillan Cancer Support Centres are similar to Maggie’s
Centres. The difference is that Maggie’s Centres are considered as a home for
socialising and relieving the stress whereas the MacMillan Centres are more

26

informative. The first MacMillan cancer support centre was established in 1993 in
Hertfordshire. The centres aim to inform patients about cancer and the suitable
treatment route available for them. Additionally, they provide confidential
counselling and psychological support.
The MacMillan Cancer Centre in London is located in the University College
London Hospital. The importance of cancer care institutions is increasing as the
number of patients diagnosed with cancer increase. “Over 27,000 people in
London are currently living with cancer, and the number is growing” (MacMillan,
2014). Morale is significant for cancer patients and one way of increasing the
effectiveness of cancer care centers could be the integration of nature. The
MacMillan Cancer Centre located in the University Hospital of South Manchester
states that “The gardening group is in its infancy and would welcome people with
all levels of interest in vegetable growing and who enjoy nature” (UHSM
Hospital, 2013).
The Metro Hospital is located in Wyoming, United States. In 2001 Metro Health
decided to refurbish the hospital to an environmentally friendly building. One of
the key aspects considered when designing the refurbished building was to ensure
it had a connection with the community. The new design sought to create a
beneficial environment for patients.
There are two buildings on the hospital site, one that is five stories lower than the
main patients building (see fig. 9). The lower building has a green roof. This is a
design feature that allows a view from the patient rooms located in the main
building onto the green roof, which creates a natural setting. In addition, there are
therapeutic gardens within the hospital, which are open all year-round.
Horticultural therapies are undertaken in these gardens. Gardening activities under
the assistance of horticultural therapists is a mechanism of this therapy. This type
of therapy is mainly applied to patients with mental illnesses.

27

Fig. 9. Alice St. Clair. 2013. Metro Health Hospital
Another hospital that has integrated a garden for the well-being of patients is the
Henry Ford Hospital is located in Detroit, United States. There are indoor healing
gardens in this hospital aimed at creating a therapeutic environment (see fig. 10 &
11). The hospital consists of two atriums that are regarded as the ‘lungs of the
hospital’ because “the atriums have approximately 2,500 live plants” (Wolverton,
B. 1996). The hospital is designed to provide views looking into the atriums from
the inpatient rooms.
The atriums are considered to be a place of stress relief (see fig. 10 & 11). The
horticultural therapies in the gardens in the atrium meet the standards of the sixth
biophilic design element; evolved human-nature relationships. “The atriums are
maintained under the supervision of senior horticultural specialists” (Wolverton,
B. 1996). The assistance of horticultural specialists ensures the purpose of the
atriums is maintained.

28

The external healing gardens are more recognised than the internal healing
gardens, however, both systems achieve the aim of healing. “Patients exposed to
natural environments can experience lower blood pressure and reduce muscle
tension, producing recovery from stress within four to six minutes” (Wolverton,
B. 1996). In addition to the physical benefits, these healing gardens also have
psychological benefits. “The presence of interior plants creates an environment of
wellbeing for employees and enhances positive perceptions for the workplace.”
Wolverton, B. 1996).
Nevertheless, the disadvantage of the internal gardens is that it requires regular
maintenance. If there is a lack of maintenance the dust created by the plants could
lead to other health problems. “Excellent maintenance is critical to delivering a
healthy environment and long-term value.” (Wolverton, B. 1996).
Fig. 10. Gerard Van Grinsven 2013. Henry Ford Hospital Atrium

29

Fig.11. Gerard Van Grinsven 2013. Henry Ford Hospital Atrium
Case studies
The following case studies will be analysed in depth in the Investigations, Findings
& Analysis Chapter of this dissertation.
The two professors Kathleen Beautchemin and Peter Hays investigated patients in
the Cardiac Intensive Care Unit (CICU) of an anonymous hospital. They aimed to
examine the possible correlation between the exposure of natural light and the
recovery time of a patient diagnosed with depression.
Patients that were diagnosed with depression were split into two groups in the
symmetrical CICU. Due to the opposite orientation of the divided rooms, one group
of patients were exposed to maximum natural light and the other group was treated
in rooms that lacked natural light. The results identified that the patients exposed to
natural light experienced shorter recovery time.
Dr. Roger Ulrich is a professor at architecture and has undertaken many
investigations for the well-being of patients. He was the first professor to test the

30

hypothesis that the natural world has a potential impact on the well-being of
patients. This investigation was named View Through a Window (Ulrich, R.
1984).
The experiment he accomplished involved testing the benefits of views through
the windows in inpatient rooms. Patients that received the same surgical treatment
were divided into two groups in a symmetrical ward. One side of the ward had a
view out to nature and the other side had a view out to a brick wall. The results
identified that those patients that were exposed to the view of nature experienced
a shorter recovery time.
The professional horticultural therapist Matthew Wichrowski, assessed the impact
of horticultural therapy (HT) on patients in an cardiopulmonary rehabilitation
program. There were two components of the cardiac rehabilitation program,
which were HT sessions and education classes (PECs). The two groups were
tested to determine, which session had an impact on the well-being of the patients.
The results identified that the group that attended the HT sessions had an
improved mood state and stress levels were reduced.

31

Chapter Three – Research Design & Methodology
This chapter of the dissertation will provide a detailed explanation of the proposed
methodology to meet the objectives of this dissertation which are listed below:
• To investigate whether biophilic design is understood and used by
architectural practices that specialise in healthcare design
• To assess how nature can be incorporated in healthcare design projects
• To study the interaction between human and nature in healthcare
institutions
• To compare the difference in the recovery of patients in health institutions
influenced by biophilic design and those that are not
There are limitations to this research topic due to the lack of information
available. These limitations have had an affect on the approach of organizing how
the required data will be collected. Therefore, the objectives above will be studied
through qualitative and quantitative research methods due to the limitations.
Focusing on one research method for each objective enables a variety of different
methodologies to be used, which simplifies the goal for each research approach.
For example, the proposed questionnaires only aim to answer one of the
objectives. This simplifies the questionnaire for speedier responses and ensures
the collection of adequate information in comparison to designing a questionnaire
that aims to answer all four objectives. This will create a complex and vague
approach as you will have fewer responses and the analysis will not be as clear.
Additionally, this approach may not be classified as a reliable technique, as you
are only relying on one research method to answer the dissertation objectives.
Possible Research Methods
To ensure that the most effective and appropriate research method was selected, a
variety of possible options were considered. The literature review was completed
as forethought to analyse the available secondary data. This analysis of literature
outlined that the available secondary data was not adequate to undertake this

32

dissertation. This meant that additional research had to be completed and one
research method would not be satisfactory.
To meet this satisfaction, the following research methods were considered:
Fig. 12. Tasyurdu, O. 2014. Division of Qualitative and Quantitative Research
As a forethought the advantages and disadvantages of qualitative and quantitative
data were investigated to acknowledge which research route is appropriate.
Quantitative data is based on statistics and numeric data. This creates a reliable
strategy as it endorses an argument with numerical data. However, it will indicate
if something is occurring but will not emphasis why it is occurring. Therefore, a
qualitative research approach will also be considered to satisfy the information
required that could not be obtained through the quantitative data. Qualitative data
focuses on the entire issue embracing why and how the issue has occurred.
The possible research methods were divided into two categories; quantitative data
and qualitative data. This division allowed to distinguish between the two
different types of methodologies allowing a clear presentation of which

33

methodology will satisfy which research technique. For example, this dissertation
has undertaken a questionnaire that was satisfied by an interview, as a
questionnaire will indicate if the issue is occurring and an interview will provide
the in depth information on why and how it is occurring.
A focus group was considered during the early stage of research however, it was
decided that it could be intimidating for the patients. There could have been
disagreements during the discussions and it could have been intimating for the
patients, as they are very sensitive.
Interviews receive a higher rate of response, as the interviewer is present to
complete and ask all questions. It can receive more reliable responses as the
interviewer is present to simplify and explain any misunderstood questions,
“Interviewers can solicit information by asking questions; they can repeat or
rephrase questions for clear understanding, or even modify the structure for more
effect with complicated and contingency questions” (Cargan, L. 2007).
Additionally, interviews are open to further spontaneous discussions, which could
cover out-of-mind ideas.
Participant observation is not an ideal methodology for this dissertation. The
objectives do not require this type of observation. Only the reaction of patients is
to be observed when they are in contact with nature.
Therefore, covert or overt observations were considered. Covert observations can
cause ethical problems due to lack of consent. An overt observation will be
appropriate since it is ethically sound. This type of observation allows you to
examine how patients interact with nature and their reactions to these activities.
This type of research method will satisfy the objective; to study the interaction
between human and nature in healthcare institutions.
Laboratory experiments are a reliable method that allows you to be physically
involved in the research practically. This would have been an ideal research

34

method however; this dissertation topic can only be practically experimented by a
professional in a hospital or clinic environment. For this reason, scientific
experiments that have been undertaken by professionals will be analysed as a
secondary data.
Questionnaires provide a comprehensive view on the issue of a large population.
Self-administration questionnaires are ideal as it prevents the respondent to feel
under pressure, as they do not need to give immediate answers. Additionally, self-
administered questionnaires give the respondent authority to be anonymous; this
may enable them to express their real thoughts and feelings.
Online surveys are appropriate for general surveys as you can receive a high
response rate in comparison to a traditional survey strategy. However, this
dissertation requires specific information from architectural practices that
specialise in healthcare. Therefore, the questionnaires need to be directly mailed
to the appropriate professionals.
Telephone interviews are not as reliable as face-to-face interviews as you cannot
judge the interviewee’s body language and facial expressions. “It isn’t just that
you miss cues or visual qualification of what people are saying; you also lose
much of that empathy.” (Gillham, B. 2005). For this reason, telephone interviews
will not be adopted.
Longitudinal studies are appropriate for issues that require monitoring over a long
period of time by repeating the observation to test any correlation. This type of
research method is not suitable for this dissertation due to lack of time.
The evaluation of the possible research methods explained above has allowed for
the appropriate methodology to be selected for this dissertation. Out of the ten
discussed methods, interviews, questionnaires and overt observations have been
adopted to this study to fulfil the objectives. The questionnaires have satisfied the
objective; to investigate how biophilic design is understood and used by

35

architectural practices that specialise in healthcare design. This is an objective that
requires a higher response rate in order to produce statistics and generalise a
conclusion. The interviews were an ideal option for this dissertation as there is a
lack of data available and the interviews will allow to gather in depth information.
The interviews will meet the objective; to study the interaction between human
and nature in healthcare institutions, through asking the consultants or nurses the
behaviour of patients when they are in contact with nature. The overt observations
were ideal to observe patients while they are interacting with nature i.e.
gardening. This observation will justify two objectives; to assess how nature can
be incorporated in healthcare design projects; to study the interaction between
human and nature in healthcare institutions.
Chosen Primary Data
Primary data was collected through interviews, questionnaires and overt
observations. The reason to why three means of primary data was undertaken is
due to the lack of secondary data available regarding biophilic design.
The interviews were designed with principles under the semi-structured interview
approach, which consist of a number of set questions related to the objective, to
study the interaction between human and nature in healthcare institutions. For
example, what activities do you provide that engage the patients to the natural
world? These questions have directly answered the above objective and were open
to further discussion. “The semi-structured interview is constructed around a core
of standard questions…the interviewer may expand on any question in order to
explore a given response in greater depth” (Mitchell,M.L 2012).
This type of interview structure creates a flexible discussion with the interviewee.
This prevents any pressure to the interviewer about answering the structured
questions. “The semi-structured interview allows the investigator to ask additional
questions to follow up on any interesting or unexpected answers to the standard
questions” (Mitchell, M.L. 2012). As stated by Mitchell this approach enables the
interviewer to expand on any question that could benefit the research hugely.

36

Self-administered questionnaires will be conducted in order to investigate the
understanding and the use of biophilic elements in healthcare design practices.
The self-administered approach has been selected to allow privacy for the
participants. This approach ensures that the answers will be reliable as the
respondents will not be intimated by the questioner and will have the authority to
complete the questionnaire when they feel ready.
Prior to sending the questionnaires to the professionals, a sample questionnaire
will be given out to five people who will only be expected to give feedback on
how clear and understandable the questionnaire is. Once, the questionnaire is
approved local architectural practices that specialise in healthcare will be selected
through an intense online research. The two variables that will not change when
selecting companies will be the location (UK) and the sector (healthcare design).
Additionally, practices at different demographics will be selected in order to
ensure a reliable outcome adopted from companies at different sizes.
The aim is to select above ninety architectural practices to complete the
questionnaire. The researcher is aware that normally there is a low response rate
and therefore the more questionnaires emailed the better. The self-administered
questionnaire will be mailed with a short cover letter briefly explaining the
dissertation and the required information. The cover letter will be written in a
modest approach to prevent any pressure to the participants.
The questionnaire consists of a total of five questions. Four of the questions will
be structured in a closed format and one of them will be an open format question.
The questionnaire consists of an introduction listing the six elements of biophilic
design being; Environmental features; Natural shapes and forms; Natural patterns
and processes; Light and space; Place-based relationships and Evolved human-
nature relationships. The reason for this introduction is that some companies may
not use the term ‘biophilic design’ when in actual fact they incorporate these
biophilic design elements in their healthcare projects. The questionnaire is

37

designed only to answer one of the objectives; to investigate how biophilic design
is understood and used by architectural practices that specialise in healthcare
design. Hence, only one open question was designed out of the five. The open
question encourages the respondents to state their intention when incorporating
biophilic design elements into their projects. The other questions are simple
questions that aim to directly answer the objective above, such as ‘Do you have an
understanding of biophilic design?’
The average time to complete the questionnaire is one minute and has been
purposely designed not to exceed this time length. This is to achieve a higher
response rate and to prevent the respondents feeling under pressure by an intense
questionnaire.
The overt observations will be undertaken in an exploratory approach as there is a
lack of information available and primary data needs to be explored. Covert
observations will be prohibited due to ethical concerns. Patients that visit clinics
and care centres will be observed to fulfil the objective; to study the interaction
between human and nature in healthcare institutions.
The patients and staff will be notified about the observation, however, there will
be patients that have been diagnosed with dementia and may not be mentally fit to
understand they are being observed. Their consultants will be notified and the
observation will be undertaken with the company of their consultants.
The observations will not be structured as this could create a biased observer
analysing the patients according to a structure. However, if the observation is
spontaneous it will create an unbiased observation. Beverley Taylor states;
“structured observation has the disadvantage of not accommodating unexpected
behaviours” (Taylor, B. 2008). This is a significant disadvantage to the research
of this dissertation, as unexpected behaviours of patients will benefit the
observation for an accurate result.

38

Quantitative research
Naoum states that; “in quantitative studies…the objective is to test or verify a
theory, rather than develop it” (Naoum, S.G. 2012). A quantitative study answers
whether an issue is occurring or not. The development is tested by a qualitative
study where you will acknowledge why it is occurring.
Quantitative research is the most appropriate research method to use if the
research objective is to find facts gathered from a large population for statistical
evidence. The research method used for this dissertation that falls under this type
of data is the self-administered questionnaires. The collected data will be analysed
by mathematical calculations to create graphs and charts as visual aids.
“Quantitative data are, not abstract; they are hard and reliable; they are
measurements of tangible, countable, sensate features of the world” (Naoum, S.G.
2012). Hence, quantitative data is reliable due to the endorsement from a large
population.
Qualitative research
Qualitative research on the other hand is “subjective in nature” (Naoum, S.G.
2012). As stated above this type of data emphasises why an issue is occurring.
The information gathered is exploratory and not statistical. “Exploratory research
is used when you have a limited amount of knowledge about your topic” (Naoum,
S.G. 2012). As indicated previously, there is lack of information available about
biophilic design. For this reason, exploratory research was essential to meet the
objectives of this dissertation. The exploratory research will be undertaken with
interviews and overt observations described in the primary data section of this
chapter.
Managers and consultants of care homes and clinics will be interviewed to ask
their observation of patients when they are in contact with nature. Questions will
be asked to identify whether they monitor a change in the patients wellbeing and
health. The overt observations are very vital in investigating how patients interact

39

with nature and how they respond to nature. This qualitative data will enable the
identification of patient behaviour when in contact with nature.
Secondary Data
The secondary data will be collated using the principles of a desktop study
approach. This technique analyses existing data from scientific databases and the
public domain. This will include a comprehensive study of literature around the
dissertation objectives. The literature review will be provided from professional
publications such as books, reports, journals and governmental documents. Most
of these documents are highly dependent on Stephen Kellert and Edward Wilson’s
publications since they both have completed in depth research into biophilia and
biophilic design. Government documents such as the publications by the
Department of Health have been analysed to investigate whether their
requirements endorse biophilic design.
One of the objectives of this dissertation is; to compare the difference in the
recovery of patients in a health institution that influences nature and in a health
institution that does not influence nature. This objective requires a scientific
experiment of patients regarding their contact with nature. A testing of patients
cannot be undertaken directly as a means for primary data as this requires
competent expert knowledge. For this reason, experiments undertaken by experts
have been analysed as a means of secondary data in a case study approach.

40

Table of Chosen Research Methods
Objectives of
Dissertation:
Secondary
Data
Qualitative
Data
Quantitative
Data
Research
Method
To investigate
whether biophilic
design is
acknowledged and
used by architectural
practices that
specialise in
healthcare design
✓ • Questionnaires
To assess how nature
can be incorporated
in healthcare design
projects
✓
• Overt
Observations
To study patient and
nature interactions in
healthcare
institutions
✓ ✓
• Overt
Observations
• Case Studies
• Interviews
To compare the
difference in the
recovery of patients
in healthcare
institutions
influenced by
biophilic design and
those that are not
✓ ✓ • Case Studies
• Interviews
Table 1. Table of Chosen Research Methods

41

Chapter Four - Investigation, Findings and Analysis
This chapter of the dissertation is an analysis of the primary and secondary data
obtained from the questionnaires, interviews, overt observations and the case
studies. The primary data will be studied prior to the secondary data in order to
emphasise the directly obtained data first. The research methods will be studied in
the order of questionnaires, interviews, overt observations and the case studies.
Primary Data
Questionnaires
The self-administered questionnaires include a short introduction and a list of the
six-biophilic design elements to ensure participants have a clear understanding.
The questionnaire consists of a total of five questions. Four of the questions are in
a closed format and one of them is in an open format. Prior to sending the
questionnaires to the professionals, a sample questionnaire was given out to five
people who were only expected to give feedback on how clear and understandable
the questionnaire is. All five respondents indicated that the questions were clear
and easy to understand. Subsequently, ninety-two architectural practices were
selected after a conducted direct online research. Hence, ninety-two
questionnaires were emailed to local architectural practices that specialise in
healthcare design. Seventeen out of the ninety-two participants responded to the
questionnaires indicating a response rate of 18.5%.
The responses will be analysed through statistical means. The following section of
this chapter will go through each response to each question. The results will be
presented in visual statistics.

42

Fig. 13. Pie Chart Illustrating Answers for Question 1 of Questionnaire.
Question one of the questionnaire is in a closed format and directly answers the
objective; to investigate how biophilic design is understood and used by
architectural practices that specialise in healthcare design. Eleven respondents out
of seventeen indicated that they have an understanding of biophilic design. This
reveals that 65% of the respondents are aware of biophilic design suggesting that
the majority of healthcare design practices have an understanding of biophilic
design.
Fig.
14.
Pie Chart Illustrating Answers for Question 2 of Questionnaire.

43

The answer to the first question suggests that biophilic design is understood by
architectural practices that specialise in healthcare. This had answered the first
part to the objective stated above. However, the second part of the objective
enquires whether biophilic design elements are integrated in healthcare projects.
The second question of the questionnaire aims to answer this. The pie chart above
illustrates that nine practices out of seventeen integrates biophilic design elements
into their healthcare design projects. This indicates that 47% of the respondents do
not integrate biophilic design elements into their healthcare projects even though
65% of the respondents have knowledge of biophilic design.
There is a significant difference between how many practices understand biophilic
design and how many companies apply the principle. The reason for this could be
that they are not aware of the benefits of biophilic design or their company does
not have the adequate technology. Additionally, this could also be a client related
requirement. The results for this question relates to the content covered in the
literature review that there is lack of knowledge on the benefits of biophilic
design.
0"
1"
2"
3"
4"
5"
6"
7"
8"
9"
Environmental"
Features"
Natural"Shapes"
and"Forms"
Natural"Pa@erns"
and"Processes"
Light"and"Space" PlaceDBased"
RelaGonships"
Evolved"HumanD
Nature"
RelaGonship"
No.$of$Responses$
Biophilic$Design$Elements$
Q3.$Which$biophilic$design$elements$have$you$
integrated$within$the$healthcare$design$
projects?$

44

The above bar chart illustrates the use of the six biophilic design elements. it is
evident that the fourth biophilic design element is highly used in the construction
industry. The Evolved Human-Nature Relationship is one of the elements that
have received a low response rate. This may relate to the data explained in the
literature review that, “Although the therapeutic use of horticultural activities
have been practiced for hundreds of years, objective documentation of its benefits
is relatively recent.” (Wichrowski, M.,J. 2005).
The environmental Features and Light and Space are the two elements they
received the highest response rate. These elements are highly relevant to
achieving sustainable design outlined by the Government. Therefore, this may
suggests that they are integrating biophilic design elements to meet the
expectations of the UK Government.
Question four of the question was asked to those respondents that have integrated
biophilic design elements in their projects. The question was, “If you have
answered question 3 what were the intended benefits and do you believe the
benefits were achieved?” (See Appendix A).
There have been various answers to this question answering their intention of
using biophilic design elements. One of the respondents answered that their use of
biophilic design was a client requirement. This may suggest that the hypothesis
expressed in the analysis of the second question is correct. Even though,
seventeen respondents are aware of biophilic design only nine of them have used
it.
Five of the respondents out of nine that indicated that they use biophilic design
elements explained that their use of these elements are related to the well-being of
patients. Additionally, two of the respondents did not answer the reason to their
use of biophilic design. The Manser Practice expressed that in one of the projects
they designed there was a view our to the Derbyshire Landscape in each of the
patient rooms. The nurses that observed them indicated that the patients called

45

staff less. This indicates that the view to the landscape has had a positive impact
on the patients.
Question three suggests that the use of biophilic design elements may be relevant
to the Governmental expectations to receive funding. However, the answer to this
question indicates that the majority have used these elements for the well-being of
patients.
The fifth and last question of the questionnaire is an opinionated question. Eleven
responses out of seventeen have stated that they believe biophilic design elements
should be integrated in healthcare design projects for the well-being of patients.
When comparing these results to the results of the first question, it is clear that
those eleven practices that have an understanding of biophilic design all believe
that these elements should be integrated in the building design for the well-being
of patients. Hence, the total percentage of respondents that have answered yes are
65%. Nevertheless, when considering that the eleven respondents have stated that
they have an understanding of biophilic design have also stated that they believe
11"
6"
Q5.$Do$you$think$biophilic$design$elements$should$be$
integrated$into$healthcare$design$projects$for$the$well$
being$of$pa<ents?$
Yes"65%"
No"35%"

46

this integration of nature should be applied. This emphasizes that all participants
that are aware of biophilic design are also aware of the benefits of these biophilic
design elements and those six practices that do not have an understanding of
biophilic design are not aware of the benefits. This may indicate that if those six
companies did have an understanding of biophilic design they would have
recognised the benefits. This relates to the statement expressed by Stephen
Kellert, which was analysed in the literature review, “Biophilic design is, thus,
viewed as the largely missing link in prevailing approaches to sustainable design”
(Kellert, S. 2008).
There was a dedicated section in the questionnaire where respondents could add
any additional comments. The company One Limited, stated “Although this is not
classed as a biophilic approach, the principles that BREEAM try to drive into
design definitely assist and enhance the introduction of the elements to a building
such as natural ventilation, natural light, outdoor space and arts in health” (See
Appendix A). This was useful information that allowed the researcher to
accomplish additional research into the requirements of BREEAM for healthcare
institutions. As referred to in the literature review, the requirements of BREEAM
influence some of the biophilic design elements, however they do not use this
term when expressing the requirements. This could be a reason to why some
companies integrate biophilic design elements subconsciously. As explained in
the literature review, Edge Lane Hospital, in Liverpool integrated “extensive soft
landscaping to improve health and well-being of particularly vulnerable building
occupants” (BRE Global. 2013) and this was one reason to why they achieved a
BREEAM excellent rating.
Interviews
The interview questions were semi-structures and only main questions were asked
as explained in chapter three. The first interview was conducted with Tom who is
the manager of Sydenham Gardens. Sydenham Gardens was founded in 2002 and
aims to improve the health and well-being of the local residents in Bromley and

47

Lewisham. The duration of the interview was forty minutes. The interview was
semi-structured as mentioned in chapter three and the main questions asked were:
• What does Sydenham Gardens aim to achieve?
• What activities do you provide for patients that visit the centre?
• Which activities do the patients enjoy the most?
• Have you seen improvements in the well-being of patients?
• Do you think people are aware of these courses?
Sydenham Gardens is a charity organisation and is highly dependent on
volunteers. It is cheaper than other dementia care therapy organisations. Tom
stated, “We are highly subscribed and have a waiting list.” This could be either
because they are cost effective in comparison to other organisations or because
they provide a better service. Tom indicates; “We aim to improve the well-being
of the dementia patients that attend our courses. There is a dementia curve and we
aim to make the dementia curve longer.” The dementia curve is the graphical
curve that illustrates the pattern from when a patient is first diagnosed with
dementia to death.
Tom stated “Sydenham Gardens provides arts and craft sessions, tai chi lessons,
horticultural therapy and counselling session.” He indicated that the activities are
undertaken in groups and are not specific to the individual. They have a higher
attendance percentage during summer months where the garden is most in use. He
explains that, “during summer we have a attendance of nearly 100% but in winter
months the attendance can drop down to 50%”. This may emphasise that people
enjoy the activities in the garden more in comparison to indoor therapy activities.
The content in the literature review in chapter two emphasise that there is an
improvement in patients that undergo horticultural activities. Tom endorses this
hypothesis by explaining an anecdote. “One of the patients hadn’t spoke to
anyone including his family after he was diagnosed with dementia. After his third

48

session with us he spoke to his family and his family realised that he wasn’t as
bad as they thought he was.”
Tom also emphasises that there is a higher improvement of well-being of patients
with higher determination, as he states, “there is one patient who is very
determined to avoid the rapid decline of dementia and he has been living with it
for a very long time”.
The content in the literature review indicate that people lack the knowledge of
biophilic design and are not aware of the benefits. However, Tom indicates, “all
of our partners are aware of the benefits of these types of organisations.” This is
not a definite answer as these partners are based in South London and only
represents a small population.
The second interview was undertaken with Desponia who is the dementia care
worker at Sydenham Gardens. The duration of the interview was fifteen minutes.
The questions that were asked were:
• Which activities do the patients enjoy the most?
• Have you seen improvements in the well-being of patients?
Desponia stated that “patients do not enjoy traditional methods of therapies but
they enjoy coming here because they don’t realise they are in a therapy. The
therapy is undertaken during either art and craft activities or gardening activities.”
This emphasises that patients may feel intimidated by traditional therapies
whereas when they are attending gardening activities they enjoy it.
The interviewee emphasised that, “The patients here are very special but it can be
very hard to control because the illness makes them very stubborn. So, we treat
them like children because they don’t lose their long-term memories we believe
they may feel comfortable in environments that trigger their long-term memory.”

49

Desponia’s response relates to the content in the literature review that stated;
“Patients with Alzheimer’s disease, the most common form of dementia, and their
caregivers say the illness leaves them feeling isolated” (Ostrow, N. 2012).
Dementia patients can feel isolated and attending these organisations where
everyone else there is the same may make them feel less isolated.
Desponia stated that, “Half of the people that come to us have recording
improvements. We have carers surveys were they explain to us any improvements
they see”. This emphasizes that these types of organisations are useful for the
well-being of patients and can make their illness less stressful.
The third interview was conducted with Bernie, the manager of the Maggie’s
Centre in Charing Cross, London. The duration of the interview was fifteen
minutes.
• What services to you provide for cancer patients?
• Which activities do patients attend the most?
The Maggie’s Centre in Charing Cross provides a drop session for counselling
Monday to Friday 9am-5pm. This ensures patients are able to have professional
support when they need to. They provide practical support through coping with
hair loss, emotional support through sessions with a psychiatrist, social support
through socialising with other patients. Bernie indicated “our aim is to help
cancer patients during their treatment procedure. We provide emotional support
five days a week and everyone is welcome including family members of patients
diagnosed with cancer.”
The manager stated, “our visitors tend to spend most of their time here either in
the kitchen or in the garden.” This indicates that patients like to treat the Maggie’s
Centre as a socialising home rather than a centre for cancer patients as they enjoy
socialising in the kitchen and garden.

50

The last interview was undertaken with a patient that had attended a consulting
session at the Maggie’s Centre. This interview was the shorter out of all of the
interviews accomplished as the counsellor at the Maggie’s Centre advised that the
researcher ensures the patient does not feel intimidated by the interview questions.
Two main questions were asked to the patient which were:
• What activities do you undertake when you visit the Maggie’s Centre?
• Have you seen any improvements in your well-being since attending the
Maggie’s Centre?
The patient answered the following to the first question; “I don’t like to think I am
here because I am ill. This is my way of relieving the stress from the illness.
Everyone here is equal so I feel less isolated and happier. We make tea, sit in the
garden, read books and sometimes share our stress because we understand each
other better.”
The patient answered the following to the second question “Of course I have seen
huge improvements in myself at least now I have a place of relieving stress.
Instead of sitting at home and watching my children feel sorry for me I feel
happier to come here and feel like I am doing something for myself. My children
are happy that I come here because they say I seem more energetic than when I
was first diagnosed with breast cancer.” The above answers indicate that the
patient enjoys visiting the Maggie’s Centre as it gives her the opportunity to
forget about her health problems.
Overt Observations
In order to fulfil the objective; to study the interaction between human and nature
in healthcare institutions, ten patients that have been diagnosed with dementia
were observed during their horticultural therapy (HT) in Sydenham Gardens. The
observation length was one hour and the overt observation principles were
applied.

51

The steps of the HT activity followed in the order of; walk in the garden, planting
in the garden, planting in the green house and final walk in the garden. Sydenham
Gardens is located in a nature reservation area and the building is located in the
centre of this nature reservation area. This allows longer HT activities as the
footprint of the garden allows for many activities to be achieved.
There are biophilic design elements evident inside the building, such as the view
out to the garden in the consultation room (see fig. 20). The entrance of the garden
clearly indicates that it is located in a nature reservation area (see fig. 17). It was
designed with maximum vegetation to ensure a positive engagement with nature
as they stepped in the gates of Sydenham Gardens.
Fig. 17. Tasyurdu, O. 2014. Entrance to Sydenham Gardens

52

Fig. 18. Tasyurdu, O. 2014. View from Garden to Main Building
Fig. 19. Tasyurdu, O. 2014. Back Garden Entrance

53

Fig. 20. Tasyurdu,O. 2014. Consulting Room
Fig.
21.
Tasyurdu,
O.
2014.
Sydenham
Gardens

54

Fig.
22
Tasyurdu,
O.
2014.
Dementia
Patient
at
Sydenham
Gardens

Fig. 23. Tasyurdu, O. 2014. Garden Area for Planting

55

The therapeutic activities aim to retain physical abilities and prevent confusion.
The first stage of the therapy was to walk around the garden and identify the
objects and plants in the garden, in which their engagement with the dementia
care worker was positive. They then were asked to plant a rosemary seed, in
which they physically interacted with nature. There were some confusion with
some patients on how to dig out the soil and the positioning of the seed. However,
there were no signs of aggression or intimidation while undergoing this activity.
They then repeated the same procedure of planting but this time in the green
house. The last stage was to walk around the garden the final time to test whether
the patients remember the objects and names of plants that were identified in the
first walk. Seven questions were asked to the patients and out of seven, they
answered four.
Additionally, after the final walk around the garden a patient had forgotten the
route back to the building. However, previously when the dementia care worker
asked whether he could identify the types of plants in the garden, he was able to.
This may suggest that although he appears to have forgotten other things he has
not forgotten his interaction with nature.
The observation anticipated that the patients responded well to the horticultural
therapy. It was evident from their facial expressions and physical actions that they
were enjoying the activities in the garden.
Even though these patients are suffering from memory loss the researcher has
observed that the patients adapted well to the nature integrated activities. The
reason for this could be that “Because biophilia is rooted in human biology and
evolution, it represents an argument for conserving nature based on long-term
self-interest” (Kellert, S. 2005). This quotation was referred to in the literature
review and emphasises that nature is a long-term self-interest to human beings.
This may identify the reason to why the dementia patients at Sydenham Gardens
responded positively to the nature integrated activities as dementia patients lose
their short-term memory first and then gradually loses their long-term memory.

56

Moreover, some of the most common symptoms of dementia are depressed and
withdrawn mood and physical aggression. These activities aim to reduce the
levels or stress and aggression. As referred to in the literature review, the case
study completed by in relation to HT indicated that those patients that attended the
HT had reduced stress levels in comparison to those that did not. In addition as
emphasised in the literature review, the Forestry Commission indicated in
relevance to HT that, “Especially those which include contact with nature have
been shown to enhance quality of life and a person’s ability to cope with stress”
(Forestry Commission. 2013). Hence, it is evident that the results identified from
the overt observation at Sydenham Gardens are endorsed by the content analysed
in the literature review.
Secondary Data
Case Studies
This dissertation analysed three case studies in depth to satisfy the objective; to
compare the difference in the recovery of patients in healthcare institutions
influenced by biophilic design and those that are not.
As referred to in the literature review, the two professors Kathleen Beautchemin and
Peter Hays investigated the patients in the Cardiac Intensive Care Unit (CICU) of an
hospital in Edmonton, London. They aimed to examine the possible correlation
between the exposure of natural light and the recovery time of a patient diagnosed
with depression.
Patients that were diagnosed with depression were split into two groups in the
symmetrical CICU. Due to the opposite orientation of the divided rooms, one side
of the unit was exposed to maximum natural light and the other group was treated in
rooms that lacked natural light. The north facing beds were sunless and the south-
facing rooms were bright. “The north-facing rooms registered 200-400 lux, the
south-facing rooms 1200-1300 lux” (Beauchemin, K. and Hays, P. 1998).

57

The recovery of the patients was observed and the number of days that the patients
stayed in the hospital was compared for both sides of the ward. “We found that
depressed patients in sunny rooms stayed an average of 2.6 days (15%) less than the
others (P<0.05).” (Beauchemin, K. and Hays, P. 1998). The results identified that
the patients exposed to natural light experienced shorter recovery time. This case
study will be analysed in depth in the results and analysis chapter of this
dissertation.
Another similar case study that endorses this outcome was the investigation
undertaken in the Mackenzie Health Sciences Centre in Canada. They had
examined the impact of natural light on the recovery time of patients. The
researchers; “found that depressed patients in sunny rooms recovered 15% faster
than those in darker rooms” (UK Green Building Council. 2014).
Additionally, they accomplished further research and analysed whether there is a
correlation between the amount of daylight in a room and the number of deaths. The
analysis consisted of the data back dated from four years. The outcome of patients
in dull rooms and bright rooms were investigated for those four years and the results
identified that “deaths were consistently more frequent on the dark side in each of
the four years studied” (Beauchemin, K. and Hays, P. 1998). This case study can be
endorsed with the statement Stephen Kellert indicated in his book, “when contact
with nature involves exposure to natural light or sunlight, yet another pain-reduction
mechanism may come into play”. (Kellert, S. 2008).
Dr. Roger Ulrich is a professor at architecture and has undertaken many
investigations for the well-being of patients. He was the first professor to test the
hypothesis that the natural world has an impact on the well-being of patients. This
investigation was named View Through a Window (Ulrich, R. 1984). This case
study is highly relevant to this dissertation as it analyses the difference in the
recovery of inpatients that are exposed to biophilic design elements and those that
are not.

58

As referred to in the literature review the experiment Ulrich accomplished
involved testing the benefits of views through windows in inpatient rooms in a
suburban Pennsylvania hospital. Patients that received the same surgery of
cholecystectomy, which is a gall bladder surgery, were divided into two groups in
a symmetrical ward. One side of the ward had a view out to a natural setting and
the other side had a view out to a brick wall. In addition, the two groups of
patients were coordinated for gender, age and general health. The patients on both
sides of the ward received the same treatment to achieve accurate results.
The results identified that those patients that were exposed to the view of nature
experienced a shorter recovery time. “Ulrich found that patients with the view of
the trees used fewer narcotics and milder analgesics, indicating that they
experiences less pain.” (Ulrich, R. 1984). This result indicated that there is a
positive impact on the well-being of patients that have a connection with nature.
In addition, these patients also had shorter recovery time alongside a much
positive recovery after the surgery.
The professional horticultural therapist Matthew Wichrowski assessed the impact
of horticultural therapy (HT) on patients in a cardiopulmonary rehabilitation
program. These patients were diagnosed with coronary heart disease. There were
two components of the cardiac rehabilitation program, which were HT sessions
and education classes (PECs). Fifty-nine patients were involved in the HT group
and forty-eight patients were involved in the education classes. The variation
between the numbers of patients in each group did not have an impact on the
results.
Each participant of the two groups was examined before the test and their
modality before and after the test was noted to determine the impact of the
sessions. The examination consisted “of the completion of a Profile of Mood
States (POMS) inventory, and an Heart Rate (HR) obtained by pulse oximetry”
(Wichrowski, M,J. 2005).

59

Table 2. TMD Before and After HT Class and PEC
It is clear from the data presented in the above table that the group, which
attended the HT sessions, had an improved mood state and stress levels were
reduced. It is noticed that there was an increase in mood disturbance of those
patients that attended the education class. Whereas, the total mood disturbance
rate for those patients that attended the HT session was significantly reduced.
Table 3. HR Before and After HT Class and PEC
Additionally, the above table demonstrates the heart rate of patients before and
after the HT and PEC classes. It is clear that there is a significant decrease of the
heart rate of those patients that attended the HT classes in comparison to those
patients who attended the PEC classes.

60

Table 4. Effect of HT and PEC On The Individual Mood Dimensions Assessment By the POMs
The above table illustrates the effect of the HT sessions in comparison to the PEC
classes on the moods of individuals. When comparing the rates, it is clear that
there is a significant reduction of tension, depression, anger and fatigue of those
patients that attended the HT sessions. This is relevant to the information
indicated in the literature review; “Especially those which include contact with
nature have been shown to enhance quality of life and a person’s ability to cope
with stress” (Forestry Commission. 2013). Furthermore, the rate for vigor had
increased after the HT sessions, which endorses the statement above.
However, there is a slight increase in the rate for tension, depression, anger and
fatigue of those patients that attended the education classes and there is a decrease
in the rate for vigor. This identifies that the education classes have a negative
impact on patients in comparison to the HT sessions.
The results of this case study relate to the data outlined in the literature review
that patients enjoy participating in HT activities. “It was determined that
participants engages in horticultural activities for greater period of time than in
non-horticultural activities” (Chalfont, G).

61

Chapter Five - Conclusions & Recommendations
Limitations to this Research Study
The main limitation to this dissertation was the lack of secondary data. These
limitations have had an affect on the approach of organizing how the required data
will be collected. An extensive primary data strategy had to be undertaken.
Another limitation to the research was the lack of time. A useful primary analysis
could have been undertaken by observing a clinical experiment of the impact of a
biophilic design element such as a view to landscape from a patient room. The
researcher could not investigate this directly due to limited time.
Conclusions
The aim of this dissertation was to investigate whether the application of
Biophilic Design strategies have an impact within healthcare institutions upon the
recovery of patients. This aim was investigated through the analysis of the
following four objectives.
The first objective was designated to investigate whether biophilic design is
acknowledged and used by architectural practices that specialise in healthcare
design. The literature review identified examples of healthcare buildings, which
have incorporated components of biophilic design. This suggested that some
architectural firms are aware of this principle. However, this information was not
sufficient to determine a definite answer to the extent of knowledge and use of
biophilic design in healthcare design practices. Consequently, self-administered
questionnaires were conducted as a means of primary data to investigate this
objective further. The findings of the questionnaire indicated that 65% of
architectural practices are aware of biophilic design, however, only 47% apply the
principle. This reveals that a majority of architectural practices are aware of
biophilic design, however, only a smaller population apply the principle. This
could be due to lack of technology or rejection of client requirements. This
supports Kellert’s theory expressed in the literature review that “biophilic design

62

is, thus, viewed as the largely missing link in prevailing approaches to sustainable
design” (Kellert, S. 2008) and Wichrowski’s theory that “the therapeutic use of
horticultural activities have been practiced for hundreds of years, objective
documentation of its benefits is relatively recent.” (Wichrowski, M.,J. 2005).
The second objective was outlined to assess how nature can be incorporated in
healthcare design projects. The literature review addressed examples of healthcare
institutions that have integrated nature within the building design. An example is
the view to St. Joseph River in the waiting area for ambulatory surgery in
Lakeland Hospital, Michigan. Another example is the integration of plants in the
courtyard of the Maggie’s Centre in Glasgow and the use of exterior glazed panels
allowing views to the surrounding vegetation. The Henry Ford Hospital in United
States has two atriums used as indoor healing gardens for the inpatients. The
stepped back roof of the Maggie’s Centre in London allows maximum daylight
into the area where patients socialise the most, which is relevant to the forth
biophilic design element of, Light and Space. These strategies of integrating
nature in healthcare buildings are supported by the field research of observing
Sydenham Gardens in London. The consultation room in the care centre contains
a large window with a view out to the garden, symbolising a picture frame,
likewise with the Maggie’s centre in Glasgow. The arts and crafts study room
consists of many large windows to maximise daylight levels and the garden has
extensive vegetation likewise with the Maggie’s Centre in London. In addition,
the large garden of Sydenham Gardens provide space for horticultural therapies
likewise with the indoor healing gardens at the Henry Ford Hospital.
The third objective was proposed to study patient and nature interactions in
healthcare institutions. The literature review outlined strategies of connecting
patients with nature. An example is horticultural therapies, which allows patients
to physically interact with nature through gardening activities. Examples of
passive connections with nature are addressed in the literature review as views to
landscape from patient rooms or care centres, such as the view of St. Joseph
River, expressed above. The literature review also depicts another passive
connection through exposure to natural light, as addressed by Kellert, “when

63

contact with nature involves exposure to natural light or sunlight, yet another
pain-reduction mechanism may come into play”. (Kellert, S. 2008).
The field research relevant to this objective was undertaken through overt
observations and interviews. The interviews outlined that nature integrated
activities had a positive impact on the well-being of patients and they enjoyed
these activities more than educational sessions. The manager of Sydenham
Gardens stated that, “during summer we have a attendance of nearly 100% but in
winter months the attendance can drop down to 50% (refer to chapter four). In
addition, he stated a patient had not been speaking to anyone after he was
diagnosed with dementia, however, after three sessions at Sydenham Gardens he
started to talk again. This supports the evidence indicated in the literature review
that “Especially those which include contact with nature have been shown to
enhance quality of life and a person’s ability to cope with stress” (Forestry
Commission. 2013).The overt observations of the dementia patients at Sydenham
Gardens indicated that the patients could familiarise with nature even though they
suffer from memory loss. Their body language and facial expressions indicated
that they enjoyed the nature-integrated activities. This supports the information
presented in the literature review that horticultural therapies improve the physical
and mental state of patients.
The fourth objective prerequisite to compare the difference in the recovery of
patients in healthcare institutions influenced by biophilic design and those that has
not. A field research approach could not be committed to this objective, as this
requires competent expert knowledge. For this reason, experiments undertaken by
experts have been analysed as a means of secondary data in a case study
approach. The analysed three case studies indicated that biophilic design elements
have had an impact on the recovery time and well-being of patients. For example,
the case study undertaken by Ulrich Roger regarding views out to nature in the
patient rooms concluded that, “patients with the view of the trees used fewer
narcotics and milder analgesics, indicating that they experiences less pain”
(Ulrich, R. 1984). This is relevant to Wolverton theory that “Patients exposed to
natural environments can experience lower blood pressure and reduce muscle

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