Experts
In recent years, there has been increasing interest in the “healing properties” of architecture. I understand that this concept influenced your design plans for a new psychiatric clinic in Borås, Sweden. Can you give me a brief overview of how this inspired your work, and describe the recognition you have received for your plans?
Stefan: Sweden’s Southern Älvsborgs Hospital (SÄS) wanted to create a new psychiatric clinic that would elevate the importance of behavioral healthcare within its system, while providing a welcoming space for patients that will respect their dignity and will incorporate the healing properties of nature. This led us to create a design for a new facility that would operate as part of the general hospital and would provide more integration between psychiatric and somatic care. We also wanted our design to help normalize psychiatric care and remove some of the perceived stigma for patients.
Cristiana: We began with the idea of designing a psychiatric “block,” but this later expanded into an entire “quarter” as we began to think of a way to centralize the psychiatric care of the whole region, as well as to seamlessly include a broad array of services—including inpatient care and outpatient treatment and services for children and adults.
Our design plans for this project took first prize in the 2011 architectural competition and first prize in the WAN Healthcare Award 2013 for future healthcare projects. Construction on the facility began in the fall of 2017 and is expected to be complete in 2021.
How did you use research to guide your efforts right from the very beginning of your work on this project?
Stefan: There was a lot of discussion about research related to evidence-based design during the planning process during the planning process. One of the people who influenced our thinking was Roger Ulrich, PhD, who is Visiting Professor of Architecture and Civil Engineering, Building Design at the Center for Healthcare Building Research at Chalmers University of Technology in Sweden. He is also a well-known researcher in evidence-based design.
We also visited other facilities in Sweden and abroad, to learn from their examples. There is a trend in Sweden to work in multidisciplinary teams that bring together psychiatrists, psychologists, and other staff members to share ideas and information. There is also a trend toward more integration with outpatient and inpatient treatment. We wanted to learn more about these concepts.
The main example we looked at for ideas was another White Arkitekter project, a cutting-edge psychiatric clinic at Östra Sahlgrenska University Hospital in Gothenburg, Sweden. In that facility, they used many of the concepts we wanted to incorporate in our new clinic, such as focusing on healing, providing access to nature, and respecting the dignity of patients. These concepts seemed to be effective in their setting. A study looking at their facility before and after the new clinic was open identified a significant reduction in the use of restraints and medication among patients in the new space [this study is documented in “Architecture as Medicine – The Importance of Architecture for Treatment Outcomes in Psychiatry,” a book where Lundin is editor and co-author]. It’s believed that these improvements are related to the changes that were made.
I understand you also incorporated input from different user groups that you hoped would lead to improvements in quality of care. Can you explain why this was an important component of your planning process and how you accomplished it on this project?
Cristiana: Healthcare projects are always done, in tight collaboration with staff in Sweden because we believe in a collaborative design process. It takes longer, of course, because we have to allow time to discuss challenges and solutions and find ways to communicate in a common language. But it’s worth the time and effort to include this step because the staff knows how they work and how they need to use the building to be most effective. Ultimately, when staff and designers get together, this leads to better quality of patient care.
In a psychiatric institution, it can add another step because there are different groups and they sometimes need different design tools and solutions. We manage this by having one person in the design group who is representing users in our meetings. This person goes back and discusses questions with the larger user group and gets feedback from them.
In this project, the user representative got feedback on everything from patient rooms, the entrance hall, and gardens. For instance, we got input from the users and patients that they did not want to have an entrance hall that was large in scale. A lot of patients are afraid of bigger spaces and have trouble finding their way. This prompted us to design an entranceway that will be less grand and easier for people to navigate. The users also had strong feelings about the way we take care of emergency patients. They had a strong opinion that to respect the dignity of patients in crisis, who are in a vulnerable position, a separate entrance was needed. This prompted us to include elevators that open into a more private corridor on all floors, where emergency patients will be able to be brought in privately so they will not be exposed.
To get more feedback on our plans, we also created a mock-up where the staff and patients could see the design, material, and furniture we were proposing and offer suggestions and improvements to help guide our choices.
What are some of the key questions and concepts you considered throughout your design process?
Stefan: Early on in the process, we explored the merits of constructing a new building versus using the existing facility. Ultimately, we decided to do both. (We will talk more about this decision later in the interview.) Another very important question we debated was whether it was a good idea to combine inpatient and outpatient care in one place. Initially when we began designing, we were just focused on inpatient care, but the project went through different stages as we went along. Ultimately, we decided to include outpatient, too. We followed the current thought, which is that you can regard the inpatient period as a brief segment of the longer spectrum of outpatient care. Another big question is whether adults and children should use the same entrance for a facility. We eventually decided that yes, they should come in through the same place. As a result, we will create one main entrance in the new space.
What are some of the defining design features that you ultimately decided to include?
Cristiana: We wanted the facility to be a place full of energy and guests, so we’ve really struggled in the design phase to find ways to make the entrance as normal as it can be so patients won’t feel they are entering a psychiatric institution but, rather, that they are entering a regular building. The entryway will have good daylight and good orientation. When complete, it will also connect to a café, a restaurant, a conference center, and other services, in addition to serving as a bridge to the adult and children’s psychiatric wards, outpatient treatment offerings, and the general hospital. This “mix of functions” is intended to minimize the stigma psychiatric patients might otherwise feel if they were singled out.
As Stefan noted earlier, in the final design plans, we use an existing building, which is dedicated to outpatient services. The total facility will be 26,000 square meters (close to 280 square feet). The new building will consist of two basement floors, a main entrance floor, and three upper floors (two floors for adults and one for children).
There will be a total of four adult inpatient wards, with every ward housing 18 patients; each of these patient wards will be sub-divided into three units of six patients each. The children’s ward will consist of six patient rooms. Each ward will have a separate nursing station in close proximity. We want to have a very close connection between staff and patients.
One of the design features that you suggest might reduce aggression in psychiatric patients is allowing single rooms. This is a controversial topic because the benefits of autonomy and privacy are contrasted with the increased risk for self-harm when psychiatric patients are unobserved. How did you decide to weigh in on the side of privacy in your design?
Cristiana: If there is a conflict between healing design and security, the healing design always comes first. We believe it will help people get better more quickly. There are a lot of situations where a solution is better for the healing design but may not be as safe. In these cases, such as with single rooms, we chose the healing option. We believe it will give better quality of care and patients will react more positively. For example, because some of the wards were placed above ground floor, we struggled for many months with the idea of including private balconies in each patient room. In Sweden, we believe it is part of the treatment to have access to the garden or to nature, so this was an important element of the design, even though it raised many concerns at the same time. It finally came down to one question: is it important to have a balcony? The answer was yes. This meant that we will include the balcony. Of course, there is always the risk that a few patients might use the balcony to smuggle in drugs or try to elope. In that case, we won’t give a patient we believe is at risk access to a balcony. But we don’t want to take it away from everyone else who is not at risk.
If there is a conflict between healing design and security, the healing design always comes first. We believe it will help people get better more quickly.
Stefan: We believe patients should have private rooms designed like an apartment or flat where they can be alone to eat their food and read books. Patients should also be able to close the doors from inside, which means that the rooms have to be designed to be very safe to prevent them from hurting themselves. But it is challenging because you can’t say a patient room in itself is ever very safe or secure. But for us, we feel it’s important to normalize the treatment experience as much as possible. When someone is constantly reminded that he or she is sick, it will affect their emotion and behavior, so we try to avoid that.
Providing opportunities for staff to observe patients is a controversial topic in psychiatric facility design today. How did this issue influence your design choices?
Stefan: We will have a well-placed team station to allow the staff to overlook the corridors of our wards. This is important because we want to create opportunities for dual communication, but in the design phase we had a lot of concern over the sight lines and what would be most appropriate. For the staff members, we know that they want the possibility to see patients so they will know what the patients are doing and how they are feeling. It’s also important that patients can see the staff to feel safe. But a bigger issue for us is whether the staff should even stick within the work station and serve as a “watch tower.” We have three nursing stations in each ward, one station for each unit (6 patients unit). One of the three stations is placed in a strategic central position so it can be used for night shifts or weekends. The nurse stations are partly glazed to the corridor but the idea is that the staff is out with the patients, not closed in the room.
We feel that if patients are actively doing their part by taking their medicines and participating in activities, the building design must respect their freedom.
We also considered whether we wanted to have windows that would enable staff to look into patient rooms. Our answer was absolutely not. We believe you don’t look into the room if want to respect the patient’s privacy. We also don’t believe in using cameras to observe patients. We feel that if patients are actively doing their part by taking their medicines and participating in activities, the building design must respect their freedom.
How did use evidence to guide your decisions on such controversial topics?
Stefan: We had a lot of philosophical discussion around those controversial design elements such as security, privacy, and safety. It is hard to find conclusive evidence if something works better one way or another. We had very deep discussions around this and we turned to the staff for their input to help guide us.
In making specific material, color, and furniture choices, how did you decide what to use, and how much did durability and safety impact your choices?
Stefan: We are trying to achieve an environment that doesn’t feel like a traditional hospital. Our idea is to use natural materials like wood that will remind patients of nature and will be likely to appeal to their senses. Our client asked us if wood and other material could be destroyed by the patient. Our experience is that if you try to do good things for patients and give them a dignified environment, they will realize and they will respect that. Ultimately, this means that they won’t destroy the material.
Cristiana: We also try to stay away from the stereotypes. Every so often on a project, you have someone ask what the best environment is for psychiatric patients. Often you get the answer that it’s few colors, little artwork, and white walls and ceilings. Yet we feel that is actually the most horrible environment for psychiatric patients. We believe that it’s okay to have a calm environment, but to us, that means using natural material that you use in a residential setting. We don’t want to make it an institutional environment. We will use wood walls, wood furniture, and textiles as much as possible. We are trying to bring as much nature and greenery as we can into the building. When it comes to color, we use natural concrete, warm beach wood, and natural linoleum. We don’t add extra color. We believe we will let the furniture and artwork be the colorful part of the project, but the building itself will be kept very natural and mild.
Stefan: The facility is also designed to make the most of the landscape. To do this, in addition to the private balconies we mentioned earlier, we will also incorporate common balconies in each of the main patient areas and courtyards on the grounds to encourage patients to enjoy fresh air and the scenery.
In Sweden, we believe nature is one of the most healing factors, so it’s important that the facility will provide an array of opportunities for the patients to interact with the environment throughout their stay.