Salutogenic Architecture in Healthcare Settings

26
Jan A. Golembiewski

Introduction (Dancer 2004). Lighting, soundscape design and things like

wall paint colour have also been considered (Hurst 1960;
In recent years, the term ‘salutogenic’ has become a buzz- Vaaler, Morken, & Linaker 2005), along with seating layout
word for marketing architecture for health and nursing care. in psychiatric settings (Bitterman 2013; Sloan Devlin 1992).
The term was coined to describe a model for socioenvir- While these theories are all important to hospital design,
onmental influences on health, but in the designers’ hyper- they ignore the elephant in the room—that architecture can
bole it now rarely means more than fuzzy intentions to create be psychologically manipulative, for better or for worse.
restorative environments by providing views that represent Architecture does this by providing a narrative context that
nature: whether it be designed parkland, grassy areas, views affects a person’s behaviour, neural and endocrine systems,
of the sky or even video representations of these things. The and through its influence on the brain and the body, archi-
term is thus bleached of meaning. The design industry needs tecture can directly influence health (Golembiewski 2016).
a theory to establish whether or not views of nature are likely Antonovsky’s salutogenic theory provides an accessible
to be restorative on a case-by-case basis, and perhaps more overarching logic for determining these effects in design
importantly, to reach beyond this axiom and locate other (Golembiewski 2012b).
ways to design and improve restorative environments. The Salutogenic theory is not a perfect model of health
marketer’s sense that salutogenic theory is a powerful tool (Mittelmark & Bull 2013), but as theory, it does have a
for understanding the impacts of the design process on the scope and perspective that other ways of understanding
health and illness continuum is well-placed; as Antonovsky health lack (Antonovsky 1996). Salutogenesis is a way of
suggested, salutogenesis could be the only comprehensive understanding the entire spectrum of wellness and illness,
theory of health promotion (1996), something the industry regardless of specificity and detail. In other words, it
needs for the design process itself, not just for provides an overarching narrative structure that transcends
marketing spin. the individual differences between people, and the differen-
Substantial evidence shows aesthetic design changes in tiation between diagnoses, circumstances, environmental
healthcare settings can improve health outcomes for variation and so forth. Salutogenic theory is thus useful for
patients. A number of theories have been offered to explain ‘broad-stroke’ approaches to grappling the well-being and
these effects—but most of them are limited to the specific health/illness spectra, and as such, it is useful for managing
stimulus under the microscope of the theorists. Examples indirect, complex, obscure or unknown factors in health
include an evolutionary hypothesis to explain the influence conditions (this complexity typifies the health influences of
of ‘views of nature’ (Ulrich 1991), and the ecological theory the physical environment). Because Salutogenic theory has
of Lawton and Nahemow (1973), which argued that there is this higher-level validity that makes sense beyond the spe-
a ‘sweet-spot’ to be found in a trade-off between designing cific findings of particular experiments and design
for comfort and designing for mental and physical interventions (Strümpfer et al. 1998a; 1998b), it provides a
challenges. Others argue that the most important issues for basis for informed decision making in the absence of specific
health in design are cleanliness and pathogen control knowledge, or whenever circumstances are too complex to
suggest easy solutions. Understanding this, Dilani (2006,
2008) and the International Academy of Design and Health
J.A. Golembiewski, BfA BArch MArch PhD (*) (which he chairs) has actively promoted the theory to indus-
Psychological Design, 1 Glenview St, Sydney, NSW 2021, Australia try. The results have been a rapid improvement in the overall
e-mail: [email protected]

# The Author(s) 2017 267

M.B. Mittelmark et al. (eds.), The Handbook of Salutogenesis, DOI 10.1007/978-3-319-04600-6_26
268 J.A. Golembiewski

quality of new healthcare buildings around the world, and The Generalised Resistance Resources
while this is very welcome, industry lacks the nuanced
understanding of the theory needed to bespoke and expand ‘Comprehensibility’ is a person’s ability to make sense of
the scope of salutogenic interventions. one’s life narrative, one’s context and current circumstances,
Following from the above, this chapter discusses how and without this fundamental knowledge, people have little
salutogenesis can be, and has been, applied to healthcare capacity to make the most of circumstances or negotiate
architecture. life’s challenges (Golembiewski 2012b). After all basic
needs (manageability) are met, the desire to understand
circumstances in order to make the most of them is essential.
The sense of Coherence This is the essence of comprehensibility.
‘Manageability’ is a person’s ability to manage day-to-
Salutogenesis proposes that good emotional, psychiatric and day physical realities, like paying bills, staying warm, dry,
somatic health is maintained through a dynamic ability to clean, rested and nourished and other maintenance of their
adapt to life’s changing circumstances. The opposite is also physical lives. At a minimum, it serves the basic
true—forces that prevent the ability to adapt exert an requirements to maintain homeostasis: to maintain body
aetiological influence on illness. One ‘succumbs to illness’, temperature, blood glucose, hydration and other critical
when demands exceed one’s capacity to cope with them. So somatic concerns (Golembiewski 2012b).
a germ on its own is insufficient to cause a disease—it needs ‘Meaningfulness’, according to Antonovsky (1979) and
to be cultured in an environment that has deficient capacity Frankl (1963), is the foundation of the desire to live. It is
for resistance (Antonovsky 1972). Models that accept ‘mul- meaningfulness that gives life forward thrust—the will to
tiple causation’ typically describe the forces that cause resist the entropy of illness and death’s inevitability, and as
maladaptivity as ‘stressors’, a grab bag of influences that such it is possibly the most important of the salutogenic
includes everything from joyous events to life’s tragedies resources. Meaningfulness is also the most elusive because
and banal concerns (Antonovsky 1987). In effect, everything meaning is difficult to define and is highly personal. Mean-
can be considered a stressor, making stress a useless concept. ingfulness is found in the intensity of personal connections,
The forces at work to improve adaptability, on the other responsibilities and desires with the outside world: ‘Pro-
hand, are specific enough to allow practical, buildable and found ties to concrete, immediate others . . . and between
highly bespoke solutions. These forces have been labelled a an individual and his community are decisive resistance
‘sense of coherence’, also known as SOC (Antonovsky resources’ (Antonovsky 1972, p. 542). People find meaning
1979). in different social groupings, in different causes and
The sense of coherence is the sum of all generalised concerns, and often disagree wholeheartedly about how
resistance resources (or GRRs—hereafter ‘resources’) concerns should be prioritised. Yet, it is in these distinctions
minus all generalised resistance deficits (Antonovsky that people find the basis of a sense of identity (Frankl 1963;
1987). Resources fall into three basic (but interrelated) Searles 1966). Without meaningfulness, people find them-
domains—those that enhance comprehensibility, those that selves utterly bereft of meaning and of any desire to act
enhance manageability, and those that enhance meaningful- (Searles 1960, 1966).
ness. Resistance deficits (GRDs), on the other hand, are the
ubiquitous challenges to these resources. Resistance deficits
are entropic, meaning that without a positive sense of coher-
ence thrust, resistance deficits exert a continuous disintegra-
The Biochemical Response to Design
tive force, allowing illness to overcome a person
Both animals and people behave radically differently when
(Antonovsky 1996). With the total failure of manageability,
threatened and when they are happy (Calhoun 1970; Isovich,
death ensues, unless the most basic support for manageabil-
Engelmann, Landgraf, & Fuchs 2001; Salmivalli 2001).
ity is delegated to intensive care systems.
They behave more accommodatingly when they are elated
When one is unable to adapt to circumstances and
with lofty emotions such as awe. These emotions are not
experiences, physical or mental health will ‘breakdown’
superficial but have real and long-lasting implications
(Antonovsky 1972, p. 64). But by focusing on the sense of
(Rudd, Vohs, & Aaker 2012). The science is relatively
coherence and on resources, a scaffold emerges that can be
new, and requires far more research, but it appears that a
readily applied to health facility design. Sense of coherence-
number (if not all) of the neurotransmitters react to environ-
supportive design can help liberate the resources that enable
mental stimuli, and therefore react to design (Golembiewski
resistance to illness and reduce the disintegrative forces that
2016). Acetylcholine, for instance, moderates balance,
cause maladaptation in the first instance.
homeostasis, muscular tone and most of the things we
26 Salutogenic Architecture in Healthcare Settings 269

associate with comfort—body warmth, the senses of touch Aesthetics, the Built Environment and Health
and hunger (Changeux & Edelstein 2005). Light is thought
to moderate serotonin and the hormones on the serotonergic For millennia humans have customised their accommoda-
pathway such as melatonin (Rao et al. 1992). In turn, these tion as a resource to protect against danger, discomfort,
hormones have an influence on circadian rhythms, control of wildlife, social threats and the deleterious effects of weather.
inflammation and among other things, the mobility of Architecture’s role in these protective purposes is fundamen-
gallstones. The other neurotransmitter that can be highly tal. However, the supportive effect of architecture is not only
reactive to environmental stimuli is dopamine (Koppisetti physical, but psychological too—if people cannot find
et al. 2008), and this neurotransmitter is the one that’s most respite from the pressures of life at home, the resulting
closely associated with the emotions. compounding mental and emotional strain may be enough
Dopamine is interesting because it is directly implicated to cause debilitating mental illness, possibly even without an
in many mental illnesses (Howes et al. 2013). Dopamine has underlying biological or genetic dysfunction (Golembiewski
strong connections in the limbic area of the brain (Floresco, 2013). But all shelter is not equal: even once we have
Blaha, Yang, & Phillips 2001), an area characterised as the achieved the basic need for shelter from the weather, the
centre of both narrative cognition and emotional balance. wild and other humans, we continue to customise the envi-
The hypothesis is that dopamine mediates the intensity of ronment on an aesthetic level, in what appears to be an
our experience of stories. These stories are composed from attempt to make the environment better on a psychological
information that is gathered from the environment around us level. And the evidence is that such efforts are rewarded.
by the hippocampi (which moderate story structure) and the The idea that aesthetics have any impact on health (and
amygdalae (which moderate ipseity: the sense that a story is even on mortality) appears to be superstitious and occult and
about me) (Le Hunte & Golembiewski 2014). Unfortunately, is thus not nearly as widely accepted as it should be
when people are mentally ill, and their dopamine is (Golembiewski 2016). The concept of aesthetic impact on
deregulated, they may suffer too much intensity for trifles, health has been scientifically tested thousands of times,
and too little in the face of important events. including dozens of studies against a null hypothesis—a
The hypothalamus, another limbic organ, works like a statistical method used to demonstrate causality. In 2005, a
switch: when the other organs signal that the emergent story systematic review located and analysed 30 peer-reviewed
indicates danger, the hypothalamus switches all the time- articles that showed this effect to be significant and reliable
consuming, thought intensive, creative and considered parts (Dijkstra, Pieterse, & Pruyn 2006), with findings that some-
of the brain off, and instead switches the automatic and times defy belief—for example, 30.8 % faster recovery and
instinctive systems on. The hypothalamus also triggers the 38 % lower mortality were found when patients were given
endocrine system to go into a kind of emergency mode, sunlit rooms for psychiatric disorders (Beauchemin & Hays
short-circuiting the normal endocrine cascade. Cholesterol 1996, 1998).
is blocked from being reprocessed into oestrogen, progester- From a salutogenic perspective, such findings are of
one, testosterone and other desirable and essential hormones immense importance: when people are healthy they demon-
as it normally would. Instead, cholesterol remains in its raw strate a theoretical surplus of resistance resources, so aes-
forms, ready to clog the vascular system (as this is a useful thetic improvements are redundant, but when people are ill,
first line defence against bleeding or heart failure). Along they suffer in the balance between deterioration and recov-
with this, arginine vasopressin, corticotropin, cortisol and ery, so any genuine influences (whether for better or worse)
other hormones that are important in physical emergencies should reflect in outcomes.
are released. These hormones dictate much of how we feel There are a number of relationships that our bodies have
on an emotional level, but they more than just that: they with the outside world. Firstly, there’s the physical relation-
protect the body from famine, dehydration and blood-loss, ship: the built environment is replete with restrictions—like
for example. However, just as we do not always need to feel fences and walls, and opportunities like pathways, bridges or
panicked or angry, most of the negative responses these windows and these determine many of the choices we make.
hormones trigger are redundant when the environment is Some of these are insignificant—for example, there is little
physically safe or when health-building is an objective. phenomenological difference between a left or right turn,
After long-term exposure, all of the negative hormonal even though they are opposites. But many physical
responses we see here are directly associated with the epide- restrictions and opportunities moderate our behaviour, and
miology of ‘lifestyle disease’. On the other hand, stories that are intended to do so. As such, they are an important target
‘look good for me’—especially if the associated experiences for policy design initiatives that aim to create healthy
are awe-inspiring, enable the rostral dopaminergic pathway environments—for example, cities around the world are
to open, and with it a whole set of desirable behaviours and compiling ‘fit city’ design guidelines to encourage people
endocrinal effects, which feel good and aid recovery to take the stairs, and leave the car behind, and walk or cycle
(Golembiewski 2012b, 2014a).
270 J.A. Golembiewski

instead (City of New York 2013; Jackson & Sinclair 2012). (Golembiewski 2010). Nowhere is this more important than
Physical interventions like these are often thought to be the in psychiatric facilities—especially for long stays. These
most the built environment can do to improve health. facilities are routinely designed with centralised staff
But when people are recovering in a hospital, ‘fit city’ stations, both to improve manageability for the staff, and
initiatives are of little use. Indeed, the one place where lifts also to completely disempower patients, whose actions are
and nearby parking is really useful is in a hospital, because considered bad, irritating for staff and even dangerous
when people are sick, it is not the time to impose an exercise (Foucault 1977). To prevent this loss of independence and
regime. In the impressive results reviewed by Dijkstra the subsequent atrophy of essential life skills, MAAP
et al. (2006), none of the health improvements of persons (an international architectural firm with a reputation for
in healthcare institutions were because the hospitals had healthcare design innovation, where the author worked
more steps or longer corridors. The causal factors were until mid-2016) routinely does away with central staff
aesthetic—they were psychological rather than physical. stations, thereby turning the locus of control from the staff
As pointed out early in this chapter, the traditional lens back to the patients. To enable alternative opportunities for
for understanding the impact of the built environment on patient-monitoring that are discrete and democratic, we
health is focused on how well it provides basic functionality identify informal places where nurses can sit and observe
and shelter. This is especially true in healthcare, with its top most of the goings on in the unit (Golembiewski 2014a)
requirement being that the built environment support more (Fig. 26.1).
efficient patient management, more reliable clinical
procedures, better infection control, etc. The main point of
this chapter is to demonstrate that this is a very low bar. Architecture for Patient Comprehensibility
Salutogenic architecture has the capability to also support
enhanced patient manageability, comprehensibility and In contrast to the traditional approach to health facility
meaningfulness, and their collective synthesis: the sense of architecture, salutogenic design aims to enhance not only
coherence, in other words to help a person through the just manageability for the institution, but also the manage-
natural process of recovery. ability, comprehensibility and meaningfulness of the patient.
Comprehensibility is the capacity to understand and
negotiate the contexts we find ourselves in. As Donne
Architecture and Patient Manageability observed in 1624, hospitals have a long tradition as places
where such understanding is delegated. In a hospital, a
The traditional healthcare environment addresses pretty patient is rarely expected to understand what they are
much only manageability, one of the three GRRs. So, if suffering from or how the service is going to make them
there is any context that is well understood in the healthcare better. When a patient enters a hospital, a receptionist or
setting, it is planning for manageability. Hospitals make triage nurse will tell them where to go and it is the doctor’s
environments more manageable for staff via centralised responsibility to know what was wrong with them and how
food and cleaning services and more manageable for patients to treat their affliction. But this is changing. Patients now
through intravenous drips, incubation, heating, cooling, have tools at their disposal for self-diagnosis and treatment,
catheterisation, dialysis, ventilation and cardiopulmonary and this awareness has become essential for the basic main-
bypasses, etc. In a hospital, it is striking just how much a tenance of good health and for identifying illnesses early
patient’s life can be maintained by others—indeed, patients (Parker 2000).
do not even need to breathe for themselves. It is hardly a After an era of neglect, architecture has now begun to
stretch to say manageability is traditionally the only provide for patient comprehensibility in a meaningful way.
organising principle when designing healthcare facilities: For example, as the carefully crafted patient journeys in the
thus better patient oversight, better infection control, more Centre for Respite and Recovery (Fig. 26.2) illustrates, the
efficient catering, laundry, pharmacy, filing and even centre is truly designed so patients can rest assured that
parking are prioritised over whimsical things like aesthetics. there could be no better place to recover, and this knowl-
At its most basic, the architect’s role in improving man- edge does assist recovery (Golembiewski 2016). A much
ageability in the healthcare milieu involves improving the greater emphasis on intuitive way finding is now de rigeur,
delivery of all the services that the hospital already and this, in a more minor way helps patients to help
considers. In hospital briefing jargon, this is ‘the functional- themselves. Architecture now looks to outdoor views for
ity’ of the unit. But an architect armed with an understanding global orientation, identifiable urban street patterns and the
of salutogenesis can go much further; paying attention to use of distinctive landmarks like sculptures. But compre-
how design can enhance the patient’s resources for recovery hensibility in a salutogenic sense is far more than just
26 Salutogenic Architecture in Healthcare Settings 271

Fig. 26.1 Psychiatric centres

designed without centralised staff
stations turn the locus of control
from staff back to the patients. In
these facilities, everyone has
good observation, not only the
staff. This is an essential response
to recovery centred models of
care. Image courtesy of the
Author and MAAP

Fig. 26.2 The plan of The Centre for Respite and Recovery (MAAP, patients can keep and train birds. These affordances are all designed to
Aecom and Makower Architects) has an urban street-grid like plan to maximise opportunities for self-empowerment and to generate the
enable intuitive way-finding, it is littered with gardens, has horse feeling there is a high probability that things will work out for the
stables and a lunging arena to train them and an aviary also, where best. Image courtesy of MAAP and the Author

knowing where to go or knowing about medical conditions. The question then is, how does healthcare architecture
More importantly, comprehensibility is used to enhance or enhance our sense of personal narrative—the sense we make
reinforce a person’s efficacy in their endeavours. In this of the context we find ourselves in? Even the most funda-
centre, patients are given the opportunity to train horses mental axioms of understanding (and therefore of compre-
and birds in order to develop skills and demonstrate evi- hensibility) are structured in narrative terms: a premise, a
dence personal success. process and a conclusion. The most important aspects of
272 J.A. Golembiewski

comprehensibility in healthcare settings revolve around the care (Wistow 2012). Hospitals also create social isolation
narratives of a patient’s sequential experience while by restricting the visiting hours of friends and family and
negotiating ‘the patient journey’ (or as it was called in the by forbidding pets.
beaux arts tradition, the marche). Yet, the healthcare architect can still design to enhance
The narrative sequence has the capacity to foster a sense meaningfulness for patients. People very rarely actively
of control and personal security, but without sufficient care, search for meaning, but the right context might inspire a
our natural inclination to perceive narratives and read the search, or at least enrich one. Khoo Teck Puat Hospital in
environment can also destroy confidence. A patient can all Singapore provides an abundance of planting, thereby
too easily discover themselves on a set from a medical encouraging an explosion in wildlife in the public areas—
drama: on a bed, surrounded by blue vinyl curtains, next to they even have a butterfly register (Fig. 26.4)! This is
a machine with a red flashing light. In the medical drama, the intended to inspire patients with the wonders of the world.
setup spells inevitable disaster, and so the architectural The Royal Children’s Hospital has a meercat enclosure for
vocabulary takes the same hue. Shiny vinyl floors, similar reasons (Fig. 26.5). At the Centre for Respite and
windowless rooms, machines with flashing lights, blue Recovery, patients tend horses and birds; there are also
curtains and strip lighting are all therefore to be avoided. really good facilities for visitors (especially for visiting
Instead, the Centre for Respite and Recovery is a psychi- children), so patients can be expected to receive happier
atric facility design that would be rejected by TV set-finders and more regular visitors, thereby promoting a sense of
(Fig. 26.2). All bedrooms are private, they have king-sized belonging (Smith, Golembiewski, Hunyh, Raz, & Wu
beds, they open out onto leafy gardens, the lights are dim- 2014). In Wilcannia Hospital, which caters for especially
mable, the windows and doors are usable, there are timber for an indigenous population in Australia, architect Dillon
and stone finishes and high coffered ceilings and the colours Kombumerri designed patient accommodation on the
and textures are rich and non-institutional. The language ground floor, with wide verandas looking out into native
used extends to the typology of the building: it reads as a landscapes to allow space for visits from the tribe (typically
resort or a fancy hotel—a place where the promise of respite people arrive in large numbers rather than individually) and
and recovery rings true. This building was purposefully to let patients know that their tribal mores are respected and
designed to give patients the ‘dynamic feeling of confidence acknowledged (Fig. 26.6).
that one’s internal and external environments are predictable
and that there is a high probability that things will work out
as well as can reasonably be expected’ (Antonovsky 1987, Discussion
p. xiii). As we see from the Centre for Respite and Recovery,
it is well within the designer’s capacity to use salutogenic Since Dilani (2006) brought the concept of salutogenesis to
principles in order to help a patient feel secure (Fig. 26.3). healthcare design, he has led the International Academy for
Design and Health to promote salutogenic theory in
healthcare architecture throughout the world, even offering
Architecture for Patient Meaningfulness an annual prize for excellence in salutogenic architecture. As
a result, the concept has grown in popularity and has become
“. . . how little and how impotent a piece of the world is any a buzzword in the healthcare architecture procurement
man alone?” (Donne 1624) chain. The result is that salutogenesis is now a respected
Because meaning in life is so important for one’s sense and encouraged design goal. The downside is that the term
of coherence, it should be a pivotal concern for architects ‘salutogenic’ is overused by architects, most of whom do not
when designing for better healthcare. But meaningfulness know how to drive their schemes with a salutogenic meth-
has an intrinsic relationship with the real-world outside the odology, and do not even have a solid grasp of what
facility: people’s most significant thoughts are likely to be salutogenesis means. As a result, at times, the term can
for animals, the global ecology, for religion, politics, sport, mean nothing more systematic than ‘friendly-looking’ or
for family, friends, for music, art, literature, perhaps the ‘leafy’. This is not to criticise those designs—after all,
exercise of power. Hospitals are not ideal places to affirm ‘nice looking’ and ‘leafy’ are often the outcomes of more
meaning, because patients are physically removed from systematic salutogenic approaches, but there is so much
most of that which gives life meaning: they are full of more unexplored potential in the concept. There are now
Kafakaesque endless corridors, broken promises (‘you’ll systematic methods to bring salutogenic principles into
feel better soon; you might feel a little uncomfortable . . .’), healthcare design (Golembiewski 2010) and emergency
false alarms, of institutional aesthetics and inconsistent care (Golembiewski 2012a). And when adopted
26 Salutogenic Architecture in Healthcare Settings 273

Fig. 26.3 Sculptures and bright

colours to provide a sense of play
and to serve as landmarks for
orientation in Lady Cilento
Children’s Hospital. The
architects (Conrad Gargett &
Lyons Architects) hope these
innovations will improve the
salutogenic sense of
comprehensibility. Image by
Christopher Fredrick Jones,
courtesy of Conrad Gargett and
Lyons

Fig. 26.4 The patient spaces at

Khoo Teck Puat Hospital (CPG
Consultants, architects and
Peridian Asia and landscape
architects) are environments for
butterflies and other wildlife, in
the hope that the abundance of
nature will inspire patients and
therefore enrich meaningfulness.
Image courtesy of CPG
Consultants
274 J.A. Golembiewski

Fig. 26.5 The ambulant area in

the Royal Children’s Hospital
(Bates Smart, Billard Leece and
HKS) has a habitat for meercats
to develop a sense of
meaningfulness by keeping
children engaged in enquiry about
the world around them. (Photo by
John Gollings, courtesy of Bates
Smart)

Fig. 26.6 For the Indigenous people of Australia, meaning is derived accommodate large numbers of visitors. Architects: Dillon
from a connection to the land and tribe. For this reason, patient rooms in Kombumerri in Merrima, an office of the NSW Government Architect
Wilcannia Hospital are all on the ground floor looking out into the (Image: Brett Boardman)
landscape and have a shared veranda that is big enough to

appropriately, salutogenic architecture is invariably exem-

plary. Some of these projects even reach beyond the Challenges for the Future
accepted evidence basis for health-promoting design
(generic factors like views of nature and allowances for Salutogenic principles are a practical way to integrate the
natural daylight) and explore the realms of story-making, dynamics of health and experience with architecture. But for
psychology, neuroscience and endocrinology. people in praxis, challenges abound: in most countries the
26 Salutogenic Architecture in Healthcare Settings 275

procurement systems are conservative—led by precedents Antonovsky, A. (1996). The salutogenic model as a theory to guide
and guidelines, and controlled by stakeholder groups who health promotion. Health Promotion International, 11(1), 11.
Beauchemin, K. M., & Hays, P. (1996). Sunny hospital rooms expedite
struggle to save capital, often with little regard for on-going recovery from severe and refractory depressions. Journal of Affec-
healthcare costs. The decision-makers are usually poorly tive Disorders, 40, 49–51.
informed or simply do not believe in the capacity of Beauchemin, K. M., & Hays, P. (1998). Dying in the dark: Sunshine,
aesthetics to influence health. To add to this, the pathogenic gender and outcomes in myocardial infarction. Journal of the Royal
Society of Medicine, 91, 352–354.
model of health is dominant in the healthcare sector, and that Bitterman, N. (2013). Psychiatric ward dayroom: Human factors and
has enormous inertia, which will not reorient towards health design issues. In A. Dilani (Ed.), World Health Congress. Brisbane:
promotion easily. As a result, stakeholder groups usually International Academy of Design and Health.
value functional efficiencies, traditional finishes and Calhoun, J. B. (1970). Population density and social pathology.
California Medicine, 113(5), 54.
approaches (such as central staff stations) over what they Changeux, J.-P., & Edelstein, S. (2005). Nicotinic acetylcholine
may consider risky new inventions. Although some groups receptors: From molecular biology to cognition. New York: Odile
(particularly in the private sector) are beginning to under- Jacob.
stand salutogenic values, when faced with shrinking City of New York. (2013). Active design: Shaping the sidewalk expe-
rience. New York: NYC.
budgets, tight deadlines, constricted sites and profit-oriented Dancer, S. J. (2004). How do we assess hospital cleaning? A proposal
project managers, even they will lack courage to go beyond for microbiological standards for surface hygiene in hospitals.
landscape planting. As a result, the journey to discover that Journal of Hospital Infection, 56(1), 10–15.
nature is just the tip of the iceberg can be difficult. Dijkstra, K., Pieterse, M., & Pruyn, A. (2006). Physical environmental
stimuli that turn healthcare facilities into healing environments
To enable the blossoming of salutogenesis in healthcare through psychologically mediated effects: Systematic review. Jour-
architecture, far more research—practice-based, theoretical nal of Advanced Nursing, 56(2), 166–181.
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ideally through open-access journals, because architects in planning. World Hospitals and Health Services, 41(4), 17–21.
Dilani, A. (2008). Psychosocially supportive design: A salutogenic
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pass the pay walls that protect so much knowledge today. In Health Scientific Review, 1(2), 47–55.
addition, salutogenesis should be given a place in the canon Donne, J. (1624). Devotions upon emergent occasions and severall
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Floresco, S. B., Blaha, C. D., Yang, C. R., & Phillips, A. G. (2001).
potential for salutogenic design to reduce healthcare budgets Modulation of hippocampal and amygdalar-evoked activity of
and improve health on a population level is impressive, but it nucleus accumbens neurons by dopamine: Cellular mechanisms of
must be tested and retested so the arguments for salutogenic input selection. The Journal of Neuroscience, 21(8), 2851.
approaches are as watertight as research for new Foucault, M. (1977). Discipline and punish: The birth of the prison.
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Open Access This chapter is distributed under the terms of the Golembiewski, J. (2010). Start making sense: Applying a salutogenic
Creative Commons Attribution-Noncommercial 2.5 License (http:// model to architectural design for psychiatric care. Facilities, 28
creativecommons.org/licenses/by-nc/2.5/) which permits any noncom- (3/4), 100–117.
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