The Covert Life of Hospital Architecture

The Covert Life of Hospital Architecture addresses hospital architecture as a set of interlocked, overlapping spatial and social conditions. It identifies ways that planned-for and latent functions of hospital spaces work jointly to produce desired outcomes such as greater patient safety, increased scope for care provider communication and more intelligible corridors.

By advancing space syntax theory and methods, the volume brings together emerging research on hospital environments. Opening with a description of hospital architecture that emphasizes everyday relations, the sequence of chapters takes an unusually comprehensive view that pairs spaces and occupants in hospitals: the patient room and its intervisibility with adjacent spaces, care teams and on-ward support for their work and the intelligibility of public circulation spaces for visitors. The final chapter moves outside the hospital to describe the current healthcare crisis of the global pandemic as it reveals how healthcare institutions must evolve to be adaptable in entirely new ways. Reflective essays by practicing designers follow each chapter, bringing perspectives from professional practice into the discussion.

The Covert Life of Hospital Architecture makes the case that latent dimensions of space as experienced have a surprisingly strong link to measurable outcomes, providing new insights into how to better design hospitals through principles that have been tested empirically. It will become a reference for healthcare planners, designers, architects and administrators, as well as for readers from sociology, psychology and other areas of the social sciences.

Praise for The Covert Life of Hospital Architecture
'a refreshing and relevant look at the evidence base for the design of more humane and effective hospital architecture.'
HERD: Health Environments Research & Design Journal

• Language: English
• Publisher: UCL Press
• Release date: Mar 22, 2022
• ISBN: 9781800080911

Book preview

Chapter 1

The spatial dimension of hospital life

Julie Zook

Within the intense functional concerns of hospital architecture, there lurks a soft and personal dimension. Hospital space is experienced by users who are both positioned socially in roles, such as patient, doctor or nurse, and positioned physically in specific locations within a spatial pattern. This book demonstrates ways that the experiential side of hospital architecture systematically and probabilistically affects outcomes. Specifically, this book presents cases where hospital plans are spatially analysed to reveal underlying patterns of paths and visual fields that impact behaviours and outcomes that are important: namely intensive care unit (ICU) mortality, inpatient provider teamwork and hospital wayfinding.

The authors here are interested in how building spaces organise life activities and how built forms are designed to fortify some activities and relationships and not others. For example, built forms convey expectations that nurses are to restore themselves in the break room, escort patients in the hallways and exchange information with other care providers at the designated team station. But in practice, unexpected spatial behaviours and relationships emerge; nurses track doctors in the hallways, talk with patient companions at the station and don’t take breaks at all. What a building is made for and what it is used for inevitably fail to fully match up. A building’s sanctioned activities are augmented or undermined by informal, emergent ones.¹

Studying hospital architecture compels attention to the complex social and functional life of buildings. Hospitals present a concentrated version of the challenges that prevail more broadly in architectural thought and practice. An expensive architecture that rarely produces artistic innovation, hospital architecture nevertheless struggles to cope with persistent and sometimes paradoxical functional problems, such as providing patient privacy while maintaining visibility or constraining caregiver travel distances while increasing the size and complexity of hospitals. What is more, the design of hospitals touches on the urgent. Going into the hospital is too often a needlessly harmful or fatal event.²

Many rich, industrialised parts of the world are presently in a moment characterised by the imprint of medicine on daily life, a consumerist orientation to health care, access and quality as political issues, looming shortages of healthcare workers and a stratospheric (and climbing) amount of healthcare data that is largely untouched by healthcare architects. These themes are intensified by a global pandemic, escalating climate change and intransigent health inequities. We are challenged to rethink the relationship between society and health, as well as the place of architecture in that relationship.

Architects, for their part, are at long last questioning whether prizing formal novelty has led us too far from professional ideals of social responsibility,³ whether we are ready to seriously challenge exclusionary practices in the profession⁴ and why we have shamefully achieved so little in the face of the climate crisis.⁵ It is from this location, this specific tangle of architecture, society and health, that this book was written.

The spatial dimension

The main insights in this book reveal points of contact between the planned and emergent functions of hospitals, with special attention to the moments where the planned and the emergent collide in such a way that they produce outcomes of greater patient safety, increased scope for care-provider communication and more intelligible corridor systems. These phenomena become apparent through forms of spatial analysis that are tied back to tendencies in human spatial perception and cognition, and they probe the question of how spontaneous activities in space – which can be as minute as catching a colleague’s eye or reading a patient’s facial expression – support the dedicated and planned functions of hospitals. Embedding the user and experience in the measures themselves enables these approaches to sidestep the form-function dichotomy and point in the direction of intentional spatial design.⁶

Social scientists have long recognised the ways that space and society construct and reinforce one another are bound up with how opportunities to use space are afforded to or withheld from individuals and groups.⁷ This volume uses approaches from space syntax,⁸ which takes as its premise that society and space are mutually constructive and extends this premise into methods for understanding the morphology of buildings plans and city street networks. Space syntax elaborates theorisations of the intrinsic association between society and space by defining spaces mainly in terms of their relationships to one another. One purpose of evaluating spatial configuration is to better describe how space-as-reflecting-society has a patterned relationship to behaviour-as-observed. Another use of space syntax that is especially germane to this book is that syntax-based approaches can give designers insights into how what exists now can form a basis for productively imagining what is possible in the future. There is no shortage of books and research articles on how to design healthcare spaces using evidence. However, too many of these sources are missing clear theoretical foundations that both link to useable measures and provide meaningful explanations of how things work. Explanation in healthcare design research is often based on discrete, individual-level experiences, preferences and outcomes related to building features that are already generally understood to be positive: nature views, privacy, paths free of trip hazards and other broadly beneficial things that are, to be clear, well worth striving for. Absent theory that explains more deeply, data can be collected and calculated in controlled ways, and it can be marshalled to persuade building owners and developers to do better by their buildings’ occupants. But this approach to design research runs the risk of too strongly endorsing present conditions, while offering too little with which to transform architecture as a social structure.⁹

Space syntax methods often address the relational properties of the spaces represented in floorplans. In many cases, space syntax measures have predicted human spatial behaviour, with a fairly consistent capacity for relational spatial measures to predict how densities of people are distributed throughout built space. Space syntax is good at revealing how copresence is spatialised.¹⁰ Space syntax can make visible how, under the banner of function or architectural type, profoundly social and affective dimensions of space are quietly installed and enshrined, creating a covert life that arises from ways that floorplan layouts give rise to patterns of visibility, encounter and awareness. This focus on deep, non-obvious and sociologically inflected dimensions of architecture means that space syntax can act as a representational language for insights on how architecture structures social life.¹¹

Research, hospitals and architecture

David Theodore describes mid-century architectural research on hospitals in the United Kingdom as modelled on how medicine as a profession integrated scientific research.¹² The Nuffield Provincial Hospitals Trust Studies in the Functions and Design of Hospitals investigated design using rational and empirical methods through the 1950s.¹³ Two decades later, the Yale Studies in Hospital Function and Design undertook a similar task. As their titles suggest, both studies were premised on the importance of establishing a science that identified associations between function and design, with the aim of developing standards for hospital. Both responded to glaring deficits in the post-World-War-II hospital stock. John Thompson and Grace Goldin, of the Yale study, note that what became apparent post-war was that ‘the architects did not know how to build hospitals’.¹⁴ They were referring to things like a prevalence of two-foot-wide doors that would make evacuation of bedbound patients impossible in case of fire.

Both studies are remarkable for the range of topics they cover. In Nuffield, these included studies of departments, of caseloads as related to population and of the physical environment, from ventilation to noise and to colour, among other things. Sensibilities and measures from the Nuffield approaches remain with contemporary architectural practice, including the measure square feet per patient bed, nurse-to-patient-to-space ratios and the application of time-motion study techniques to nurse work. Yale, similarly, made broad studies, which included privacy, health-promoting environments, staff supervision and layout efficiency. Regarding layout efficiency, the authors employed the Yale Traffic Index, which aimed at minimising nurse walking distance based on a generalised model of trip frequency and trip length in inpatient units (this study is revisited by Rosica Pachilova and Kerstin Sailer in Chapter 3). Nuffield and Yale call for contemporary hospital design standards through research, with architects as the intended audience of research