May2023

HUMAN-CENTRED THERAPEUTIC ENVIRONMENTS:
A NEW FRAMEWORK FOR BIOPHILIC DESIGN
Thesis Submitted in Accordance with the Requirements of the University of Liverpool

for the Degree of Doctor in Philosophy
By:
Bekir Huseyin TEKIN, B.Arch., M.Arch.
School of Architecture, University of Liverpool, UK

2023
ABSTRACT
The emergence of biophilic design as a discipline refers to the innate human connection
to nature and natural processes to promote health and well-being in the spaces we inhabit.
The principles that define biophilic design can be examined from three different
perspectives: as established in building regulations and standards, as used in design
practice and as investigated in research practice. When examining each of these areas, we
can find several issues and disconnections. In practice and regulatory frameworks, we can
observe the use of an unbounded design framework that is not underpinned by scientific
facts, do not prioritise principles or parameters, and even considers as a design intervention
the use of disparate evocations of nature that do not hold a meaningful sustained
connection. In scientific academic environments, there is abundant research on many of
the different aspects of biophilic design, but all of this in-depth research providing scientific
facts about the importance of nature on humans has happened separately or for a specific
design parameter, and not in a holistic way. Current biophilic design frameworks fail to
provide efficient guidance, as their design recommendations do not differentiate the level
of value of each design parameter for each building programme and context. My position is
that a biophilic design framework can only be efficient if it is adapted to specific building
functions and is geographically and culturally contextualised.
Likewise, the evolution of therapeutic architecture has mostly focused on managerial
priorities (mass health working like a machine) and neglected the users' concerns. There is
increasing research corroborating that the qualities of the setting in which a patient
receives healthcare positively influence health outcomes. Therefore, it has become
progressively important to review the concept of therapeutic environments, as places
where users are supported in psychological, emotional and social terms. This quest for the
optimal healing environment brings to the forefront the need to include other parameters
in our design briefs, where the application of biophilic design proves to be paramount, as
exposure to nature is associated with multiple health benefits.
This study assessed the application of biophilic design in therapeutic environments in
the UK and provided a revised conceptual framework that can more efficiently guide
designers and policy in future interventions. This framework was informed by synthesised
analyses from the user’s experiences, and the data obtained from semi-structured
interviews with architects and managers, which was then benchmarked against scientific
data about the impact of biophilic design on humans. This comprehensive approach helped
to identify and rank those biophilic design parameters that appear the most critical for
promoting and supporting health and wellbeing in healthcare settings and provided an up-
to-date compilation of crucial design actions to enact the necessary change in future design
practice.
Keywords: Biophilia Theory, Biophilic Design, Therapeutic Environment, Healthcare Design,
Human-centred Design, Systematic Review, Meta-synthesis
I
DEDICATION
To my beloved parents
For supporting me with great patience to reach my goals over the years
Firdevs and Hüsnü Tekin
II
DECLARATION
I certify that this thesis constitutes my own work/investigation, except where otherwise
stated; other sources are acknowledged by explicit references.
I declare that this thesis describes original work that has not previously been presented
for the award of any other degree of any institution.
Signed: Bekir Huseyin Tekin
Date: 05.05.2023
III
ACKNOWLEDGEMENTS
I would like to express my sincere gratitude to my supervisor, Dr Rosa Urbano Gutiérrez, for her
guidance, inspiring suggestions and contributions from the very beginning of this journey. I would
not have been able to finish this thesis without her knowledge, patience, motivation in my research.
I am thankful and lucky to be supervised by her throughout my research and writing of this thesis, as
she is a supervisor everyone would wish to have.
I would also like to thank my secondary supervisor, Professor Rhiannon Corcoran, for her great
help, encouragement and insightful comments with her immense knowledge in all critical moments
whenever I needed a wise help.
I shall give my great respect to Professor Steve Sharples, who was my second supervisor in my
first year. Although it was a short period of times, his advice with his wealth of experience
contributed my research path. I also extend my thanks to Professor Carl Hopkins and Dr Pyoung-Jik
Lee who reviewed my progress in all Annual Progress Reviews as external eyes.
My sincere thanks also go to Dr Evangelia Chrysikou and Dr Haniyeh Mohammadpourkarbasi for

agreeing to examine my research and for taking the time to review this thesis.
Furthermore, I profoundly thank to Ivan Harbour (Rogers Stirk Harbour + Partners), Piers Gough
(CZWG), Darron Haylock (Foster + Parners), Lucy Brittain (Cullinan Studio), Eoin O’Dwyer (A_LA), and
Lesley Howells (Maggie’s Centre Research Lead) for dedicating their time and attention to my
research.
I should also thank to my financial sponsor, Turkish Ministry of National Education. A PhD in the
University of Liverpool would not be more than a dream If I was not awarded with this scholarship.
I would like to express my appreciation to my colleagues and friends at the University of

Liverpool for their support, technical assistances and constructive criticisms. Although COVID-19
pandemic separated us very long time we managed to help and support each other. Moreover, I
extend my thanks to my neighbours and my community outside the university who were always
there to share my time in Liverpool.
Finally, a special thanks to my parents and my sisters, for their support, understanding and
encouragement in all aspects of my life. Their patience is much appreciated. My gratitude can never
be enough.
IV
TABLE OF CONTENTS
ABSTRACT.................................................................................................................................. I
DEDICATION ............................................................................................................................. II
DECLARATION ......................................................................................................................... III
ACKNOWLEDGEMENTS ........................................................................................................... IV
TABLE OF CONTENTS................................................................................................................ V
LIST OF TABLES ......................................................................................................................... X
LIST OF FIGURES ..................................................................................................................... XII
LIST OF ABBREVIATIONS AND SYMBOLS ............................................................................... XVI
CHAPTER 1 ............................................................................................................................... 1
1. INTRODUCTION ................................................................................................................ 2
1.1. Research Problem .................................................................................................... 5
1.2. Research Aim, Question and Objectives .................................................................. 7
1.3. General Methodology .............................................................................................. 8
1.4. Outline of Thesis .................................................................................................... 10
CHAPTER 2 ............................................................................................................................. 12
2. BIOPHILIA AND BIOPHILIC DESIGN: RESEARCH, PRACTICE, AND STANDARDS .............. 13
2.1. Biophilic Design ...................................................................................................... 14
2.1.1. Research: Benefits of Connecting with Nature .............................................. 16
2.1.1.1. Light ........................................................................................................ 19
2.1.1.2. Greenery ................................................................................................ 22
2.1.1.3. Water ..................................................................................................... 23
2.1.1.4. Fresh Air and Natural Ventilation .......................................................... 23
2.1.1.5. Thermal Comfort and Variability............................................................ 24
2.1.1.6. Natural Materials ................................................................................... 24
2.1.1.7. Colour ..................................................................................................... 25
2.1.1.8. Experiences of Nature ............................................................................ 26
2.1.2. Current State of Biophilic Design Practice ..................................................... 27
2.1.3. Standards ....................................................................................................... 35
2.2. Concluding Remarks............................................................................................... 37
CHAPTER 3 ............................................................................................................................. 39
3. HEALING ENVIRONMENT ............................................................................................... 40
3.1. Environment and Healthcare: Examples of Connection with Nature from History
40
V
3.2. Other Relevant Theories and Approaches of Therapeutic Environment............... 45
3.2.1. Stress Recovery Theory (SRT)......................................................................... 45
3.2.2. Attention Restoration Theory ........................................................................ 46
3.2.3. Supportive Design Theory .............................................................................. 46
3.2.4. Therapeutic Environment Theory .................................................................. 47
3.2.5. Evidence-Based Design (EBD) Approach ........................................................ 47
3.2.6. Salutogenic Approach .................................................................................... 48
3.2.7. Psychosocially-Supportive Design (PSD) ........................................................ 49
3.2.8. Superarchitecture Approach .......................................................................... 49
3.2.9. Sense-Sensitive Design................................................................................... 50
3.3. Clinical and Non-Clinical Healing Environment ...................................................... 50
3.3.1. Building Codes and Standards for Healthcare Settings in the UK .................. 50
3.3.2. Clinical Therapeutic Environments ................................................................ 53
3.3.3. Non-Clinical Environment: Maggie’s Centres Case ........................................ 59
3.3.3.1. Maggie's Architecture and Landscape Brief........................................... 60
3.3.3.2. Existing Centres and architectural features ........................................... 62
3.4. Cancer: Statistics, Effects, Problems and Approaches ........................................... 73
3.5. Concluding Remarks............................................................................................... 76
CHAPTER 4 ............................................................................................................................. 78
4. ASSESSMENT OF BIOPHILIC DESIGN PARAMETERS IN THERAPEUTIC ENVIRONMENTS
WITH A SYSTEMATICALLY SEARCHED REVIEW....................................................................... 79
4.1. Systematic Review Methodology ........................................................................... 79
4.2. The Review Question ............................................................................................. 81
4.3. Search Strategy, Inclusion and Exclusion Criteria .................................................. 82
4.4. Screening and Selection ......................................................................................... 88
4.5. Data Extraction and Analysis of the Selected Studies............................................ 89
4.5.1. Study 1: Cancer Patients’ Recommendations for Nature-Based Design and
Engagement in Oncology Contexts: Qualitative Research............................................. 91
4.5.2. Study 2: The experiences of cancer patients within the material hospital
environment: Three ways that materiality is affective .................................................. 97
4.5.3. Study 3: Nature-based care opportunities and barriers in oncology contexts:
a modified international e-Delphi survey .................................................................... 102
4.5.4. Study 4: Inadequacy and impact of facility design for adolescents and young
adults with cancer ........................................................................................................ 108
4.5.5. Study 5: Perceived Importance of Wellness Features at a Cancer Center:
Patient and Staff Perspectives ..................................................................................... 111
4.5.6. Study 6: Multi-sensory, Nature-Inspired Recharge Rooms Yield Short-Term
Reductions in Perceived Stress Among Frontline Healthcare Workers ....................... 117
VI
4.5.7. Study 7: Restorative Design Features for Hospital Staff Break Areas: A Multi-
Method Study .............................................................................................................. 119
4.5.8. Study 8: Biophilia and Salutogenesis as restorative design approaches in
healthcare architecture ............................................................................................... 125
4.5.9. Study 9: Healthcare Settings ........................................................................ 130
4.6. Quality Assessment .............................................................................................. 131
4.7. Synthesis of the Biophilic Design Parameters...................................................... 133
4.7.1. The Prominent Biophilic Design Parameters in Clinics for Patient-Based
Perspective ................................................................................................................... 134
4.7.1.1. Preferred Clinical Environment for Outpatient Cases.......................... 135
4.7.1.2. Preferred Clinical Environment for Inpatient Cases............................. 137
4.7.2. Biophilic Design Parameters in Clinics for Staff-Based Perspective ............. 138
4.8. Concluding Remarks............................................................................................. 140
CHAPTER 5 ........................................................................................................................... 142
5. A META-SYNTHESIS: ANALYSING PRIMARY DATA FROM EXISTING RESEARCH ON
MAGGIE’S CENTRES ............................................................................................................. 143
5.1. Search Strategy and Screening ............................................................................ 143
5.2. Data extraction and Analysis................................................................................ 146
5.2.1. General Overview of the Analysed Documents ........................................... 148
5.2.2. Analysis of the Codes and their Interrelations............................................. 153
5.2.3. Interventional Codes and Their Outcomes .................................................. 157
5.2.3.1. Architectural Form, Layout and Furnishing.......................................... 157
5.2.3.2. Light- Daylight ...................................................................................... 164
5.2.3.3. Greenery- Plants .................................................................................. 167
5.2.3.4. Sensory Experiences............................................................................. 170
5.2.3.5. Materials .............................................................................................. 178
5.2.3.6. Colour ................................................................................................... 182
5.2.3.7. Bringing the Outside to the Inside ....................................................... 183
5.2.3.8. Spaciousness ........................................................................................ 185
5.2.3.9. Air ......................................................................................................... 186
5.2.3.10. Seasonal Changes ................................................................................. 188
5.2.3.11. Thermal Comfort .................................................................................. 190
5.2.3.12. Water ................................................................................................... 191
5.2.3.13. Fire ....................................................................................................... 192
5.2.4. Interaction Between Outcome Codes .......................................................... 193
5.2.4.1. Welcoming Place- Feel Relax ............................................................... 195
5.2.4.2. Personal Past – Sense of Belonging ..................................................... 198
VII
5.2.4.3. Refuge- Feeling Safe ............................................................................. 199
5.2.4.4. View- Prospect ..................................................................................... 201
5.2.4.5. Socialising ............................................................................................. 203
5.2.4.6. Curiosity ............................................................................................... 204
5.2.4.7. Perception by Gender .......................................................................... 205
5.3. Summary of Findings............................................................................................ 206
CHAPTER 6 ........................................................................................................................... 211
6. EXPERIENCE AND PRACTICE OF THERAPEUTIC ENVIRONMENTS ................................ 212
6.1. Semi-Structured Interview Methodology ............................................................ 212
6.2. Non-Clinical Therapeutic Environment Design in Practice: Maggie’s Centres
Example ............................................................................................................................ 214
6.2.1. Design Process and Decisions ...................................................................... 214
6.2.1.1. Approach to Maggie’s Architecture and Landscape Brief.................... 214
6.2.1.2. Preparation to Design .......................................................................... 215
6.2.1.3. Communication with the Client ........................................................... 217
6.2.1.4. Setting up Design Drivers ..................................................................... 218
6.2.1.5. Working with Consultants and Experts ................................................ 219
6.2.1.6. Budget .................................................................................................. 220
6.2.1.7. Site Decisions ....................................................................................... 220
6.2.1.8. Male-Friendly Approach....................................................................... 223
6.2.2. Biophilic Design Parameters ........................................................................ 223
6.2.2.1. Greenery-Landscape ............................................................................ 224
6.2.2.2. Natural Material ................................................................................... 226
6.2.2.3. Views .................................................................................................... 229
6.2.2.4. Light ...................................................................................................... 231
6.2.2.5. Colour ................................................................................................... 232
6.2.2.6. Inside-Outside Effect ............................................................................ 233
6.2.2.7. Multisensory Environment................................................................... 235
6.2.2.8. Thermal Comfort .................................................................................. 235
6.2.2.9. Welcoming Relaxing ............................................................................. 236
6.2.2.10. Prospect ............................................................................................... 238
6.2.2.11. Refuge- Feeling Safe ............................................................................. 239
6.2.2.12. Privacy .................................................................................................. 240
6.2.3. The Designs Problems .................................................................................. 242
6.3. Recommendations for Clinical Therapeutic Environment Design ....................... 243
VIII
CHAPTER 7 ........................................................................................................................... 251
7. DISCUSSION OF THE FINDINGS: BIOPHILIC DESIGN GUIDELINES FOR THERAPEUTIC
ENVIRONMENTS................................................................................................................... 252
7.1. Decision-Making and Design Process................................................................... 256
7.2. General Biophilic Design Recommendations to Create Therapeutic Environments
257
7.3. Designing Non-Clinical Settings for Cancer .......................................................... 260
7.3.1. Building Form and Layout ............................................................................ 261
7.3.2. Entrance ....................................................................................................... 262
7.3.3. Rest Rooms and Private Areas ..................................................................... 262
7.3.4. Common Spaces ........................................................................................... 263
7.3.5. Consultation Rooms ..................................................................................... 265
7.3.6. Outdoor Settings .......................................................................................... 265
7.3.7. Designing from a Staff-Centred Perspective ................................................ 266
CHAPTER 8 ........................................................................................................................... 268
8. CONCLUSION ................................................................................................................ 269
8.1. Limitations of the Research ................................................................................. 274
8.2. Opportunities for Future Work ............................................................................ 275
REFERENCES ......................................................................................................................... 278
Appendix .............................................................................................................................. 306
IX
LIST OF TABLES
Table 1-1: Detected problems in biophilic design practice, regulations and research............ 6
Table 2-1: Elements and Attributes of Biophilic Design (Kellert, 2008)................................. 28
Table 2-2: Experiences and Attributes of Biophilic Design (Kellert and Calabrese, 2015)..... 29
Table 2-3: 14 patterns of biophilic design (Browning et al., 2014). ....................................... 31
Table 2-4: Design Recommendations from 14 Patterns of Biophilic Design (W. Browning et
al., 2014). ............................................................................................................................... 31
Table 3-1: General spatial requirements in Maggie's Architecture and Landscape Brief
(Maggie’s Keswick Jencks Cancer Trust, 2015) ...................................................................... 61
Table 3-2: Operating Maggie’s Centres (September, 2022) (maggies.org). .......................... 63
Table 3-3: Common well-being problems of patients with cancer. ...................................... 74
Table 4-1: Differences in a review process between systematic and narrative reviews
(Boland et al., 2017). .............................................................................................................. 81
Table 4-2: Keyword plan. ....................................................................................................... 83
Table 4-3: Inclusion and exclusion criteria............................................................................. 84
Table 4-4: Searching results (22.09.2020). ............................................................................ 86
Table 4-5: Searching results (26.09.2021). ............................................................................ 87
Table 4-6: General overview of the included studies. ........................................................... 90
Table 4-7: Background information of the included studies. ................................................ 91
Table 4-8: Cancer Patients’ Nature-Related Recommendations and Cautionary Advice
(Revised version based on number of informants for each statement). ............................... 92
Table 4-9: References to biophilic design parameters. ......................................................... 94
Table 4-10: Highest-ranked opportunity items as expressed by experts, and identified direct
references to biophilic design parameters (Ranking and Item descriptions were quoted from
Blaschke et al., (2017))......................................................................................................... 104
Table 4-11: Ranking of biophilic design parameter groups based on analysis of the
opportunities. ...................................................................................................................... 105
Table 4-12: Highest-ranked barrier items by experts (Blaschke et al., 2017). ..................... 106
Table 4-13: Adequacy of the built environment (Peditto et al., 2020). ............................... 109
Table 4-14: The environmental characteristics that had direct or indirect references to the
biophilic design parameters. ................................................................................................ 110
Table 4-15: Building features ranked by patients according to outcome (Tinner et al., 2018).
............................................................................................................................................. 112
Table 4-16: Building Features Ranked by Staff According to Outcome (Tinner et al., 2018).
............................................................................................................................................. 114
Table 4-17: Patient and Staff Mean Building Feature Rankings. (Note. 1 = strongly disagree,
2 = disagree, 3 = neutral, 4 = agree, and 5 = strongly agree. Bold values are statistically
significant (p < .05) (Tinner et al., 2018). ............................................................................. 115
Table 4-18: Ranking of biophilic design parameters for staff and patients. ........................ 116
Table 4-19: The restorative impact of biophilic patterns on the four types of human
resources (Abdelaal & Soebarto, 2019). .............................................................................. 126
Table 4-20: The quality assessment of selected studies. ..................................................... 132
Table 4-21: Important biophilic design parameters for outpatient environments in the
studies. ................................................................................................................................. 135
Table 4-22: Important biophilic design parameters for outpatients in clinical settings based
on synthesis results. ............................................................................................................. 136
X
Table 4-23: Important biophilic design parameters for inpatient environments in the
studies. ................................................................................................................................. 137
Table 4-24: Important biophilic design parameters for inpatients in clinical settings based on
synthesis results. .................................................................................................................. 138
Table 4-25: Important biophilic design parameters for staff in the studies. ....................... 139
Table 4-26: Important biophilic design parameters for staff in clinical settings based on
synthesis results. .................................................................................................................. 140
Table 5-1: The search record of databases and the number of results. .............................. 144
Table 5-2: The Interventional and Outcome code groups. .................................................. 146
Table 5-3: Included documents for analysis. ....................................................................... 151
Table 5-4: Number of references in all documents for each code. ..................................... 153
Table 8-1: Comparison of the existing biophilic design frameworks and the new conceptual
framework............................................................................................................................ 271
XI
LIST OF FIGURES
Figure 1-1: Methodological process....................................................................................... 10
Figure 2-1: Decision Timeline for Biophilic Design Implementation (W. D. Browning & Ryan,
2020). ..................................................................................................................................... 34
Figure 2-2: Summary of LBC criteria (International Living Future Institute, 2019)................ 36
Figure 3-1: General current state of the modern hospitals [source: a, b, c, h)
https://commons.wikimedia.org,d) https://thehospitallocation.co.uk,e)
www.anticancermom.com, f) https://www.imperial.nhs.uk, g) https://www.reddit.com, i)
https://scrubsmag.com, j) https://www.cahcare.com]. ........................................................ 54
Figure 3-2: Circle Bath Hospital (©Foster+Partners). ............................................................ 56
Figure 3-3: Cancer Centre at Guy’s Hospital (©RSHP). .......................................................... 57
Figure 3-4: Alder Hey Children's Hospital (©BDP). ................................................................ 58
Figure 3-5: Walton Life Room, Liverpool, UK. ........................................................................ 60
Figure 3-6: Maggie’s Forth Valley (©Garber & James). ......................................................... 67
Figure 3-7: Maggie’s Manchester (©Foster+Partners). ......................................................... 68
Figure 3-8: Maggie’s Newcastle (©Cullinan Studio). ............................................................. 69
Figure 3-9: Maggie’s Nottingham (©CZWG Architects). ....................................................... 70
Figure 3-10: Maggie’s Southampton (©AL_A)....................................................................... 71
Figure 3-11: Maggie’s West London (©RSHP). 72
Figure 4-1: Identification of included articles in the systematically searched review. .......... 89
Figure 4-2: Interrelation between the recommendations’ titles and biophilic design
parameters. ............................................................................................................................ 93
Figure 4-3 References to the biophilic design parameters in the recommendations. .......... 95
Figure 4-4: Features that increase patient confidence in quality of care—% (Tinner et al.,
2018). ................................................................................................................................... 112
Figure 4-5: Patient infusion area treatment space preference—% (Tinner et al., 2018). ... 113
Figure 4-6: Patient treatment area preferences comparison (Tinner et al., 2018). (Based on
rating following statements 1 (disagree) to 5 (agree), a) I prefer quiet over social
interaction, b) I prefer privacy over daylight and views of nature.) .................................... 113
Figure 4-7: Patient waiting area preferences, based on ranking the importance 1 (disagree)
to 5 (agree) (Tinner et al., 2018). ......................................................................................... 114
Figure 4-8: Patient and staff building feature ranking results arranged according to
difference (Tinner et al., 2018). ........................................................................................... 115
Figure 4-9: Distributions of perceived stress ratings of healthcare workers before (A) and
after (B) a 15-minute experience in the Recharge Room (Putrino et al., 2020). ................. 118
Figure 4-10: Preferred views from break rooms (Nejati, 2015). .......................................... 122
Figure 4-11: Privacy for existing vs. desired outdoor break spaces. .................................... 122
Figure 4-12: Space configuration for existing vs. desired outdoor break spaces (Nejati,
2015). ................................................................................................................................... 123
Figure 4-13: Amenities for existing vs. desired outdoor break spaces (Nejati, 2015). ........ 123
Figure 4-14: Visual assessment of images (Nejati, 2015). .................................................. 124
Figure 4-15: The correlation between biophilic patterns and attributes and the hospital’s
restorative zones to be used in the framework (Abdelaal & Soebarto, 2019). ................... 128
Figure 4-16: Proposed restorative healthcare environmental design framework (Abdelaal &
Soebarto, 2019). .................................................................................................................. 129
Figure 4-17: Classification of the identified biophilic design parameters in a clinical
environment based on the systematically searched review. .............................................. 134
XII
Figure 5-1 Identification of included articles in the review. ................................................ 145
Figure 5-2: An example of Intervention-Outcome relation. ................................................ 147
Figure 5-3: A sample coding method used in this review was the function of Responses,
References and Codes are illustrated. ................................................................................. 148
Figure 5-4: Classification of the codes. ................................................................................ 155
Figure 5-5: Mind map of the codes (Thickness of arrows illustrates the importance of
connection based on this study. All arrows targeting the same code are represented with
the same colour). ................................................................................................................. 156
Figure 5-6: Entrance on Maggie’s Southampton Plan (Image Copyright AL_A). ................. 158
Figure 5-7: a) Maggie’s Southampton Entrance (© AL_A), b) Maggie’s Dundee Entrance (©
Courtesy of Gehry Partners, LLP). ........................................................................................ 158
Figure 5-8: a) Maggie’s Edinburgh (© Richard Murphy Architects), b) Maggie’s Cheltenham
Entrance (© MJP Architects)................................................................................................ 158
Figure 5-9: a) Maggie’s Highlands architectural form design (© Page & Park Architects), b)
Kurokawa’s sketch of Maggie’s South West Wales (© Kisho Kurokawa Architect &
Associates). .......................................................................................................................... 159
Figure 5-10: Maggie’s Oldham open plan layout (© dRMM). ............................................. 160
Figure 5-11: a) Maggie’s London, visual contact between floors (© RSHP), b) Maggie’s
Edinburgh half-landings (© maggies.org). ........................................................................... 161
Figure 5-12: a) Maggie’s Manchester kitchen (© Foster+Partners), b) Maggie’s Oldham
kitchen.................................................................................................................................. 162
Figure 5-13: a) The screen in Maggie's West London (©Angela Butterfield), b) Maggie’s
West London (© RSHP). ....................................................................................................... 162
Figure 5-14: a) Maggie’s Southampton furnished room with operable windows (© AL_A), b)
Maggie’s West London sliding door (© RSHP)..................................................................... 163
Figure 5-15: References to the Architectural Form, Layout, Furnishing and Fittings, and
interrelation with the other codes referred together. ........................................................ 164
Figure 5-16: Natural lighting examples from Maggie’s Centres a) Maggie’s Southampton, b)
Maggie’s Oldham, c) Maggie’s South West Wales, d) Maggie’s Gartnavel, e) Maggie’s
Manchester, f) Maggie’s Southampton, g) Maggie’s South West Wales, h) Maggie’s
Gartnavel, i) Maggies’s Cardiff. ............................................................................................ 166
Figure 5-17: Natural lighting examples from Maggie’s Centres a) Maggie’s Southampton(©
AL_A), b) Maggie’s Oldham, c) Maggie’s South West Wales (© Garbers & James), d)
Maggie’s Gartnavel (© OMA), e) Maggie’s Manchester (© Foster+Partners), f) Maggie’s
Southampton(© AL_A), g) Maggie’s South West Wales (© Garbers & James), h) Maggie’s
Gartnavel (© OMA), i) Maggies’s Cardiff (© Dow Jones Architects). .................................. 167
Figure 5-18: a) Indoor garden Maggie’s West London (© RSHP), b) Indoor garden Maggie’s
Manchester (© Foster+Partners)......................................................................................... 167
Figure 5-19: Buffer zones surrounding Maggie’s Dundee. .................................................. 169
Figure 5-20: References to Greenery-Plants, and interrelation with the other codes referred
together. .............................................................................................................................. 170
Figure 5-21: References to all sensory experiences, and interrelation with the other codes
referred together. ................................................................................................................ 171
Figure 5-22: References to Olfactory Experience, and interrelation with the other codes
Figure 5-23: The water pool in Maggie’s Cheltenham (©Angela Butterfield). .................... 173
Figure 5-24: References to Auditory Experience, and interrelation with the other codes
XIII
Figure 5-25: a) Maggie’s Manchester (© Foster+Partners), b) Maggie’s Oldham. ............. 175
Figure 5-26: References to Tactile Experience, and interrelation with the other codes
Figure 5-27: References to Multi-Sensory Experience, and interrelation with the other codes
Figure 5-28: a) Maggie’s Highlands (© Page & Park Architects), b) Maggie’s Manchester (©
Foster+Partners). ................................................................................................................. 179
Figure 5-29: Maggie’s Newcastle (© Cullinan Studio). ........................................................ 180
Figure 5-30: Maggie’s Dundee timber ceiling (© Courtesy of Gehry Partners, LLP). .......... 181
Figure 5-31: Maggie’s South West Wales with the glass rim on the ceiling (©Garber &
James). ................................................................................................................................. 181
Figure 5-32: References to Material, and interrelation with the other codes referred
together. .............................................................................................................................. 181
Figure 5-33: References to Colour, and interrelation with the other codes referred together.
............................................................................................................................................. 183
Figure 5-34: a) Maggie’s Gartnavel (© OMA), b) Maggie’s Fife (© Werner Huthmacher).. 184
Figure 5-35: References to the Bringing Outside to Inside, Furnishing and Fittings, and
interrelation with the other codes referred together. ........................................................ 185
Figure 5-36: Maggie’s Highlands section (© Page & Park Architects). ................................ 186
Figure 5-37: Maggie’s Highlands section. ............................................................................ 186
Figure 5-38: References to the Air, and interrelation with the other codes referred together.
............................................................................................................................................. 188
Figure 5-39: Maggie’s Dundee (© Courtesy of Gehry Partners, LLP). ................................. 189
Figure 5-40: References to Seasonal Changes, and interrelation with the other codes
Figure 5-41: References to Thermal Comfort, and interrelation with the other codes
Figure 5-42: References to the Water, and interrelation with the other codes referred
together. .............................................................................................................................. 192
Figure 5-43: Fireplace a) Maggie’s Manchester (© Foster+Partners), b) Maggie’s Cardiff (©
Dow Jones Architects). ......................................................................................................... 193
Figure 5-44: References to Fire, and interrelation with the other codes referred together.
............................................................................................................................................. 193
Figure 5-45: Interrelation of Outcome codes (Thickness of arrows illustrates the importance
of connection based on this study. All arrows targeting the same code are represented with
the same colour). ................................................................................................................. 194
Figure 5-46: References to the Welcoming-Relaxing spaces, and interrelation with the other
codes referred together. ...................................................................................................... 198
Figure 5-47: References to Personal Past-Sense of Belonging, and interrelation with the
other codes referred together. ............................................................................................ 199
Figure 5-48: References to Refuge-Feeling Safe, and interrelation with the other codes
Figure 5-49: References to View-Prospect, and interrelation with the other codes referred
together. .............................................................................................................................. 203
Figure 5-50: References to Socialising, and interrelation with the other codes referred
together. .............................................................................................................................. 203
Figure 5-51: References to Curiosity, and interrelation with the other codes referred
together. .............................................................................................................................. 205
XIV
Figure 5-52: References to Perception by Gender, and interrelation with the other codes
Figure 5-53: Ranking of the codes by number of comments. This figure also shows
importance levels of biophilic design parameters (*Although Air should be in the third
group based on the results, it is considered 1st level based on the limitation explained in
5.2.3.9) ................................................................................................................................. 209
Figure 6-1: Lowering the ground level of the site in Maggie’s Southampton (©AL_A). ..... 221
Figure 6-2: The glass house (© Nigel Young / Foster + Partners). ....................................... 224
Figure 6-3: Maggie’s Nottingham (©CZWG Architects). ..................................................... 226
Figure 6-4: Timber structure in Maggie’s Manchester (© Nigel Young / Foster + Partners).
............................................................................................................................................. 226
Figure 6-5: Maggie’s Southampton a) the reflective stainless-steel surface behind the
ceramic wall, b) polished concrete floor (©AL_A)............................................................... 228
Figure 6-6: Maggie’s Southampton a) expending nature perception with stainless steel, b)
big windows (©AL_A). ......................................................................................................... 229
Figure 6-7: Maggie’s Forth Valley (© Keith Hunter). ........................................................... 230
Figure 6-8: a) Georgian house, Liverpool, b) Maggie’s Nottingham (© Maggies.org). ....... 232
Figure 6-9: a) Maggie’s West London (© RSHP), b) Ceramic wall in Maggie’s Southampton
(© A_LA)............................................................................................................................... 233
Figure 6-10: Maggie’s Southampton visual connection through the ceramic wall straps (©
A_LA). ................................................................................................................................... 239
Figure 6-11: The Circle Bath inside (© Foster+Partners). .................................................... 244
Figure 6-12: Sketches of design decisions in Guy’s Cancer Centre (©RSHP)....................... 246
Figure 6-13: The villages, shown in the section of Guy’s Cancer Centre (©RSHP). ............. 246
Figure 6-14: Guy’s Cancer Centre (©RSHP). ........................................................................ 247
Figure 6-15: The Catkin Centre and Sunflower House in Alder Hey Children’s Hospital in
Liverpool (© Cullinan Studio)............................................................................................... 249
Figure 7-1: Data compilation map of the biophilic design framework. (Systematically
searched review part is updated) ........................................................................................ 252
Figure 7-2: New conceptual framework for biophilic design in a therapeutic environment.
............................................................................................................................................. 255
XV
LIST OF ABBREVIATIONS AND SYMBOLS
SBS Sick Building Syndrome

SAD Seasonal Affective Disorder
WHO World Health Organization
LBC Living Building Challenge
ADHD Attention Deficit Hyperactivity Disorder
BRE Building Research Establishment
BREEAM Building Research Establishment Environmental Assessment Method
LEED Leadership in Energy and Environmental Design
IWBI International WELL Building Institute
WELL WELL Building Standard
SRT Stress Recovery Theory
ART Attention Restoration Theory
EBD Evidence-based Design
PSD Psychosocially Supportive Design
NPS Net Promoter Score
HVAC Heating, Ventilation, and Air Conditioning
XVI
CHAPTER 1
1
1. INTRODUCTION
The term “biophilia” has been increasingly used in the field of architecture. According to
A Dictionary of Psychology (Colman, 2015), it stands for “love of life and living things” or
“love of or empathy with the natural world”. Biophilia became popular in the 1980s, when
the biophilia hypothesis was presented by Edward O. Wilson, who asserted that “the
tendency of humans to focus on and to affiliate with nature and other life-forms has, in
part, a genetic basis” (E. Wilson, 1984). As corroborated by numerous studies, in today's
world we still very much need to be well-connected to nature for our well-being and health
(Bodin & Hartig, 2003; Dopko et al., 2014; Hartig, 1993; Hartig et al., 1996; R. Kaplan, 1993;
R. Kaplan & Kaplan, 1989; S. Kaplan, 1995; Ulrich, 1983, 1984, 1993; van den Berg et al.,
2003).
While creating protected and controlled environments, we are designing our cities in a
way that is harming our natural environment and moving us away from nature. Even
though there is abundant research and practice prioritising design strategies that minimise
the impact of buildings on natural resources through the development of sustainable
architecture, it does not explicitly focus on reinforcing how to link us back to nature. The
emergence of biophilic design as a discipline, therefore, aims to cover this shortcoming:
biophilic design refers to the innate human connection to nature, and the natural processes
to promote health and well-being in the spaces we inhabit (our built environment).
This is becoming more critical since the research conducted by the United Nations in
2018 confirmed that 55% of the world's population lives in urban areas. Moreover,
according to the United Nations projections, this ratio will reach 68% in 2050 (United
Nations, 2018). Today, the most urbanised regions are North America (82%), Latin America
and the Caribbean (81%), Europe (74%) and Oceania (68%). The level of urbanisation in Asia
is now approaching 50%. In contrast, 43% of the African population lives in cities (United
Nations, 2018). Thus, in our rapidly urbanising and industrialising world, biophilia cannot be
only seen as an aesthetic option but very much a great need for human beings (Allen et al.,
2016). Furthermore, recent surveys show that we spend about 90% of our lives indoors
(Ibid.). This increasing urbanised lifestyle brings some health problems due to the lack of
natural elements in indoor spaces. For instance, Sick Building Syndrome (SBS), Seasonal
Affective Disorder (SAD), or probably the most important one, a shortage of vitamin D,
which is vital for human beings. At least a billion people worldwide are estimated to be
2
vitamin D deficient (Holick, 2008), mainly in the northern hemisphere at latitudes higher
than 40°N, because of inadequate exposure to sunlight (Spiro & Buttriss, 2014).
Thus, the goal of biophilic design in architecture is to promote health and high-quality
wellbeing standards in habitats in which occupants find optimal psychological and
physiological conditions, and their activities can develop emotional support. For instance,
producing hospitals where patients will recover faster, schools where children will be more
successful, offices where employees will be more productive, and housing where people
are better acquainted with their neighbours and families, and live happier (S. Kellert et al.,
2011). This need for a better connection between humans and the natural world has
become a priority because of the rapidly increasing urbanisation of territories, and
migration of the global population towards urban environments.
However, there is a debate on the universality of this innate preference for

green/nature. In light of some research, nature does not have a considerable impact on a
good way on everybody and can affect individuals in different ways. For instance, a study
showed that nature can yield fear, and people respond to nature with varying levels of fear
depending on their gender, sensitivity and lifestyle (van den Berg & ter Heijne, 2005).
Furthermore, another study claims that not everyone actually likes nature due to people
being used to relying on controlled and protected building environments to make us feel
safer from the threat from nature (Bixler & Floyd, 2016). Despite the findings in these
studies, the majority of the health and wellbeing literature demonstrates the importance
and benefits of nature on us, as human beings. More importantly, findings from the
background review in this study showed that this need to connect nature to the design of
our spaces as a major vehicle for delivering high-quality well-being standards it is
paramount in the case of healthcare environments.
Considerations about the quality of the environment in which healthcare is delivered

can be tracked as early as ancient history. In Western culture, healthcare architecture
evolved from the Asclepeions (healing temples) in Ancient Greece (Sternberg, 2009), to the
military infirmaries in use during Roman times, Valetudinariums (Thompson & Goldin,
1975), and the hospitals run by the Church (monasteries) in Medieval and Renaissance
times, which were later operated by town authorities during early Modernity (Verderber &
Fine, 2000). These traditionally developed settings are early examples of biophilic thinking:
they were usually built far from the high temperature, noise, dirt, and dust found in towns,
and they typically offered a good view of nature and nearby freshwater sources. In the
3
18th century, hospitals started to diversify and specialize, producing medical research and
training, and laying the foundations of modern hospital care. The first design principles for
hospital wards developed by Florence Nightingale in her 1863 book Notes on Hospitals,
were a crucial contribution towards establishing sanitation standards, which comprised
considerations related to spatial layout, materials and colour, but most importantly to the
quality of the environment, where natural elements such as daylight, fresh air ventilation,
and heating played a key role (Nightingale, 1863; Verderber & Fine, 2000). From the time of
this publication up to the Second World War, there was little literature on hospital design,
however, soon after the war, the UK government started a proactive initiative for planning
and post-design evaluation of this complex and costly building typology, as part of the new
vision for the modern city (Kenny & Canter, 1979; Stone, 1976). Post-war hospital planning
privileged the building's circulatory systems and mechanisation with the aim of increasing
efficiency in the use of human and technical resources, rationalizing and accelerating the
delivery of clinical care (reducing in-patient lengths of stay to the minimum clinically
necessary, and through increases in day surgery and out-patient treatment) (Hughes, 1997).
Nightingale’s principles were progressively disregarded in this process, which together with
the dramatic growth of urbanization, the advent of the germ theory and rapid changes in
medical technology, led to an environmental approach to healthcare exclusively focused on
healing through medical interventions (Murphy & Mansfield, 2017). From the mid-20th
century to today’s ‘mega hospitals’ (Verderber & Fine, 2000) , ‘mall hospitals’ (Sloane &
Sloane, 2002), or ‘factory-hospitals’ (Jencks, 2017), healthcare environments have focused
on the goals and objectives of the organisation (fast physical recovery, mass health working
like a machine), while neglecting the users (staff, patients) concerns and aspirations, and
with this, their emotional, mental and spiritual health (Abdelaal & Soebarto, 2019; Murphy
& Mansfield, 2017; Silverstein, 2009). This is particularly important for patients who are
diagnosed with cancer and are undergoing treatment, as many studies have confirmed that
they may experience high levels of psychological discomfort, with many experiencing
fatigue, anxiety or depression (Blazer et al., 1994; Guthrie, 1996; Mayou et al., 1991;
McDaniel et al., 1995; Turner & Kelly, 2000; Zabora et al., 1997). There is research evidence
that corroborates that the physical qualities of the setting in which a patient receives
healthcare positively influence health outcomes in those mental disorders (Chrysikou, 2014;
Evans, 2003; Galea et al., 2005; Laursen et al., 2014; T. H. M. Moore et al., 2018; Rao et al.,
2007; Ulrich et al., 1991; Yadav et al., 2018).
4
In this context, it has become progressively important to review therapeutic
environment design which should be a place that supports their users (staff, patients and
their families), in psychological, emotional and social terms with the environmental
conditions (Smith & Watkins, 2016; Ulrich et al., 2008). Since the 1950s, research has been
increasingly investigating optimal healing environments (e.g., Stress Recovery Theory,
Attention Restoration Theory, Therapeutic Environment Theory, Salutogenesis, and
Supportive Design Theory), bringing to the forefront the need to include other parameters
in our design briefs, where the role of nature, and with it, the application of biophilic
design, proves to be paramount (e.g. Abdelaal & Soebarto, 2019; Blaschke, 2017; Blaschke
et al., 2018; Chrysikou et al., 2020). However, studying the clinical side of healthcare
architecture needs advanced expertise in medical sciences, and needs teamwork with
researchers from various fields of expertise. Therefore, this thesis mainly focuses on
therapeutic environments, and the outcomes represent a framework for non-clinical
therapeutic environments, although studies from clinical applications of biophilic design
were also investigated in order to have a broader insight into users’ expectations.
1.1. Research Problem

The scoping review of the literature by the authors confirms that there are three areas
in which biophilic design has been developed: as investigated in research institutions, as
used in design practice, and as established in building standards. Examining each of these
areas uncovers several issues and disconnections. In scientific academic environments,
there is abundant research on many of the different parameters of biophilic design, but this
research examining the effects of nature on humans has happened separately for specific
aspects of the design parameters and has not been brought together in a holistic and
coherent way to support the frameworks. The design recommendations provided by the
existing frameworks, the WELL Building Standard and the Living Building Challenge
(certification schemes created to support the nourishment of wellness in the built
environment) (International Living Future Institute, 2019; International WELL Building
Institute, 2020), are too broad and generic, and developed from a Western perspective.
These biophilic design frameworks don’t differentiate the level of value of each design
parameter for each context, and therefore, as design instruments, are too vague. My
position is that a biophilic design framework can only be efficient if it is specifically adapted
to building function and geographical and cultural context. For instance, these frameworks
recommend daylight as a parameter beneficial to humans, but don’t specify adjustments
regarding the daylighting requirements needed in a hospital of those needed in an
5
educational building; or regarding the biological needs of people who live in extreme
climates (e.g., northern latitudes or desert climates); or even regarding cultural dictates
that might prioritize some parameters over biological needs (e.g., privacy over daylight in
Muslim cultures). Therefore, to be able to provide efficient design guidance, it is necessary
to determine a selective hierarchical structure for each context, as specific parameters from
within the established general frameworks become especially relevant for the users.
With this in mind, Table 1-1 summarises detected problems in biophilic design practice,
regulations, and research throughout an extensive background review. Therefore, a
collective problem from these three perspectives emerged as: There is no holistic scientific
framework which defines borders and definitions of biophilic design that specialised for
different building typologies and guides designers through a clear path.
Table 1-1: Detected problems in biophilic design practice, regulations and research.
Perspective Problem
Regulations • Current standards do not specialise in biophilic design, and do not indicate
biophilic designs but use biophilic values as criteria among the many other
non-biophilic features.
• Employs no holistic compulsory conditions related to biophilic design.
Research • Definitions and borders of biophilic design have changeable and debatable
means.
• Although nature and natural elements’ benefits have been examined, no
compiled guideline defines frames for biophilic design specific to building
function, cultural and geographical context.
Practice • Current frameworks are not efficient as they are not adapted to specific
building functions, and are not geographically and culturally contextualised.
• Many existing ‘biophilic’ buildings show a lack of deep understanding in the
use of biophilic theory, due to the broad definitions of biophilic parameters,
which have not been hierarchised to guide designers to design with a higher
level of accuracy. Thus, there are buildings that have been claimed as biophilic
designs for commercial purposes, many of which are not close to present
biophilic qualities.
No doubt that examining all the building typologies with such a level of detail is a huge
endeavour that cannot be undertaken within the timeframe of a PhD study. Therefore, this
research focused on a particular building typology to narrow the field down to a reasonable
extent. Since healthcare provision has mostly focused on managerial priorities and
neglected the users' concerns, thus, improving the current state of healthcare design and
its environmental quality is a momentous need. So, it has become progressively important
to review the concept of therapeutic environments, as places where patients are treated
with the most advanced medicine and technology, but also support their users in
6
psychological, emotional and social terms. Especially in relation to the latter, non-clinical
healthcare environments have taken a prominent position in providing this support to
patients, above all those who suffer distressful diseases such as cancer.
1.2. Research Aim, Question and Objectives

In light of the research problems above explained, the main goal of this research study is
the redefinition of a scientifically underpinned biophilic design framework, with a particular
focus on non-clinical therapeutic environments. This research also aims to hierarchise the
parameters included in the new framework in a way that can more efficiently guide
designers, revealing which are the most critical for promoting and supporting human health
and wellbeing in these environments. Hence, to reach these research aims, the following
research question emerged to be answered in this research:
Which biophilic parameters are critical in the design of a non-clinical therapeutic

environment, and how can designers implement them adequately in their designs within
the limits of a holistic scientific and regulatory framework?
On the way of answering the research questions, this research aims to achieve the
following theoretical, methodological and practical objectives:
1] Study the biophilic design discipline as investigated in research practice, as used in

design practice, and as established in regulations and standards to understand the
needs for biophilic restoration.
2] Explore the benefits of connecting with nature and natural elements based on
scientific facts.
3] Study the theoretical premises and approaches that support physiological,
psychological, and emotional health in therapeutic environments.
4] Examine and analyse existing literature and scientific facts systematically to
compile scientific evidence for answering the research question, using
systematically searched review and meta-synthesis methodologies to achieve the
most accurate and less biased compilation of data.
5] Carry out semi-structured interviews with experts and practices to support and
enrich scientific evidence with experience and practice-based knowledge.
6] Hierarchise biophilic design parameters based on importance and demand level in
therapeutic environments in the context of the UK.
7] Introduce qualitative and quantitative findings from primary and secondary sources
and reveal recommendations to inform design practice.
7
8] Propose a design framework that will guide designers to implement biophilic design
adequately in their buildings.
9] Recommend practical, research, design and methodological future implications
based on findings, results and interpretations.
In order to reach these objectives different methodological approaches have been used
in this research. Although the methodological steps are explained in the chapters in detail,
the following section gives an overview of the methodology.
1.3. General Methodology

The methodological approach included data collection from two different sources: 1]
Scientific evidence, and 2] Professional practice and experience. A narrative literature
review, systematically searched literature review, and meta-synthesis informed the
scientific evidence with secondary sources, while professional practice and experience were
investigated with primary data collected from the semi-structured interviews. As illustrated
in Figure 1-1, methodological steps evolved as follows:
1] A grey literature review: to get an insight into the demands of patients and
required environmental features of healthcare settings from reports. The grey
literature review contributed to the research by revealing keywords and practical
questions that were used in the interviews.
2] A narrative literature review: to support scientific evidence in terms of the biophilic
design discipline as investigated in research practice, as used in design practice, as
established in regulations and standards, and in healing environment and relevant
theories; to explore the benefits of connecting with nature and natural elements
with scientific facts; to trace the evolution of healthcare environment design
through historical background, and establish a conceptual foundation of common
therapeutic building typologies by signifying spatial characteristics and user groups;
and to study the theoretical premises and approaches that support physiological,
psychological, and emotional health in therapeutic environments.
3] A systematically searched review: to provide scientifically reliable and less-biased
insight into the importance of the biophilic design elements in clinical environments
from peer-reviewed journal papers. The systematically searched review followed
rigorous replicable peer-reviewed steps: a review question; a systematic search
strategy consisting of searching keywords, searching syntaxes based on the
selected databases, and a set of inclusion and exclusion criteria; screening and
selection of literature; data extraction and quality assessment. The systematically
8
identified nine studies helped to identify and rank the biophilic design parameters
that appear the most critical for promoting and supporting human health and well-
being in clinical therapeutic environments, from the users’ perspective. Although
the main focus of this research is non-clinical environments, this study provided
users’ needs and perspectives which can be adaptable to their non-clinical
environments. It also provided an up-to-date compilation of crucial design
interventions related to biophilic parameters and as such provides benchmark
information for future research and design guidance in these environments.
4] A meta-synthesis: to identify, compare and synthesize all the published qualitative
literature on Maggie’s Centres, as non-clinical settings, systematically. This
methodology aimed to investigate Maggie’s Centres’ architecture, well known for
their carefully designed buildings and gardens to provide bespoke healing
environments, from the users’ and the designers' perspectives, assessing their
experiences in these buildings and their design intentions. There have been
previous qualitative research on these centres which included interviews, focus
groups, observations and questionnaires but were conducted from different
standpoints (e.g. Annemans et al., 2012; Birch et al., 2014; Martin et al., 2019; van
der Linden et al., 2015). Thus, while a great amount of qualitative data exists within
the published body of research, it has not been analysed through a biophilic lens.
This research aimed to review and integrate this body of research using a meta-
synthesis methodology. Particularly, direct quotations of users and architects,
obtained via interviews and focus groups, may be considered primary data as it has
not been analysed with this research intention before. The analytic process
included a systematic search strategy, data extraction and classification of salient
concepts using an open-coding approach, and lastly an interpretive evaluation. The
systematically selected data helped to identify and rank the biophilic design
parameters that appear the most critical for promoting and supporting human
health and well-being in non-clinical therapeutic environments, from the users’
perspective. It also offered a compilation of distinctive design interventions related
to biophilic parameters, which provides benchmark information for future research
and design guidance in non-clinical therapeutic environments.
5] Semi-structured interviews with experts and practices: to enable the collection of a
set of information from practice and support and enrich scientific evidence with
experience-based knowledge, verify the results obtained from a systematically
searched review and meta-synthesis studies by crosschecking the results from
9
primary sources, and support and expand the results based on recommendations of
the experts. The interview population consisted of therapeutic environment
experts: a psychologist, and five architects. Architect participants were invited
among the architects of Maggie’s Centres who were also involved in the design of
clinical settings or hospitals. The research reached saturation with five architects
who designed the centres that have various key features that the study wanted to
contrast: urban versus rural settings; use of low-key resources versus non-restricted
design; employed special materials, gender-friendly explorations, as well as
presenting a variety of early period centres and recently designed centres.
Eventually, the biophilic design guidelines for therapeutic environments with a
conceptual framework were created by analysing and synthesising the data obtained from
the systematically searched review, the meta-synthesis, the interviews, and the narrative
literature review, in which design recommendations for biophilic design applications and a
hierarchised provision of biophilic design parameters can be found based on spatial
requirements and user groups’ preferences.
Figure 1-1: Methodological process.
1.4. Outline of Thesis

Following this introductory chapter, the thesis is presented according to the following
briefly outlined chapters:
10
Chapter 1 introduces the research by defining general background information, research
problem, research aim, research question, research objectives, general methodology and
outline of the thesis.
Chapter 2 describes the notion of biophilia and biophilic design discipline as investigated in
research practice, as used in design practice, and as established in regulations and
standards, and examines the benefits of connecting with nature and natural elements using
scientific facts.
Chapter 3 briefly traces the evolution of healthcare environment design through history,
and establishes a conceptual foundation of common therapeutic building typologies by
signifying spatial characteristics, outlining theoretical premises and approaches that
support physiological, psychological, and emotional health in therapeutic environments.
Chapter 4 reports the systematically searched review study that provided scientifically
reliable and less-biased insight into the importance of the biophilic design elements in
clinical environments from peer-reviewed journal papers, with methodological steps,
protocol, data extraction, analysis, synthesis and quality assessment.
Chapter 5 reports the meta-synthesis analysis that identified, compared and synthesized all
the published qualitative literature on Maggie’s Centres, which included a systematic
search strategy, extraction and classification of salient concepts using an open-coding
approach, and lastly an interpretive evaluation for non-clinical environment design.
Chapter 6 analyses the semi-structured interviews with experts and practices, which
enabled the collection of a set of information from practice and to support and enrich
scientific evidence with experience-based knowledge, informing the biophilic design
process, decision making, and recommendations to design practice for both clinical and
non-clinical settings.
Chapter 7 introduces the biophilic design guidelines for therapeutic environments with a
conceptual framework, created by analysing and synthesising the data obtained from the
systematically searched review, the meta-synthesis, the interviews, and the narrative
literature review, and ultimately summarises design recommendations for biophilic design
applications.
Chapter 8 presents the conclusions drawn from the research, and conveys practical,
research, design and methodological recommendations for future implications based on
the findings, results and interpretations.
11
CHAPTER 2
12
2. BIOPHILIA AND BIOPHILIC DESIGN: RESEARCH, PRACTICE, AND
STANDARDS
A Dictionary of Psychology explains that the term ‘biophilia’ etymologically comes from
the ancient Greek words ‘bios-’ meaning ‘life’, and ‘-philos’, meaning ‘friendly feeling
toward’ (Colman, 2015) . Biophilia is defined at its most straightforward meaning as the
love of life (E. Wilson, 1984). The term may be a relatively new one, but the concept is not.
Therefore, people have been intuitively aware of it since ancient times, when natural
objects, shapes, and patterns have often acted as a source of inspiration for architects all
over history.
The concept of biophilia can be traced back in written literature to the times of Aristotle,
although its popularisation started in the second half of the 20th century (Santas, 2014).
The psychologist Erich Fromm, first used the term biophilia in his book The Heart of Man in
1964. He defined biophilia as a “tendency to preserve life and to fight against death”
(Fromm, 1964). In his The Anatomy of Human Destructiveness book of 1973, Fromm also
explained biophilia as “the passionate love of life and of all that is alive”, and “the wish to
further growth, whether in a person, a plant, an idea, or a social group” (Fromm, 1973).
Although the term was coined by Fromm in modern literature, it was popularised by
Edward O. Wilson. Professedly, Wilson never associated his work with Fromm, but he used
the term “biophilia” and developed it a few years later in socio-biology. Wilson’s first
mention of the concept was in The New York Times Book Review in 1979, an article titled
Biophilia, which served as an advertisement for Harvard University Press with the headline:
Capital Ideas from People Who Publish with Harvard. The ‘capital’ idea expressed in this
article was (E. O. Wilson, 1979):
Our deepest needs stem from ancient and still poorly understood biological
adaptations. Among them is biophilia, the rich, natural pleasure that comes from
being surrounded by living organisms, not just other human beings but a diversity of
plants and animals that live in gardens and woodlots, in zoos, around the home,
and in the wilderness.
Wilson started to define biophilia as “the innate tendency to focus on life and lifelike
processes” in his book titled Biophilia (E. Wilson, 1984). Nine years after this book, in 1993,
he wrote another book, The Biophilia Hypothesis together with Stephen R. Kellert. Biophilia
was defined once again in this book as “the innately emotional affiliation of human beings
13
to other living organisms” (S. Kellert & Wilson, 1993). Fromm's study was focused on
human health, and his definitions for other parts of nature remained incomplete. However,
Wilson and Kellert focused primarily on the improvement of natural factors and on
sustaining biodiversity, considering the relationship between nature and human beings,
thus improving human health. Hereafter, Stephen R. Kellert explored biophilia as a design
tool, developing a new approach to architectural design.
2.1. Biophilic Design

Biophilic design is the deliberate attempt to translate an understanding of the
inherent human affinity to affiliate with natural systems and processes—known as
biophilia—into the design of the built environment (S. Kellert et al., 2011).
The emergence of biophilic design as a discipline refers to the innate human connection
to nature and natural processes to promote health and well-being in the spaces we inhabit
(S. Kellert et al., 2011; S. Kellert & Calabrese, 2015; S. Kellert & Wilson, 1993). After the
Industrial Revolution, urbanisation started to increase rapidly and is still increasing. People
spend most of their time in places that are far from their natural context. At this point, the
emergence of biophilic design, inspired by biophilia, aimed to strengthen the relationship
between the modern building stock and nature, and ensure that people live within natural
conditions in order to promote their wellbeing and health.
The term ‘biophilic design’ was introduced in 2004 by authors of different disciplines
participating in a symposium named Biophilic Design: The Theory, Science and Practice of
Bringing Buildings to Life (W. Browning et al., 2014; Ojamaa, 2015). A book, with the same
name, compiling all the papers presented in the symposium was published in 2008, in
which biophilic design was defined as an approach to designing the built environment in a
way that emphasises the necessity of “maintaining, enhancing, and restoring the beneficial
experience of nature” and is “the deliberate attempt to translate this understanding of the
inherent human affinity to affiliate with natural systems and processes in the built
environment” (S. Kellert et al., 2011). Thomas Heatherwick, a multi-award winning British
architect, explained the biophilic design concept in the Foreword of Nature Inside: A
Biophilic Design Guideline, published by RIBA in 2020, claiming that there was a
misunderstanding of biophilia which had been commonly assumed as just pretentiously and
over-complicatedly expressed way to say the inclusion of plants are good, but in the true
definition of biophilic design, it is actually “the science of our emotional responses to the
world” (W. D. Browning & Ryan, 2020).
14
Another misunderstanding about biophilic design theory is that it is commonly confused
with sustainable design. Biophilic design shares some principles with sustainable design but
is not the same concept. In short word, sustainable design focuses on the environmental
impact of buildings and on mitigating these impacts, while biophilic design focuses on the
impact of nature on the physical environment and combining natural elements for the
benefit of human health and well-being (Molthrop, 2011).
Biophilia has been defined in many different ways over decades to different extents. For
example, apart from the earliest definitions stated above, Salingaros defined human
ambition for natural daylight as photophilia, and for natural environments (colour, gravity,
fractals, curves, detail, water, life) as topophilia, while classifying all these physiological
responses under the term ‘biophilia’ (Mehaffy & Salingaros, 2017; Salingaros, 2015).
Biophilic design has been defined by the pioneers of the field as explained above.
However, my position is that the current definitions are not efficient enough in the support
of design practice. Biophilic design is not just about listing all the parameters that can put
us in close proximity with nature, or about examining how to design with natural elements
individually. Equally, the inclusion of natural elements per se is not exclusive to biophilic
design. Even though daylight or fresh air are natural parameters, designers have always
been aware of the need to include them adequately to create a healthy and comfortable
space, and the prescription and regulation of these parameters form part of every design
guideline. My view is that biophilic design can only be fully achieved if the relevant
parameters for the targeted user groups work together harmoniously in the space. For
example, a picture of nature on a wall or a bright room without a view cannot be defined as
biophilic. Likewise, designing a garden from a biophilic perspective cannot just be for
providing oxygen, but also for enabling a full experience in connection with nature,
including a multi-sensory immersing scenario working in synergy: with elements such as
plants, smells, freshness, animals, colour, sounds, water or textures but also feelings of
mystery, prospect, refuge or even danger. This is what biophilia is about, feeling the
connection with nature in that complex and intricate relationship between different
parameters. The idealogy that Kellers, Browning or Salingaros presented did not explain
clearly how that connection happens. Moreover, not all parameters are equally important
for every type of building, this harmony should be established for each building typology
and attending to climate and local culture, since people have different notions and
perceptions of nature. Biophilic design frameworks should be focused on building
programme, user profile, and context.
15
Although the biophilic design concept is considered a new discipline, many researchers
have examined the human-nature relationship for many years, and its positive impact was
proven by a wide range of perspectives. The following section presents the benefits of
connecting with nature and investigated natural parameters that were supported more
frequently by empirical data (based on research of Browning et al. (2014)) : light, greenery,
water, fresh air, thermal variability, natural materials, colour, and experiences of nature
such as prospect, refuge, curiosity.
2.1.1. Research: Benefits of Connecting with Nature

Along with the knowledge that natural settings offer the most preferred environments
(Hartig, 1993; R. Kaplan & Kaplan, 1989; Ulrich, 1983; van den Berg et al., 2003), a rich body
of research proved that engagement with nature and natural processes impacts human
health and wellbeing both psychologically and physiologically. Research on nature’s impacts
became popular after the 1980s. In 1981, Ernest Moore of the University of Michigan
experimented with the South Michigan State Prison, where half of the prisoners were held
in rooms with windows leading to fields and trees, while others were held in rooms facing
the enclosed courtyard. It was found that prisoners in the rooms facing a courtyard visited
the doctor 24 per cent more compared to prisoners with a natural view (E. O. Moore,
1981). Another pioneering study was carried out by Roger Ulrich in the 200-bed
Pennsylvania hospital. Some of the rooms had a view of woodland and greenery, while the
other rooms were facing the brown brick walls of the next building. Ulrich investigated the
length of hospital stay, patients’ records for pain and anxiety medications, frequency of
minor medical complications along with the notes of nurses for the last ten years. The
result revealed that patients with natural views had statistically shorter hospital stays (7.96
days compared to 8.70 days), less need for pain and anxiety medication, and less harmful
interpretations in nurses' notes compared to patients with brick wall views (Ulrich, 1984).
Subsequent research revealed many other benefits of contact with nature. In general,
contact with nature has been shown to promote emotional, mental and spiritual health,
reducing stress and triggering positive shifts in mood, and a sense of belonging (Abdelaal &
Soebarto, 2019; Berman et al., 2008; W. Browning et al., 2014; Gillis & Gatersleben, 2015;
S. Kellert et al., 2011; Murphy & Mansfield, 2017; Purani & Kumar, 2018; Rosenbaum et al.,
2018; Silverstein, 2009). The most noticeable benefits revealed that contact with nature
restores attentional fatigue (Bodin & Hartig, 2003; S. Kaplan, 1995; Korpela et al., 2017),
fosters recovery, and reduces stress levels (Beute & de Kort, 2014; W. Browning et al.,
2014; Cordoza et al., 2018; Duzenli et al., 2017; Hartig et al., 2003; Joye & Dewitte, 2018; R.
16
Kaplan & Kaplan, 1989; Marcus et al., 1995; B.-J. Park et al., 2007; Ryan et al., 2014; Ulrich,
1993, 2002; Ulrich et al., 1991, 2008; M. White et al., 2010; Zijlstra et al., 2017). Therefore,
it implicitly helps to recover from the problems caused by stress. Stress level impacts
mental stress state and promotes negative emotions (Brosschot et al., 2005), and it can
increase the risk for particular illnesses such as cardiovascular diseases, arthritis, and
diabetes, or worsen them (Cohen et al., 2012). Stress might have an impact on brain lobs
which can even cause degrading memory (Sauro et al., 2009), and can affect cognitive
performance by boosting negative emotions (Ellenbogen et al., 2002). Furthermore, some
studies have claimed that a natural view not only helps relieve stress but also can immunise
people against stress if a person is exposed to natural views before confronting a trigger of
stress (Parsons et al., 1998), because exposure to a natural view ten minutes before
experiencing a mental stressor affects parasympathetic activity and heart rate (Barton &
Pretty, 2010). In addition to coping with stress, a controlled safe nature can reduce
negativity on mood while boosting positive mood (Berman et al., 2008; Hartig et al., 2003;
Ulrich et al., 1991), and direct experience with natural settings stimulates sensory
perception and relaxing feelings (Kjellgren & Buhrkall, 2010), a sense of pleasure and calm
(Maller et al., 2006), and positive emotions (Berman et al., 2008; Gillis & Gatersleben, 2015;
Murphy & Mansfield, 2017). Positive emotions are overall beneficial to health (Pressman &
Cohen, 2005) and buffer the potential harms of stress (B. L. Fredrickson & Joiner, 2002).
Additionally, studies have proved that natural engagement lessens physiological arousal
and decreases heart rate (Laumann et al., 2003), accelerates cardiovascular recovery (B. L.
Fredrickson & Levenson, 2010), helps relax muscles (B.-J. Park et al., 2007) and regulation
of digesting activities (Brown et al., 2013), reduces blood pressure, tension, anxiety, fatigue
(Abdelaal & Soebarto, 2019; Barton & Pretty, 2010; Berman et al., 2008; Hartig et al., 1991,
2003; Murphy & Mansfield, 2017; B.-J. Park et al., 2007; Silverstein, 2009), increases
spiritual health, positive thoughts, coping ability (Marcus et al., 1995; Murphy & Mansfield,
2017), and creates a sense of tranquillity (Hunter et al., 2010; Pheasant et al., 2010). Views
of nature through windows were associated with decreasing the time of hospital stay after
surgery, reduced Sick Building Syndrome (SBS) and anxiety, and improved performance at a
task (Heschong & Mahone, 2003; S. R. Kellert, 2005; Loftness & Snyder, 2008; Mendell,
1991; Ulrich, 1984). Furthermore, natural elements increase cognitive functionality and
performance, productivity, and concentration (S. Kaplan, 1995; Larsen et al., 2016;
Shoemaker et al., 1992; Thomsen et al., 2011), and restorative to pay attention (Berto,
2005; Bodin & Hartig, 2003; Lee et al., 2015). The benefits of nature were also
demonstrated in the studies on children with Attention Deficit Hyperactivity Disorder
17
(ADHD), since nature helped to enhance their concentration (Faber Taylor & Kuo, 2009,
2011).
It has been attested that physical exercise in nature is more beneficial than urban
environment (Thompson Coon et al., 2011), and surprisingly, exposure to nature makes
people physically more active (Ward Thompson & Aspinall, 2011). Ellett et al. (2008) found
that walking in a bustle urbanised environment enhances mental health problems of adults
with poor mental health, whereas nature walks to increase positive mood and mindset(Roe
& Aspinall, 2011). In the study of Bodin & Hartig (2003), 12 runners went on two routes
each, one through a nature reserve featuring a pine-birch forest and open fields, the other
along sidewalks and streets in an area of mid-rise apartment houses and commercial
developments. The runners rated their emotions after each of the runs, in the categories of
revitalisation, tranquillity, anxiety/depression, and anger, permitting a comparison of the
two environments. The results were in favour of the natural setting (Bodin & Hartig, 2003).
The first five minutes of nature experience are the most impactful period on positive mood
and self-esteem (Barton & Pretty, 2010).
In addition, the social impacts of nature were measured at Chicago’s Robert Taylor
Homes. These 28 identical blocks had the opportunity to measure biophilic design effect,
because of both busy unnatural highway and railway views from one side, and full of tree
and grassland natural views on the other side. The results were striking: nearby trees are
associated with higher levels of attention and self-discipline, less violence and other
aggressive behaviours, lower crime rates, and better interpersonal relations (Kuo, 2016;
Kuo & Sullivan, 2016a, 2016b)
Some studies also compared nature with different characteristics. For example, an
ordinary plain view of autumn fall was detected as less restorative than a more complex
natural landscape that includes water elements (Felsten, 2009). Compared to a real natural
view, images of nature were less stress-reducing yet effective in certain spaces, such as
clinics (Blaschke et al., 2016; Kjellgren & Buhrkall, 2010). For example, Kahn et al. (2009)
found that heart rate recovery from low-level stress was 1.6 times faster with a real natural
view through a glass window than a technological natural view stimulation on a screen.
Also, real views still attract people’s attention and interest over time whereas artificial view
diminishes the level of interest (Biederman & Vessel, 2006).
However, it should be taken into account that nature, as a multisensory environment,
does not consist of only visual characteristics but also auditory, olfactory, haptic and
gustatory features. For example, research showed that natural sounds increase motivation
and decrease fatigue (Jahncke et al., 2011), help recovery from stress 37 per cent faster
18
(Alvarsson et al., 2010); aromatherapy with natural fragrances has a positive impact on
immunity and particularly on healing process (J. T. Kim et al., 2007; Q. Li et al., 2012);
horticulture activities where people involved in gardening, along with the physical benefits,
decreases fatigue (Kam & Siu, 2010; Millet, 2009; Yamane et al., 2004), touching real plants
rather than artificial leaves creates a feeling of relaxation by changing blood flow rate (Koga
& Iwasaki, 2013). Furthermore, animal therapy in which the main focus is companionship
and petting reduces stress and anxiety with a calming impact (Ambrosi et al., 2019; Folse et
al., 1994; Souter & Miller, 2007). However, people only like a moderate multisensory
environment, and overstimulation should be avoided, whereas lack of sensory richness can
create a boring environment that makes dwellers more passive (J. Heerwagen, 2006).
Apart from all the benefits, scientific research also suggested that the notion of ‘nature
is beneficial’ is not right for everyone on an equal level. For example, although a natural
connection creates a sense of belonging, consideration of natural elements' benefits should
be assessed within specific cultural and ecological contexts, since cultural and ecological
attachment to an environment has been found highly restorative (Devine-Wright & Howes,
2010). Moreover, a study stated that not everyone actually likes nature because people
have been used to relying on controlled and protected building environments to feel safer
from threats from nature (Bixler & Floyd, 2016). With this in mind, the gender of
individuals can also affect their perception of nature. van den Berg & ter Heijne (2005)
revealed that male individuals’ responses to nature and natural threats are more positive
than female individuals, or sensation seekers respond more positively than non-seekers.
Furthermore, another study showed that natural images reduced stress and anger levels
significantly in male participants while the impact was not significant in female participants
(Kweon et al., 2007). On the contrary, plants helped to improve the performance of female
participants, unlike male participants in Shibata & Suzuki (2004).
The following sections examine the psychologic, physiologic, and cognitive benefits of
particular natural elements and biophilic design parameters separately.
2.1.1.1. Light
Having looked at the natural elements separately, the impact of light has been the most
frequently studied element, undoubtedly. It is commonly known that sunlight is essential
for human health and well-being. Sunlight exposure duration is also a vital issue because
lack of sunlight causes health problems such as vitamin D deficiency, rickets, SAD, sadness,
anxiety, alcohol addictions, irritability, suicide, decreased appetite, hypersomnia, lethargy,
carbohydrate craving and so on, whereas overexposure can also cause health problems
19
such as skin cancer (Beute & de Kort, 2014; Nabil & Mardaljevic, 2006; Rosenthal et al.,
1984).
Overall, natural light has been found beneficial for psychologic and physiologic health
and wellbeing (P. R. Boyce, 2010; W. Browning et al., 2014; Gillis & Gatersleben, 2015;
Husein & Salim, 2020; S. Kellert et al., 2011; Küller & Lindsten, 1992), as it reduces negative
mood, fatigue, stress, heart and pulse rates, relieves pain after surgery, enhances positive
mood and joy of living, helps to overcome depressive mood, and positively affects
chemotherapy receivers (Denissen et al., 2008; Leppämäki et al., 2002; Lieverse et al., 2011;
Liu et al., 2005; Marberry, 1995; Partonen & Lönnqvist, 2000; Walch et al., 2005).
Sunbathing supports overcoming mild hypertension (Krause et al., 1999), and impacts
cortisol production (Leproult et al., 2001). Daylight regulates the biological clock and
circadian rhythm that provide better sleep quality (M. Figueiro et al., 2011; M. G. Figueiro &
Rea, 2014; Hubalek et al., 2010; Kandel et al., 2013; Lieverse et al., 2011; Riemersma-van
Der Lek et al., 2008; Smolders et al., 2013), while disruption in circadian rhythm can cause
some health risks including cancer, obesity, diabetes and heart diseases (van Cauter et al.,
2008). Furthermore, many studies proved that inpatients who receive better daylight
(approx. 300 lux, as recommended by Illuminating Engineering Society of North America
(2020) for hospital rooms) have a shorter length of stay (Beauchemin & Hays, 1996;
Benedetti et al., 2001; Choi et al., 2012; A. Joarder et al., 2009; A. R. Joarder, 2011; M. Y.
Park et al., 2018; Salonen et al., 2014; Walch et al., 2005), however, Beauchemin & Hays
(1998) found that women were affected from sunlight exposure more than men since
women’s overall length of stay was reportedly shorter. Another research surprisingly
claimed that daylight only shortened the length of stay for illiterate patients (X. Li et al.,
2022).
Despite this, the studies relevant to intensive care units have not found a clear result.
For example, Beauchemin & Hays (1998) claimed that the mortality rate is lower in bright
cardiac intensive care units, while Simons et al. (2014) have not detected any impact of
sunlight exposure in the development of intensive care unit acquired delirium, or Wunsch
et al. (2011) found that presence of daylight and window in intensive care units did not
show any improvement on the investigated patients who were critically ill with bleeding in
the space that surrounds the brain. Undoubtedly, further investigations are required to
have a better understanding of daylight's impact in intensive care units concerning different
illnesses.
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As one of the main triggers of many psychologic problems, Seasonal Affective Disorder
(SAD) can be diminished by sunlight exposure (Avery et al., 2001), and daily outdoor
walking during sunny times decreases SAD symptoms (Wirz-Justice et al., 1996).
Moreover, it is widely known that daylight is one of the main factors that activate and
synthesises Vitamin D which is vital for human being as it provides protection from many
diseases including cancer, influenza, cardiovascular diseases, depression, diabetes, etc.
(Kauffman, 2009). Vitamin D deficiency might even cause schizophrenia (Chiang et al.,
2016; Cui et al., 2021). Vitamin D also promotes serotonin production that increases
happiness and positive mood (Lambert et al., 2002; Lansdowne & Provost, 1998). However,
change in mood depends on many other parameters such as personality, age, seasons, and
time (Denissen et al., 2008), thus, Kaida et al. (2007) claimed that 30 minutes of exposure
to sunlight (approx. 3000 lux) improved the mood positively. Specifically, artificial light
should be considered more rigorously with caution. Some psychological and physiological
problems like eye pressure, headaches depression, and fatigue can emerge as a result of
over-exposure to artificial light (Husein & Salim, 2020). Lighting design is also an important
parameter whether it is daylight or artificial light. Light as a biophilic design element can be
examined in various states of its design and existence within the space, although the most
straightforward meaning is the direct inclusion of natural light and its full-colour spectrum.
Filtered and diffused light, particularly by mitigating the effects of glare, can improve the
benefits of light as well as encourage feelings of connectedness by establishing a variable
and mediated connection between spaces. Moreover, reflected light which also enhances
the penetration of light into interior spaces can promote the mitigation of glare (S. Kellert
et al., 2011). A complementary contrast of light and shadow can promote momentous
satisfaction of the space, and a creative harmony of light and shadow can evoke curiosity,
mystery, and a feeling of refuge (S. Kellert et al., 2011). Furthermore, warm light can
increase the feeling of security. Kellert also stated that creating stimulating, dynamic and
sculptural forms by manipulating natural light facilitates mobility, curiosity, imagination,
exploration, and discovery. In short, diffuse lighting provides a feeling of calmness, while
accent lighting creates curiosity and interest, task lighting gives flexibility in intensity and
focus and, dynamic light and shadows attract attention (W. Browning et al., 2014).
Additionally, in modern medicine, bright light therapy is used to heal major depressive
disorder, dementia, premenstrual dysphoric disorder, Parkinson's disease, and bulimia
nervosa (Leppämäki et al., 2002; Lieverse et al., 2011; Wirz-Justice et al., 2009).
Daylight also impacts cognitive performance and promotes productivity and
concentration (P. Boyce et al., 2003; Brotas et al., 2013; de Giuli et al., 2008; Heschong &
21
Mahone, 2003). Zadeh et al. (2014) claimed that the presence of windows and natural light
in healthcare settings improved the communication and performance of nurses. Exposure
to daylight three hours a day increased job satisfaction and decreased work-related stress
in a hospital environment (Alimoglu & Donmez, 2005).
Another important example of the cognitive and physiologic impact of light by Nicklas
et al. (1996) investigated the effect of full-spectrum light on students. The students in full-
spectrum light were healthier and they attended school 3.2 to 3.8 days more per year than
those in usual classrooms. Libraries with superior daylight resulted in significantly lower
noise levels. Full-spectrum lighting induced more positive moods in students, and due to
the additional vitamin D dental caries were nine times less, and they biennially grew an
average of 2.1 cm more than students attending average-lit schools. Moreover, the
students who attended daylit schools out-performed the students who were attending non-
daylit schools by 5 to 14 per cent.
2.1.1.2. Greenery
As one of the well-known parameters of biophilic design, the impacts of engagement

with greenery and plants were broadly investigated by many researchers. The presence of
plants has been found effective on physiological health, in particular impact on the
reduction of stress, anxiety, fatigue, and lessening pain, heart rate, and blood pressure
(Barton & Pretty, 2010; Bodin & Hartig, 2003; Bringslimark et al., 2009; Dijkstra et al., 2008;
Küller & Lindsten, 1992; Larsen et al., 2016; Marcus & Barnes, 1999; Orsega-Smith et al.,
2017; Pheasant et al., 2010; Thomsen et al., 2011; Ulrich et al., 2020), thus, a presence of
plants also psychologically supports patients to response treatment (Matsunaga et al.,
2011; S. H. Park & Mattson, 2009). The studies reported that both individual cases and
communities that live with a higher percentage of green space (from single space to urban
context) have better health conditions in general (Maas et al., 2006; Ward Thompson et al.,
2012). Furthermore, it was found that the presence of plants in a workplace context
increases productivity (Nieuwenhuis et al., 2014), while Larsen et al., (2016) claimed that
the high density of plants, on the other hand, decreases productivity despite offering higher
positive impact. A moderate level of plants, therefore, is more efficient in a working
environment to create balance. Additionally,Qin et al. (2013) claimed that slightly scented
plants with green and small leaves are the most appropriate and effective plants for health
and wellbeing, whereas red flowers are fatiguing impact over time.
Green roofs have also been studied extensively, Lee et al. (2015) found viewing green
roofs have a micro-restorative impact on attention even after only 40 seconds. On the
22
other hand, another study claimed that commonly used ‘sedum’ vegetation has scarcely
more impactful than bare roofs, thus, the type of vegetation and landscape design is critical
to providing the restorative potential to the green roofs (E. v. White & Gatersleben, 2011).
S. Kellert & Calabrese (2015) stated that one of the most effective ways of bringing the
direct experience of nature into the built environment is to use vegetation, particularly
flowering plants. The general concept of biophilia claims that the application of single or
isolated plants is not effectively beneficial. Vegetation should be rich and ecologically
connected while the plants should be chosen from local species (S. Kellert et al., 2011).
2.1.1.3. Water
When people were asked about their ideal therapeutic environment they pictured an
environment with water elements, thus, water is undoubtedly one of the most preferred
elements in a therapeutic environment (J. H. Heerwagen & Orians, 1995; R. Kaplan &
Kaplan, 1989; Völker & Kistemann, 2011; M. White et al., 2010). Water elements, from
small fountains to oceans, have restorative and stress recovery impact on human beings
with visual, auditory and tactile features (Alvarsson et al., 2010; W. Browning et al., 2014; S.
Kellert et al., 2011; Pheasant et al., 2010; Ulrich et al., 1991). Some researchers even
claimed that water scenes in an urban environment have an equal restorative impact with
solely natural waterless scenes (Jahncke et al., 2011; Karmanov & Hamel, 2008). Also,
Barton & Pretty, (2010) suggested that the presence of water encourages self-esteem and
positive mood more than green spaces. However, the restorative effect of the water
depends on its quality, supporting evidence suggested that dirty and brown water are less
restorative than clear water (J. H. Heerwagen & Orians, 1995; Ryan et al., 2014; M. White et
al., 2010). Moreover, the repetitive and abundant experience of water can cause to lose
interest and start to be boring, hence, the optimum level should be implemented in
practice without exaggerating (Biederman & Vessel, 2006; W. Browning et al., 2014).
2.1.1.4. Fresh Air and Natural Ventilation
Scientific data proved that natural ventilation and fresh air, enhance health and
wellbeing, as oxygen is one of the vital elements to survive. For example, by providing
indoor air quality with natural ventilation instead of an air conditioner, students'
attendance rate can be increased, and sickness rates and Sick Building Syndrome (SBS)
symptoms can be diminished (Burge et al., 2004; Drinka et al., 1996; Preziosi et al., 2004;
Shendell et al., 2004). Another example study analysed 920 professional middle-aged
women in France with monthly surveys. When the participants with natural ventilation in
the workplace were compared with the employees in air-conditioned places, 57.1 per cent
23
decrease in illness rate, 16.7 per cent decrease in doctor visits, and 34.7 per cent decrease
in hospital stays were observed in participants with opportunity for natural ventilation
(Preziosi et al., 2004).
Seppanen et al. (1999)’s review of 43 scientific studies reportedly suggested that natural
ventilation is found to be beneficial for reducing headache, mucosal symptoms, influenza,
cold, cough, circulatory problems, and sick building syndrome (SBS), and increasing
productivity, attention, concentration. The results also suggested that to improve indoor air
quality and provide a better state of health, ventilation rates should be higher than 20 cfm
and up to 40 cfm per person (Seppanen et al., 1999; 2002).
2.1.1.5. Thermal Comfort and Variability
Thermal discomfort, which is experienced when the temperature goes below 18oC or
rises above 24oC, represents not only a lack of satisfaction depending on the environmental
temperature but also a potential risk for health. Hence, thermal discomfort can cause
respiratory diseases. Specifically, cold temperatures increase the risk of asthma, dry cough
and pneumonia, cardiovascular or cerebrovascular events, thickening of the blood, and
hypertension, respiratory stress (below 16oC), cardiovascular stress (below 12oC). On the
other hand, exposure to high temperatures increases the risk of heat stroke, respiratory
and cardiovascular illnesses and deaths (Ormandy & Ezratty, 2015; Sun et al., 2021).
Furthermore, as thermal variability is a part of natural processes, a variety of thermal
conditions within a space is found to be comfortable, and beneficial to improving cognitive
performance, productivity, concentration, perception, pleasure, and restoring attention
(Hartig et al., 2003; J. Heerwagen, 2006; Parkinson & de Dear, 2012; Wigö & Knez, 2005).
However, overstimulation can cause boredom, so a moderate level of thermal variability is
preferred by occupants (Elzeyadi, 2012; J. Heerwagen, 2006).
2.1.1.6. Natural Materials
Natural materials are stimulating as they reflect the dynamic qualities of organic matter
in an adaptive response to challenges of long-term life (S. Kellert & Calabrese, 2015).
According to S. Kellert et al. (2011) people usually prefer natural materials rather than
artificial even if the artificial ones are visually exact duplicates of the natural material. The
reason for this preference might be artificial materials’ inability of aging, weathering, and
other dynamic features of natural materials.
Based on existing literature, it is found that natural materials’ psychological and
physiological impact was an under-researched topic. Wood was the only material that has
been studied deeply. Current scientific literature suggested that natural materials (mainly
24
wood) improve environmental quality, immune system, recovery from illnesses, and overall
health, and encourage creativity and productivity (Q. Li, 2010; McCoy & Evans, 2010; Nyrud
et al., 2014; Tsunetsugu et al., 2007). Tsunetsugu et al. (2007) revealed that wooden
material application on 45 per cent of the whole surface creates a feeling of comfort and
reduces blood pressure and rises pulse rate. On the other hand, 90 per cent of wooden
surface coverage decreases brain activity. Research revealed that only a moderate level of
wooden material application creates the desired environment (e.g. only floors and
furniture), whereas completely wooden covered surfaces or rooms with no wooden
material are not usually created desirable environments (Nyrud et al., 2014). (Gillis &
Gatersleben, 2015) recommended for future biophilic design research to investigate the
impact of different types of natural materials such as clays, stone, earth, straw bale, wool,
cotton and so on. Also, indigenous materials’ impact on local populations can be
investigated.
2.1.1.7. Colour
Colour has been studied by many researchers, however, the impact of natural colours
has not been investigated deeply since all colours can be found in nature. Nevertheless,
green colour is the most frequently linked colour with nature. Green colour’s positive
impact on creativity has been proven, moreover, it was claimed that green is more
distinguishable than other colours (W. Browning et al., 2014; Lichtenfeld et al., 2012).
Schatz & Bowers (2016) reviewed scientific data on colours’ impact in general.
Accordingly, colour preference depends on age and place since young people preferred
warmer colours and North Americans preferred blue red and green colours respectively
while white was also significantly important among Asian people. Colours undoubtedly
have an impact on emotions, however, colours’ representation can vary by different
cultures' socioeconomic and historical traditions. Therefore, scientific data suggested that
pink colour reduces aggression, warm-coloured rooms are exciting and have a slightly
stimulating impact, while cool colours are calming but can increase a depressing effect. On
the other hand, scientific facts had been varying regarding the emotional outcomes for
example a research team found that the red colour caused more stress, anxiety, confusion,
and tension compared to the blue colour (Kwallek et al., 1997). All studies examined in this
review agreed that room colour affects productivity and performance, even though their
findings contradicted each other. Besides these contributions, (Schatz & Bowers, 2016)
found that colour does not directly affect motivation and satisfaction. Also, scientific
25
studies failed to prove a relationship between perceived temperature and colour, and a
relationship between people’s appetite and environmental colour.
In conjunction with the ecological valence theory (Palmer & Schloss, 2010): soft and
natural blues help to feel relaxed as they remind sky and water; shades of vibrant green
give energy and make people calm as they remind of meadow or forest; yellows are
warming and welcoming and create a social and energised atmosphere as they remind
warm summer and sun; purple and mauves are spiritual and meditative colours, and evokes
mystery as they remind dawn and dusk; oranges and reds can be energising, exciting and
stimulating as they remind ripe fruits and berries; dark colours associated with
sophistication, depth and mystery, and feeling of security and refuge, but if they are not
used carefully space can easily be oppressive and overwhelming. With this in mind, using
colour in much the same proportions with a sense of harmony, as in nature, is an important
point to avoid overwhelming people (Heath et al., 2021).
2.1.1.8. Experiences of Nature
As a dynamic and alive mechanism, nature does not consist of only natural elements but
also experiences with its complexity and order, such as prospect, refuge, mystery, risk and
peril.
The prospect and refuge concept represents a very basic human instinctive response to
the material world “see without being seen” (Lorenz, 1949). Based on this statement, Jay
Appleton’s Prospect and Refuge Theory introduced these two distinctive activities as
complementary theories that do not contradict each other. Thus, this theory proposed that
human beings were coded to be fully aware of their prey and protect themselves to be a
prey, afterwards finding a protected refuge space where they relaxed and have some
privacy (Appleton, 1975).
Providing prospects and refuge in space have been found physiologically restorative
(Gatersleben & Andrews, 2013). Once looking into these two concepts separately, prospect
is found to be reducing stress, fatigue, irritation, and boredom, and improves comfort
(Clearwater & Coss, 1991; Grahn & Stigsdotter, 2010; Herzog & Bryce, 2007); while refuge
similarly reduces stress, blood pressure, fatigue, perceived vulnerability, and encourages
attention, feeling of safety, and concentration (Grahn & Stigsdotter, 2010; Ulrich, 1993; K.
Wang & Taylor, 2006). Grahn & Stigsdotter (2010) claimed that health responses for refuge
are considerably higher than prospect, nonetheless, health responses are reportedly higher
when these two concepts are combined. In Gatersleben & Andrews (2013), the most
26
restorative applications of prospect and refuge combinations were explained. Low-level
refuge and high-level prospect combination were found to be restorative whereas a vice
versa condition can increase stress, fatigue and negative emotions. Therefore, a moderate
prospect distance should be higher than six meters (short depth), although the distance of
the preferred prospect was stated as above 30 meters (long depth) (Herzog & Bryce, 2007).
Prospect can be applicable in both interior and exterior spaces, an interior prospect is
applicable by providing a visual connection between the spaces and it has a greater impact
with the opportunity to see multiple spaces together (Hildebrand, 1991).
A true natural setting generates risk which is triggered by nearby danger. The level of
the perceived threat and control differentiates risk and fear. While fear in such activities in
mountains, forests, or ocean can engender anxiety (Rapee, 1997), controllable risk can lead
to positive outcomes such as pleasure or increased dopamine level which supports
motivation, problem-solving ability and memory. Nonetheless, an overdose dopamine leads
to mood disorders and depression, thus, long-term risk and peril exposure should be
avoided (Kandel et al., 2013; Kohno et al., 2015; van den Berg & ter Heijne, 2005). Also,
mystery and curiosity stimulate a strong feeling of pleasure (W. Browning et al., 2014).
2.1.2. Current State of Biophilic Design Practice

After the first initiatives that introduced biophilic principles in design, to contribute to
both research and practice, several design frameworks were proposed. Dimensions,
Elements and Attributes of Biophilic Design, The Practice of Biophilic Design, and 14
Patterns of Biophilic Design are the most commonly used and endorsed more detailed
perspectives.
The first classification for the biophilic design elements was produced by Kellert in 2008,
in the first chapter, Dimensions, Elements and Attributes of Biophilic Design, of Biophilic
Design: The Theory, Science and Practice of Bringing Buildings to Life (S. Kellert et al., 2011).
His classification included six main biophilic design elements that represented 72 biophilic
design elements and attributes (Table 2-1):
• Environmental features
• Natural shapes and forms
• Natural patterns and processes
• Light and space
• Place-based relationships
• Evolved human-nature relationships
27
Table 2-1: Elements and Attributes of Biophilic Design (Kellert, 2008).
Environmental features Natural shapes and forms Natural patterns and processes
Colour Botanical motifs Sensory variability
Water Tree and columnar supports Information richness
Air Animal motifs Age, change, the patina of time
Sunlight Shells and spirals Growth and efflorescence
Plants Egg, oval, and tubular forms Central focal point
Animals Arches, vaults, domes Patterned wholes
Natural materials Shapes resisting straight lines Bounded spaces

and right angles
Views and vistas Simulation of natural features Transitional spaces
Façade greening Biomorphy Linked series and chains
Geology and landscape Geomorphology Integration of parts to wholes
Habitats and ecosystems Biomimicry Complementary contrasts
Fire Dynamic balance and tension
Fractals
Hierarchically organized ratios and

scales
Light and space Place-based relationships Evolved human-nature relationships
Natural light Geographic connection to Prospect and refuge

place
Filtered and diffused light Historic connection to place Order and complexity
Light and shadow Ecological connection to Curiosity and enticement

place
Reflected light Cultural connection to place Change and metamorphosis
Light pools Indigenous materials Security and protection
Warm light Landscape orientation Mastery and control
Light as shape and form Landscape features Affection and attachment
Spaciousness Landscape ecology Attraction and beauty
Spatial variability Integration of culture and Exploration and discovery

ecology
Space as shape and form Spirit of place Information and cognition
Spatial harmony Avoiding placelessness Fear and awe
Inside-outside spaces Reverence and spirituality
This framework superficially examined the biophilic design elements regardless of the
applicability to design practice. Also, the framework did not specify any building typology or
did not demonstrate any comparison between different parameters. Moreover, the author
28
emphasised that this description was insufficient because this work was still in progress,
and the framework will be modified in the future as knowledge in this area increases,
leading to some of the categories might overlap. Therefore, Kellert presented a more
organised and more focused new framework in 2015, The Practice of Biophilic Design.
Table 2-2: Experiences and Attributes of Biophilic Design (Kellert and Calabrese, 2015).
Direct Experience of Indirect Experience of Experience of Space and Place

Nature Nature
Light Images of nature Prospect and refuge
Air Natural materials Organized complexity
Water Natural colours Integration of parts to wholes
Plants Simulating natural light and Transitional spaces

air
Animals Naturalistic shapes and Mobility and wayfinding

forms
Weather Evoking nature Cultural and ecological attachment

to place
Natural landscapes and Information richness

ecosystems
Fire Age, change, and the patina

of time
Natural geometries
Biomimicry
The Practice of Biophilic Design proposed a more organised and developed framework
that systematised biophilic design parameters in a more comprehensible way to inform the
application of design practice. According to The Practice of Biophilic Design, written by
Kellert and Calabrese, the successful application of biophilic design requires consistently
adhering to certain fundamental principles. These principles represent primary conditions
for the effective practice of biophilic design (S. Kellert & Calabrese, 2015). The principles
were specified as follows (Ibid.):
1. Biophilic design requires repeated and sustained engagement with nature.

2. Biophilic design focuses on human adaptations to the natural world that
over evolutionary time have advanced people’s health, fitness and wellbeing.
3. Biophilic design encourages an emotional attachment to particular settings
and places.
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4. Biophilic design promotes positive interactions between people and nature
that support an expanded sense of relationship and responsibility for the human
and natural communities.
5. Biophilic design encourages mutual reinforcing, interconnected, and
integrated architectural solutions.
This renovated framework employed 24 ‘attributes’ under three main categories: Direct
Experience of Nature, Indirect Experience of Nature, Experience of Space and Place (Table
2-2). However, this framework was also not specific to any building typology but explained
the parameters more organised and in more detail. Moreover, the importance level of each
parameter was still missing, hence, it did not guide designers in a clear way on how to
consider their design is efficiently biophilic.
Apart from Kellert’s works on biophilic design, Terrapin Bright Green LLC, a sustainability
consulting company that provides support to create a healthier environment, performed
extensive research on biophilic design and published a number of reports and books, most
notably Nature Inside: A Biophilic Design Guideline (2020), Biophilia & Healing
Environments (Salingaros, 2015), 14 Patterns of Biophilic Design (Browning et al., 2014),
and contributed some significant publications. The 14 Patterns of Biophilic Design booklet,
published in 2014, introduced a new framework by considering biophilic design parameters
in an interdisciplinary context. The primary application principles were explained
superficially, and ultimately, it presented the classification that has been the design
framework used in many studies in the biophilic design discipline. This book was
fundamental in providing a more comprehensive framework to define and assess design
based on biophilic principles. The classification was supported by empirical evidence and
the work of the authors of the book Biophilic Design: The Theory, Science and Practice of
Bringing Buildings to Life. This framework proposed 14 patterns, aimed to be flexible and
adaptable for practical use in the application or development of biophilic designs due to
their more exact definitions than in previous frameworks (Browning et al., 2014).
The framework developed by Terrapin Bright Green LLC framed biophilic design
parameters within 14 titles by naming them “patterns”, and classified them within three
main categories, as follows (Table 2-3):
• Nature in the Space: the direct, physical and temporary presence of nature
in a space or place.
• Natural Analogues: organic, non-living and indirect evocations of nature.
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• Nature of the Space: spatial configurations in nature that trigger ancient
emotional needs of humankind.
Table 2-3: 14 patterns of biophilic design (Browning et al., 2014).
NATURE IN THE SPACE NATURAL ANALOGUES NATURE OF THE SPACE
***Visual Connection with Nature *Biomorphic Forms & Patterns ***Prospect
**Non-Visual Connection with Material Connection with ***Refuge

Nature Nature
**Non-Rhythmic Sensory Stimuli **Complexity & Order **Mystery
**Thermal & Airflow Variability *Risk/Peril
**Presence of Water
**Dynamic & Diffuse Light
Connection with Natural Systems
As a significant difference from the other two frameworks, 14 Patterns of Biophilic

Design addressed the patterns that were supported by empirical data (indicated with
asterisks (*) as shown in Table 2-3). Thus, Visual Connection with Nature, Prospect and
Refuge was found to be supported by many scientific facts, whereas scientific data was
limited in relation to Material Connection with Nature, and Connection with Natural
Systems. The framework is not able to address which parameters are more critical
according to building typology or context, although the parameters were scientifically
examined. Browning et al. (2014) also listed scientifically supported recommendations to
inform general design practice (Table 2-4). Nevertheless, the application of biophilic design
specific to building typology is yet to be investigated.
Table 2-4: Design Recommendations from 14 Patterns of Biophilic Design (W. Browning et al., 2014).
PATTERN DESIGN RECOMMENDATIONS

VISUAL • Prioritise real nature over simulated nature; and simulated nature over no nature
CONNECTION • Prioritise biodiversity over acreage, area or quantity
WITH • Prioritise or enable exercise opportunities that are in proximity to green space
NATURE • Design to support a visual connection that can be experienced for at least 5-20 minutes per
day
• Design spatial layouts and furnishings to uphold desired view lines and avoid impeding the
visual access when in a seated position
• Visual connections to even small instances of nature can be restorative, and particularly
relevant for temporary interventions, or spaces where real estate (floor/ground area, wall
space) is limited.
• The benefits of viewing real nature may be attenuated by a digital medium, which may be of
greatest value to spaces, due to the nature of its function (e.g., hospitals radiation unit) cannot
easily incorporate real nature or views to the outdoors.
NON-VISUAL • Prioritise nature sounds over urban sounds
CONNECTION • Design for non-visual connections that can be easily accessed from one or multiple locations,
WITH and in such a way that allows daily engagement for 5 to 20 minutes at a time
NATURE • Integrate non-visual connections with other aspects of the design program
• A single intervention that can be experienced in multiple ways can enhance the impacts
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• Design for visual and non-visual connections to be experienced simultaneously to maximize
potential positive health responses
NON- • As a general guideline, non-rhythmic sensory experiences should occur approximately every
RHYTHMIC 20 minutes for about 20 seconds and, for visual stimuli, from a distance of more than 20 feet
STIMULI away.
28 14 Patterns of Biophilic Design
• Many stimuli in nature are seasonal, so a strategy that is effective year-round, such as with
multiple interventions that overlap with seasons, will help ensure that non-rhythmic sensory
experiences can occur at any given time of the year.
• In some cases, the intervention may be similar to that of [P1] Visual or [P2] Non-Visual
Connection with Nature; what’s important here is the ephemeral and stochastic quality of the
intervention.
• An intervention that leverages simulation (rather than naturally occurring) natural stimuli will
likely necessitate early collaboration with the mechanical engineer or facilities team.
• A non-rhythmic stimuli strategy can be interwoven with almost any landscape or horticulture
plan. For instance, selecting plant species for window boxes that will attract bees, butterflies
and other pollinators may be a more practical application for some projects than maintaining a
honeybee apiary or butterfly sanctuary.
• Humans perceive movement in the peripheral view much quicker than straight ahead. The
brain also processes the movement of living things in a different place than it does of
mechanical objects (Beauchamp et al., 2003), whereby natural movement is generally
perceived as positive, and mechanical movement as neutral or even negative. As a result, the
repeating rhythmic motion of a pendulum will only hold one’s attention briefly, the constant
repetitive ticking of a clock may come to be ignored over time, and an ever-present scent may
lose its mystique with long-term exposure; whereas, the stochastic movement of a butterfly
will capture one’s attention each time, for recurring physiological benefits.
THERMAL & • Incorporation of airflow and thermal conditions into materials, daylighting, mechanical
AIRFLOW ventilation and/or fenestration will help distribute variability over space and time.
VARIABILITY • Thermal comfort is a vital bridging component between biophilic design and sustainable
design, especially in the face of climate change and rising energy costs. When thermal and
airflow variability is implemented in a way that broadens people’s perception of thermal
comfort, it may also help reduce energy demands for air conditioning and heating.
• Designing in features that allow users to easily adapt and modify their perceived thermal
conditions of their environment will increase the range of acceptable temperatures by two
degrees Celsius above and below the conventional parameters for thermal comfort (Nicol &
Humphreys, 2002).
• Coordination of design strategies among a project team (e.g., architect, lighting designer and
MEP engineers) as early as the schematic design process will be particularly important for
achieving design intent.
PRESENCE OF • Prioritise a multi-sensory water experience to achieve the most beneficial outcome.
WATER • Prioritise naturally fluctuating water movement over predictable movement or stagnancy.
• High volume, high turbulence water features could create discomfort, impact humidity levels
or decrease acoustic quality, so proximity may influence appropriateness.
• Water features can be water and energy intensive and as such should be used sparingly,
particularly in climates with little access to water. Shading the water, using high albedo
surfaces, and minimizing the exposed water surface area will minimize water loss through
evaporation, and possibly contribute to the biophilic experience.
DYNAMIC & • Dynamic lighting conditions can help transition between indoor and outdoor spaces.
DIFFUSE • Drastically dynamic lighting conditions, such as with sustained movement, changing colors,
LIGHT direct sunlight penetration and high contrasts, may not be appropriate for spaces where
directed attention activities are performed.
• Circadian lighting will be especially important in spaces the people occupy for extended
periods of time.
CONNECTION • Integration of rainwater capture and treatment into the landscape design that respond to
WITH rain events
NATURAL • In some cases, providing visual access to existing natural systems will be the easiest and most
SYSTEMS cost-effective approach. In other cases, the incorporation of responsive design tactics (e.g., use
of materials that change form or expand function with exposure to solar heat gain, wind,
rain/moisture, or shading), structures (e.g., steps wells), and land formations (e.g., bioswales,
arroyos, dunes) will be necessary to achieve the desired level of awareness
• Design for interactive opportunities, especially for children, patients, and the elderly (e.g.,
integrative educational curriculum; horticulture programs, community gardens; seasonal
cooking/diet)
32
BIOMORPHIC • Apply on 2 or 3 planes or dimensions (e.g., floor plane and wall; furniture windows and
FORMS & soffits) for greater diversity and frequency of exposure.
PATTERNS • Avoid the overuse of forms and patterns that may lead to visual toxicity
• More comprehensive interventions will be more cost effective when they are introduced
early in the design process.
MATERIAL • Quantities of a (natural) material and colour should be specified based on intended function
CONNECTION of the space (e.g., to restore versus stimulate). In the same vein, a degree of variability of
WITH materials and applications is recommended over high ratios of any one material or colour.
NATURE • Real materials are preferred over synthetic variations because human receptors can tell the
difference between real and synthetic, so minimally processed materials from real nature are
preferred whenever possible.
• Incorporating instances of the colour green may help enhance creative environments;
however, scientific studies on the impact of the colour green have mostly been conducted in
controlled lab environments, so dependence on colour to engender creativity should be
considered experimental.
COMPLEXITY • Prioritise artwork and material selection, architectural expressions, and landscape and
& ORDER master planning schemes that reveal fractal geometries and hierarchies.
• Fractal structures with iterations of three will be more impactful than a design limited to two
iterations.
• Computer technology using the algorithms of mathematical and geometric functions can
produce fractal designs for architectural, design and planning applications with ease. If a fractal
design is being created, consider using geometries with a mid-range dimensional ratio (broadly
speaking, D=1.3-1.75).
• Over-use of and/or extended exposure to high-fractal dimensions could instil discomfort or
even fear, countering the intended response: to nourish and reduce stress. Avoidance or
under-utilization of fractals in design could result in complete predictability and disinterest.
• A new building or landscape design should take into account its impact on the fractal quality
of the existing urban skyline.
PROSPECT • Orienting building, fenestration, corridors and workstations will help optimize visual access to
indoor or outdoor vistas, activity hubs or destinations.
• Designing with or around an existing or planned savanna-like ecosystem, body of water, and
evidence of human activity or habitation will help the information-richness of the prospect
view.
• Providing focal lengths of ≥20 feet (6 meters), preferably 100 feet (30 meters); when a space
has sufficient depth, spatial properties can be leveraged to enhance the experience by
removing visual barriers. Limiting partition heights to 42” will provide spatial barriers while
allowing seated occupants to view across a space. Understory vegetation or hedges should use
a similar guide; preferred height limitations will depend on terrain and how the space is most
experienced (e.g., while sitting, standing, on a bicycle)
• Locating stairwells at building perimeter with glass façade and interior glass stairwell walls
can form a dual prospect condition.
• When high ceilings are present, perimeter or interior spaces elevated 12-18” will enhance the
Prospect condition.
• Often the view quality and the balance between Prospect and Refuge will be more important
than the size or frequency of the experience.
• Refer to [P1] Visual Connection with Nature to optimize the Prospect experience with a
quality view.
REFUGE • Indoor refuge spaces are usually characterized by lowered ceiling conditions. For spaces with
standard ceiling heights, this may equate to approximately 18-24 inches below the main
ceiling, and is often achieved through treatments like a soffit, a drop-ceiling or acoustical
panelling, or suspended fabric.
• Outdoor or indoor spaces with particularly high ceilings (>14 feet), a more drastic differential
may be necessary to achieve the desired outcome; freestanding or vegetative alcoves and
mezzanine-like structures are often effective.
• When designing for larger populations or multiple activity types, providing more than one
kind of refuge space can address varying needs, which can often be met through differing
spatial dimensions, lighting conditions, and degree of concealment.
• Light levels in refuge spaces should differ from adjacent spaces and user lighting controls will
broaden functionality as a refuge space.
MYSTERY • Curving edges that slowly reveal are more effective than sharp corners in drawing people
through a space.
• Dramatic shade and shadows can enhance the mystery experience. • Strategies that provide
dark shadows or shallow depth of field could instil unappreciated surprise or fear.
33
• The speed at which users are transiting through a space will influence both the size of the
aperture and the size of the subject; faster typically means bigger.
• Organically evolved mystery conditions (e.g., low maintenance gardens with winding paths)
are expectedly going to change characteristics over time. These changes should be monitored
as they may enhance the mystery condition, or otherwise degrade it as it evolved into a
surprise condition (e.g., overgrowth of plantings leads to obscuring of depth of field).
RISK/PERIL • Risk/Peril design interventions are usually quite deliberate and as such will not be
appropriate for all user groups or places.
• Design strategies that rely on spatial conditions will be easier to implement when
incorporated as early as concept design and schematic phases of the design process.
• The element of safety must protect the user from harm while still permitting the experience
of risk.
A recent publication, Nature Inside: A Biophilic Design Guideline (W. D. Browning &
Ryan, 2020), by the same authors introduced a guideline based on the same biophilic
design framework with 14 Patterns of Biophilic Design, but increasing the number of
Patterns to 15 by adding ‘Awe’. This guideline explained the economics and design steps
for the biophilic design process (Figure 2-1). This design guideline examined case studies of
applied biophilic design regarding different building typologies: housing, schools, retail,
offices, hotels, hospitals, factories, and communal spaces. However, the guideline did not
direct designers on a clear path, although it presented successful examples.
Figure 2-1: Decision Timeline for Biophilic Design Implementation (W. D. Browning & Ryan, 2020).
In order to consider biophilic design elements and attributes effectively during the data
collection stage, their inclusion in this research, reported in the following chapters, did not
completely follow any of these frameworks, because of their unclear transitions and
contradicting parts to each other. The parameters investigated in this thesis took form
throughout the analysis of collected data. Therefore, the employed parameters were
evaluated in two main groups: Parameters of the physical environment: Fresh Air, Daylight,
34
Thermal Comfort, Multisensory Environment, Spaciousness, View, Natural Colour,
Greenery-Plants, Natural Material, Seasonal Changes, Water, Fire, Spaciousness; and
parameters of emotional and psychological wellbeing: Refuge-Privacy, Prospect, Sense of
Belonging, Curiosity, Welcoming and Relaxing Feelings, Mastery and Control.
The term ‘parameter’ was selected as a collective definition of elements, attributes, or
patterns. While the term ‘element’ was used for physical or assessable components of
biophilic design (e.g. natural material, light, greenery, water, etc), the term attributes
commonly referred to emotional and sensational features of the biophilic design (e.g.
prospect, refuge, enticement, sense of belonging). The use of the term ‘pattern’ is peculiar
to the concepts defined in 14 Patterns of Biophilic Design, thus, the ‘pattern’ term will
always refer to this specific framework.
2.1.3. Standards
As a design philosophy, biophilia does not well fit quantitative measurement tools.
However, health-oriented metric certification systems somewhat include biophilic design in
their programme. Particularly, some green building standards incorporate biophilic design.
For example, BREEAM (Building Research Establishment Environmental Assessment
Method), founded by the Building Research Establishment (BRE) in 1990 in the UK, includes
criteria in relation to health and wellbeing in which Hea 01 Visual comfort, Hea 02 Indoor
air quality, Hea 04 Thermal comfort, Hea 07 Hazards (Safe and Healthy Surroundings), and
Hea 08 Private space topics can be considered assessment of some biophilic values
(BREEAM International New Construction Version 6, 2021). On the other hand, LEED
(Leadership in Energy and Environmental Design), developed by the U.S. Green Building
Council (USGBC) in 1993 in the USA, more directly employs biophilic design in some topics:
EQpcl23 Designing with Nature, Biophilic Design for the Indoor Environment; SS Open
Space; SS Protect or Restore Habitat; MR Building Product Disclosure and Optimisation;
MRpcl02 Legal Wood; EQ Enhanced Indoor Air Quality Strategies; EQ Interior Lighting; EQ
Daylight; EQ Quality Views; EQ Acoustic Performance.
However, at present two certification systems take biophilic design as a focus in the
assessment process: the WELL Building Standard and the Living Building Challenge (LBC).
The Living Building Challenge (LBC) is an international sustainable building certification
programme created in 2006 by the Seattle (U.S.A)-based non-profit International Living
Building Institute. LBC applies a holistic set of building performance standards that certify
new construction, renovations, and exterior spaces such as landscaping and infrastructure
projects (International Living Future Institute, 2019). The Living Building Challenge
35
certification programme consists of seven “Petals”, which act as performance categories:
Place, Water, Energy, Health & Happiness, Materials, Equity and Beauty. There are 20
“Imperatives” in total, which are organised into seven Petals. Imperatives are specific
strategies or goals that help to provide understanding for a topic or guideline. Certification
can be awarded based on the employed Petals, each of which should be fulfilled based on
the imperative requirements (Figure 2-2). Some of the Imperatives are directly or indirectly
relevant to biophilic design: 04 Human Scaled Living, 09 Healthy Interior Environment, 10
Healthy Interior Performance, 11 Access to Nature, and 19 Beauty + Biophilia (International
Living Future Institute, 2019).
The Living Building Challenge also includes a biophilia design initiative that is used as a
resource for designers and architects. The initiative provides a resource for ideas, events,
and networking opportunities, as well as access to network archives and file resources
related to biophilic design. Designers may also have an opportunity to develop their own
draft of biophilic implementation strategies and documents for the Living Building
Challenge (International Living Future Institute, 2019).
Figure 2-2: Summary of LBC criteria (International Living Future Institute, 2019).
The WELL Building Standard, founded in the USA in 2013 and administered by the
International WELL Building Institute (IWBI), exclusively focuses on human health and
wellbeing in the built environment (IWBI, 2021). The WELL Building Standard certifies new
36
constructions or renovation projects. The current version of the standard, WELL V2,
contains 11 concepts, including Air, Water, Nourishment, Light, Movement, Thermal
comfort, Sound, Materials, Mind, Community, and Innovations. Within WELL V2, some
biophilic design principles were integrated into eight features under five concepts: Air 07:
Operable Windows, Light 03: Circadian Light Design, Light 05: Enhanced Daylight Access,
Mind 02: Access to Nature, Mind 07: Restorative Spaces, Mind 09: Enhanced Access to
Nature, Sound 05: Sound Masking, Thermal Comfort 03: Thermal Zoning (IWBI, 2021).
Regarding the Access to Nature feature, the standard’s provision for direct connection
to nature is at least two of the following biophilic design features to be achieved through
design: plants, water, light, or nature scenes. On the other hand, an indirect connection to
nature is proposed to be achieved by using colour, patterns, natural materials, or images.
The Enhanced Access to Nature feature must employ at least two of the following
conditions (IWBI, 2021):
• Outdoor access to nature: at least 25% landscaping or gardens which consist of
real plants or natural elements (at least 70%).
• Indoor access to nature: at least 75% of spaces should be occupied with indoor
plants, and advised to be supported by safe water features.
• Nature views: at least 75% of occupied spaces should have visual contact with
exterior nature views in direct line of sight.
• Nearby access to nature: at least one green space (minimum 0.5 Hectares)
within 300 meters of walking distance from the built environment.
To sum up, in both certification systems (LBC and WELL), there is not enough definite
requirement for biophilic design elements holistically. Although they deal with several
biophilic parameters in the rating process. Thus, biophilic design is accepted as only one of
the supportive tools to be able to accomplish standards’ requirements.
2.2. Concluding Remarks

The literature review conveyed in this chapter is critically important to understand the
biophilia and biophilic design, the importance and benefits of connecting with nature and
natural elements which also informs and helps to define ways to answer the research
question by contributing design recommendations for biophilic therapeutic environments.
Furthermore, having insight into the current state of biophilic design from different
perspectives (research, practice and regulations) strengthen the main goal by underpinning
the importance of how this research will contribute scientific and practical knowledge.
37
The second part of the literature review, in Chapter 2, revealed why improving
environmental quality with biophilic design is necessary for healthcare environments with
the historical and theoretical background of the healing environment concept.
38
CHAPTER 3
39
3. HEALING ENVIRONMENT
The World Health Organization (WHO) defines health as “a state of complete physical,
mental and social well-being and not merely the absence of disease or infirmity”
(“Constitution of the World Health Organization,” 1946). In line with this statement, the
theory underpinning the concept of a therapeutic environment, claims that the
characteristics of the physical environment in which a patient receives healthcare affect the
patient's recovery period or adaptation to particular acute and chronic conditions (Stichler,
2001). Healing environments should not only be places where patients are treated with the
most advanced medicine and technology but also places that support their users (staff,
patients and their families), in psychological, emotional and social terms (Smith &
Watkins, 2016).
Smith & Watkins (2016) claim that all environments have a positive or negative impact,
thus, there is no neutral environment. So, they explain the criteria that make the healthcare
environments therapeutic in a positive way:
▪ Supports clinical excellence in the treatment of the physical body

▪ Supports the psycho-social and spiritual needs of the patient, family, and staff
▪ Produces measurable positive effects on patients' clinical outcomes and staff
effectiveness (Smith & Watkins, 2016).
A sustainable therapeutic environment is guided by thinking about health and well-being
in its broadest context (Boscherini, 2017) by an understanding that includes the health and
well-being of building occupants, the health of the local community and the natural
resources and health of the global community (Peters, 2017).
The existing literature frequently uses the terms “healing environment” and
“therapeutic environment” interchangeably. Nevertheless, this thesis will use the term
“therapeutic environment” to refer to all healing environments regardless of their size, and
clinical or non-clinical function.
3.1. Environment and Healthcare: Examples of Connection with Nature

from History
Healthcare architecture is not a new practice. Although the architecture of health has
been poorly documented and historic physical remains have not survived well, its root goes
back to ancient times and can be tracked as early as Ancient Egypt and Ancient Greece.
40
There is extensive research on the evolution of hospital design and healing environments
and their historical background from which we learn there are numerous examples of the
inclusion of natural elements in the healing process. Earliest examples may be Asclepeion
temples in ancient Greece, a collection of buildings against a stunning landscape that
served as a kind of healthcare setting that was visited by terminally and chronically ill
people (Heathcote, 2021; Sternberg, 2009; Thompson & Goldin, 1975). They were built far
from the high temperature, noise, dirt, and dust of the settlements, typically with a good
view of the sea and nearby freshwater sources (Sternberg, 2009). Despite they were not
hospitals, the idea of holistic treatment was prevailing in these therapeutic temples where
patients followed special diets, and prayers along with fresh air, view of nature, fresh
water, music, and socialising. The cure in Asclepeion was cultural, spiritual, and medicinal
(Heathcote, 2021; Sternberg, 2009).
Roman Valetudinariums, Islamic Bimaristans, Medieval Hospices, Renaissance Hospitals

and many other historical examples used courtyards and gardens as main providers of
nature connection. Courtyards offered sheltering spaces where the patient could still go out
and experience fresh air and sunlight while being sheltered. Some examples also included
water elements such as fountains or pools to create sensory variability (Cilliers & Retief,
2002; Heathcote, 2021; Saliu et al., 2016; Thompson & Goldin, 1975; Verderber & Fine,
2000). Courtyard development and the use of natural elements was commonly observed in
Bimaristans. These centres aimed to heal not only the physical body but also the soul and
mental health of patients through both programme and architecture. Each department had
fountains to supply fresh water and an auditory experience. Outpatient departments and
inpatient wards were naturally ventilated. Music was played in the courtyards for those
who had difficulty sleeping. Musicians and storytellers entertained the users, and each
patient received a sum of money at discharge to afford expenses until resuming work
(Cilliers & Retief, 2002; Heathcote, 2021; Porter, 1997). Along with the courtyards and
gardens, Renaissance period hospitals integrated new construction techniques and
innovations, which helped to increase natural elements such as daylight, fresh air,
fireplaces and so on (Verderber & Fine, 2000). For example, Filarete’s Ospedale Ca’Granda
in Milan, the first building to use cross-plan had two cross-shaped wards, each designed for
60 beds, surrounded by courtyards (Saliu et al., 2016; Thompson & Goldin, 1975), while the
design of courtyards as secondary public space in Hospital Real at Santiago de Compostela
in Spain encouraged privacy and silence (Heathcote, 2021).
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Overall, while traditionally approached, healthcare settings were early examples of
biophilic thinking since they were usually built far from the high temperature, noise, dirt,
and dust found in towns, and they typically offered a good view of nature and nearby
freshwater sources.
With the Enlightenment and modernity, healthcare design emerged as an architecture

that was supported by science and objectivity. Radical changes in the hospital design were
started by the fire at Hotel Dieu in Paris in 1772. The biggest and one of the earliest
hospitals in Europe, in which 1,280 patients were accommodated every year, it had a series
of courtyards located on the bank of the Seine River that supported the building by
providing water, ventilation and fresh air (Heathcote, 2021). However, records from before
its destruction by a fire concluded that one out of four and a half patients were dying in
that hospital. Therefore, the debates on reconstruction led the design committees to
critically think about an effective hospital design (Wagenaar, 2006), although these
deliberations were focused on the building’s layout (Heathcote, 2021), as the reformers
assumed that it was not the medicine that provided the healing conditions, but the clean air
provided by the surrounding natural environment (Wagenaar, 2006). These debates led the
designers to design smaller day-lit and naturally ventilated pavilion buildings that were
connected with arcades as happened in the Royal Naval Hospital in Stonehouse in
Plymouth, which achieved great success in healthcare as an example of pavilion layout
hospitals (Heathcote, 2021).
Another noteworthy example to understand the importance of environmental

conditions for healing in the course of historical evolution is the works of Florence
Nightingale. The importance of designing a healing environment was widely accepted after
Florence Nightingale asserted her observations during the Crimean war in 1854. Nightingale
was a trained nurse and statistician who joined the frontline to treat wounded British
soldiers in Üsküdar, Istanbul, where the old military barracks were allocated to the British
forces as a temporary hospital. She realised that the majority of casualties were caused not
by the war wounds but by the rapidly transmitted diseases due to the lack of ventilation
and light, and poor conditions of the aid tents and the old barracks. After she reported
these conditions to London, prefabricated wards designed by Isambard Kingdom Brunel
were produced in the UK and assembled in Renkioi (Erenköy, Turkey) in 1855. All wards
were self-sufficient with nurses' rooms, lavatories, and an operating theatre. The Renkioi
hospital, which was made of wood and fully insulated, offered a healing environment with
ventilating windows that provided sufficient daylight. The astonishing results showed the
42
mortality rate fell from 42 per cent to two per cent (Heathcote, 2021; Murphy & Mansfield,
2017). Nightingale’s principles, published in her book Notes on Hospitals in 1863, outlined
the design of wards, quantity of windows, daylight quality, bed placement, spaciousness,
the atmosphere of space, heating and ventilation systems, material and colour (Murphy &
Mansfield, 2017; Nightingale, 1859; Verderber & Fine, 2000). After her return from the
frontline, she worked for hospital reform and influenced many pavilion hospitals in London
and Paris (Heathcote, 2021).
Nightingale’s principles were followed in the late 19th and early 20th centuries,
however, these principles have been progressively disregarded when the dramatic growth
of urbanisation together with the advent of the Miasma and Germ theories, led to an
environmental approach to healthcare exclusively focused on healing with medical
interventions (Murphy & Mansfield, 2017; Wagenaar, 2006), so the idea of pavilion
hospitals was abandoned in favour of basic hygiene (Heathcote, 2021). Secondly, the
invention of the X-ray and the Röntgen machines started a new era in hospital design.
These expensive machines were kept in the hospitals, therefore rather than receiving
treatment at home, the upper-class population started to use the hospital, which until then
had been only used by the poorest people (Wagenaar, 2006). Thereafter, ongoing criticism
about the need for patient privacy, not being adaptable to a ward system, and rapidly
increasing population and developing technology brought massive and complex block
hospitals: the concept of 'Mega-hospitals’ (Verdeber and Fine, 2000).
Regarding the ‘Mega-hospital’ concept, Wagenaar (2006) explained: "Great and

monumental though these hospitals could be, they lost an essential architectural feature of
older pavilion system: the ambition to create healing environments that emulated nature".
The natural environment was abandoned in healthcare setting design as the only focus was
accommodating science and technology efficiently and cost-effectively. Everything in these
massive and urban buildings was subject to the requirements of science and technology
disregarding human needs and well-being (Wagenaar, 2006). However, this was not the
case for all healthcare buildings in the first half of the 20th century. For example, in Alvar
Aalto’s Sanatorium in Paimio (1929-1933), where the architect designed the centre in every
detail with a combination of industrial, organic, and aesthetics as an exemplar of the
architecture of convalescence, calm and clarity by including plenty of daylight, visual
connection with nature and greenery, and balconies where patients have easy access to the
outdoor (Heathcote, 2021).
43
When looking at the post-war healthcare examples, their planning mainly privileged the
building's circulatory systems and mechanisation to increase efficiency in the use of human
and technical resources, rationalising and accelerating the delivery of clinical care (reducing
in-patient lengths of stay to the minimum clinically necessary and through increases in day
surgery and out-patient treatment) (Hughes, 1997). Nightingale’s principles were
progressively disregarded in this process, which together with the dramatic growth of
urbanisation, the advent of the germ theory and rapid changes in medical technology, led
to an environmental approach to healthcare exclusively focused on healing through
medical interventions (Murphy & Mansfield, 2017). Verderber and Fine (2000) defined
these new facilities as Minimalist Megahospitals where newly formed departments and
more specialised healthcare zones were included. This approach also did not prioritise
connection with natural elements to encourage the healthcare facilities toward efficiency,
sanitary and controlling infection (Heathcote, 2021; Wagenaar, 2006).
However, the healthcare environment became more patient-centred with the help of
the health insurance system and capitalist ideology, although today's healthcare
environment is still criticised. Healthcare environments have focused on the goals and
objectives of the organisation (fast physical recovery, mass health) while widely neglecting
the users (staff, patients) concerns and aspirations, and with this, their emotional, mental
and spiritual health (Abdelaal & Soebarto, 2019; Murphy & Mansfield, 2017; Silverstein,
2009). In this context, Verdeber and Fine (2000) stated that hospitals are considered as
“healing machines”, and Charles Jencks, co-founder of Maggie’s Centres, described today’s
healthcare settings as 'factory-hospitals' where all technology and medicine are dedicated
to mass health. With the creation of Maggie’s Centres, Jencks evidenced the need for and
pursued the provision of non-clinical therapeutic support centres (Jencks, 2017).
Supporting emotional, mental, and spiritual health is essential, particularly for patients
who have been given a diagnosis with cancer, as numerous studies have shown that these
patients may experience significant levels of psychological discomfort, with many of them
reporting fatigue, anxiety, or depression. (Blazer et al., 1994; Guthrie, 1996; Mayou et al.,
1991; McDaniel et al., 1995; Turner & Kelly, 2000; Zabora et al., 1997). Supporting evidence
suggests that the physical qualities of the healthcare setting influence health and well-being
outcomes (Evans, 2003; Galea et al., 2005; Laursen et al., 2014; T. H. M. Moore et al., 2018;
Rao et al., 2007; Ulrich et al., 1991; Yadav et al., 2018). In this context, it has become
increasingly essential to reconsider hospital design and the therapeutic environment
concept, as it should be a place that supports its users (staff, patients, and their families), in
44
psychological, emotional, and social terms, in addition to being a place where patients are
treated with the most cutting-edge medicine and technology (Smith & Watkins, 2016;
Ulrich et al., 2008).
Evidence of health benefits associated with exposure to nature includes pain reduction,
less medication, lower blood pressure, faster recoveries and decreased all-cause mortality
in general (S. H. Park & Mattson, 2009; Ulrich, 1984). Biophilic design also has a crucial
effect on supportive care, particularly important for cancer patients, who often have to
deal with psychological distress, fatigue, anxiety or depression (Clarke & Currie, 2009;
DeJean et al., 2013; Evans, 2003; Laursen et al., 2014; T. H. M. Moore et al., 2018; Turner &
Kelly, 2000; Ulrich et al., 1991). Contact with nature has shown to promote emotional,
mental and spiritual health, reducing stress and triggering positive shifts in mood (Abdelaal
& Soebarto, 2019; Berman et al., 2008; Murphy & Mansfield, 2017; Silverstein, 2009).
The focus of this research is not analysing clinical environments but rather focusing on
the crucial role of the environment to give psychological support. To this end, not only
biophilic design as a framework has focused on this support, as a range of design theories
have emerged in this direction. The next section will briefly introduce some of the
therapeutic design theories that follow this approach.
3.2. Other Relevant Theories and Approaches of Therapeutic

Environment
3.2.1. Stress Recovery Theory (SRT)
Initially, Stress Recovery Theory (SRT) was introduced by Roger S. Ulrich in 1983. SRT is a
critical framework to explain nature’s restorative effects (Ulrich, 1983; Ulrich et al., 1991).
This theory specifically tries to clarify how exposure to nature can help people experience
less psychophysiological stress. According to SRT, natural environments and elements still
evoke pleasant effects in people of modern ages as the modern human brain is configured
for prehistoric behaviours according to Evolutionary Psychology (Cosmides & Tooby, 1997),
which may subsequently decrease psychophysiological stress (Ulrich, 1993). Basically, SRT
claims that human beings are biologically equipped to show positive impacts from nature
and natural processes. Therefore, contact with nature can generate a quick impact that
reduces negative emotions and helps to recover from stress and health problems (Parsons
et al., 1998; Ulrich, 1983, 1993; Ulrich et al., 1991).
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3.2.2. Attention Restoration Theory
Another important framework that explains nature’s restorative effects is Attention
Restoration Theory (ART), which was introduced by Rachel and Stephen Kaplan in 1989.
ART’s fundamental belief is that there are two types of attention that people can depict:
“Directed attention” which requires an effort that can cause mental fatigue, and “soft
fascination” which might help restoration from directed attention fatigue. ART discusses
the restorative benefits of natural settings in terms of recovering from directed attention
fatigue. The theory proposes that interaction with nature helps to relieve stress and mental
fatigue without much cognitive work (R. Kaplan & Kaplan, 1989; S. Kaplan, 1995; S. Kaplan
& Berman, 2010). In ART’s proposal, individuals can benefit from being away from everyday
stress, engaging in endeavours that are "compatible" with human innate tendencies, and
experiencing stimuli (S. Kaplan, 1995). According to ART, nature can particularly play a role
to provide restorative opportunities because of its “aesthetic advantage”(R. Kaplan &
Kaplan, 1989; S. Kaplan & Berman, 2010). In contrast to SRT, which focuses on people's
immediate emotional reactions to nature as a source of restoration, ART concentrates on
the potential cognitive advantages that may result from contact with natural environments.
3.2.3. Supportive Design Theory

Supportive Design Theory, as a continuation of SRT, emerged as a result of Roger
Ulrich’s interpretation of his studies that proved the impact of the physical environment on
humans in healthcare settings (Hamilton & Watkins, 2008; Ulrich et al., 1991). The theory
defends that designing healthcare settings should aim more than functionally efficient
budget ‘healing factories’, and designers can achieve this goal by encouraging well-being by
creating a psychologically and socially supportive physical environment (Ulrich, 2000).
Supportive healthcare design should be patient-centred and help patients cope with
stress and anxiety, rather than merely complementing medical treatment. Ulrich (2000)’s
guideline leads designers to enhance patient control and privacy, improve social support,
and increase access to nature for creating patient-centred healthcare settings. Hereby, he
claimed that a `supportive design’ will reduce stress and anxiety, improve sleeping, reduce
pain, lower infection occurrence, and improve satisfaction. Along with the patient’s
outcome, it will be beneficial for staff in terms of reduced stress, improved job satisfaction,
the possibility of reduced turnover, and greater attraction of qualified employees.
Moreover, the application of supportive design saves costs by improving medical outcomes
and staff’s quality of life (Ulrich, 2000).
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3.2.4. Therapeutic Environment Theory
Therapeutic environment theory claims that typical hospitals increase patients’ stress
levels, which can facilitate immune system disorder, emotional destruction and hamper
recovery. The theory of the therapeutic environment derives from the fields of
environmental psychology, neuroscience and psychoneuroimmunology (Smith & Watkins,
2016). The theory proposes four factors for designing a healthcare environment to reduce
the stress of patients and their families (Ibid.):
▪ Reduce or eliminate environmental stressors

▪ Provide positive distractions
▪ Enable social support
▪ Give a sense of control
Application of these four factors provides new environmental conditions such as; access
to daylight and appropriate lighting, noise reduction, appropriate use of technology, and
same-handed patient rooms (standardises all rooms within a unit) (Watkins et al., 2011),
providing 'off-stage' areas for respite. Furthermore, this theory suggests that new
environmental conditions can also improve staff in terms of satisfaction, and effectiveness;
thus, staff’s improvement will help patients’ outcomes (Smith & Watkins, 2016).
3.2.5. Evidence-Based Design (EBD) Approach

Evidence-based design (EBD) is a novel concept in architectural healthcare design in the
21st century. The Centre for Health Design (About EBD | The Center for Health Design,
2022.) defines EBD as “the process of basing decisions about the built environment on
credible research to achieve the best possible outcomes”.
As design decisions are based on reliable scientific evidence, this strategy aims to
provide a closer match between design intentions, and medical and organizational
outcomes. Thus, the conceptual sub-categories of EBD were defined as; access to nature,
options and choices, positive distractions, social support, environmental stressors, and clear
design steps to reduce stress and enhance the recovery of patients (Freimane, 2013).
Ulrich et al. (2008) claimed that EBD can help designers to create a healthcare
environment that is comfortable and less stressful for all users and can provide a faster
recovery to patients.
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3.2.6. Salutogenic Approach
The theory of Salutogenesis was introduced by Aaron Antonovsky in 1979 in his book
Health, Stress and Coping (Mazuch, 2017). The term Salutogenesis stands for ‘health
origins’, coined from the Latin salus meaning health, and the Greek genesis for origin
(Antonovsky, 1979). The Salutogenesis concept focuses on active health and wellbeing
rather than a pathogenic approach that focuses exclusively on resultant disease and injury
(Mazuch, 2017).
The framework for salutogenic design incorporates three key factors (Boscherini, 2017):
welcoming spaces for meeting and social exchange; familiar spaces for orientation and
reassurance; and quiet spaces for meditation and restoration.
Salutogenesis claims that coping with stress mainly is an outcome of the quality of the
environment which is in relation to the individual’s sense of coherence (Lyon, 2017).
Boscherini (2017) explained the relationship between the physical environment and an
individual’s sense of coherence as:
We understand this commonly as ‘keeping it together’ in the face of adversity, and

it manifests itself, when facing serious health challenges, through manageability:
the availability of resources and a supportive social network; comprehensibility,
intended as a comforting backdrop that offers order and familiarity; and
meaningfulness, understood as the inspiring realisation that there are important
‘phenomena’ in life and nature.
Dilani (2014) explained salutogenic design as: “An approach used to promote health and
well-being by creating a built environment that includes wellness factors, contributing to
the sense of well-being for staff and strengthening the healing process. It provides a basic
theoretical framework for psychosocially supportive design.” He also emphasised that
implementing salutogenic designs into healthcare facilities can accelerate the recovery of
health.
Although salutogenic design is very commonly mentioned along with biophilic design. It
is mainly about promoting active health and wellbeing rather than only coping with
illnesses pathogenically, while biophilic design is mainly about helping the healing process
and wellbeing by cooperating with nature (Boscherini, 2017).
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3.2.7. Psychosocially-Supportive Design (PSD)
The Psychosocially Supportive Design (PSD) framework, introduced by Alan Dilani,
focuses on promoting environmental qualities in clinical environments to support
psychosocial behaviours which are neglected due to merely concentrating on treating
patients. PSD encourages patients socially and mentally and also promotes their sense of
coherence. This approach primarily strives for attracting attention to start a mental
progression that will promote positive psychological emotions and may cope with anxiety
(Dilani, 2008). Dilani (2008) explained how to employ the PSD approach as:
Psychosocially supportive design should incorporate and consider factors such as

access to symbolic and spiritual elements; access to art; good lighting; attractive
space for social interactions; private spaces; and an interior environment that
provides positive experiences. Other factors include visual and physical access to
nature, and personal control over, for example, lighting, daylight, sound, indoor
sense of coherence, thereby enhancing his or her coping strategies and health.
Psychosocially supportive design is not only the task for one person, but requires
that the entire organisation understands the meaning of salutary management.
PSD may offer some benefits when it is applied in healthcare facilities. It can help to
reduce the anxiety and stress levels of patients, can help to decrease pain, and promote
medical outcomes and quality of sleep while providing a comfortable environment (Dilani,
2008).
3.2.8. Superarchitecture Approach

The superarchitecture concept is not only sustainable but offers positive benefits for
both human wellbeing and the environment, thus, it employs a combination of biophilic
design and sustainable design for purpose of creating this ‘super’ architecture (Peters,
2017).
This design concept aims for more than minimal harm to the environment, buildings
should offer assessable mutual benefit for environmental sustainability and human health
and wellbeing. To create these healthy green buildings, architects should endeavour not
merely to improve the recovery process, but also to enhance users’ physical and mental
abilities (Peters, 2017).
Peters (2017) argued that high-performing sustainable designs also offer benefits for
human health and wellbeing, if some particular biophilic design principles are applied
49
elaborately, such as: daylight, access to nature, colour, natural ventilation, noise,
spaciousness, furniture and fittings and thermal comfort.
3.2.9. Sense-Sensitive Design

The goal of this approach is to create the most powerful healing environments for every
individual within the healthcare facilities by focusing particularly on the five senses: sight,
hearing, touch, smell and taste (Mazuch, 2017). The sense-sensitive design was formed by
TH!NK, a specialist group within the practice. Mazuch (2017) explained this approach as:
Sense-sensitive design is a rigorous, evidence-based design approach that identifies
ways in which individual sensory receptors of varied patient groups experience built
environments, thereby enabling the designer to deliver optimal healing healthcare
settings. Studies clearly show that elements of the internal environment such as
natural light, artificial light, views, art, smell, modulation of space and form,
juxtaposition of furniture, manipulation of scale, proportion and rhythm, together
with sound, texture, materials, ease and flow of movement through space and time,
and indoor/outdoor landscape, offer powerful healing and therapeutic benefits to
varied patient groups.
3.3. Clinical and Non-Clinical Healing Environment

It is critical to this study to understand the differences between clinical and non-clinical
healing environments, as necessary settings in which patients receive different types of
support. The Cambridge English Dictionary defines the term ‘non-clinical’ as
“(of medical work or workers) not involving the examination and treatment of ill people”,
whereas the term ‘clinical is defined as “used to refer to medical work or teaching that
relates to the examination and treatment of ill people” (Cambridge English Dictionary,
2022). Starting with the current building regulations for healthcare settings in the UK, this
section provides an explanation of the scope of clinical and non-clinical therapeutic
environments in this study by using examples.
3.3.1. Building Codes and Standards for Healthcare Settings in the UK

In addition to the different design theories that have emerged in research and practice,
it is widely acknowledged the benefits that nature can bring to our health, and knowledge
in this area has successively informed regulatory frameworks and policies across countries,
and most certainly in the UK. The key documents for all health buildings have been
organised by the Department of Health for healthcare buildings in England as the Health
Building Notes. The Health Building Notes have been arranged based on 17 core subjects
50
and currently consist of 30 guidelines. These guidelines aim to “promote the design of
healthcare facilities with regard to the safety, privacy and dignity of patients, staff and
visitors” and give best practice guidance to design healthcare buildings by explaining policy,
regulatory overview and design considerations for each subject (Core elements, Cardiac
care, Cancer care, Mental health, In-patient care, Older people, Diagnostics, Renal care,
Long-term conditions/long-stay care, Children, Young people and maternity services,
Surgery, Community care, Out-patient care, Decontamination, Medicines management,
Emergency care, Pathology). Apart from the NHS Constitution, this guidance followed two
main legislations: Building Regulations 2010 – regulations that govern the construction and
services within buildings, and Health and Safety at Work etc Act 1974 – regulations that
govern the working conditions within buildings. Moreover, health and safety regulations
(Health and Safety at Work etc Act 1974, Workplace Regulations 1992, Management of
Health and Safety at Work Regulations 1999, The Construction Regulations 2007, Manual
Handling Operations Regulations), Climate Change Act 2008, The Code of Practice on
Infection Prevention and Control (HCAI, 2008) are other legislations the healthcare design
needs to follow (Department of Health, 2013a, 2014).
The Core Elements provide policy and regulatory overview, strategic and master
planning, and evidence-based design ideas for a therapeutic environment by explaining the
design considerations and regulations. The policy advise increasing design quality since
“well-designed healthcare buildings can help patients recover their health and well-being
and have a positive effect on staff performance and retention”, although their content
prioritises the requirements in relation to safety and suitability of premises; safety,
availability and suitability of equipment; and cleanliness and infection control (Department
of Health, 2014).
As expected, the guidelines highlight some points that are not only relevant to this
study, but also establish minimum standards that should be met. Firstly, the material and
furniture choice have to consider risk assessment and infection control protocols.
Particularly, the most common safety incident, falling, was highlighted (Department of
Health, 2013a, 2014). However, there is no supportive statement for natural material use,
as the guidance only priortise infection control and risk assesment rather than guiding
towards psycologically supportive environment design. Colour selection was advised to be
thought with lighting design, and monochromatic colour selection should be avoided to
ease wayfinding and reduce accidents since some people can confuse same-tone colours.
Therefore, walls, floors and furniture colours should visually contrast. Moreover, wall and
51
floor coverings have to be appropriate for easy cleaning (Department of Health, 2013a,
2013b, 2014).
The guidelines encourage natural lighting to reduce psychological problems and reduce
sickness among both patients and staff. View of the outside is also recommended,
however, the indication was that natural light without a view is preferable to no natural
light(Department of Health, 2014).
Natural ventilation is also encouraged wherever possible considering safety and security
protocols (particularly windows restrictor regulations). Although sustainability protocols
encourage natural cross-ventilation for reduced carbon footprints, it may be against
acoustic privacy regulations. Therefore, the designers are reminded to consider a balance
with privacy requirements. The importance of building orientation design is indicated while
considering noise control and natural ventilation. The use of artwork is also encouraged to
assist in wayfinding along with reducing physical and emotional stress (Department of
Health, 2013b, 2014).
The Health Building Notes also provide the designers with evidence-based design ideas
for therapeutic environment guidelines, which reports evidence and general design
considerations for different parts of the healthcare environments: arriving (outside),
arriving (inside), circulation, waiting areas, in-patient rooms, consultation,
socialising/meeting, vending areas, sanctuary (outside), toilets and washrooms, sanctuary
(inside)(Department of Health, 2014).
In terms of cancer-related regulations, Health Building Note 02-01: Cancer treatment

facilities explain general treatment steps of cancer and technical information about
Chemotherapy, Radiotherapy, Surgical oncology, Emergency care, In-patient care, and
necessary spatial organisation considerations for these environments. The guidelines
recommend the project teams to get an insight into all users before the start of the design
process. In relation to the quality of the environment, some important features are
recommended, such as “external views and access to gardens where possible; positive
distractions, for example with interesting artwork; the ability to control temperature locally
(some patients are very sensitive to temperature), especially in the treatment suites;
control over noise and lighting; and control over privacy” (Department of Health, 2013c).
Also, the guidelines recommended to all cancer services to adopt the Macmillan Quality
Environment Mark (MQEM), a certification system designed by Macmillan Cancer Support
to assess the quality of the environment and physical space with patient experience in
52
cancer facilities (Department of Health, 2013c; Macmillan Cancer Support, 2015). MQEM
identifies five main principles for cancer care environments: Accessibility, Privacy and
dignity, Comfort and well-being, Choice and control, and Support. In order to assess these
principles, the accreditation system follows a 14-step assessment process. Some of the
assessment criterion show relevance with biophilic design parameters and natural
elements: Privacy and refuge, access to natural light, good quality artificial light design,
contributing to their sense of comfort and wellbeing with colour and artwork, having access
to attractive outdoor and natural spaces, having control on noise levels, light, temperature
and climate in the spaces, preventing unpleasant odours, etc (Macmillan Cancer Support,
2015).
In summary, since the nature of these guidelines mainly focuses on safety, security, and
infection control, environmental psychology and, in particular for this thesis, the inclusion
of natural elements was considered as a secondary topic. Current standards do not
specialise in biophilic design and do not indicate biophilic parameters directly but use
biophilic values as criteria among the many other non-biophilic features. It can be observed
that the guidelines highly encourage the inclusion of natural light, view, natural ventilation,
access to natural spaces and outdoor environments, privacy and feeling of refuge, and
creating a sense of welcome. Although there is some exceptional specific guidance (i.e.
designers should prefer natural light over view, if not possible to employ both of them in
the design), these recommendations did not reflect a clear order of importance and
emphasis on the minimum application requirement as my position defends these biophilic
parameters should be involved in the design together harmoniously to provide the best
therapeutic environmental conditions, otherwise, the application in design practice is also
missing important parameters in terms of biophilic design.
Although the building standards are highly developed and human-centred in the UK,
examples of psychologically and emotionally non-supportive healthcare environments can
frequently be observed. The following sections exemplify both undesirable and successful
examples of the current condition of therapeutic architecture in the UK.
3.3.2. Clinical Therapeutic Environments

Clinical therapeutic environments in this study refer to the places where the patients
received medical treatment and examination by medical workers such as hospitals, cancer
centres, medical clinics, and so on. However, the main focus to examine clinical settings are
53
from a cancer patients’ perspective, since this population visit these environments on a
regular basis, and face psychological wellbeing problems frequently.
A B C
D E
G
F G
H I J
Figure 3-1: General current state of the modern hospitals in the UK.
As stated before, Charles Jencks, architect and co-founder of Maggie’s Centres,

described today’s healthcare facilities as factory-hospitals, where the relevant medical and
technical resources are dedicated to mass health (Jencks, 2017). Therefore, today still many
environmentally poor healthcare facilities can be observed across the UK, although the
number of patient-centred good examples has been increasing. This study examines clinical
environments in the scope of different spaces within the current state of clinical healthcare
settings, which were grouped in the ‘Architecture for Healthcare book by Andrea Boekel
(Boekel, 2007): Foyer and reception areas (Figure 3-1a), waiting areas (Figure 3-1b), nurses’
station and staff break areas (Figure 3-1i), corridors (Figure 3-1g), diagnostic, surgical, and
54
recovery areas (Figure 3-1 c, e, f), patient rooms (Figure 3-1d, h), cafeteria facilities (Figure
3-1j).
As explained in section 3.1, many studies have confirmed that patients who are
diagnosed with cancer and are undergoing treatment may experience high levels of
psychological discomfort, with much experiencing fatigue, anxiety or depression. Research
has also shown that the built environment has an important effect on health, well-being,
anxiety, depression, emotional distress and other mental health issues directly and
indirectly. Therefore, in order to have a break from the poor quality of the ‘factory
hospitals’, Jencks’ vision for Maggie’s Centres confirmed the need for non-clinical, human-
centred therapeutic environments, as the main driver of their design agenda (Jencks, 2017).
Along with the non-clinical settings developments (See 3.3.3), clinical settings can also be
improved with natural processes.
In order to decrease a ‘hospital feeling’ and promote users’ well-being, some practices
aimed to create homely comfortable spaces in their hospital designs by including biophilic
elements into the environment. In order to give an insight into this practice trend, the
following three examples show some of the current transformations in clinical healthcare
settings in the UK in this direction. These examples were selected due to their outstanding
biophilic values, and they are used as cases in Chapter 6 where interviews with the
architects are presented.
Circle Bath Hospital
Circle Bath Hospital, designed by Foster+Partners, was opened in 2009 in Bath, UK. The
location was chosen in the outskirts of the city to create a better connection with the
countryside feel in terms of view, fresh air and greenery. Along with the comfortable more
domestic furniture choice, the design team also aimed to introduce timber as a building
material, as much as possible. The atrium and big windows were used to get more light
inside the building. Figure 3-2 shows the details and pictures from this hospital. Although,
this hospital has not been called ‘biophilic’, its strong connection with natural elements, the
inclusion of natural light, natural ventilation, nature views, natural material and greenery
harmoniously in the space lead me to present it as an example of biophilic design
healthcare facility in the UK.
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Circle Bath Hospital
Architect: Foster+Partners Location: Bath-England
Opened: 2009 Building Area: 6,367m²
Figure 3-2: Circle Bath Hospital.
Cancer Centre at Guy’s Hospital
The Cancer Centre at Guy’s Hospital, designed by Rogers Stirk Harbour + Partners, was
opened in 2016 in London. The design aimed to change the clinical perception of the users.
The designers also worked with the cancer patients to reveal their problems within the
spaces. Therefore, Guy’s cancer centre became the first in Europe to locate radiotherapy
treatment above the ground level. The 14-storey building is vertically divided into four
‘villages’ and the welcoming zone. This division helped to increase wayfinding and less
institutional feeling. Daylight, greenery, and natural ventilation were prominently thought
of in the design process. Figure 3-3 shows detailed information and images from this
centre.
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Cancer Centre at Guy’s Hospital
Architect: Rogers Stirk Harbour + Partners Location: London-England
Opened: 2016 Building Area: 20,000 m²
Figure 3-3: Cancer Centre at Guy’s Hospital.
Similar to the previous example, this facility used many biophilic parameters
harmoniously in their design; maximising natural light by building rotation, providing
natural ventilation and offering easy access to the outdoor via balconies where greenery
welcomes people, providing a feeling of prospect with a great view of the city, the inclusion
of natural timber material and variety of colours. As stated above, this facility even
introduced a radiotherapy service on the upper floor where the patients found access to
daylight, which is unusual for radiotherapy departments usually located underground in
hospitals. Also, the organisation of various services in different ‘villages’ increased the
57
sense of welcome and wayfinding. Along with the environmental design, organisational
arrangements also increase a sense of relaxation. For example, a no-reception idea was
introduced in the facility, therefore, a volunteer team friendly welcomes people in the
villages and helps them during their visit.
Alder Hey Children's Hospital
The Alder Hey Children's Hospital, designed by BDP, was opened in 2015 in Liverpool.
Although this hospital has not been labelled as ‘biophilic’, the harmonious inclusion of
some biophilic parameters can be a good example for future designs. The designers aimed
to create a hospital that engenders well-being and raises users’ spirits and quality of life by
integrating the hospital with the nearby park for the therapeutic benefit of children, their
families and staff. The majority of the rooms offer a park view and sufficient daylight was
provided via panoramic windows. . Connection with the outdoor environment and fresh air
was also provided via terraces and gardens which are equally accessible to all users. The
effective inclusion of various colours and natural materials increased the biophilic value of
the space. Figure 3-4 shows detailed information and images from the hospital.
Alder Hey Children's Hospital
Architect: BDP Location: Liverpool-England
Opened: 2015 Building Area: 6,367m²
Figure 3-4: Alder Hey Children's Hospital.
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3.3.3. Non-Clinical Environment: Maggie’s Centres Case
The scope of the ‘non-clinical’ therapeutic environment in this research includes places
where the patients received practical, emotional and social support from trained healthcare
professionals. In comparison with clinical settings, patients are not delivered medical
treatments in non-clinical settings.
Having examined non-clinical environments in relation to health and wellbeing, the

decision was to examine Maggie’s Centres, which provide free practical, emotional and
social support to people with cancer and their family and friends, following the ideas about
cancer care originally laid out by Maggie Keswick Jencks.
Maggie’s Centres are widely considered examples of biophilic design because of its well-
defined design guidelines, where the main criteria are based on natural elements to
promote the wellbeing of users(Maggie’s Keswick Jencks Cancer Trust, 2015). These designs
have very distinctive architecture, designed by renowned architects, and provide an
alternative attitude for the image of healthcare, in which the primary intention is to
promote well-being. Also, Maggie Keswick Jencks and her architect husband Charles Jencks,
who were the founder of the concept (1993-1995) for the first Maggie’s Centre, which was
built in Edinburgh in 1996, had the ideology that architecture can help people through
critical moments, and they aimed to provide a nature-connected architecture in these
facilities (Keswick Jencks, 1995).
As another example of non-clinical therapeutic settings, a new initiative is taking place in

the Merseyside region which is called Mersey Care Life Rooms. In this case, these facilities
are focused on how to provide a community space for people with mental health issues.
Life Rooms is a concept developed by Mersey Care NHS Foundation Trust, designed to
provide enhanced support for the mental health and well-being of service users, carers,
their families and the local community through a social model. The first Life Room was
opened in Walton in May 2016, followed by Southport Life Room in May 2019, Bootle Life
Room in October 2019, and Lee Valley Life Room in May 2022 (liferooms.org, 2022).
Compared to Maggie’s Centres, Life Rooms reuse existing buildings, refurbished for this
new purpose, so their spatial resources are more limited. However, they have exciting
aspects in many cases, like the use of the buildings that are well-known buildings within the
community, which might provide familiarity, closeness, a sense of belonging and pride, etc.
In these initiatives, the new programme tries to be a part of the neighbourhood.
Furthermore, while Maggie’s Centres prioritise individual well-being, Life Rooms also
59
focuses on social-communal well-being. Figure 3-5 shows the earliest Life Room, in Walton,
which was occupied in the well-known building that used to be Carnegie Library, built in
1911. The centre’s design process collaborated with the local community; therefore, the
library characteristic was preserved along with a public cafeteria where everybody can pop
in to have a drink to socialise. The amount of daylight, spaciousness, plants and
comfortable furniture stand out as the most prominent environmental features.
Figure 3-5: Walton Life Room, Liverpool, UK.
Regarding the profound connection with biophilic design parameters, this thesis
exclusively investigates Maggie’s centres. The following sections examined Maggie's
Architecture and Landscape Brief and reviews examples of Maggie’s centre architecture.
3.3.3.1. Maggie's Architecture and Landscape Brief
Over the course of seven years, Maggie experienced cancer diagnosis, treatment,
remission and recurrence. During that time, she took the insight and experience she
had gained and transformed it into a pioneering approach to cancer care. Among
Maggie’s beliefs about cancer treatment was the importance of environment to a
person dealing with cancer. She talked about the need for “thoughtful lighting, a
view out to trees, birds and sky,” and the opportunity “to relax and talk away from
home cares”. She talked about the need for a welcoming, reassuring space, as well
as a place for privacy, where someone can take in information at their own pace
(Maggie’s Keswick Jencks Cancer Trust, 2015).
The brief is a quite generic guideline that prominently draws the picture of feelings they
want to convey to visitors with the design of the spaces. Emphasises the demand for
spiritually raising, friendly, inviting, welcoming and safe architecture that evokes curiosity
by attracting the attention of the patients just after leaving the hospital. The brief demands
a building that works like a sanctuary by providing refuge from the intimidating hospital
60
environment, while the landscape of the centre allows the visitors a bit of breathing space
between the hospital life and the outside world.
As cancer patients need courage, self-confidence and resourcefulness, the atmosphere

should offer a calm, inviting, encouraging and bold environment where patients also can be
encouraged to make choices. Maggie’s belief proposes that even the small choices they
make, such as where they want to drink coffee or choose the cushion to arrange the height
of the chair, break the rigidity of the choiceless feeling of cancer.
Building a natural environment by creating a strong connection between the inside and
outside spaces is a critical criterion in the brief. Prospect, refuge, and reflecting seasonal
changes inside were recommended strongly to create inside-outside impact within the
centres. There should be as much natural light as possible. Furthermore, indoor and
outdoor planting also demanded providing a multisensory environment and privacy by
filtering the view from outside.
Another important criterion of the brief is creating socialising space to take people out
of the feeling of isolation. However, this socially encouraging environment should also be a
possibility to withdraw and rest in privacy when needed.
The generic brief draws a general picture of a required centre atmosphere. Each centre
varies in size and proportion; therefore, the client team involves in the design stages.
However, all centres need to be aesthetic, domestic, and small humane buildings with a
strong connection with nature and natural elements that raises the users’ spirit. The
homely and domestic environment should not remind the hospital environment of what is
now commonly recognised as demoralising layout with long corridors, closed doors,
artificial light, smell of medicine, signposting etc.
Table 3-1 explains the general spatial requirements in Maggie's Architecture and
Landscape Brief.
Table 3-1: General spatial requirements in Maggie's Architecture and Landscape Brief (Maggie’s Keswick Jencks
Cancer Trust, 2015)
Space Requirements
Entrance The entrance should be obvious, welcoming, and not intimidating, with a place to hang
your coat and leave your brolly. The door should not be draughty, so perhaps there
should be a lobby
Entrance/welcome We think of this as a “pause” space, in which a newcomer can see and assess what’s
area: going on without feeling they have to jump right in. The first impression must be
encouraging. There should be somewhere for you and a friend or relative to sit, a shelf
with some books and an ability to assess, more or less, the layout of the rest of the
building.
Office: The office space should be discreet but positioned so that a member of staff working at
61
their desk can spot somebody new coming in to the Centre, (there will be no reception
desk). There should be generous storage room for stationery and leaflets. Space will be
needed for a photocopier, printer, server etc. Each of the three main workstations
needs a telephone, computer point and light, shelf and drawer space. As well as the
main ones there should be six smaller workstations.
Kitchen: The kitchen area should have room for a large table to seat 12 and is usually the main
hub of the building. A fairly large “island” with additional seating for two or three
people is essential for nutrition workshops, and extra space for setting up food or
drinks. You need to be able to move around the table, and between it and the island.
The layout of the kitchen should encourage people to help themselves to tea and
coffee. We need ideally two dishwashers (or one large and one small), a large fridge or
two smaller ones, one and a half sinks, an oven and a hob.
Computer desk: We need two computer areas for people visiting the Centre who want to access
information online, and these need to be within shouting distance of the office area for
help if needed…the two areas don’t have to be side by side.
Notice board: There should be space for a notice board to include fundraising and programme
messaging – somewhere subtle, not too “in your face” but visible.
Library: A place to find books and information and be able to sit and look at them comfortably.
Some part of the library needs to have shelving for leaflets and booklets. This space
could well be integrated with the “pause space” or an extension of it.
Sitting rooms: We need three “sitting rooms” which can be shut off from each other or opened up
depending on how they are to be used:
1. The first large room will be used for relaxation groups, t’ai chi, yoga, lectures or
meetings and should provide space sufficient to accommodate 12 people lying down
and storage room for folding chairs and yoga mats. It also needs to be able to store
table(s) for up to 10 people. A flexible space with options to provide more or less
privacy would be helpful. The noise from the main hub area of the building needs to be
buffered…it doesn’t have to be completely sound-proof. It helps if this room is
contiguous to the kitchen area, so that it is also possible to have fundraising events
there.
2. The second medium-to-large-sized room will be used for workshops and sessions,
and needs a table able to seat 12 people, which could be permanent or easy to
assemble and store. This room doesn’t have to be completely sound-proof either, but
should be able to be private and not to be looked in on.
3. A third smaller sitting/counselling room for up to 12 people with a fireplace or stove
which doesn’t have to be very big - it makes for a friendlier atmosphere if people have
to budge up a bit.
Consultation Two small rooms used for counselling or therapy, these need windows looking out to
rooms: grass/trees, or at least a bit of sky. One of the rooms should be able to take a
treatment bed. Both should be sound-proof and private when in use, but could be
open when not in use.
Toilets: Two toilets with washbasins and mirrors, which should be big enough to take a
chair and a bookshelf and one of them must have disabled access. They must be
private enough to cry. They must be nice places; they should NEVER have gaps beneath
the doors.
Retreat: A very small quiet space to have a rest or a lie down would be good.
Views out: It is important to be able to look out and even step out from as many of the internal
spaces as possible even if it is only into a planted courtyard. Planting works well here
too. It not only gives a focus to look out at, it can filter privacy in a room with glass
doors or windows to the outside. We want the garden, like the kitchen, to be a space
for people to share and feel refreshed by.
Views in: The interior shouldn’t be so open that people feel watched or unprotected.
Parking: Most projects require some parking spaces.
3.3.3.2. Existing Centres and architectural features
Maggie’s Cancer Trust has 24 centres across the UK (Aberdeen, Barts – London (City &
East), Cambridge, Cardiff, Cheltenham, Dundee, Edinburgh, Fife, Forth Valley, Glasgow,
62
Highlands, Lanarkshire, Manchester, Newcastle, Nottingham, Oldham, Oxford, Royal Free,
Royal Marsden, Southampton, Swansea, West London, Wirral, Yorkshire), and three
international centres (Hong Kong, Tokyo, Kalida Barcelona) (Table 3-2). Also, Maggie’s
centres in Northampton, Coventry, Bristol, Preston, Norway, and the Netherlands are
currently (2022) in development and will start to be in service in near future. This study
focused on various centres which were examined by the previous researchers from
different perspectives in Chapter 5, while Chapter 6 focused on six particular centres (Forth
Valley, Manchester, Newcastle, Nottingham, Southampton, and West London). The
selected centres presented various features: either located in a crowded urban
environment or more rural countryside; lower budget and more expensive centres;
employed special materials; aimed to attract more males; and so on. The presented
examples were selected from different period centres from 2001 to 2019.
Table 3-2: Operating Maggie’s Centres (September, 2022) (maggies.org).
Centre Image Designer Location Year Key Features

Aberdeen Snøhetta Aberdeen 2013 Shelf form aimed to
/ create a sense of
Scotland refuge.
Barts Steven Holl London / 2017 No Garden, but

Architects England provides rich
daylight in a dense
urban context.
Cambridge No purpose-built
building.
Cardiff Dow Jones Cardiff / 2019 Reflects the
Architects Wales domesticity of the
neighbouring
streets.
Cheltenham Sir Richard Cheltenha 2010 Combination of a

MacCormac m/ restored Victorian
England house and a
modern extension.
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Dundee Frank Dundee/ 2003 The first new-build
Gehry Scotland Maggie’s Centre.
Modelled on
traditional Scottish
cottage style.
Edinburgh Richard Edinburgh 1996 The first centre. A

Murphy / Scotland redevelopment of
Architects the old stable
blocks. Traditional
Scottish stonework
was applied
together with
modern methods.
Fife Dame Zaha Fife/ 2006 Particular on
Hadid Scotland natural light and
view through glass
façade. Black coal
emulated form
represents local old
mining community.
Forth Valley Garber & Larbert/ 2017 Near a loch, in a

James Scotland rural context.
Glasgow Rem Glasgow/ 2011 Located among the

Koolhaas, Scotland woodland in the
OMA grounds of the
Hospital. The
interlocking rooms
to flow into one
another while still
remaining separate.
Highlands David Page Inverness/ 2005 Spiral shapes
and Brian Scotland dominate the
Park garden, with the
grassy mounds and
gravel shapes
mirroring and
complementing the
shape of the
building.
Lanarkshire Reiach and Lanarkshir 2014 the creation of a
Hall e/ matrix of
Scotland courtyards that
result in a porous
building.
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Manchester Foster + Manchest 2016 Timber structure
Partners er/ enriched with glass
England surfaces. A glass
house inspired from
greenhouse idea.
Newcastle Ted Newcastle 2013 The man-friendly

Cullinan / centre. A successful
England combination of
concrete and
timber material.
Nottingham Piers Nottingha 2011 Elevated to contact

Gough m/ with greenery.
England Located in a
woodland.
Oldham Alex de Oldham/ 2017 Thermally treated

Rijke England tulipwood material.
Oxford Wilkinson Oxford/ 2014 The concept is

Eyre England based around a
treehouse.
Royal Free Daniel London/ No purpose-built

Libeskind England building yet. The
new building is
under construction.
Royal Ab Rogers London/ 2019 Comprises four

Marsden Design England volumes, clad in red
glazed extruded
terracotta, and is
set in an idyllic
garden.
Southampto Amanda Southamp 2021 Offers glimpses and

n Levete ton/ views of nature and
England provides privacy, as
well as places to
come together as a
group by moveable
walls.
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Swansea Kisho Swansea/ 2011 Its cosmic whirlpool
Kurokawa Wales shape reminiscent
with of the Milky Way,
Garbers & and this evokes an
James inspirational and
uplifting feeling.
West London RSH+P London/ 2008 The idea was to try

England to minimise the
overbearing impact
of Charing Cross
Hospital.
Wirral HB Merseysid 2021 In a more rural

Architects e/ context.
England
Yorkshire Heatherwic Leeds/ 2019 Porous materials

k Studio England such as lime plaster
help to maintain
the internal
humidity of the
naturally
ventilated building.
Hong Kong Frank Hong 2013 The first Maggie's

Gehry Kong/ Cancer Caring
China Centre outside of
the UK. References
to vernacular
therapeutic
architecture
Tokyo Cosmos Tokyo/ 2016 References to
More Japan vernacular
architecture
Kalida Benedetta Barcelona 2019 Compatible with

Tagliabue / surrounding
Spain heritage hospital
buildings.
Maggie’s Forth Valley
Maggie’s Forth Valley, designed by Garber & James, opened in 2017 on the grounds of
Forth Valley Hospital in Larbert- Scotland. The centre is located on the shore of Larbert Loch
which encouraged contact with nature within the centre. The rural location is also another
66
contributor to introducing biophilic design more effectively. Figure 3-6 shows detailed
information and images from the centre.
Maggie’s Forth Valley
Architect: Garber & James Location: Larbert-Scotland
Opened: 2017 Building Area: 269 m2
Figure 3-6: Maggie’s Forth Valley.
Maggie’s Manchester
Maggie’s Manchester, designed by Foster+Partners, opened in 2016 on the grounds of

the Christie Hospital in Manchester. The centre is located in a residential neighbourhood
away from traffic noise. The glass house and garden design aim to encourage users to be
involved in growing plants. The inclusion of daylight, plants and timber structures are the
most salient features of the centre. Figure 3-7 shows detailed information and images from
the centre.
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Maggie’s Manchester
Architect: Foster+Partners Location: Manchester-England
Opened: 2016 Building Area: 500m²
Figure 3-7: Maggie’s Manchester.
Maggie’s Newcastle
Maggie’s Newcastle, designed by Cullinan Studio, was opened in 2013 on the grounds of
Freeman Hospital in Newcastle upon Tyne. The design team aimed to increase the male
user population because the statistics showed that one-third of the users were male.
Therefore, material choice, facilities and the programme of the design reshaped the user
population. Figure 3-8 shows detailed information and images from the centre.
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Maggie’s Newcastle
Architect: Cullinan Studio Location: Newcastle upon Tyne -England
Figure 3-8: Maggie’s Newcastle.
Maggie’s Nottingham
Maggie’s Nottingham, designed by CZWG Architects, was opened in 2011 on the

grounds of Nottingham City Hospital. The location was chosen inside the woods with grown
trees in order to strengthen the connection with natural elements. The elevation from the
ground level that creates a visual connection with tree leaves is the most prominent feature
of the design. Figure 3-9 shows detailed information and images from the centre.
69
Maggie’s Nottingham
Architect: CZWG Architects Location: Nottingham-England
Figure 3-9: Maggie’s Nottingham.
Maggie’s Southampton
Maggie’s Southampton, designed by AL_A, opened in 2021 on the grounds of

Southampton General Hospital. The allocated location was a corner of the car park area
where the design team intervened in the topography to create an isolated quiet
environment with a sense of nature. Ceramic and stainless steel was used in a novel
application method that increased nature perception. Figure 3-10 shows detailed
information and images from the centre.
70
Maggie’s Southampton
Architect: AL_A Location: Southampton-England
Figure 3-10: Maggie’s Southampton.
Maggie’s West London
Maggie’s West London, designed by Rogers Stirk Harbour + Partners, was opened in
2008 on the grounds of Charing Cross Hospital in London. The centre is located at the
junction between Fulham Place Road and St Dunstan’s Road, which are quite busy lines in a
highly urbanised area. Landscape and building design aimed to create an environment
which is as quiet as possible. Maggie’s West London is the first Maggie’s Centre in England
71
and one of the earliest centres, therefore, its design inspired many other centres’ designs
approach. Figure 3-11 shows detailed information and images from the centre.
Maggie’s West London
Architect: Rogers Stirk Harbour + Partners Location: London-England
Figure 3-11: Maggie’s West London.
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In order to understand spaces for cancer, it is important to have an insight into the
cancer illness, its treatments and side effects and the problems patients faced. Thus, the
following section discusses cancer, problems and side effects of cancer and chemotherapy,
psychological and socio-economic perspectives, and design principles for cancer settings
from some architectural companies.
3.4. Cancer: Statistics, Effects, Problems and Approaches

Cancer is the second most common reason for death in the world (Adler & Page, 2008;
Fitzmaurice et al., 2018; Tabuchi, 2020). Statistics show that three million people have
cancer in the UK and this number is projected to be 5.3 million by 2040 (Macmillan Cancer
Support, 2022). In 2019, 391,000 people were diagnosed with cancer, and 167,000 people
died of cancer in the UK, however, it was also reported that numbers have less dramatically
increase over the last decade (Macmillan Cancer Support, 2022).
Cancer treatment follows a combination of chemotherapy, radiotherapy and surgery,

and the treatment process may take years where the patients have to attend clinics
regularly (Adler & Page, 2008; Morishita & Tsubaki, 2017). Along with physical problems,
the diagnosis of cancer also brings psychological and social problems (Adler & Page, 2008;
Mehnert et al., 2014; Mitchell et al., 2011; Singer, 2018; Singer et al., 2010). Diagnosis of
cancer is a quite traumatic event which usually shocks the patients (Chua et al., 2018), and
they link their illness with stigmatisation, loss of control, intense pain, and death (Singer,
2018). Recent research showed that majority of the cancer patients reported that the
mental health consequences of cancer diagnosis are worse than the physical effects of
cancer (Bevan & Wilson, 2022a). Therefore, about 30% of the patients face mental health
problems during cancer treatment (Mehnert et al., 2014; Mitchell et al., 2011; Singer,
2018), and depression, anxiety, and adjustment disorders are the most often diagnosed
conditions(Adler & Page, 2008; Singer, 2018). Depressed or anxious people have lower
social functioning, more disabilities, and overall functional impairment than people who are
not affected by these conditions. Stress and anxiety also cause other extra problems such
as pain, fatigue, and sleeping problems as well as promote unhealthy behaviours such as
smoking, drinking alcohol or overeating (Adler & Page, 2008). As with other chronic
illnesses, cancer can generate fear, anger, guilt, confusion, feelings of loss of control, and
sadness (Adler & Page, 2008; Stanton et al., 2007).
In parallel with the literature review, grey literature was scanned narratively in January
2020 in the scope of this thesis before starting the systematically searched review ( see
73
Chapter 4), to gain insight into relevant keywords for healing environments and cancer-
related well-being problems. The grey literature review focused on reports published by
cancer trusts and NHS online sources. The common problems stated by patients and
professionals were listed and the researcher (with support from the Psychology
Department) classified the prominent problems in groups to decide on the most extensive
keywords. Hereby, the main issues people with cancer confront were depression and
anxiety (Howells et al., 2019; Macmillan Cancer Support, 2019; Maggie Keswick Jencks
Cancer Trust, 2018a, 2018b, 2019a, 2019b, 2020a, 2020c, 2020b, 2021). Table 3-3 shows
the classification of all keywords identified in the grey literature review.
Table 3-3: Common well-being problems of patients with cancer.
1-Depression 2-Anxiety 3- Other feelings 4-Other Problems

Anhedonia Uncertainty Emotional distress Chemo Brain
Lose of the joy of living Fear Confusion Difficulty concentrating
Loss of interest in activities Changeable emotion Loss of sense of belonging Difficulty remembering
Grief Adjustment disorder Resilience and coping Changes in sleep
Guilt Sense of respite Changes in appetite
Irritability Isolation Increasing interest in
alcohol
Feeling down Feeling alone Upset stomach
Hopelessness Loss of independence Panic attacks
Worthlessness Paranoia
Anger Worry
Sadness Loss of energy and
motivation
Loss of self-esteem Suicidal thoughts
Based on the existing literature, Cankurtaran (Cankurtaran, 2020) listed briefly the
factors that affect the emotional distress and mental health problems of cancer patients as
follows: biological problems, side effects of medication, reactions to chemotherapy,
changes in body image, lack of information or skills needed to manage the illness, loss of
self-reliance, fear of suffering, confrontation with death, family members’ reaction to the
disease, pre-existing family problems, disruptions in work, school, and family life, death of
other patients, logistic and financial problems, and personality factors.
Moreover, psychological distress after diagnosis can be severe and may result in
clinically relevant mental health conditions (Singer, 2018). Apart from the patients, their
family and friends also spend a lot of time and energy while supporting them and they can
also suffer from mental health conditions (Adler & Page, 2008; Mehnert et al., 2010).
Socioeconomic condition also affects the treatment and recovery process. It is widely
accepted that low socioeconomic status is linked to both poor health and restricted access
74
to healthcare (Arrossi et al., 2007; Mutuma et al., 2017; Singer et al., 2010), and cancer
death rates were found to be higher in people with lower socioeconomic level (Tabuchi,
2020). When a patient is diagnosed with cancer, their socioeconomic status may even
decline, especially if they lose their work as a result of a cancer-related impairment (Singer,
2018). After receiving a cancer diagnosis or treatment, a significant proportion of people
discontinue working or change jobs (Adler & Page, 2008). Cancer & Employment Survey
results showed that in the UK 25 per cent of the participants did not return to their work
after completing their treatment, and 15 per cent of those who returned their work worked
with a different employer. Financial problems are defined as one of the major stressors for
cancer patients and their families (Bevan & Wilson, 2022a).
Cancer and chemotherapy treatment have prominent side effects that can be still
experienced long after recovery. The most common problems and side-effects of the
treatments that cancer patients faced are fatigue, depressed mood, appetite loss, sleep
problems, muscle weakness, pulmonary dysfunction, neurological disturbances, and pain
(Adler & Page, 2008; Bernhardson et al., 2008; Bevan & Wilson, 2022b; Chen et al., 2021;
Goodman, 1989; Morishita & Tsubaki, 2017; T. Wang et al., 2018). Partridge et al. (2001)
listed the most common short-term side-effects of chemotherapy as: emesis, nausea,
stomatitis, alopecia, myelosuppression, thromboembolism, myalgias, neuropathy, fatigue;
and long-term side-effects as premature menopause/infertility, weight gain, cardiac
dysfunction, leukemia/MDS and cognitive dysfunction. Taste and smell changes are also
frequently observed side effects of chemotherapy. Particularly, taste alteration is reported
by cancer patients undergoing chemotherapy as one of the most distressing side effects
together with hair loss, sleeping difficulties, vomiting, loss of appetite, fatigue and nausea
(Bernhardson et al., 2008; Zabernigg et al., 2010). A self-reported research showed that 67
per cent of participants experienced taste changes while 49 per cent experienced smell
changes at some point during the treatment, and more women reported smell change
experience than men (Bernhardson et al., 2008).
Although cancer care design mainly focused on providing safe and practical spaces for
treating the disease biomedically, cancer clinics have been considering patients’ emotional
and psychological needs by offering friendly, warm pleasant, more patient-focused
environments (Goodm, 2003; Zeliotis, 2017). The designers of these patient-focused
centres usually aim to create bright, attractive, social, accessible and homely environments
that will make patients feel more normal, and help them somehow to forget challenges
they faced . For example, HEAPY, one of these companies, reported their five design
75
considerations for modern cancer centres: feeling at home by designing more spacious and
cosier rooms with improved way-finding and a sense of familiarity; adaptable environment
that can be controlled by the patients; privacy and dignity; designed for wellness by using
appropriate HVAC systems and making use of natural light; seamless technology integration
(HEAPY, 2023). The architecture company HOK’s healthcare design group prioritise giving
patients the ability to take some control of the environment (HOK, 2020). The Healthcare
Facilities Management magazine advised designers to consider noise control, using safe
material, easy wayfinding and accessible spaces which do not require long-distance
walking, more privacy, a variety of furniture configurations that provide socialisation
opportunities, soft seating since cancer patients lose weight, maximise natural light and
views (Itani, 2015). However, above all design goals designers focus on infection control in
cancer centres as one of the most crucial points of healthcare design. Designers can be
involved in infection control by designing air ventilation and filtration systems, water
systems, choice of material (particularly avoiding toxic materials such as benzene, asbestos,
vinyl chloride, radon, and arsenic), designing self-cleaning opportunities (i.e. hand-washing
sinks and antibacterial gel stations close to treatment locations), or avoiding real plants
where they can be infectious for patients (Berry et al., 2020).
Cancer is an illness of the era. Scientific evidence supports that fighting stress and
anxiety has a profound impact on the recovery process. Therefore, the environment can
help to reduce the stress and anxiety of the inhabitants. However, the environmental
perception and needs of people with cancer should be taken into account.

This chapter gave insight into the definition and context of a healing environment with
examples close to biophilia of healthcare settings in the Western culture, from ancient
times to the present. Furthermore, it also presented a brief overview about the theories
that propose environmental agendas to promote healing characteristics of architecture,
mainly for healthcare settings. The definition of ‘clinical’ and ‘non-clinical’ notions brought
clarity for further chapters of this thesis with the examples that were frequently mentioned
in this research. Also, the current state of building regulations, building codes, and good
and bad examples of clinical and non-clinical settings will mainly be investigated in Chapters
4, 5, and 6.
76
In light of the knowledge conveyed in the literature review chapters (Chapters 2 and 3),
the following chapters will report the research that investigated biophilic design
parameters and implementations in therapeutic environments.
77
CHAPTER 4
78
4. ASSESSMENT OF BIOPHILIC DESIGN PARAMETERS IN
THERAPEUTIC ENVIRONMENTS WITH A SYSTEMATICALLY
SEARCHED REVIEW
A systematically searched review of existing scholarly literature on the importance of
biophilic design parameters and their impact on human health and well-being within clinical
therapeutic environments was chosen as a methodology for this study. This chapter
explained the systematic review methodology, its protocol, selected studies and their
quality assessment, extracted data, and synthesis of the results. The goal of this chapter is
to extract information from users (cancer patients and staff) to have their expectations
from a therapeutic environment and to understand their perspective for the clinical
environment that can also inform design recommendations in non-clinical environments.
4.1. Systematic Review Methodology

A systematic review methodology is a form of a literature review using a systematic
procedure, which originally emerged to help diagnose processes of illnesses, and is
prevalent in health and medicine studies (Cook et al., 1997) and tailored to different fields
with its clear system to answer research questions (Kitchenham, 2004). It was defined in
The PRISMA Statement as "A systematic review is a comprehensive review of a clearly
formulated keywords of a question that uses systematic and explicit criteria to identify,
select, and critically appraise relevant research, and to collect and analyse data from the
studies that are included in the review", (Moher et al., 2010). Likewise, Boland et al., (2017)
claimed that the best way of synthesising the findings of several studies which look for
answers to the same questions is the systematic review methodology. This kind of review
follows clear, well-defined and transparent steps, which offer a chance to be checked by
repeating the process, and always requires: a well-defined question or problem,
identification and critical appraisal of the evidence, synthesis of the findings and drawing
relevant conclusions (Boland et al., 2017). Since this study in the architecture field is not
able to carry out a full systematic review as in the medicine field. I will refer to the review
as a ‘systematically searched review’ in this thesis.
Although a narrative literature review was used for this PhD research's background, in
this chapter a systematically searched review was carried out instead of a narrative review
to obtain quantitative scientific facts for answering the main research question and
supporting the research by looking at existing research systematically. Systematic reviews
are different from traditional narrative reviews in several ways. Systematic reviews contain
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more scientific information and produce stronger evidence (Boland et al., 2017). This
methodology always requires well-defined and focused question(s) and a pre-defined
search strategy, and follows a protocol and an explicit and rigorous methodology (Boland et
al., 2017). In comparison to narrative reviews, the reasons for the acceptance of systematic
reviews as scientific processes can be listed as (Boland et al., 2017; Cook et al., 1997;
Karacam, 2013):
• Systematic reviews are more objective, less biased and more reliable.
• A systematic review is much more comprehensive and can be repeated
since it is done with a certain systematic and well-defined method.
• Inclusion and exclusion criteria for sources are clearly identified.
• Bias of included result sources is evaluated by using Quality Assessment
Tools.
• Peer reviews are done at some key steps for carrying out a more objective
review and preventing possible bias of the main researcher.
• Even the smallest evidence is included in the compilation when extracting
the data from the sources.
• The results can be confirmed anytime by repeating the proposed protocol.
The differences between the two types of reviews are collected in Table 4-1.
Although the process and steps of a systematic review methodology are the same, many
researchers have classified the systematic review stages differently so far. Cook et al. (1997)
listed six steps required for a robust systematic review: Question, Sources and search,
Selection, Appraisal, Synthesis and Inferences. The Prisma statement developed by Moher
et al. (2010), explained the protocol in four main stages: Identification, Screening,
Classification and Inclusion. According to Khan et al. (2003), a systematic review consists of
five main stages: Framing the question, Identifying relevant publications, Assessing study
quality, Summarising the evidence, and Interpreting the findings. Kitchenham, (2004)
adopted the systematic review methodology to the engineering field as three main stages:
Planning the review, Conducting the review, and Reporting the review. However, the steps
and methods of the process are the same for all systematic reviews as follows (Boland et
al., 2017):
▪ Planning the review
▪ Identifying the review question, scoping searches, inclusion and exclusion
criteria, and the protocol
▪ Literature searching
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▪ Screening titles and abstracts
▪ Obtaining papers
▪ Selecting full-text papers
▪ Data extraction
▪ Quality assessment
▪ Analysis/Synthesis
▪ Writing up and editing
Table 4-1: Differences in a review process between systematic and narrative reviews (Boland et al., 2017).
Narrative Reviews Systematic Reviews

Defining a question May not be clearly defined Always required, clearly defined and
well-focused
Writing a protocol Not required Essential
Methodology Does not follow explicit or rigorous Follows explicit or rigorous
methodology methodology
Searching No pre-defining search strategy Exhaustive and with an appropriate
Not necessarily comprehensive balance of sensitivity and specificity
Generally relies on published Carried out across a number of
literature bibliographic databases, hand
Search strategies may be based on searching of reference lists from
expert experience relevant papers and high-yield journals
and documents.
Grey literature sometimes searched
Comprehensive and explicit searching
methods used and reported
Definition of inclusion and Not essential Essential
exclusion criteria No selection of studies based on Study design can be selected
study design (e.g. only include qualitative data)
Screening titles and Generally carried out by one Explicit and systematic screening and
abstracts; selecting full- researcher by reading through selection, using pre-defined method
text papers relevant papers and based on their Usually cross-checked by another
own experience researcher
Quality assessment Not necessarily Yes
Data extraction Yes Yes
Analysis and synthesis No clear method of synthesis Can involve meta-analysis, narrative or
qualitative synthesis
Application Any field Any field
Timescale May be carried out relatively Can be time-consuming due to rigour
quickly required
Replication Not easily replicable Explicit methods and therefore
replicable
This systematically searched review followed the steps listed above from Boland et al.
(2017) systematic review guideline. After planning the review, the following stages started
with the identification of the review question.
4.2. The Review Question

Before starting the review, the research problem should be defined in the form of a
simple, unambiguous and organised question or several questions (Khan et al., 2003). The
research team should define the frame of the research question for which the purpose of
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the systematic review is established (Karacam, 2013). The question initially might be stated
as a query in a free-form format. However, the question also can be structured in a more
explicit way. A structured question, commonly in the fields of evidence-based healthcare,
focuses on four parts: the populations, the interventions, the outcomes, and the study
design (Ibid.).
In this review, the main research question of the PhD research was adopted, and it was
implemented as a free-form review question: Which biophilic criteria are most important in
a clinical therapeutic environment and how do they inform design?
Having set the question in a free form, the research team can modify the protocol where
alternative ways of describing populations, interventions, and results or study designs arise
(Karacam, 2013). Therefore, after defining the question, the systematically searched review
started with establishing a frame of the search strategy in the following section.
4.3. Search Strategy, Inclusion and Exclusion Criteria

A clear search path usually suggested as an explicit protocol, is necessary for a
systematic review search not to be inconsistent (Wong et al., 2013) while also being
replicable. Every transaction must be recorded throughout the process to be able to
reproduce it (Boland et al., 2017).
Having established the search question, the search strategy was created in accordance
with the book "Doing a Systematic Review: A Student's Guide" by (Boland et al., 2017).
Thus, the process and progress of this review adhere to the overall principles of this
guideline, following the guideline’s systematic review steps listed in section 4.1.
First of all, a well-developed search strategy uses appropriate keywords relevant to the
systematically searched review question and determines the most appropriate electronic
databases for scanning. Thereafter, a search syntax should be formulated with the
keywords in keeping with the database searching guidelines (as they might have some word
limitations or different formulations for advanced searching). Boolean operators are
preferred since they are more specific in searching within the databases (Corsini et al.,
2019).
Initially, a scoping search was conducted in August 2020 to provide an overview of

relevant literature and to have an insight into the selected databases, keywords, boolean
codes and search fields. The databases were decided by looking at related existing
systematic review studies in the field of architecture and the sources used in the narrative
82
literature review carried out for the background sections of this thesis. Recommended
databases for architects by the University of Liverpool Library were also included in the
scoping search. After conducting a pilot search, six databases were selected for searching
relevant published literature, through the University of Liverpool Library: Scopus, Web of
Science, JSTOR, ProQuest, ScienceDirect and Ebscohost, see details in Table 4-4.
The scope of the resources was restricted to only academic journal articles in order to
reduce the risk of bias as peer-reviewed publications are likely to be more reliable. In
parallel with the grey literature review, explained in 3.4, depression and anxiety keywords
were selected to direct and narrow down the search to reach more relevant data. It was
crucial to understand the emotions and conditions accompanying cancer-related disorders,
to decide which design parameters could better support their mental health.
A challenge in selecting keywords for biophilic design parameters was the lack of
common terminology. It would be a cumbersome and highly time-consuming endeavour to
examine each of the biophilic design parameters separately, as each of them conforms to
areas of research that have been extensively investigated. On the other hand, using just
global terms such as 'biophilic design' alone produced very limited results, as the biophilic
design has only been recently developing as a research and practice field. Although the
term `biophilic design’ was not commonly used, there was abundant research related to
some of the elements (parameters) that define it (synonyms or variations) (Table 4-2).
Relevant disciplines in architecture (i.e. Ecological Design) were also included in the
keywords to cover this limitation; thus, a number of irrelevant publications had to be
eliminated during the initial abstract review step.
Table 4-2: Keyword plan.
KEY TERMS Biophilic Design Therapeutic environment Wellbeing
Synonym Terms Natural design Healing environment Depression

or Variations Restorative design Hospital Anxiety
Ecological design Healthcare
Biophilia Care Centre
Biophilic Design
Bibliographic databases provide wide-ranging and advanced searching options that

allow specifying the publication's date, field, author, journal, etc. However, keywords can
be addressed more associated with publications by using the combining tools known as
Boolean operators (Boland et al., 2017). Boland et al. (2017) explained the main Boolean
codes as follows:
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▪ AND: Combines terms and therefore narrows the search and identifies
references containing all of the words entered.
▪ OR: Broadens the search and identifies references containing any of the
words entered.
▪ NOT: Used to exclude something and therefore narrows the search and
identifies references that do not contain the term following it.
The basic search syntax with Boolean operators considered in this systematically
searched review was: ("biophilic design" OR biophil* OR "natural design" OR "restorative
design" OR "ecological design") AND ("therapeutic environment" OR "healing environment"
OR hospital OR healthcare OR "care centre") AND (well-being OR depres* OR anxi*).
However, these codes showed alteration depending on the search limitations of
bibliographic databases. Table 4-4 shows the details of the variations in the search syntax
used for each database.
Table 4-3: Inclusion and exclusion criteria.
Inclusion Criteria Exclusion Criteria

Population Those who use therapeutic places regularly Those who are not related to
therapeutic environments
Nature of the Therapeutic environment Retail or shopping
Intervention Clinical settings Residential buildings
Healing environment Neighbourhoods or urban districts
Hospitals or healthcare Universities or schools
Workspace or Office setting
Comparators Biophilic design parameters Non-biophilic elements
Biophilic variables of the biophilic design
patterns
Outcomes Studies that give strong insights or scientific facts Studies that examine only one or
to compare or rank a cluster of biophilic patterns an inadequate number of
patterns.
Cultural / English Non-English
Linguistic
Period 1973 to current Pre-1973
Study Design Empirical research News, reports and reviews
Qualitative or Quantitative
Any primary comparative study
Types of Academic Journals Editorials or commentaries
Documents News reports
Magazines
Book
Reports or Proceedings (published
or unpublished)
Dissertation
Thesis or Dissertation
Before starting the search, it should be determined the inclusion and exclusion criteria
that draw the boundaries of the search. The determination of the inclusion and exclusion
criteria should comprise all possible sources that can answer the review question. Also, the
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criteria should be well framed in order to not exclude useful data or include unnecessary
studies (Meline, 2006). Boland et al. (2017) claimed that operative inclusion and exclusion
criteria should represent criteria related to Population, Intervention, Comparators,
Outcomes and Study Design. Thus, this systematically searched review determined the
inclusion and exclusion criteria following this approach, as seen in Table 4-3.
The criteria for Population were connected with the studies that look at patients, staff
and visitors who use these healthcare settings regularly. The Nature of the Intervention
employed the cases done in healthcare environments, with a particular focus on clinical
environments, while excluding the studies that examined all other typological cases (e.g.,
educational, residential or commercial buildings). The basic Comparator was biophilic
design parameters, and all studies that gave holistically (not focused on only one or several
biophilic design parameters) insight into the impact of biophilic design parameters were
included in the review. Although many reviewed studies did not associate the examined
environmental features with the biophilic design parameters, the reviewer and supervisory
team decided to include them upon their knowledge about biophilic design and its
parameters, as many of the environmental features in the studies were variations of
biophilic design parameters or had deeply connected with them. The Comparator criteria
led to the Outcome criteria. The review team rigorously examined the data to decide
whether it was able to lead to a comparison of the parameters or indicated important
environmental biophilic features. Once again, it was crucial to assess the results during the
full-text reading step in this review because the details in the outcomes revealed the
important biophilic design parameters as many of the studies did not indicate the
parameters under the name of ‘biophilic’. Thus, after reading the full text of the selected
papers, the peer reviewers (supervisory team) re-read all these publications to assess which
studies may give stronger insights or the most relevant scientific facts to compare biophilic
design parameters.
The Study Design of selected papers was restricted to empirical, qualitative or

quantitative research and any primary comparative studies aiming to obtain primary data
to reveal important parameters from the users’ perspective to a more objective point of
view. Even though news, reports and reviews were excluded, some reviews that
represented extensive insight into biophilic parameters were considered for inclusion by
the reviewer. Furthermore, the systematically searched review only employed academic
journal papers while editorials, commentaries, news reports, magazines, books, reports,
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and thesis were excluded from the search, given that the data from peer-reviewed
academic journals increases reliability and reduces the risk of bias.
Table 4-4: Searching results (22.09.2020).
Date Number
Performed Database Search Syntax of
Results
22.09.2020 Web of ALL=("biophilic design" OR biophil* OR "natural design" OR 7
Science "restorative design" OR "ecological design") AND ("therapeutic
environment" OR "healing environment" OR hospital OR
healthcare OR "care centre") AND (well-being OR depres* OR
anxi*)
22.09.2020 Scopus ("biophilic design" OR biophil* OR "natural design" OR 443

"restorative design" OR "ecological design") AND ("therapeutic
anxi*)
22.09.2020 JSTOR (("biophilic design" OR biophil* OR "natural design" OR 145

healthcare) AND (well-being OR depres* OR anxi*))
22.09.2020 Ebscohost ("biophilic design" OR biophil* OR "natural design" OR 70

anxi*)
22.09.2020 ProQuest ("biophilic design" OR biophil* OR "natural design" OR 402

anxi*)
22.09.2020 ScienceDirect ((biophilic" OR "natural design" OR "restorative design" OR 28

"biophilic design") AND ("therapeutic environment" OR hospital)
AND (well-being OR depres OR anxi))
Having done the scoping search, the main search was conducted in September 2020 on
the six databases selected. The language was limited to only English, and the searching
period was defined by the starting date of 1973, which is when Fromm coined the term
biophilia and established it as a general concept, to the search time (September 2020). A
total of 1,095 publications were exported to Rayyan QCRI, a systematic review software
developed by the Qatar Computing Research Institute, which helps accelerate the initial
screening of abstracts and titles using a semi-automatised process (Ouzzani et al., 2016).
Although the software Covidence and EPPI-Reviewer were also examined, Rayyan QCRI
software was selected for this review due to its advanced interface that offers easier data
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compilation and arrangement through an open-access system. Table 4-4 shows the search
records and number of results exported for screening in the next stage.
Table 4-5: Searching results (26.09.2021).
Date Number
Results
26.09.2021 Web of ALL=("biophilic design" OR biophil* OR "natural design" OR 3
Science "restorative design" OR "ecological design") AND ("therapeutic
anxi*)
26.09.2021 Scopus ("biophilic design" OR biophil* OR "natural design" OR 3

anxi*)
26.09.2021 JSTOR ((biophilic" OR "natural design" OR "restorative design" OR 0

26.09.2021 Ebscohost ("biophilic design" OR biophil* OR "natural design" OR 6

anxi*)
26.09.2021 ProQuest ("biophilic design" OR biophil* OR "natural design" OR 83

anxi*)
26.09.2021 ScienceDirect ((biophilic" OR "natural design" OR "restorative design" OR 11

Screening and selection of the papers explained in the following section, took quite a
long time since the whole team reviewed the papers individually. Moreover, COVID-19-
related restrictions affected other parts of the PhD research, thus, the research team had to
adjourn the review for a while. For all reasons above, a second search was conducted on
26.09.2021 in order to keep the review updated (Table 4-5). The second search followed
the same protocol and was conducted in the same databases, but the publishing date was
restricted to the period from September 2020 to the search date (26.09.2021). A total of
106 new publications were exported to Rayyan QCRI.
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4.4. Screening and Selection
The application of inclusion and exclusion criteria requires two stages: screening titles
and abstracts, and screening and selecting full-text publications (Boland et al., 2017). The
next steps in the process after having extracted the sources were listed by Boland et al.
(2017): de-duplicating references, developing a screening and selection tool, screening all
titles and abstracts taken into account the inclusion and exclusion criteria, obtaining the
full-text papers for final selection and identifying the included eventual publications.
Some scholars recommend the use of the Mendeley software as the best for de-
duplicating bibliographic software (Kwon et al., 2015). As a systematic review software, not
a bibliographic software, Rayyan QCRI provides a de-duplication tool as well. For obtaining
the most reliable results, both software, Mendeley and Rayyan QCRI, were used for
removing duplicated documents, and both of them showed equal quality control and
removed the same duplicates from the pool of collected studies. After removing 156
duplicates via Rayyan QCRI, 37 other duplicates were detected and deleted manually during
the initial screening.
The reviewer initially screened all the titles and abstracts in accordance with the
inclusion and exclusion criteria detailed in Table 4-3. The systematic review methodology
denominates the process of screening abstracts and titles as “initial review” (Boland et al.,
2017). Therefore, the initial review in this study was repeated five times to ensure that the
requirements had been successfully employed. During the first three phases, 861
publications were excluded, of which 168 papers were irrelated reviews and systematic
reviews, and five papers were published in foreign languages, 688 papers were about
irrelevant fields and topics to this review, including urban, horticultural and animal-assisted
studies even though they were relevant to biophilic design elements. In the fourth
screening, seven more papers were excluded due to their non-holistic approaches to
specific biophilic elements. In the last phase of the process, the final 34 articles were
screened by the peer reviewers as well as the reviewer to ascertain the final decision on
which sources should be included or excluded. After this, 16 publications passed to the next
stage, full-text reading, where the reviewer and the peer reviewers read these publications
separately to provide objective and independent results. Five other publications from
external sources were included in this stage so the total number of sources that reached
this stage was 21. The reviewer examined the full texts of these 21 documents separately to
reduce the risk of bias. After having selected the final papers from full-text reading
separately, the team decided on the final included papers by matching their individual
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selections and explaining the reasons for inclusion. Finally, seven papers were included in
the systematically searched review throughout a systematic search process.
The second review was carried out in September 2021 following the additional search
explained in the previous section. The same procedure was followed throughout the new
review (Figure 4-1). Firstly, four duplicates were removed and initial screening was done
with 98 documents where only four articles were selected for full-text examination. The
reviewer decided on including two more studies in the systematically searched review. The
data extraction and analysis began with the final nine studies.
Figure 4-1: Identification of included articles in the systematically searched

review.
4.5. Data Extraction and Analysis of the Selected Studies

After having selected the included studies, the next step is to identify and extract
relevant data from each individual study. Data extraction is a process of extracting relevant
data from the included papers and storing them in a single format (Boland et al., 2017). It is
advised to use a single format of form or table to extract data. However, the analysis of
papers and the data extraction for this particular systematically searched review followed
individual methods for each study because all studies used divergent methodological
89
approaches. Another reason was the extracted data (biophilic design parameters) were
referred to in a wide range of definitions as predicted in the light of the greater research
gap of this PhD study “there is no standardised framework about biophilic design
parameters”.
Table 4-6: General overview of the included studies.
Study Reference Method Participant Population Contribution to

number /Context the Review
1 (Blaschke et al., Qualitative 20 Patient/Oncology Inpatient /
2018) Clinical
2 (Wiltshire et al., Qualitative 18 Cancer Patients Outpatient/
2020) Clinical
3 (Blaschke et al., Quantitative 38 Experts/Oncology Inpatient/
2017) Clinical
4 (Peditto et al., Quantitative 104 Young Cancer Inpatient/
2020) Patient Facilities Clinical
5 (Tinner et al., Quantitative 72 Staff, Staff and Patient/ Staff,
2018) 62 Patient Cancer Centre Outpatient/
Clinical
6 (Putrino et al., Quantitative 496 Frontline Staff/ Clinical
2020) Healthcare
Workers/ COVID-19
7 (Nejati et al., Mixed 10 Interviews, Professional Nurses Staff / Clinical
2016) 993 Surveys and Healthcare
Workers
8 (Abdelaal & Mixed method NA Patients Inpatient and
Soebarto, review Outpatient/
Clinical
2019)
9 (K. Tanja- Review-Mixed Case 1: 62 Cancer Patients Outpatient and
Dijkstra & Survey Inpatient /
Clinical
Andrade,
2018)
Table 4-6 summarises the general overview of the selected studies. Study 1 and Study 2
were qualitative studies, the data extraction followed a second analysis of the statements
and facts reported in these studies by using Nvivo 12 software, a tool to support qualitative
analysis by organising and visualising unstructured or semi-structured data through a
system of codes (NVIVO, 2012).
Study 3, Study 4, Study 5 and Study 6 represented quantitative data from different
groups of participants. Finally Study 7, Study 8, and Study 9 employed mixed methods. All
studies contributed to the goal of the systematically searched review from both patients'
and staff’s perspectives. Detailed information about the publications was presented in the
following sections along with the data extracted.
Table 4-7 shows the background information about the included studies. All nine studies
were published between 2016 and 2020. Four of the studies were conducted in the United
90
States, three in Australia, one in the United Kingdom, with one study co-conducted
between the UK and the Netherlands. Five of the studies were published by health and/or
medicine-related authors, two studies were published by academics in environmental
disciplines and two were conducted by academic architects. Additionally, the majority of
the publications (seven) were focused on cancer care settings.
Table 4-7: Background information of the included studies.
Study Country Year Field

1 Australia 2017 Faculty of Medicine
2 UK 2020 Department for Health,
3 Australia 2017 Faculty of Medicine
4 USA 2020 Dept. of Design and Environmental Analysis,
5 USA 2018 Department of Forest and Natural Resources Management,
6 USA 2020 Department of Rehabilitation and Human Performance
7 USA 2016 Department of Architecture
8 Australia 2019 Department of Architecture
9 Netherlands-UK 2018 Department of Clinical, Neuro and Developmental Psychology
4.5.1. Study 1: Cancer Patients’ Recommendations for Nature-Based Design and

Engagement in Oncology Contexts: Qualitative Research
‘Cancer Patients’ Recommendations for Nature-Based Design and Engagement in
Oncology Contexts: Qualitative Research’ was published in Health Environments Research &
Design Journal in 2018 by Sarah Blaschke, Clare C. O’Callaghan and Penelope Schofield.
The main objective was to explore cancer patients’ recommendations for nature
engagement in cancer settings based on their experiences, and to gain insight into nature-
based design in an oncology context. The research used a qualitative methodology that
employed semi-structured interviews with diagnosed cancer patients. Twenty interviewees
were selected heterogeneously in diverse sample groups in terms of age, gender,
diagnoses, and treatment status like inpatients, outpatients and who had completed
treatment in order to obtain a rich variety of data. The participants were required from an
Australian tertiary cancer hospital; however, the hospital was anonymised and no detailed
information about the environmental features was defined. The interview presented in this
publication sought answers to the following two questions from participants: what are their
nature-based environmental recommendations for other cancer patients, and what is their
advice for nature-based opportunities in cancer settings?
The paper analysed and investigated the results in two main contexts, recommendations
and cautionary advice. Recommendations were compiled and presented on the basis of
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natural features and functions in the cancer settings (Table 4-8). The interviewees defined
possible useful environmental changes to enhance contact with natural features in cancer
settings: views to nature, natural design features (except water), contact with water
specifically, animals, and nature art. They also described some beneficial functions as
outcomes of engagement with natural features for cancer treatment along with the usual
clinical actions: Providing desired levels of engagement (sensory and private), Promoting
physical activity, Events, entertainment and activities, Helpful mental activities and
techniques for distraction and social opportunities, and Healthcare service integration and
expansion.
Table 4-8: Cancer Patients’ Nature-Related Recommendations and Cautionary Advice (Revised version based on
number of informants for each statement).
Recommendation Recommendation functions Cautions

features
Views to nature 12 Desired engagement (sensory 13 Appropriateness 7
and private)
Natural design features 10 Physical activity promotion 11 Safety 6
(other than water)
Contact with water 9 Events, entertainment, and 7 Allergies 4
specifically activities
Animals 5 Accompanying clinical 6 Healthcare investment 3
procedures
Nature art 3 Helpful mental activities and 6 Negative trigger 3
techniques
Social opportunities 6 Overwhelm 3
Healthcare service integration 2 Sensory 3
and expansion overstimulation
Not valued/not 1
interested
The paper highlighted only three of the featural and functional items as the most
important of all since they were recommended by more than half of the participants;
desired engagement (sensory and private) (n=13), views to nature (n=12), and physical
activity promotion (n=11). However, the portion of ‘Natural design features (other than
water)’ should not be disregarded because half of the participants (n=10) recommended it.
The fact remains that the study examined the natural design features in two different titles
by separating ‘Contact with water’ which was also asserted by nine participants. A holistic
point of view combined two titles by calculating how many different interviewees
recommended either of them featured the ‘Natural design features’ title with a total of 14
recommendations.
In order to have a deeper insight into the recommendations and to extract their
references to the biophilic design parameters in more detail, the key terms and phrases
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used by study participants were analysed in NVIVO 12 software. Figure 4-2 showed the
correlation between recommendations and biophilic design parameters.
Figure 4-2: Interrelation between the recommendations’ titles and biophilic design parameters.
As shown in Table 4-9, while participants referred to the most recommended function
‘Desired engagement’, explicit expressions indicated some of the biophilic design
parameters to create this engagement. Four references were related to Multi-Sensory
Environment, four references were related to Fresh Air, four references were related to
Welcoming-Relaxing Environment, three references were related to Greenery and Plants,
and one reference to Daylight. Four out of 12 informants recommended views to nature in
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connection with the contact with Daylight, primarily, while nine responses referred directly
to View and Prospect.
Table 4-9: References to biophilic design parameters.
Welcoming-
Spaciousne
Oustide To
Greenery
Prospect
Relaxing
Bringing
Material
sensory
Colour
Inside
Water
View-
Multi-
Light
Total
Air
ss
0 0 0 0 0 0 1 0 1 0 1
Animals 3
0 0 0 0 0 0 0 0 1 6 4
Contact with water specifically 11
2 2 1 6 4 2 0 1 1 0 3
Natural design features 22
0 0 0 0 0 0 0 0 0 0 0
Nature art 0
0 0 0 0 4 0 0 0 9 0 0
Views to nature 13
0 0 0 3 1 0 0 0 2 1 0
Accompanying clinical procedures 7
Desired engagement (sensory and 4 0 0 3 1 0 4 0 0 0 4
private) 16
Events, entertainment, and 0 0 0 0 0 0 0 0 0 0 0
activities 0
Healthcare service integration and 0 0 0 1 0 0 0 0 0 0 1
expansion 2
Helpful mental activities and 0 1 0 1 0 0 3 0 0 1 0
techniques 6
0 0 0 2 0 0 1 0 0 0 0
Physical activity promotion 3
0 0 0 1 0 0 0 0 0 0 0
Social opportunities 1
Total 6 3 1 17 10 2 9 1 14 8 13
Although the ‘physical activity promotion’ recommendation was the third most
commonly advised in the paper, only three references to biophilic design parameters were
identified in this category: two references to Greenery, and one to the Multi-Sensory
Environment.
On the other hand, the “natural design features” was recommended by only half of the
participants, but they provided 22 references connected to biophilic design parameters:
Greenery and Plants led with six references, followed by four references to Daylight, three
references to Welcoming-Relaxing Environment, two references to Fresh Air, Bringing
Outside to Inside and Materials, and one reference to Colour, Spaciousness and View-
Prospect. One of the natural design features was Water, analysed under a different title:
“contact with water specifically”. Therefore, in the given responses, 11 references were
identified in connection with biophilic design parameters, six of which explicitly referred to
Water elements, such as rivers, lakes and running water; four references related to
Welcoming-Relaxing feelings, and one reference was connected to perceiving Spaciousness.
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Socialising opportunities was one of the most commonly sought functions of therapeutic
designs for cancer patients, as observed in this study. Despite the fact that Socialising is not
a biophilic design parameter, biophilic interventions are able to promote socialising
characteristics of the space. There were nine references about Socialising, extracted from
the recommendations, but they were not included in the analysis shown in Table 4-9 and
Figure 4-2, since they employed only explicit biophilic design elements. Moreover, the
study had several recommendations in relation to fittings and furniture design to enhance a
visual connection with the outside.
The results indicated that the main objectives of all recommendations were to create a
distraction from unpleasant thoughts and conditions caused by cancer itself and the clinical
environment, and to relax and calm the people while fighting death. In order to reach these
objectives, this study revealed important environmental expectations of cancer patients.
These features were mainly related to the biophilic design parameters although the authors
did not specifically define them as “biophilic”.
17
14 13
10 9 8
6
3 2 1 1
Figure 4-3 References to the biophilic design parameters in the recommendations.
In summary, the analysis showed that the resulting recommendations included 84

references to 11 different biophilic design parameters. Greenery was the most frequently
mentioned parameter out of all biophilic design parameters, with a total of 17 references,
followed by View-Prospect with 14 references, Welcoming-Relaxing Environment with 13
references, and Daylight with 10 references. Also, Multi-Sensory Environment, Water, Fresh
Air and Bringing Outside to Inside were other outstanding parameters (Figure 4-3). It should
be noted that this research concluded with recommendations for cancer patients in clinical
settings specialised in the oncological treatment, thus the recommendations were
principally focused on promoting the environmental quality of hospital rooms in which
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cancer patients usually cannot have active movement ability due to their health conditions.
Therefore, their aspirations and recommendations for a better clinical environment were
concentrated on two main outcomes. Firstly, they sought an opportunity for relaxing and
calming, exacerbated by their lack of physical activity condition. Secondly, they usually
directed their recommendations toward finding a distraction from unpleasant thoughts and
better-preventing stress and anxiety.
The second part of the research conveyed cautionary advice from participants in which
they identified eight aspects of natural engagement that might cause adverse experiences.
The study classified these aspects: Appropriateness, Safety, Allergies, Healthcare
investment, Negative trigger, Overwhelm, Sensory overstimulation, and Not valued/Not
interested.
Appropriateness and Safety were considered important cautions by a significant portion

of participants (Table 4-8). Seven participants mentioned Appropriateness, and their
concerns primarily focused on financial spending and suitable design materials. Although
the cautions related to Safety and Allergies mainly concerned allergic reactions, toxic plant
material, and contact with bacteria, the study stated that some participants explicitly
expressed “nature engagement in the clinal environment being no greater risk than their
everyday contact with nature outside”. The cautionary advice, however, presented a
dilemma since the concerned samples were mainly individual cases with specific issues like
allergic reactions. Artificial nature was advised to grant safety and prevent allergy-related
issues by some interviewees, but some others found fake natural elements inappropriate.
To sum up, interviews with patients in this study also revealed their expectations and
recommendations about how nature connection can be applied in practice:
• In order to relieve the stark atmosphere, the design can introduce natural materials
such as natural timber and natural wall colours, fish tanks, and natural objects.
However, the designers should avoid design elements that are undesirable or
demanding, as they may trigger intense dislike, overstimulation or overwhelm.
Also, safety should be considered cautiously by investigating and preventing the
inclusion of allergy-inducing, slippery or otherwise challenging surfaces.
• Indoor planting can be incorporated with potted plants and green walls when
appropriate and with caution. However, safety is of paramount concern when
engaging with nature in a clinical setting, consideration must be given to factors
such as allergy-inducing and toxic plants, soil bacteria for patients at high risk of
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infection, and sensory overstimulation. Considering the restrictions of clinical
environments, high-quality artificial plants can be installed at a low cost and with
minimal maintenance requirements in areas where live plants are not permitted or
unsafe.
• Indoor seats and inpatient beds that are strategically located to maximise the use
of natural window views can motivate patients and staff to take advantage of these
opportunities.
• Patients suggested collaborating with volunteer services to provide opportunities
for assisted walks outside the hospital building and visits to hospital gardens and
courtyards, as well as contact with therapy animals.
• During clinical procedures, digital devices with interactive nature displays and
sounds, such as virtual reality headsets, can be used to distract patients from
unpleasant thoughts and reduce anxiety. Furthermore, patients reported using
technology to listen to nature sounds to help them sleep better. The ability to
appropriately scale visual, sound, and tactile intensities is one advantage of such
technology-based nature experiences.
4.5.2. Study 2: The experiences of cancer patients within the material hospital
environment: Three ways that materiality is affective
‘The experiences of cancer patients within the material hospital environment: Three
ways that materiality is affective’ was published in Social Science & Medicine Journal in
2020 by Gareth Wiltshire, Emma Pullen, Frankie F. Brown, Mike Osborn, Sarah Wexler,
Mark Beresford, Mark Tooley and James E. Turner.
This research’s main goal was to explore the role of the material hospital environment
for cancer patients in order to improve the patients’ experience. The study reported focus
group interviews with 18 cancer patient participants from one medium-sized acute hospital
trust in the UK, where patients receive treatment within existing and new clinical facilities.
No more information about the environment was provided.
The focus groups employed two questions to start a dynamic conversation around the
topic: Which features of the hospital building are good/not so good for wellbeing? and
What kinds of visual and sensory features bring on feelings of pleasure or discomfort in the
building?
According to the study, numerous patients reported the importance and efficacy of
Welcoming-Relaxing (calming and restful) feelings that originated from being in connection
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with natural elements within the healthcare environment. The presence of Plants and
Water, Visual Natural Scenes and Views, Sensory richness and Quietness were associated
with relaxing feelings. The study analysed some responses from the patients about existing
natural features as follows (p.4):
One participant enjoyed the sight of the floral arrangement at the reception desk as
she entered the hospital foyer, and a fish tank that was previously kept at the
reception was well-received “because it’s very relaxing.” Both of these ephemeral
feeling states rely on the visual field of the patients as they unconsciously recognise
and begin to co-produce the ‘pre-emotional’ affective qualities that direct lived
experience. Interestingly, the pleasant intra-actions with nature were also
experienced when those elements were artificial depictions. Indeed, one patient
claimed, “I quite like visual scenes of environment – mountains and streams that
sort of thing. That is pretty commonplace [in this hospital] and it’s quite restful.
The absence of pleasant visual contact was indicated in the responses. The windows
were criticised in this regard because they were too high to benefit from a direct line of
sight to the outside area, a patient claimed: “you can’t even see a tree moving or anything”.
While another participant expressed the general yearning of cancer patients for pleasant
sights (p.4): “You just think ‘if only that were a nice garden space that you could wheel your
drip out to and get a glimpse of cloud’.”
Visual connection with a natural environment was also associated with bringing focus
for distraction from unpleasant thoughts, as the patients experienced the importance of
distraction provided by some artworks such as photograph exhibition in the setting (p.4):
“There are ones [artworks] that you just see and you forget what you’re here for.”
Another crucial point was Daylight and Spaciousness since several participants described
the hospital’s atmosphere as dark and depressing due to the low ceilings. Furthermore, the
doors of the oncology were perceived as psychologically overwhelming by a breast cancer
patient who “felt sick to her stomach because of the sight of the doors”. The study
recommended the Maggie’s Centres’ doors from Martin et al.’s (2019) study in which the
symbolic quality of the material features and warm greeting of the doors were reported.
Access to the natural environment from waiting rooms where the users usually feel
stressed was another critical concern. The participants complained that they felt stuck in
waiting rooms because of the fear of missing their names announced, therefore they were
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unable to go to the courtyard to have access to Fresh Air, Daylight and Views in order to
calm themselves down.
The participants criticised the Sensory Environment of the hospital environment. Noises
of medical equipment, ‘buzzing’ of alarms, ‘bleep’ of the drips, and overall noisiness
irritated the participants with a general agreement. The poor auditory experience caused
by the machines was explained by a high-grade lymphoma patient (p.4):
I’d forgotten just how much that got to upset me by the end of it … By the end of it, I
found the whole place really irritating and upsetting. I didn’t really realise how
much it was affecting me until on the odd occasion my wife came and met me and I
was on edge. And the noise was one of the big things, especially when they’re busy
and it’s endless. Bingbong, bing-bong, bing-bong, bing-bong.
Patients were more sensitive to the smell of the hospital since they commonly faced
anxiety and nausea experiences. A patient claimed: “The last thing you want to be doing
when you come in through this – especially when you’re feeling nauseous – is to go into a
place that smells.”
In terms of Thermal Comfort, overall it was agreed that the environment was
uncomfortable and too hot (p.4): “Everything was far too hot in the hospital”. Along with
the heating system, the material choice was shown as another reason for the feeling of an
over-heated space. The plastic material used in furniture irritated some of the interviewees,
exemplified in the plastic seats, which were described as uncomfortable since they made
the users sweat. One patient said (p.4): “The seats make you very hot. That was one thing
that we did [give feedback about] because they’re plastic.”
The physical characteristics of the environment in the doctor’s room where they got to
learn their diagnosis, was also prominent in the responses, as this moment was a turning
point in their life. Spaciousness, Comfort and Calmness were sought by considering
Material choice, furniture and other objects in the diagnosis rooms. A participant shared
her experience of receiving the diagnosis (p.6):
The room is absolutely tiny. There’s not really anywhere to sit. And you have to
actually sit on the bed. I sat on the bed, yeah. If you’ve got a visitor. Your visitor sits
on the chair and then the doctor stands and talks to you. The image you get of
being told you’ve got cancer is, you know, sitting in front of the desk, you know, the
doctor sitting in a chair. He’s got reference books, you know. Whereas, you sort of
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feel like you’re sat in this little poky room because you’re not important enough.
And you just feel that you … it’s just really awkward to be told you’ve got cancer
sitting on a bed, tiny little room with two doctors standing there – because mine
was two doctors standing – talking to you. So, for them to now tell me I am
terminal, standing there in this tiny little room, no window at all … I wasn’t sitting
comfortably, as I was sitting on the bed. They need to make you feel that they are
talking to you and you alone, they’re not standing waiting to go out the door to talk
to someone else.
Another focus of the study was the impact of Socialising on the environment. Interacting
with other cancer patients can have psychological drawbacks along with benefits. In some
cases, it was claimed that meeting or just observing other cancer patients evoked a feeling
of worry and anxiety by thinking “is that my future? I don’t want to be like that” or “are
they further down the line than me?”. However, in many cases, social interaction was
welcomed because talking with other cancer patients increased their awareness of the
illness and helped them to understand whether their symptoms are normal. Another
concern was the spatial layout, the cancer patients felt segregated. The space arrangement
was such that it exposed cancer patients while going to the chemotherapy room, which
only cancer patients were allowed to access. This caused a feeling of being “tucked away”
from those who do not have cancer. Also, the journey between the waiting room and the
therapy or diagnosis room was perceived as a “walk of shame” because of noticing, gazing,
wondering, and judging the sights of other people (p.5):
And we don’t want to feel like we’re tucked away. Whereas here we feel like we’re
tucked away because we go up this little ramp and you’re like, you’re away from
everybody else because you’ve got cancer! And you’re infectious! We’re the ones
that nobody wants to talk to! [laughter] You know, it does feel a bit like that doesn’t
it. Because you’re in there and then there’s this other door. That’s where people go
when they’ve got no hair.
Moreover, lack of privacy was another crucial issue for cancer patients, particularly after
diagnosis (p.5):
I remember going out and crying in the waiting room with my daughter. I was just
hugging her. She was crying. She was crying and I was crying. And it was in front of
everybody. We had nowhere to go that was a private space.
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Therefore, the statements in this study proved that cancer patients need an
environment that allows them to socialise with others without being isolated as long as
they have an opportunity to withdraw for privacy. Prostate cancer patients also preferred
privacy in toilets, instead of waiting to use toilets consistently in the corridors since their
treatments involve drinking more fluid than other cancer treatments.
Overall, the participants sought biophilic design elements within oncology settings.
Contact with nature was welcomed even if it was artificial, as a patient claimed (p.4):
There’s this artificial window that’s got blue sky and a tree with blossom on, and
suddenly it was just really lovely to see that, although it’s completely artificial. And
also the little room you have to wait in for an hour while things are draining through
you, they’ve got beautiful paintings on the wall and wildlife and lavender and
things. And I remember that and just thinking ‘wow, this is almost like being outside
again’.
This study proved that Welcoming-Relaxing feelings originated in cancer patients from
contact with natural elements, where Fresh Air, Daylight, Spaciousness, Plants, Water,
Views, Multi-Sensory environment, were especially important. Also, the need for Privacy
was highly underlined, while Socialising opportunities were welcomed as long as they could
have a chance for withdrawal and get privacy.
In summary, the study supported the following guidance:
• The entrance of the facility is an important space as arriving people often face high
levels of stress and anxiety. Creating a welcoming atmosphere with biophilic
touches such as a floral arrangement at the reception desk, or a fish tank in the
foyer can relax people.
• In spaces where contact with real natural elements cannot be created, the
environment can be supported by artificial scenes, plants, electronic windows, or
nature-related artworks. Even if the artificial elements are not able to enrich a
sensory environment, they can bring a visual focus for a distraction though.
• High ceilings can be recommended to create a spacious and light environment,
along with light accessible fittings which do not overwhelm patients. The doors
were particularly indicated in the study, welcoming sliding doors with warm natural
material can be the best option based on the examples (Maggie’s Centres) given in
the study.
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• The waiting rooms should have easy and rapid access to the outdoor environment
where the patients are able to hear when their name is announced or see a board
showing the list of announced people. Also, the indoor environment should provide
sufficient fresh air, daylight and view to reduce the need for leaving the room.
• The auditory and olfactory quality of the facilities should be improved, the noises of
medical equipment should be minimised as well as the heavy smell of medicine and
plastic.
• Material choice and heating system should be considered in terms of thermal
comfort of the patients, as the study reported that the environment was overall too
hot. Plastic materials also should not be preferred in furniture to increase thermal
comfort.
• Spaciousness and calmness were sought in diagnosis rooms. Furniture and
materials should be comfortable and relaxing.
• Socialising opportunities can be created by spatial arrangement; however,
socialising should not be enforced by the environment on everyone but should be
easy for people who need to interact with others.
• Privacy should be one of the most critical concerns in the design, some private
enclosures or spaces should be provided to those who want to cry or disappear
from the sight of unfamiliar people. The spatial arrangement between waiting
rooms and chemotherapy rooms should consider privacy either to prevent long
walks when the patients are exposed to others’ gazes. Also, privacy in front of the
toilets or in waiting queues should be designed well.
4.5.3. Study 3: Nature-based care opportunities and barriers in oncology contexts: a

modified international e-Delphi survey
‘Nature-based care opportunities and barriers in oncology contexts: a modified
international e-Delphi survey’ was published in BMJ (British Medical Journal) Open in 2017
by Sarah Blaschke, Clare C O’Callaghan and Penelope Schofield.
The main objective of this publication was to explore healthcare and design experts’
recommendations for nature engagement in cancer settings and to gain insight into nature-
based design in the oncology context. The study used a four-round electronic Delphi study.
A Delphi study produces new questions based on responses from the previous round of
questions (Schmidt & Kong, 1997). In this study, 200 potential participant experts,
identified from healthcare practitioners, managers, designers, architects and researchers,
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were invited to complete a questionnaire (Questionnaire 1) where the experts were asked
to consider recommendations from the patients as well as their own recommendation for
nature-based care opportunities. Consequently, 38 experts across seven countries replied
to the first round of questionnaires, and the response rate for the next three rounds was
approximately 83%. Questionnaire 2 validated categorised items from the responses of
Questionnaire 1. Questionnaire 3 contributed to prioritising identified items, while
Questionnaire 4 aimed to rank the items. The opportunities and barriers for nature-based
cancer setting design were extracted from these responses and ranked, based on the level
of importance attributed by the participants.
The study revealed the ten highest-ranked opportunities and barriers. Table 4-10
explains these opportunities. The highest-ranked item was ‘Window views from clinical
areas onto nature, garden, sea, sky, weather, people watching, greenery, trees, outside
world, daylight, night sky, escape, movement, change, without glare, attention to privacy
(one-way views)’. This item plainly indicates the importance of visual connection with
natural elements in a hospital room. Although it mainly focused on the View parameter of
biophilic design, some references to other biophilic design parameters contributed to this
statement: Greenery, Water, Seasonal Changes, Outside-Inside Effect, Daylight, Prospect
and Refuge. However, this item only referred to the visual perception of these biophilic
elements, except for Prospect and Daylight, which principally are contained within visual
senses.
The second item prioritised was accessibility to outdoor settings, gardens and
courtyards; and the third item represented outdoor physical activity opportunities.
Although there was no direct reference to biophilic design parameters, the term ‘garden’
can be associated with Greenery and Plants and their Multi-Sensory Environment, Fresh Air,
and Daylight.
No association with biophilic design parameters was detected in items 5 and 7. Whereas
the sixth item ‘Design for privacy’ represented the biophilic design parameters of Refuge,
feeling Safe, and feeling Relaxed. Safety (item 8), and Socialising (item 9), were emphasised
as essential features of a healing environment. Even though Safety and Socialising are not
classified as biophilic design parameters, they should be taken into account during the
implementation of biophilic design interventions in healing environments, since the wrong
application of some biophilic elements in the design process might be counterproductive if
they were not considered well.
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Lastly, the tenth item ‘Indoor design to maximise use of biophilic elements: natural
materials, natural colours, airflow (including windows that open safely) and natural light’
directly referred to the biophilic design parameters: Natural Material, Natural Colour, Fresh
Air, and Daylight.
Table 4-10: Highest-ranked opportunity items as expressed by experts, and identified direct references to
biophilic design parameters (Ranking and Item descriptions were quoted from Blaschke et al., (2017)).
Ranking Item description Detected references to

Items biophilic design
parameters
1 Window views from clinical areas onto nature, garden, sea, sky, View, Prospect, Daylight,
weather, people watching, greenery, trees, outside world, Greenery, Seasonal
daylight, night sky, escape, movement, change, without glare, Changes, Outside-Inside
attention to privacy (one-way views) Effect, Water, Refuge
2 Accessible outdoor settings, gardens and courtyards: easy and Greenery, Multi-sensory
effortless access, automatic doors, nearby, some areas with high Environment, Fresh Air,
visibility, close proximity to clinical assistance, remove barriers Daylight
and thresholds, available for patients, carers and staff
3 Physical exercise adapted to patient requirements: stroll garden, Greenery, Multi-sensory
walking paths with points of interest and distance markers (plant Environment, Fresh Air,
species, medicinal plants), meandering trails, resting points, Daylight
exercise opportunity for staff, nature walks, mindful walking,
mobility and balance training, gardening tasks, assisted walking,
nature exercise rooms, labyrinths
4 Appropriate safety measures and surface materials for limited Natural Material
mobility: handrails, smooth paved paths, ramps rather than
steps, colour contrasting curbing along pathways
5 Educate healthcare team, management, patients, designers,
policy and decision-makers about value, benefits and appropriate
implementation of nature-based opportunities
6 Design for privacy: zoning, screening, semi-enclosed spaces, Refuge, Feeling Safe,
restful, contemplative and solitary spaces, some outdoor spaces Feeling Relaxed
shielded from inside views, separate but nearby spaces for staff
to retreat (away from patients and workplace)
7 Design proposal needs to address repair and maintenance
requirements of nature-based features within available
maintenance budgets (easy to maintain). Tasks to be carried out
by skilled professionals
8 Protection from adverse weather conditions (sun, shade,
high/low temperatures) and unpleasant stimulation
(overpowering scents, noise, loud sounds, toxic plants, clutter)
9 Socialising: range of seating options, gathering and communal
spaces, BBQ area, children play areas, semiprivate enclosures for
personal conversations
10 Indoor design to maximise use of biophilic elements: natural Natural Material, Natural
materials, natural colours, airflow (including windows that open Colour, Fresh Air, Daylight
safely) and natural light
The analysis of these design opportunities helped to identify a hierarchical order for
those biophilic design parameters mentioned by the informant experts in the e-Delphi
study. The ranking of groups was created by taking into account how clearly and
comprehensively the parameters were expressed in the item descriptions. The importance
levels of the examined biophilic design parameters are explained in Table 4-11, group by
group.
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The first group includes the most critical parameters of biophilic design in an oncology
setting. View, Prospect, Refuge, and Daylight were clearly stated in Item 1 above. The
statements in the description comprehensively defined the environmental characteristics
relevant to these parameters as View, Prospect and Refuge, and Daylight can be employed
through windows. However, Greenery, Seasonal Changes, Outside-Inside effect, and Water
were not included in the first group because they were only considered in relation to their
visual impact, regardless of the other sensual stimulations they provide. Therefore, it made
more sense for these parameters to be in a separate group, and were allocated to the fifth
group.
The second group consisted of parameters extracted from items 2 and 3: Greenery,
Multi-Sensory Environment, Fresh Air. Greenery was also implied in item 1, but only
visually. The third group contained the parameters Feeling Safe and Feeling Relaxed.
Although item 6 was also clearly related to Refuge, it was categorised in the first group, as it
had a stronger correlation. Natural Material and Natural Colour were expressed in item 10
clearly and comprehensively and were allocated to the fourth group.
Table 4-11: Ranking of biophilic design parameter groups based on analysis of the opportunities.
Importance Level Biophilic Parameters

1st Group View, Prospect, Refuge, Daylight.
2nd Group Greenery, Multi-sensory Environment, Fresh Air
3rd Group Feeling Safe, Feeling Relaxed
4th Group Natural Material, Natural Colour
5th Group (Only Visual Perception Described) Seasonal Changes, Outside-Inside Effect,
Water
The highest-ranked barriers, collected in Table 4-12, described the most common
problems encountered to achieve a relationship with nature in oncology settings. The items
‘Building design and site constraints’, ‘Inaccessibility’, ‘Inappropriate design choices and
execution’ and ‘Inauthenticity of nature-based design elements’ were directly related to
design decisions and design process, and can be accomplished if the designers prioritise a
biophilic design approach. The ninth item is closely related to the barrier stated, which
expresses the lack of biophilic thinking in the examined projects: ‘Not prioritised in
construction and development phase of healthcare projects’. However, as stated in the
sixth item, the design guidelines for healthcare facilities are often primarily focused on the
efficient provision of medical treatment to patients.
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Table 4-12: Highest-ranked barrier items by experts (Blaschke et al., 2017).
Ranking Item description

1 Building design and site constraints, missed opportunities: layout, building orientation,
surrounding views, lack of available space was not considered in planning and development
phase
2 Decision makers, management and administration often lack knowledge and/or awareness
about benefits of nature engagement
3 Inaccessibility: heavy, locked doors, no electronic door opener, barriers, thresholds, doorways
and pathways too narrow for wheelchair or gurney access or for two wheelchairs to pass, too
wide paver joints become tripping hazards, insufficient seating, co-opted as smoking areas,
access for the very sick and frail not considered
4 Cost and resource allocation: cost for routine repair and maintenance, staff and volunteer
time, acquiring indoor equipment (screens, virtual reality, A/V), lack of funding, often based
on fundraising and grants
5 Inappropriate design choices and execution: limited greenery, cold and stark, too much
hardscape (concrete, glare), uncomfortable seating, too demanding, complex, static or boring
environments, insufficient shading, materials too hot to the touch, structures/sculptures that
cast odd shadows
6 Healthcare facilities design often guided by clinical functionality, efficiency, cost restrictions
and/or habitual practice, not necessarily the patient perspective/experience
7 Mainstream values (decision makers) do not prioritise nature-based opportunities or ‘design
thinking’
8 Champion (advocate) needed
9 Not prioritised in construction and development phase of healthcare projects
10 Inauthenticity of nature-based design elements: fake plants, fake scents, tokenistic, corporate
design (‘cutting edge’ award-seeking designs)
In summary, the study guided some design implementation based on the opportunities
and barriers surveyed with the experts:
• First and foremost, the most important barriers to creating a biophilic healing
environment are caused in the decision-making process before designing the
healthcare settings. Decision-makers do not prioritise nature-based opportunities
or ‘design thinking’. Clinical functionality, efficiency, cost restrictions or habitual
practice are often the main concern of healthcare facilities' design regardless of the
patient perspective/experience. In order to sort these barriers, decision-makers,
designers, management, and administration should have knowledge about the
importance of nature engagement and biophilic design, therefore, the site decision,
layout, building orientation, surrounding views, etc. can be considered in the
planning stage. Skilled professionals can regulate the design proposal that
addresses repair and maintenance requirements of nature-based features within
available maintenance budgets. Furthermore, the lack of knowledge and ability of
the designers also leads to inappropriate design choices and executions, such as
cold and stark spaces, too much hardscape like concrete, glaring materials, or
materials too hot to the touch, uncomfortable furniture, too demanding, complex,
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static or boring environments, insufficient shading or lighting, structures that cast
odd shadows that might lead to anxiety, etc.
• Indoor design should maximise the use of biophilic elements: natural materials,
natural colours, airflow and natural light. However, this maximisation should be
within the frame of safety and security considerations. The users should be
protected from overstimulation such as overpowering scents, noise, loud sounds,
toxic plants, clutter; or adverse weather conditions and high-low temperatures like
overexposure to the sun, or shade. The inauthenticity of nature-based design
elements was claimed as a barrier to nature engagement such as fake plants, fake
scents, and tokenistic. However, plants are strictly prohibited in some clinics due to
infection risk, thus, fake plants or scents are welcomed to create nature
engagement on some level.
• Window views from clinical areas onto natural elements and the outside world are
critical to creating a healing environment, appropriate natural light exposure should
be provided without glare. Windows design should also give attention to privacy by
providing one-way views. Positioning patient beds regarding the view and daylight
exposure can also help to improve perceived environmental features. Another
important factor is windows should provide airflow naturally in the scope of safety
arrangements.
• Outdoor settings should have easy and effortless access to patients and staff, all
barriers and thresholds should be removed for patients, and automatic doors can
improve easy access. Greenery and comfortable amenities where users can chill
and relax should be sufficient. Shade and sunny areas should be balance in order to
provide space for individual comfort. Outdoor settings should offer physical
exercise opportunities for both staff and patients, particularly adapted to patients’
conditions, such as stroll gardens, walking paths with points of interest and
distance markers (plant species, medicinal plants), meandering trails, resting
points; in terms of staff exercise opportunities, nature walks, mindful walking,
mobility and balance training, gardening tasks, assisted walking, labyrinths, etc.
were recommended.
• Accessibility and safety should be considered in all details. For example, non-slip
surface materials, smooth paved paths, ramps rather than steps, and colour
contrasting curbing along pathways can be implemented in the design. Also, heavy
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doors, barriers thresholds, narrow doorways and pathways for wheelchairs are
some expels of barriers that should be avoided.
• The efficient healthcare design should provide privacy as well as socialising
opportunities. Privacy can be included in the design by zoning or screening spaces
or providing solitary spaces for rest or contemplation. Outdoor spaces shielded
from inside views can increase nature engagement, particularly staff need separate
places for a retreat away from patients but with easy access back to patients. On
the other hand, socialising opportunities can be included in the design by arranging
seating and gathering options, the inclusion of communal spaces, children's play
areas, semiprivate enclosures for personal conversations, and even BBQ areas.
4.5.4. Study 4: Inadequacy and impact of facility design for adolescents and young
adults with cancer
‘Inadequacy and impact of facility design for adolescents and young adults with cancer’
was published in the Journal of Environmental Psychology in 2020 by Kati Peditto, Mardelle
Shepley, Naomi Sachs, Jane Mendle, and Anthony Burrow.
The study aimed to measure the differences between the current provision of
healthcare environments and the actual needs of adolescent and young adult cancer
patients. This quantitative research obtained data via a questionnaire with cancer patients
aged 15 to 39 years. The participants were recruited through various cancer organisations’
social media channels and private groups. Having eliminated the ineligible informants and
spam, it was found that a total of 104 people completed the questionnaire. The
questionnaire asked participants to rate the importance of environmental qualities in
treatment settings and to rate the importance of environmental characteristics. The results
revealed that patients reported a noteworthy discrepancy between importance and
effectiveness for 22 environmental characteristics.
According to the results, all characteristics indicated in Table 4-13 were markedly
inadequate, however, “outdoor space,” “patient-only lounge,” “visitor beds in patient
rooms,” “meditative space,” “temperature control,” and “personalisable rooms” were
found the most inadequate.
Table 4-13 ranked 22 characteristics in reference to the importance of effectiveness

based on the questionnaire results. The first and second most important characteristics
stood for privacy. Even though privacy is not a biophilic design parameter, it is deeply
connected with refuge, security and protection parameters as well as it supports welcoming
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features. Likewise, the ‘daylight’, ‘temperature control’ and ‘outdoor space’ were the
characteristics directly or indirectly associated with biophilic design parameters and ranked
in the top six most important characteristics.
Table 4-13: Adequacy of the built environment (Peditto et al., 2020).
Mean Importance Effectiveness

Private bathrooms 4.76 (0.65)
Private bedrooms 4.70 (0.65)
Daylight 4.68 (0.64)
Internet and computer resources 4.67 (0.63)
Temperature control 4.61 (0.69)
Outdoor space 4.42 (0.75)
Visitor beds in patient rooms 4.26 (0.84)
Therapy area (PT, OT, art, music) 4.23 (0.84)
Recreation (TV, games) 3.91 (1.04)
Small number of patients per 3.88 (0.95)
unit
Staff-patient consulting area 3.79 (0.97)
Family-patient lounge 3.76 (0.97)
Moveable seating 3.63 (1.01)
Meditative space 3.62 (1.01)
Personal desk space 3.60 (1.13)
Personal closet space 3.53 (1.14)
Artwork 3.53 (1.08)
Access to kitchen 3.39 (0.99)
Personalizable rooms 3.32 (1.02)
Motivational message board 3.18 (0.94)
Patient-only lounge 2.98 (1.06)
Classroom 2.74 (0.95)
Although they did not refer to biophilic design parameters in an obvious way, the
environmental characteristics ‘Visitor beds in patient rooms’, ‘Family-patient lounge,
‘Personal desk space’, ‘Personal closet space’, ‘Access to kitchen’, ‘Personalisable rooms’,
and ‘Patient-only lounge’ hinted to the parameters sense of belonging, feeling comfortable
and welcoming indirectly. However, the informants considered these characteristics less
important than the ones stated above.
Once again, having examined the interrelationship found between the environmental
characteristics described in the study and several biophilic design parameters, it was
possible to establish a ranking order and determine those biophilic design parameters that
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proved to be crucial in oncology settings for adolescents and young adults. Table 4-14
summarised the environmental characteristics by order of importance as well as the related
biophilic design parameters. It can be seen that the parameters Refuge, Feeling
Comfortable, Feeling Relaxed, Security and Protection were ranked at the top, however, it
should be taken into account that the participants' responses referred to them indirectly.
The following most important was Daylight, which was literally identified as an
environmental characteristic. The third group contained Thermal Comfort, Mastery and
Control.
Table 4-14: The environmental characteristics that had direct or indirect references to the biophilic design
parameters.
Ranking Environmental Characteristics Biophilic Parameters
1 Private bathrooms* Refuge, Feeling Comfortable, Feeling Relaxed, Security

2 Private bedrooms* and Protection
3 Daylight Daylight
5 Temperature control Thermal Comfort, Welcoming
Mastery and Control
6 Outdoor space Greenery, Multi-sensory Environment, Fresh Air,
Daylight
7 Visitor beds in patient rooms* Sense of Belonging
12 Family-patient lounge* Feeling Comfortable and Welcoming
15 Personal desk space
16 Personal closet space
18 Access to kitchen*
19 Personalizable rooms
21 Patient-only lounge*
ASTERISK (*) INDICATED THE ENVIRONMENTAL CHARACTERISTICS INDIRECTLY CONNECTED TO THE
BIOPHILIC DESIGN PARAMETERS
The fourth group of comments contained references to Greenery, Multi-Sensory

Environment, Fresh Air, and Daylight, as it is broadly accepted that ‘outdoor space’ is highly
associated with these biophilic design parameters. Lastly, some less important
environmental characteristics are referred to as the parameters of Sense of Belonging,
Feeling Comfortable and Welcoming.
To sum up, the environmental characteristics indicated in the survey also showed how
to apply biophilic design parameters in a clinical environment. Private bathrooms, private
rooms, visitor beds in the room, family-patient or patient-only lounge, personal desk, closet
spaces, and access to a kitchen were seen as important characteristics which can improve
and contribute to Refuge, Welcoming-Relaxing feelings and a Sense of Belonging. View and
Daylight can be involved in the space through windows. Physical access to the outdoor
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settings, where Greenery, Fresh Air, Multi-Sensory Environment and Daylight can be
experienced, was also stated as important environmental characteristics.
4.5.5. Study 5: Perceived Importance of Wellness Features at a Cancer Center:

Patient and Staff Perspectives
‘Perceived Importance of Wellness Features at a Cancer Center: Patient and Staff
Perspectives’ Research’ was published in Health Environments Research & Design Journal in
2018, by Michelle Tinner, Paul Crovella, and Paula F. Rosenbaum.
This study aimed to reveal the importance of the impact of wellness features on the
quality of care in a cancer centre, from both patients' and staff’s perspectives, who also
expressed their preferences for specific features. A post-occupancy evaluation via surveying
two user groups was carried out. In total 72 staff and 62 patients were required in the
survey to evaluate 11 building wellness features in the studied cancer centre, where the
participants experienced a well-designed environment with sufficient daylight exposure,
four-season enjoyable trees and greenery in the rooftop garden, direct view to nature from
chemotherapy delivery rooms and child oncology department, indoor plants, and the
presence of murals and other art pieces throughout the centre. The anonymous centre has
also other distinct characteristics such as lack of visible medical equipment in the lobby and
waiting areas, thermal comfort, access to spaces for social interaction, access to quiet space
for privacy, and ease of movement as well as having attempt to avoid anticipatory nausea
provoked by stimuli similar to the surroundings during chemotherapy.
The results showed that ‘Ease of movement’ was the overall most important feature of
the building for patients, followed by ‘Thermal comfort’, ‘Natural light’, ‘Art and murals’,
and ‘Views of nature,’ respectively (Table 4-15). ‘Art and murals’ were also considered
biophilic design elements since it was stated that artists represented nature in these pieces
of art. ‘Not seeing medical equipment’ evoked a non-clinical feeling at least in common
spaces and waiting rooms, and it surpassed ‘Plants inside the building’ and ‘Access to the
roof garden’, which enabled direct contact with greenery and fresh air. Curiously, the least
important feature was ‘Access to social spaces’.
It should be noted that there were inconsistencies in the results of this study, evidenced
in how the same parameter receives different appreciation based on how the question is
formatted. For instance, when patients were asked about which features increased their
confidence in the quality of care, ‘Views of nature’ was ranked as the most important
feature (Figure 4-4.), while it was ranked in fifth place in the previous question (Table 4-15)
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, where they were asked to rank features according to outcome, which explicitly asking
about healing process and relationship with staff, highly related to the quality of care.
Likewise, ‘Ease of movement’ was ranked in fourth and first places respectively.
Table 4-15: Building features ranked by patients according to outcome (Tinner et al., 2018).
Overall Improve(s) Improve(s) Improve(s) Improve(s) Improve(s)

Interaction Healing Relaxation Positive Mood
s With Process Thinking
Staff
Building Features Rank Rank Rank Rank Rank Rank
Ease of movement 1 1 2 2 n/a 2
Thermal comfort 2 3 3 1 1 1
Natural light 3 2 1 3 2 3
Art and murals 4 5 4 3 3 5
Views of nature 5 7 6 5 4 4
Access to private spaces 6 4 5 6 n/a 6
Not seeing medical 7 6 8 9 n/a 8
equipment
Plants inside the building 8 9 7 7 5 7
Access to the roof garden 9 8 9 8 6 9
Access to social spaces 10 10 10 10 7 10
100 93
90 78
80 73 69 66
70 59
60 54
47 46 44
50 42
40
30
20
10
0
Figure 4-4: Features that increase patient confidence in quality of care—% (Tinner et al., 2018).
In another set of questions, patients were asked about patient infusion area treatment
space preferences during chemotherapy treatment. As shown in Figure 4-5, 69% of the
informants stated that they prefer getting treatment near the windows. The vast majority
of them explained the reason for preferring being by windows was the presence of natural
light and views of nature. Even though the spatial concept near the windows offered an
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opportunity for socialising, none of those who preferred being near the windows indicated
socialising opportunity as a reason for their preference for the treatment location.
80 69
70
60
50
40
30
20
16 13
10 2
0
Near the Private room In the centre Near the
windows mural wall
Figure 4-5: Patient infusion area treatment space preference—% (Tinner et al., 2018).
The research also investigated some juxtapositions based on statements provided by the
centre’s architects, such as the benefits and disadvantages of the open-plan design, as
open-plan enabled the highest exposure to natural light but it also generated a noisier
environment. In this regard, it was asked whether the patients preferred Quietness over
Social Interaction and Privacy over Daylight and Views of Nature in the treatment area. It
became evident that the majority of informants preferred Quiet treatment areas rather
than Social Interaction, and Privacy to Daylight and Views of Nature (Figure 4-6).
Social
Quiet 3,74 1,26
Interaction
Daylight
Privacy 3,31 1,69 and Views
of Nature
0 1 2 3 4 5
Figure 4-6: Patient treatment area preferences comparison (Tinner et al., 2018). (Based on rating following
statements 1 (disagree) to 5 (agree), a) I prefer quiet over social interaction, b) I prefer privacy over daylight and
views of nature.)
Furthermore, the patients were asked to evaluate four environmental features in the
waiting area. Unlike preferences related to the chemotherapy area, where the patients
favoured Privacy over Natural Light, the most preferred feature in the waiting area was
natural light (Figure 4-7).
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Natural Light
Quiet Space
Privacy
Social Interaction
3 3,2 3,4 3,6 3,8 4 4,2
Figure 4-7: Patient waiting area preferences, based on ranking the importance 1 (disagree) to 5 (agree) (Tinner
et al., 2018).
The results showed that the staff’s preferences were different from the patients’.
Namely, ‘Access to private spaces’ was the overall most important feature of the building
for staff, followed by ‘Access to quiet space’, ‘Thermal comfort’ and ‘Natural light’,
respectively (as shown in Table 4-16). ‘View of nature’ was ranked in seventh place, while
other features relevant to biophilic design such as ‘Plants inside the building’, ‘Art and
murals’ and ‘Access to the roof garden’ were decreasingly ranked as less important features
for staff.
Table 4-16: Building Features Ranked by Staff According to Outcome (Tinner et al., 2018).
Overall Improve(s) Improve(s) Improve(s) Reduce(s) Improve(s) Improve(s)

Interactions Interactions Ability to Stress Focus on Mood
With With Provide Levels Work
Patients Colleagues Care
Building Features Rank Rank Rank Rank Rank Rank Rank
Access to private 1 1 2 2 1 3 5
spaces
Access to quiet 2 3 3 1 2 1 4
spaces
Thermal comfort 3 5 4 3 4 2 3
Natural light 4 2 1 5 3 4 1
Ease of movement 5 4 6 4 5 5 8
Access to social 6 8 5 6 7 6 7
spaces
Views of nature 7 7 7 8 6 8 2
Not seeing medical 8 6 8 7 10 6 11
equipment
Access to the roof 9 10 9 9 8 10 6
garden
Art and murals 10 9 9 10 9 9 9
Plants inside the 11 11 11 11 10 11 10
building
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Figure 4-8 illustrates the differences between staff and patients’ opinions in terms of
overall outcome mean for all building features. ‘Plants inside the building’ (Mean Difference
(MD)=0.51), ‘Art and murals’ (MD=0.4), ‘Access to social spaces’ (MD=0.3), ‘Views of nature’
(MD=0.25) and ‘Access to the roof garden’ (MD=0.25) showed the greatest differences,
while ‘Thermal comfort’ (MD=0.08), ‘Access to private space’ (MD=0.08), and ‘Natural light’
(MD=0.09) showed the smallest differences.
Access to social space

Access to the roof garden
Plants inside the building
Not seeing medical equipment
Access to privacy
Views of nature
Pictures of nature and artwork
Natural light
Comfortable temperature
Ease of movement
3,2 3,4 3,6 3,8 4 4,2 4,4
Staff Mean Patients Mean
Figure 4-8: Patient and staff building feature ranking results arranged according to difference (Tinner et al.,
2018).
Table 4-17: Patient and Staff Mean Building Feature Rankings. (Note. 1 = strongly disagree, 2 = disagree, 3 =
neutral, 4 = agree, and 5 = strongly agree. Bold values are statistically significant (p < .05) (Tinner et al., 2018).
Feature Patients Patient Staff Staff Significance

Mean Ranking Mean Ranking (two-tailed)
Ease of movement 4.28 1 4.06 5 0.78
Comfortable temperature 4.27 2 4.19 3 0.637
Natural light 4.25 3 4.16 4 0.609
Pictures of nature and artwork 4.19 4 3.68 10 <.001
Views of nature 4.16 5 3.91 7 0.039
Access to privacy 4.15 6 4.23 1 0.554
Not seeing medical equipment 4.01 7 3.77 8 0.147
Plants inside the building 4.00 8 3.60 11 0.007
Access to the roof garden 3.95 9 3.70 9 0.067
Access to social space 3.62 10 3.92 6 0.075
Access to quiet space n/a n/a 4.21 2 n/a
Furthermore, independent t-test results, as seen in
Table 4-17, indicated those features that statistically had significant differences. A t-test
is a type of inferential statistic used to determine if there is a significant difference between
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the means of two groups, which may be related to certain features (T. K. Kim, 2015).
Therefore, patient and staff opinions differed significantly in three features, ‘Pictures of
nature and artwork’, ‘Plants inside the building’, and ‘Views of nature’. All three of these
features, which also represent biophilic features, were more valued by patients than by
staff.
Overall, in terms of design features directly related to biophilia, Thermal Comfort and
Daylight were considered the most important parameters for both groups of respondents,
as there was no significant difference between patient and staff opinions. View followed
Thermal Comfort and Daylight since it was ranked in the first place by patients as a trigger
of confidence in the quality of care, and the overall ranking did not differ as much as
‘Pictures of nature and artwork’ did. Although Privacy was more strongly favoured by staff
and ranked as the most important feature, the statistical differences were not significant in
patients’ opinions. Thus, Privacy was also one of the most important features of the cancer
centre. The study did not include patients' overall opinions on ‘Access to quiet space’, but it
was one of the most preferred features, as illustrated in Figure 4-4, Figure 4-6 and Figure
4-7, as well as being the second most valued feature by staff. Interestingly, plant and
greenery relative features were ranked among the less important features by both patients
and staff. However, the staff was considerably less interested in plants. The study
suggested two main reasons for this: the chore of having to water them and the fact that
they can bring pathogenic fungi that pose a threat of infection to patients, which was
proved by several studies (Hedayati et al., 2004; Summerbell et al., 1989). Table 4-18
demonstrates a ranking of biophilic design parameters groups arrangement based on the
result of the study.
Table 4-18:
Ranking of biophilic design
parameters Ranking Patients Staff for staff and
patients. 1st Thermal Comfort Privacy-Refuge,
Natural Light Quietness
View-Prospect
2nd Privacy Thermal Comfort,
Quietness Natural Light
Pictures of Nature
3rd Plant-Greenery View - Prospect

4th Plant-Greenery
In summary, lessons learnt in terms of implementation into practice from the study:
• Creating a non-clinical feeling is an important design driver, medical equipment

should be hidden from patients' eyes where it is possible, for example in common
spaces and waiting rooms.
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• Ease of movement is the most important feature of the building for patients,
accessibility should be maximised, and all barriers should be removed. Also, rapid
and easy access between outdoor settings, foyer-waiting rooms, and treatment
settings should be rigorously considered.
• As the most commonly preferred location within the treatment (chemotherapy)
room, seats nearby the windows should be maximised, and the spatial arrangement
should be designed to deliver optimum daylight and provide uninterrupted views in
a bigger portion of the room.
• Open-plan layout provides the highest exposure to daylight and socialising
opportunities, but creates a noisier environment. According to this study, patients
sought more quietness and privacy in the treatment area. Therefore, the inclusion
of open-plan spaces needs more rigorous in order to create a balance. The ways of
creating privacy and quietness should be examined and implemented in open-plan
designs.
• Waiting areas should allow more daylight exposure, and generate a quiet
environment to reduce patients' stress levels.
• The study claimed that providing optimum thermal comfort is a mixed-use scenario
as it depends on the season, windows effect as well as personal reasons such as
clothing or occupants’ metabolic rate. Therefore, the designers were recommended
to focus on personal adaptation by providing personal control devices like warmed
blankets or heated seating during the cold season and small fans during the hot
season.
• Easy access to private and quiet spaces, such as break rooms or outdoor settings
where they should also be able to enjoy adequate daylight and thermal comfort,
were the most desired environmental features for staff.
4.5.6. Study 6: Multi-sensory, Nature-Inspired Recharge Rooms Yield Short-Term

Reductions in Perceived Stress Among Frontline Healthcare Workers
‘Multi-sensory, Nature-Inspired Recharge Rooms Yield Short-Term Reductions in
Perceived Stress Among Frontline Healthcare Workers’ was published in Frontiers in
Psychology Journal in 2020, by David Putrino, Jonathan Ripp, Joseph E. Herrera, Mar Cortes,
Christopher Kellner, Dahlia Rizk and Kristen Dams-O’Connor.
The study reported the user’s responses to the Recharge Rooms experience in New York
City Hospital. The Recharge Rooms was a research initiative implemented by the research
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team, consisting in converting an empty laboratory into a resting and refreshing place for
healthcare workers, in order to reduce their perceived stress levels during the COVID-19
pandemic. The Recharge Rooms was designed following Attention Restoration Theory (ART)
principles, where the users experienced natural scenes with projected natural landscapes,
low lighting that is tailored in colour to match the projected landscapes, and silk imitation
plants, a nature-inspired multi-sensory environment that included high definition audio
recordings of nature sounds paired with relaxing music and infusion of oil diffusers.
The users were asked to complete a single-item Likert-style survey to measure their
stress level prior to a 15-minute experience. Having experienced the room, they also
reported their stress level with the same measurement technique. Furthermore, a well-
validated measure of user experience, Net Promoter Score (NPS), was prompted to report
by asking how likely they will recommend this experience to a friend. A total of 496
participants completed the survey during the 14-day data collection period.
The result showed that the experience of the Recharge Room reduced the participants'
stress levels dramatically. The mean stress level was reported as 4.6 out of 6 before they
entered the room, while it was 1.85 out of 6 after the 15-minute experience (Figure 4-9).
Moreover, the NPS experience reported a result of 99.3%, so nearly all the participants
would recommend this experience.
Figure 4-9: Distributions of perceived stress ratings of healthcare workers before (A) and after (B) a 15-minute
experience in the Recharge Room (Putrino et al., 2020).
This study revealed the importance of a nature-inspired Multi-Sensory Environment, and

the visual perception of Plants and nature scenes to reduce the stress level of the users,
even though the installation used artificial and imitating resources of nature. Although
there was no recommendation for the application in practice, the study proved the
effectiveness of a Multi-Sensory Environment of recharge rooms for healthcare workers.
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4.5.7. Study 7: Restorative Design Features for Hospital Staff Break Areas: A Multi-
Method Study
‘Restorative Design Features for Hospital Staff Break Areas: A Multi-Method Study’ was
published in Health Environments Research & Design Journal in 2021, by Adeleh Nejati,
Mardelle Shepley, Susan Rodiek, Chanam Lee, and James Varni.
This study aimed to investigate the main restorative environmental features of the staff
break areas in healthcare settings. A multi-method study was employed by triangulating the
qualitative and quantitative data collected for the research. The interviews were conducted
with 10 professional nurses in order to gain insight into the environmental characteristics
and requirements. An online survey, including both open and closed-ended questions, was
delivered to 10,866 healthcare workers, and 993 participants completed the survey within
one-month period. The survey also included a visual assessment section where the five
variations of a break room, created in photoshop, were asked to be assessed.
The interview participants were recruited among the healthcare consultants of the top
50 healthcare-sector architectural firms in the United States. The interview was designed
with 10 open-ended questions to develop an initial understanding of (a) how nursing staff
felt about their break areas, (b) how they defined their environmental needs and
preferences, (c) what they considered beneficial about taking rest breaks, and (d) what
environmental features would meet their needs in break areas. According to the paper, all
interviewees reported the necessity and importance of accessing nature and daylight and
they appreciated all variety of nature contact ranging from indirect contact via nature-
related artwork to the indoor plants within their break areas and a window view of nature
such as mountains, gardens, and landscapes.
The interview results reported that the most powerful stress reliever was the provision
of direct access to the outdoors, because of the opportunities to direct contact with natural
elements (p.23): “to walk in a garden, to be around diverse plants and flowers, to listen to
the sound of water, and to receive direct sunlight.” A participant described the ideal break
area features (p.23): ‘‘they had a beautiful staff lounge and it had a door that opens to a
balcony, an outside balcony . . . just the ability to get fresh air, I think they would just love
that.’’
The informants emphasised the importance of easy and quick access to the outdoors
due to the short break time. Seven of the 10 interviewees indicated the refreshing and
stress-reducing value of physical access to the outdoor environment during break times.
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However, the primary concern was to have quick access back to patients. The study
reported that participants offered rooftop gardens where they should have direct access to
the nursing unit, and a patio garden which is directly accessible to the staff break rooms
and cafeteria. The general idea of desirable indoor break area location followed the same
concern, easy and rapid access to patients (p.21):
If they’re not able to have immediate access back to the unit, like if the break room
is not on the unit, then oftentimes they won’t take breaks.
You need to get away from the unit, at least behind a door so that the noise is not
crazy and you’re not hearing everything. But that being said, you also can’t go very
far away because your patients are sick and if you’re their nurse, it’s really difficult
to not be right there.
The study revealed that visual or physical contact with the outside world and biophilic
elements (i.e. View, Prospect, Daylight) played a critical role in obtaining mental relief. The
importance of this connection was stated by participants as follows (p.22):
When I had a window it made all the difference in the quality of my day, being able
to look at out and see what was going on.
I think the access to a view or to daylight and to the changing of the time of the day
and the seasons is critical to the mental health and well-being of the staff.
The nurses also frequently indicated a strong need for quiet and private indoor and outdoor
spaces, to which the patients and their families would not have access. Privacy and being
away from non-staff sight were emphasised by participants (p.22):
If you’re going to have outdoor access, then I think it does need to be a quiet
environment; again, private—it would be a private garden, not a garden like with
families and kids running around.
It has to be segregated because if families see staff members sitting outside . . . the
family members are going to find them.
Another functional suggestion about the break areas was they should provide
completely private time as well as socialising opportunities where they eat and sit in small
groups. One participant commented (p.22):
I think they need complete privacy because it is part of your decompression time
where you’re mulling over your life... But it’s also a place where they need to
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decompress with what’s going on with their patients... So, they need a lot of privacy
because it is patient information shared.
Additionally, the interviewees sought comfortable furniture and appropriate appliances

in both indoor and outdoor break areas. They suggested comfortable furniture would help
to physical relieve from hours of standing and walking. Another suggestion for furniture
design was the ability to rearrange the items easily for individual or group activities.
The recommendations to be implemented in practice revealed the three most

commonly sought amenities for outdoor break areas to be: comfortable seating, covered
patios, and a rich natural environment. The quotations referred to a Multi-Sensory
Environment of Greenery and Water elements while defining the perfect condition for a
relaxing environment (p.23):
In my perfect world, there would be plants—not anything too crazy that requires a
lot of maintenance. There would be a water feature that just gave that noise, that
waterfall noise, and then benches to sit on. It doesn’t have to be a big walking path
because I just don’t have time.
Trees, bushes, or flowers that have aroma to them; perhaps access to nature sounds
[such as] running water or birds. I mean all of those elements of nature that we
know nourish us as individuals.
The survey included 50 open and close ended questions that assessed the existing
environmental values in the staff break areas and preferred amenities for future design.
The questions were arranged in six categories: (1) demographic information, (2) work
environment and experience, (3) rest break patterns, (4) quality of staff break areas, (5)
future staff break areas, and (6) additional feedback. The results related to the existing
amenities were not included in this analysis since they did not indicate a clear insight into
the importance of biophilic design parameters. This survey also examined the additional
amenities staff would like to have in breaking areas. Therefore, the word frequency analysis
of the preferred environment indicated that the informants used the word ‘window’ 79
times in responses, considering that only 40.2% of the participants had windows in their
break areas.
The survey also revealed that the most desired elements of views from the staff break
areas were nature-based: trees, sky, flowers, park-like area and lawn respectively (Figure
4-10).
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Figure 4-10: Preferred views from break rooms (Nejati, 2015).
Moreover, the importance of privacy was highlighted in the results obtained from the
survey. In response to the question about preferences in the break areas, 59.1% of the
participants demanded private outdoor break spaces for all staff in the healthcare facility,
and 28.8% supported the private break area for only nursing staff, whereas only 10.6%
agreed with the idea of a public break area accessible for everybody (Figure 4-11).
Considering 87.4% of the existing outdoor break areas were open to the public, the staff
was unhappy with the existing privacy conditions.
Figure 4-11: Privacy for existing vs. desired outdoor break spaces.
When the participants were asked about additional amenities that they would like to
see added to their indoor and outdoor break spaces. The most frequently used word was
‘window’ (79), and the second one was ‘comfortable’ (57). A total of 129 words were
related to comfortable furniture, including ‘‘sofas’’ (29), ‘‘couches’’ (31) and ‘‘recliners’’
(35). When expressing their preferences for future outdoor spaces, respondents’ responses
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indicated (Figure 4-12) that the most desired space configurations were the ones that
prioritised privacy and sheltering, like a courtyard, porch, and a roof terrace where only
staff allowed to use. The healing garden, patio, atrium, balcony, viewing garden and
screened porch were also highly rated by over 8% of participants. Similarly, the data in
Figure 4-13 shows that the most desired amenities were seating, plants, flowers, tables,
trees, shade, and water features respectively. The study also indicated that preferences for
shade, tables, flowers, and water features surpassed the prevalence of those features in
existing facilities.
Figure 4-12: Space configuration for existing vs. desired outdoor break spaces (Nejati, 2015).
Figure 4-13: Amenities for existing vs. desired outdoor break spaces (Nejati, 2015).
Lastly, the survey asked the participants to rank the stress-reducing restorative qualities
of two sets of images that were manipulated photographs of two break room examples.
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Both sets of images had five variations: 1) room with a solid wall, 2) room with a plant 3)
room with a painting of nature on the wall 4) room with a window 5) room with a balcony.
The results proved that the healthcare staff definitely preferred having physical access
to the outdoors, followed by the view through a window, and a painting of nature was
preferred over a plant. Although this part of the survey generated an evident hierarchical
order, it should not be ignored that this ranking was based on only the visual assessment of
images, therefore it might not provide results as reliable as those from real experiences.
Figure 4-14: Visual assessment of images (Nejati, 2015).
To sum up, overall the most emphasised environmental preferences in a break area
were access to the outdoors, where they could benefit from sufficient Natural Light, Fresh
Air, Greenery and other unspecified natural elements; accessing nature and daylight were
also specified for both indoor and outdoor break areas separately. Once again, the
importance of Privacy and Refuge was exceptionally indicated in all cases. View, along with
the Prospect, was another critical feature of indoor preferences, however, Prospect was
also sought for outdoor spaces. A need for quietness and quiet space during break times
emerged in interviews and open-ended surveys. Comfortable amenities and furniture were
accepted as a criterion for the restorative quality of the break areas. Lastly, Greenery,
Water, and Multi-Sensory Environment were referred to throughout the study.
In terms of recommendations for practical implementation:
• All variety of nature contact should be involved in the design ranging from indirect
contact via nature-related artwork to the indoor plants within their break areas and
window view of nature such as mountains, gardens, and landscapes. Particularly,
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view through windows was the most frequently desired feature in indoor break
areas.
• Break areas should be well-located in terms of easy and rapid access to the
patients, and the outdoor environment. This is one of the most critical applications
of biophilic design for the staff, as they are unlikely to have a break if their
movement is restricted or challenging between refreshment areas and fieldwork.
• Physical access to outside and natural settings is another crucial intervention,

considering its critical role in obtaining mental relief. Porches, courtyards, patios,
balconies, terraces, and gardens should be rigorously integrated into the design.
The privacy should be seriously considered, particularly private break areas free
from patients and their companions. However, these spaces should provide
socialising opportunities for staff through spatial organisation and furniture choice.
Also, these outdoor areas should be enriched with greenery, trees, shade, tables,
flowers, and water features.
• Even though the recommendation for furniture in this study does not refer to
biophilic design in a direct way, it contributes to biophilic design by associating to a
homely and comfortable environment. Sofas, couches, and recliners were the most
frequently mentioned desired furniture. Also, easily rearrangeable furniture for
individual or group activities was recommended.
4.5.8. Study 8: Biophilia and Salutogenesis as restorative design approaches in

healthcare architecture
‘Biophilia and Salutogenesis as restorative design approaches in healthcare architecture’
was published in Architectural Science Review journal in 2019, by Mohamed S. Abdelaal
and Veronica Soebarto.
This research aims to propose a framework to utilise the therapeutic impact of being in
contact with nature in the hospital environment by using biophilia and salutogenesis
approaches. A mixed-method was used by combining literature review and case study
analysis The Royal Children’s Hospital in Melbourne was renovated in 2011 using principles
of biophilic and salutogenic design to meet the physical, psychological and social needs of
its users.
This study approached the healing environment in a holistic way that proposed to think
of the environment with all human needs in mind, and acknowledging that the qualities of
the environment can play a noteworthy restorative role in healthcare in all terms: physical,
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emotional, mental, and spiritual. A need for a holistic approach was critical, as most
healthcare institutions' design criteria, guidelines, and medical considerations are only
focused on physical recovering, neglecting the other three domains. The study proposed
that this holistic restorative healing approach can be possible by implementing biophilic
design in the healthcare environment, as biophilic design has the ability to support the
physical, emotional, mental, and spiritual needs of human beings. In order to support this
hypothesis scientifically, the study examined the biophilic design framework 14 Patterns of
Biophilic Design proposed by Browning et al. (2014), and classified the patterns based on
the scientific facts that support four human resources (physical, emotional, mental, and
spiritual) (Table 4-19).
Table 4-19: The restorative impact of biophilic patterns on the four types of human resources (Abdelaal &
Soebarto, 2019).
Human Associated biophilic pattern(s) Benefits according to key literature

Resources
Physical Visual connection with nature (VC) Reduced occurrence of illness (infection)
(Bringslimark et al., 2007; Colley et al.,
2016); shorter stay
(Ulrich, 1984)
Complexity & order (CO) Decreased stress (Q. Li et al., 2008)
Thermal & airflow variability (NVC) Pain relief, social restoration (Reeve et
al., 2017); positive impact on well-being
and work performance (Lamb &
Kwok, 2017).
Prospect & refuge (P&R) Improved productivity (Romm &
Browning, n.d.); improved ability
to perform tasks (Han, 2008)
Dynamic & diffused light (DL) Lower heart-rate variability (Stefani et al.,
2016)
Connection with natural systems (CNS) Reduced headaches (Hansmann et al.,

2007)
Emotional Presence of water (W) Facilitates social interaction; social
empowerment (Zelenski & Nisbet,
2012); positive emotional responses
(Windhager et al., 2011);
reduced anger/frustration
(Grafetstätter et al., 2017; Kuo &
Sullivan, 2016a)
Connection with natural systems (CNS) Increased self-esteem (Pretty et al.,
2006); improved mood (Shibata &
Suzuki, 2002)
Visual connection with nature (VC) Positive impact on attitude & overall
happiness (Korpela et al., 2017)
Non-visual connection with nature (NVC) Pleasure and satisfaction (Pallasmaa,
n.d.)
Thermal & airflow variability (TFV) Improved perception of temporal and
spatial pleasure (alliesthesia)
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(Parkinson & de Dear, 2012)
Prospect & refuge (P&R) Reduced boredom, irritation, fatigue
(Clearwater & Coss, 1991)
Risk (R) Strong dopamine or pleasure response
(X. Wang et al., 2016)
Mental Mystery (M) Improved concentration, attention and
perception of safety (X. Wang et al.,
2016); reduced mental fatigue (M. Moore
et al., 2006)
Non-rhythmic sensory stimuli (NRS) Positive distraction (Jiang et al., 2017)
Prospect & refuge (P&R) Stress reduction (Day & Rich, 2009)
Complexity & order (C&O)
Biomorphicforms & patterns (BFP)
Non-visual connection with nature (NVC) Reduced anxiety (X. Wang et al., 2016)
Spiritual Dynamic & diffused light (DL) Fosters imagination (Glăveanu et al.,
2014); promotes
creativity (Steidle & Werth, 2013)
Biomorphic forms & patterns (BFP) Spiritual restoration and inspiration

(Pretty, 2004)
Visual connection with nature (VC) Therapeutic spiritual inspiration (L. M.

Fredrickson & Anderson, 1999)
Non-visual connection with nature (NVC) Enhances spiritual experience

(Heintzman, 2013); greater awareness
and empowerment (Lehman, 2011)
Material connection with nature (MCN) Increased inspiration (L. M.

Fredrickson & Anderson, 1999)
The second step of the research examined The Royal Children’s Hospital in Melbourne,
as the case study, using official care and performance reports, online images, virtual tours
and architectural magazines. The study defined that the forms, colours, patterns, and
spatial arrangements of the hospital were inspired by the natural world in order to provide
a stimulating and therapeutic environment for children, staff, and the general public. Many
parts of the hospital's design were derived from the nearby Royal Park's bushland
environments. The study observed that courtyards, a sweep of coloured 'leaves,' panoramic
vistas of the parks, a two-story coral reef aquarium, large-scale artworks, and a miniature
zoo were all employed to maximise the connection to nature. According to the reports
examined in this study, compared to the condition prior to renovation, these new design
ideas have significantly reduced the hospital's users' pain, worry, and anxiety by
normalising tactile and engaging environmental experiences.
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Figure 4-15: The correlation between biophilic patterns and attributes and the hospital’s restorative zones to be
used in the framework (Abdelaal & Soebarto, 2019).
Finally, the study proposed a framework for restorative healthcare environment design
that considered the 14 patterns of biophilic design based on four human sources in
different zones and specific areas of the healthcare environment where stress, depression
and anxiety symptoms are most likely to affect patients, families or caregivers in different
levels (Figure 4-16). The study classified hospital zones into five categories according to the
intensity of stressors: (a) high-risk emergency departments, intensive care units and
operating theatres; (b) day surgery and cancer treatment units ; (c) diagnostic clinics and
imaging departments; (d) common spaces including lounge areas and social spaces, which
can mitigate the level of stress within hospitals; and (e) outdoor therapeutic gardens, which
can be an indispensable source of restoration and recovery (Figure 4-15).
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Figure 4-16: Proposed restorative healthcare environmental design framework (Abdelaal & Soebarto, 2019).
The classified framework based on the results of the systematically searched review and
case study analysis, shown in Figure 4-15 and Figure 4-16, exposed those biophilic design
patterns that were claimed to help to treat humans physically, emotionally, mentally, and
spiritually from the most restoration demanded hospital zone to the least one. Despite the
fact that the scientific facts relevant to biophilic design patterns that support the physical,
emotional, mental, and spiritual wellbeing were defined in Table 4-19, the paper did not
explain what were the contributions and main drivers of this selection and classification of
the patterns in particular healthcare areas in detail. Once looking at the restoration
demand level, the result indicated a ranking between biophilic design patterns, the
framework shows that the presence of water, biomorphic forms and patterns, complexity
and order, and material connection with nature are more important than the other
parameters since they were used in the treatment of the most restoration demanded
zones. However, the fact should not be ignored that these zones have different spatial
requirements, patient conditions, and staying duration. Furthermore, the study was not
able to inform enough about the environmental features in the case study, and the answers
could not be found about which features and amenities impacted the users and in which
way the particular features impacted them, although general impact (reduced the hospital's
users' pain, worry, and anxiety) of the renovation with natural features were explained.
Finally, the quality assessment appraisal (see section 4.6) classified this study as low quality
for this systematically searched review, but the data were used to consider the reliability of
the data collected from previous papers.
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4.5.9. Study 9: Healthcare Settings
‘Healthcare Settings’ was published as a chapter in the book ‘Environmental Psychology
and Human Well-Being: Effects of Built and Natural Settings’ in 2018, by KarinTanja-Dijkstra
and Cláudia Campos Andrade.
Although book chapters were excluded in the search, this study was included in the
systematically searched review because it was written in academic journal article format
and published by Elsevier Inc. the paper also evaluated cancer patients’ preferences and
satisfaction in relation to two case studies of oncology therapeutic environments.
The first case study, which was reported in a journal paper in 2017 (D. K. Tanja-Dijkstra
et al., 2017) (excluded in the systematically searched review search because the paper was
published in Dutch), examined a garden pavilion designed for cancer patients to receive
chemotherapy on the grounds of a Dutch hospital. The pavilion was constructed with a
timber structure and glass roof, allowing users a view of the greenery in the garden and the
sky, and it was bespoke furnished, trying to maximise comfort. A questionnaire was
completed by 62 patients during their therapy sessions, either in the hospital
chemotherapy room or in the pavilion. The majority of the participants preferred treatment
in the garden, indicating that they enjoyed the nice weather, nature, and fresh air as the
most important reasons. Those who received therapy in the pavilion also reported that the
environment affected them slightly more positive and that the connection with natural
elements evoked restorative feelings.
The second case was cancer care units designed by the Teenage Cancer Trust in some
UK hospitals, including Queen Elizabeth Hospital in Birmingham and Royal Hospital for
Children in Glasgow. These units were carefully designed for young people in deep detail,
with the intention to create a relaxed and comfortable home-like environment and
maintain a sense of normality. The reports produced by the same trust were examined in
this study. Comments from the reports defined the environment in the following way (p.
326-327):
The walls are bright, the furniture is funky, and there’s often a social space, Wi-Fi
access, flat-screen TVs, Xboxes, and jukeboxes. You might walk into a unit and find a
game of pool going on, someone chatting to friends online, or a photography
workshop going on.
The paper claimed that five aspects contributed to the positive impact of these
environments: control of the environment, comfort, stimulation, personalization, and being
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connected. Nonetheless, no more details about these inferences were given in the paper.
However, the authors claimed that these attributes were matched with the dimensions of
Ulrich’s Supportive Design Theory (see Chapter 3): perceived control, positive distraction
(simulation), and social support (being connected).
To sum up, the first case showed the patients’ preferences towards natural elements
with the mention of fresh air, view, visual connection with nature, greenery, plants, and
nice weather (light and seasonal changes) in order to experience more positive and
restorative feelings. While the second case indicated the importance of feeling
comfortable and relaxed in a home-like environment, and a sense of normality to handle
stress and anxiety. Unfortunately, this study did not comprehensively inform this work as it
does not report original peer-reviewed research but rather, an analysis of two cases
forming a book chapter. Therefore, the lack of information and methodology about the
examples led this work to be classified as low quality within the scope of this systematically
searched review (see section 4.6). Nonetheless, the data were kept as supportive
knowledge of the data compiled from other papers.
4.6. Quality Assessment

After selecting the studies in accordance with the inclusion and exclusion criteria, the
process follows the data extraction step. However, it is recommended to assess the quality
of the selected studies in order to consider the reliability of the data before deciding on the
final results (Boland et al., 2017). The meaning of term “quality” in systematic review
methodologies is defined by Khan et al., (2003) as “The degree to which a study employs
measures to minimise bias and error in its design, conduct and analysis”.
Even if the included studies were published in peer-reviewed journals, they shouldn’t be
deduced as free of biased. The quality assessment is not a mandatory step for a systematic
review, but it is crucial for reliability since the assessment and appraisal of the selected
studies give the review results confidence, reliability and trustworthiness (Boland et al.,
2017). Scheduling and deciding the timeline of the quality assessment depends on the
reviewer. The time of quality assessment can be implied after or before the data extraction
during the progress. It may be carried out before the data extraction in order to exclude
poor-quality studies. However, assessing the quality after the data extraction is also
strongly advised as the reviewer will be blind to study quality, thus, the reporting is less
likely to be biased. Also, assessment after the extraction will help to answer the quality
assessment questions with a greater familiarity with the examined studies (Boland et al.,
2017). Therefore, the quality appraisal in this systematically searched review was carried
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out after the stage of data extraction, but before synthesising the results. The data
extracted from the poor-quality studies were not eliminated and were considered as
controlling criteria with the data from higher-quality publications. However, the quality of
the studies was considered for creating the final evaluation of the biophilic design
parameters.
Table 4-20: The quality assessment of selected studies.
Quality Assessment Questions S1 S2 S3 S4 S5 S6 S7 S8 S9

Research Was there a clear and sensible ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ x
Question research question?
and Design Was the research design ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ NA
appropriate?
Sampling Was the sampling frame ✓ ✓ ✓ ✓ ✓ x ✓ NA NA
sufficient and representative?
Did all the participants ✓ ✓ ✓ ✓ ✓ ✓ ✓ NA NA
understand what was
required?
Instrument Did questions cover all relevant ✓ ✓ ✓ ✓ ✓ ✓ ✓ NA NA
aspects of the problem in a
non-threatening and non-
directive way?
Were qualitative (open-ended) ✓ ✓ ✓ ✓ ✓ ✓ ✓ NA NA
or quantitative (closed-ended)
questions used appropriately?
Was a pilot version NA NA ✓ ✓ ✓ NA ✓ NA NA
administrated to the
participant’s representative
and modified accordingly?
Response Was the response rate ✓ NA ✓ ✓ ✓ ✓ ✓ NA NA
reported?
Were non-responders ✓ NA ✓ x ✓ ✓ ✓ NA NA
accounted for?
Coding and Was the analysis appropriate ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ NA
Analysis and were the correct
techniques used?
Presentation Have all relevant results been ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ NA
of Results reported?
Is there any evidence of data x x x x x x x x x
dredging (analyses that were
not hypothesis-driven?)
Relevance Can the document assist in the ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓
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synthesis process in leading to
clarity on the effect of the
intervention in achieving the
outcome?
The quality assessment tool in this systematically searched review was adopted from the
study developed by Holloway Cripps (2016) who created a checklist based on PRISMA
guidelines and modified in accordance with the systematic review guidelines from Boland
et al., (2017), in which the reliability of the studies is assessed through 13 questions forming
a checklist. Table 4-20 shows the quality assessment questions and the corresponding
answers obtained from each study. According to this checklist, Study 3, Study 5, and Study
7 were considered High-Quality studies in terms of reliability, since they were able to
respond positively to all questions. However, Study 1, Study 2, Study 4, and Study 6 could
not satisfactorily respond to one, three, one, and two questions respectively. Broadly
speaking, the general reason was unknown information, stated as Not Applicable (NA), this
meant that no explanation or mention of the requested information from the quality
assessment questions was found in these studies. Accordingly, these four studies were
classified as only Good Quality. Study 8 could not answer the majority of the questions
because of the methodological inappropriateness of this systematically searched review. It
was a review study that proposed a holistic framework for hospitals in general, and its case
study did not employ primary data from users but used reports and online visual sources.
Study 9 also presented a general review of the healing environment, which provided partial
summarised data related to the analysed case studies, and did not provide detailed
information about the case studies’ stages and processes. Although these two last studies
were considered Poor Quality in terms of reliability for this systematically searched review,
they were kept as a control group for assessing the results obtained from the other seven
studies.
4.7. Synthesis of the Biophilic Design Parameters

The analysis of the selected studies proved that clinical settings cannot be examined as
one whole environment in terms of the users’ requirements and the importance of biophilic
design parameters. The clinical spaces assessed in the studies were places where patients
received treatment as well as working environments for the staff. Therefore, this
systematically searched review study examined biophilic design parameters in clinical
environments from two different perspectives: patient-based perspective and staff-based
perspective. Within this classification, further differentiation was determined to be needed,
as the analysis revealed some differences in environmental perception between the
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inpatient users and outpatient users. Thus, the synthesis was also carried out separately
considering inpatients’ and outpatients’ needs for a biophilic environment. The
classification of the most important biophilic design parameters in clinical environments, as
obtained in the synthesis from the selected studies in the systematically searched review is
illustrated in Figure 4-17. The following sections in this chapter analyse these results,
according to each of the three groups of users.
Figure 4-17: Classification of the identified biophilic design parameters in a clinical environment based on the
systematically searched review.
4.7.1. The Prominent Biophilic Design Parameters in Clinics for Patient-Based

Perspective
In terms of the patient-based perspective, the studies focused on the most commonly
used spaces by cancer patients in clinical environments. Therefore, the data obtained gave
an extensive insight into chemotherapy units, waiting rooms, wards/rooms, outdoor areas
accompanying hospitals or clinics, and doctor/diagnosis rooms. The studies that recruited
outpatient participants (Studies 2, 5, 8, 9) mainly focused on chemotherapy units and
waiting rooms as well as doctor rooms. On the other hand, in the inpatient-based studies,
the main focus was ward or hospital room environments and, in some cases, outdoor areas
for patients who can go out for refreshment (Studies 1, 3, 4, 8, 9).
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4.7.1.1. Preferred Clinical Environment for Outpatient Cases
The data in relation to the outpatients’ perspective was collected from four studies.
While Study 8 and Study 9 employed both inpatient and outpatient participants, Study 2
reported data for only outpatients and Study 5 had both outpatient and staff perspectives.
The results showed variations depending on the studies because of the directed questions,
different approaches and existing environment of the population, and the scope of the
studies. Although these differences in the results made the progress more complicated in
terms of extracting general conclusions and obtaining a clear ranking of biophilic design
parameters, they contributed to making the study more extensive and less biased.
As shown in Table 4-21, while Study 5 studies presented a hierarchy between the
important biophilic design elements, the other studies only indicated important parameters
without ranking them. Therefore, this synthesis ranked the biophilic design parameters
(holistically by groups, based on the importance levels reported in the studies as well as
taking into account the reliability and quality of the studies, as examined in section 4.6). For
example, although the data from Study 8 and Study 9 gave an insight into important
parameters, the ranking prioritised Study 2 and Study 5’s results because the unknown
criteria in the quality assessment of these two studies made them less reliable than others.
Table 4-21: Important biophilic design parameters for outpatient environments in the studies.
Ranking Study 2 Study 5 Study 8 Study 9

1st Welcoming, Thermal Comfort Presence of Water, Fresh Air, View,
Relaxing, Calming Natural Light Complexity and Visual Connection
and Restful Feelings View of Nature Order with Nature,
2nd Fresh Air, Light, Privacy Non-Visual Greenery, Plants,
Spaciousness, Quietness Connection with Light and Seasonal
Plants, Water, Pictures of Nature Nature Changes
View, Sensory Connection with
3rd Richness, And Plant-Greenery Natural Systems
Quietness Material
Privacy-Refuge Connection with
Nature
The synthesised groups of the biophilic design parameters for a clinical environment for
outpatient users are summarised in Table 4-22. Even though all these parameters were
explicitly commented on by outpatient participants as required biophilic design parameters,
some of them were emphasised and reported as more critical. Therefore, three different
groups were created in order to hierarchise these biophilic design parameters. The
parameters within the groups were listed alphabetically regardless of any ranking since
there was no exact comparison of parameters in the examined studies. The first group
135
consisted of the parameters that were commonly indicated as the most important features
in the centres: Fresh Air, Light-Daylight, Thermal Comfort and Welcoming and Relaxing.
Multi-sensory Richness and Quietness, Refuge-Privacy, and Spaciousness were classified in
the second group. Lastly, Greenery-Plants was classified in the third group because Study 5
clearly stated that it was one of the less rated features by patients. Bringing the Outside to
the Inside, Colour, Natural Material, and Seasonal Changes were the other important
parameters in this third group.
These specified biophilic design parameters should be taken into account to create
stress-reducing, relaxing and comfortable environments for outpatients in cancer clinics.
The outstanding spatial and environmental requirements for these clinical settings were
summarised from the examined studies as:
• Waiting rooms need to have access to outdoor spaces as well as contact with
natural elements inside since patients have a strong need to be relaxed and
refreshed while waiting for therapy or diagnosis.
• Waiting rooms or commonplaces should offer private zones for patients and their
families as well as minimise separation from the non-cancer population in order to
reduce the feeling of isolation.
• Treatment rooms should have a more visual and sensorial connection with the
outside and natural elements and create opportunities for interacting with other
patients.
• Diagnosis rooms should be well designed to be restorative, comfortable and
spacious since the environment strongly affected the patients psychologically as
they considered the quality of the atmosphere guides a self-deprecating- feeling at
a time that is a turning point in their life.
Table 4-22: Important biophilic design parameters for outpatients in clinical settings based on synthesis results.
Importance Level Biophilic Design Parameters

1st Group Fresh Air
Light-Daylight
Thermal Comfort
Welcoming and Relaxing
2nd Group Multi-sensory Richness and Quietness
Refuge-Privacy
Spaciousness
View-Prospect
3rd Group Bringing Outside to Inside
Colour
Greenery-Plants
Natural Material
Seasonal Changes
Water
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4.7.1.2. Preferred Clinical Environment for Inpatient Cases
Five of the examined studies reported data about the environmental needs of
inpatients, particularly in oncology settings. Study 1, Study 3 and Study 4 focused only on
inpatients’ environments. While Study 1 and Study 4 collected data directly from cancer
patients, Study 3 used professional experts’ views. On the other hand, Study 8 and Study 9
employed data from both inpatient and outpatient groups. The important biophilic design
parameters extracted from these five studies are shown in Table 4-23.
Table 4-23: Important biophilic design parameters for inpatient environments in the studies.
Ranking Study 1 Study 3 Study 4 Study 8 Study 9

1st Greenery- View, Prospect, Refuge, Feeling Presence of water, Feeling
Plants, Refuge, Light Comfortable, Biomorphic forms and comfortable
View-Prospect, Feeling Relaxed, patterns, and relaxed
Welcoming- Security and Complexity and order
Relaxing, Protection Material connection
Light with nature
2nd Multi-sensory Greenery, Daylight Prospect and Refuge
Environment Multi-sensory Light
Water, Environment,
Air Fresh Air
3rd Bringing the Feeling Safe, Thermal Comfort,

Outside to the Feeling Relaxed Mastery and
Inside, Control
4th Material Natural Greenery, Multi-
Colour Material, sensory
Spaciousness Natural Colour Environment,
Fresh Air
5th (Only Visual Sense of
Perception Belonging
Described)
Seasonal
Changes,
Outside-Inside
Effect, Water
Even though the important parameters for inpatient-based environments were not
quite much different from outpatient-based environments, the detected priority
differences may impact the environmental quality since the function of the spaces and
patients’ physical conditions are different. The synthesised groups of the important
biophilic design parameters for a clinical environment for inpatient users are summarised in
Table 4-24. Even though all these parameters were specified as required biophilic design
parameters by patients and experts, some of them were emphasised and reported as more
critical. Therefore, three different groups were created in order to hierarchise these
biophilic design parameters. As before, the parameters within the groups were listed
137
alphabetically regardless of any ranking since there was no exact comparison of parameters
in the examined studies. Regarding the patients who are usually spending their time in the
wards or hospital rooms on their beds, the most important parameters were View,
Prospect, and Daylight through windows. Therefore, the beds’ position and connection with
windows were important to apply these biophilic features efficiently. Another outstanding
parameter in the first group was Refuge, Security and Protection as the patients need to
feel safer because of their unforeseeable health conditions, fear of death, and desperate
neediness for unfamiliar people (healthcare workers). Lastly, Feeling Relaxed and
Comfortable, and Welcoming was the last parameter of the first group. The second group
consist of Fresh Air, Greenery, Mastery and Control, Multi-sensory Environment, and
Thermal Comfort. Finally, the third important group of biophilic design parameters included
Bringing the Outside to the Inside, Colour, Natural Material, Seasonal Changes, and Water.
However, it should be considered that these parameters were usually mentioned in the
studies for their visual impact, not for physical contact as these patients’ movement is quite
restricted, but the studies also sought access to outdoor settings where it is compatible
with the patients’ health condition.
Table 4-24: Important biophilic design parameters for inpatients in clinical settings based on synthesis results.
Importance Level Biophilic Design Parameters

1st Group Feeling Relaxed and Comfortable,
Prospect,
Refuge, Security and Protection,
Light-Daylight,
View
2nd Group Fresh Air
Greenery,
Mastery and Control,
Multi-sensory Environment,
Thermal Comfort
3rd Group Bringing Outside to Inside
Colour
Natural Material
Seasonal Changes
Water
4.7.2. Biophilic Design Parameters in Clinics for Staff-Based Perspective

The most important biophilic design parameters in clinical environments were examined
from the staff point of view separately, as their needs were different from those of
patients, being these environments their workplaces. The studies in relation to staff
(Studies 5, 6, 7) mainly examined the restoring characteristics of spaces with a particular
focus on break areas. Study 6 and Study 7 collected data about staff break areas, while
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Study 5 assessed the clinical environment from both patient and staff points of view. The
biophilic design parameters extracted from these three studies are shown in Table 4-25.
The synthesised groups of the biophilic design parameters for a clinical environment for
staff are summarised in Table 4-26. Like in patients previously examined, all these
parameters were stipulated as required biophilic design parameters by staff participants,
some of them were emphasised and reported as more critical in the examined studies.
Therefore, four different groups were created in order to hierarchise the most relevant
biophilic design parameters. Once more, the parameters within the groups were listed
alphabetically regardless of any ranking since there was no exact comparison of parameters
in the examined studies.
Table 4-25: Important biophilic design parameters for staff in the studies.
Ranking Study 5 Study 6 Study 7

1st Privacy-Refuge, Nature-Inspired Multi-sensory Physical Access to the Outdoor,
Quietness Environment, Natural Light,
Visual Perception of Plants, Fresh Air,
Nature Scenes (View) Greenery,
Privacy and Refuge,
View-Prospect
2nd Thermal Comfort, Quietness,
Natural Light Comfortable Amenities and
Furniture
3rd View of Nature Indoor Plants,
Water,
Multi-Sensory Environment
4th Plant-Greenery
The results showed that the staff’s requirements for the environment had obvious
differences from those of the patients. The most outstanding demands were Privacy and
Refuge, and the need for Quietness was also frequently emphasised. The studies indicated
the importance of physical access to the outdoor environment. The second group
represented this demand, which consisted of five biophilic design parameters: Fresh Air,
Natural Light, Prospect, Thermal Comfort, and View. Multi-sensory Environment were
placed in the third group because Study 6 prioritised it. Whereas Greenery was classified in
the fourth group because Study 5 indicated that plants and greenery were not important
for the participants. Study 7 also ranked indoor plants in break areas very low, although the
same study referred to the visual impact of greenery during outdoor breaks. The fourth
group also included Water elements.
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Table 4-26: Important biophilic design parameters for staff in clinical settings based on synthesis results.
Importance Level Biophilic Design

Parameters
1st Group Privacy-Refuge,
Quietness
2nd Group Fresh Air,
Natural Light,
Prospect,
Thermal Comfort,
View
3rd Group Multi-sensory Environment
4th Group Greenery - Plants
Water

The synthesis of findings in this chapter helped to identify and rank the biophilic design
parameters that appear the most critical for promoting and supporting human health and
wellbeing in clinical therapeutic environments, within and across three different user
categories: Outpatients (Fresh Air, Light-Daylight, Thermal Comfort, Welcoming and
Relaxing); Inpatients (Feeling Relaxed and Comfortable, Prospect Refuge, Security and
Protection, Light-Daylight, View); and Staff (Privacy-Refuge, Quietness). This review also
showed that inpatient, outpatient and staff users had similar desires but sometimes
divergent priorities and requirements and that the provision of the same or similar biophilic
elements to different groups could support distinct affordances.
The main limitation of this review was that not all the examined studies had as their
main aim to produce data directly related to the assessment of biophilic design but rather
to general hospital design environments. However, this could also be a benefit allowing a
better understanding of the value of nature-based design and where it fits within general
healthcare design. It was also noticed that the available case studies were limited in
number, however, they were systematically selected based on the criteria. This stringent
selection is actually very important, because it frames the research to meet this research’s
specific goals, and provides the necessary rigour to produce a substantive contribution to
this early literature by revising it within this specific frame. The selected studies were
localised in industrialised Western countries and typically of less than high methodological
quality. Studies 8 & 9, showing the lowest level of reliability, proved not to contradict the
high-quality studies but did not offer any further evidence to the synthesis, having no input
into the design recommendations. Climate and culture influence human perceptions of
nature, so as more research is conducted in various regions, climates and cultures, a wider
range of data will contribute toward more effective biophilic design frameworks.
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Having examined clinical therapeutic environments with a systematically searched
review, the following chapter investigated non-clinical therapeutic environments with the
case of Maggie’s Centres.
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CHAPTER 5
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5. A META-SYNTHESIS: ANALYSING PRIMARY DATA FROM EXISTING
RESEARCH ON MAGGIE’S CENTRES
This study aimed to look into Maggie’s Centres’ architectural features and how these
features impacted the users’ who were affected by cancer and members of staff from their
perspective and to discover their opinion and experiences about Maggie’s Centres'
buildings and architectural objectives (See section 3.4). Originally, this study planned to
obtain these data using semi-structured interviews and ethnographic observations, a
qualitative research method where the researcher observes or interacts with participants in
their usual daily environment (Denzin & Lincoln, 2011). Given the restrictions experienced
during the Covid-19 pandemic1, a new approach was envisioned to still collect and analyse
this type of data.
Up to this date, several researchers had studied Maggie’s architecture in different
contexts and with diverse focuses, and this information had been published extensively.
These publications included ethnographic studies comprising interviews, focus groups,
observations and questionnaires directed to this specific audience. Although all these
studies examined Maggie’s Centres’ architecture and their healing features, they have not
employed a particular focus on biophilic design theory and its parameters. Thus, a great
amount of data was lying in all these documents but had not been examined through a
biophilic lens. Particularly, direct quotation speeches from users and architects obtained via
interviews and focus groups may be considered primary data, as they have not been
processed by other researchers. The obtained data were examined and strained by
considering the main biophilic design parameters defined in Chapter 2, and the observed
parameters and their interrelations were analysed in order to hierarchise them based on
reference frequency from the user’s perspective which is an important input as including
end-users’ view in the design provides a successful path (Chrysikou, 2018).
This methodology follows a systematic search strategy, analytical data extraction and
classification, and interpretive result analysis.
5.1. Search Strategy and Screening

Initially, a scoping search was conducted in December 2020 to provide an overview of
relevant literature and insight into the databases that could be used to carry out a
systematic search to export studies related to Maggie’s Centres’ architecture. After
1
As a result of the COVID-19 pandemic, all on-site case studies were cancelled by the University of
Liverpool Senior Management Team from 19.03.2020 to 12.10.2021. Likewise, the Maggie’s Centre
Research Advisory Group stated that Maggie’s Centres were not in a position to support any
research during the pandemic.
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conducting an initial plot search, the databases Scopus, Web of Science, JSTOR, ProQuest,
ScienceDirect and Ebscohost through the University of Liverpool Library were selected to
search the relevant literature systematically, since these databases provided appropriate
results that were able to answer the searching goal.
The resources were restricted to academic journals, conference material, master and
doctoral theses, and architectural magazines, and only architectural news was excluded
since the initial search proved that the news had not provided related primary data. The
main aim was to compile all publications relevant to Maggie’s architecture, so the selected
keywords used in a basic searching syntax were: "Maggie's centre" AND (architecture OR
building OR design OR environment). While selecting sources, the “population” was limited
to studies that focused on patients, staff and visitors who used these therapeutic spaces on
a regular basis, as well as designers of any of the Maggie’s Centres. The most crucial
inclusion criteria were direct quotations related to Maggie’s architecture, so all data had to
be scanned regardless of their results or research objectives since the data were extracted
from the methodological processes for this meta-synthesis.
The main search was conducted on 14th December 2020 using six databases. The
language was limited to only English, and the search period went from 1996, when the first
Maggie’s Centre was opened in Edinburgh, to the search date (14th December 2020). A total
of 97 publications were exported to Rayyan QCRI software. Table 5-1 shows the search
records and the number of results exported for screening.
Table 5-1: The search record of databases and the number of results.
Date Number
Results
14.12.2020 Web of "Maggie's Centre" AND (architecture OR building OR design OR 2
Science environment)
14.12.2020 Scopus "Maggie's Centre" AND (architecture OR building OR design OR 17
environment)
14.12.2020 JSTOR "Maggie's Centre" AND (architecture OR building OR design OR 6
environment)
14.12.2020 Ebscohost "Maggie's Centre" AND (architecture OR building OR design OR 44
environment)
14.12.2020 ProQuest "Maggie's Centre" AND (architecture OR building OR design OR 7
environment)
14.12.2020 ScienceDirect "Maggie's Centre" AND (architecture OR building OR design OR 21
environment)
After removing 10 duplicates via the Rayyan QCRI software duplicate removal system,
the initial screening consisted of reading abstracts and, in some particular cases, checking
full texts. All review papers and non-architectural studies, such as medicine-based cancer
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studies, were excluded. Thus, 18 studies were employed for the full-text reading stage,
while 69 papers were excluded (Figure 5-1). At the same time, the researcher also
contacted the Maggie’s Centres Research Advisory Group, to learn about prior research
studies on Maggie’s, which they kindly provided. After obtaining this information, some of
these researchers were contacted directly to collect information about their publications.
They recommended 11 publications that provided primary qualitative data. Hereby, along
with the 18 papers, six of which were also recommended by members of the Advisory
Group and researchers themselves, another five publications were included for full-text
reading.
Figure 5-1 Identification of included articles in the review.
During the full-text reading of these 13 publications, the focus was on the primary data
which generally exists as direct quotations. The main difference with a systematic review
methodology was that the topic, objectives or results of the studies in question were not
important facts for this review. The straightforward aim of this method was to extract
primary data from secondary sources and examine this data from a biophilic standpoint.
Thirteen documents were included in the final full-text reading stage: one PhD thesis,
one conference poster, three conference proceedings, one book chapter, three
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architectural magazine articles, and four academic journal papers (Table 5-3). These 13
resulting documents were imported to Nvivo 12, a qualitative data analysis software.
Although MaxQDA and Atlas.ti are software which have quite similar analysing systems,
these software were selected since the University of Liverpool has a licensing protocol.
5.2. Data extraction and Analysis

All 13 documents were analysed in NVIVO 12 software by creating codes. The codes
represent in connection with the contents of the data by considering biophilic design
elements and their impacts on human health and wellbeing. Therefore, biophilic design and
other architectural design elements that were used by designers as intervention tools for
the environment were considered “Interventional” codes; and all feelings, mental and
salutogenic impacts caused by the Interventions were referred to as “Outcome” codes.
However, it is important to be aware that not only the Interventional codes but also the
Outcome codes included a variety of biophilic elements/parameters that were framed by
previous researchers (Browning et al., 2014; S Kellert et al., 2011; Stephen Kellert &
Calabrese, 2015): such as Curiosity, Refuge, or Prospect. Table 5-2 shows the classification
of the codes. The classification was arranged based on the most frequent characteristic of
the parameters, although there was no exact border between the Interventional and
Outcome codes since an Interventional code can also exemplify an outcome of another
intervention and vice versa. All parameters were deeply connected to each other. For
example, furnishing design can use a material that creates a tactile experience that
engenders a feeling of relaxation. Therefore Tactile Experience becomes an outcome of
Material while it is also a feature that creates a sense of relaxation (Welcoming-Relaxing) as
Interventional code (Figure 5-2).
Table 5-2: The Interventional and Outcome code groups.
Interventional Codes Outcome Codes

Air Curiosity
Architectural Form, Layout, Furnishing and Fittings Perception by Gender
Bringing Outside to Inside Perception by Personal past- Sense of Belonging
Colour Refuge- Feeling Safe
Fire Socialising
Greenery - Plants View- Prospect
Light- Daylight Welcoming - Relaxing
Material
Multi-Sensory Experience
- Auditory Experience
- Olfactory Experience
- Tactile Experience
Seasonal Changes
Spaciousness
Thermal Comfort
Water
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Figure 5-2: An example of Intervention-Outcome relation.
Figure 5-3 illustrates the coding system that was used in the meta-synthesis. Every
response from interviewees quoted in the included studies was considered a base for
coding. Every connotation for an outstanding architectural or biophilic element, which
stands for a code, in one response was accepted as one reference to that code. Regardless
of the number of references for a code in one response, all references to a code in one
response were accepted as one since the informant was the same person. For example, in
Figure 5-3, Response 1 was a base for coding. The green highlighted expressions were
referring to the Greenery code, while the blue highlighted expression was a reference to
the Auditory Experience code, and the yellow highlighted expressions referred to the
Welcoming-Relaxing code. In this response, Auditory Experience and Greenery were
Interventional codes because they caused a Welcoming-Relaxing feeling, which was an
Outcome code here since it defined a resulting characteristic. Therefore, Response 1
comprised three References for three codes. In order to yield more reliable results,
repetitions in quotations were ignored, and all expressions for a code were accepted as one
Reference. For instance, the expressions “tranquillity”, “peace”, “such a pleasure to come
here”, and “relaxing” referred to the Welcoming-Relaxing code, so all these four
expressions were accepted as one Reference, while one expression “no noise of the city”
was accepted as one Reference either for the Auditory Experience.
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Figure 5-3: A sample coding method used in this review was the function of Responses, References and Codes
are illustrated.
5.2.1. General Overview of the Analysed Documents

After deciding on the included documents, they were examined in detail by creating
codes as explained in the previous section and illustrated in Table 5-2, for every detected
architectural characteristic and their impacts regardless of whether they were biophilic
features or not. Therefore, the results proved that Maggie’s Centres’ architecture had
plenty of biophilic characteristics as was foreseen considering Maggie’s Centre Architectural
Brief (Maggie’s Keswick Jencks Cancer Trust, 2015).
The 13 documents provided extensive insight into how Maggie’s architecture works and
the relationship between architectural elements which are substantively biophilic. In total
474 quotes related to biophilic parameters were compiled in 23 varieties of codes from
these publications (Table 5-3). Comments about the data obtained from these publications
are listed below, ranked in order of relevance to this research:
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The majority of data, accounting for 143 references, was collected from a doctoral
dissertation produced by Angela Butterfield, titled ‘Resilient Places? Healthcare Gardens
and The Maggie’s Centres’, completed at the University of The Arts London and Falmouth
University in 2014. Although this study focused mainly on the gardens, interviewees had
given plenty of data about the buildings themselves and their architectural connection with
the gardens because people used the centre as a whole not only the gardens or the
buildings. Thus, these interviews provided data on 20 different codes which represent the
elements and impacts of architecture. However, it is important to emphasise that not all of
the direct quotations from interviewees were used in the study; the parts that only focused
on botany and other architectural irrelevant responses were ignored due to compiling
confidential data for comparison with other parameters. For instance, the interview
responses explained variations of plant names and their characteristics botanically.
Another crucial publication was the article ‘Affecting care: Maggie's Centres and the
orchestration of architectural atmospheres’, published by Daryl Martin, Sarah Nettleton,
and Christina Buse in 2019 in Social Science & Medicine journal. This study was carried out
by interviewing 66 visitors, 22 staff members and 7 architects of Maggie's Centres across
the UK and internationally. This source provided 81 references in 19 different codes.
‘Architects’ Approaches to Healing Environment in Designing a Maggie’s Cancer Caring

Centre’ by Valerie Van der Linden, Margo Annemans, and Ann Heylighen was published in
the Design Journal in 2016. This was a key source to obtaining data about the architects’
design approaches and observations of Maggie’s architecture, however, the architects’
opinions on the architectural brief and general design principles were mainly disregarded in
this analysis, as the main goal was to collect data that have primary characteristics.
Nonetheless, a total of 60 references were extracted in 14 different codes.
The subsequent publication was ‘A home from home: Maggie's West London excels at
providing comfort and sanctuary’, by Amanda Birch, Charles Jencks and Ivan Harbour, an
architectural magazine article published in the Architects' Journal Vol. 239, Issue 15, in
2014. Although it was a paper providing an overview of Maggie's West London and its
design, this publication included useful interviews with professionals such as an art
therapist and a horticulturalist who were visiting the centre regularly, the architect Ivan
Harbour, the centre’s head and staff, the property director, centre’s users and Charles Jenks
as the client. Therefore, the paper delivered abundant valuable data, leading to 46
references, and 14 various codes.
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The next study on the list was ‘You’d want an energy from a building: User experience of
healing environment in a Maggie’s Cancer Caring Centre’, by Valerie Van der Linden, Margo
Annemans, and Ann Heylighen, from KU Leuven University. This paper was the published
conference proceedings of the Third European Conference on Design4Health, which took
place in Sheffield in 2015. This study aimed to show how architecture plays role in the
user’s wellbeing and reported the findings from a focus group interview with visitors and
staff of the Maggie’s Centre in Dundee. From this publication, 31 references in 10 different
codes were obtained.
Another included conference paper from KU Leuven University was ‘What Makes an
Environment Healing? Users and Designer About the Maggie’s Cancer Caring Centre
London’ by Margo Annemans, Chantal Van Audenhove, Hilde Vermolen and Ann Heylighen,
and published in Proceedings of the 8th International Design and Emotion Conference,
London, September 2012. This paper gave insights from users and architects via interviews.
A total of 25 references were collected from this source in 8 different codes.
Angie Butterfield from Falmouth University and Daryl Martin from the University of York
presented ‘The Silent Carers: Exploring the Role of Architecture and Gardens at the
Maggie’s Cancer Care Centres’ as a poster that was published in the Journal of Psycho-
Oncology, Vol. 23, pp. 318-319, in October 2014. In this publication, they examined
interview results in terms of both Maggie’s buildings and Maggie’s gardens. It contributed
18 references in 11 various codes.
‘Social Impact: Maggie’s Nottingham’, based on Kelly Watson’s post-occupancy

evaluations was the next source of data. This was a chapter in the book Building
Knowledge: Pathways to Post Occupancy Evaluation, created by an author team from the
University of Reading, and published by the RIBA in 2016. The post-occupancy evaluation
was carried out for six months through interviews, focus groups, surveys and observations.
However, this massive research work was mainly summarised in this short chapter, thus,
outcomes will be more rigorously taken into account in the thesis conclusion. 18 references
in 10 different codes were yielded from this document.
‘Designing emotion-centred Product Service Systems: The case of a cancer care facility’
was the next more important publication for this analysis. This was a journal paper
published by Patrick Keith Stacey and Bruce S. Tether in Design Studies journal in 2015.
Although the paper provided a variety of data from interviews with architects, professionals
and staff, only the data that referred to the observations about the buildings’ atmosphere,
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and experiences in the use of space were employed in the analysis. General information or
usual experts’ views on the design process were excluded. From this paper, 13 references in
6 different codes were included in the scrutiny.
Table 5-3: Included documents for analysis.
Title Reference Type Number Number

of Code of Coded
Variants Texts
Resilient Places? Healthcare Butterfield, A. (2014) Doctoral 21 143
Gardens And The Maggie’s dissertation
Centres
Affecting care: Maggie's Martin, D., Nettleton, S., & Journal Article 19 81
Centres and the Buse, C. (2019)
orchestration of
architectural atmospheres
A home from home Birch, A., Jencks, C., Architectural 14 46
Harbour, I. (2014) Magazine
Architects’ Approaches to Van der Linden, V., Journal Article 14 60
Healing Environment in Annemans, M., & Heylighen,
Designing a Maggie’s Cancer A. (2016)
Caring Centre
The Silent Carers: Exploring Butterfield, A., & Martin, D. Conference Poster 11 18
the Role of Architecture and (2014)
Gardens at the Maggie’s
Cancer Care Centres
Affective sanctuaries: Butterfield, A., & Martin, D. Journal Article 10 13
understanding Maggie’s as (2016)
therapeutic landscapes
Social Impact: Maggie’s Watson, K. (2016) Book Chapter 10 18
Nottingham
“You’d want an energy from Van der Linden, V., Conference 10 31
a building”: User experience Annemans, M., & Heylighen, Proceeding
of healing environment in a A. (2015)
Maggie’s Cancer Caring
Centre
A man-friendly Maggie's Mark, L. (2013) Architectural 9 9
Magazine
Empathic Service Systems: Stacey, P., Bascavusoglu- Conference 9 13
‘Designing’ Emotion in a Moreau, E., & Tether, B. Proceeding
Cancer Care Service System (2011)
What Makes An Annemans, M., Van Conference 8 25
Environment Healing? Users Audenhove, C., Vermolen, Proceeding
And Designer About The H., & Heylighen, A. (2012)
Maggie’s Cancer Caring
Centre London
Designing emotion-centred Stacey, P. K., & Tether, B. S. Journal Article 6 13
Product Service Systems: (2015)
The case of a cancer care
facility
Maggie’s Centre Barts, Foges, C. (2018) Architectural 3 4
London: Steven Holl Magazine
Architects L’Observatoire
International’
Following, ‘Empathic Service Systems: ‘Designing’ Emotion in a Cancer Care Service

System’ by Patrick Stacey, Elif Bascavusoglu-Moreau and Bruce Tether was a published
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proceeding of the 44th Hawaii International Conference on System Sciences in 2011. The
data was collected from Maggie’s London, which was the first and only Maggie’s Centre in
England, regardless of the other five centres in Scotland, when this research was carried out
(P. Stacey et al., 2011). This publication had more information on the expert opinion of
architects, professionals and staff. However, some data were ignored due to repetition with
the previous source, ‘Designing emotion-centred Product Service Systems: The case of a
cancer care facility’, as the two authors were the same in these two papers. Even so, 13
references in 9 codes are compiled from this document.
Subsequently comes ‘A man-friendly Maggie's’, an architectural magazine article written

by Laura Mark in 2013 in Architects' Journal, Vol. 238 Issue 12, p34-40. Even though it was
not a long text, it gave a different point of view for looking into Maggie’s architecture by
examining spatial perception depending on gender. As mentioned in Chapter 2, some
researchers claimed that nature was perceived differently by different genders as its effect
was not the same on men and women(van den Berg & ter Heijne, 2005). The study focused
on the Newcastle Maggie's Centre and included interviews with male visitors, staff and the
architect. It delivered 9 references in 9 different codes.
Lastly, another architectural magazine article gave insight into lighting technologies used
in Maggie’s London to promote a sense of well-being in the centre. ‘Maggie’s Centre Barts,
London: Steven Holl Architects L’Observatoire International’, written by Chris Foges, Lydia
Lee, Mairi Beautyman and Kelly Beamon in Architectural Record in May 2018, Vol. 206, n.5.
This article was deemed to be incorporated in this study although it mainly focused on
lighting because it included quotations from the architect and engineer that strengthened
and complemented the data obtained so far.
After having sorted all references from these 13 documents, the researcher analysed
and synthesised all codes, particularly focusing on cycles and relations between the
Interventional and the Outcome codes. Table 5-4 shows the number of references for each
code for all documents. Although interrelation between all codes was analysed one by one
regardless of whether they were classified in the Interventional or the Outcome group, the
data reported in section 5.2.3 is based on Interventional codes and their outcomes, and
interactions between Outcome codes were examined in section 5.2.4.
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Table 5-4: Number of references in all documents for each code.
Butterfield and Martin, 2014
Butterfield and Martin, 2016
Van der Linden et al., 2016

Van der Linden et al, 2015
Stacey and Tether, 2015
Annemans et al., 2012
Martin et al., 2019
Stacey et al., 2011

Butterfield, 2014
Birch et al. ,2014
Watson, 2016
Foges, 2018
Mark, 2013
Identified Codes
Air 0 3 1 0 6 0 1 0 0 0 0 0 0
Architectural 7 6 0 1 7 0 1 10 4 2 7 13 4
Form, Layout and
Furnishing
Bringing Outside 0 0 1 0 8 0 0 1 0 2 1 0 2
to Inside
Colour 3 0 0 0 5 0 0 8 0 0 0 0 1
Curiosity 0 0 0 0 1 0 0 2 0 0 3 4 0
Fire 0 3 0 0 0 0 0 0 0 0 0 1 0
Greenery- Plants 1 3 3 1 20 0 1 1 2 1 0 4 0
Light- Daylight 1 7 2 1 9 2 1 6 0 2 2 3 2
Material 0 0 2 0 2 0 1 11 0 0 1 2 2
Multi-Sensory 0 3 1 1 10 0 0 7 1 0 0 2 0
Environment
• Auditory 0 2 0 1 6 0 0 3 0 0 0 1 0
Experience
• Olfactory 0 1 1 1 2 0 0 2 1 0 0 0 0
Experience
• Tactile 0 0 0 1 1 0 0 3 0 0 0 0 0
Experience
Perception by 0 0 1 0 0 0 1 1 0 0 0 0 0
Gender
Personal Past- 0 4 1 0 10 0 1 2 0 1 1 5 1
Sense of
Belonging
Refuge- Feeling 0 1 0 0 10 1 1 7 0 0 3 1 0
Safe
Seasonal changes 0 0 0 0 8 0 0 0 0 0 0 0 0
Socialising 4 1 1 0 3 0 0 1 2 2 5 1 2
Spaciousness 1 0 0 0 3 0 0 1 0 1 3 4 1
Thermal Comfort 0 4 0 0 3 0 0 1 0 0 0 0 0
View- Prospect 1 2 0 1 7 0 1 2 0 1 0 6 2
Water 0 0 0 1 5 0 0 0 0 0 0 0 0
Welcoming - 7 6 4 2 17 1 0 11 3 1 5 13 1
Relaxing
5.2.2. Analysis of the Codes and their Interrelations

After sorting all comments from these documents, the data was analysed and all codes
were synthesised, particularly focusing on cycles and relations between the Interventional
and the Outcome codes. Table 5-4 shows the number of comments for each code for all
documents. The interrelation between all codes was analysed one by one regardless of
whether they were classed as Interventional or Outcome codes. Based on this classification,
the Maggie’s Centres architecture can be examined under two main subjects: “Architectural
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Design Parameters” (Interventional codes) and “Experiential Wellbeing and Psychological
Support Parameters” (Outcomes codes). It is important to notice that the Outcome codes
also included mentions of several biophilic parameters, as identified in established biophilic
design frameworks (W. Browning et al., 2014; S. Kellert et al., 2011; S. Kellert & Calabrese,
2015).
The list of specific parameters identified in these studies is: Light-Daylight, Greenery-
Plants, Natural Colour, Water, Seasonal Changes, Fire, Sensory Stimuli, Spaciousness,
Inside-Outside Connection, View, Prospect, Refuge, Personal Past-Sense of Belonging
(Cultural Connection to Place, Affection and Attachment, Historic Connection to Place,
Integration of Culture and Ecology), Feeling Safe and Curiosity-Enticement. Although
Natural Material is a biophilic parameter, not all material references were natural and only
in some cases the design of Thermal Comfort was biophilic, hence, these codes were
considered partly biophilic (see Figure 5-4). Welcoming-Relaxing is not an established
biophilic parameter, but was found as an ‘umbrella’ code intrinsically connected to some
biophilic parameters, namely: Mastery-Control, Affection-Attachment, Attraction-Beauty,
Information-Cognition, Reverence-Spirituality, Spirit of Place. Therefore, the identified set
of “Biophilic Design Parameters” intersects both subjects. During this classification, it was
noticed that some codes present some ambiguity, as they could be interpreted as being
partly Interventional and partly Outcome, and were discussed using a gradation system
with three levels in each subject area. Figure 5-4 illustrates this classification of the codes.
As an overarching code, Architectural Form, Layout, and Furnishing was the most
prominent Interventional code to support a healing environment. It is not an established
Biophilic Design parameter, but it was included in this analysis since it was deeply
connected to aspects of biophilic design that were applied to Maggie’s architecture:
Personal Past-Sense of Belonging, Refuge- Feeling Safe, Curiosity, Material, Colour, Light-
Daylight, View-Prospect, Bringing the Outside to the Inside, Spaciousness, Air, Greenery-
Plants, Thermal Comfort, and Fire. As it contained or affected other Architectural Design
Parameters it was categorised as a Level 1 Interventional code (Figure 5-4).
The Level 2 of Interventional codes included Light-Daylight, Greenery-Plants, Colour,

Water, Seasonal Changes, Fire and Material (Figure 5-4). These codes formed part of the
Architectural Form, Layout, and Furnishing code. Based on the analysis, the Level 3
Interventional codes were Sensory Experiences, Spaciousness, Bringing the Outside to the
Inside, and Thermal Comfort. These elements did not exist by themselves and all of them
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were affected by the Levels 1 and 2 Interventional codes, but they were placed within
Interventional codes because they impacted and contributed to the Outcome codes
(Experiential Wellbeing and Psychological Support Parameters). All the Level 2 and 3
Interventional codes were also biophilic design elements, however, the Material and
Thermal Comfort codes also represented non-biophilic elements in their category.
Figure 5-4: Classification of the codes.
The meta-synthesis proved that the Welcoming-Relaxing code was the most prominent
Outcome code, including some of the fundamental goals as claimed in both biophilic design
and Maggie’s architectural brief, such as being “comfortable”, “stress reductive”,
“relaxing”, “calming”, “friendly” and “welcoming”, thus it was categorised as a Level 1
Outcome code (Figure 5-4). The Level 2 Outcome codes included effects of Interventional
codes, but these codes could also impact each other as well as the Welcoming-Relaxing
code. Three of the second-level Outcome codes represented biophilic design parameters
(Personal Past-Sense of Belonging, Refuge-Feeling Safe, and Curiosity- Enticement);
whereas the other two, Socialising and Perception by Gender, were not Biophilic Design
parameters but they had value in Maggie’s Centres’ environment. The only Outcome code
classified in Level 3 was View-Prospect. These two different Biophilic Design parameters
were examined in the same code since they are intrinsically connected, and they were
usually referred to together by interviewees. For example, a cancer patient in Study 1
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defined the view of Maggie’s Dundee as “I like the fact that you can see lots of things – the
road. It is tranquil, especially with the grasses rustling. You can still see life and people and
things going on.” Hence, they were categorised together under the Outcome codes, but
“View” as an Architectural Design Parameter, had a stronger intervention character, while
“Prospect” was more clearly its Outcome.
As explained above the codes were interconnected and some of them contributed and
triggered each other. These interconnections are depicted in a mind map (Figure 5-5). It can
be clearly seen that the Architectural Form, Layout and Furnishing code had an impact on
almost all codes, particularly on other Interventional codes. Likewise, almost all codes
contributed to the Welcoming Relaxing code. Other codes in between, mainly biophilic
design parameters, generated new Outcomes or strengthened this connection in various
interactions. This mind map only indicates the strongest connections revealed through the
meta-synthesis analysis for higher clarity. A detailed discussion of each code is exposed in
the next section, presenting some of the users’ specific comments interpreted in our
analysis. This section is structured to sequentially present each of the Interventional codes
and their corresponding Outcomes.
Figure 5-5: Mind map of the codes (Thickness of arrows illustrates the importance of connection based on this
study. All arrows targeting the same code are represented with the same colour).
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5.2.3. Interventional Codes and Their Outcomes
This section examines meta-synthesis analysis with a particular focus on Interventional
codes and their relationship with each other, and also defines the Outcomes of each
Intervention.
5.2.3.1. Architectural Form, Layout and Furnishing
People referred to architectural forms, design of layout, furniture and fittings in 62

responses. Although it was a substantial code and had connections with 18 of the codes,
the analysis shown in Figure 5-15 confirmed that Socialising and Welcoming-Relaxing were
the most significant Outcome codes linked to this code.
In terms of being welcoming and feeling at home, the most mentioned characteristic
was the entrance of the buildings. People found Maggie’s Centres as non-clinical and quite
welcoming since there was no reception desk, they just felt relax to enter the buildings
without being intimidated by a front desk where they might feel obliged to give
explanations (Figure 5-6).
The feeling free also triggered being more social; the absence of a reception desk was
frequently indicated in the interviews. Usually, the notion of a reception desk made people
think of a reason why they needed to visit the place. On the other hand, people would
create a relationship with the receptionist staff and would avoid interacting with other
people, the situation was explained by a professional staff (Study 11, p.7):
Not having a reception desk means that you can see somebody, that you already
have a personal relationship ready. Somebody comes up to you to see how you do
and you can make a cup of tea and you can already start interacting. If you come in
the front door then you have the main table where people sit around the corners
and you can have a conversation.
The reassuring small entrances were considered as a relaxing place that helped people
to prepare themselves before entering the centre, and it slowed people down with a feeling
of being at home (Figure 5-7) (Studies 2, 3, 8, 11). Besides, entering the centre was
considered a meaningful turning point by patients, since entering the centre means
accepting their cancer and starting to fight it (Study 4). Therefore, the architects tried to
calm down people by distinguishing the entrance with their own design approaches. The
entrance of Maggie’s Dundee (Figure 5-7b) was appreciated for its unconventional
geometrical form and its spaciousness, which also aroused curiosity to explore (Study 4). In
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contrast, the visitors at the centres in London, Edinburgh and Cheltenham criticised the
entrances which were not clearly visible, a visitor emphasised that she struggled in her first
visit when she freshly figured out her illness and was in a state of shock (Figure 5-8) (Study
1).
Figure 5-6: Entrance on Maggie’s Southampton Plan.
A B
Figure 5-7: a) Maggie’s Southampton Entrance, b) Maggie’s Dundee Entrance.
A B
Figure 5-8: a) Maggie’s Edinburgh, b) Maggie’s Cheltenham Entrance.
Attracting people to the centres by curiosity is mostly mentioned along with the
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architectural form of design. The unconventional striking architectural forms or non-
traditional shapes and visual eccentricity were usually featured by interviewees since these
forms aroused curiosity and encouraged people to step in (Figure 5-9) (Studies 1, 2, 4, 9,
12). Some responses confirmed that these centres let people feel safe in their homely
small-scaled forms (Studies 1, 2, 4). A male visitor likened Maggie’s Dundee to an old
fisherman-type cottage, so this familiar feature made him feel welcomed and relaxed while
in the building (Figure 5-7b) (Study 1).
Although unfamiliar forms triggered curiosity and attracted people to the centres, this
could also be seen as risky in the long term in terms of a sense of belonging. Because they
do not get used to such forms in their usual life that were exaggerated and unfamiliar for
some of the informants. Thus, a visitor did not appreciate irregularly shaped centres and
interpreted them as the architect's flight of fancy (Study 2). However, according to the
responses of users, the architects handled this risk substantively by using relaxing natural
elements and homely designed layouts which also aroused a sense of belonging in a
different way. Also, the sharp and unconventional striking architectural forms were used by
some designers to attract male visitors more (Study 9).
A B
Figure 5-9: a) Maggie’s Highlands architectural form design, b) Kurokawa’s sketch of Maggie’s South West
Wales.
People frequently praised the layouts of centres, mostly in association with the
provision of a relaxing, safe place, due to the very distinctive plans so different from clinical
settings. The open space concept has been commonly adopted by the designers of these
centres because this spatial organisation allows the users to socialise and supports the non-
clinical feeling, as the usual layout in hospitals and other health centres is based on highly
compartmented spaces with a high proportion of corridors (Figure 5-10). One could think
that open plans bring an issue with privacy provision, however, despite visitors being a
vulnerable population, it was emphasised in a focus group that “the open-plan
configuration does not threaten privacy as long as it allows withdrawal” (Study 4). To
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address this issue, some designers claimed that they created enclosable spaces to provide
privacy rather than fully closed cellular rooms (Ibid.). Private spaces and individual therapy
rooms were usually set apart from busy communal areas and situated with a view to the
outside (Study 3). The balance between socialising and privacy for the visitors was
appreciated (Study 8; p.7): “When you are used to the Centre and used to using it, you
understand that you can do private without being isolated.”
Figure 5-10: Maggie’s Oldham open plan layout.
In Maggie’s West London, privacy was supplied by designing with reverberate (transmit)
acoustic in the communal areas where the visitors liked talking without being overheard
(Study 10). The open plan configuration was appreciated by visitors because they liked the
feeling of being together and because it promotes social activity, which was exactly what
the open-plan building offers, as people did not get to disappear easily around a corner.
This layout allows to have glimpses of the communal activities without hesitation feeling
intimidated or obliged to participate, and It also grants visual connection with the spaces
upstairs, with half-landings providing a feeling of control of space and awareness of what
activities were being held (Figure 5-11a) (Studies 3, 4, 8). A visitor clearly stated that she felt
relaxed while socialising in one of Maggie’s Centres' open spaces; whereas she used to feel
quite depressed and wanted to leave as soon as possible when she had been visiting
another cancer centre (Study 11). Open spaces also enabled caregivers to keep an eye on
visitors without attracting their attention and to deliver therapy easier. Nevertheless, this
transparency still caused some privacy problems from the staff point of view (Studies 4, 8),
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which was clearly stated by a staff member (Study 1; p.321):
It is an open and fluid building. At a functional level it is fluid and enmeshed. There
is a mutual sense of belonging. But I find it challenging as a worker. I have no
personal space. Visitors use the space as their own – that is a wonderful thing but I
think the openness and perception of privacy here is detrimental to staff.
One of the most important attributes of the architectural planning of Maggie’s Centres
was their capacity to support spontaneous socialising. For example, the planning of
Maggie’s Edinburgh with its visual connection between the first floor and ground floor
(Figure 5-11b) was associated with the idea of visiting a house where they were welcomed
by others with tea and could interact next to a fireplace (Study 3). Another visitor
summarised the impact of Maggie’s Centres’ interacting architecture in the study (Study 8;
p.5): “It’s very much designed so you can’t avoid meeting people. Can you? You can’t come
here and disappear into a room in the corner somewhere.”
A B
Figure 5-11: a) Maggie’s London, visual contact between floors, b) Maggie’s Edinburgh half-landings.
Apart from the layout, furniture and fittings had also a crucial role in making people
social and relaxed. The kitchen table was one of the most distinguishable characteristics of
Maggie’s Centres from the conventional healthcare settings. After having entered the
centre through the ‘welcoming’ entrance, people came and sat around the table and made
tea for themselves while getting used to the atmosphere, and this friendly ritual
encouraged them to use the centre efficiently, and this friendly ritual encouraged them to
talk and greet the other visitors and staff (Figure 5-12) (Studies 3, 7, 8, 11). Having a
kitchen table instead of desks maximised the interaction (Study 7). The interviewees
emphasised the meaning of the kitchen table: "Ooh that is our table. That is our family
table." Or "That is our anchor that is the family anchor." (Study 11).
The kitchen table and the atmosphere of the kitchen had the power for the feeling of
safety and refuge that calmed down many angry and worried patients immediately and the
place was safe enough to socialise with their minds at peace (Study 3). People emphasised
how this congregation around a table allowed them to interact with people and had a
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homely feeling (Studies 3, 7, 8, 11). The head of Maggie’s West London explained one of
her observations about the kitchen atmosphere in this response (Study 3; p.5):
A woman came in recently really angry, and she reached the kitchen and
immediately calmed down. Later she said she found it hard to be angry because the
building wasn't what she expected. Children instinctively pick up on the feelings of
calmness and friendliness here. Some have called the centre, the 'chillout building'.
Aspects of the architecture are designed to produce a feeling of containment, and
every room has a sense of contained space, so people feel protected.
A B
Figure 5-12: a) Maggie’s Manchester kitchen, b) Maggie’s Oldham kitchen.
Design related to big windows and the use of curved walls reflected the quality of the
balance between the feelings of prospect and refuge (Studies 4, 8). Another architectural
element that encouraged prospect and refuge by allowing people to see outside without
being seen was the window screens in Maggie’s West London, shown in Figure 5-13 (Study
1). A member of staff in Maggie’s West London stated her observations regarding the
refuge and prospect characteristics of the centre (p. 212):
It is that thing of sharing. Of being open. Not being possessive. Being open about
cancer. I feel there is, within the centre, also an openness, although it is contained
and closed too. People can see, we can see out without being totally exposed. There
are privacy and protection.
The huge walls around the garden were also indicated as a sign of feeling protected and
escaping from the horror of the hospital environment (Study 1).
A B
Figure 5-13: a) The screen in Maggie's West London, b) Maggie’s West London.
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Another outstanding fitting characteristic, there were no signs in the centres, which
helped to enhance the non-clinical homely feeling. However, this helped the new visitors to
start interacting with others by forcing them to ask questions. A professional member of
staff stressed their aim (Study 12; p.96): “There are no signs to the toilet because actually
asking where the toilet becomes an opportunity for communication, it signals a simpler
environment, more informal. we wanted our building to encourage human interaction.”
The same procedure was suited for manually operable windows for which people asked
others whether they felt cold or warm. Operable windows allowed people to regulate
thermal comfort and air quality and also helped to improve relaxing and homely feelings by
giving an option to adjust the environment according to the users’ comfort (Figure 5-14a)
(Studies 8, 12).
Sliding doors also had an unpredictable impact, as tacit a sign of privacy in the centre.
When the visitors saw a door closed, they knew the room was occupied, thus, people did
not need to knock on the door (Figure 5-14b). They did not have to ponder as with a normal
door whether they were meant to knock or not. This use of sliding doors allowed people to
feel and move comfortably within the centre because they did not need to hesitate or
check the rooms before entering (Studies 3, 4, 10, 11). The use of sliding doors was
explained by a member of staff (Study 10; p.6):
We’ve got private spaces where you can shut the door and you can have a group or
a consultation in complete privacy and we’ve got a language which has developed, I
think, which is the sliding door type thing, where when a room’s not in use it’s just
open. You don’t have to have In Use, it’s just a language that people get familiar
with is that when the door is open you can wander in and use the sofa.
A A B
Figure 5-14: a) Maggie’s Southampton furnished room with operable windows, b) Maggie’s West London sliding
door.
Throughout all the studies, quality and choice of furniture and fittings were also stated
by visitors. Some of them told that the quality and choice of furniture in the buildings made
them feel special, warm and comfortable (Figure 5-14) (Studies 2, 7). However, a visitor also
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mentioned some drawbacks about them, such as some uncomfortable chairs and poorly
working toilet taps (Study 3).
Figure 5-15: References to the Architectural Form, Layout, Furnishing and Fittings, and interrelation with the
other codes referred together.
5.2.3.2. Light- Daylight
There was a limitation in this study in relation to daylight, as all responses about the
impact of light were not included in publications by authors because daylight was
mentioned frequently with similar outcomes, thus, authors did not want to reiterate similar
responses in their studies. This presents an obvious obstacle for this study to analyse
possible nuances in the different comments on the perception of daylight in connection
with wellbeing. However, Study 12 stated that all those interviewed pointed out daylight as
a very important way of improving their emotional well-being. Here, it was understood
that natural light was more important than it was in their analyses, and should have more
references than those documented in these 13 studies. Also, in Study 4, the focus group
showed that ‘light’ and ‘spaciousness’ were accepted as architectural contributors to the
healing experience by providing relaxation and stimulation, and both made people feel
good physically. As stated in the previous section, it was expected that natural light would
be a key factor in therapeutic environments, along with plants, to how the building feels
(Study 3).
Daylight was actually an important criterion in Maggie’s Architectural Brief (Maggie’s
Keswick Jencks Cancer Trust, 2015), and it is a clear common factor that the centres’
architects wanted to expose the inside to natural light as much as possible. Although the
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fully glazed facades or big windows were mainly used for bringing daylight in (Figure
5-16a,b,c) (Studies 2, 3, 4, 5, 7), some other daylight sources were mentioned in the
interviews such as clerestories, the roof fenestrations fitted with selective shading devices,
roof openings (Study 3), atria, courtyards, glass-walled porches (Study 1), small openings
and skylights (Figure 5-16) (Study 4). The gardens and balconies, however, were the places
where users frequently enjoyed direct sunlight (Studies 1, 4, 5).
Rather than stating outcomes of the daylight, many people admired, loved and indicated
the presence of daylight itself as a sign of high quality and healing architecture, and
emphasised that they just needed that light for the healing process (Studies 1, 2, 3, 4, 5, 8,
9, 10, 11). Abundant daylight and the provision of bright space contributed to the non-
institutional feeling, and it was a basic element to create a comfortable sanctuary away
from the stressful clinical hospital environment (Study 3). The presence of daylight aroused
a homely feeling by relaxing patients. Also, some of the interviewees, particularly foreign
people, connected sunlight together with some other elements to remind their hometowns
and trigger a sense of belonging to the centre (Studies 1, 3). A patient explicitly claimed
that the natural light and air in the centre took him away from cancer and helped him in the
healing process (Study 6).
The daylight prompted pleasant thoughts in the visitors; the welcoming and relaxing
effect of natural light place was also indicated (Study 1). Together with the plants, it also
made the centres alive and provoked a motivation for living. The gardens, balconies, winter
gardens, and sunny corners, in short places where there was sunlight exposure, became
places to have positive, happy, refreshing feelings for the cancer patients, particularly
whenever they were upset, stressed or wanted to be private but not isolated (Ibid.).
Receiving the sunlight also helped to be aware of the time of day and seasonal changes
which made some of the staff feel better and less stressed compared to working in their
previous jobs in closed, mainly artificially illuminated wards and other healthcare
environments (Ibid.).
The lighting design evoked spirituality as well, a cancer patient expressed that the light
in the centre had a similar feeling he had at a church that he recently visited (Study 2). An
architect clearly stated taking the daylight inside while planning the design was far more
important than colours and wallpapers, which were commonly a consideration for
designers of healthcare settings (Ibid.). In short, the daylight exposure in the centre
promoted important characteristics of a healing environment such as peace, calm and
stress reduction (Study 8). The warmness and softness of light were also associated with
the feeling of safety (Study 13), privacy and protection (Study 1).
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Daylight was required by the designers as a tool for creating a distinction from usual
healthcare facilities, and many of the interviewees pointed out their impression of the light
and how they did not expect this light and the bright environment in a hospital (Studies 1,
3, 5). The designers were also rigorous about the functions of rooms and their lighting
requirements. The art therapy classes required bright light, while softer and dimmer light
was used in relaxation classes (Study 3). On the other hand, the staff used artificial light
along with the natural one to make people relaxed, it was expressed that they left
overhead and task lighting on even if there was sufficient daylight because patients with
anxiety felt more comfortable (Study 3). The warm, soft and bright lighting made the
people feel welcome regardless of the time of day (Study 13). Figure 5-17 illustrates that
the Light-Daylight code had a relation with 21 other codes in this review; this important
code had the strongest connections with the Spaciousness, Greenery-Plants, Welcoming-
Relaxing, and View-Prospect codes.
A B C
D E F
G H I J
Figure 5-16: Natural lighting examples from Maggie’s Centres a) Maggie’s Southampton, b) Maggie’s Oldham, c)
Maggie’s South West Wales, d) Maggie’s Gartnavel, e) Maggie’s Manchester, f) Maggie’s Southampton, g)
Maggie’s South West Wales, h) Maggie’s Gartnavel, i) Maggies’s Cardiff.
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Figure 5-17: References to Light-Daylight, and interrelation with the other codes referred together.
5.2.3.3. Greenery- Plants
A healing environment includes the presence of plants and greenery (Study 11) since
greenery has always been the element that is more strongly associated with nature in
people’s minds, compared to the other elements. Greenery was included in the centres in a
variety of ways and purposes. Although green elements and their contexts in the centres
were mentioned in a variety of ways (as indoor plants, indoor gardens, balconies, roof
gardens, potted plants, vibrant cut flowers etc.), the most stated context in which greenery
was appreciated was the centres’ gardens themselves (Figure 5-18).
A B
Figure 5-18: a) Indoor garden Maggie’s West London, b) Indoor garden Maggie’s Manchester.
Almost all of the interviewees stated that plants in Maggie’s Centres affected their
health, wellbeing and feelings in a positive way. Plants and vegetation, in general, were
perceived as ‘healing’ (Study 11), ‘admirable’, ‘fantastic’, ‘feels like home’ (Study 3),
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‘peaceful’, ‘relaxing’, ‘protected space’, ‘feeling safe’ (Study 5), ‘alive and changing’, ‘sense
of welcome’, ‘barrier with the outside world’, ‘buffer zone’, ‘threshold’, ‘place of
relaxation’, or ‘calming’ (Studies 1, 4). The garden and its plants slowed people down and
relaxed them when they approached the buildings and encouraged them to enter (Study 1).
Plants created an atmosphere that distinguished Maggie’s Centres from most healthcare
environments, where a male interviewee defined these other environments ‘as no place to
linger, no place to revisit, no sense of welcome’. However, the same person said (Study 1;
p.201):
Maggie’s Centres’ entrances begin the process of arriving that engenders pleasant
thoughts and feelings where colours and greenery are light and airy. Viewing
gardens from inside pleases the viewer and connects them with a wide empathic
space.
It was widely accepted by the interviewees that the gardens and greenery had a
powerful relaxing impact, even in a very short distance walk in the gardens before arriving
at the entrance made them feel calm and relaxed. Also, pots of beautiful flowers were put
at the entrance by staff to create a feeling of a threshold. The variety of plants created a
sensory richness and encouraged people to enter and discover the centres to some extent,
also, various plants reflected the seasonal changes and transformed the centres'
atmosphere every day (Study 1).
A visitor said that there were no grim corners thanks to the plants, while some of the
participants saw the plants as the most important stress-dropper, and one of them told
that she would be sick without these plants. Watching living plants was perceived as
refreshing and motivating while the people here were trying to survive (Study 1). Although
the plants and gardens were associated with the feelings of ‘alive’ and ‘joyful’, some people
with cancer complained about dying plants and leaves which remind them of their mortality
(Study 10). The spiritual effect of greenery was explicitly expressed by a cancer patient
(Study 1; p.274):
There is something about that here. The greenery – ‘it all fits’. It lifts – it’s not
overwhelming, it’s calming. I can’t imagine it without the greenery. Look at that
majestic tree. Look how it’s moving. The greenery is the closest I get to God – it’s
not the people, its nature, cycles, birds, purpose, never dead.
Another outstanding impact of the gardens and greenery was the barrier and buffer
effect between the centres, and hustle and bustle of the outside environment and the
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nearby hospitals (Figure 5-19) (Studies 1, 9, 12). Moreover, these barriers created a refuge
where people felt safe, protected, and private (Studies 1, 5, 9). A visitor explained how she
felt about the garden and plants (Study 5; p.1):
As soon as you turn the corner you are affected by the woodland feel, the
tranquillity, peace and no noise of the city. Everything is so green. It’s like a different
planet here, it has always been such a pleasure to come here. The building is
fantastic, relaxing.
Figure 5-19: Buffer zones surrounding Maggie’s Dundee.
The greenery was one of the most crucial elements that triggered users’ feelings. The
designer stated “The plethora of natural light and planting is key to how the building feels”
in Study 3. Along with the visual impact of the greenery and plants, it was extracted from
the responses that they elicited other sensory perceptions in people: the smell of scented
plants and blossoms (Studies 3, 5), the tactile texture of the tree trunks and sitting on the
grass, hearing rustling leaves and rain’s pattern on the leaves, hearing the singing of birds
that perched on the trees, or the taste of edible plants and fruits (Study 1, 12).
Although Greenery-Plants was an extensive code presenting a relationship with 20 other

codes, the strongest connections were found with the codes of Welcoming-Relaxing and
Light-Daylight (Figure 5-20).
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Figure 5-20: References to Greenery-Plants, and interrelation with the other codes referred together.
5.2.3.4. Sensory Experiences
These codes focused on the main sensual perceptions of the interviewees in their
experience of the centres, however, the sense of sight was not included in these codes
since comments related to visual perception were highly detailed in the other codes. The
interviewees' responses were classified in the code of the multi-sensory experience and its
three sub-codes: the olfactory experience, the tactile experience, and the auditory
experience. According to the collective analysis of all four sensual codes (Figure 5-21), the
sensory experience in Maggie’s Centres was substantively framed around and associated
with one outcome code, Welcoming-Relaxing, and three interventional codes: Greenery-
Plants, Materials, and Light-Daylight. in addition to this, Refuge-Feeling Safe, Personal Past-
Sense of Belonging, Water, and Thermal Comfort were other outstanding codes for sensory
experiences.
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Figure 5-21: References to all sensory experiences, and interrelation with the other codes referred together.
a. Olfactory Experience: Sense of Smell
In terms of the olfactory experience of Maggie’s Centres, the gardens and green spaces
were mentioned the most by far (Figure 5-22). People admired the fragrance of bloom,
flowers, grass and plants, and the smell of soil when it rained (Studies 1, 3, 5, 12). It was
pointed out that the smell of the garden was also coming into the centre with the breeze,
which created a strong connection between the outside and the inside (Study 1). Just after
defining the smells, the users frequently associated the space with a homely feeling, feeling
relaxed and feeling safe (Studies 1, 3, 5, 12). The smells of plants had a calming down and
meditating impact, particularly on the cancer patients who were feeling vulnerable and
experiencing a lack of capacity to feel sensations due to their treatments. A cancer patient
pointed to this situation (Study 1; p.238): “I love the fact that the plants are scented. The
garden tickles all your senses. And it’s nice to be able to smell as I can’t taste anything at
the moment.”
The fragrance of plants also aroused curiosity and lifted the people’s spirits. Staff stated
that the sweet fragrance of a particular blooming plant was carried by the breeze, and
some people were coming to ask about the source of this smell because it lifted their
feelings and spirits (Study 1).
Apart from the plant and garden-originated fragrances, the smell of burning wood on
the fireplace was also associated with a powerful feeling of coming home (Study 3).
The most important feature of smell was the recalling power of personal past, people
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felt safe and homely because the smell reminded them of their personal experiences. The
smell of space was employed as a tool by the designers. They avoided passing on the smell
of the hospital where the visitors usually had time that they did not want (Study 2). Thus,
visitors were smelling the spiritually rising natural fragrances in the centre rather than the
smell of medicine, so this olfactory experience triggered sometimes a sense of being
relaxed, some others a sense of belonging by recalling memories from personal past (Study
1). A member of staff explained how she felt while sitting on the porch (p.256):
The jasmine reminds me of Tunisia when one night it rained and the scent of the
jasmine was very strong. I have that memory. It is very sensory. In summer you can
smell the jasmine in the courtyard.
Figure 5-22: References to Olfactory Experience, and interrelation with the other codes referred together.
b. Auditory Experience: Sense of Hearing

In Maggie’s Centres' case, as a meditating support centre, silence enhanced the quality
of the auditory experience more than hearing voices. People stressed the quietness felt in
the centres due to some sound attenuating design features (Studies 1, 2, 3, 6). Interviewed
designers pointed out their effort for creating a noise-proof atmosphere via buffering with
the greenery (Studies 1, 9, 12), the double-glazed curtain walling system and the integrated
asymmetric acoustic panels (Study 3). Although the sound-proofing precautions worked at
a great scale and visitors were happy with the noiselessness, some deficiencies were
reported in the interviews. The architect of Maggie’s West London, Ivan Harbour, observed
the following after regular visits to the centre: “We had wanted to keep the outside noise
down by bouncing sound off the walls. However, the roof bounces the sound in, so it's not
as quiet as we expected” (Study 3). Likewise, permanently preventing all traffic noise from
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the vicinity was not possible at the centres located in the heart of an urban area. Interviews
in Study 4 reported the noise problem in an open-plan centre (p.529):
Users tolerated the noises, as they liked being aware of other activities without
participating. Yet, they brought up some privacy issues, for example, acoustic
problems during meditation sessions and consultations. This highlights the
importance of modifying acoustic relations, as in certain situations, users might feel
the need for a soundproof space to withdraw to.
However, the noise was not perceived the same by everyone. In Maggie’s West London,
a female visitor said (p.249): “It’s right in the middle of London. The noise of the traffic is
somehow ameliorated. That’s what that garden is – it’s a reassurance.” Another female
cancer patient expressed a very different experience (p.249): “I love the garden when
people from the hospital come and plonk themselves down. There is always the noise of
the traffic but that is just the way it is” (Study 1).
The sounds had a similar impact as the smells in terms of recalling memories that helped
to improve feelings of welcome and relaxation (Figure 5-24). The most commonly
mentioned sounds originated from the gardens: the moving and rustling tree leaves,
branches, and plants (Studies 1, 6); patterns of rain on the huge leaves (Study 12); joyful
singing and chirping of birds (Study 6); bumble of bees (Study 1); chickens crowing (Study
4). The gardens were “never dead” with all these movements and sounds, this aliveness
made the cancer patients' feelings uplift while they were endeavouring to survive (Study 1).
Also, people confirmed they enjoyed the sound of water elements, which made them feel
relaxed, calmed down and welcomed. In Study 1, a patient chose the designed water pool
as her favourite part of the building (Figure 5-23) and said (p.250): “The calming sound of
water as you walk to the centre. This is a new feature. It is rather lovely. I love the sound
going onto the pebbles.”
Figure 5-23: The water pool in Maggie’s Cheltenham (Study 1).
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Interestingly, the lack of a water sound was criticised by a member of staff in Maggie’s
Dundee (Study 1) who identified sound and presence of running water as something
missing as an important factor to complement the aims of the centre’s environment
(p.251):
I would love a water feature. Down by the bench there [below the terrace]. You
would also hear it on the terrace. Something simple with the noise and the effect of
running water. That’s the thing missing.
As in all codes, the designers did not want to bring any resemblance between clinical
environments and hospitals through the auditory experience either. The announcements,
shouting names, and constantly ringing phones, in short, all the usual background noise of
the hospital environment was replaced by quiet atmospheres which were encouraged to
include natural sounds (Study 2). According to all these published studies, Maggie's
architects were substantially successful with the auditory experience and creating a
welcoming, mutable and lively atmosphere in Maggie’s Centres. To sum up the sense of
hearing, an interviewee described her sound experience in the following way (Study 2; p.4):
I always described Maggie's as having lots of different voices, and so there are days
I'll go over and you feel OK to chat to people because it's just lots of conversations
of relaxed things. Other days you'll go over and it's a quiet building because there
are lots of separate very personal conversations going on, and then other days you'll
go over… it's really loud and it's full of laughter and they're all teasing. So, it has lots
of different voices and I think that for me is the really lovely thing about it, that it
just translates. On the same day, it can be four different things and it takes it, the
building can take it and hold it and it's good.
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Figure 5-24: References to Auditory Experience, and interrelation with the other codes referred together.
c. Tactile Experience: Sense of Touch
As happened in all other sensory experiences, one of the main sources of a sense of
tactility came from the gardens and green spaces, where the users felt their connection
with softness or gentleness (Studies 1, 2, 6). Apart from the wood trunks of trees in
gardens, the warmth of wooden materials inside was also indicated specifically (Figure
5-25). While a patient was describing the womb-like feeling of Maggie’s Centre, she
stressed the importance of the tactile feeling of wood: “I love wood, I think it's very tactile, I
can't go near it without touching it” (Study 2). Even though the interviews did not specify
any other particular material, the choice of material, and their textures and tactile qualities
were widely appreciated. As shown in Figure 5-26, these qualities prompted a welcoming
and safe atmosphere that offered warmth and greeting (Study 2).
A B
Figure 5-25: a) Maggie’s Manchester, b) Maggie’s Oldham.
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Figure 5-26: References to Tactile Experience, and interrelation with the other codes referred together.
Lastly, looking at the multi-sensory experience, Maggie’s Centres effectively used

natural elements and their relation to elicit sensations. The gardens took the lead in terms
of multisensory experience as well as all the senses individually by providing a direct
connection with nature. The gardens were the environment where users experienced a
higher diversity of stimuli coming from fragrances, sounds and textures, enhancing the
feelings of relaxation, greeting and safety and encouraging them to continue their therapies
and fight death (Figure 5-27). This sensory experience explicitly was claimed to calm them
down and lift their spirituality during their fight to survive (Studies 1, 3, 4, 5, 12). A male
cancer patient described the healing effect of the garden with its sensory richness in this
way (Study 6; p.703):
The garden and green spaces are areas to take you away from the hustle and bustle
of everyday life and give you the opportunity to stop, look around and appreciate
nature. Admire the blooms, enjoy the fragrance, listen to the joyful singing of birds,
feel the wind and warm sunshine on your face. This takes you away from cancer and
who would dare to say it does not help in the healing process?
The landscape architect of a Maggie’s Centre explained the multisensory experience
they aimed to offer in the garden (Study 12; p.97):
There are these huge leaves in one of the courtyard gardens, so when it rains you
get this ‘patter’ on the leaves. Then there is the perfume, so that recurs again, again
and again in the garden, and then there is taste, so in all the gardens there are
edible things. So, by stimulating people’s senses you just very naturally get them to
tune into a place.
The wood-burning fireplaces, with the smell of burning wood and the crunching sound
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of it, (Study 3), and the water elements (Study 1) also helped to multisensory experience in
Maggie’s environment.
It was a key principle for architects and designers to design the centre as much different
as possible from the hospital environment, and in order to do so, they aimed to heighten
and uplift the senses (Study 4). As all the responses showed, they succeed in stimulating the
senses by using natural elements. A member of staff, a cancer specialist, described the
multisensory environment of a typical hospital environment as opposed to the
distinguishing characteristics of Maggie’s Centres (Study 2; p.4):
[Typical hospital environments] smell a certain way, they look a certain way, the
phone's constantly ringing, there are buzzers going off, always… so the situation you
were in with other people at hospital was that they started to feel that they were an
irritation if they were asking you something because they can hear the buzzer go,
they can hear the phone ringing, there's somebody shouting your name down a
corridor, all that kind of stuff, everything is all, in those environments is all about
moving you away from the situation you're in.
Eventually, all the emotional effects of these sensory experiences were also supported
by the recalling feature of multisensory experience. People felt familiar with the
environment based on their personal past, and their own memories of their past
experiences. Some of them smelled the same flower that they experienced during their
holidays; some of them heard natural sounds that reminded them of their hometown, and
some others sat in front of the burning wood as they used to do in their childhood home.
Thus, this sense of familiarity triggered in turn the sense of feeling at home welcomed and
calmed.
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Figure 5-27: References to Multi-Sensory Experience, and interrelation with the other codes referred together.
5.2.3.5. Materials
Maggie’s architecture used different materials to create welcoming, warm and safe
places, which were also employed to attract attention and curiosity in some cases.
Materials, in general, were seen as a greeting part of the centres with their texture and
tactile features (Study 2). For instance, the surface materials were warm to touch (Study 7).
The soft and natural materials stimulated users’ feelings and brains by fascinating them
(Study 8).
Wood was likely to be the most mentioned material by the interviewees. Wood as a
building material for structures and surface finishes was welcomed by many of the patients
and commonly mentioned for its ‘warmth’ and ‘natural feeling’, which ‘settled their mind’
(Figure 5-28a) (Study 1). Wood and timber trusses were also associated with a high quality
of architecture, as they drew people’s attraction and created a retreat space where they
felt safe and relaxed (Figure 5-28b) (Studies 1, 2). Wood was widely appreciated as a soft
material by both the visitors and the staff (Study 8), and it was mostly just ‘loved’ without
defining any reasons or specific feelings. An example of the expression of the emotional
impact of wood materials reported by a patient in a focus group (Study 2; p.5):
I love wood, I think it's very tactile, I can't go near it without touching it. I just love
it, and if I was coming in as a centre user and I needed time to myself, I would hide
myself in there, because I feel it is womb-like and comforting. I just, I can't say
enough about it, I just love it.
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A B
Figure 5-28: a) Maggie’s Highlands, b) Maggie’s Manchester.
Even though concrete was seen as a cold and unpleasant material in general, this study
revealed in which conditions concrete as a material was welcomed by the interviewees.
People usually came with prejudice about concrete, a patient expressed his first impression
about a centre made of concrete as (p.5): “if you described it to me and gave me a
percentage of how much of this building was concrete I'd be thinking really, it wouldn't
work”, and he went on how the building was clever with its design, colours, fittings and
natural features, all together made him feel safe and welcomed (Study 2). Another visitor
explained how much he/she loved the building and the concrete parts which were like little
legs that made him/her feel sheltered, thanks to the designer’s clever touches (Ibid.). The
interviews in Study 2 disclosed the reality of creating warm and alive spaces by using cold
and sharp materials, a visitor expressed the reason why these materials were not
unpleasant in Maggie’s Centre (p.6): “The glass, the angles, the concrete, the exposed
materials, but it's all softened, not by textiles but by nature, because you've got that lovely
garden…”
Also, concrete was used ad hoc to attract men to Maggie’s Newcastle, increasing the
number of male visitors by eleven per cent. The head of the centre explained how the
architect became successful due to the clever inclusion of concrete, which was not ‘girlish’,
therefore, the architect designed the interior in concrete walls which were juxtaposed with
timber for softening edges, while using Corten steel cladding panels (Figure 5-29) (Study 9).
Not only concrete but also the use of different materials, in general, would attract the
men’s attention. While a centre head expressed that the male visitors noticed the wood
material far more than the female visitors (Study 2), a cancer specialist staff provided the
following observation (Study 5; p.1):
This building works for men better than I’ve seen elsewhere. They get intrigued by
how things, the materials that have been used and things like that, they very quickly
offer you an opinion on it. It’s a door opener, it’s far better than a half-hour
preamble about football.
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Figure 5-29: Maggie’s Newcastle.
On the other hand, the texture or appearance of materials was not the only attraction
for the users, also the creativity with which materials were used and the craftsmanship of
the workers were pointed out. An architect interviewee reported that all materials during
the centre’s construction were raw, thus, the construction workers showed their creativity
and professionalism in the production of the building (Study 2). The creativeness of the
woodwork and the curves were interpreted as the centre was built with ‘love’ (Ibid.).
The architects used warm and soft materials, or softened cold materials, as a tool to
create a homely atmosphere in order to distinguish these environments from the usual
healthcare environments. The responses showed that warm material choices and the
quality of craftsmanship in the centres were successful for this purpose: they were found
welcoming, safe, warm and homely (Study 2). The plaster walls and ceilings, an oak floor
and familiar domestic furnishing were given as examples of how the interior design created
a non-institutional feeling by an interviewee (Study 7). Another goal of some architects was
to create a visual focus for the visitors to enhance their mental state; they used materials
along with unconventional architectural forms for this purpose. In Maggie’s Dundee, the
timber ceiling attracted people’s eyes to its organic shapes (Figure 5-30); while in Maggie’s
South West Wales, the ceiling with its glass rim allowed people to focus (Figure 5-31) (Study
2). The material choices were mainly appreciated in the interviews. However, the only
negative comment was about the plastic chairs in the centre which were not comfortable
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(Study 3). An architect interviewee summarised what he avoided in terms of material
choice (Study 2; p.4): “The worst thing you could do is have vinyl on the floors and those
blue chairs…”
Figure 5-30: Maggie’s Dundee timber ceiling.
Figure 5-31: Maggie’s South West Wales with the glass rim on the ceiling.
Figure 5-32: References to Material, and interrelation with the other codes referred together.
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5.2.3.6. Colour
From the visitor’s point of view, the colour of the centres was often referred to as a
distinctive feature from clinical healthcare settings. Their statements about colours were
usually followed by a comparison with other healthcare facilities, particularly hospitals.
Quite a few people mentioned the orange-red colour of Maggie’s West London where this
striking colour was used for arousing curiosity and attracting people. When people left the
hospital, this orange-red colour was attracting their attention where everything was
expected to be white, grey or redbrick on the usual hospital campus (Studies 1, 2, 11). The
orange colour shocked some patients; however, they were quite happy about this colour
owing to the that it gave life around (Study 11). A visitor interviewee defined how she was
feeling safe (Study 1; p.294):
I came first with my daughter and I loved the orange. It is such a huge jump from
Charing Cross Hospital and you immediately feel somebody cares about you. Like
someone bringing you a cup of tea in bed. It was the coming in, the huge wall to
enclose it and to isolate it from the horror of the hospital.
Some responses referred to the interior painting as well. The splash of warm colours and
tactile texture of materials at the entrance were also stated as engendering elements of
feeling welcome and the warmth of the greeting (Studies 1, 2). A response indicated that
colourful decoration gave a sense of family and invited them with feelings of welcoming
and relaxing. A psychologist staff member told that different themes of these buildings
helped people to look from a different perspective, so she/he was delivering therapy every
time in different rooms painted in different colours (Study 2).
Along with greenery, light and air, colour was associated with emphatic spaces that
engendered pleasant thoughts and feelings, and a strong sense of welcome, contrasting to
most healthcare environments (Study 1). Colour was generally emphasised regardless of
the different types of colour, but people did specifically refer to their characteristics, such
as “the colours are so vibrant”, “contrast colours” (Study 1), “splash of colour”, “lots of
quirky colours”, “colourful” (Study 2). People liked the feeling of not recalling the hospital
environment where they usually just left before entering this safe sanctuary, thus, they did
not care that much about which colour it was painted, but how these colours were
different from a hospital environment. Another visitor proved this view with his/her
response in Study 2 (p.5):
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I think the lack of colour made me feel a wee bit uncomfortable, because then it was
really stark, wasn't it? They've only recently just started to get the pictures on the
walls and things like that. It was very clinical then, it's warmer now, but it still needs
a bit more work to it.
In all analysed interviews in this study, it was clearly indicated that visitors expected a
colourful effect from Maggie’s Centres. For instance, although her centre’s building was
colourful, a visitor complained about the lack of colour in the garden and recommended
planting bulbs and tulips (Study 1).
According to the analysis, Colour was mostly connected to the codes Welcoming-
Relaxing, the Architectural Forms, Layout and Furnishings, and the Light-Daylight (Figure
5-33).
Figure 5-33: References to Colour, and interrelation with the other codes referred together.
5.2.3.7. Bringing the Outside to the Inside
The connection between outside and inside environments was highly appreciated by
people in these studies. Basically, the two main features of the centres associated with the
way of creating a connection with the outside were gardens and windows. Bringing the
outside to the inside was considered as easy access to the garden, just through the doors or
having no barrier between the outdoor garden and the indoors, while the gardens were
seen as barriers between hustle and bustle of the outside world and the centre (Study 1).
Garden and building connections were commonly embraced as the interviewees saw the
gardens as an extension of the inside of the centres (Ibid.). An interviewee, who walked
around the building every day and examined it, told the reason for examining it as the
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building had a very strong connection with the outside and garden, therefore it was always
changing (Study 2). While the majority of people mentioned the inside-outside connection
via windows (Studies 1, 7, 10) some others also emphasised the operable doors, amount of
glass, balconies (Study 7), terraces, and indoor gardens, plants and trees (Figure 5-34)
(Study 1). The most noticeable factor of this inside-outside effect was the affordance of
visual connection, such as a view of the sky, water, or greenery. The multisensory
experience was also highlighted, such as feeling the warmth of sunlight, scented plants
(Study 5) or the warm breeze from open doors (Study 1).
The benefits of the inside-outside connection were also extracted throughout all
responses from the interviews. A staff member expressed the importance of this
connection as some people did not have the energy to walk around, thus, they found an
opportunity to have access to nature while being inside (Study 1). Figure 5-35 showed that
the Bringing the Outside to the Inside code is highly associated with the Welcoming-
Relaxing code. According to interviewees, the inside-outside connection made the centre
calming, peaceful (Study 8), welcoming, inviting, safe place, house-like (Study 1), relaxing,
uplifting and healing (Study 10).
A A B
Figure 5-34: a) Maggie’s Gartnavel, b) Maggie’s Fife.
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Figure 5-35: References to the Bringing Outside to Inside, Furnishing and Fittings, and interrelation with the
other codes referred together.
5.2.3.8. Spaciousness
According to the analysis shown in Figure 5-36, the code Spaciousness was by far the
most associated and mentioned together with light-daylight (Studies 1, 2, 4, 7, 8, 11, 12).
The interviewees considered bright and spacious spaces as features of healing
environments due to their calmness and peace impacts (Studies 8, 11), and these two
elements created a sense of space (Study 1). Qualitative evidence suggested that
spaciousness and light are contributors to relaxation and stimulation that made the users
physically feel good (Study 4). According to an architect interviewee, little things like the
ceiling height and the amount of daylight greatly improved the quality of space and the
perception of spaciousness (Figure 5-37) (Study 2). On the other hand, the high ceilings and
the big windows that expose the light and allow clear view was frequently defined as the
main constituents of spaciousness (Studies 1, 2, 4, 8). The airy spacious rooms helped to
stop claustrophobia and to reduce the feeling of stress (Study 1). Study 8 stated that
spaciousness was a major feature for energising the centres, a participant expressed the
feeling of spaciousness (p.5):
There’s something about having space above your head. It is almost like your
thoughts feel less in your head. It’s almost like they expand out. So physically that’s
something, I think, that makes you feel better.
The architects of Maggie’s Glasgow, Office for Metropolitan Architecture (OMA), stated
that they wanted to create a relaxing atmosphere which was a very important feature for
cancer patients according to their background research, so they decided to design the
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centre around a very big homely living room. Therefore, one of the main features they
aimed for in this design was spaciousness (Study 4). Also, spaciousness with the explosion
of volume was used for evoking curiosity and a feeling of welcome.
Figure 5-36: References to Spaciousness, and interrelation with the other codes referred together.
Figure 5-37: Maggie’s Highlands section.
5.2.3.9. Air
People explicitly mentioned or implied the term air only in 11 responses, which was less
than expected. This could be due to being an indiscernibly common element for living
organisms, which could lead to being easily ignored by the users’ perspective. However,
fresh air and air-flow features were mentioned by some visitors and professionals. These
responses were quite helpful to have an obvious insight into some design principles and
outcomes.
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Fresh air’s impact became much more perceivable when users got physically in contact
with open spaces, gardens, winter gardens and balconies because the notion of fresh air
intensity was higher in these spaces. Therefore, the air was mentioned most commonly
together with greenery and light.
Compared to the other codes explained in previous sections, people did not provide a
lot of comments about outcomes related to fresh air. However, they expressed that fresh
air was one of the reasons they were spending a lot of time in these particular locations,
such as the winter garden, balcony or garden, above all in the warm weather (Studies 1,
10). Two people connected these spaces with feeling relaxed and feeling at home (Study 1).
A member of staff observed that the balcony was her favourite time spending spot, as she
felt protected there due to the plants, the fresh air and the sunshine (Study 5). Specialist
staff also commented, in terms of therapy techniques, that Maggie’s better suited to art
therapy thanks to its very airy and light environment (Study 3).
The entrances were another space commonly emphasised by visitors as welcoming and
encouraging. Being airy was also mentioned along with the greenery, natural light and
colour. One of the visitors claimed that the approach to the building had a “winding country
feel” which slowed people down and gave them time to relax in there and encouraged
them to get into Maggie’s (Study 1).
As predicted, the air was also associated with thermal comfort. In the interviews, a
cancer patient told that chemotherapy made them very sensitive to the cold, so he/she
referred to the indoor garden as a sheltered place for a feeling of being outside with fresh
air, plants, and light (Study 1). Another staff member defined the indoor spaces as “it is
literally breath of fresh air” while explaining the room with its outside connection and the
perception from the centre to its surroundings (Study 1). Some visitors also said that when
the doors opened, a breeze of fresh air from water elements (the river Chelt and the
fountain in the garden) made them feel an inside-outside effect (Ibid.). Likewise, these
comments displayed the connection between ‘bringing outside to inside’ code and air as
well.
Maggie’s London was mentioned in another comment in relation to its cross-flow

natural ventilation system, which offered a comfortable indoor environment, thanks to
manually opening well-positioned big sliding doors and top-hung windows (Study 3). A
visiting engineer explained the good ventilation of the centre (p.7):
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Entering Maggie s West London feels like entering someone's house, and this is
reflected in the minimal layout of its HVAC services. A simple but effective extract
ventilation system, fully integrated to the wall lining, gently forces fresh air in from
the main entrance doors and moves it across the main social space, where it merges
with fresh air entering the space through other routes.
As expressed at the beginning of this section, an engrained function for human beings
might have been widely neglected by interviewees. Therefore, it can be deduced that the
air quality of Maggie’s Centres was successful, as people did not notice it. Otherwise, some
symptoms (e.g. Sick Building Syndrome) or complaints could have been reported, because
some crucial aspects of air quality may attract attention once they are absent (e.g., odour).
Figure 5-38: References to the Air, and interrelation with the other codes referred together.
5.2.3.10. Seasonal Changes
The seasonal changes were observed frequently, above all in connection with the
gardens, where the impacts of daylight and plant mutations over the annual cycle are most
perceptible (Figure 5-40). The interviewees stated that the gardens reflected these changes
either through strong scents, blooming flowers, dew drops, rain or snow, and sometimes
through pristine colours (Study 1). People remembered their first visits in association with
the seasons: “It was snowing” or “I came here first in the spring. The magnolias were set
against the orange” (Study 1). The natural flow of the garden showed the expression of the
seasonal changes in the centre, which was referred to as relaxing for some of them and
reducing the stress level. For most people, daylight was the most important element that
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represented the seasonal changes, daytime or climate. A staff member, who had worked in
a closed hospital environment for a long time, stated that the view of the sky and the
perception of daytime and the seasonal changes had a powerful stress-reduction impact
(Study 1). The majority of responses praised the feeling of seasonal change inside the
buildings and in the gardens. However, a member of staff complained that the garden
lacked seasonal changes in Maggie’s Dundee, which was composed of only a meadow and
azaleas, instead of a variety of plants; likewise, a male visitor who had cancer also criticised
the garden in the same centre and reported how important the perception of seasonal
changes was for the cancer patients (p.232):
In winter the garden looks drab and into December, January and February there is
little of interest. Where are the snowdrops and crocus to give brightness and hope
for the forthcoming year? Where are the daffodils followed by tulips to reinforce the
feeling of a renewed life? That is what cancer patients wish to experience, hope for
the future.
Figure 5-39: Maggie’s Dundee.
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Figure 5-40: References to Seasonal Changes, and interrelation with the other codes referred together.
5.2.3.11. Thermal Comfort
Thermal comfort was mainly mentioned together in conjunction with air quality,
however, there was no significantly outstanding connection with any particular codes
(Figure 5-41). Although the overall thermal comfort quality was praised, the feeling of
thermal comfort was an objective evaluation, so some of the comments proposed slightly
warmer or cooler places. Cancer patients highlighted the fact that they were very sensitive
to the cold due to chemotherapy side effects (Studies 1, 3), thus, thermal comfort was
more important in Maggie’s Centres compared to standard design principles. A patient
pointed out that the temperature was comfortable, and particularly welcoming with the
wood fire (Study 3). In the cold weather, the thermal comfort was comfortable and
watching the outside while being warm inside was found relaxing by a patient (Study 1).
The indoor garden was especially appreciated in connection with providing thermal comfort
that allowed people to enjoy the feeling of being outside and encouraged the connection
with green elements in cold weather (Ibid.). Also, manually opening windows and sliding
doors helped people to feel relaxed since they can intervene in the room temperature or
air quality (Study 3).
On the other hand, in Maggie’s London, the upper level was warmer than the lower
level when the underfloor heating system was in operation. Also, people reported that one
of the activity rooms was getting significantly warmer than the other rooms (Study 3).
Therefore, one of the critiques regarding thermal comfort was about the consistency of
temperature in different parts of the buildings. Another suggestion by a visitor was to block
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the wind in the garden by using benches (Study 1). An architect indicated that they avoided
reaching a temperature of 24°C to not remind a hospital ward (Study 2).
Figure 5-41: References to Thermal Comfort, and interrelation with the other codes referred together.
5.2.3.12. Water
The most important design goal of the water elements was to stimulate the sensory
experience (Figure 5-42). Water triggered the senses through its sound and visuality. People
stressed the calming and relaxing impact of water elements in the gardens (Study 1). A
female cancer patient in Maggie’s Edinburgh expressed her experience with water
elements (p.250):
The bamboo and water feature give a calm, zen-like aura which settles the mind as
you enter Maggie’s – a connection with nature is a connection with life.
A cancer patient interviewee in Maggie’s Cheltenham described the sound of water as

‘always tranquil’ (Study 1). Also, the rivers or the lakes close to the centres projected their
smell and sounds to the centre, apart from providing a view (Ibid.). The water elements had
also a welcoming impact by slowing down the visitors (Study 6; p.701):
Walking down the path with the fountain—it’s coming on a little journey. I always
stop and look at that and think about the water going all the way back again. I
always follow the curves in my mind. It’s a stopping point for me. I instinctively do it.
I don’t think about it.
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On the other hand, the absence of a water element was pointed out by a member of
staff in Maggie’s Dundee, she claimed the sound and streaming effect of water was missing
at the centre (Study 1).
Figure 5-42: References to the Water, and interrelation with the other codes referred together.
5.2.3.13. Fire
Fire was classified as an element of biophilic design by Kellert (S. Kellert et al., 2011; S.
Kellert & Calabrese, 2015); however, its use in the designs of Maggie’s Centres was quite
restricted. The designers used fireplaces in Maggie’s Centres to create a warm and homely
atmosphere where people can gather around, thus, the fireplaces encouraged social
interaction (Figure 5-43) (Study 4).
While the people’s personal past, namely, defined what home means to them, was
supporting the homely feeling, the environment encouraged a sense of belonging (Figure
5-44). Along with creating a homely, safe and socialising environment, fire unsurprisingly
supported opinions on thermal comfort. As cancer patients, the visitors stressed their
sensitivity to cold, so they found the fireplace very welcoming and comfortable (Study 3).
Although the gas fire was commonly used by the centres’ designers, the first wood-
burning stove was used in Maggie’s West London, and some other new centres were
designed with the wood-burning stove too. Therefore, the multisensory experience was
supported by the warmth and smell of fire; particularly these qualities of wood fire
fascinated some of the interviewees (Study 3).
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A B
Figure 5-43: Fireplace a) Maggie’s Manchester, b) Maggie’s Cardiff.
Figure 5-44: References to Fire, and interrelation with the other codes referred together.
5.2.4. Interaction Between Outcome Codes

The identified Outcome codes have been explained in the previous section in connection
with the Interventional codes. However, apart from Perception by Gender, all Outcome
codes were also interrelated, showing different degrees of connection, as represented in
Figure 5-45.
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Figure 5-45: Interrelation of Outcome codes (Thickness of arrows illustrates the importance of connection based
on this study. All arrows targeting the same code are represented with the same colour).
The analysis showed that there was a very strong connection between the personal past
of the users and their welcoming and relaxing perceptions of the space (Table 2). The
interviewees expressed very frequently that they felt like ‘coming home’, therefore they
had a feeling of being welcome and safe when they entered the centres (Studies 3, 4, 7, 8,
10). One of the reasons why they associate Maggie’s centres as a homey environment was
their actual personal and cultural perception of what home means to them and their
families. Therefore, there was a strong connection between the sense of belonging, a
biophilic design attribute, and the feeling of welcome and relaxation.
The creation of a homely and non-institutional environment was referred to as the main
design strategy to arouse these feelings too. People calmed down and felt relaxed because
the building was quite different from usual healthcare settings in their memory, while quite
similar to the feeling of a home that they got used to. Therefore, the users’ personal past
and sense of belonging became highly associated with the welcoming place and feeling
relaxed code (Studies 1, 2, 3, 4, 7, 8, 12).
On the other hand, Personal Past and Sense of Belonging engendered and supported
refuge and feeling safe the most among the codes (Figure 5-48). (Studies 1, 2, 3, 8, 13).
Hence, the centres provided safe environments where the users had the feeling of refuge
which triggered feelings of relaxation and welcome.
In terms of the outcome codes, Socialising was the second most associated code with
the feeling welcomed and relaxed after the sense of belonging (Figure 5-46). Regarding the
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responses, these two codes, the socialising and the welcoming-relaxing triggered each
other. While the feeling of socialising with people, and feeling the freedom of speech and
expression made patients relaxed and adapted to space, the feeling of welcome and peace
let them talk and socialise with people (Study 1, 2, 7, 8).
Apart from codes the curiosity and perception by gender, all codes had more or less
connection with the code welcoming-relaxing (Figure 5-46) and evoked the feelings of
greeting, welcoming, relaxation, calm and peace to different extents.
To sum up, according to the responses, views and prospects triggered feelings of
welcome, relaxation (Studies 2, 3, 4), and curiosity (Study 4). Also, a successful balance
between prospect and refuge helped people feel safe (Studies 1, 4).
5.2.4.1. Welcoming Place- Feel Relax
Welcoming place and feeling relaxed was the most outstanding code in all codes that
had connections with 20 other codes with 71 references (Figure 5-46). These two feelings
were highly connected and supported each other, thus, they were examined in the same
code. Although the atmosphere and the overall centres were referred to as welcoming and
relaxing, the results showed that this code was also a conclusive outcome of the other
feelings. Such as feeling safe or a sense of belonging stimulated the feelings of relaxation
and welcomed, or daylight, architectural form, furnishing, greenery, etc. enhanced the non-
institutional feeling which promoted the feeling of relaxation or feeling safe. All these
senses were interrelated to each other. Consequently, the feelings of welcome and relaxed
were the most mentioned Outcome in the interviews because it was one of the most aimed
aspects of the Maggie’s Centres designers (Study 4). The terms ‘calm’, ‘relaxing’,
‘comfortable’ and ‘welcoming’ were the most frequently used descriptions for centres by
their designers (Ibid.).
Secondly, the architectural layout, furniture and fittings were designed in order to
create a homelike environment, and according to the visitors’ responses this approach
worked and stimulated the feeling of welcome and greeting, and people felt relaxed and
calmed down in the centres (Studies 1, 2, 3, 4, 7, 8, 11, 12). Architectural forms, planning,
elements and furnishing and fittings, which supported the feelings in question, were
explained in detail in 5.2.3.1.
The gardens were places where the people had a direct and the strongest connection
with natural elements. The visual and sensory connection with the gardens and greenery
stimulated people’s feelings whether they were outside or inside the buildings. As
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explained in 5.2.3.3, the green elements had a remarkable impact on calming the people
and made them feel relaxed. Particularly before entering the buildings, the gardens and
plants slowed the patients down and greeted them (Studies 1, 3, 5, 6). The daylight
exposure (see 5.2.3.2) had a similar impact with the greenery, it increased spending time at
the centre by greeting visitors and evoking feelings of relaxation, peace and calm (Studies 1,
3, 5, 6, 8, 13). The sensory stimulations; the multisensory experience (Studies 1, 2, 3, 6), the
auditory experience (Studies 1, 2, 6), the tactile experience (Studies 2, 6), and the olfactory
experience (Studies 3, 6) had strong roles on to evoke welcoming and relaxing feelings.
Owing to explained in detail in all codes separately above in section 5.2.3, this section
looked into the responses that explained the welcoming and relaxing impact of Maggie’s
Centres regardless of the other codes.
In order to explain the reason why Maggie’s had a welcoming and relaxing impact, the
visitors usually referred to the atmosphere and energy of the centres (Study 11; p.5): “Ooh
my god this is gorgeous feeling, relaxing. Yes, the energy.”
The greeting energy of Maggie’s buildings gave the users an uplift and a feel-good factor
(Study 8). A female visitor interviewee expressed based on her experience that it was the
energy of the building that was healing and enhancing her mood apart from the therapy
delivered and socialising (Study 5; p.1):
There’s a very strong, powerful sense to it, it’s not just peaceful, there’s real
strength, one day … the class had started when I got there, and I opened the door
and the energy was palpable… that’s partly a group exercising together, but a lot of
it is the building.
A member of staff observed that even the first step from the door made people at ease
(Study 11). The importance of the building’s atmosphere for being welcoming and relaxing
was also stressed in Study 2 by two different interviewees at two different sites. For their
first time, both of them entered the centres while there was no one around, and they felt
the greeting and warmth from the inviting space. The source of these feelings was not
based on greeting from people or therapy from the staff, it was the building’s atmosphere.
They were still receiving the same energy from the architecture during every visit.
The place gave optimism and confidence to the patients who were often desperate. All
the participants in the focus group agreed with these statements, and no negative
connection with the centre was associated (Study 11). An art therapist staff of Maggie’s
West London particularly stressed the calming impact of the centre (Study 3; p.5):
The building is an escape for people. They often come in from the hospital between
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blood tests and chemotherapy and it provides a calming space. It’s almost as if they
can breathe again. You see them visibly relax into the building.
A male cancer patient in Maggie’s Dundee also used the building similarly as breathing
and relaxing zone just after leaving the hospital (Study 1; p.265):
When I come here, typically it’s about getting bad news and sometimes Maggie’s is
about just allowing time to pass before going home. It’s important that this space is
very nice. It is a buffer zone because you don’t want to take that straight home.
A group of participants defined everything that Maggie’s Centres did as solely about its
sanctuary and peace (Study 6). This was what the cancer patients needed to handle the
stress and anxiety while fighting their illness.
It’s like a warm hug, you just come in here and are sort of enveloped in something,
like a warmth, magic, warm feeling (Study 5; p.1).
Overall, the participants pointed out how the architecture had energy and an
atmosphere that encouraged them to feel relaxed and welcomed. However, a psychologist
staff explained that Maggie’s Centres still needed some improvement to make people more
relaxed to stay in (Study 2; p.6):
You could have a building that is fantastic and really impressive, but actually not a
nice place to be in. I think a Maggie’s centre still needs to have that closeness and
you need to feel held in it. It’s not just about doing something really impressive and
inspiring, you know. A cathedral can be impressive and inspiring but you might not
feel you want to sit there and have an intimate chat with somebody there.
Lastly, one of the important aspects in terms of architectural impact, that made people
relaxed and welcomed was the non-intuitional characteristics of the centres (Studies 1, 2, 3,
4, 5, 8, 12). Even though the impact of the non-intuitional feeling of the spaces was highly
associated with the personal past, it might affect the people even if they were not much
familiar with the hospital environment. The people often described the centres as contrasts
of a clinical hospital environment which was referred such as stressful (Study 3), depressing,
drab, gloomy and horrific (Study 1), and antisocial (Study 2). People did not feel relaxed and
welcomed in usual healthcare settings because they had a “sense of secrets” and “lack of
trust” due to strict restrictions on the use of spaces, locked rooms and gardens, hardly or
not operable windows etc. All these spatial conditions evoked a feeling of being trapped
(Study 12). However, there was no lock or key in Maggie’s Centres where the metaphor of a
house was used, from the signs to operable windows, from the kitchen tables to natural
elements which created a contrasting atmosphere with the nearby cancer hospitals,
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therefore, people felt welcomed, calm, peace and relaxed along with the feeling of safety
(Studies 8, 12).
Figure 5-46: References to the Welcoming-Relaxing spaces, and interrelation with the other codes referred
together.
5.2.4.2. Personal Past – Sense of Belonging
One of the dominant reasons for users feeling safe was confirmed to be enabled by
experiencing a sense of belonging or associating their own memories from their personal
past with the experience of Maggie’s spaces. People expressed very frequently that they
felt like coming home, and therefore they felt welcome and safe when they entered the
centres (Studies 3, 4, 7, 8, 10). An important consideration about why they related Maggie’s
Centres to home lies in their own perception of what home means, and the notion of family
and home culture, which depends on the context in which they grew up. Therefore,
unsurprisingly, there was a strong connection between the sense of belonging and feeling
welcome and relaxed. In consequence, those responses that referred to a ‘homely
environment’, which also indicated the interviewees’ perception of ‘home’, were included
in this code although there was no clear data that confirmed whether their perception was
related to their personal past.
Architectural layout and interior design such as the kitchen table or the open-plan with
living room-like furniture (Studies 3, 7, 8), daylight exposure (Studies 3, 5) and greenery
(Study 3) had a central role in creating a homelike environment for the Maggie’s Centres
users. Also, the multi-sensory experience had a striking impact to help people to create a
connection between their memories and the centres’ features as explained in detailed
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section 5.2.3.4 (Studies 1, 5). Some people described how they remembered their
memories such as touching pine cones gave energy to someone due to reminding memory
from a holiday on a Greek island (Study 5), or natural daylight, the sliding doors and visual
connection with greenery recalled the hometown, Japan, of a visitor (Study 3). Else, linking
the centre to a church in terms of the level of spirituality aroused a kind of sense of
belonging, because the interviewee had to have a familiarity with the church’s spiritual
atmosphere to create this connection (Study 2). On the other hand, people stressed how
different these centres are from the hospitals they did not want to remember (Studies 1, 4,
7).
Thus, considering personal past experiences, feelings, and memories were clearly
identified as significant factors, it was important to make people not only remind them of
the positive things in life but also forget these unpleasant and negative memories. In
Maggie’s Centres, the collective unpleasant memory of visitors was hospitals and clinical
environments where they learnt about their illness and regularly visited for treatments
while facing death. For this reason, crucial criteria for the architects were focusing on
homely environments and nature-based stimulators (Study 4).
Figure 5-47: References to Personal Past-Sense of Belonging, and interrelation with the other codes referred
together.
5.2.4.3. Refuge- Feeling Safe
The architects wanted to create a safe environment which was also supported in the
Architectural Brief (Maggie’s Keswick Jencks Cancer Trust, 2015; Study 2). Hence, the
buildings were found safe and private overall, many interviewees expressed their feelings
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without specifying a reason, such as “when I walk in here, I feel like I’m in my mother’s
arms” (Study 9) or “this building is very clever, very clever. It brought me in, I felt very safe,
which was important” (Study 2). The visitors who had cancer usually found the centres safe
enough to unveil their emotions or to cry privately without being isolated. Thus, the staff
stressed the importance of the welcoming and safe atmosphere of the centres where
people were getting used to how to use it privately without being isolated (Study 8). A
visitor described how she felt safe at the centre (p.4):
It’s a bit like coming in to a gigantic womb: coming in and the whole thing sort of
enfolds you, like, you know, it’s giving you a great, big hug. And there’s no end to it.
No... It’s, must be a word for it: unconditional.
Some defined the centres as ‘chillout building’ in which the architecture reflected a
feeling of containment in every room, so they felt protected (Study 3). Although some
interviewees pointed out the buildings as safe places as a whole with all features, some
others described some features that encouraged the feeling of safety and created a refuge.
As explained in section 5.2.3.1, the application of some architectural forms, layout, kitchen
tables, windows and huge or curved walls had an impact on creating refuge and safety.
For example, one felt safe due to the huge barrier between the centre and the hospital,
which was perceived as a horror experience (see 5.2.4.2) because that environment
reminded her of unpleasant memories. The same patient continued: “This was the only
place I could cry. The main thing about this place is you feel safe”. However, another person
felt powerful and safe because she likened the centre to a church in terms of spirituality
(Study 2). The reason why she found the church sort of level of spirituality was her personal
past and sense of belonging.
Once more, light, plants and greenery were frequently mentioned in terms of creating a
safe atmosphere. The barrier effect produced by plants was appreciated, however, some
people recommended even increasing the plant barrier to feeling safer. A patient
emphasised how she was feeling secure and safe in the indoor garden, away from the
horrible hospital wards. The trees protected the inside but allowed the chance to get a
glimpse from the outside, to have an idea of what was inside. Although some of the staff
members pointed out that they did not have enough privacy since it was a workplace for
them, all of them said the plants in her centre’s garden shielded them from the visitors’
view, which created privacy both ways (Study 2).
Lastly, the material choice had an impact on the feeling of safety along with the
architectural form and furniture. A patient described the concrete parts of the structure of
a centre as the provider of enough shelter (Study 2). However, wood was the only material
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that was associated with feeling safe, and defined as womb-like and comforting (Ibid.) (see
5.2.3.5).
Figure 5-48: References to Refuge-Feeling Safe, and interrelation with the other codes referred together.
5.2.4.4. View- Prospect
Although view and prospect are different notions, both of them have a great portion in
common and allowing a view from inside also encouraged the prospect according to the
sources examined in this meta-synthesis. Thus, these two notions were taken into account
together in this section.
View and Prospect code was highly mentioned together with the Light and the Greenery
codes (Figure 5-49). Views were fundamentally provided through windows from which the
natural light was also coming in (Studies 1, 2, 3, 4, 7). In terms of connections with
greenery, all Maggie’s Centres had green elements and a strong bond with the gardens, so
the views from the buildings usually had a deep visual perspective of the plants (Studies 1,
3, 4, 9).
As mentioned in section 5.2.4.3, the balance between prospect and refuge was
important in Maggie’s architecture. For example at Maggie’s London, people stated that
they easily saw who was coming to the centre wherever they were in the building, which
also promoted social interaction (Study 11), while they were away from the foreign eye
without being exposed (Studies 1, 3).
Maggie’s Centres allowed the users to have visual contact with the outside and within
the buildings which supported handling stress and calming down along with the sanctuary-
like impact of the refuge features. Therefore, view and prospect helped to create a contrast
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with the hospital environment around (Study 3) and enhanced the respiting characteristic
of the spaces (Study 6).
Viewing out, particularly the greenery of the gardens or blue sky, encouraged the feeling
of relaxation and a sense of comfort (Studies 1, 2, 3, 4, 9). A cancer patient visitor stated:
“The fully glazed doors and windows allow me to see the greenery outside, and I feel as if
I’m in the country” and she emphasised that the centre made her feel good and happy
(Study 3). Spacious space with a view from windows reduced the feeling of claustrophobia
(Study 1).
Some interviews stressed that viewing the outside life was important because they did
not like the feeling of being isolated, although they did not want to remember the feeling of
the nearby hospital (Study 1; p.213):
It is still attached. I like the fact that you can see lots of things – the road. It is
tranquil, especially with the grasses rustling. You can still see life and people and
things going on.
However, visual contact with the outside life was not a widely accepted expectation by
all the visitors, some others wanted a fully introspective experience away from the outside
world while they were calming down there in silence and with a view of nature, or
socialising with the people who had similar problems to share (Studies 4, 12). An
interviewee in Study 9 supported not having a visual connection with the surrounding
urban area (p.4):
I like this one, though. It is very light and airy. The best thing about it is the garden.
When I’ve seen photos of this building it looks like it is in an open space, but it is
actually surrounded by other buildings but, once you’re inside, you don’t feel it. You
see the gardens, rather than the buildings.
Interviews with architects in Study 4 revealed that all designers wanted to design the
centres towards nature as much as possible because, independently from Maggie’s
Architectural Brief, their research and experiences had also proved that nature had a
therapeutic agency. Therefore, if it was possible in those locations they used the stunning
views to create a strong connection with nature (i.e. Dundee, Forth Valley, South Wales).
However, even if there were no natural settings in some centres located in more urban
areas, contact with nature was a key principle in their design as well, thus, the gardens and
views of the sky took the main role in this context.
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Figure 5-49: References to View-Prospect, and interrelation with the other codes referred together.
5.2.4.5. Socialising
As explained in 5.2.3.1, socialising was primarily encouraged via architectural layout and
some simple furnishing and fitting touches.
Overall, Maggie’s Centres provided a variety of private and social interacting spaces
(Study 7). Participating in the activities with people who had similar problems and goals,
and sharing the same feelings helped the cancer patients to be adjusted to the community,
and not feel alone and isolated. One of the main reasons why the cancer patients were
visiting the centre was the socialising opportunity (Study 2; p.4): “I’ll go over and you feel
OK to chat to people because it’s just lots of conversations of relaxed things.”
Figure 5-50: References to Socialising, and interrelation with the other codes referred together.
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5.2.4.6. Curiosity
The quality that triggered curiosity was usually the ‘mystery of space’, which was
considered an essential element of biophilic design (Browning et al., 2014). The mystery
was expressed to be given to Maggie’s spaces via architectural design, by generating
particular spatial experiences (Study 8). The unconventional external architectural forms
and non-traditional shapes of these buildings and the materials used in them were the most
emphasised stimulation for curiosity or the factor that intrigued people and enticed them
to visit the centres. The power of iconic architecture attracted people even if they didn’t
know anything about Maggie’s Centres buildings (Studies 2, 4). Study 4 stated that all
participants stressed the fascination and curiosity evoked by surprising architectural form
and exposed roof structure. Curiosity was also aroused by offering glimpses inside the
centre but not exposing the activities. Sometimes the gardens and trees created this effect
for outsiders while providing refuge for visitors. Sometimes the openings of the building
attracted some interviewees to inside Maggie’s West London (Studies 1, 4).
The responses showed that arousing curiosity not only encouraged the people to step
in, but also made them explore the centres and activities within the place (Study 8). The
outside-inside connection, for example, made the centre changeable, like a living organism,
thus intriguing people to keep exploring the centres, by that time they were getting
integrated into the community (Study 2). Curiosity sometimes turned into a shock with a
mystery of unexpected features, which was described as a ‘disarming effect’. A member of
staff explained how helpful it was this ‘disarming effect’ of architecture for inviting new
patients (Study 2; p.6):
I think even if it’s just sometimes a second or two, you see quite a lot of people
forgetting their cancer once they see the building, even if it’s just for a few minutes.
After coming in they feel safe, and they just get it all.
Overall, the architectural form was the code that most triggered curiosity among all
codes as explained also in 5.2.3.1 (Figure 5-51). The responses obtained in interviews and
focus groups in these studies (Studies 2, 4) emphasised the successful architecture of
Maggie’s centres by combining both familiar and relaxing domestic features that made the
people feel safe and homely with surprising and stimulating features which attract people
by curiosity.
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Figure 5-51: References to Curiosity, and interrelation with the other codes referred together.
5.2.4.7. Perception by Gender
The data about perception differences based on gender came mainly from observations
from the staff and were scarce. According to responses in the interviews, the most
prominent feature of Maggie’s Centres that attracted the male visitors’ attention in
comparison to their female counterparts, was the choice of material (Studies 2, 5, 9). The
wooden materials and the high specs of the design of the building were always far more
noticed by men and sparked their curiosity (Study 2). A cancer specialist staff explained this
in her observation (Study 5; p.1):
This building works for men better than I’ve seen [elsewhere]… they get intrigued by
how things, the materials that have been used and things like that, they very quickly
offer you an opinion on it… it’s a door opener, it’s far better than a half-hour
preamble about football.
Furthermore, concrete as a building material was accepted more by male visitors, so the
architects of Maggie’s Newcastle, who wanted to build a male attractive centre, used fair-
faced concrete walls that were juxtaposed with softer timber edges (See 5.2.3.5). Other
than the material choice, an outdoor gym located on the rooftop was also added to the
design to attract more male visitors. As a result of these interventions, 45 per cent of
Maggie’s Newcastle’s visitors were male, while the male visitors were 34 per cent of the
total visitors overall in Maggie’s Centres (Study 9).
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Figure 5-52: References to Perception by Gender, and interrelation with the other codes referred together.
5.3. Summary of Findings

The contrast of the nice green. It is open plan with that horrendous building next to
it. Maggie’s that’s what it’s about. I have heard many people laugh and smile here.
It is the contrast. It highlights them even more. My first impression of Maggie’s was
that it was positive, light, happy, refreshing and I still feel this. I remember the
colours and the helpfulness and friendliness. It’s the people that make the place. The
open space and light (Study 1; p.296).
In the context of cancer care, mental health issues are confirmed to cause a detrimental
impact on patients, in particular stress, depression and anxiety regarding how cancer will
affect all aspects of their lives. Thus, patients and their families highly value places that
mitigate these feelings. It is clearly stated in numerous comments from users in this study
(474) the need for a provision of relaxing and welcoming environments. It was confirmed
that users found themselves relaxed and welcome when exposed to specific design
parameters, being biophilic design critical in the planning of these environments, with two
‘umbrella’ parameters/codes driving the design decisions: Architectural Form, Layout and
Furnishing and Welcoming-Relaxing. Architectural Form, Layout and Furnishing is not per se
an established Biophilic Design Parameter but agglutinates a number of Biophilic Design
Parameters, identified as Interventional codes in this study. Similarly, Welcoming-Relaxing
is not an established Biophilic Design Parameter but is fed by other Biophilic Design
Parameters, such as Mastery-Control, Affection-Attachment, Attraction-Beauty,
Information-Cognition, Reverence-Spirituality or Spirit of Place, as well as other Outcome
codes. In this context, it is clear that these two new concepts would be critical parameters
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in a revised design framework.
According to the results, creating a welcoming and relaxing environment was the most
important of all architectural features of the therapeutic environment. Welcoming-Relaxing
code was referred to in 71 responses, not only with the interventional codes but also with
the outcome codes referred to this code. Whereas Architectural Form, Layout, Furnishing
And Fittings were the most effective intervention techniques and the main interventional
code. These two codes represented the two basic features of the therapeutic design: the
architectural form, layout, furnishing and fittings were the main tool that the designers
used for reaching the main aim, a welcoming and relaxing place. Although all the other
codes had their specific aims and outcomes, almost all of them either supported them or
were supported by them. Thus, these two codes had outstandingly referenced by the
interviewees.
The Light-Daylight was the third most referenced code with 38 references. It was
followed by Greenery-Plants which had 37 references. Even though there was only one
reference difference between them, the light was more important than the greenery.
Because both of them had limitations in this review. The light had fewer references than
reality because the light was not included in all interview responses in the previous studies
by the authors, who did not want to repeat in their studies. Study 12 claimed that all
interviewees stated the importance of daylight which was improving their emotional
wellbeing. On the other hand, the studies of Angie Butterfield (Studies 1, 5, 6) mainly
focused on the gardens, thus, this review had sufficient data in terms of the greenery and
plants.
Personal Past and Sense of Belonging had a striking impact on feeling welcomed, relaxed
and safe. Thus, it was the second most important Outcome feature for therapeutic
environment design. The result showed that representing or adumbrating some trails from
the local, vernacular and traditional features was important to arouse mood-lifter feelings.
The codes Multisensory Experience, Refuge-Feeling Safe, View-Prospect, Socialising, and

Material were referred in over 20 responses each. Socialising was the only one that was not
a biophilic design element. However, the study showed that it was one of the most
important characteristics of a therapeutic environment like Maggie’s Centres.
Air was the most underrated code in this study, considering the vital importance of air.
As explained in 5.2.3.9, it was likely that the importance of air was widely ignored by the
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interviewees. However, it could be accepted that the air quality was sufficient in the
centres because nobody reported a symptom of the absence of fresh air.
Study 7 summarised the important design features based on her six-month period post-
occupancy evaluation in Maggie’s Nottingham. She indicated the design of windows which
provided sufficient natural light, nature view, and improved inside-outside connection
while maintaining privacy. The nonclinical-homely environment, interacting possibility, a
range of social and private spaces, the quality and choice of furniture, colourfulness,
domestic scale lightings, warm and tactile surface materials and gender neutrality were the
other important design features that had wellbeing and performance-related outcomes
(Study 7).
Out of all the Biophilic Design Parameters (‘patterns’) established in current frameworks,
the parameters that users found most relevant in this building typology
(healthcare/therapeutic programmes) are: Light-Daylight, Greenery-Plants, Natural Colour,
Water, Seasonal Changes, Fire, Sensory Stimuli, Spaciousness, Inside-Outside Connection,
View, Prospect, Refuge, Personal Past-Sense of Belonging, Feeling Safe, Curiosity-
Enticement, Natural Material, and Thermal Comfort. Out of these, Daylight, Air, Greenery-
Plants are the most important, while Seasonal Changes, Thermal Comfort, Water, Fire were
less relevant parameters. Figure 5-53 illustrates all relevant codes in ranking order and
shows the importance level of biophilic design parameters.
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Figure 5-53: Ranking of the codes by number of comments. This figure also shows importance levels of biophilic
design parameters (*Although Air should be in the third group based on the results, it is considered 1 st level
based on the limitation explained in 5.2.3.9)
How the prominence of these parameters is determined, as well as their interactions

with other parameters, are in turn driven by two factors in this context. Firstly, for both
users and designers, it was crucial to establish a clear difference with standard clinical
environments, to avoid any remembrance with the painful experiences associated with the
treatments and procedures but also with the environmental discomfort experienced in
hospitals in terms of smells, noise, lack of natural light, endless corridors or high
temperatures. Secondly, it was also critical not only to avoid the hospital environment but
to create spaces that reminded users of safe and pleasant experiences, using references to
homely feelings, promoting a sense of belonging and eliciting memories. All biophilic
parameters work towards achieving these two factors, and this is done mainly through the
two ‘umbrella’ concepts/parameters explained above.
Qualitative research is an invaluable method for gaining new insights into inclusive
design. This meta-synthesis approach allowed to look deeply inside the efficacy of biophilic
design parameters in the non-institutional therapeutic environments from the users’ point
of view. The main limitation of this study was that the analysed studies did not aim to
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collect data to specifically test the value of biophilic design, so questions and their
corresponding responses were guided by other goals. But equally, they were not affected
by the potential bias that can be inadvertently induced through targeted questions.
Obtaining primary data from studies with a focus on biophilic design is critical to providing
more rigorous results. Still, as the analysed studies provided substantial information about
established biophilic parameters, I believe that the extracted conclusions are indeed
reliable, and can contribute to the revision of a more accurate framework to guide future
design in the area. Another limitation was the fact that the analysed research studies were
anonymised for ethical reasons, and in most cases did not include the name of the studied
buildings, which led to a lack of clear connection between the participants’ comments and
specific design features. Therefore, the assessment of some characteristics was done by
contrasting these comments with the design of Maggie’s buildings in a general way.
The data obtained in this chapter and the previous chapter (Chapters 4 and 5) were
supported and crosschecked by the primary data in the following chapter. Chapter 6
reports and analyses semi-structured interviews carried out with professionals and experts.
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CHAPTER 6
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6. EXPERIENCE AND PRACTICE OF THERAPEUTIC ENVIRONMENTS
This chapter examines the interviews carried out with experts and practitioners in
therapeutic environments design. These interviews aimed to provide a means to contrast
the results obtained from the systematically searched review and meta-synthesis studies
presented in Chapters 4 and 5 by crosschecking data obtained from a primary source, as
well as to complement the input to the final conceptual framework based on
recommendations offered by experts and practitioners.
6.1. Semi-Structured Interview Methodology

Semi-structured interviews are a useful tool for exploratory and explanatory studies as
they can allow to infer causal relationships between variables (Cooper et al., 2008). This
sort of interview approach can be the most advantageous in research where there are a
large number of questions to be answered, the questions are either complex or open-
ended or the order and logic of questioning may need to be varied (Easterby-Smith et al.,
2012; Saunders et al., 2009). The semi-structured interview approach serves to understand
the reasons for the decisions your research participants have made, or the reasons for their
views and opinions (Saunders et al., 2009), and also gives an opportunity of probing the
answers of interviewees who may be asked to explain or build on their ideas and allow to
investigate the meanings of words or ideas that will add value and depth to the data
collected. Moreover, this approach can lead the conversation in directions that had not
been considered before but emerge as important parts to address the research question
and objectives (Ibid.). Due to the above-explained opportunities, the purpose of this
research and the nature of the data collection questions, it was decided that semi-
structured interviews should be employed in this PhD study. It is paramount for this process
to be rigorous and the interviews conducted as objectively as possible because the semi-
structured interview method entails a risk of bias, subjectivity, reactivity and inaccuracy
(Saunders et al., 2009).
The interview population consisted of therapeutic environment experts and
practitioners in the fields of psychology and architecture. Lesley Howells, psychologist and
research lead of the Maggie’s Centres Research Advisory Group, agreed to be interviewed
as an expert on these special therapeutic environments. Additionally, architects of some of
the Maggie’s Centres, who were also knowledgeable and involved in the design of clinical
settings, were invited to be interviewed. Five architects (Darron Haylock from
Foster+Partners, Eoin O’dwyer from A_LA, Piers Gough from CZWG, Lucy Brittain from
Cullinan Studio, and Ivan Harbour from Rogers Stirk Harbor + Partners) participated in these
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interviews, which took place between March 2021 and February 2022. The meetings were
performed remotely via video call due to the COVID-19 restrictions, where the mean
session duration was 45 minutes. The research reached saturation with five architects, as
the centres to be discussed in the interviews covered the whole range of design situations:
urban and rural context; ambitious and modest approaches; use of a variety of materials;
implementation of gender-focused strategies; and the selection also considered the
inclusion of early period and recently designed centres.
The questions designed for the architects were focused on generic design decisions, to
start conversations that sought open answers in specific. These included issues such as
assessment of their awareness of the biophilic design theory; Maggie’s Architecture and
Landscape Brief and its importance in the process; the effectiveness of communication and
management with the client; the design process and steps that were unusual; design
intentions, specifically in connection with considerations of the human-nature relationship
in the spaces; the main design aspects or drivers behind the project; their background
research and required consultant fields; their approach to site analysis/context in the
project; their design considerations in relation to biophilic design parameters; the success
of the buildings based on post-occupancy feedbacks and detected drawbacks; and
environmental features that provided a healthy environment for patients and staff. In
terms of clinical environment design, questions were focused on the creation of the
best connection with nature in clinical settings, and the differences between the clinical
and non-clinical (Maggie's) environment design processes.
The interview questions for the research lead from Maggie’s Centre Research Advisory
team mainly focused on the impact of the environment on users based on her and other
staff observations. The general theme of the question design included: the most successful
elements in the buildings in terms of first impressions and the buildings’ impact on users;
observed differences between in-centre therapy and remote therapy during the COVID-19
restrictions; qualities of the space that are considered when allocating the different
activities or parts of the programme in the different spaces of the centre; functional
qualities of the buildings that staff can appreciate and visitors don't get to appreciate; the
success of Maggie’s Architecture and Landscape Brief in connection to nature in the
buildings; visitor profile based on gender differences; and the impact of biophilic design
parameters and seasonal differences.
All interviews were recorded and transcribed verbatim. The transcripts were imported
to NVivo 12 software for analysis, then coded and organised into exclusive and exhaustive
categories to discover overarching themes, which are examined in the following sections.
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6.2. Non-Clinical Therapeutic Environment Design in Practice: Maggie’s
Centres Example
This section reports the interview themes relevant to Maggie’s Centres, which were
undertaken as a central case study for therapeutic environments. The research departed
from the hypothesis that Maggie’s Centres’ could offer a relevant example of non-clinical
biophilic design and that the information obtained from Maggie’s Centres’ design process,
design decisions, and application of biophilic design parameters could inspire and guide
clinical biophilic design environments, although clinical environments have more strict and
complex procedures and programme.
6.2.1. Design Process and Decisions

The studies in Chapter 5 and post-occupancy reports showed that Maggie’s Centres'
environments were successful to mitigate mental and emotional health problems.
Therefore, understanding the design process and design decisions can guide architects
when designing therapeutic environments. So that the interviewed architects’ opinions and
their advice reported in this section will inform the preparation and design process of non-
clinical settings as well as clinical settings.
6.2.1.1. Approach to Maggie’s Architecture and Landscape Brief
Maggie’s Architecture and Landscape Brief was extremely appreciated by all participants
as a guideline that describes all requirements of the programme and demanded
environmental features in a way that does not limit the imagination of architects and
encourages them to design uniquely. Brittain highlighted the emotional and human-centred
descriptions in the brief:
Maggie’s brief is very open and imaginative and considers how people feel in the
building rather than specific space requirements. For example, they ask for a toilet
that someone can use with space for a short break or a cry if needed… In Maggie’s
brief, visitors are encouraged to feel at home in the space and invited to make
themselves a drink in the kitchen. There is a choice of places to sit, to either be
engaged with people or places of refuge for quiet or to observe activities within the
building.
Moreover, the non-descriptive language of the brief that explains the required
atmosphere was emphasised by Harbour:
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The lovely thing about the brief, as I was talking about how good the brief was… It
wasn't prescriptive. It just set a scene, we can then interpret it as architects. I think
there was an aspect of that, which was about the sense of home… Beyond that, I
think there was nothing as developed as the brief exists today, with our immediate
connection with the environment around us and to the outside world, to nature. But
it was sort of implied.
O’dwyer described the brief as incredibly focused on the building, but also on nature
and the relationship with natural elements. It encourages to move away from the typical
clinical hospital environment. The brief pictures a place “like a kind of oasis in the hospital
complex that cancer patients and their families or friends can go and get benefit from a
peaceful environment which is the exact opposite to a clinical environment that can be
quite distressing and busy. Also, you're not always in the best state when you're getting
treatment”.
Maggie’s brief supported and encouraged them to create a strong connection with
nature, promoting privacy, site and landscape decisions with a highly established portfolio.
Although it was tricky and challenging to apply nature connection and create the required
atmosphere in the landscape of Maggie’s Southampton, the team made an effort to follow
the brief’s descriptions. Moreover, O’dwyer highlighted that every Maggie’s building is
quite different and has unique approaches to considering the brief but all have the same
relieving impact and strong connection with nature thanks to the brief:
One of the first things that we were keen on, was to visit some of the older centres,
so we went to the centres in Hammersmith… in Cardiff… in Glasgow and a couple
more... And we understand that the relationship with nature is very strong in all
centres. They all have very different challenges. Every site is completely different…
Every architect has a solution to the brief quite differently. For instance, Maggie’s
West London has this red wall that wraps around and shields it from a quite busy
road that goes next to that. We didn't have to have quite such a shielding device for
our project. But we liked the idea of shielding the site from the car park. So we use
the trees to do something similar [shield] but it was less built up.
6.2.1.2. Preparation to Design
Prior to engaging in the design process, all interviewees preferred to visit existing
Maggie’s Centres to observe how the buildings worked with users, and how the brief's
requirements were implemented in the design. As Gough stated, visiting sites is an
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‘architect’ way of research: “I think architects learn from other architects, buildings”.
Qualifying this, the brief was not descriptive of the building in detail, so visiting and
observing existing buildings was critical:
I approached the guidelines by visiting a number of other Maggie's. And the point is
that most architects they [Maggie’s] employ, get more or less the same brief which
is quite prosaic. It's quite factual and doesn't particularly tell you what to do. And
they [client] love the fact that each architect interprets it in their own way, and
they're [client] very generous to different architectural interpretations. As we see no
two Maggie's are the same or even many of them are quite different on different
spectrums. Some are very much involved with the landscape and the surroundings,
and some are on quite austere landscapes.… I just went around and had a look at
them, and then just formulated my own way of doing it. So, my brief to myself was
to try and do something more economic.
The architects of more recently designed centres had a large variety of occupied centres
to visit and learn from, as 24 centres are in use today (20.03.2022), whereas for the first
centres this design process did not include this opportunity, and architects had mostly the
brief and the clients’ opinions. Therefore, our interview with Ivan Harbour, architect of
Maggie’s West London, which is England’s first centre, shed light on the design process of
early centres. He visited Maggie’s Centres in Scotland but Maggie’s Dundee, the first
purpose-build Maggie’s Centre, was not occupied yet and Maggie’s Fife was under
construction:
I went to Maggie's in Edinburgh and just sat there in the space. What I was
interested in was not necessarily the architecture. I just wanted to know what the
ambience was, how did the day work, and how did they operate the centre? And…
how did people use it? That's what I was trying to understand there.
However, Maggie’s Edinburgh was not a purpose-built centre, therefore, the way of
learning from the building was restricted:
So the approach to the design process meant us talking to the client more
frequently during the process of conception. It was actually rather interesting,
because they were a very good client, and they were very prepared to listen and
give us space to work. Their commentary on the design was made in a way that
they would point to sort of pragmatics things rather than expressing opinions over
global sort of realisation and thinking of the idea. [This pragmatic approach] is
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actually very important, because the best architecture is essentially about sending a
whole set of compromises that, in the end, work and don't feel like a compromise. I
think that approach, which says they point to the pragmatics of things, is a way of
just saying go away and think about something and let's see what happens, let's see
if it evolves in a particular way. And it did, to be honest. So when we started, its
conceptual plan was much more striking. But probably had a certain amount of
impracticality about it, which would have come out further on down the line in any
event. But certainly, it is also because of working with Laura Lee and Marcia
Blakenham and, of course in those days, Charles [Jencks], we did design workshops.
It was a good way of evolving and making the thing seem simpler, [but] it takes a
long time to do a simple thing… It took a long time to evolve as well, that sort of
process.
Harbour stated that the success of their design comes from the amount of brainpower
and architectural thinking with knowledgeable and conscious clients. Although Maggie’s
Centre was a quite small project the architectural team had to put in a lot of effort. He
compared their effort in this project with the Madrid–Barajas Airport project that he was
working on at the same time as the Maggie’s Centre. The 1.2 million square meters of
construction of the Madrid–Barajas Airport and the 300 square meters of construction of
Maggie’s West London almost ran together.
6.2.1.3. Communication with the Client
Moreover, the attitude of the client also supported the creativity of the architects within
the frame of general spatial requirements. Haylock and O’dwyer appreciated Maggie’s
team as experienced clients who were involved in every step, and coordinated and
communicated with the designers at all times, O’dwyer explained his experience:
I think there was always an understanding. Maggie’s [client team] are very open
and willing to listen to the architect’s advice or ideas. And they have very particular
elements that go into a building, but they're always very open to having a
conversation with the architect to give them their thoughts… They also want to not
restrain the creative ideas of the architects, which is a really refreshing approach to
working with a client...
Communication with the client team was very important for the architects as the brief
does not elaborate on every detail of the building. The client team, consisting of Laura Lee
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and Marcia Blakenham, as Brittain explains, was an experienced team who had full
knowledge of Maggie’s needs, and therefore it was highly beneficial to work with them:
For the original project, the client team consisted of Laura Lee, Maggie’s original
nurse, and Maggie’s friend Marcia Blakenham. Therefore, there was a very strong
connection with Maggie’s original intentions and ideas. They were very open to us
interpreting the brief as we thought best, and open to architectural ideas.
The interviews supported the following premise posed in Chapter 4: decision-makers,

designers, management, and administration should have knowledge about the importance
of nature engagement to sort the barriers (See 4.5.3). The buildings are so successful not
only because the designers were experts in their job, but also the clients. Gough confirmed
this aspect of the clients in his observation:
You really wish to have all jobs like that [because] the client was so experienced.
They built quite a few Maggie’s Centres. They are always attentive to your ideas
rather than imposing their ideas. They are fascinated by how every architect does
something different. That's inspiring… You are trusted [by client], very much trusted,
and you are almost pushed to be as honest as you want to be, and do anything you
want to do.
6.2.1.4. Setting up Design Drivers
As stated above, architects usually tend to learn by visiting sites and buildings, in a
traditional way. Brittain said: “We always start with understanding the site and meeting
the client. We visited other Maggie’s Centres beforehand to understand how the brief was
delivered in other Maggie’s Centres.” She also stated that they also discussed with the
users of existing centres to decide on the design drivers. Besides, doing research at the
beginning of the projects or consulting specialist consultants were also common
approaches that they follow during the process. Haylock explained their approach to
starting the design for both Maggie’s Centre and other projects for clinical settings they had
done:
We speak to as many people as possible, we speak to specialist consultants, and we
also do our research and formal analysis. Very often you will find something that
you think you will establish a very strong design driver…. So, it's important to do the
research. And from that research, then it'll become a design driver.
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Harbour clarified that they collaborate with young architects who do actual research in
the office to develop their system of searching and developing design drivers. According to
his point of view, the experience and ideas of many people make a design driver more
successful. With this in mind, the design team listen to each other's ideas by brainstorming
and absorbing all imagery and ideas (including the ideas they do not like). He claimed that
to be successful in this approach “what you need to be as naive as you can,…, an educated
sort of naivete, you need to be open-minded.”
6.2.1.5. Working with Consultants and Experts
Also, consulting the experts about the user group was relevant to support their design
ideas. As the main user group in Maggie’s Centres are cancer patients, Brittain explained
their research method, which also looked outside Maggie’s Centres:
We discussed the project with the oncology department and key stakeholders in the
hospital, held a community consultation event and discussed the successful
principles of other Maggie’s Centres with the existing users.
The interviews revealed that all architecture offices preferred to consult experts and
consultants. This was not only for the usual typical collaboration with consultants such as
structural engineers, mechanical engineers, or electrical engineers, but also, they were
aware of designing Maggie’s Centres being more of a responsibility because of being charity
and its reputation. For example, in Maggie’s West London, after designing the centre the
architecture office required a garden designer, Dan Pearson, in order to strengthen their
design’s indoor-outdoor connection and reduce the impact of the noisy and busy urban
characteristics of the site with the help of landscape design. In Maggie’s Southampton,
landscape designer Sarah Price helped to revive spirit of The New Forest, one of the largest
forests in southern England located west of Southampton, in the centre’s garden, and
ceramic experts from Spain were involved in all steps of the project since the main material
was ceramic. O’dwyer said: “The project was a lot of collaboration with lots of different
specialists.” Gough collaborated with Paul Smith, a renowned fashion designer, to enhance
the homely feeling with furniture and interior design, as well as the colour selection of
interior spaces of the centre. Once again, Cullinan studio also collaborated with Sarah Price
and a lighting expert:
We used simple passive design solutions, so didn’t get into specialist technologies in
this scheme. We worked with Sarah Price who is an expert horticulturist to design a
rich, layered planting design that would have interest and structure throughout the
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year. Also, there was a lighting designer who helped create a calm internal
environment.
Although it was stated by Gough that experienced architects do not usually seek to get
consultation or site visits to design all kinds of buildings (e.g. shopping malls in his case), all
architects who designed healthcare settings (particularly clinical) stated that they worked
with specialists to be sure they have done the right arrangements in different rooms, and
create a healthier and safe environment.
6.2.1.6. Budget
Interestingly, the strategy and consideration of the finances of the designs were not the
same for everybody because the client team did not want to restrict designers with a
budget, as they wanted to offer the best architecture possible. However, one of the design
drivers for Gough was being economic:
My brief to myself was to try and do something more economic. I thought a lot of
the architects are becoming quite indulgent, and spending too much money, which
is charity money. So, I tried to do a more compact building… Therefore, I was quite
happy to have quite an economic exterior elevation. And they [client team] said to
me “no, no, no, you have to do something more rich and expensive. You are famous
for coloured buildings. How do you want to do that?” So, I suppose ceramics is the
only safe way to do really good-coloured buildings. And they said, “Well, you have
to do ceramics because we want you to do what you are the best at.” … As a client,
they were very receptive but also gave you a nice push to do even better than you
perhaps had imagined doing. It was wonderful. I mean, they were just the best.
Therefore, although the architects did not charge anything the budget of the client was
also encouraging parameters to design a successful environment as not being restricted
economically gave designers flexibility and the opportunity to implement all they wanted.
But Harbour said that the process took a long time because the client needed to know what
it was going to cost and the Maggie’s as being a charity can raise the money for it. The
important thing about that was the design should be properly priced and designed before it
went out to tender, and needed to be completed on a decided budget.
6.2.1.7. Site Decisions
Although the sites were usually selected by the hospital administration or the client, the
architects aimed to approach the sites to maximise contact with nature and offer a sense of
enclosure from the hospital environment. Haylock explained their interventions and
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decisions on the site that enhanced the quality of the design and connection with natural
elements:
The reason why we selected the site is that it was at the end of this green boulevard
because the journey from the hospital to the Centre is also important. So, you don't
walk across car parks. Around the corner, you walk down quite a nice avenue to the
site… at the end of the avenue, you arrive at the heart of the project. We were
creating a sense of the landscape, a sense of enclosure, and a definition of place,
but also thinking about how the sun will move around the site, and where will we
locate the gardens to maximize the sun.
According to O’dwyer, they decided to bring a piece of the garden by transferring the
idea from a local forest, The New Forest, into the midst of the concrete landscape within
the hospital environment because the site of Maggie’s Southampton is in an “incredibly
sprawling complex of buildings” and surrounded by a “sea of car parks”. Their approach to
the site was to create an oasis: “The challenge towards us was to bring Maggie's design into
this harsh environment that provides the relationships in nature and a kind of oasis in this
kind of urban and built environment.” Another device that they used, to enforce a sense of
privacy within space by lowering the ground level of the site. After bringing The New
Forest’s spirit, the building now would be surrounded by trees and vegetation, but there
will be still a visual connection between the centre and the cars surrounding and some of
the hospital buildings. Thus, the designers decided to play with the topography of the site
to support a visual contact with nature (Figure 6-1):
What we thought here is if we lower the site, and use that [excavated] earth to
create a mountain-like barrier around the site, with this you are forcing that sense
of enclosure. So when you are in the building, as you are slightly lower than the cars
around in the trees, your eye line becomes more into the canopy of the trees and
vegetation.
Figure 6-1: Lowering the ground level of the site in Maggie’s Southampton.
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The site of Maggie’s West London had the problem of being in a busy urban
environment as well, so the solution was sought with landscape design: to create a nature-
supported escape and enclosed building from the outside environment. Harbour explained
his perception of the site in the following way:
I think the very interesting thing, from my point of view, is that the site was a
location that was well known to me. I mean, our office was five minutes walk away
from the place. So, I knew the site very well. And, I also knew that the site was on a
rather awful road, which was one of London's worst roads because it connects two
major arteries that come into London. It is always a bad road. Certainly, the centre
needed to be something quite as remarkable. But also, the fact that it was such a
hostile corner, we should be able to effectively create its own foreground and its
own space. So it was not fighting with that hostile environment around it… It picks
up first of all, really the only significant piece of nature along the street, which is the
row of London plates.
Brittain said that their site was an “unloved” corner in the car park at the back of the
hospital. So their key goal was to connect the spaces within the building as closely as
possible with the outside space and to provide a green outlook, which is psychologically
separated from the hospital setting. They considered natural passive design principles in
terms of layout and orientation in a fixed position restricted site with activities and building
works all around.
Unlike other architects’ sites, Maggie’s Nottingham’s site was in a woodland kind of
environment. Therefore Gough decided to elevate the building up to create a visual
connection with the green leaves and brunches of the trees rather than the plain trunks.
[In the site] green space was considered very good. And many Maggie’s have
gardens. We are lucky enough to have trees beyond the site, either on the site or
just around the site. This site was chosen for its trees. Because the trees were quite
beautiful, and also it seemed unlikely that the hospital would want to use this site.
That was part of the consideration because we did not want to get in the way of
hospital expansions or new hospital buildings. We wanted to choose the site that
was almost unbuildable for a hospital, no use to them. Therefore, this very treed site
was an ideal combination, although it was quite hilly, it is quite steep… The main
idea of the Maggie's was to put perch the building up in the tree canopy rather than
down where the tree trunks are. You are kind of up with the branches. Then, we
have outside balconies coming out of that space. So, you are not just looking at the
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trees, but can almost shake hands with a tree because the branches are coming
over onto the balcony, and you can sort of feel you are in them. We felt this was a
very magical and marvellous kind of environment to put a Maggie's, which was
existing, we did not have to wait for the plants to grow. It was kind of ready to go. It
was like an instant bit of environmental green gorgeousness.
6.2.1.8. Male-Friendly Approach
Another important issue for Maggie’s Centres is gender differences in their user
population, as approximately two-thirds of the visitors are female. Lesley Howells explained
that the reason is not related to Maggie’s Centres: “that is because of how men use
healthcare, generally. So, you probably find the same sort of figures in terms of the use of
GPs or other support services…. it's not unique to Maggie's at all. And having said that, it's
always our target [to reach equal numbers].” Cullinan Studio prioritised this situation and
aimed to design a male-friendly centre:
In discussions with current patients of other Maggie’s Centres, Ted recognised that
men are often less keen about using these kinds of facilities to meet and talk about
their feelings and issues. He designed the facility to allow opportunities for relaxed
interaction, such as gardening or having a BBQ in the courtyard, to help facilitate
informal interactions and discussions amongst users of the facility (Brittain).
Brittain also claimed that their design intentions worked, and men are visiting more than
other centres. Although the studies in Chapter 5 explored that material and construction
details have contributed in relation to encouraging and attracting men to the centre,
Howell claimed that the programme and activities have a significant role in this
improvement:
That could equally be because of the way that relationships that the centre head
built. So I do not think there are any buildings, which are too feminine, to be honest.
Not at all.
6.2.2. Biophilic Design Parameters

Although all biophilic design parameters were not specifically discussed in the interviews
by the interviewees, the most outstanding parameters were explained and refereed in the
course of the conversations. This section indicates the application and perceived impact of
these parameters.
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6.2.2.1. Greenery-Landscape
Gardens, plants and the connection between building and landscape were one of the
most outstanding aspects of Maggie’s Centres design. All architects worked towards
creating a strong connection with greenery and plants through different approaches.
In Maggie’s Manchester, along with the garden itself, a glass house concept was
integrated into the centre that became a distinctive characteristic of the centre where the
users enjoyed various vegetation in the four seasons and a multisensory environment that
allowed users to be involved in activities such as growing plants. Haylock explained their
glass house concept (
Figure 6-2):
I would say the Glass House at the end of the building is totally unique to Maggie’s
Manchester. That was effectively a greenhouse because they do grow tomatoes in
there like a traditional greenhouse. But its base is to extend those months where
you can sit outside and be surrounded by greenery. It is a beautiful space when you
are in there. It is just like the pillars of greenery and lushness and smells and a
different environment. Maybe in the summer, slightly hotter than outside. But in the
winter, it's slightly warmer, again, than the outside. So, you have this kind of
freshness. Also, it is beautifully ventilated. It's super successful. So, the glass house is
really a focus for the Centre, and I use that for many different purposes. Whether it
is writing classes, or just consultations or reflection. They love it. It has a really well
view… but also, it helps with the healing as well in terms of the fresh products, and
the flowers. The flowers are grown in the garden and then brought into the building.
So, there are many different levels of using biophilic aspects to benefit and improve
the well-being of the occupants.
Figure 6-2: The glass house (Copyright Nigel Young / Foster + Partners).
As explained above in 6.2.1.7, in Maggie’s Southampton, the way to increase visual

connection with greenery was by lowering the ground level of the site. Also, an organic
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fabric of the local forest was adapted in the garden. O’dwyer said: “One of the inspirations
is the New Forest, the local Flora and topography in a wild landscape, it's quite old, it makes
you feel very good. You do not have to go very far from the road to feel like you are in a
completely different world when you go in there. So, this is the idea that defines creating a
protective landscape around the building or the human environment.” Thus, the architect
team also aimed to create a natural refuge with landscape and vegetation by protecting
users from the sight outside.
In Maggie’s Newcastle, they aimed to separate the centre from the hospital setting
psychologically and visually by providing a green outlook and mounded landscape. In
conjunction with Maggie’s Nottingham, where Gough created a strong visual connection
with trees by lifting the centre from ground level and designing a garden and landscape
around the building where the people can become involved with the planting of and the
maintenance of the garden (Figure 6-3). He also warned that contact with nature,
particularly the plants, should be in balance as nature is not beneficial every time based on
his experience and knowledge:
In fact, there is research that people in the hospital who have a view of a tree
recover more quickly than people without a view of a tree. So, there are definite
good outcomes to nature. And the only problem with nature is that it has its time of
the year when it dies. When autumn turns to winter, some people find it quite
depressing. That time of the year brings out certain problems for people. So, if you
make your building predicated on dying plants, then maybe people will die inside.
So, you have to be a little bit careful with this notion that nature is wholly good.
There's a very interesting study of people who emigrated to Australia from Britain
and spent their time at home, particularly wives. Husbands, in the olden days,
meant to work and the wife stayed at home. They could not understand why so
many wives were so depressed. What they worked out was that the Australian trees
shed their leaves all the time, they don't have seasons. They have various
indigenous trees in Australia that drop their leaves all the time. This dropping of
leaves was what brought about a kind of autumnal depression, which was sort of
permanent, instead of just being in the autumn, [the depression] was all year round.
Absolutely fascinating, and that is sort of unexpected. The relationship between
nature and people's feelings is definitely something to be looked at. So, there may
be people who find too much of that. Too much of falling leaves might mean a bad
time of year for feeling great about the world. But on balance, I am sure that it was
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the right decision to put [the centre] in this environment because it was so mature.
And I think that is very comforting.
Figure 6-3: Maggie’s Nottingham.
6.2.2.2. Natural Material
Material choice was another important parameter for the architects to strengthen the
relaxing feeling coming from a connection with nature. Maggie’s Manchester’s structure
was constructed with timber, and the material defined the space with triangulated
geometrical grids in which they were very keen to be sure that there was no visible metal
fixing by using secret straps. Haylock stated that timber as the main material choice was
mainly to encourage a biophilic feeling (Figure 6-4):
The idea of using timber as a lightweight material, having that biophilic feeling was
something that we borrowed from some early designs which was an aircraft
hangar. How timber is used effectively, in a lightweight way, to create a light and
airy structure.
Figure 6-4: Timber structure in Maggie’s Manchester.
Ceramics was chosen by both Gough and O’dwyer. It was used for the external cladding
in Maggie’s Nottingham, and as the main construction material in Maggie’s Southampton.
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O’dwyer highlighted three of their material choices, in particular, that also encouraged and
enhanced nature in space and the perception of contact with nature in Maggie’s
Southampton. Ceramic blocks were used in the construction of the walls instead of
concrete. The earthy feeling of the ceramic facade was to feed a biophilic impact on the
users:
The ceramic walls were quite rigid. But it worked really well against this very
natural landscape. You have this kind of juxtaposition where you have a very strong
form and a natural landscape working together. I think the choice of materials helps
that. Also, you have got a reflective glaze on the ceramic, so it is flexible, a green
landscape, but then you also have the earthy tones of terracotta clay.
In contrast to the main ceramic walls, the external privacy rooms and boxes were
constructed of treated wood and enveloped with a stainless-steel topping that reflects and
visually expands the greenery:
It was quite a conscious decision to do it [polished stainless-steel envelope]. It's
quite reflective, quite mirrored. They almost dematerialized. They disappear into
that landscape. What we really see when we are looking at this view is a quite
striking architectural ceramic wall, then you have this amazing organic landscape
around it. And you almost have to look twice to see the privacy box behind it.
Actually, they [visitors] do not see a bit of the building. It is quite traumatic (Figure
6-5a).
With this in mind, the design team decided to ripple the surface to not mirror perfectly:
Polished stainless steel, the manufacturer added a ripple to the stainless steel. The
reason we quite liked having a ripple in it was that when you are standing in front of
it, you do not get a perfect reflection of yourself. Because we thought that it might
be a bit strange. It [ripple] breaks up the reflection and diffuses a bit, and you get
this lovely, kind of watery, rippled effect of the landscape that is going to soften the
reflection a bit. Because we certainly did look at the idea of having a perfect mirror
panel. But actually, when you think about it, if you are walking into a building and
you are feeling anyway exposed or delicate, even if you have been diagnosed and
you are not feeling great, do you really want to look at a perfect mirror image of
yourself when you are walking into that building? We weren't so sure. So we had a
lot of conversations about diffusing it a bit and breaking up the reflections.
However, even when you stand back, you still get this amazing reflection of the
lights of the landscape, from these elements.
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Thirdly, they adapted the idea of reflecting daylight and view from outside to floor
surfaces. Therefore, polished concrete was preferred (Figure 6-5b):
You might get on an industrial floor. But the reason we liked it [polished concrete
floor] was the idea of having a uniform material that linked all the spaces together.
But also, we wanted something that was quite reflective. It was perfect for the
reflectivity off the floors. It is quite stunning at times. This idea of having this
polished concrete floor, without the walls very strong elements dividing the space
up, but what links the spaces together is this uniform floor. But also, actually has an
almost subservient ceiling. It is just a very plain white plaster ceiling, all the spaces
are then linked by the floor finishing, and in the ceiling. When you are in the centre
of space you see these reflections. Some days, we get lovely pink, green, and natural
colours coming in from the garden. Even the light, you get reflecting from the centre
brightens up the space.
A B
Figure 6-5: Maggie’s Southampton a) the reflective stainless-steel surface behind the ceramic wall, b)
polished concrete floor.
In Maggie’s West London, concrete was the main construction material. Harbour said:
“The idea of just concrete floors, concrete ceiling, all those things very tough. So, we
wanted to display the softer things, the furniture and all of the rugs. We felt it was better to
have this quite raw, also not ostentatious.” The use of concrete was also preferred in
Maggie’s Newcastle, where attracting more men was the design driver. However, the
concrete was softened with timber. Brittain explained what underpinned their material
choice and sustainability concerns:
We wanted to have a building surrounded by landscape earth mounds, so needed a
material that would work in this environment. We chose concrete to allow thermal
mass and a robust fair-faced finish for the interior. We used GGBS (Ground
Granulated Blast-Furnace Slag) to replace some of the cement to reduce the carbon,
which also created a light-coloured concrete that provides a calm, cool internal
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finish. Externally corten steel was used as low maintenance and robust finish, and
provided a good backdrop for the green landscape. The green roof provided
additional outdoor space and helped with water retention on site.
6.2.2.3. Views
In terms of providing a view of nature, the architects maximised the natural elements
outside the building by designing gardens and landscapes to provide a direct view of natural
elements through windows. Brittain, Gough, Haylock and O’dwyer claimed that they aimed
to create a strong visual connection with the greenery on the site. Gough used a view of
existing trees, while others produced their vegetation and landscape as the sites were
located in a densely built environment. O’dwyer said that they used very big windows to
have big views where they created a hilly landscape to replace the visual connection with
car park to vegetation (Figure 6-6a). Also reflecting feature of stainless steel increased and
deepen visual perception of greenery (Figure 6-6b):
You have a nice, generous light above the centre, and big windows. You are always
reminded of being close to the landscape, even when you are in the heart of the
building.
A B
Figure 6-6: Maggie’s Southampton a) expending nature perception with stainless steel, b) big windows.
Also, a view of water increases the quality of space. Howells described her observation
and experience in relation to the view in Maggie’s Forth Valley where the site is located
beside a loch. As a dynamic feature, the view of water offers a variety of views depending
on the weather conditions and the time of day:
Perhaps these times socially distance from the person that I was speaking with, but
[without the pandemic] I would be sitting on the sofa behind, both of us would be
able to look out on the loch, whenever things get too much, you can take a break,
you can pause by looking in a particular direction. So that could be looking out the
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way into the beauty of whatever is out there [in the loch], or it could be looking up
and seeing a dove up there… Looking out on a loch that has birds flying over it, you
can see the changes of the light on the loch and the changes in the sky and the
swans coming in. The coots are playing in front of you, coots are another kind of
bird… So there is always somewhere you can just pause and let your mind settle and
recalibrate yourself before you go on to the next thing… I could go and just sit and
look at the loch, or go to another part of the centre, just sit and have the phone call
whilst looking on onto the loch. For me, that is simultaneous therapy. But it also
helps my well-being to know that I am enabling other people every day so that they
can come in and see me but in a space that is really conducive to their well-being…
There is a kind of office space. As a member of staff, when you are sitting at one of
the chairs, if you just literally turn your head, you have got a view right over the loch
again. The way that things are positioned, you can still see the loch. It just takes you
by surprise as well, it is just full of lovely surprises that break the moment. You can
be stressed out by something in your day, you walk around the corridor and see this
beautiful reflection, or you see a view that you weren't expecting to see. And that
just breaks the moment and then brings a smile, really.
Figure 6-7: Maggie’s Forth Valley.
Howells claimed that one of the most important environmental features is water. As
Maggie’s Forth Valley was next to a loch, apart from the view and multisensory
environment, the reflected light from the loch surface gives life to the building, and created
a changing atmosphere experience in the centre:
If it is a sunny day, you end up with the reflection of the water cast into the centre.
You can see the water or the ripples of the water, or the change of the light of the
water playing out on one of the walls, in the interior walls. How lovely is that! I can
walk around the corner, not looking towards the loch, I am looking into the internal
wall, but I have got a kind of light playing on it. So I can just see the movement
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something that is outside. I do not know whether it was by design, but it is
beautiful. It really is. There is life in this movement. And there is a sense of surprise.
But in a good way. That is why when you walk in, you do not have to do something
extra special, you just have some things which are a lovely surprise. The water
playing on that wall, or the reflection, it is a surprise.
6.2.2.4. Light
Light was another important biophilic design parameter, the architects referred
frequently to their consideration of daylight in the design and its benefits for health and
wellbeing. The designs commonly employed big windows, skylights, reflective materials,
and glass surfaces to expose more daylight. Although a balance between light and shadow
was aimed, the architects tend to increase openings considering the typically cloudy and
rainy weather conditions of the UK. In Maggie’s Manchester, the aim of the glass house was
also to get higher daylight exposure and offer nature-related activities on rainy and cold
days. The skylight in Maggie’s Southampton was designed with a curved surface that
diffuses light into the centre of the kitchen (Figure 6-5b):
It [light from the skylight] is a very soft, lovely way of bringing light in, and diffusing
it into the space. We had used it once or twice on other projects that we find it
really successful (O’Dwyer).
Rather than maximising openings and glasses, Gough followed a more domestic
approach by applying a Georgian-style window rhythm in the design (Figure 6-8), as he
claimed that the best way of creating a balance between light-shade and thermal comfort is
following the traditionally learnt way of the local architecture, which also promotes a sense
of belonging:
Well, what is interesting is that Georgian houses have about an equal amount of
windows and walls, and that produces very pleasant light in Georgian rooms.
Terraced housing has windows where you get a bit of brick, a bit of window a bit of
brick, a bit of window. That seems to be quite a nice balance of a sense of enclosure,
and good views, and the amount of daylight that you get. So this building was just
built on that, it does not have too much light, it does not have too little, it is
balanced. And, of course, that is good for not overheating in summer and not losing
too much heat in winter. So it is not a sort of all-glass extravaganza. And neither is it
a solid building with small holes. It learns from Georgian architecture more than
anywhere, how much glass to put in, and how much not to put in. One of the
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lavatories is particularly nice because it has got a lovely, great window. Onto the
main balcony by the kitchen, there is a wide full-width window, which is a sort of
gesture towards that being the way out onto the balcony. But other than that,
windows tend to be fairly conventionally set. Quite domestic.
A B
Figure 6-8: a) Georgian house, Liverpool, b) Maggie’s Nottingham.
Also, the naturally reflected colourful lights were employed in Maggie’s Southampton
and Maggie’s Forth Valley to give a dynamic life to the building. In Maggie’s Southampton,
the light together with the reflection of vegetation in the centres were brought by big
windows and reflective polished concrete surfaces:
We have these amazing reflections on the floor, bringing the colour and the
atmosphere in the gardens right into the building through this kind of reflective
finish [polished concrete floor]. This amazing picture-framed view can change quite
dramatically, depending on the season, depending on maybe the orientation and
the view (O’Dwyer).
6.2.2.5. Colour
Either using a more natural approach or a contemporary approach, architects employed

colour as a tool to contribute to their goals. For example, Gough chose a green colour for
his building, because it would be in a harmony with the surrounding trees and green is the
symbol colour of Nottingham. The striking red colour of Maggie’s West London was aimed
to stand out in contrast with the pale hospital campus, and thus attract people. Whereas in
Maggie’s Southampton, more earthy natural colours and clay were chosen in the ceramic
walls, combined with pastel blue and pink tones to support wayfinding, as they used
various colours in the walls for this purpose:
We have got four ceramic walls…The two walls go north-south. So, we used one
colour on the entrance wall so that when you are in the building, not necessarily
knowing the orientation of the walls, you will remember that you entered the
building and came in past the light blue wall. It gives you a little bit of orientation
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when you are in the building... For the east-to-west walls, we used pink, the lighter
colour, but when you are inside the building you are mostly seeing the terracotta
colour, the natural colour of the clay. That enforced the relationship to the outside
nature. When you are outside looking in, you see the front of the blocks, the glaze
colour the light blue or light pink. It has more reflectivity too. So, you get a bit more
in the greens and blues and the shadows, and the blue has a link to the sky. The
greens work quite nicely. The blue and the pink helps a little bit with the wayfinding
and navigation.
A B
Figure 6-9: a) Maggie’s West London, b) Ceramic wall in Maggie’s Southampton.
6.2.2.6. Inside-Outside Effect
The connection between indoor and outdoor environments is another important feature
of Maggie’s Centres, according to the results of the meta-synthesis analysis described in
Chapter 5. Interviews confirmed that these connections were intentionally aimed by the
architects, and it can also be applied in clinical settings as it was one of the most commonly
recommended environmental features in Chapter 4, having easy access to outdoor settings,
removing barriers, and ending a strong inside-outside connection. Howells emphasised that
it is not easy in the UK to use outdoor settings in a planned way, as the weather conditions
are unpredictable. However, architects were keen to create a connection with the outside
in a more protected way. Big windows, doors, canopies, interior garden (courtyard), glass
house etc. were successfully included in the designs:
In the UK, we have to be careful, we cannot assume that we can use the outdoors.
But one of the things factored into my research is the ability to use it whenever you
can. So, the ability to just simply step from, as I say, a consultation room outside, I
basically do not have to go down a corridor or downstairs to do this. I just literally
open the door and walk outside. And that is something really important for us and
our visitors. There are so many things that are difficult to achieve, whilst you are
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going through some of these cancer experiences that they are having. So, we may
cover things easy, right? The idea, if you can see the loch [view outside], let's find a
way in which you can simply open the door to be outside. And each of the centres
has a similar something whereby that catches your attention, you can get to it. We
intentionally reduce the barriers within the centre, because we know that there are
so many barriers in the person's life in other respects (Howells).
The elevated structure of Maggie’s Nottingham also aimed to enhance the connection
with the outside environment:
The main idea of the Maggie's was to put perch [sic] the building up in the tree
canopy rather than down where the tree trunks are. You are kind of up with the
branches. Then we have outside balconies coming out of the space. Not just look at
the trees, but can almost shake hands with a tree because the branches are coming
over onto the balcony, and you can sort of feel you are in them (Gough).
Howells told that this ability to bring the outside in also helps to air quality as they can
easily ventilate inside, particularly after the COVID-19 pandemic, the need for ventilating
the spaces increased:
COVID times there is a lot of ventilation, so we use whatever ventilation is going

on. There is a very discreet kind of vent then that we can open, then the doors.
One of the things which are important in Maggie’s Centre is the ability to let the
outside in. So, all of the doors, for example, in this centre all the windows are
French windows, so you can open the window as if it is a door.
In conjunction with the following section, sensory stimulations were usually provided
through gardens by the Architects, and these experiences were brought inside by creating a
strong inside-outside effect, as Haylock expressed:
I think the connection to the outside is very important, even just to see the weather
to see the flora and the fauna and the wildlife. Even if in the corner you can see a
tree moving, it has another stimulation, in another connection. And that was very
important to us [in the design]. For example, you may see some windows that you
think they have strange high, a waste part. But those windows are for there, when
you're sitting on a couch or laying on a bench, you can actually see through the
windows as well, you could see the outside. So, we are very mindful of different
experiences from different types of spaces.
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6.2.2.7. Multisensory Environment
The architects aimed to create a multi-sensory environment mainly with vegetation,

attracting wildlife, the smell of wood burning fire and water elements. However, as
explained above, the gardens were the main source of multisensory stimulation, as Haylock
defined the winter garden with its sensory characteristics: “the pillars of greenery and
lushness and smells and a different environment…”
Howells, as an expert in this area, highlighted the importance of a multi-sensory
environment:
One of the things I do daily with people, and just very simple by design, is to help
them to deal with what is going on in their heads, I often invite them to get involved
with our senses, and engage with our five senses. That is what Maggie’s Centres do,
there is a wealth of opportunity when you find yourself getting lost in difficult
thoughts to actually be with your senses. Being with your senses is one of the most
basic therapeutic things a human being can do. Because as soon as you are with
what you can see, or what you can hear, or what you can taste, or touch, or smell,
you are not caught up with this kind of difficult chatter in your head. [For example]
If you are bathing your children at night, and you are really lost in the bubbles, and
the giggles, and the smells and the warmth of the bathroom and all the way you can
see, If you are truly letting your senses really absorb all of that, you are not in your
head with any worries about the next day. And it is the same within Maggie’s
Centres. I mean, there are spaces where you are actually invited to talk because that
is good, that is therapeutic. But there are other times where you can actually do
what we are suggesting, just get lost in your senses rather than lost in your head.
So, this is built into every single Maggie’s Centre. And every single one of them has a
way in which somebody can get lost in their senses rather than lost in their head….
People say that they just feel stilled by it. I would say that in every single centre,
there will be a space where people will gravitate to.
6.2.2.8. Thermal Comfort
In terms of thermal comfort, the buildings aimed to get maximum sunlight as in the UK
the solar gains for thermal comfort have to be maximised. Brittain explained their
approach: “The building faces south to maximise solar gain, with solar shading to avoid
overheating.” Howells also explained that all the centres employed operable windows,
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French balconies, etc. which also allows users to adjust the thermal comfort when day
need.
Furthermore, the fireplaces help the architects to create thermal variability and comfort
as well as entail a homely focus and the sensory experience contributed by burning wood
as Harbour explained: “Maggie's said that we like to have a fireplace because it's a focus for
home. Beyond that, I think, the warmness, comfort and smell of it [fire]…”
6.2.2.9. Welcoming Relaxing
The post-occupancy evaluations showed that the centres were successful in terms of
offering a welcoming and relaxing environment for both visitors and staff. Users like to
spend their time in the buildings, and instead of just visiting shortly for consulting and
therapy, the inviting environment encouraged them to participate and socialise with
others. Brittain explained the feedback they received:
The post-occupancy feedback has been anecdotal from the centre head, with whom
we have a close relationship. We have heard many stories of how the staff feel
uplifted by the building, as well as many reports from the patients. They have
described the building being used in many unexpected ways, beyond the counselling
and therapy sessions, such as for quiet respite between treatment, sunbathing on
the roof and even a wedding! This has demonstrated that the building has been
successful in helping users feel at home and relaxed in the building. There is now
also a successful Monday men’s group which brings a lot of men to the centre
(Brittain).”
The architects’ approach to creating a welcoming environment primarily tended to
arrange a homely environment via comfortable furniture choices. O’dwyer said the
furniture is one of the most important features that make the centres welcoming and
relaxing. So, they spent plenty of time choosing the furniture and making sure that they've
something that users feel very strongly about. Haylock also highlighted the importance of
furniture:
The furniture changes as further you go into the building. At the entrance, the
furniture is quite high and is kind of approaching furniture like a barstool. When you
get further into the building you may sit at a dining room table, to have lunch or to
have a conversation. Then when you get further into the building, you have the
lounge chairs and chaise longues where you can really chill and relax. The element
or material of the furniture is also important. It should make people feel
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comfortable because it can be quite intimidating going into a new building. And
certainly, if you have cancer and there are lots of things going on in your mind, all
you want to do is just to escape for a moment…That is what you can do at the
centres or if you would like to have some help, some support. It is also there.
As emphasised in Chapter 5, the architects also supposed that not having a reception
desk supported welcoming feelings. Haylock explained how this changed the way of
greeting people:
The selection of the furniture as you go into the building is really important. There
is no reception desk. So, when you're first welcomed into the Centre, it's not
welcome with “Good afternoon Bekir, how can I help you today?”, it is “Good
afternoon. Hi, how are you doing, I have just put the kettle on, do you like a cup of
tea?” So, it is that kind of welcoming, which is really relaxing, it is not
confrontational at all. It is just like you just walk into your home room, or you walk
into your kitchen. It is that kind of feeling that is really important.
The kitchens are the focus and main space of all Maggie’s Centres which were also
accepted and designed as one of the most welcoming parts of the buildings by the
architects. Haylock explained one of the phrases they used to express the kitchen’s
welcoming impact:
There were a couple of phrases that we used a lot to explain the building to
colleagues and different consultants. I think one that sticks into my mind is it [the
kitchen] is like having a coffee in your best friend's mom's kitchen. If you think about
that, what does that mean? It means that once you are having a coffee, you are
very welcome. It is your best friend’s mom's kitchen, there is a sense of relaxation,
but there is also a sense of respect. So, you do not abuse the space. You look after it.
But there is a kind of feeling that you are welcomed. You could help yourself to a
coffee and biscuits and so forth.
O’dwyer claimed that giving chance to think, at the entrance and observe what is
happening inside the centre is important to welcome and attract people. Therefore, they
provided a visual connection inside by leaving straps on the ceramic wall (See Prospect and
Refuge in the following sections) and a glass door through which visitors can see inside.
Architects aimed by designing fireplaces to offer a homely welcoming feeling and

improve socialising quality of the space. Howells said the fireplace is one of the welcoming
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elements of the centres, particularly in the first impression:
If you walk into Maggie's Forth Valley, there is a wood-burning stove, but also a
view of the loch. So, you are not confronted with anything associated with cancer or
potentially any of your problems, you are actually associated with things that are
symbolic of beauty and warmth and comfort. Those are first impressions and the
building's impact. I think it is a thing that they are not expected. It is unexpected
but in a good way.
Another aspect stated about Maggie’s Centres is the comfortable toilet facilities where
users can find privacy and space to be alone. Privacy and comfort in the toilet were one of
the issues detected in the systematically searched review (Chapter 4), therefore, the toilet
system in the Maggie’s can be adaptable in clinical settings. Howells stated that even it is
welcoming for some staff to be able to “linger in the loo”. Toilets were designed to have
extra space where people can sit alone and be able to cry without being seen. Gough also
designed a toilet with big windows where plenty of daylight comes in.
Not having signs in the centre enhanced the non-clinical homely feeling. According to
Haylock, their design intentions to reach a welcoming, relaxing and socialising quality of the
space were supported by this approach:
We made the buildings feel like home. We become to remove all the introducing
things. You do not see any fire escapes signs. You do not see any toilet signs. You do
not say see any arrow saying that this way to the reception, or library over here. If
you want to know where the toilet is, you ask. I think that is part of the interaction.
Also, as part of psychology, if you go to the toilet the staff will know you are in the
toilet. So, if you have been there for a long time, they can come and knock door ‘Hi!
Everything is okay?’. So, lots of levels of circumstances, which is fantastic. It works
so well.
6.2.2.10. Prospect
As it is the same in all Maggie’s Centres, there are no reception desks, and the entrances
are welcoming with a non-institutional feeling. Maggie’s Southampton’s prospect and
refuge approach at the entrance promoted the welcoming impact as they arranged the
entrance lobby as a place where people can enter and pick leaflets to get information and
see the kitchen through straps on the ceramic wall without being seen by the people inside,
so they can decide to enter or leave without feeling any obligation (Figure 6-10). O’Dwyer
explained their design idea:
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We have a big glass door and you are able to see into the building. Therefore, you
can go in. When you arrive inside the building, there's a shelf of leaflets, so you can
read those leaflets. If you want to go further into the building, if you feel like it's the
right time for you to do that, then you can do that. But not everyone wants to enter
the first time they go. Maybe they want to just take a leaflet, read it in the lobby,
and then leave. And I think, it was always about having a reasonably large
entrance, like a lobby where you can see right in. When you are in the lobby, you get
these glimpses through the straps, and you can see into the kitchen table, if you see
that you want to go in further, it is really up to the person to decide to do that.
Figure 6-10: Maggie’s Southampton visual connection through the ceramic wall straps.
6.2.2.11. Refuge- Feeling Safe
The architects tried to create a refuge where the users were ensured with feeling safe.
Using natural elements was quite common to reach this goal. For example, as mentioned
before, Maggie’s Southampton arranged landscape and vegetation to promote feeling safe,
or Maggie’s Nottingham was elevated from the ground level, like a treehouse, which also
helped to create prospect and refuge. However, Gough claimed that although there is a
prospect and refuge effect, it cannot be generalised for everybody as everybody is different
and has different feelings about nature and feeling protected. Brittain and O’dwyer claimed
that their key driver was to design the centres as an oasis where people take refuge and
relaxed as the site is surrounded by the hospital environment:
Creating the building’s own oasis was a key driver in the scheme – there was no
relaxed outlook and we did not want the building to look back at the hospital so we
created its own sheltered courtyard surrounded by mounded landscape. This
provided a green therapeutic outlook with a calm courtyard which all the main
spaces look out onto. It also benefits the surrounding buildings and car park by
creating a green pocket in the hospital grounds (Brittain).
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Howells conveyed her experience that the predictability of the centre promotes a
feeling of safety. Her observations during the COVID-19 lockdowns supported her
perspective:
People are working from home [Due to COVID-19]. For the first time ever they are
able to contrast… Why do they really like being in the centre?…. People say that
there are things which they miss about the centre; a sense of containment, a kind
of it is a safe place.… Ironically, it is [centre] giving a sense of certainty in an
uncertain world. When people walk into Maggie’s Centre, they will be always
walking into the same scene, maybe walking in with a different emotional state or a
different set of questions in their head. But they are always walking into the same
safe space, which is predictable. While life is all completely unpredictable. When
they walk into Maggie’s Centre, they can predict what they are going to find. There
are different people, but it does not mean that they can always predict the people
that are in it. But they can always predict the setting. It is going to be uncluttered, it
is going to be attention to detail on the walls, there is light, there is the view that
you admire… The Maggie’s Centre actually then acts as a kind of decompression, it
is a decompression space. When they enter, they are walking towards a difficult
potentially difficult conversation, but in a surrounding that gives a sense of safety
because of that predictability of it. After the conversations are finished, they are
not just pitched off a Zoom meeting and they are back on their sofa, they take leave
of that difficult conversation being in the surroundings, perhaps having another cup
of tea, going to the toilet, or just putting on the coat. It is the way that the building
sets the stage and it creates the agenda… you cannot do that on Zoom or Team's
call, you just pitch in and then you pitch back out again. And so, all that important
decompression is lost. It is the building that does that. If there was not a building,
then it would not happen. And the quality of the building and the predictability of
the building is the other important thing.”
6.2.2.12. Privacy
In general, Maggie’s Centres provided private spaces for therapy and conversations and
corners or spaces where the visitors can withdraw for a while. Also, the privacy level of the
rooms was offered to be arrangeable based on the visitor’s wish:
The doors to the consulting rooms are sliding so that users can decide the amount
of privacy they require. This allows an informal and more subtle connection
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between spaces, as even during private discussions, some people prefer to keep the
doors slightly open (Brittain).
Moreover, the COVID-19 lockdowns revealed an auditory sort of privacy opportunity for
Maggie’s Centres:
So, I was talking about the idea of the change in the ambient sound, which means
that we cannot rely on ambient sound to create privacy in terms of conversations.
So, it is tricky having these two conversations going on in the same space because
you can overhear them. Whereas normally, you would not, because there would be
enough chatter there would be enough ambient sound. So that is one part where
sound plays in. But the other part of it is that, particularly at the moment,
households are very busy. If they have children, or if people are working from home,
or you have got husband upstairs working from home, wife downstairs working
from home, children at the kitchen table, everybody in the sitting room trying to
work, then it is awful. So, Maggie’s Centres have been a space of tranquillity as well.
They are not comfortable and cannot speak openly because do not want to be
overheard. They missed the most quietness and privacy in Maggie’s Centre where
they can talk about things that are potentially quite frightening. So yeah, that is
definitely been something that we have been observing.
Although Maggie’s Centres provided privacy and socialising opportunities for visitors in a
homely environment, the staff sometimes expressed their need for more privacy, as
explained in Chapter 5. This problem was also detected by Cullinan Studio from post-
occupancy feedback, therefore, the solution was offered for a planned extension of the
project:
In the extension project, we are also looking at slightly remodelling the office
adjacent to the entrance. The Maggie’s Centres aim to avoid having a reception, but
this was situated to allow passive supervision of the entrance. However, staff find
they are approached by visitors quite a lot and do not have quite enough privacy
when dealing with confidential issues, such as phone calls. We are remodelling
some of the walls to make this area slightly more separated.
Having expressed the issues about the design process and how they approached a
connection with nature, the architects also explained the problems they realised after post-
occupation.
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6.2.3. The Designs Problems
When the architects were asked about design problems in their centres the answers
were usually concerning technical problems or details. This question explicitly asked: Based
on post-occupancy observations, is there anything in the design that you think you should
have designed differently, have you detected any problem? In this regard, Harbour admitted
that they overlooked the possibility that sound could come from the street and hit the roof,
therefore he claimed that the acoustics probably could be better internally if they had
noticed this problem earlier. However, this problem was eased to some extent by using
curtains. Haylock indicated a technical detail: “The vents in the roof. They can either open
or closed, and I think we should have made them open a little bit. So, it is just a boring
technical thing, but I think the Centre works very well, we are very proud of it.” Thereafter,
O’dwyer said that they actually wanted the sliding entrance door to be automated, but the
client did not agree as it will make the entrance less of a homely environment, so a pivot
door could have been a better option. Regarding these sorts of detail or technical problems,
Gough said that the feedback can reflect the individual opinion and might not be applied to
everyone:
We have had some feedback from the director who is now left. She had quite a lot
of comments which were critical, or not critical, but she suggested various
improvements. And funnily enough, now we have a new director. I went to see her,
and she does not have the same problems. And she is very happy with how it
actually is.
On the other hand, the problems stated by Gough and Brittain can affect all centres
someday, and designers should take them into consideration. As explained above in the
previous section, staff need more privacy in the centres’ visitor-centred and homely
environment, they need private spaces for confidential issues. Interestingly, in Maggie’s
Nottingham they need more kitchen space while the kitchens are the main focus of the
centres, they faced an unpredicted problem in time, Gough explained the extension project
that they are currently considering:
A bigger kitchen, that is the most pressing problem, because what has happened is
quite interesting psychology. The original people, who first went there 10 years ago
or more, have kind of taken some ownership of it. And they continue to come
because they like going there during the day, they like being there. They have really
almost adopted the kitchen as their space. And it is more difficult for new people to
use the kitchen because it is already full of oldies. They cannot say to the oldies to
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go away. But it's [the centre] partly for new people, and they expect it to be mostly
for newly diagnosed cancer patients. However, somehow some people treat it as a
club that they are a member of for life, and they keep coming back. So, what they
now thinking is that they need a bigger kitchen so the old people do not dominate
it. And indeed, there is even some crazy idea that we keep the old kitchen to the old
guys, therefore, they could hang on there, and build a new kitchen for people who
newly arrived. So, we may end up with two kitchens, which is quite funny.
6.3. Recommendations for Clinical Therapeutic Environment Design

Haylock and his team worked on a hospital project, The Circle Bath, in Bath, UK, where
there is an emphasis on natural light and views throughout the hospital. The team did their
research in this project to create a healing environment and also used what they learnt in
Maggie’s Manchester:
Connection with nature in a healing environment, I think the psychology of it is also

very important. We did do some studying a few years ago now about the benefits of
natural daylight and the connection to landscaping in a hospital. And it all helps to
reduce the heart rate and increase recovery. So, if you are connected to nature, that
means that you get back soon. So, we worked on a project in Bath in the UK called
The Circle Bath, and we learnt a lot from that project. And we continue that theme
through to the Maggie’s Centre. But I would say the Maggie’s Centre that we took it
to another level.
Based on their research, Foster+Partners decided on their main design drivers that will
reduce stress and anxiety by using natural elements and non-clinical feelings. For example,
although the building was concrete, timber materials were introduced on the floors and
walls to reduce the institutional feeling (Figure 6-11). The location was available to provide
a view of the countryside landscape, while they also designed private and quiet gardens
around the hospital. Therefore, they maximised the view and natural light in the building.
Furthermore, Haylock also emphasised on sensory experience that the olfactory and
auditory elements should lessen the clinical feeling, along with thermal comfort as the
hospital environment is usually hot. Lastly, interior design and furniture choices should be
more domesticated and homelier to evoke a sense of belonging and relaxation.
What is driving the design of the Circle Bath hospital was the simplicity of the
design, and it is all about making the experience when you visit the hospital as very
pleasurable as possible because there is a lot of anxiety when you go to a hospital.
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So, we tried to design as relaxing as possible, more like a hotel, more like a spa. So,
the introduction of timber and trying to make the building less institutional as
possible was one of the targets. Because when people go to hospitals, they have got
the smell, the temperature up…, all the furniture and all the environment is so
standard, so typical. You even got into that cubicle before you go for an operation,
you are feeling that environment. So, we thought that if we can reduce that anxiety,
people can be more relaxed. Also, when they recover, that space is more like a
domestic hotel room rather than a hospital room. So, having things like timber on
the floors, in the invasion bedrooms, would be better than just having an
environment of a normal hospital. So, we make the spaces more domesticated,
more like home, than a hospital.
Figure 6-11: The Circle Bath inside.
In Guy’s Cancer Centre, a clinical setting opened in 2016 in London, Harbour and his
team followed Maggie’s Centres’ approach and adapted it to the clinical environment.
However, implementing natural elements in a clinical setting was more challenging than in
the non-clinical Maggie’s Centre:
What we implemented in Guy’s Cancer Centre was our first attempt at trying to
bring some of the philosophy of what we had learnt at Maggie's, into a clinical
setting. The key parts of that were, first of all, to distinguish between the science of
technology and the art of care. So, that was our first distinct division and the
building is literally split insight. The art of care, backed up by the factory, is the
science of treatment. Except that you have this high-tech space, where all the
machines go ping, but related to a space that you can feel is more human. And it
was a real battle… Because the people that are charged in hospital’s infection
control will not be allowed to treat as anywhere else… And what we managed to
achieve in Guy’s was really how far we can go down this concept of being aware of
the border environment of nature.
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They worked with specialists to understand space organisation requirements, and then
developed a new approach to lessen clinical feeling through spatial design. The scale of the
building was domesticated and humanised by dividing the departments into a new
understanding. Also, the design provided easy access to different settings as all relevant
facilities were bubbled in the same divided area, called ‘villages’. The new organisation also
aimed to maximise contact with nature (Figure 6-12). For example, people who had
experienced radiotherapy tend to receive it in the basements in usual healthcare settings
which was described ‘airless dungeon’ where no daylight or fresh air comes in, however,
the architects managed to plan the radiotherapy on the second floor where the patients
have access to many natural features they were deprived (Figure 6-13). The balconies were
aimed to bring the notion of a garden, and big windows created contact with nature, and
light and offered view and fresh air as much as possible. Timber was also integrated as a
material to enhance the homely and relaxing feeling as well as the colourful walls and
surfaces ( Figure 6-14).
The first aspect beyond the splitting was to bring the scale of the building down. So
rather than feeling as if you are in an edifice. This is a building of 14 floors
effectively, but it is divided up into four ‘villages’. They bring together some clinical
aspects in there, day cases minor operations, chemotherapy, radiotherapy, and
complementary therapies. What we have done is to break the building out, there is
a common very informal reception, you would not even really understand it as a
hospital reception, in a sense picking on some of the strengths of Maggie’s. It's still,
unfortunately, got an NHS-type typical café… When you go into the lift, you
basically got three buttons, the buttons have the name of the floor, so radiotherapy
is a button. So, the point is, it is not relevant what floor you are in, what is relevant
is where you are going. And when you arrive in that radiotherapy village, which is a
three-storey high village, you have greeted there as well. And there is the art of
care piece, it is a much more human scale, it brings in a lot of timber as a material,
there is a lot of daylight, there are balconies, which feel like outside. We have tried
as much as we can to bring the notion of the hospital garden onto up the buildings,
so they figure on the balconies.
Harbour highlighted that they also aimed to provide a better workplace for staff by
providing private staff areas where they have Views, Prospects and Socialising
opportunities. This also contributes to the problems commonly stated by staff in Chapter 4:
There are also aspects for the staff, staff coming together and having a relationship
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with their staff area [facing] to the street, so they can see people coming and going.
It's not tucked away, around the back.
Overall, Harbour claimed that some of the approaches in that hospital were quite radical
approaches, which were inspired by Maggie’s Centres, and are quite successful based on
feedback and rewarded specialist care and architecture awards. Another aspect of this
success was that the design had very strong patient input, the patients were actively
involved and conveyed their opinion on how the design really works from the users'
perspective. Thus, this building can be an example of a new standard for clinical
environments according to Harbour.
Figure 6-12: Sketches of design decisions in Guy’s Cancer Centre.
Figure 6-13: The villages, shown in the section of Guy’s Cancer Centre.
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Figure 6-14: Guy’s Cancer Centre.
In order to design clinical settings using Maggie’s Centres’ approach, the architects
should consider every detail deeply and rigorously as designing a clinical environment
comes with a problem of risk and responsibility. Harbour said that, for example, cleanliness
as a measurable thing is ranked higher than the quality of space, thus, the designer should
consider solutions where both mutually exist. Another recommendation was to think
adjacencies very well:
We discovered that the design of a hospital is all about adjacencies between what is
considered important to the people working in the hospital. And what sort of
adjacencies are agreed no one dares question them or tries to rationalise them to
make a building more understandable. So, adjacency is most important.
Lastly, Harbour explained a risk that they discovered after the building was designed
which was in relation to budget, as the hospital said they were not able to afford a second
receptionist as normal hospitals have one reception area:
The old patients came to help again, they have a volunteer network. So
interestingly, someone had a very clever idea. Well, the volunteers could be sort of
staff in the villages to help patients. So, it gave them a sense of space, a very like a
small-scale little hospital of their own, to become just friends, to get advice. So, sort
of working in the way that Maggie’s works. They do not quite yet offer the cup of
tea, because of course, they do not have the tea points.
According to O’dwyer, biophilic design and Maggie’s architectural philosophy can be
adaptable in clinical settings, at least in waiting rooms, entrances, outdoor settings or
corridors, but the main barrier to reaching this standard is budget. However, the benefits of
connecting with nature by reducing stress and anxiety can also help to save money by
reducing stay time in the hospital: “If you spend more money on a better healing process,
potentially people will spend less time in hospitals.”
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Similar to the other architects, Brittain recommended similar approaches for clinical
setting design. In her point of view, connection to nature is key, and providing a choice of
space to meet people’s requirements – quiet, calm spaces, and more social areas. In order
to create the best connection in a clinical environment, she highlighted that having a view
of nature helps with many aspects such as wayfinding, orientation and aspects such as
circadian rhythms. Also, the principles people find therapeutic in nature can be used in
buildings, such as evolutionary principles – legibility, mystery, coherence and complexity –
as well as good daylight and use of natural finishes, water features etc.
We have not designed large-scale clinical hospitals but with Maggie’s we were able
to follow domestic principles rather than strict infection control protocols etc.
However, there are many spaces in hospital settings which do not need to feel
institutional, but can be welcoming to users, and have good wayfinding, natural
light and materials.
Brittain is currently working with the Alder Hey Children’s Hospital in Liverpool on a new
extension and inpatient mental health facility for young people, the Catkin Centre and
Sunflower House, which brings together a range of clinical services in a therapeutic setting.
The office is also working on the redevelopment of the surrounding Springfield Park,
creating a holistic healthy setting for the hospital and the surrounding community. Their
primary aim in this project was to make the building as non-institutional and welcoming as
possible. This aim occurred from the first interaction with the building, which was from the
under croft car park:
We ensured this was as light-filled as possible with views to a planted embankment,

and visitors could start their approach to the building through a landscaped route.
Similar to Harbour’s approach, Cullinan Studio also followed Maggie’s non-clinical

feeling philosophy to some extent. The inclusion of timber as a Natural Material, Colours,
View, and Greenery were emphasised:
Both buildings are focused around a courtyard, providing constant views of nature
and a clear sense of orientation. We are aiming to minimise signage, but use colour
for wayfinding where possible. There is a timber cone structure that brings natural
light into the central waiting space, and there is a choice of types of waiting spaces
to allow for different requirements. The residential building is made from CLT (Cross
Laminated Timber) panels and we used the timber as a robust, natural finish in all
the communal spaces and bedrooms. The consulting rooms have bay windows to
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bring a child’s sense of scale to the space, and avoid soulless square clinical feeling
spaces.
The strict standards and budget were indicated by Brittain as the facts why creating
contact with nature was more challenging in this project than in Maggie’s Newcastle:
The Sunflower House inpatient facility had much more stringent requirements as it
was all designed to Tier 4 mental health standards, with anti-ligature fixings and
clear passive supervision throughout. However, we feel it has still retained a clear
non-institutional feel, with break-out spaces and a generous courtyard, bay window
desks in the bedroom etc. Also, the budget was a difficult constraint as with all NHS
projects.
Figure 6-15: The Catkin Centre and Sunflower House in Alder Hey Children’s Hospital in Liverpool.
Apart from the previous comments, Gough highlighted the use of plastic material and
smell in clinical settings as the main problem that reduces the quality of space. Natural
materials and comfortable furniture with nice and soft fabric can promote quality.
However, as also stated in Chapter 5, he claimed that the decision-makers and clinicians
will not easily accept changing the system, “I think the clinicians, not good psychologists,
they think that it's all about a process, it's like you're in a machine for getting you better”,
whereas they tend to be more flexible in children hospitals:
I would love to do it [designing with these ideas]. But I am quite sure, I probably lose
the argument against the clinicians. There is a whole history of how things are done.
The suppliers, the whole way in which hospitals are procured through PFI or
whatever, absolutely militates against changing its formula. And the formula is a bit
worrying. We should probably look to children's hospitals to see where compassion
is allowed to come in. They tend to be more gentle, and less clinical, and I'm sure
there is an equal need to be clinical, but they somehow soften it. Because it is
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children. They think they have to, they should. Just because you are grown-up does
not mean you do not have the same emotional needs as when you are a child.

The semi-structured interviews allowed to look deeply inside the efficacy of biophilic
design parameters and practical implementation in the non-clinical and clinical therapeutic
environments from the expert point of view. The synthesis of findings in this chapter
helped to have an insight into decision making and design process, some design problems
that architect had faced, and design recommendations, and also helped to understand the
importance level of biophilic design parameters that appear the most critical from experts’
perspective for promoting and supporting human health and wellbeing. The experts
underpinned the importance of Greenery, Daylight, Natural Material, Colour, Views,
Welcoming Relaxing, Prospect and Refuge. However, different than findings in previous
chapters, importance and benefits of Water was highly emphasised, particularly in non-
clinical environment where the application is less restricted. Therefore, particularly ranking
of Water parameter have been affected in the new conceptual biophilic framework which is
presented in the following chapter with design guideless for clinical and non-clinical
environment design.
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CHAPTER 7
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7. DISCUSSION OF THE FINDINGS: BIOPHILIC DESIGN GUIDELINES
FOR THERAPEUTIC ENVIRONMENTS
This chapter discusses and synthesises the results obtained from the three different
methodological approaches examined in Chapters 4, 5 and 6: the meta-synthesis, the
systematically searched review and the semi-structured interviews, which were supported
by the data from the narrative literature review (Figure 7-1).
Figure 7-1: Data compilation map of the biophilic design framework. (Systematically searched review part is
updated)
Although the meta-synthesis and interviews supported and shaped the framework for
non-clinical therapeutic environments directly, the narrative literature review and the
systematically searched review fed and encouraged the framework with the interpretations
of the researcher since they were extensively focused on clinical environments. The data
from the clinical environment cannot be directly applicable to the non-clinical settings, such
as Maggie’s centres, but the patient’s needs and statements give us benchmarks that can
be translated into their non-clinical environments. These benchmarks are what should be
provided for vulnerable cancer patients since the most vulnerable person gets affected by
the building and environment the most. However, we cannot adapt buildings to this
population one hundred per cent, as the needs of people with cancer (including different
types of cancer, age, gender, type of treatment, stages in the treatment, etc.) differ from
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one person to another. For example, not all types of cancer patients have issues with
infection control as strictly as patients in with haematology treatments. Thus, we cannot
use everything detected in a clinical environment in a systematically searched review in
non-clinical design, but this data shows what is important for patients. Therefore, the final
results were critically examined in this regard and comprehensively combined to holistically
present those key biophilic design parameters and design applications.
With this in mind, all results are summarised within a holistic framework (Figure 7-2)
that presents the analysis from all research methods in three different steps: the first part
of the framework states the recommendations for the decision-making and design process;
the second step identifies and groups the critical biophilic design parameters; the last step
conveys the summary of design recommendations revealed throughout the research. The
important biophilic design parameters for non-clinical settings were defined for the whole
setting, given that these types of settings are commonly small and less complex buildings.
The framework also aims to inform designers about the criteria that will make their
designs biophilic. All parameters included in the framework are critical for the therapeutic
environments, based on the research reported in this thesis. The order of importance was
grouped mainly based on the results from the meta-synthesis and the interviews, however,
the systematically searched review results and the narrative literature review also affected
the level of importance. For example, Fresh Air and Thermal Comfort’s rankings were
increased because they were highlighted in the studies examined as well as the current
certifications (WELL certificate and Living Building Challenge). Thus, each of these four
levels of importance (groups A, B, C and D) will help to understand and apply the
parameters in the design processes in a more efficient way. The order of importance shows
that Group A (Fresh Air, Light-Sunlight, Greenery) represents extremely important
parameters which are the most critical biophilic design parameters for users, therefore, a
designer cannot claim a space as biophilic design if the space does not employ even one of
the parameters represented in this group. Group B (Multisensory Environment, Refuge-
Privacy, Sense of Belonging, Thermal Comfort, View, Prospect, Water,) represents very
important biophilic design parameters which are almost as important as the parameters in
Group A, however, these parameters were considered in the second group not because
they were indicated as less important but because the users emphasised their need for the
parameters in Group A was more than the parameters in Group B. To create a biophilic
space, designers should employ all the parameters in Group B rigorously, nevertheless, they
can be disregarded only if experts prove that environmental conditions are unfeasible or
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the application of a parameter in this group can be harmful to some users. The parameters
in Group C (Natural Material, Natural Colour, Bringing the Outside to the Inside,
Spaciousness, Curiosity) are defined as important, and designers should employ these
features as much as they can. Finally, Group D (Seasonal Changes, Fire) represents the
moderately important parameters, but still, these parameters indicated their positive
impact on the user’s health and well-being, therefore, the inclusion of these parameters in
a design will progressively increase environmental biophilic quality.
The following sections explain the design recommendations in the framework in more
detail. Having explained the recommendations in relation to the decision-making and
design process, general design recommendations for implementing biophilic design
parameters and design recommendations for each group of users are explained in
consecutive sections.
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Figure 7-2: New conceptual framework for biophilic design in a therapeutic environment.
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7.1. Decision-Making and Design Process
A successful project emerges as a result of harmonious coordination and communication
between clients and architects, as well as a non-descriptive and architecturally flexible
design agenda offered by clients. As clearly revealed in Chapters 4 and 6, decision-makers,
clients and designers should have knowledge about the importance of nature engagement.
Based on this research, the most important barriers to creating a biophilic healing
environment are generated in the decision-making process before designing healthcare
settings. Decision-makers usually do not prioritise nature-based opportunities or ‘design
thinking’. Functionality, efficiency, cost restrictions or habitual practice are often the main
concern of healthcare facilities' design regardless of the patients’ opinion and the quality of
their experience. In order to eliminate these barriers, decision-makers, designers,
management and administration must know the importance of biophilic design so that
decisions regarding the site, layout, building orientation, surrounding views, and so on can
be considered in the planning stage. Skilled professionals need also to consider the repair
and maintenance needs of biophilic features within available maintenance budgets.
Furthermore, the lack of knowledge and ability of the designers also leads to inappropriate
design choices and executions, such as: cold and stark spaces; too much hardscape, glaring
materials or materials too hot to the touch; uncomfortable furniture; environments that
are too demanding, complex, static or under-stimulating; insufficient shading or lighting;
and structures that cast odd shadows that could raise anxiety. In order to prevent these
wrong implementations and to adopt a biophilic design philosophy appropriately, doing
research at the beginning of the projects or consulting with specialist consultants can be
efficient approaches as recommended by the interviewed architects. Research findings and
consultant advice should be adopted in the designs through brainstorming processes and
absorbing all imagery and ideas in an open-minded state with all design teams and clients if
applicable.
Furthermore, during the decision-making process, visiting sites which have a similar
programme and are located in a similar context is an important step to detect problems
and observe successful applications, and more importantly, to know what the ambience is,
how a day cycles, and how do people operate and use the spaces. Along with the site visits,
it is highly recommended that the designers discuss the project with the relevant user
groups or conduct public opinion investigations before setting up design drivers, so that this
will lead to more efficient human-centred buildings.
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Additionally, if the decision for building located within the given site is left to the
designers, they might aim to approach the sites to maximise nature contact and offer a
sense of enclosure if the site is in a highly urbanised, industrialised and crowded
environment. In any case, enhancing nature engagement should be well-thought, and
solutions to offer a fully sensory connection with nature must be well-considered. The
designer’s goal should be to connect the spaces within the building as closely as possible
with outside spaces and to provide a green outlook, psychologically separating it from an
undesirable clinical setting feeling. Natural passive design principles in terms of layout and
orientation can also be considered to achieve this.
Although the priorities or level of importance for either type of setting differs for
programme guidelines, spatial considerations and requirements in different therapeutic
settings the recommendations stated above are applicable in all types of therapeutic
environments. However, the design strategies and biophilic parameter requirements differ
based on the user group and purpose of use.
7.2. General Biophilic Design Recommendations to Create Therapeutic

Environments
Examined literature and research on biophilic design in this study showed that some
biophilic design application principles arise as specific needs of this typology while the
application of some other principles can be generalised.
Firstly, a designer should prioritise working with real nature and natural elements, or at
the very least simulated nature should be considered where the application of real one is
not possible. Also, prioritising biodiversity and variability increases the efficiency more than
the quantity or area of natural elements.
The spatial organisation should allow users to exposure to natural views and
multisensory natural environments for at least 20 minutes per day but no less than five
minutes at a time. Thus, designers should consider how to enhance visual and non-visual
connections in detail, such as user routes and circulation of the building that regularly
passes across natural areas or arranging spatial layouts and furniture to provide
uninterrupted view lines to natural landscapes in a seated position. Moreover, a
simultaneous experience of visual and non-visual connection maximises the restorative
quality of an environment.
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As in nature, a biophilic design application should also reflect non-rhythmic stimulation
on the senses, where the efficient frequency of non-rhythmic stimulation is about 20
seconds of exposure around every 20 minutes. The best way to create this atmosphere is to
bring the outside to the inside and reflect seasonal changes in the space. For example,
attracting wildlife (at least visually) through plants or fragrances, reflecting cloud
movements or rain, taking a breeze in, or exposing the building to spontaneous natural
sounds such as birds chirping or water babbling.
Thermal variability is another stimulating feature in design as the temperature changes

non-rhythmically in nature, providing thermal variability in space will increase comfort and
perception, however, overstimulation should be avoided. To distribute and prolong thermal
variability, designers can incorporate other biophilic design parameters (e.g. fresh air flow,
daylight, natural materials) or mechanical and electronic systems can be applicable where
necessary. In order to provide healthy thermal comfort, the temperature should be
between 18oC and 24oC, but this research also showed that reaching 24oC creates an
unwelcoming feeling in therapeutic environments. Designers can avoid temperatures over
22oC where it is safe for users to create a more welcoming and relaxing space, however,
they should consult specialists in medicine and doctors for the temperature of specific units
and patients’ rooms.
An efficient biophilic design considers fresh air level rigorously, and architectural
elements for natural ventilation should be prioritised over mechanical ventilation where
possible. Therefore, to improve indoor air quality and provide a better state of health,
ventilation rates should be higher than 20 cfm and up to 40 cfm per person in space.
In terms of greenery and plants in biophilic design, supporting evidence suggested that a
high density of plants in an indoor environment also decreases cognitive performance as
well as the quality of space. Therefore, a moderate amount of greenery should be engaged
based on the spatial programme. The general concept of biophilia claims that the
application of single or isolated plants is not effectively beneficial. Vegetation should be rich
and ecologically connected while the plants should be chosen from local species. Although
designers should prioritise local plants and vegetation, it should be taken into account that
slightly scented plants with green and small leaves are the most appropriate and effective
plants for health and wellbeing, whereas red flowers produce a fatiguing impact over time.
Wrongly implementing water elements, as an important restorative biophilic design

parameter, can cause discomfort. Repetitive and abundant experience with water can
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cause a loss of interest. Moreover, a high volume of running water can reduce the acoustic
quality of the space and increase humidity. Hence, an optimum amount of water features
should be implemented in practice, avoiding exaggeration. Also, the restorative effect of
water depends on its quality. Clear water should be prioritised and designers should also
consider the sustainability of water quality and its maintenance, as dirty and brown water is
less restorative than clear water.
A healthy environment provides an opportunity for direct exposure to sunlight

(approximately 3,000 lux) for at least 30 minutes a day. When designing lighting and taking
daylight inside, it is critical to consider a balance between dynamic and diffuse light to avoid
a negative impact. For example, long-time direct sunlight penetration, changing light
colours or sharp transitions can create discomfort. Consideration of circadian lighting is also
critical, particularly in long-period occupied spaces, such as patient rooms.
Since human receptors can detect and differentiate real and synthetic materials, real
natural materials would be more effective and stimulating. According to studies on timber,
the application of wooden materials on 45 per cent of the whole surface creates a feeling of
comfort, and over-use can cause harm to cognitive performance. Thus, designers should
avoid monotonous overstimulating natural material applications, and can use various
materials to buffer and soften overstimulating or boring atmospheres. Likewise, the colour
choice should follow the same principles to avoid a feeling of dullness. Moreover, various
colours impact human psychology in different ways: soft and natural blues help to feel
relaxed as they remind us of the sky and water; shades of vibrant green give energy and
make people calm as they are associated with meadows or forests; yellows are warm and
welcoming and create a social and energised atmosphere as they remind us of warm
summers and the sun; purple and mauves are spiritual and meditative colours, and evoke
mystery as they represent dawn and dusk; oranges and reds can be energising, exciting and
stimulating as they are the colours of ripe fruits and berries; dark colours are associated
with sophistication, depth and mystery, and feelings of security and refuge, but if they are
not used carefully the space can easily be oppressive and overwhelming. With this in mind,
using colour in much the same proportions and with a sense of harmony as in nature, is an
important point to avoid overwhelming people.
Low-level refuge and high-level prospect combinations were found to be restorative,

whereas low-level prospect and high-level refuge can increase stress, fatigue and negative
emotions. Therefore, a moderate prospect distance should be higher than six meters (short
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depth), although the distance of the preferred prospect was stated as above 30 meters
(long depth). Prospect can be applicable in both interior and exterior spaces; the interior
prospect is to provide a visual connection between the spaces and it has a greater impact
with the opportunity to see multiple spaces together. Prospect and refuge can be designed
and regulated by orienting buildings, corridors, glass walls, or playing with ceiling heights.
Also, a refuge space might be created through the use of light and shadow, which can also
endow a mysterious character to the space.
7.3. Designing Non-Clinical Settings for Cancer

Based on the analysis of Maggie’s Centres and the interviews with a selection of their
architects, the following general guidelines regarding the design of non-clinical healthcare
settings can be proposed:
• Importance of human-scale spaces: avoid imposing architecture, particularly at

entrances and reception areas.
• Sympathetic building form: embed the human preference for curvature, and
craftsmanship within the quality design.
• Open layouts: diaphanous spaces with the flexibility to create enclosable areas,
using high ceilings and sliding doors.
• Abundant natural light and air: use materials and designs that let light and air from
fully glazed facades or extensive windows, smaller manually operable windows,
clerestories, skylights, atria, courtyards, balconies or winter gardens, including
adjustable shading devices.
• Warm materials: wood play a key role.
• Accessible landscapes: in- and outdoor spaces that include water features, and
which are sensitive to seasonal and time changes.
• Warm spaces: include fireplaces and do not overheat (>24C).
• Sensory spaces: focus on natural views, tranquillity, natural fragrances, sounds and
textures, however, overstimulation must be avoided.
• Colourful spaces: aiming for vibrant, high-contrast, quirky, colourful spaces.
• Vernacular marks: inclusion of local and traditional features strengthen a sense of
belonging.
In addition to the general summary of non-clinical environment design, each part of the
setting should be designed to reflect particular characteristics.
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7.3.1. Building Form and Layout
There are two considerably successful design strategies found in terms of the strategic
use of building form. Firstly, as a tactic to elicit curiosity in order to attract people to the
centre. However, these unfamiliar forms can sometimes prevent them from providing a
homely human-scaled environment, thus, the architects should select their drivers
rigorously and approach unfamiliar forms well-thought-throughout. Secondly, as a way to
create a sense of belonging to the visitors, designers can follow the tracks of local
architecture and culture.
In terms of layout design, it should encourage the visitors to socialise while providing an
opportunity to withdraw when they need it. The visual connection between the different
parts of the buildings is also another necessary contributor to enhancing welcoming and
relaxing feelings. Thus, an open-plan approach was the most commonly preferred strategy
for layout, as it can also promote a non-clinical feeling. However, this visual and social
connection should also be in balance with the needs of staff who sometimes need to be
away from the visitors for their personal work and have some break.
According to cancer patients’ preferences identified in Chapter 4, ease of movement is

one of the most important aspects that the buildings should offer to patients. As such, the
maximisation of accessibility and the removal of barriers should be seriously considered.
This includes rapid and easy access between outdoor settings, foyer-waiting rooms and
treatment settings with safety that must be considered as an overarching priority in
relation to movement. For example, the use of non-slip surface materials, smooth paved
paths, ramps rather than steps and colour-contrasting curbing along pathways. Barriers to
be avoided can be heavy doors, narrow doorways and pathways, etc. In order to provide
physical access to the outside, all barriers and thresholds should be removed for patients.
In some cases, automatic doors can be suggested to improve ease of access.
The material choice and heating system are another concern in terms of the thermal
comfort of the patients, who are usually more sensitive as a result of chemotherapy, as it
was reported that the environment often tended to be over-hot in hospitals. Also, as was
reported by users in Chapter 5, the material quality and feature are more important than
the design or price of the furniture. Therefore, plastic materials should be avoided as
furniture options as it increases temperature perception.
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7.3.2. Entrance
The entrance to the facility is an important space, as upon arrival people often face high
levels of stress and anxiety. Therefore, creating a welcoming atmosphere with biophilic
touches can relax people: for instance with the use of natural materials such as wood,
natural wall colours, fish tanks and natural objects. As always, safety should be a
paramount design criterion, avoiding the inclusion of allergy-inducing elements, and
slippery or otherwise challenging surfaces.
Reassuring small and calm entrances can encourage people to enter the building. As
these non-clinical environments are envisioned to be environments where the visitors
receive mental, psychological and social support, entering the building usually means that
they have accepted their illness and decided to fight it, which is a turning point for the
visitors. Therefore, the entrance is a space that should be distinguished in its design.
Curiosity or familiarity (that promotes a sense of belonging) can be applicable principles in
distinguishing the entrances. As learnt from Maggie’s Centres, not having a reception desk
creates a homelier character and less institutional atmosphere, which also contributes to
social interaction among the visitors.
Along with the physical interventions, prospect and refuge should also be considered
specific to the design of entrances, where the users should have the opportunity to pause
and observe without being seen and before getting involved in any activities and decide to
participate without feeling pressure or obligation.
7.3.3. Rest Rooms and Private Areas

Therapeutic environments also offer spaces for users to retreat and rest in more private
corners or rooms where they can comfortably rest and clear their minds in peace, have a
nap, read a book, or freely cry without being seen by others. As the studies in Chapter 4
revealed that connection with the outside and nature is highly demanded in these kinds of
more private spaces. Learning from inpatient environments for cancer patients, windows
should provide uninterrupted views, prospects and sufficient natural light exposure, along
with natural ventilation. Supporting evidence suggested that approximately 300 lux daylight
is sufficient in inpatient rooms, thus, this amount of daylight can also be adaptable in these
non-clinical private spaces. Window design should also pay attention to privacy, safety and
refuge by providing one-way views. Indoor seats or beds that are strategically located to
maximise the use of natural window views can motivate patients to take advantage of
these opportunities.
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As observed in Maggie’s centres, toilets can play a great role in providing a withdrawal
space for patients, they can offer a more spacious atmosphere where patients can have
solitary break or comfort to cry freely. Studies in chapter 4 also revealed that toilet
entrances should be protected from others’ sight since some cancer patients need to use
toilets more frequently and some reported that they do not want to be seen always waiting
for the toilet.
7.3.4. Common Spaces

As Maggie’s Centres are the case study for non-clinical settings in this research it is
important to understand the kitchen concept as they are the common communal space in
Maggie’s centres. In the kitchens, the table was the most distinguishable characteristic that
promoted socialising and homely feelings. Thus, the common spaces should have
comfortable, relaxing, and socialising characteristics as well as provide features that
promote refuge and feeling safe. In order to create a non-institutional feeling, the inclusion
of a kitchen table, a fireplace, or living room-like furniture can improve the environmental
quality in common spaces, as all of them also contribute to socialising. It was particularly
noticed in this study that providing a fireplace in these centres, with the smell of burning
wood, the crunching sound of it, and the visual and thermal effect of fire itself, was a
prominently effective tool to restore the quality of the space. In practice, an open-plan
layout provides the highest exposure to daylight and socialising opportunities, but it also
creates a noisier environment and impacts the provision of withdrawal spaces. Therefore,
the inclusion of open-plan spaces needs more thought in order to create a balance between
opportunities for socialising, privacy and tranquillity. Privacy can be encouraged through
zoning or screening or by offering solitary spaces for resting or contemplation.
Sliding doors are preferable, as it was found that sliding doors promote a feeling of
relaxation and privacy. Also, they contribute to the non-institutional feeling, along with the
notion of ‘signlessness’, in which the settings decide not to use any sign on the doors.
In order to create contact with the outside environment, big windows and French doors
to access a garden, a balcony or a terrace can be included in the design. Barriers between
the outside and the inside should be removed as much as possible. The most noticeable
factor of the inside-outside relationship should be the affordance of visual connection, such
as a view of the sky, water or greenery. As some patients do not have the energy to walk
around, they should find an opportunity to have access to nature while being inside.
Windows should be operable with the aim to take fresh air in and give control to users to
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regulate their thermal comfort and the air quality of the environment. Although the users
are given the option to control the thermal quality of the space, designers must avoid
reaching a temperature of 24°C to not remind a hospital ward.
Moreover, various architectural elements can be used to get more daylight inside, such
as clerestories, roof fenestrations fitted with selective shading devices, roof openings, atria,
courtyards, glass-walled porches, and small openings and skylights. The amount of daylight
and ceiling height greatly improves the quality of space and the perception of spaciousness,
which helps to stop claustrophobia and to reduce the feeling of stress. Also, spaciousness
with the explosion of volume can be used for triggering curiosity and a welcoming feeling.
Additionally, daylight can be a tool for creating a distinction from the usual healthcare
facilities, along with the direct benefits of daylight. Since the daytime is quite short in
winter (in the UK), artificial lighting should be designed in accordance with the natural light
spectrums. This study showed that the warmth of soft light was associated with feeling
safe, thus, the artificial lighting use in the buildings can be chosen to be warm (3,000-4,000
Kelvin) or soft (2,700-3,000 Kelvin) range. The lighting should be designed specifically in
some rooms, for example, the art therapy classes require bright light, while softer and
dimmer light is used in relaxation classes in some of Maggie’s centres.
The material choice should offer warm, calming and tactile experiences. For example,
wooden, earthen or ceramic materials can be employed in construction. Material choice,
organic shapes, and structural elements can be used to attract attention in settings since a
visual focus or distraction helps some patients to forget their unpleasant thoughts.
However, concrete or steel like ‘cold’ materials should be softened by combining with
natural materials or painting. Strategic material craftsmanship, and structural components
can be used to arouse curiosity and invite people to explore the setting, particularly to
attract more men visitors as observed in the study. In any case, the surface materials
should be warm to the touch, and plastic materials should be avoided.
In contrast to the usual clinical healthcare settings, the designers should aim for vibrant,
high-contrast, quirky, colourful spaces. According to the analysis in this research, colourful
decoration gives a sense of family and floods people with feelings of welcome and
relaxation. Moreover, different spaces with different colours help people to look from a
different perspective.
Within the setting, designers can use vernacular elements from material to furniture
choice. The inclusion of local and traditional architectural traces and elements from ‘home’
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culture of the local users will strengthen a sense of familiarity and a sense of belonging,
which contributes to welcoming and relaxing feelings. In order to create a homely
environment, the designers should understand very well the local people’s own perception
of what home means, as they will be the main user group and the notion of family and
home culture depends on the context in which they grew up. Besides, nature-based smells
and sounds should be used while avoiding chemical medicine-like fragrances and sounds,
because the multi-sensory experience has a striking impact to help people to create a
connection between their memories and space. This should be taken into consideration
that, as it was clearly detected in this study, combining both familiar and relaxing domestic
features that makes the people feel safe and homely with surprising and stimulating
features will attract people by curiosity.
Lastly, the space should offer a sense of protection and refuge, as the user groups will
mainly be vulnerable patients or their relatives. Façade openings can be designed following
the prospect-refuge principles, in which the main idea is “see without being seen”. View
angles can be arranged in this regard, and be supported with greenery and plants in the
garden. Screening on some windows or curtain systems can also be implemented.
7.3.5. Consultation Rooms

The consultation rooms are the places where direct psychological therapy is delivered.
The position of seats should maximise the view from windows to allow patient and
psychologist to give visual breaks and time to think whenever they need since the topic
sometimes can be intense and they might need a relaxing focus. These rooms work in a
kind of similar way to the specialist care units investigated in Chapter 4, therefore, seats
near the window were also regarded there as the most commonly preferred location within
the treatment rooms, in which optimum daylight and uninterrupted views for a larger
portion of the room were sought. Moreover, as learnt from the systematically searched
review, cancer patients seek a spacious calm atmosphere while consulting with a doctor,
nurse or specialist.
7.3.6. Outdoor Settings

The importance of easy and effortless physical access is frequently emphasised in the
studies in Chapter 4. Thus, porches, courtyards, patios, balconies, terraces and gardens can
encourage easy connection with the outdoors. However, it is important to consider a
balance between shaded and sunny areas and use adequate greenery and comfortable
amenities.
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Garden design should reflect nature by avoiding artificial or over-designed features. The
variety of plants creates a sensory richness and encourages people to enter and discover
the settings. Also, various plants reflect seasonal changes and transform the atmosphere
every day. Gardens should be enriched with diverse plants and flowers to heighten and
uplift the senses. Also, wilderness such as birds, bees, or small animals, can be attracted or
owned to trigger all senses: the smell of scented plants and blossoms, the tactile texture of
the tree trunks and sitting on the grass, hearing rustling leaves and rain’s pattern on the
leaves, hearing the singing of birds that perched on the trees and chickens crowing, or the
taste of edible plants and fruits and so on. Water features, particularly running water, are
also a very useful tool to create a calming restoring sensory environment. A well-designed
pool or fountain can easily promote the environmental quality of the gardens.
Moreover, in an urban context, plants can be used as a buffer zone around the gardens
to create a quiet refuge and a breathing place between the setting and the outside world.
A glass house or winter garden concept can be integrated into the setting, which can
become a distinctive characteristic of the centre, where the users can enjoy diverse
vegetation in any season and a multisensory environment, and are involved in activities to
grow plants. This concept can help to improve spatial and biophilic quality as they offer
easy access to natural elements to users, particularly those who do not have enough power
to walk out, in all seasons. Regarding patients who might be sensitive to cold weather, this
kind of sheltered space can confidently offer contact with natural features such as daylight,
fresh air, greenery, and a multi-sensory environment. Additionally, the production of plants
and vegetation in these greenhouse-like spaces can also contribute to the setting’s social
opportunities.
Another point staff indicated is that they sometimes they need privacy, particularly, an
opportunity to have separate outdoor options for staff to which visitors do not have access
would increase the speed of refreshing during the breaks.
Lastly, experts supposed that including physical exercise opportunities (regarding

patients’ physical ability) can also be helpful for their mental state such as stroll gardens,
walking paths, meandering trails and resting points, mobility and balance training,
gardening tasks, assisted walking and labyrinths.
7.3.7. Designing from a Staff-Centred Perspective

The systematically searched review in Chapter 4 revealed that easy access to private and
quiet spaces, such as break rooms or outdoor settings shielded from inside views, where
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they should also be able to enjoy adequate daylight and thermal comfort, are the most
desired environmental features by healthcare staff. These needs have also been identified
clearly in Maggie’s centres. Staff break areas should be located in ways that provide easy
and rapid access back to patients, and also to outdoor spaces which appears to be one of
the most critical applications of biophilic design for staff wellbeing. Although staff want to
have private spaces, they still strictly indicated that the best withdrawal space should allow
a one-way visual connection with patients to keep an eye on them, thus, they can rest and
relax comfortably. The general idea of a desirable indoor break area location follows the
same concern, easy and rapid access to patients.
View through windows is a frequently desired feature within staff indoor break areas,
since visual or physical contact with the outside world and biophilic elements (e.g., View,
Prospect, Daylight) played a critical role in staff’s restoration. In fact, the most powerful
stress reliever was found to be the provision of direct access to the outdoors, because of
the opportunities to direct contact with natural elements.
A homely environment is recommended in break areas, where a sensorial connection

with nature could provide a relaxing environment to reduce stress. The furniture in break
areas should be easily rearrangeable, and comfortable, for individual and group activities,
with sofas and recliners.
Given that refuge and quietness are the most important biophilic parameters for staff,
designers may think of private outdoor break areas free from patients and their
companions where the environment is enriched with greenery, trees, shade, tables, flowers
and water features.

Having established a biophilic design framework and guidelines specific to therapeutic
environments in this chapter, the biophilic assessment of therapeutic environments is
possible by considering the criteria defined in the chapter. Moreover, designers can follow
recommendations and the guidelines defined in this chapter to design more efficient
biophilic therapeutic environments for users as the general definition and standards of
being biophilic were framed from users’ perspectives.
The following chapter will conclude this thesis by explaining the importance of this
research and its findings, limitations, and recommendations for future research.
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CHAPTER 8
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8. CONCLUSION
The examination of the current practice of biophilic design from the three different
perspectives reported in Chapter 1 (scientific research, architectural practice and regulatory
frameworks, and standards), revealed that there is no holistic systematic framework that
defines borders and provides enough specificity for each building typology and climatic and
cultural context. This, in turn, implies that current frameworks do not enable designers to
be efficiently guided through a clear path. Therefore, this study aimed to assess the
importance of biophilic design in therapeutic environments and provided a novel
conceptual framework that can more efficiently guide designers and policy in future
interventions in therapeutic environment design. The premise of this research was that a
rigorous design framework should include synthesised analysis from clinical and non-clinical
environments, primary data obtained from a mix of qualitative methods, and it should be
benchmarked against objective scientific data about the impact of biophilic design on
humans. This objective and subjective analysis of each of the biophilic design parameters
was investigated in this PhD research and provided a comprehensive discussion and
complement guidance.
This study claimed that existing biophilic design frameworks fail to provide efficient
guidance since their design recommendations do not differentiate the level of value of each
design parameter for each building programme and context. Thus, my position was that a
biophilic design framework can only be efficient if it is adapted to specific building functions
and is geographically and culturally contextualised. So, to be able to provide efficient design
guidance, it was necessary to determine a selective hierarchical structure for each context,
as specific parameters from within the established general frameworks become especially
relevant for the users.
As explained in Chapter 2, there are three main original biophilic design frameworks.
The framework in Dimensions, Elements and Attributes of Biophilic Design, of Biophilic
Design: The Theory, Science and Practice of Bringing Buildings to Life (S. Kellert et al., 2011)
superficially examined the biophilic design elements regardless of the applicability to design
practice. Also, the framework did not specify any building typology or did not demonstrate
any comparison between different parameters. Kellert’s second framework, The Practice of
Biophilic Design (S. Kellert & Calabrese, 2015), was more organised and more focused, and
also systematised biophilic design parameters in a more comprehensible way to inform the
application of design practice. However, this framework was also not specific to any
269
building typology, and the importance level of each parameter was still missing, hence, it
did not guide designers in a clear way on how to consider their design is efficiently biophilic.
Another framework, the most commonly used in research and practice, described in 14
Patterns of Biophilic Design (Browning et al., 2014), considered biophilic design parameters
in an interdisciplinary context. This book was fundamental in providing a more
comprehensive framework to define and assess design based on biophilic principles. The
classification was supported by empirical evidence and addressed the parameters that were
supported by more empirical data, although it was not ranked by importance level. So, this
framework aimed to be flexible and adaptable for practical use in the application or
development of biophilic designs due to their more exact definitions than in previous
frameworks. However, the framework was not able to address which parameters are more
critical according to building typology or context, although the parameters were
scientifically examined. Also, it listed scientifically supported recommendations to inform
general design practice. Nevertheless, the recommendations were general for biophilic
design applications, with no specification for each building typology. Following this
framework, a design guideline, Nature Inside: A Biophilic Design Guideline (W. D. Browning
& Ryan, 2020), explained the economics and design steps for the biophilic design process
and examined case studies of applied biophilic design regarding different building
typologies: housing, schools, retail, offices, hotels, hospitals, factories, and communal
spaces. However, the guideline did not direct designers on a clear path, although it
presented successful examples.
In comparison to the previous frameworks, this thesis presented a biophilic design

framework specifically developed for therapeutic environments and specific to non-clinical
typologies in the UK context (Table 8-1). The criterion for biophilic buildings was clearly
stated by hierarchising biophilic design parameters based on the user groups'
requirements. For example,a designer cannot claim a space as biophilic design if the space
does not employ even one of the parameters represented in Group A, which represents
extremely important parameters, or designers should employ all the parameters in Group
B, which represents very important biophilic design parameters, nevertheless, they can be
disregarded only if experts prove that environmental conditions are unfeasible or the
application of a parameter in this group can be harmful to some users. Therefore, the new
conceptual framework directs designers and more precisely draws the borders of biophilic
design, in contrast with some practice that uses biophilic design as a self-promoting tool,
employing an insufficient and inefficient application of biophilic design parameters. The
270
new framework was also supported by design recommendations from general principles to
specific recommendations for spaces in therapeutic environments that will guide designers
to fulfil required biophilic design features. Therefore, the proposal of this new conceptual
framework answers the main research question of this doctoral study: Which biophilic
parameters are critical in the design of a therapeutic environment, and how can designers
implement them adequately in their designs within the limits of a holistic scientific and
regulatory framework?
Table 8-1: Comparison of the existing biophilic design frameworks and the new conceptual framework.
Existing Biophilic Design Frameworks and Guidelines The New Conceptual

Dimensions, The Practice of 14 Patterns of Nature Inside: A Framework for
Elements and Biophilic Design Biophilic Design Biophilic Design Biophilic Design in
Attributes of Guideline Therapeutic
Biophilic Design Environments
General to all General to all General to all General to all Specific to non-
typologies typologies typologies typologies but clinical therapeutic
with examples of environments
different
typologies
Unnecessary Adequate Adequate No definition of Adequate definition
categorical division definition of the definition of the the parameters of the parameters
and insufficient parameters parameters
definition of
parameters
Slightly supported Moderately Supported by Moderately Fully Supported by
by scientific supported by scientific supported by scientific knowledge
knowledge scientific knowledge scientific
knowledge knowledge
No reference to No reference to No reference to No reference to Based on the UK
cultural or regional cultural or regional cultural or cultural or context: Western
characteristics characteristics regional regional culture and humid
characteristics characteristics temperate climate
No indications of No indications of No indications of No indications of Hierarchised and
an order of an order of an order of an order of standardised
importance for importance for importance for importance for recommendations,
parameters parameters parameters parameters based on order of
importance in the use
of parameters
Very rarely Occasionally Included general Included Included detailed
included guidelines included guidelines guidelines for guidelines for general and specific
for practice for practice practice practice based on guidelines for
specific examples therapeutic
environment practice
On the way of answering this question and fulfilling research objectives, firstly, a
narrative literature review was carried out to support scientific evidence in terms of the
biophilic design discipline as investigated in research practice, as used in design practice, as
established in regulations and standards, and in a healing environment and relevant
theoretical premises and approaches that support physiological, psychological, and
emotional health in therapeutic environments. The literature review also profoundly
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contributed to exploring the benefits of connecting nature and natural elements with
scientific facts that informed the framework and design guidelines for therapeutic
environments. Furthermore, tracing the evolution of healthcare environment design
through a historical background gave insight into the consequences of interventions and
the current state of healthcare environments. Therefore, the establishment of a conceptual
foundation of common therapeutic building typologies by signifying spatial characteristics
and user groups served as a layout for further investigations and analysis. Apart from the
narrative review of academic literature, a grey literature review gave an insight into the
demands of patients and required environmental features of healthcare settings from
reports and contributed to the research by revealing keywords and practical questions that
were used in the interviews.
The systematically searched review also provided scientifically reliable and less-biased
insight into the importance of the biophilic design elements in clinical environments from
peer-reviewed journal papers. The systematically searched review followed rigorous
replicable peer-reviewed steps and systematically identified nine studies that helped to
identify and rank the biophilic design parameters that appear the most critical for
promoting and supporting human health and well-being in clinical therapeutic
environments, from the user’s perspective. The results showed that biophilic design
parameters in clinical environments cannot be examined under one umbrella concept, but
the assessment should be specific to each space based on user groups. Although this
research mainly focused on the non-clinical environments, this review provided insight into
cancer patients’ and staff’s needs and indirectly supported the data from the non-clinical
Maggie’s centre focused parts of this research as well as provided benchmark information
for future research and design guidance in these environments.
The meta-synthesis contributed to this study by systematically identifying, comparing
and synthesising all published qualitative literature on Maggie’s Centres. This methodology
helped to investigate Maggie’s Centres’ architecture, from the users’ and the designers'
perspectives, assessing their experiences in these buildings and their design intentions from
previous qualitative research on these centres which were conducted from different
standpoints. Thus, this great amount of qualitative data exists within the published body of
research, and they have been analysed through a biophilic lens in this research. The
systematically selected data helped to identify and rank the biophilic design parameters
that appeared as the most critical for promoting and supporting human health and
wellbeing in non-clinical therapeutic environments, from the user’s perspective. Therefore,
272
the critical biophilic design parameters were classified into four main groups in order of
importance. This classification took its final form in the new conceptual framework with the
support of data from semi-structured interviews and the narrative literature review. The
meta-synthesis study also offered a compilation of distinctive design interventions related
to biophilic parameters, which provided benchmark information for future research and
design guidance in non-clinical therapeutic environments.
Following the data compilation from existing literature, semi-structured interviews with
experts and practices enabled the collection of a set of information from practice and
supported and enriched scientific evidence with experience-based knowledge, verified the
results obtained from a systematically searched review and meta-synthesis studies by
crosschecking the results from primary sources. These interviews also supported and
expanded the results based on the recommendations of the experts and practitioners. The
interview results provided a larger scale of information about therapeutic environments, as
many of the architect participants were involved in both the design of clinical settings or
hospitals and the design of Maggie’s Centre. The studied Maggie’s Centres were selected
based on various key features that the study wanted to contrast: urban versus rural
settings; use of low-key resources versus non-restricted design; employment of special
materials, gender-friendly explorations, as well as presenting a variety of early period
centres and recently designed centres. In the new conceptual framework, the most
prominent contributions from the interviews were that they clarified the importance of
some parameters that appeared with a more ambiguous role in the existing literature (such
as Water in non-clinical settings), offering a set of recommendations for decision-making
and design process, and contributing to design recommendations to inform design practice
in both clinical and non-clinical environments.
Moreover, this thesis proposed a guide for biophilic design applications in non-clinical
environments with a particular focus on cancer patients. The guidelines were mainly
shaped around the needs and problems of cancer patients. The recommendations followed
their physiological needs (i.e. recommendations regarded various side effects such as
sensitivity to cold or smell by offering patients control over the thermal variability or fresh
air, access to sunlight, furniture with natural material to prevent over-heat etc.) and
psychological needs (socialising opportunities, more private refuge spaces, relaxing and
calming indoor and outdoor spaces with natural elements, offering visual focuses with
nature view or daylight to distract unpleasant thoughts etc.). Although the existing
regulations and standards examined in Chapters 2 and 3 emphasised the importance of
natural light, view, fresh air, thermal comfort, access to natural spaces and privacy, they do
273
not specialise in biophilic design and specific populations and do not indicate biophilic
parameters directly but use biophilic values as criteria among the many other non-biophilic
features. On the other hand, the guidance in this thesis proposes a clear frame for biophilic
design applications (in which designers know how to classify their spaces as biophilic), in a
specific typology (non-clinical therapeutic environments) for a specific population (those
affected by cancer) in a specific climate (humid temperate oceanic climate) and specific
cultural context (western culture in the UK) in accordance with my positon to the biophilic
design’s definition.
To sum up, based on my findings in these studies this thesis proposes a new definition
of biophilic design that will reduce misunderstandings in practice, application of regulations
and research environments: Biophilic design is a harmonious reflection of natural
parameters that work together in order to make the users feel the connection with nature
with all aspects. All biophilic design parameters cannot be equally important for every type
of building, this harmony should be established for a particular type of building regarding
the particular type of climate and local culture since people have different notions of
nature and perceptions of nature.
As explained in Chapter 7, the research question has been answered by proposing a new
conceptual framework with design guidelines, which took shape based on the data
obtained from the four main methodologies of this research: the narrative literature
review, the systematically searched literature review, the meta-synthesis, and the semi-
structured interviews with experts and practitioners.
8.1. Limitations of the Research

The main limitation of the research was the COVID-19 outbreak and subsequent
relevant restrictions that took place in the UK since March 2020, which was the second year
of this doctoral study. Having set up the methodological approach for qualitative field
studies (semi-structured interviews with patients and staff, focus groups, and ethnographic
observations) and obtained ethical permissions to collect data from human participation
(including vulnerable participants), all on-site case studies were cancelled by the University
of Liverpool Senior Management Team from 19.03.2020 to 12.10.2021. Therefore, all case
studies had to be remotely investigated. However, the remote data collection from user
groups of a selection of buildings, which included case studies from NHS-affiliated
institutions and Maggie’s Centres, was not possible during such an extraordinary period. It
was immediately impossible for such a strained moment for the NHS to be involved in the
study. Likewise, the Maggie’s Centre Research Advisory Group, after developing a
274
customised research plan with them for months, ultimately stated that Maggie’s Centres
were not in a position to support any research during the pandemic, due to the majority of
their staff being on furlough. They suggested to meet again a year later to reassess the
situation, but that would not be feasible within the PhD timeframe.
Therefore, the alternative determined method was to collect the data that will answer
the research question from the existing body of research, which included interviews, focus
groups, observations and questionnaires (users’ views), but had been conducted from a
different perspective and was yet to be analysed through a biophilic lens. Hence, another
limitation emerged as the existing studies did not intentionally seek answers for biophilic
design applications, therefore, some parameters were not found as directly referred, so
they were extracted by gaining deeper knowledge about the biophilic design and
parameters to include in the ranking. On the other hand, this limitation was also beneficial
to produce less biased claims in the framework, since the participants were not asked for
information about biophilic design as researchers might unintentionally direct them to
speak about some biophilic design parameters that were not important for the participants.
Additionally, it was noticed that the available case studies about biophilic design and
healthcare environments were limited in number. Also, the employed studies were mainly
localised in industrialized Western countries and typically were of less than high
methodological quality. Climate and culture influence human perceptions of nature, so as
more research is conducted in various regions, climates and cultures, a wider range of data
will contribute toward more effective localised biophilic design frameworks. However, as
the framework in this study aimed to be produced for the UK context, the selected studies
were able to inform this research.
8.2. Opportunities for Future Work

This research was conducted specifically in the UK context so that humid temperate
climate and Western culture were the main contexts of this new conceptual framework. As
stated above, climate and culture influence human perceptions of and relationships with
nature, thus, more research about the application of biophilic design in therapeutic
environments in various regions, climates and cultures is necessary to contribute toward
more effective localised biophilic design frameworks. For example, the application of
biophilic design in healthcare settings located in extreme climates such as desert or tundra
climates, where the application of some biophilic design parameters is challenging; in
various cultures such as the Muslim culture, which attributes great importance to privacy;
275
or in highly industrial regions, where the inevitable pollution will play an important role in
the connection between inside and outside.
In conjunction with this, this study also showed that inpatient, outpatient and staff users
had similar desires but sometimes divergent priorities and requirements and that the
provision of the same or similar biophilic elements to different groups could support
distinct affordances. Thus, a biophilic design framework for clinical environments should be
developed based on the types of illnesses even among the types of cancer, side effects,
environmental perception of patients, and biomarkers changes. However, this kind of
research needs a well-equipped team including experts in a variety of fields of expertise
such as architecture, medicine, and psychology. Moreover, future research should
investigate the different building typologies and programs based on their specific user
groups and contexts, to provide efficient and rigorous biophilic design frameworks. This
new conceptual biophilic design framework understanding can be extended to different
typologies such as housing, schools, retail, offices, hotels, and factories as well.
The biophilic design concept is increasingly popular, and research in this area is
markedly growing. Particularly after the COVID-19 pandemic, lockdowns and curfews,
people comprehended how important it is to have a connection with nature and natural
elements. Undoubtedly, the tendency to biophilic design will progressively increase in the
near future in both practice and research. However, regarding the increasing urbanisation
and ‘concretion’ as the number of concrete blocks has been increasing in rapidly growing
cities, the biophilic design discipline should be more substantially introduced to the real
world. Thus, researchers should seek clear routes to share their knowledge with
practitioners, and policymakers should take biophilic design into their agenda in health and
well-being-related regulations. Last but not least, designers and contractors should not
exploit and corrupt the biophilic design concept for marketing purposes, since a sort of
‘green washing’ practice can be seen, which claims to apply biophilic design by just adding
green walls or pictures of nature on a wall. In fact, these so-called ‘biophilic buildings’ have
been increasingly advertised and this trend is likely to continue. Therefore, the definition of
scientifically underpinned biophilic design frameworks specific to the context and each
typology is fundamental in this discipline.
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“Nature itself is the best physician”
Hippocrates
277
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Appendix
306
Appendix A.1 Semi-Structured interview Questions with Architects
Interview Questions
Title: Human-Centred Therapeutic Environments: A New Framework for Biophilic Design
Ph.D. candidate: Bekir Huseyin Tekin

School of Architecture, Department Architecture, University of Liverpool, UK
Email: B.Tekin@liverpool.ac.uk
Questions for Designers (Architects)
Do you have any knowledge about biophilic design theory? If so, have you considered
biophilia in the design?
How did you consider the Maggie's design guidelines in the design process?
Could you please explain your design intentions and consideration of the human-nature
connection in the spaces?
Was the design process for this project the same as in other projects, or did you follow a
different process?
How was the management and communication with Maggie's?
Did you do any research for this project or any readings that were particularly influential?
Did you collaborate with any specialist consultants?
How did you approach site analysis/context in this project?
What were the main design aspects or drivers behind the project?
Have you done any post-occupancy monitoring to confirm your design intentions?
What underpinned/informed your material choices?
Did you have any other conversations with any other key stakeholders or who else
contributed to the project?
Can you explain design considerations in relation to light, garden, view, comfort, sensory
experience, colour, public/private spaces?
Based on post-occupancy observations, is there anything in the design that you think you
should have design differently?
In terms of clinical environment design, which kind of environmental features do you think
provide a healthy environment for patients and staff?
How can designers create the best connection with nature in clinical settings?
What are the differences and challenges between the clinical (hospital) and non-clinical
(Maggie's) environmental design processes?
307
Appendix A.2 Semi-Structured interview Questions with Expert Staff
Interview Questions
Title: Human-Centred Therapeutic Environments: A New Framework for Biophilic Design
Ph.D. candidate: Bekir Huseyin Tekin

School of Architecture, Department Architecture, University of Liverpool, UK
Email: B.Tekin@liverpool.ac.uk
Questions for Experts (Staff)
Introduction about Maggie's Centres' architecture
The building form is aimed to be designed to attract people: the idea is that the striking
architectural forms can have an impact in encouraging visitors to take that first step to visit
the centre, entering the building should be a meaningful moment and also for them to
forget for a few minutes about their own problems as they immerse in a special space, in
which many visitors report to feel welcome and safe.
1. In terms of first impressions and the building's impact, what do you think have been the
most successful elements in the buildings you work, the most special? What is what visitors
make more comments about?
Has this impression changed during the COVID-19 restrictions? (
Prompt: What I mean is, part of this can certainly be attributed to the building design, but
also to the atmosphere that staff generate in the space, which is now different.)
What do you think the people who received therapy in the building in a limited way due to
these restrictions miss the most about using the building?
What do you think the people who have been given remote therapy as a result of the
restrictions after the COVID-19 pandemic might miss the most about not being in the
building?
2. In which ways does your building impact visitors the most? In which ways does your
building impact staff the most?
3. (We'd like you to take a photo of your favourite part of the building before the meeting
so you can give your opinion on it) Can you describe your favourite corner/part of the
building and tell us why you like it?
Do you think that this preference is shared by other members of staff?
4. When planning where to allocate different activities/parts of your programme in the

different spaces of the centre, which qualities of the space do you take into consideration?
Do you feel that the space is flexible and versatile, or do you feel that each corner/area has
specific values/identity that is best to keep as this benefit specific activities?
Do you find it easy, convenient, efficient, comfortable for the different work tasks?
308
Appendix A.2 Semi-Structured interview Questions with Expert Staff
5. Do you think there are design qualities that one can appreciate only after using the
building a lot? Are there any functional qualities that you think you (people who work here)
can appreciate from the building that visitors don't get?
6. At Maggie's, the staff are perceived to be more invested in looking after the visitors.
Visitors appreciate that there is no reception desk, the staff cannot hide behind a computer
to do their own thing; they feel personally welcomed and attended. Do you keep
discussing/evolving this interaction with visitors in connection with the way space should
be used? We are wondering if there is a 'protocol' that keeps being revisited, or if this
'protocol' is bespoke for each building and gets reviewed for new buildings?
7. Part of Maggie's brief is to provide a connection between inside and outside/nature.

Which parts of your building are more successful in providing this connection to nature?
Based on your observations over the years, how would you interpret the relationship of
your visitors to the building's natural elements? For example, do they usually prefer to
establish a visual connection with the outdoor space where they spend time indoors? Have
you noticed an improvement in their therapy or a significant decrease in stress levels when
they go out to the garden or establish a connection with the outside space?
8. How would you describe the atmosphere of your centre? (PROMPT: Is natural light
important?)
9. As far as we know, women visit the centres significantly more than men (overall 34%). Do
you think there are differences in visitors depending on gender? What are the reasons in
your point of view?
10. Regarding the sensory experience;
What role do you think other sensual perceptions (sound, smell, tactile experience, taste…)
play in the identity of Maggie's?
Do you think this sensorial atmosphere has changed during covid-19 restrictions?
What is the impact of these sensations based on your experience?
Do visitors show a tendency to spend time where they can get more air or a warmer space
(by the fireplace) as a special environment?
11. Have you observed a seasonal change in visitors' visits to the building and their length
of stay or the way they use the spaces? For example, those who like to spend more time in
the centre because the building gets better sunlight in winter, or the tendency to spend
more time in good weather in the garden of the building or in the spaces that have a visual
connection with the garden.
309
Appendix B List of Publications and Conferences
Tekin, B. H., Corcoran, R., & Urbano Gutiérrez, R. (2021). A New Reading of Therapeutic
Environments: Biophilic Elements in Maggie’s Centres. The 8 Th International Conference on
Architecture PROCEEDING The 8 Th International Conference on Architecture and Built
Environment with AWARDs, 289–298. www.s-arch.net
Tekin, B. H., Corcoran, R., & Gutiérrez, R. U. (2023). The impact of biophilic design in
Maggie’s Centres: A meta-synthesis analysis. Frontiers of Architectural Research, 12(1), 188-
207. https://doi.org/10.1016/j.foar.2022.06.013
Tekin, B. H., Corcoran, R., & Gutiérrez, R. U. (2023). A Systematic Review and Conceptual
Framework of Biophilic Design Parameters in Clinical Environments. HERD: Health
Environments Research & Design Journal, 16(1), 233-250. doi:
10.1177/19375867221118675
Tekin, B. H. & Urbano Gutiérrez, R. (2022). Healing Architecture: A Review of the Impact of
Biophilic Design on Users. PLEA 2022 - Will Cities Survive? Proceedings of the 36th
International Conference on Passive and Low Energy Architecture Santiago, 22 November
2022
Tekin, B. H. & Urbano Gutiérrez, R. (2022). Disentangling the Mass Health Machine: A New
Conceptual Framework for Biophilic Healthcare Design. SPACE International Conference
2022 on Architectural Design and Theory London, 24-25 November 2022
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HUMAN-CENTRED THERAPEUTIC ENVIRONMENTS:

A NEW FRAMEWORK FOR BIOPHILIC DESIGN

Thesis Submitted in Accordance with the Requirements of the University of Liverpool

Bekir Huseyin TEKIN, B.Arch., M.Arch.

School of Architecture, University of Liverpool, UK

Firdevs and Hüsnü Tekin

Signed: Bekir Huseyin Tekin

My sincere thanks also go to Dr Evangelia Chrysikou and Dr Haniyeh Mohammadpourkarbasi for

I would like to express my appreciation to my colleagues and friends at the University of

SBS Sick Building Syndrome

However, there is a debate on the universality of this innate preference for

Considerations about the quality of the environment in which healthcare is delivered

1.1. Research Problem

1.2. Research Aim, Question and Objectives

Which biophilic parameters are critical in the design of a non-clinical therapeutic

1] Study the biophilic design discipline as investigated in research practice, as used in

1.3. General Methodology

Figure 1-1: Methodological process.

1.4. Outline of Thesis

2.1. Biophilic Design

2.1.1. Research: Benefits of Connecting with Nature

As one of the well-known parameters of biophilic design, the impacts of engagement

2.1.1.8. Experiences of Nature

2.1.2. Current State of Biophilic Design Practice

Colour Botanical motifs Sensory variability

Water Tree and columnar supports Information richness

Air Animal motifs Age, change, the patina of time

Sunlight Shells and spirals Growth and efﬂorescence

Plants Egg, oval, and tubular forms Central focal point

Animals Arches, vaults, domes Patterned wholes

Natural materials Shapes resisting straight lines Bounded spaces

Views and vistas Simulation of natural features Transitional spaces

Façade greening Biomorphy Linked series and chains

Geology and landscape Geomorphology Integration of parts to wholes

Habitats and ecosystems Biomimicry Complementary contrasts

Fire Dynamic balance and tension

Hierarchically organized ratios and

Light and space Place-based relationships Evolved human-nature relationships

Natural light Geographic connection to Prospect and refuge

Light and shadow Ecological connection to Curiosity and enticement

Reﬂected light Cultural connection to place Change and metamorphosis

Light pools Indigenous materials Security and protection

Warm light Landscape orientation Mastery and control

Light as shape and form Landscape features Affection and attachment

Spaciousness Landscape ecology Attraction and beauty

Spatial variability Integration of culture and Exploration and discovery

Space as shape and form Spirit of place Information and cognition

Spatial harmony Avoiding placelessness Fear and awe

Inside-outside spaces Reverence and spirituality

Direct Experience of Indirect Experience of Experience of Space and Place

Light Images of nature Prospect and refuge

Air Natural materials Organized complexity

Water Natural colours Integration of parts to wholes

Plants Simulating natural light and Transitional spaces

Animals Naturalistic shapes and Mobility and wayfinding

Weather Evoking nature Cultural and ecological attachment

Natural landscapes and Information richness

Fire Age, change, and the patina

Non-Visual Connection with Material Connection with *Refuge

Non-Rhythmic Sensory Stimuli Complexity & Order **Mystery