COVID Insights, Perspectives 06.23.2020

Healthcare Design: Looking Back, Looking Forward

From our Sao Paulo studio, Lara Kaiser reflects on the role of observation in design-thinking.

As we collectively seek to apply solution-based expertise to challenges surfacing from the COVID-19 pandemic, I am reminded of history’s role in design education and application. Historical reference grounds both our continued observation of human interaction with space and our creative process—and it is playing a significant role in the transformation of healing and wellness institutions as we continue to shift, on a global scale, in response to our current crisis.

The history of hospitals and the evolution of health facilities are rooted in social, economic, scientific, and technological factors. In the Middle Ages, for example, hospitals were unsanitary and had high mortality rates. Priority was placed not on the patient, but on isolating unwell individuals from the healthy population. These environments had very little natural lighting, and ventilation was almost non-existent. The heating systems, which functioned on wood or coal, resulted in poor air quality.

Patient well-being was far from the design goal.

It was not until the end of the 18th century that healthcare environments became human-centric. Heavily criticized as overcrowded spaces, with data showing mortality rates up to 90%, hospitals began looking to design for solutions. History has revealed the transformational impact one individual can bear on a system; In this case, Florence Nightingale revolutionized healthcare globally based on her observation of the direct relationship between facilities and patient conditions.

Left: Florence Nightingale; Right: Hospital Lariboisiére inspired Nightingale's exploration of the relationship between design and patient recovery.
Image (Right) courtesy Wikimedia Commons

When visiting Hospital Lariboisiére, in 1853, Nightingale made a connection between the hospital’s adequate lighting and ventilation and its low patient mortality rate. During the Crimean War (1854-1856), Nightingale also noted improvements in patients who were empowered to write and post letters, giving them direct communication with loved ones. Further, she created administrative systems that improved hygiene by designating space for laundry care.

Nightingale captured her observations and knowledge in notes, reports, and publications. Notes on Hospitals (1863) outlines the Environmental Nursing Theory (ENT), her recommendations for hospital construction and renovation that argues for the relationship between the built environment and human condition. She emphasized design’s role in both the recovery and health decline of patients.

Through narrative and drawing, Nightingale illustrates the relationship between the environment and the efficacy of therapeutic treatment. Designs known as the Nightingale Pavilion and the Nightingale Nursing Wards addressed design elements such as:

  • Distancing between beds
  • Air renovation (ventilation)
  • Natural lighting
  • Bed-to-window relationship
  • Bathroom and lavatory placement
  • Nursing station and operation room placement
Nightingale’s Nursing Wards
Image courtesy of European Healthcare Design
Nightingale’s Pavilion Model
Image courtesy of Notes on Hospitals by Florence Nightingale

COVID Response and Field Hospitals

The novel coronavirus pandemic created a global public calamity, generating a need for the quickest and most efficient action possible in the health sector. Most health systems were not prepared for the sudden patient surge. In response, field hospitals were built in many areas and in large scale to help support the immense increase in patients.

The first field hospital dedicated to COVID-19 infected patients was built in China in only 10 days. In São Paulo, Brazil, there are units in stadiums and parks. Private hospitals are also being adapted to amplify the capacity. These public field hospitals have the following characteristics in common:

  • Metallic structure (quick construction, light, and economical)
  • Pods and prefabricated structures (quick construction of areas such as bathrooms, nursing stations, and consulting rooms)
  • Melamine and vinyl (easy to install and clean)
Field Hospitals in Wuhan, China (Left) and Pacaembu Stadium, in São Paulo (Right).
Images courtesy of Global Construction Review (Left) and Istoe Magazine (Right)
A field hospital in China references a Nightingalean model.
Image courtesy of ArchDaily

Field hospitals built globally have another thing in common: the resemblance with the Nightingalean models created in the 19th century. We are seeing a return to pavilion planning where spaces are divided into wards with dedicated nursing stations and support areas.

Perspectives for the Future

While we carry Nightingalean principals forward in modern healthcare, we also continue to create transformational designs that move the practice forward. Prior to COVID-19, we saw a growing trend toward flexible, resilient healthcare buildings; the pandemic naturally accelerated this. Hospital Geral, in São Paulo, offers elements that facilitate a quick crisis response in a pandemic such as this one. The hospital was designed with one surgical center per floor which supports germ isolation, allows for quick emergency procedures, and reduces risk of contamination by shortening the path from operating room to patient beds. Specification of convertible beds also allows for immediate care as well as supporting flexible ICU capacity.

Designers are avid observers of the human experience. We research, we discover, and we respond. From idea to implementation, our design goals focus on humanistic, holistic solutions that positively affect people’s lives. Our response to COVID-19 requires us to dig deeper, explore wider, and be bolder. As we re-imagine healthcare spaces to meet unprecedented needs, we will reference what we’ve learned from the past as well as find new solutions that strengthen the interconnection of people and the places that support them.

Hospital Geral designed by our Sao Paulo studio has a dedicated surgical center