Healing Architecture: The Hospital after COVID

Michael Kerbler got to the heart of the matter right at the beginning of the panel discussion "Organism of the Hospital after Covid-19": This year’s theme of the Venice Architecture Biennale, "How will we live together?," also comprises the partial aspect of "How do we want to care for each other and for sick people — together and from a holistic point of view?" Today, hospitals are mostly perceived as machines. People are reluctant to go there, and probably everyone associates one or the other — usually rather negative — feelings with them. This image, however, is very unfortunate for buildings where people are supposed to get well and experience convalescence. Therefore, whitewashing terms such as "health center" are often used instead of "hospital." Such fine-tuning of the designation has never made a great difference, though. Even though the design and layout of new hospital buildings are improving noticeably, the topic of Healing Architecture continues to be neglected, as some of the participants in the discussion deplored.

So, what exactly is Healing Architecture? It is a planning premise that aims to create a health-promoting environment for the physical and psychological well-being of patients and staff through a design using light and air, an unobstructed view of nature, acoustically effective materials, colors that aid orientation, and an awareness of the odors of a place. Since this is important, Andreas Frauscher, CEO of Architects Collective, found that construction costs should be put in relation to running costs. After all, investing in Healing Architecture leads to shorter hospital stays, higher staff satisfaction, and lower sickness rates; this is welcome from a business and economic point of view, and additional costs will quickly pay off. Richard Klinger, also CEO of Architects Collective, added: "This approach is related to materials, but also to the building structure. You can’t reduce this topic to curtains and flooring materials, rather it reaches into the basic structure of a building."

The problem is well known in the field of planning, Klinger added. The expert for master planning in the health sector and in hospital planning has already conducted many discussions in the run-up to building projects, and the topics addressed have often been the same. While the goals used to be set high, it is now clear that discussions about the budget and also about technical aspects unfortunately always take center stage in the end. According to Klinger, the sustainability concept usually perishes during the execution stage. Yet experience shows that the spatial experience also has a decisive influence on the quality of the workplace, if you consider the number of sick days among staff. Since such experience cannot be adequately documented and, above all, quantified monetarily, it is difficult to persuade clients to change their way of thinking. Moreover, the funds for the construction of a hospital usually come from a different source than those for its operation. If, for example, the nursing staff think it necessary to be able to offer patients therapy tubs, this comes after the building has long been built — and the necessary space is missing.

The small panel discussion at Gleis 21, an event space in Vienna, aimed to highlight problems and engage with decision makers in a discussion about the "post-pandemic hospital." In the past year, hospitals and their staff all over the world have been put to an acid test and had to cope with extreme workloads. According to an online survey conducted by DGIIN, the German Association for Internal Intensive Care and Emergency Medicine (PDF link, in German) in April 2021, one third of employees in nursing and health care professions said they would like to quit their jobs in the next twelve months or at least strive to have their workloads reduced.

In addition to fair pay, the respondents also wanted lasting adjustments of working conditions. Klinger’s question as to whether one would even want to, and be able to, afford a "clinic of well-being" led Kerbler to add: "What do we have to prepare for if we have to change our approach to include the provision of reserves? Do we have to abandon the idea that a hospital is finished once it has been built? Do we have to think of it as a growing building?"

Pulmonary specialist and occupational physician Sylvia Hartl, who heads the pulmonary department at the Penzing Hospital in Vienna, agreed. A hospital functions organically and has to be constantly adaptable, as the coronavirus pandemic has just proved. The problem is that the hospital has an ethical mission, but simultaneously has to fulfill economic conditions. Although it is already possible to specify various needs, changeable spaces are needed for appropriate measures. According to Hartl, the investment in patient well-being is returned tenfold. 

Beate Czegka, Director of the Nursing Management Department at Tirol Kliniken GmbH, is also convinced that "we cannot but support a healing environment from the nursing point of view. We often realize that many things pay off and that planning according to the concept of Healing Architecture is not that much more expensive. If we include these considerations in the planning process right from the start, it’s less expensive than retroactively implementing conversions or annexes." Klinger confirmed that there is definitely interest in this topic in the basic planning stage, but it is often overlooked in the course of the process: "The awareness that Healing Architecture is just as important as technology and function has not quite developed yet. Technology always prevails as soon as cuts are made," he remarked, drawing on decades of experience.

Heinz Ebner, who is himself a medical practitioner and psychotherapist and has been working as a consultant in the health sector for many years, can imagine the "breathing" clinic as a solution, whether it is the larger one-bed room, the floor and storage space requested by the staff, or even the possibility of pooling resources in the event of a pandemic. "This is an important point,” replied Siegfried Gierlinger, Technical Director of the University Hospital Vienna, "but the biggest problem still is the staff shortage in the nursing sector."

What would a path that has to be followed to achieve a holistic planning of healthcare buildings look like? At the beginning — that is, before the actual planning of a project or before a competition — enough time is needed to compile all the important requirements. "Such discussions must be held and channeled into a constructive process," said Ebner. "Arguments are welcome. It must be ensured that there are reflection processes, that people take their time. There have to be resources for that, that’s the entry point into the whole story. I usually miss that in planning processes." Siegfried Gierlinger confirmed this: "Project management is time- and cost-driven. The third pillar of planning is quality. If the quality is right, time is not quite so important; when it comes to costs, it is difficult. But you have to allow discussion and be able to listen. When you build something new, you have to expect the people involved to allow creativity."

The pandemic has shown that the wrong equipment leads to a loss of time and a high concentration of staff; the physical admission and discharge of patients did not work; and often corridors had to be reconstructed during ongoing operations. The inadequacies also became apparent during recovery, as Sylvia Hartl recalled: "You want to discharge patients in a quality manner and have the opportunity to instruct relatives beforehand — for example, in the operation of mobile respirators. When we have to do this in a hurry, there is enormous pressure on the relatives. Here it is important to instill dignity, security and confidence." In the micro-flexible hospital, such interaction is possible, Hartl reported. At the Penzing Hospital in Vienna, one ward is equipped according to feng shui principles. The patients there feel particularly comfortable. Of course, wooden surfaces in a room are more expensive to maintain than acid-resistant industrial concrete. However, it benefits everyone, including the staff, if the patients feel comfortable. Architects are called upon to take up such topics and actively integrate them into their projects. "It’s about creating a sense of security for people who are injured," Hartl said. "You can’t compensate for that by being nice; what you need is an appropriate environment."

So, what can help develop a different building practice over time and allow more scope for Healing Architecture? The participants in the roundtable made an important appeal to all planners to demand time for preliminary research and to involve other stakeholders. Interviewing patients, on the other hand, is usually difficult because the recovered person mostly lacks the opportunity to compare. In the concluding discussion, it also became clear that the hospital’s ethical stance is crucial. If the institution itself has the claim to see the facility not as a machine but as a place of recovery, planning could proceed differently than it does today.

This brings us back to the question of what working conditions are needed in the nursing sector to make this wonderful, humane and life-supporting profession more appreciated. Beate Czegka gave a simple example: overweight people often feel ashamed when two or three nurses are needed to move them. They are sick and weakened and notice that they are a burden to everyone. It would be so easy, said Czegka, to plan for load cranes in a few rooms on each floor from the outset. It is a great relief for patients, caregivers and relatives to see that the stay in hospital does not cause unnecessary problems. "This fits in perfectly with the actual mission of a place of health," she said, "because ultimately, especially at the beginning of the planning process, it is about an attitude that fulfills the ethical mission of healing and recovery and reconciles it with the economic objectives of a clinic." Heinz Ebner tried to simplify the investment issue despite all the demands: Like anywhere else, one has to balance the aspects of how much is spent on the machine and how much on well-being. You need the courage to state that less floor space is acceptable if it results in a little more well-being.

All of this can succeed if sufficient time and commitment are given to discussing the vision and benefits of the design of a hospital before the actual planning begins. To Heinz Ebner, such discussions must be held and brought into a constructive process — and arguments are allowed! "It must be ensured that there are reflection processes, that people take time; there must be resources for that." At the end of the event, Michael Kerbler summarized what had been said: There needs to be more more discussion, more reflection — some kind of joint participation model at the beginning of a project. Richard Klinger agreed: "There needs to be more discussion in advance of the planning process." And Sylvia Hartl emphasized that one must finally acknowledge the hospital as an organism that is capable of learning, otherwise it will miss the chance of adapting its existing structures and facilities to new challenges.

This article was originally published as "Healing Architecture – von der Maschine zum nachhaltigen Gesundheitsbau" on Austria-Architects. Translation by Bianca Murphy.