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CHILDREN’S HOSPITALS
The role of architecture in children’s recovery and development

Cláudia Sofia Fonseca Pinhão

Thesis to obtain the Master of Science Degree in

Architecture

Supervisor: Prof. Maria Alexandra de Lacerda Nave Alegre

Examination Committee

Chairperson: Prof. Teresa Frederica Tojal de Valsassina Heitor

Supervisor: Prof. Maria Alexandra de Lacerda Nave Alegre
Members of Committee: Dr. Paulo Oom Ferreira de Sousa

May 2016
 For the ones who are struggling,
Don’t quit, you are not alone. Together we will build a better world.
!

ACKNOWLEDGMENTS

One day someone told me that ‘life is the art of drawing without an eraser’, and each step in my
life was a beautiful draw that will drive me to do a masterpiece. Everyday I feel a step closer.
Without doubt, today I have more tools. Though, there is still a lot to shape. In this entire journey I
owe a deep gratitude to:

My mother,
who was always there for me. You not only gave me life, but also comfort, life goals and strength
to overcome everything.

My father,
who teased me to see the world in different perspectives and fight for a better and more equal
society.

I owe you both what I am today.

My grandparents Rosária and Mariano,

who I deeply miss. Grandma, you have awakened my awareness for the difficult reality of living
almost permanently in a hospital.

My grandparents Judite and Manuel,

who for their life experience thought me valuable lessons on how to deal with life.

My friends,
who wherever you are, near or far away, we have shared wonderful moments that keep me happy
and balanced.

Prof. Alexandra Alegre,

who had a relentless participation, guidance and enthusiasm during this thesis. Thank you for all
cross perspectives and insights on this journey.

Arq. Mario Hendrikx,

who promptly helped, immersing me in the complex hospital design world, merging the technical
perspectives with the human and emotional character of this typology.

Prof. Dr. Hans van Goudoever,

who enthusiastically received me in Emma Children’s Hospital and allowed the investigation to
proceed.

Children and adults from EKZ,

who accepted to share their experiences and opinions.

Professors and colleagues,

who gave me knowledge, shared and discussed ideas, and made me progress. You contributed
to improve my passion for architecture.

João,
because with you all possibilities multiply. You enhance my creativity and make me feel a better
person. You are my support and complement. We are now, drawing together.

Acknowledgements. I
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!

RESUMO

A função terapêutica dos ambientes hospitalares foi desconsiderada, durante muito

tempo, devido à sobreposição da medicina como disciplina autossuficiente na cura das
mais diversas doenças. No entanto, novas evidências científicas vêm provar o contributo
de outras áreas, tal como a arquitetura hospitalar, no processo de recuperação.

No caso dos Hospitais Pediátricos, a concepção do espaço adquire especial importância

devido à condição única de aprendizagem e relação com o mundo desta faixa etária. O
espaço hospitalar deve assim, proporcionar à criança, a oportunidade de continuar com
a sua rotina diária (oferecendo escola, espaços sociais e de recreio, etc.), num espaço
familiar e favorável ao seu normal desenvolvimento.

Relativamente à tipologia hospitalar, uma nova emergência de conceitos visa a

descentralização. No entanto, os hospitais académicos apresentam um conjunto único
de serviços, difícil de substituir e que continuará a ser competitivo no futuro.

Em suma, o objectivo deste trabalho é partir de uma tipologia atual e duradoura e

atribuir-lhe um ambiente que promova o bem-estar das crianças hospitalizadas e
estimule o processo de cura.

Numa primeira de quatro etapas, a partir de uma revisão bibliográfica, foi identificada a
evolução histórica dos espaços de saúde, contextualizando o caso dos hospitais
pediátricos e o papel da criança. Na segunda parte foi estabelecido um conjunto de
diretrizes correspondentes ao ambiente hospitalar e à relação hospital-cidade. No
terceiro capítulo foram identificadas estratégias de inclusão dos utilizadores finais no
processo de concepção espacial. Por fim, foram descritos e analisados dois casos de
estudo localizados na Holanda, seguidos de uma avaliação pós ocupação.

No domínio da investigação do Projeto Baseado em Evidência, este possibilitou

identificar que o estado clinico do paciente pode ser influenciado diretamente (por
exemplo através do isolamento de pacientes com doenças contagiosas), ou
indiretamente, através da redução de stress. Neste sentido, o poder de controlo, suporte
social, distrações positivas, dimensões sensoriais, diferenciação etária e segurança
foram considerados os principais factores influenciadores.

Relativamente aos casos de estudo analisados, estes demonstram uma alargada

correspondência com a atual teoria. No entanto, algumas estratégias projectuais foram
identificadas como perturbadoras à qualidade de vida dos utilizadores (tais como
sistemas automáticos, quartos standard, etc.), as quais necessitam de investigações
adicionais para validar os indicadores identificados.

Esta dissertação sugere não só uma relação espaço-recuperação, mas também espaço-
desenvolvimento, atribuindo às crianças hospitalizadas a oportunidade de continuar com
as suas vidas, sem uma interrupção abrupta. É tempo de refletir: todas as pessoas
merecem experiências positivas, mesmo que estejam numa situação de sofrimento.

Palavras-chave: Arquitetura de Hospitais Pediátricos, Projeto Centrado no Paciente,

Ambientes terapêuticos, Projeto Baseado em Evidencia, Arquitetura Hospitalar
Holandesa

Resumo. II
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!

ABSTRACT

The healing characteristics of healthcare environments have been ignored for a long
time. Medicine was seen as a self-sufficient subject in curing disease. However, new
evidence has revealed that other areas, such as hospital design, also contribute to the
healing process.

In Children’s hospital case, the hospital design became especially important because
children are in a singular condition of learning and interact with the world around,
requiring specific activities for a normal development. Thus, hospital design should offer
a homely comfort while bringing the outside facilities (school, playground areas, social
rooms, etc.) to the inside.

In relation to hospital typology, there is an increasing emergence of hospital new

concepts concerning decentralisation. Although, academic hospitals seem to offer a
unique set of services that will continue to be competitive in the future.

Generally speaking, the aim of this investigation was to adapt an actual, long lasting
typology, to offer a good life quality environment for hospitalised children, while
contributing to their medical recuperation.

Firstly, based on literature review, the Children’s hospital historical evolution was
contextualised in the general typology, and the impact of build spaces on children was
debated. In a second stage, a set of guidelines was compiled corresponding to factors
that influence healing environments and relation hospital-city. The third chapter identified
strategies to include final users in the design process.

Finally, two case studies, located in The Netherlands, were described and analysed in
view of theory. A further post occupational qualitative research was carried, applying the
studied methods and suggesting future developments.

In regard of Evidence Based Design, this investigation identified that medical outcomes
can be directly influenced by design, for example through contagious sick patients
isolation, or indirectly, through stress reduction. Sense of control, social support, positive
distractions, sensorial dimensions, age differentiation and security were analysed as the
main influencing factors.

The case studies analysed showed a great correspondence with the actual theory.
However, some design practices were still identified as disruptive of hospitalised children
life quality (automatic systems, standard rooms, wards’ division, etc.), which need further
research in order to validate such indicators.

This study suggests not only a correlation space-healing progress, but also space-life
progress, giving hospitalised people the opportunity to carry on with their lives, without
an abrupt interruption. It is time to think that all people deserve a positive life experience,
even if they are struggling.

Keywords: Children’s Hospital Architecture, Patient Centred Design, Healing

Environments, Evidence Based Design, Netherlands Hospital Design

Abstract. III
CONTENTS
!
I. Acknowledgments
II. Resumo
III. Abstract
IV. Contents
V. List of Figures
VI. Nomenclature

00. INTRODUCTION 2
0.1. Research Project 3
0.2. Study Object 3
0.3. Theme Justification 4
0.4. Methodology 5
0.5. State of the Art 6
0.6. Structure 8

01. CONTEXTUALISATION: CHILDREN AND HEALTHCARE SPACES 10

0.1. Hospitals’ Architecture Short History 11
1.1. Origins 11
1.2. Evolution and The Netherlands Case 13
0.2. Pediatric Hospitals 17
2.1. Emma Children’s Hospital 19
2.2. Wilhelmina Children’s Hospital 20
0.3. The Impact of Built Spaces in Children’s Lives 21

02. ARCHITECTURAL DESIGN: THE THEORETICAL APPROACH, PRINCIPLES AND

RECOMENDATIONS 24
0.1. Approaching the Hospital 25
1.1. Hospital, City and Society 25
1.2. Hospital of the Future 26
1.2.1. High-Tech 26
1.2.2. Homely Environments 27
1.2.3. Centralisation or Decentralisation 28
0.2. Hospital Environments 29
2.1. Current Terms 29
2.1.1. Child-Friendly Health Care 29
2.1.2. Child-Friendly Environments 29
2.1.3. Healing Environments and Evidence Based Design 30
2.2. Influencing Factors and Design Implications 32
2.2.1. Sense of Control 32
2.2.2. Social Support 38
2.2.3. Positive Distractions 42
2.2.4. Sensorial Dimensions 47
2.2.5. Age Appropriate Environments 52
!

2.2.6. Security 55

03. ENGAGE USERS IN THE DESIGN PROCESS 60

0.1. Participatory Process 61
1.1. Levels of Engagement in Participatory Projects 62
1.2. Participation Cycle 63
0.2. Reshearch Methods 64
2.1. Observation 65
2.2. Interviews 65
2.3. Photography 65
2.4. Walking Tour 66
2.5. Drawing 66
2.6. Focus Groups 67
2.7. Involving Parents and Practitioners 67
0.3. Quantitative and Qualitative Research 68

04. CASE STUDIES IN THE NETHERLANDS 70

0.1. Methodology 71
1.1. Selection Criteria and Applied Method 71
1.2. Selected Spaces 75
1.2.1. Entrance/Lobby 75
1.2.2. Garden 76
1.2.3. Bedrooms 78
1.2.4. Family Living Rooms 82
0.2. Wilhelmina Children’s Hospital 83
2.1. Urban Context 83
2.2. Functional and Spatial Organisation 84
2.3. Characterisation of the Selected Spaces 86
2.3.1. Entrance 86
2.3.2. Garden 88
2.3.3. Bedroom 89
2.3.3. Family Room 90
0.3. Emma Children’s Hospital 92
3.1. Urban Context 92
3.2. Functional and Spatial Organisation 93
3.3. Characterisation of the Selected Spaces 94
3.3.1. Entrance 94
3.3.2. Garden 95
3.3.3. Bedroom 96
3.3.3. Family Room 98
3.4. Post-Occupancy Evaluation 99
0.4. Discussion 106
04. CONCLUSION 112
BIBLIOGRAPHY 118
ATTACHMENTS 128
Children’s Hospitals

TABLE OF FIGURES

00. INTRODUCTION

Figure 00.1. Structure, methodology and objectives’ summary

01. CONTEXTUALISATION: CHILDREN AND HEALTHCARE SPACES

Figure 01.1. General plan of Epidaurus, Greece

Source: Lachat, Henri (1862) Epidaure, restauration & description des principaux monuments du sanctuaire
d’Asclépios. Paris: Libraries-imprimeries réunies.

Figure 01.2. Temple of Aesculapius Façade

Source: Lachat, Henri (1862) Epidaure, restauration & description des principaux monuments du sanctuaire
d’Asclépios. Paris: Libraries-imprimeries réunies.

Figure 01.3. Great Baths of Dioclatian, Rome (298 - 306 AD)

Source: http://www.poster-bargains.com/giant/382198.php

Figure 01.4. Plan of Fontenay Abbey, Burgundy, France (1118)

Source: https://s-media-cache-ak0.pinimg.com/736x/7f/61/cc/ 7f61cca4dd034ddaf57d96ef32ee7036.jpg

Figure 01.5. Interior image of Hôpital des Fontenilles, Tonnerre, France (13th century)
Source: http://image.wikifoundry.com/ image/1/yZMHI4xv6RQ2nRZ3NAInYg178737/GW340H258

Figure 01.6. Plan of Hôpital des Fontenilles, Tonnerre, France (13th century)
Source: http://www.ub.edu/geocrit/aracne/aracne-122 _archivos/image056.jpg

Figure 01.7. Plan of Ospedale Maggiore (1456), in Milan

Source: http://40.media.tumblr.com/6748dfa69d08f955dce5e506470ab0cf/tumblr_nnnyuuNmZK1rvpow5o1
_1280.jpg

Figure 01.8. Inselspital (1724), F.Beer, Bern

Source: https://upload.wikimedia.org/wikipedia/commons/thumb/b/b5/Inselspital1724.jpg/1280px-Inselspital
1724.jpg

Figure 01.9. Plan of Hôtel-Dieu (1778), J.B Leroy and J.R. Tenon, Paris
Source: http://gallica.bnf.fr/ark:/12148/btv1b8444448m/f 1.highres

Figure 01.10. Example of pavilion type. Plan of Hôpital Lariboisière (1839-1854), M.P. Gauthier, Paris
Source: http://history.amedd.army.mil/booksdocs/wwi/MilitaryHospitalsintheUS/chapter1figure3.jpg

Figure 01.11. Example of block type. Outside view of Columbia-Presbyterian Medical Centre (1926 –
1930), James Gamble Rogers, New York
Source: http://www.columbianeurosurgery.org/wp-content/2009/08/pic_his_b2.jpg?5f128f

Figure 01.12. Plan of W.G. Witteveen (1926), Ed. Cuypers, Rotterdam

Source: Mens N. and Wagenaar C. (2010) Health care architecture in the Netherlands, Roterdam: NAi
Publishers

Figure 01.13. Example of T-type hospital. Outside view of Streekziekenhuis Bennekom

Source: http://www.oudbennekom.nl/ upload/image/ziekenhuis-1970.jpg

Figure 01.14. Tridimensional representation of Diaconessenhuis, J.P. Kloos, Groningen (K=Clinic;

B= Treatment Department; P= Outpatient Department).
Source: Mens N. and Wagenaar C. (2010) Health care architecture in the Netherlands, Roterdam: NAi
Publishers

Figure 01.15. Outside view of Diaconessenhuis (1965), J.P. Kloos, Groningen

Source: http://mw2.google.com/mw-panoramio/photos/medium/122699938.jpg

Figure 01.16. Outside view of Mémorial France-États-Unis (1956), P. Nelson, Saint-Lô

Source: http://library.columbia.edu/locations/avery/da/collections/nelson/_jcr_content/layout_par_main_1/i
mage_v2_2.img.jpg/1368472160983.jpg

V. List of Figures
 The role of architecture in children’s recovery and development!

Figure 01.17. Outside view of Leyenburgziekenhuis (1971), K.L. Sijmons, The Hague
Source: https://www.hagazie kenhuis.nl/media/80189/leyenburg_1972_250x132.jpg

Figure 01.18. Outside view of Sint Elizabeth (1982), Roelfs Nijst, Tilburg
Source: http://ncctnl.ehost.com/EZH/ezh_luchtfot_55.jpg

Figure 01.19. Picture of the English Orphanage on the Oudezijdsachterburgwal, Amsterdam (1783)
Source: http://beeldbank.amsterdam.nl/beeldbank/weergave/record/?id=010097003237

Figure 01.20. Façade of the first building in Sarphatistraat (1874)

Source: http://020apps.nl/1850-1940/Sarphatistraat/104

Figure 01.21. Outside view of the architectonic set after the first two interventions
Source: http://idoverhagen.nl/wp-content/uploads/2011/12/JHM01_00881_U.jpg

Figure 01.22. Corner view after the addition of 1906

Source: http://idoverhagen.nl/wp-content/uploads/2011/12/JHM01_ 00882_U.jpg

Figure 01.23. Outside view from the Hospital with all the interventions finalized.
Source: http://idoverhagen.nl/wp-content/uploads/2011/12/DSC02676.jpg

Figure 01.24. Aerial view of the AMC hospital (2014)

Source: http://hubholendrecht.nl/wp-content/uploads/2014/06/AMC_4_-_LRkl_920_556.jpg

Figure 01.25. View of the façade of the Wilhelmina Children in Nieuwegracht, 137 (1992)
Source: http://publiek.collecties.hetutrechtsarchief.nl/detail.php?nav_id=9-1&id=1280364589&index=21

Figure 01.26. View of the ‘block’ extension of the Wilhelmina Children’s Hospital (1971)
Source: http://publiek.collecties.hetutrechtsarchief.nl/detail.php?nav_id=9-1&id=1281259791&index=84

Figure 01.27. View of the façade of Wilhelmina Children’s Hospital by the Groenestraat (1999)
Source: http://publiek.collecties.hetutrechtsarchief.nl/detail.php?nav_id=9-1&id=1280300197&index=76

Figure 01.28. Aerial view of WKZ in Nieuwegracht 137, after all expansions
Source: https://www.flickr.com/photos/umcutrecht/8567590227/in/album-72157632701810608/

Figure 01.29. Aerial view of the actual WKZ (1999)

Source: http://www.hetutrechtsarchief.nl/collectie/beeldmateriaal/zoeken/?q=nieuwegracht+137&a2=&s
&a4=&a5=&d1=&d1=&t

02. ARCHITECTURAL DESIGN: THE THEORETICAL APPROACH, PRINCIPLES AND

RECOMENDATIONS

Figure 02.1. Sense of Control Variables in Hospital Settings

Figure 02.2. The Royal Children’s Hospital (2011), by Billard Leece Partnership and Bates Smart
Architects
Source: http://melbournedesignawards.com

Figure 02.3. Design Guidelines to provide patients with sense of control

Figure 02.4. Sahlgrenska University Hospital (2010), by Kontor Kontur

Source: http://www.kontorkontur.se/recent/fabel/

Figure 02.5. Health Impacts, prevention measures and design guidelines for better socialisation
patterns

Figure 02.6. Seattle Children’s Hospital (2013), by ZGF Architects

Source: http://www.healthcaredesignmagazine.com/article/adding-and-subtracting-seattle-childrens-hospital

Figure 02.7. Play benefits and design guidelines

Figure 02.8. Education benefits and design guidelines

Figure 02.9. Royal London Hospital (2013), by Cotrell and Vermeuten Architects

List of Figures. V
Children’s Hospitals

Source: http://www.theguardian.com/artanddesign/architecture-design-blog/2013/feb/21/royal-london-hosp
ital-play-space

Figure 02.10. Art impact on children and design guidelines

Figure 02.11. Queen Silvia Children’s Hospital (2015), by Bitter Britta

Source: http://bittrabritta.se/barnrontgen/

Figure 02.12. Crown Sky Garden (2012), by Mikyoung Kim Design

Source: http://worldlandscapearchitect.com/crown-sky-garden-chicago-usa-mikyoung-kim-design/

Figure 02.13. Nature impact on patients’ well being and potential activities

Figure 02.14. Natural and Artificial light: advantages and design guidelines

Figure 02.15. Randall Children’s Hospital (2012), by ZGF Architects

Source: https://www.zgf.com

Figure 02.16. Children opinion and perception of colour

Figure 02.17. Noise impacts on patients’ health and design guidelines

Figure 02.18. Cognitive development, specific requirements and suggested design guidelines for each
age group

Figure 02.19. Randall Children’s Hospital (2012), by ZGF Architects

Source: https://www.zgf.com

Figure 02.20. Variables that enhance patients’ security

Figure 02.21. Suggested design guidelines to improve patients’ security inside the hospital

03. ENGAGE USERS IN THE DESIGN PROCESS

Figure 03.1. Hart’s ladder of participation

Figure 03.2. Children’s participation project cycle

Source: Stephenson, Gourley and Miles, 2004

Figure 03.3. Graphic illustrative of the adaptation of Sanders’ model suggested by Westerlund, 2009

04. CASE STUDIES IN THE NETHERLANDS

Figure 04.1. Case studies’ selection criteria

Figure 04.2. Design guidelines for pediatric hospital’s entrances

Figure 04.3. Design guidelines for pediatric hospital’s gardens

Figure 04.4. Design guidelines for pediatric hospital’s bedrooms

Figure 04.5. Example of a Hospital Room Design Layout with respective functional division

Figure 04.6. a) Inboard/Footwall Toilet Room; b) Inboard/Headwall Toilet Room; c) Outboard/Footwall

Toilet Room; d) Outboard/ Headwall Toilet Room; e) Inboard/Headwall Shifted Toilet
Room.

Figure 04.7. a) Same-Handed Room Layout; b) Mirrored Room Layout

Figure 04.8. Design guidelines for pediatric hospital’s family rooms

Figure 04.9. Aerial photo of Wilhelmina Children’s Hospital

V. List of Figures
 The role of architecture in children’s recovery and development!

Figure 04.10. Wilhelmina Children’s Hospital – Site Plan

Figure 04.11. Outside and inside views of Wilhelmina Children’s hospital entrances
Source: Hospital architect and in situ photographs

Figure 04.12. Garden different views

Source: Hospital architect and in situ photographs

Figure 04.13. a) Regular bedroom plan; b) Bedroom section AA’; c) Bedroom section BB’

Figure 04.14. a) Ward’s corridor; b) Bedroom

Source: Hospital architect and in situ photographs

Figure 04.15. Family rooms’ location – plan layout

Figure 04.16. Ward’s family room plan

Figure 04.17. Ronald Mc Donald’s living room

Figure 04.18. Aerial photo of the Academic Medical Centre

Figure 04.19. Academic Medical Centre – Site Plan

Figure 04.20. Functional scheme of Emma Children’s Hospital

Figure 04.21. a) Academic Medical Centre – ground floor scheme; b) Atrium view; c) Elevator Hall; d)
Ward’s door
Source: b) http://www.heijmans.nl/media/filer_public/55/9a/559a4f1d-f9e6-418f-99d0-743f5a3803df/amc-vo
etenplein-heijmans-1600.jpg
c) http://www.od205.com/data/original/2011-12-02_10-51-49_4160_DSC5145.jpg
d) http://www.dearchitect.nl/binaries/content/gallery/architect/projecten/2010/14/Amsterdam+OPER
A+Emma+Kinderziekenhuis/foto_x0027_s/hal+bewegwijzering.JPG/hal+bewegwijzering.JPG/archi
tectimage:extralargethumnail

Figure 04.22. Academic Medical Centre surroundings – green areas

Source: http://www.ulcgroep.nl/cache/thumb/a/m/AMC_4_-_LRkl_920_556.jpg
http://metaboleziekten.nl/shared_img/amc_gebouw.jpg!

Figure 04.23. a) Regular bedroom plan; b) Bedroom section AA’; c) Bedroom section BB’

Figure 04.24. a) Ward’s corridor – room door; b) Bedroom

Source: http://www.opera-amsterdam.nl/uploads/images/interior/emmakinderziekenhuis_2de_fase/_DSC06
10.jpg

Figure 04.25. ‘Ronald McDonald Parade’ – plan layout and respective photographs

List of Figures. V
Children’s Hospitals

V. List of Figures
 The role of architecture in children’s recovery and development!

NOMENCLATURE

UNICEF United Nations Children’s Fund

AMC Academisch Medisch Centrum / Academic Medical Centre

EKZ Emma Kinderziekenhuis / Emma Children’s Hospital

UMC Universitair Medisch Centrum / University Hospital of Utrecht

WKZ Wilhelmina Kinderziekenhuis / Wilhelmina Children’s Hospital

EACH European Association for Children in Hospital

EBD Evidence Based Design

WHO World Health Organisation

JCAHO Joint Commission on Accreditation of Healthcare Organisations

RMHC Ronald McDonald House Charities

Nomenclature. VI
Children’s Hospitals

VI. Nomenclature
The role of architecture in children’s recovery and development!

INTRODUCTION. 00
Children’s Hospitals

0.1. RESEARCH PURPOSE

This study, developed in the framework of the Integrated Master in Architecture in IST,
aims to explore the role of architecture in creating, not only a therapeutic hospital
environment for children, but also an environment that provides them, as much as
possible, normal patterns of life. Therefore, one of the objectives is to transform the term
‘second home’ worth of the meaning, with a truly homely environment. Furthermore, it is
suggested not only to bring home to the hospital, it is necessary to bring all the outside
society, providing school, playing areas, social rooms, family kitchens and so on. This
means to build ‘a city within a city’ so that these children are not left behind.
In this way, it is intended to understand the evolution of paediatric hospitals in a specific
context, as The Netherlands, with an actual focus on this typology connected with
academic hospitals. There is a need to perceive how the unique supportive environments
of new typologies, as is the case of Maggie’s Cancer Caring Centres, can be conceived
in these mega-hospitals. Furthermore, there is a will to investigate and compile the
studies that have been done recently in the ‘healing environments’ area, with a specific
focus on the ones including children.
Finally, it is also a goal of this study, to analyse in accordance with the reviewed
literature theory, the latest projects that have been designed, in order to establish the
present situation and potential improvements for the future.

0.2. STUDY OBJECT

For the purposes of this study, the paediatric hospitals in connection with academic
hospitals were elected as case studies. These high technological infrastructures present
an unequivocal presence in the future by their medical and investigational excellence,
proportion and global knowledge. This is a relevant reason for architects to investigate
and work in improving these environments, with a direct impact in so many lives.
Thus, it was selected two important paediatric hospitals in the Netherlands, which have
been developing a remarkable work in the healthcare settings. In the selection process,
only the options with a deep concern on child-centred design, which were informed,
implemented and accompanied by architects, were taken into account.
The selected projects were the internal renovation of Emma Kinderziekenhuis1 (2004–
2015) in Amsterdam, designed by OD205 architectuur and OPERA Amsterdam; and the
Wilhelmina Kinderziekenhuis2 (1994 – 1998) in Utrecht, designed by EGM architecten.

______________________________________________
1
Emma Kinderzienkenhuis (EZK) can be translated for Emma Children’s Hospital
2
Wilhelmina Kinderzienkenhuis (WZK) can be translated for Wilhelmina Children’s Hospital

3
 The role of architecture in children’s recovery and development!

0.3. THEME JUSTIFICATION

‘There is no doubt whatever about the influence of architecture and structure upon human
character and action. We make our buildings and afterwards they make us. They regulate
the course of our lives.’ (Winston Churchill, 1924)

Nowadays architects see their task hampered by several requirements, sometimes even
incompatible, that they need to answer during the design process. To design a building,
economical, constructive and functional assumptions should be taken into account.
However, what is the objective of a building, if it doesn’t facilitate the users’ life, or if it
even constitutes an obstacle to every day’s life?
Numerous architects have been enrolled in this theme of humanizing architecture. There
is a will to bring the material world into human life in the most harmonious way.
Humanizing architecture means creating better architecture and also exploring
functionalism in a larger scale rather than purely technical (Aalto 1991).
In fact, architecture is present everywhere, and it has a huge impact on every day’s life
and in building societies. Thus, if societies have problems that need special attention,
architecture should provide the necessary support, especially when there are particular
groups of users, who are not always aware of their rights and need someone to ensure
them.
The term vulnerable is used to describe the ones more likely to suffer discrimination or
other human rights violations (Reichert 2006). Among the vulnerable groups, we can
highlight sick children. Every day, there is a lot of children having their life affected by the
necessity of going to the hospital or even spending a great part of their childhood
hospitalised. Thus, an approach focused on users is required, since the way hospitals
are designed not only shape their experiences and quality of life, but it also reveals how
society treats their citizens. Architects help shaping the values of society.
Besides illness, children are going through a period of their lives when part of their
knowledge is constructed based on their relationships with objects, spaces, places, other
children and adults, including the sense of ownership, exclusion or limited access
(Proshansky and Fabian 1987). Therefore, apart from the expected excellency on illness
treatment, children should also have granted support to achieve a similar development to
healthy children. This means, access to school, social interaction, playing opportunities
and others.
The selected case studies are located in the Netherlands, which is considered the
country with the best overall child wellbeing when compared with the other developed
countries. It ranks in the top 10 in all dimensions analysed in the UNICEF report (2007)
and it also shows great progresses in hospital design in the recent years. This is
believed to constitute an example for other countries and can also be used as a starting
point for future advances.
For architects it should be a privilege to play such an important role, influencing and
affecting people’s lives in such a profound way that can contribute for their recovery and
improve life’s quality.

‘(...) in serving the best interests of children, we serve the best interests of all humanity.’
(Carol Bellamy, 2001)

4
Children’s Hospitals

0.4 METHODOLOGY

This study was developed in four different stages:

Bibliographic review

The first goal was to approach the evolution of healthcare facilities over time, in an
attempt to understand the capability of architecture to fulfil the varying degrees of
demands, identifying the progresses and failures. There is a special focus on the
Netherlands case because it is where the case studies are located. Furthermore, the
singular case of children’s hospital was compared with the general hospitals’ evolution in
order to understand their connection and different evolution patterns. To conclude,
children were mentioned as the target users, identifying their specific characteristics,
requirements and relation with the space around.
The information sources were mainly academic publications, the web and architecture
manuals.

Evidence collection of new hospital paradigms

This stage consisted in collecting theories and evidence, through bibliographic review,
regarding actual requirements and futuristic concepts. The research focused on recent
articles, books and publications, being developed along the following themes:
- Urban and Landscape Framing;
- Futuristic Hospital Concepts;
- Current Hospital Terms: Child Friendly Health Care, Child Friendly Environments,
Healing Environments and Evidence Based Design;
- Influencing factors of hospitalised children’s quality of life with respective health impacts
and design guidelines. Each influencing factor is illustrated with a project that was
considered to be innovative and correctly developed in the area.

Methods for Participatory Design

In regard of future hospital designs, this stage aims to alert architects for the actual need
to include final users in the design process. Furthermore, processes of inclusion and
child friendly methods are presented, in view of recent studies and methodologies, such
as the example of The Mosaic Approach.

Case Studies

In the final stage, the following strategies were applied:

1) Evidence collection about actual requirements and specific design guidelines in regard
of four different spaces: entrance, garden, bedrooms and family rooms, considered as
the most significant ones in children’s life during their stay in the hospital. It was only
selected four spaces because, in the context of a master thesis, there is no extension to
approach in detail all hospital functions;

5
 The role of architecture in children’s recovery and development!

2) Description and analysis of Wilhelmina Children’s Hospital relative to urban, context,

functional distribution and internal environments. Analysis of the four selected spaces in
relation to the evidence collected. The information was based on observations,
architect’s information and interview;
3) Description and analysis of Emma Children’s Hospital relative to urban context,
functional distribution and internal environments. Analysis of the four selected spaces in
relation to the evidence collected. The information was based on online sources,
observations and architect’s information;
4) Adaptation and application of the methods explained in ‘Methods for participatory
design’, through a qualitative post-occupational evaluation. The results of these
interviews were systematised in a textual description of the most important findings,
followed by a table connecting the methods with all respective results;
5) Discussion and comparison between the two different hospital and analysis of the
results achieved in the post occupational study.

05. STATE OF THE ART

Children’s hospitals can be considered quite recent. Only in the end of 19th century,
children’s role in society started to change and groups of physicians started gathering to
protect children’s well-being in the hospitals. England appeared as a pioneer in
defending children’s rights in the hospital, with the publication of The Welfare of
Children in Hospital (1959), specially focusing the need for parental presence.

In parallel, the British Nuffield Foundation started to elaborate scientific research in the
hospitals’ design area, in order to enhance patients’ wellbeing. In 1963, they published
the Children in Hospital report, which constitutes the first study where design guidelines
are suggested to fulfil children’s rights in the hospital.

Not long after, Roger Ulrich (1984) published the View through a window may influence
recovery from surgery that constitutes a pioneer research relating design strategies with
health outcomes (stay duration, medication dosages, etc). This encouraged further
studies, even generating new movements such as Healing Environments and
Evidence-Based Design.

In relation to children’s particular case, Olds and Daniel published the entitled first book
on the design of healthcare facilities for children, in 1987, called Child Health Care
Facilities: Design Guidelines and Literature Outline. This book marks a transition on
paediatric hospitals’ conception, from a photographic inspirational based design to a
knowledge-based design, promoting research of more scientific evidence.

Meanwhile, the patient’s psychological well-being also gained more strength. This
development on mind-body medical science, confirmed that patient stress and emotional
states affected clinical outcomes. Thus, in 1997, Ulrich published the book A theory of
supportive design for healthcare facilities, identifying the broad principles to influence
good psychological outcomes on overall patient population.

6
Children’s Hospitals

In the following year, Shepley, Fournier and McDougal published the Healthcare
Environment for Children and their families, where families are regarded as important
contributors for children’s recovery, and physical environment is seen as a critical factor
in the healing process. This study aimed to assist designers in the creation of more
human and social healthcare settings by gathering existing research exclusively
including children and families.

With the beginning of the 21st century, many new researches based on design-evidence
in healthcare settings were published. Regarding an overall population, the Role of the
Physical Environment in the hospital of the 21st Century (2004), published by Ulrich,
Zimring, Quan, Joseph and Choudhary, identifies the impact of physical environment
on patients and families behaviour and also, on health professionals’ performance. Other
general study but solely regarding children is the book Children’s environments and
health-related quality of life, published by Sherman, Shepley and Varni (2005). This
study focus on design characteristics that can improve hospitalised children’s quality of
life and, hence, their recovery.

New studies on specific functions, requirements, wards or age groups are being
produced. For example in 2001, Whitehouse, Varni, Seid, Cooper-Marcus, Ensberg,
Jacobs and Meblenbeck published the study Evaluating a Children’s Hospital Garden
Environment, where they evaluate the degree of use and levels of satisfaction of this
unique facility that allows contact with nature. In 2008, Eisen, Ulrich, Shepley, Varni
and Sherman published The stress-reducing effects of art in paediatric health care,
where the healing effects of art is explored among children age group. More recently, in
2012, Shepley, Fellows, Hintzm Johnson and Spohn published the Paediatric
Inpatient Room Experience, exploring the children’s responses to room characteristics.

These studies are part of an actual collection of evidence that is difficult to run out of new
themes and potential studies. This is the exact time to explore the majority of possible
variables in order to construct efficient and user-friendly buildings, avoiding enormous
construction costs in hospitals that do not answer scientific evidence.

In regard to hospital typology evolution, several authors have been collecting and
gathering information to publish. Cor Wagenaar in Architecture of Hospitals (2006)
offers a unique compilation of researches, historical analysis, healthcare projects and
future concepts at an international level. More recently, Verderber (2010) in Innovations
in Hospital Architecture describes the progress of hospital typology and analyses the role
of architecture in healthcare settings. Similarly, Wagennar and Mens (2010) in
Healthcare Architecture in The Netherlands, also describe and illustrate hospitals’
evolution but in the specific case of The Netherlands

Also worthy of note is the work of Clark and Moss (2005) in Spaces to Play: More
listening to young children using the Mosaic Approach, where the inclusion of children in
design process are defended, while methods to better collect children’s perspectives are
suggested.

Generally, these studies are stimulating attention from architects, hospital managers,
associations and health professionals to the impact of hospital design in patients,
families and workers. There is an increasing need to design buildings with its future

7
 The role of architecture in children’s recovery and development!

users to better answer their requirements, while they will also be more conscious about
building functioning. Furthermore, together with scientific evidence, architects are able to
increase users’ wellbeing and satisfaction, as well as improving patient’s recovery.

0.6 STRUCTURE

Chapter Objective Methodology

Approach the history of Healthcare
Facilities, with special focus on The
Netherlands case

01 Contextualisation of Children’s
Bibliographic Review
Contextualisation Hospitals, with special focus on the
case studies

Identify the special relation between

children and built spaces
Understand the present theoretical Bibliographic review
02 hospital paradigms
New Hospital Evidence Collection with
Explore conceptual strategies respective Design
Concepts and
Guidelines Inform present or future healthcare Guidelines and Health
projects Impacts

Inform new ways of complementing

03 design Evidence Collection
Participatory Design Help architects in the process of Practices Suggestions
achieving a user friendly building
Identify practical strategies and
compare with theory Evidence Collection

Find project qualities and Description and analysis

04 deficiencies in recent hospital based on theory
Case Studies buildings
Implementation of a
Suggestion of further studies in the qualitative post
area, regarding the improvement of occupational evaluation
users’ life quality inside the hospital

Figure 00.1 - Structure, methodology and objectives’ summary

8
Children’s Hospitals
 The role of architecture in children’s recovery and development!

CONTEXTUALISATION: CHILDREN AND HEALTHCARE SPACES. 01

Children’s Hospitals

01. HOSPITALS ARCHITECTURE SHORT HISTORY

The history of hospitals has not been having an easy or regular evolution process due to
their constant progress changes, deeply influenced by medicine findings and society
mentalities over time. Although the hospital has always been used as a space to care
and cure people in their illness or injury, it has not always been housed in a health care
setting, as we know nowadays. In order to better understand this typology development,
and because it is important to understand the past events to structure the future in a
better way, it is going to be reviewed the main phases of hospital evolution along history.

1.1. ORIGINS

Stephen Verderver in his book, Innovations in Hospital Architecture (2010), describes

succinctly the progress of the hospital typology, beginning in the earliest Neolithic. By
that time the closest family would take care of their sick beloved ones, in a ‘sickhouse’,
progressively isolated from the rest of the population. The healing methods were highly
determined by superstition and a strong belief in the supernatural. Against this approach,
Hippocrates3 (460 – 360 BC) revolutionized medicine being the first one to distinguish
this subject from philosophy. He argued that a rationalist physician should widely
understand the influence of environmental and climatic determinants, which in his view
were the main causes of sickness and disease. (Chadwick 1983)
The Greeks (750 – 30 BC) were the first civilisation to apply rational medicine, though
they had a strong belief in gods and their curative power. Stoa or Asklepieion4 were their
inpatient units, which despite having three enclosed sides, the southern side was always
open by an open portico. This design strategy already evokes their concerns about the
healing power of nature, such as natural light, ventilation and outside views. The
treatment was based in a wellness concept including bed rest, medications, bathing and
nutrition regimens and therapeutic exercise. (Thompson and Goldin 1975)
The following civilisation, the Romans (27 BC – 410 AD), continued the Greek medicine
principles, though they constructed advanced sanitary systems5, which contributed to
improve the health conditions of the cities. They also invented the first military hospital
enabling soldiers quicker recovery and return to battles (Loudon 1997). The Roman
thermae was also a healthcare innovation, used as bathhouses and public gyms, varying
in size, from private houses to great public baths. They also presented new features,
such as heating systems for water and mechanisms for the circulation of smoke and
heated air6 (Peck 1898). These facilities combined spiritual worship, social interaction,
hygiene and wellness at once.

______________________________________________
3
Hippocrates (460 – 370 BC) was a Greek physician, considered the “Father of Western Medicine” and founder of the
Hippocratic School of medicine.
4
Stoa or Asklepieion was a healing temple, sacred to the god Aesculapius, the Grecian God of Medicine.
5
Roman sanitary systems consisted on the construction of a network of massive aqueducts and the invention of indoor
plumbing (Loudon, 1997)
6
The ‘hypocaust system’, allowed the distribution of hot air through an under floor system, consisting in an elevated floor
supported by pillars, which was heated by gases from a fire or furnace, in order to heat the rooms above (Peck, 1898)

11
 The role of architecture in children’s recovery and development!

Figure 01.1 - General plan of Epidaurus, Greece; Figure 01.2 - Temple of Aesculapius Façade; Figure
01.3 - Great Baths of Dioclatian, Rome
!
After the decline of Rome and with the spread of deadly epidemics all over the
population, the Catholic Church assumed the Healthcare support across Europe. In this
way monastic hospitals served as centres of hospitality for ‘all manner of human
‘wretchedness’ including the aged, infirm, dying, diseased, wounded, blind, crippled,
idiot, insane, orphans, paupers, wanderers, (and) pilgrims’ (Thompson and Goldin 1975,
6), while the upper class was treated at home by physicians. The “cross ward” plan
monastery housed the patients, in such a way, that they could contemplate the altar, due
to the religious-based medicine monks used to practice. Despite their benevolence,
these chapels exhibited lack of illumination, ventilation and thermal comfort, as described
by Stephen Verderber (2010, 18): ‘(…) which had small drainage holes bored through
stone beneath each window, barely visible from the exterior. (…) It was often very cold at
night, in these great stone halls, and with poor heating, patients were forced to huddle in
their beds.’

Figure 01.4. - Plan of Fontenay Abbey, Burgundy, France; Figure 01.5 - Interior image of Hôpital des
Fontenilles, Tonnerre, France; Figure 01.6 - Plan of Hôpital des Fontenilles, Tonnerre, France
!
With the end of Middle Ages and the beginning of Renaissance in the 13th century, there
was a remarkable change of thinking. The man started to be the centre of the universe,
substituting god and the Hippocratic theories were rediscovered. This had repercussions
in hospital facilities, with a new awareness on natural environment and landscape
(Verderber 2010). This interest can be noticed in the numerous exterior spaces Filarete
designed in the Ospedale Maggiore7 in Milan (1456), presenting a symmetrical
composition with a large central courtyard and four smaller ones in each wing. This
hospital was also a symbol of the beginning of non-religious hospitals and centralisation
of healthcare in the city. (Mens and Wagenaar 2010)

______________________________________________
7
The first hospital designed according to geometrical principles of Renaissance, founded in Milan in 1456 by Antonio di
Pietro Averlino, better known as Filarete.

12
Children’s Hospitals

Figure 01.7 - Plan of Ospedale Maggiore (1456), in Milan

1.2. EVOLUTION AND THE NETHERLANDS’ CASE

Cor Wagenaar and Noor Mens in their book, Health care Architecture in The Netherlands
(2010), describe the evolution of hospitals, in this country, from the moment they became
a formal building. Starting in the 17th and 18th century, there was a focus on military
hospital construction, aiming for soldiers’ quick recovery to improve cities’ prosperity and
power. In other scale, it can also be noticed an increase in non-military hospitals
construction, but aimed for the accommodation of the poor. In this context, the corridor
hospital appeared for the first time, in Bern designed by F. Beer between 1718 and 1724
(Wagenaar 2006). This typology was characterised by a central long corridor with rooms
arranged alongside. However it soon showed its deficiencies such as the lack of
communication, form limitation and easy spread of contagious diseases.
The strong conviction that illness was a result of miasma8, made the fresh air be seen as
the best remedy and, as result, the hospitals of late 18th century were designed as
ventilation machines. This concept first started in the reconstruction plan of the Hôtel-
Dieu9, in Paris, after the great fire in 1772. J.R. Tenon and J. B. Leroy designed separate
pavilions with mine shafts shaped roofs, in order to guarantee the best ventilation
conditions (Vidler 1987). The pavilion model, most enhanced by the work of Florence
Nightingale10, aimed to bring the healing aspects of nature to the inside, with a lot of
yards and exterior windows. At the same time, this typology allowed to control the spread
of disease by designing separate wards as fingers connected by a linear spine for
circulation. This model was widely applied in France and Great Britain during the 19th
century, while in The Netherlands the corridor type continued the favourite long after.

______________________________________________
8
Miasma theory posited the major cause of disease as foul emanations from soil, water and air. As promulgated by
Thomas Sydenham in the 17th century, it became the dominant theory through the first three quarters of the 19th century”
(Susser, M.)
9
Hôtel-Dieu was an important hospital in Paris, which received a lot of complaints due to its lack of health conditions, in
order to replace it. Without success, it ends up suffering a great fire in 1772. After the disaster there were many proposals
for the replacement, from which the most prominent were the radial solution by A. Petit and B. Poyet, and the pavilion
system by J.R. Tenon and J.B. Leroy. (Cor Wagenaar, 2006)
10
Florence Nightingale introduced a temporary and military approach of pavilion type called barracks hospital, during
Crimean War of 1854. Her work is also known due to her passion for creating healing environments, which is documented
in her book Notes on Hospitals in 1863.

13
 The role of architecture in children’s recovery and development!

Figure 01.8 - Inselspital (1724), F.Beer, Bern; Figure 01.9 - Plan of Hôtel-Dieu (1778), Paris; Figure 01.10 -
Example of pavilion type. Plan of Hôpital Lariboisière (1839-1854), M.P. Gauthier, Paris

Over time, the focus on the healing factors of nature have started to be left behind, giving
place to efficiency and technology over human comfort and healing. In the beginning of
the 20th century, it was discovered that bacteria were the main agent of spreading
disease and the x-ray machine was invented. As consequences, it was no longer
necessary a ventilated hospital and the new technological advances made hospitals
unaffordable for poor (Wagenaar 2006). The hospital form shifted to a big compact
representational building named 'block’ typology, which compared with pavilion type, had
reduced walking distances, limited plot size and consequently reduced land prices.
(Cramer 1939)

Figure 01.11 - Outside view of Columbia-Presbyterian Medical Centre (1926 -1930), James Gamble Rogers,
New York; Figure 01.12 - Plan of W.G. Witteveen (1926), Ed. Cuypers, Rotterdam

During this time in the Netherlands, the majority of hospitals were constructed in a hybrid
form, combining the best of corridor and pavilion types. The pavilion-corridor model was
based on a few pavilions connected by corridors, each one flanked by rooms (Mens and
Wagenaar 2010). Ed. Cuypers designed many hospitals of this typology, from which the
original design of W.G. Witteveen in Rotterdam (1926), can be highlighted. The plan
shows a symmetrical approach, with a central pavilion for examination and treatment,
surrounded by pavilions for acute cases. Infectious diseases were separated in a set of
buildings located in the northeast part of the site plan.
Despite technological advances, ‘hospital had become symbol of social segregation’
(Wagenaar 2006, 35).

During the Second World War many hospitals were destroyed and medicine experienced
visible progresses. The liberation brought not only a will to modernize the hospital, but
also to reinstate the major target group in the hospital. This context favoured the
implementation of the International Style, which ‘reintroduced references to nature,

14
Children’s Hospitals

favouring spacious locations where the patient wards could be situated on the southern
façade facing gardens or parks' (Wagenaar 2006). The strategy used in hospital
planning was a functional division of three distinct parts – patient wards, treatment unit
and outpatient wards (Mens and Wagenaar 2010). Respecting these different parts, it
started to appear various series of types, such as T-type, H-type, K-type, etc. In the
Netherlands, the Diaconessehuis in Groningen, designed by J.P. Kloos and completed in
1963, is a great example of K-type, in which the functional separation is visible.

Figure 01.13 - Outside view of Streekziekenhuis Bennekom; Figure 01.14 - Tridimensional representation
of Diaconessenhuis, J.P. Kloos, Groningen (K=Clinic; B= Treatment Department; P= Outpatient
Department); Figure 01.15 - Outside view of Diaconessenhuis (1965), J.P. Kloos, Groningen

The 1960’s brought new issues for architecture to solve. Not only the demographic
explosion of the post-war period meant the need to increase hospital construction, but
also the quick technological progress should be anticipated for projects to be up-dated
during their duration. Consequently, hospitals started to spread and sometimes to
duplicate due to religious wills. However, in 1967, a wave of mergers stared to up-scaling
the hospital and closing the smaller ones (Van der Velde 1989).
‘Development here is proceeding at such a pace that it can be stated without exaggeration
that even in our brand-new hospitals these units are no longer up to date the moment they
are opened’ (Herres 1958, 449).

Expandability, flexibility and centralisation were new requests that the new solution,
named ‘tower on podium’ type, tried to implement. It begun in the USA11, but soon was
spread all over the world. The model aimed to concentrate the treatment and outpatient
unit in the bottom, for an easy introduction and replacement of the new technologies,
while the wards would be located on the top, where patients would not be disturbed
(Mens and Wagenaar 2010). The most recognizable example of this type in The
Netherlands is The Leyenburgziekenhuis in The Hague, designed by K.L. Sijmons, in
1971. It’s a ten-storey tower of wards above a two-storey building where clinical,
outpatient and auxiliary units take place.
Furthermore, since the beginning of 1970’s, the restraint of hospital construction became
a major theme. There was more supply than demand and the health quality was not
better. In this context a counterculture begun, against the modern society ideologies.
‘Patients were not treated as people, but rather as a collection of possible diseases (...)
Modern society was criticized as an authoritarian machine, (and) the modern hospital as a
‘medical fortress’ (Wagenaar 2006, 37).

______________________________________________
11
This strategy was firstly introduced in American veterans’ hospitals between 1950’s and 1960’s. It was only introduced
in Europe, in 1956, by Nelson in his project of Hôpital Mémorial France-États-Units in Saint-Lô. (Cor Wagenaar, 2006)

15
 The role of architecture in children’s recovery and development!

An alternative to block hospital started to appear with low-rise buildings, and greater
walking distances. ‘It’s better to go out than up’ (Rosenfield 1977, 8).
Respecting these ideals, a more flexible, neutral and patient oriented approach was
considered. In the Netherlands, there is the interesting example of Sint Elizabeth
Hospital in Tilburg, designed by Roelofs Nijst Lucas in 1982. This hospital mixes the low
rising building divided in small units12 and a high-rise block, in order to combine the
advantages of both types.

Figure 01.16 - Outside view of Mémorial France-États-Unis (1956); Figure 01.17 - Outside view of
Leyenburgziekenhuis (1971), The Hague; Figure 01.18 - Outside view of Sint Elizabeth (1982), Tilburg

The 1980’s and the 1990’s represent a continuation of the projects from the 70’s. They
present new ideas such as large passageways, huge walls and covered squares, where
one can find restaurants, shops and cafes13. However, this counterculture only changed
the hospital from medical-dominated to management-dominated, without fulfilling their
goal. (Wagenaar 2006)
Since then, many authors and movements have been trying to achieve the
counterculture real purpose: centralize the hospital on people. It has been talked about
principles of wellness, de-institutionalisation, decentralisation, urbanisation and shopping
mall medicine, as well as, concepts as Healing Environments and Evidence-Based
Design. Although the future is unpredictable, ‘the only certainty is that this is the
appropriate time for fundamental change. The fifth revolution (returning hospital to
people) has only begun’ (Wagenaar 2006, 41).

02. PEDIATRIC HOSPITALS

There are many authors that followed the typological evolution of hospitals, though the
specific evolution of paediatric hospitals is lesser known. Nevertheless, a new typology
usually emerges in unsettled times of acute need. That is the case of Dutch Paediatric
Hospitals, which appeared in Rotterdam, in a scenario of sickness and premature death.
In the mid-19th century, Rotterdam was the big stage of Industrial Revolution in The
Netherlands and the new centre of world economy, because of the construction of the
new port (Tellier 2009). For this reason, there was a massive migration from the
countryside to the city, increasing poverty, unemployment, poor hygienic conditions and
housing problems. Based on these circumstances, there was a call for government
intervention in 1850 to prevent diseases spread and improve life quality. However,
children were not included in the plans, since they were not part of the working group.
Sick children were nursed at home and treated by general practitioners (Offringa 2003).

____________________________________________
12
It was believed that small units would give a better human scale.
13
One of the cases study is inserted in the AMC (Academish Medisch Centrum), which can be integrated in this period
when a human and open hospital were main goals.

16
Children’s Hospitals

In 1863, an epidemic of measles, smallpox and whooping cough contributed to a

tremendous increase of infant mortality, with 59‰ of children dying younger than 5 years
(Lieburg 2004). Also, general hospitals were not prepared to take care of sick children,
placing children and adults, with all kinds of infectious diseases, in the same room.
A new awareness on sick children started in Paris (1802), Vienna (1837), London (1852)
and spread all over the world. This progress was also felt in the Netherlands, with the
establishment of the first paediatric hospital that appeared in Rotterdam, in 1863.
Different from the corridor type and other current tendencies, the first paediatric hospitals
were forced to occupy residential houses due to economical problems.
After Rotterdam, many other children’s hospitals opened in other cities, such as
Amsterdam (1865), Arnhem (1881), The Hague (1885), Utrecht (1888), Dordrecht (1891)
and Groningen (1892). It is curious that the individuals who took the initiative were mainly
doctors, which show that they were the ones who could closely identify the problem.
During the early days of paediatrics, they were purely charitable institutions, living from
the money collected between the privileged classes and were specially aimed to treat
poor children from families in need. Moreover, they frequently adopted the name of the
regent Queen in order to be more likely to get support. Only in 1892, the Dutch Society of
Paediatrics was founded, including the medical directors of all children’s hospitals, and
the paediatric medical specialisation was introduced (Offringa 2003).
Paediatrics, as the name predicts, focus on children’s diseases, clarifying the distinction
between them and adults. Children’s diseases occur in different ways and also respond
differently to medications due to their particular pathophysiology. Furthermore, children
raise much more ethical problems than adults, due to their little comprehension of the
world, and immaturity to make decisions. For this reason and because children need
constant accompaniment and care, parents have a major role. In Eerste Verslag van het
Kinderzikenhuis (1888), it is stressed this sense of care by stating the importance of
specialised nursing care. ‘Nurses should be civilized and educated women, who know
how to love children, who can play and read with them, thus engage them as a mother
would do’. It is also added the statement of Dr.Monchy14, in 1864, about the importance
of keeping children and adults apart, because children can see, hear and learn things
that are unsuitable for them. Even though there was a new awareness for the need of a
child friendly environment, by this time, the architecture of buildings were not distinct
from adults. It only differed in terms of room objects, type of activities and care.
It is in this context that Paediatric hospitals begun and evolved, lacking a typological
identity over time, most likely due to implementation and financial problems. They often
expanded to the neighbourhood, but they lacked the opportunity to be raised as a unique
project at once. However, at the environmental level they became the first to develop a
certain patient-centred concept, due to children’s special requirements. Over time It can
be noticed the inclusion of new spaces, such as play areas, education rooms and so on.
Only later they fused with academic hospitals, and could have a stable budget, being
included inside the hospitals or stand out with their own contemporary new design. The
following examples will show the evolution of the hospitals chose as cases study, which
constitute two very important paediatric hospitals in the Netherlands.
____________________________________________
14
Dr. Monchy is known as one of the founders of the first hospital in The Netherlands, located in Rotterdam. He was also
part of the Dutch Society for Pediatrics in Utrecht. (Lieburg, 2004)

17
 The role of architecture in children’s recovery and development!

2.1. EMMA CHILDREN’S HOSPITAL

The Children was the second children’s hospital in the

Netherlands, founded in 1865, by the initiative of Dr. Samuel de
Ranitz, in Amsterdam. The first location took place in the English
Orphanage on Oudezijsachterburgal. However, this building was
not created for this purpose, and could only offer one room for
twelve cribs (Bol 1990). The lack of capacity led the organisation
to move to a new building in 1872, located on Sarphatistraat and
designed by the architect P.J. Hammer.
The new hospital was extended several times, which is well
documented in a report presented by the Municipality of Figure 01.19 - Picture of
Amsterdam (Stadsdeel Centrum 2010). the English Orphanage on
Oudezijdsachterburgwal,
The first building consisted on a central body, which included
Amsterdam (1783)
waiting rooms, offices, service rooms and kitchen, and two lower
symmetrical wings of wards.
In 1876, a four storeys high isolation building was added.
Thereafter the wings of the original building were demolished
and replaced in different times (eastern in 1885 and western in
1891), most likely due to the lack of capacity during the harsh
winters.
In 1899, Queen Emma became patron of the institution. Under
the new name, Emma Children’s Hospital, built a new building
(1906), located in the corner of the urban block, isolated from the
others.
Only in 1959 a major renovation was observed again. The
architect H.L.J. Reck designed a continuous glazed façade
connecting all buildings and demolishing the isolation building.

The differences between the different epochs of extensions are

clear. The first building represents typological similarities with
the large villas, showing a link between the residential and the
large institutional buildings. On other hand, the extensions built
until 1906 were typologically close to the traditional Amsterdam
tree-axis housing. Also, the later approach represents the ‘use of
glass’ tendency of the time. Nonetheless, this hospital doesn’t
belong to any hospital typology but it respects the historical Figure 01.20 – 01.23 –
image of the neighbourhood. Emma Children’s
In 1988, Emma aiming the end of financial problems merged Hospital Evolution
with the AMC hospital building in the Southeast of Amsterdam.

Figure 01.24. Aerial view

of the AMC hospital (2014)

18
Children’s Hospitals

2.2. WILHELMINA CHILDREN’S HOSPITAL

‘The Utrecht Children’ was founded in 1888 by Dr. Hulshof

along with other five members of the Utrecht City Council. Its
first location took place in Oudekerkstraat 28-30, with a
maximum capacity for 9 patients. It is curious the tale of the
first patient recorded, who was sent home after being identified
she had tuberculosis (Hart 1988). This demonstrates the lack
of physical support, required to isolate contagious patients.
To deal with the problems of the location, in only two years,
the hospital moved to a neighbour building. The information
about these two properties is really scarce, however it could be
hypothesized that the occupation took place in residential
buildings due to their functional division, easily adapted to
hospital functions (rooms, bathroom, kitchen).
Over time, the lack of capacity persisted and called for change,
but the severe financial problems meant an unfeasible new
hospital construction. Nevertheless, in 1898, under the name
of the Queen, the Wilhelmina Children’s Hospital moved to a
property in Nieuwegracht 137 (Schaap 2002). Located near the
canal, the building is part of a residential composition,
respecting the size, scale and rhythm of the neighbourhood.
The following years were marked by hospital major extensions:
In 1935, the hospital occupied the next-door building, in
Nieuwegracht 139, to function as a daily clinic for childhood
diseases (Schaap 2002).
After the war, a new extension was required to accommodate
the new clinic wards, so some houses from the city block were
expropriated and demolished to open space for new
constructions. This new addition consisted of a 30-meter-high
concrete ‘tower block’ building, with a reduced plot size but
exceeding the neighbourhood scale. It represented a large
institutional building that can be integrated in the hospital
typologies of the 20th century.
The last extension started to be built in 1969, aiming to link the
new wards block with the treatment building. This new wing
connected the different heights of the small facades in the Figure 01.25 – 01.29 -
street and the high tower. Wilhelmina Children’s
Hospital Evolution
Overall, the new interventions brought a disproportionate scale
and image to a slightest city scale, widely represented in the
neighbourhood. It became predictable that city limited space
would force the hospital to move towards the outskirts of the
city. As expected, in 1999, the WKZ merged with the medical
faculty and the Academic Hospital of Utrecht, moving to a
totally new hospital construction in Uithof.

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 The role of architecture in children’s recovery and development!

03. THE IMPACT OF BUILT SPACES IN CHILDREN’S LIVES

‘Children are our future. What happens to children in their first days, months and years of
life affects their development, the development of our society, and the development of our
world.’ (Bernard van Leer Foundation 2004)

The growing attention paid to children and the recognition of their autonomy since the
mid-19th century has resulted in the creation of different childhood spaces in European
socio-cultural context. The public awareness about healthy and safe environments and
the establishment of medical, psychological and sociological scientific studies about
children are in the base of the impulse given to the childcare facilities.
Childhood presents an important age-group, not only because of their dependency to
grow up and form good citizens, but because children are in a learning process of
knowing themselves and relating with other people and the world around. There are
many physical and psychological factors involved, but this work focuses on the impact of
the physical context on children, especially the built environment, which has been
receiving a growing recognition.
Early childhood is considered the privileged time for children to develop their place
identity. This is defined by Proshansky and Fabian (1987, 22) as a substructure of self-
identity, which includes ‘cognitions about the physical environment that also serve to
define who the person is (…) represented as thoughts, memories, beliefs, values and
meanings relating to all important settings of the person’s daily life. (…) Place-identity
cognitions monitor the person’s behaviour and experience in the physical world’. A good
environment will be more likely to produce good outcomes than an ineffective one. This
is especially true when vulnerability increases the susceptibility to the exterior agents, as
the case of hospitalised children.
Hospitalisation can be a very traumatic and terrifying experience for a child. It represents
not only a change in health condition but in environmental routine, which most children
possess no skills to cope with, generating responses as regression, anger, fear,
depression and anxiety (Deitch and Rutan, 2001). By simply entering the hospital,
children can feel anxious and out of control, for which Olds (1979) suggests the
adaptation of spaces and hospital features to enable children of fulfilling their basic
personal needs without assistance. In fact, it should be a duty of hospital environment to
avoid negative responses, and let children be able to recover in dignity and grow in
harmony with what is supposed for their age. Noise, light, colour, privacy, distractions,
age-appropriate environments and family supportive spaces15 are among the main
factors that can be manipulated to reach these objectives.
Patient centred care design is starting to be applied and paediatric hospitals are finally
implemented and competitive in society. Nonetheless many hospitals today, continue to
appear as places of disposal and death, which people avoid. It is time to investigate the
needs of hospitalised children in the actual context, identifying the physical dimensions
that can be changed and how, in order to improve these environments.

____________________________________________
15
Research topics identified by Mardelle McCuskey Shepley, an associate professor in the Department of Architecture
and associate director of the Center for Health Systems and Design at Texas A&M University, in her co-authored book
Healthcare Environments for Children and their Families (1998).

20
Children’s Hospitals
 The role of architecture in children’s recovery and development!

ARCHITECTURAL DESIGN: THE THEORETICAL APPROACH, PRINCIPLES

AND RECCOMENDATIONS. 02
!
Children’s Hospitals

01. APPROACHING THE HOSPITAL

1.1. HOSPITAL, CITY AND SOCIETY

Hospitals reflect life. Every day, there are people from different ages, social classes and
genders, coming in and out. Some are working, others visiting or even living for a certain
period. Cor Wagenaar (2006) compares hospitals with cities, since both aim to construct
a living society comprising social, cultural and economic integration. The author even
relates their functional organisation, by stating that the hospital division into departments
and respective connection by corridors is similar to the cities’ neighbourhoods, streets
and squares.
Constructing a hospital may, therefore, be referred as building a ‘city within a city’16,
where a hospital is seen as a city with its own interior complexity, while it does not cease
to be a constituent element of the city. Independently of being a general or a specialised
hospital or even a clinic, it will relate with the city in terms of location, scale and
accessibility, affecting people’s lives. It is part of the architect role trying to bridge the gap
between medical world and everyday life.
Even though the mid-20th century brought a construction of big concentrated and
specialised hospitals, this trend started to fall behind with the new reorientation towards
the patient. Arguments such as reduced travel distances and easier access to earlier
diagnosis and preventive therapies (Cole 2006), or easier integration of smaller units in
the city (Wagennar 2006) are defended in order to decentralise the hospital.
However, the integration of the hospital in the city needs to respect the city’s identity, i.e.,
the hospital should fit entirely in the scale and structure of the city’s urban tissue. This
also leads to a certain level of fragmentation, since it would be impossible to respect the
road system, zoning structure and city scale if all hospital functions were agglomerated
in one block (Wagenaar 2006).
Another favouring point for decentralisation is the drop in inpatient care and increase in
outpatient care17 (Verderber 2006). This fact reduces the space needed for overnight
purposes and facilitates the division into clinics spread all over the city. Although
Verderber (2006) recognises the increased trend of small residentialist patient care and
small-scaled critical care centres, he admits that large medical school hospitals
existence will need to continue.
Such an agglomerated body of services is difficult to separate or remove. Academic
hospitals cooperate with universities, providing training and improving the learning
process of the future physicians. Furthermore, they provide a single multidisciplinary
approach, where the most specialised services are available, together with an advanced
research and technology (Steven and Wartman 2007). At an architectural level, their
location in the outskirts of the city allows more possibilities of orientation and extension.
There is a need to look for more strategies to open the hospital to the city and society
apart from decentralisation. More than look up for a place to cope with the disease,

____________________________________________
16
The ‘city within a city’ statement is frequently used in various subjects, such as in the book of Todd Robinson, where it is
examined the Civil Rights Movement and also as a popular concept of contemporary urban development in Japan. In this
context, it was used as a mean of looking to the hospital as a city inside the truly city.
17
The drop of inpatient admissions can be explained not only by the increase of outpatient demand, but also by rise in
prevention and proactive care; the release of new technologies for outpatient treatment; a pressure to reduce
readmissions; and, the practice of elective admissions. (Sullivan, 2014)

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 The role of architecture in children’s recovery and development!

hospitals can be ‘reconceptualised’ to offer wellness and some hospital amenities can be
opened for public use.
In a time when lack of physical exercise and stress are fatal for people’s health, wellness
centres are gaining roots. One challenge to the hospitals is to integrate this kind of
services, adopting a more positive image in return of attaching a medical approval to the
wellness practices (Wagenaar 2006). Furthermore, the hospital can also integrate non-
medical related attractions to invite people from the outside and new costumers.
Supermarkets, restaurants, bookshops, cafes, travel agencies are in between the
shopping mall attractions that can be implemented. Nonetheless these commercial
attractions also benefit of an assured flow of costumers (Wagenaar 2006).
Green areas, shared by both hospital and city, can also constitute an attraction. This
facility could help in the patients’ healing process, increasing socialisation and sense of
belonging to society, and decreasing the plot area.

1.2. HOSPITAL OF THE FUTURE

The ideal to reach a hospital model that comprises a harmonious connection with the city
and society, and, at the same time ensures an optimal physical and emotional support to
patients and families, became the research topic of many authors. Many new healthcare
concepts are being created, developed or only predicted, based on different approaches.

1.2.1. HIGH-TECH

The fast technological advances noticed nowadays, leads many authors to wonder in
which ways it can contribute for an advance in healthcare concepts and, consequently, in
the design of healthcare facilities. Verderber (2006) predicts that this actual technological
advances will lead to a home-based virtual healthcare, by the year of 2050. This virtual
clinic would allow patients to be consulted from the comfort of their houses, or have
access to medical information wherever they are, anytime they want. The hospitals, as a
physical building type, would certainly continue to exist (though in smaller number) in
order to support the most acutely ill, which need constant monitoring.
Cole (2006) refers the already used prototypes of home-monitoring systems. These
equipments were created to cope with the overloaded hospitals capacity caused by the
need of chronic ill patients to be constantly admitted. In this way, it would be possible to
guarantee a similar healthcare quality in the comfort of one’s home.
Other perspective is the one defended by Heckermann (2006), who talks about an
increasingly used healthcare technology, the automated and online management of
hospital. This process consists on substituting human activities by an automated and
quicker system, which should result in an increased efficiency.

2.2. HOMELY ENVIRONMENTS

Another current perspective is the substitution of hospital’s institutionalised image by a

homely and comfortable atmosphere. Hotel-like facilities are considered a good solution
since they are easy to implement in inpatients’ wings, have a comfortable image and

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Children’s Hospitals

constitute an economic solution for many patients (Hofrichter 2006). The fact is that
hospital rooms are expensive due to the presence of numerous medical and
technological machines, while hotel rooms can offer a more homely and comfortable
environment without those increased costs, as long as the patient is in a stable medical
condition. Other defended reasons to adopt this solution are the increasing number of
single people that have no one to look after them in post hospitalisation period and the
belief that health insurances will only cover the medical care, while patients will have to
pay the bill of their room. In this way, this approach would provide a homely environment
in a reduced cost with an ensured medical vigilance.
With other perspective of offering a homely-environment appears the well-known project
of Maggie Centres18, well documented by Jenks (2006). These centres were set up by
the experience and conviction of Maggie, who aimed to dedicate her last years of life to
build something that many people would benefit. A sense of informality and domesticity
were combined to give rise to several small centres, in UK, where it can be learnt how to
deal with stress, loss of control and understand the disease and potential therapies. All
this psychological and emotional support is given in an artistic and positive environment
created by the expressive architecture and gardens.

1.2.3. CENTRALISATION OR DECENTRALISATION

In an urban perspective, Boluijt (2006) defends the creation of a decentralised hospital.

The model consists in creating a central core hospital, with several satellites around the
city. The central building would have all intensive care and high tech functions, while the
satellites would offer a specialised and mono-disciplinary care. Thus, the hospital would
be spread around the city, attributing neighbourhood facilities, which would avoid
undesirable long home-hospital distances. Furthermore, their proximity to shops,
theatres and other urban amenities would add value for visitors and personnel.
On the other hand, Cole (2006) talks about the Centres of Excellence, characterised by
their high-specialised care for a specific disease or population and often located in
academic hospitals. This high medical performance recognition usually attracts more
patients. Furthermore this hospital ideal takes into account an image of a big institution,
which can be used by a big range of people, even international, with easy access by car,
public transports or airplane. However, this approach also takes into account the
importance of including family accommodations and a pleasant environment.

The focus on the potential improvement of hospital user’s lives is unquestionable, even
though the way to achieve it is uncertain. Clearly, the society will assist to an increase of
technological systems, a higher concern on well-being and a will to decentralise hospital
and bring it closer to people’s daily lives. However, as it was presented before, even if
the majority of mega hospitals will be spread through the city, at least a big central
academic hospital will have to remain due to its unique set of services. Therefore, the
Academic Hospitals is the central focus of this study, in a perspective of combining a
high medical performance with human scale departments, which should offer a homely
environment with the proper social and emotional support.

18
Maggie’s Centres are considered a hybrid building type since they join several typologies, without being any of them.
The typologies considered are home, since they give a sense of comfort and belonging; museum, due to their art pieces
and meaningful architecture; hospital, by giving psychological support and medical knowledge; and church, standing on
people’s believes and giving a determinant importance to the soul and emotional well-being. (Jenks, 2006)

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 The role of architecture in children’s recovery and development!

02. HOSPITAL ENVIRONMENTS

2.1. CURRENT TERMS

2.1.1. CHILD-FRIENDLY HEALTH CARE

A movement towards patient in healthcare is increasing since the last decades. The
patient is becoming to be seen as a client, promoting competition between the different
healthcare facilities. Thus, the best quality/cost ratio is required, raising the economic
factor to an important level in all project decisions.
Regarding children, The Council of Europe (2011, 6) defined child-friendly health care as
a ‘health care policy and practice that are centred on children’s rights, needs,
characteristics, assets and evolving capacities, taking into account their own opinion’.
This concept states that besides the high medical quality that should be guaranteed,
children19 should have the right not only to be informed, according to their age group,
consulted and heard, but also to not be separated from their family. Family-friendly
health care is considered an included notion.
The concern about Children’s rights in Hospitals only started to be further discussed in
1950’s, when some psychologists and paediatricians showed that emotional care was
detrimental for children’s well-being. For example, the separation from their families was
proved to bring long-lasting emotional disturbances (Horst and Veer 2009). Thus,
beginning in the UK, it was published The Welfare of Children in Hospital, also known as
the Platt Report (1959), in which the visitation policy and the admittance of mothers with
their infants is a main issue (Kozlovsky 2013). Not long after, in 1988, twelve voluntary
associations for the welfare of children in hospital met together in Leiden for their First
European conference. At this conference was defined the rights of children in hospital,
also known as the EACH Charter (attachment 1). Since then, the organisation has been
trying to develop more detailed explanations and promote its equal implementation in the
various countries. (EACH 2006-2016)
In The Netherlands case, the EACH charter was brought into force in 1995. The country
is actually represented by four associations in EACH, including Kind en Ziekenhuis, NVZ
(Dutch Association of Hospitals), NVK (Dutch association of Paediatrics) and V&VN
Kinderverpleegkunde. These associations aim to defend children’s best interest,
encouraging the implementation of new measures to improve quality.

2.1.2. CHILD-FRIENDLY ENVIRONMENTS

To achieve the objectives listed in the EACH charter is necessary that the hospital
environment can offer the right physical support otherwise it would not go beyond an
ideological goal. This will to translate the children’s rights in the hospitals into design
recommendations, led to the creation of The Nuffield Foundation’s Children in Hospital,
in England. This document constitutes a pioneer, unique study, where techniques such
as surveys, direct observation, and statistical analysis were used in hand with a more
humanized vision of architecture. It represents an architectural companion of Platt
____________________________________________
19
By children it is meant any person under the age of 18 and parent refers to the person with parental responsibility by
law. (The Council of Europe, 2011)

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Children’s Hospitals

Report, where notions of comfort, privacy, vigilance, parents’ presence, lightning,

acoustics and temperature are discussed (Kozlovsky 2013). Some more punctual
studies, regarding paediatric environments followed, such as Child Health Care
Facilities: Design Guidelines and Literature Outline (1987) by Anita Olds and later
Healthcare Environments for Children and their Families (1998) by Shepley, Fournier
and McDougal.
However, the majority of the actual research about healthcare settings continues to be
carried out with adults, and as it was explained before, children and adults have different
physical and psychological characteristics that disable a generalised analysis. Thus, this
lack of theory and rigorous research led healthcare architects and interior designers to
do their job based on their acquired-knowledge (Shepley 1998), projecting their own
goals. Nevertheless, there is an increasing necessity to prove, through demanding
studies, the relation between physical environments and children behaviour and well-
being, i.e., discover if a certain spatial feature has indeed a positive impact on children,
and if so, what type, and how can it be improved. The main objective should be always
to create positive outcomes by means of design.

‘(…) The Nuffield study suggests that the children hospital was increasingly socialized to
include non-medical functions that were designed to provide parents and children with
comfort, interest, and continuity with ordinary life at home and school.’ (Kozlovsky 2013,
170)

Besides hospital medicinal purposes, hospitals seems to incorporate social

responsibilities with its users, allowing them to be active citizens rather than solely sick
ones. A will to bring important aspects of outside daily-life to the hospital can be noticed
through the design of non-medical functions. Hospitalisation should provide ways to
allow a regular development and growth through the integration of a homely environment
and access to educational, social and entertainment facilities. A respectful environment
would surely help improving healing process.

2.1.3. HEALING ENVIRNONMENTS AND EVIDENCE BASED DESIGN

Although there may be other approaches, the healing effect cannot be disregarded. But,
how can architecture contribute to healing?
One of the ways is through placebo effect as Jencks argued in his article Maggie
Centres and the Architectural Placebo (2006). The placebo is considered a fake cure,
since it simply operates on patient’s beliefs, producing improvements in patient’s health,
such as reducing pain, inflammation and psychogenic problems. The author extrapolates
from the evidence that brand name placebos relieve pain better than generic placebos
and also colour influence the sedative effect. Thus style and brand image in architecture
will also have implications on patients’ outcomes.
However, one can only claim to be facing a Healing Environment if there is sufficient
collected evidence to reach that conclusion. This means, ‘a healing environment is the
result of an Evidence Based Design that has demonstrated measurable improvements in
the physical and/or psychological states of patients and/or staff, physicians, and visitors’

27
 The role of architecture in children’s recovery and development!

(Hamilton 2006, 271). Against this idea some architects defend that scientific studies
erode the intuitive and artistic side of the profession. However, Shepley (2006) claims
that such a complicated design will always leave place to intuition, and the best
healthcare design will be equally dependent of both, art and science. A multidisciplinary
approach is required, counting with the collaboration of investigators, doctors, nurses,
designers, engineers and even children.
Evidence based design (EBD) strengthens its position by the fact that evidence shows
major gains by implementing a design based on rigorous research (Ulrich 2006).
Although the medical outcomes of healing environments cannot be compared with
surgery, pharmacology or simply good nurse caring, it presents a complementary
treatment (Hamilton and Watkins 2009). Furthermore, once architects have this acquired
knowledge with proved beneficial results, they have the moral obligation to act according
to the public’s welfare. The achievement of better results is also an appeal to business-
minded administrators, who are interested in improving effectiveness and reducing long-
term costs (Hamilton 2005).
EBD origins and evolution is closely related with Ulrich’s20 work. In his article Evidence
Based Healthcare Design (2006), Ulrich advocates that the design of hospital physical
settings can avoid medical outcomes to be worsened. This is achieved by preventing
and controlling airborne or contact infection and reducing medication errors; by
minimizing environmental stressors such as noise, accesses, exposure to certain
physical features and social situations; and it can also increase patients’ safety by
reducing staff fatigue and improving patients’ observation.
Stress presents one of the major medical influencing factor that is intimately related with
the disease and medical procedures, but environmental problems are also a major
contributor. There is growing evidence that children’s health is adversely affected by
stress (Dise-Lewis 1988; Varni and Katz 1997). The body’s response includes improved
fatigue, energy waste; negative physiological, neuroendocrine, psychological and
behaviour manifestations (Brannon and Feist 2004; Ulrich 1991); reduced immune
system effectiveness; decreased resistance to infection; and, delayed recovery (Kiecolt-
Glaser et al. 1995).
After identifying the great variety of physiological, psychological and behavioural
negative manifestations, which stress could produce against patient’s wellness, Ulrich
formulated the Theory of Supportive Design. This theory evokes the removal of
environmental stressors trough design, fostering sense of control, social support and
positive distractions. These three components can positively influence stress and
wellness. This theory aims to help dealing with the existing stress through design,
preventing it to be itself a stressor element; increasing the exposure to stress reducing
activities; and, applying measures to all target groups (including visitors and staff) since
their well-being or discontent will have repercussions on patients (Ulrich 1997).

‘I am convinced that the movement towards patient and family-centred care is permanent.
Healthcare facilities of the future will be explicitly designed for a positive patient experience
and will strive to sensitively accommodate the needs of families and the important social
support systems of patients.’ (Hamilton 2005, 278)

____________________________________________
20
Roger Ulrich is professor of architecture at the Center of Healthcare Building Research at Chalmers University of
Technology in Sweden. He is the most renowned researcher in evidence-based design field, having contributed a lot to the
improvement of health outcomes and patients’ safety around the world.

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Children’s Hospitals

2.2. INFLUENCING FACTORS AND DESIGN IMPLICATIONS

The aim to achieve the best possible environment, led many authors to investigate and
publish their results in articles or books, which can serve as guidelines to design in a way
that generates better outcomes. Based on the studied literature, the influencing factors
that seem to have the most profound repercussions in children’s lives in the Hospital,
and which can be manipulated trough design, were selected. In order to deal with the
lack of specific investigation on the infant population, whenever exists lack of rigorous
information it would be complemented by research held with adults or overall population,
expecting future researches in the field.

2.2.1. SENSE OF CONTROL

In general, hospitals have established routines and rules that may lead to patients’
helplessness, i.e., ‘experiencing of uncontrollable events can lead to an expectation that
one cannot control future outcomes’ (Seligman 1975). Lack of privacy, poor way finding,
physical barriers and poor communication are among the aspects that intensify the
feeling of lack of control. Furthermore, this feeling has proven to cause an increase in
blood pressure, passivity, and depression, and suppress immune system (Ulrich 1991).
An effective way to combat it is to provide patients with choices. Even if the choices are
not ideal, the range of alternatives will increase patient’s sense of independency
(Hamilton and Shepley 2009).
The experience of losing control is almost related with every aspect of living in the
hospital, such as disability to decide what or when to eat, or even the visitation hours. To
a better balance, Huisman et al. (2012) recommend the ‘self-supporting systems’
approach, enabling an increase of control trough the design of physical settings. One
example can be enabling room changes, such as position of the bed, the degree of
natural light or sound volume (television, music).

Figure 02.1 - Sense of Control Variables in Hospital Settings

Way finding constitutes one of the aspects that influence the sense of control. It is
considered a ‘spatial problem solving’, and extensively defined as ‘the process of
reaching a destination, whether in a familiar or unfamiliar environment’ (Arthur and
Passini 1992). A mental image of the place layout is required for a spatial orientation.
Understanding the actual location, the destination location, the route to choose, how

29
 The role of architecture in children’s recovery and development!

to follow that route or when the destination is reached, are part of the problem-solving
process (Huelat 2007).
In healthcare field, the early work of Carpman (1986) defends that way finding affects
stress and can be improved through nomenclature, density (number of signs), context,
placement, and visibility. A poor way finding in such typology can lead patients to be late
to medical appointments or get lost easily, which represents an avoidable environmental
stressor. Therefore, architects play an important role not only in the image and
placement of signs, but also in the way spaces are designed. Patient’s position within the
building can be clarified, for example by placing windows in corridors, designing clear
pathways, enabling easy-to-see elevators, creating strategic placed landmarks and
designing an easily identifiable entrance (Huelat 2007).
In regard to children, their perception and navigation trough space is different from
adults, thus children’s hospital needs to provide solutions for a wide range of ages. The
use of clinical terminology seems confusing to children, but the use of colours to
differentiate areas seems suitable for all ages. Colour is ideal because it can be easily
applied in various materials and can create specific emotional and physical responses
(Mahnke 1996). Other examples are the use of mosaics, floor markers, signs or even
artwork as landmarks, which can be associated as reference points (Bayliss-Robbins
2012). Graphic work, including wall illustrations has gained an important role, since it
helps to provide a calming distraction, and also act as navigational landmarks. However,
attention should be taken in attributing a specific colour scheme and theme to each
department, attribute consistency to the mental route.

Privacy is other factor closely related with control, being defined as ‘an interpersonal
boundary process in which a person or group regulates interaction with others’ (Altman
1975, 6). This ability to control interactions can be considered even more important than
the proper social interaction (Shepley 2005) since it enables the controlled access to
personal space or to the groups whom one belongs. However, both privacy and
socialisation are important factors and should be balanced in an effective way to offer a
better hospital environment.
The fact is that routine care protocols and nursing procedures sometimes violate
patient’s personal space, invading a level that was only supposed to be reached by
family members and closer friends (Hamilton 2009). Furthermore, privacy is also
neglected when patients sleep in shared rooms with strangers; financial information is
published; the triage is done in public spaces; patients are left on gurneys in corridors
(Shepley 1998); or simply the inexistence of a space to be alone or to talk with someone
in particular. Several studies have been considering ways to provide ‘spaces to be
alone’. Children, in particular, identify a strong correlation between privacy and the type
of room attributed, considering that single rooms provide a greatest degree of control
(Lambert et al. 2014).

Finally, personalization attributes children the possibility to manipulate their

environment, being an important element of control. Personalization is an appreciated
aspect of hospitals’ capacity of adaptability and flexibility. Even though there is scarce
literature about this theme in paediatric hospitals, it can be highlighted the work of
Blumberg and Devlin (2006), in which they stated that being able to bring personal

30
Children’s Hospitals

31
 The role of architecture in children’s recovery and development!

belongings from home and to personalise the bed area, was important for teenage
group. This way, they have the possibility to establish their identity and appropriate level
of comfort. It is even stated that the opportunity for self-expression and manipulation of
the environment can be considered more important than the ward appearance and its
appropriateness for age.
Moreover Shepley et al. (1998) underlined the importance of personalization by
interpreting the aspects of built environment that could be implemented to improve this
aspect. They defended the introduction of picture boards, lockable storage and shelves.
This capability of changing the environment with one’s personal taste enables patients to
be surrounded by familiar things of value, allowing at least an emotional proximity of the
loved ones. This became especially important for long-term hospitalisations, since this
adaptability level allows patients to change their personalized elements whenever they
want.

Figure 02.3 - Design Guidelines to provide patients with sense of control!

32
Children’s Hospitals

33
 The role of architecture in children’s recovery and development!

2.2.2. SOCIAL SUPPORT

Children as their early age predicts are extremely affected by social support and parental
care. Their lack of knowledge about the world leads them to create expectancies on
surrounding people, whom they trust to be available and to give a good social support,
helping them to face any problem that may arise. Furthermore, it is desirable that this
support can be translated in a future competence for children to deal with their own
problems, developing ‘self-confidence’. (Aken 1994)
Children should socialise not only with the people on whom they are directly dependent,
but also with other children and adults. When interacting with other children, they learn
social skills, as getting friends’ attention or ask to share something or only say something
nice. Researchers stress the importance of positive relationships in childhood and later
life (Ladd 1999). In case of hospitalisation, it is important for a good development and to
avoid isolation and rejection.
Social support has been shown to reduce stress in population belonged to diverse
categories (Ulrich 1991). Thus, spaces for this purpose should be made available to
enable opportunities of socialisation for each age group (Coyne and Kirwan 2012).
However, there are only a few researches about the way hospital design can facilitate or
hinder access to social support.
An example of how physical space can inhibit socialisation is the organisation of the
traditional waiting rooms. These spaces usually concentrate the playing activities for
small children placed in the central area, while older children sit with their parents on the
chairs arranged side-by-side around the edges (James, Curtis and Birch 2007). The
main idea is to prevent that physical space become itself a barrier to socialisation, and
growing evidence has been indicating that offering lounges, day rooms, and waiting
rooms with comfortable moveable furniture will help to increase this beneficial activity
(Ulrich et al. 2004).

In relation to parental support, family appears as a primary source of social support,

even more in a specific situation as hospitalisation. Although, family support was not
always attributed this importance. After the First World War a period of strict rules
regarding sick children begun. Children were left alone, with the minimum interaction to
avoid infection. They had nothing to do but staring at the ceiling and parents could only
visit them for half or one hour each week. (Hatfield 2013)
Despite all these provisions, the mortality continued to increase. The reasons for this
event started to be studied by Spitz and Bakwin, which concluded it was resultant of lack
of emotional care and physical contact (Kozlovsky 2013).

‘(…) in infancy the loneliness involved in separation may be not only undesirable but lethal’
(Horst and Veer 2009, 123)

The first problem of hospitalisation was considered the maternal separation. Bowlby
(2009) deeply explored this subject and has identified a correlation between events of
maternal deprivation during infancy with the formation of a delinquent personality. He
claims that maternal love is a human need, and the prolonged deprivation can lead to
irreversible effects at an emotional development level (Horst and Veer 2009).

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These investigations and findings have helped to modify hospital policies. Although they
had changed slowly, they started to better answer children and their families’ needs.
Parents started to be seen as the main experts of child’s abilities and needs, and their
presence in hospital became crucial. Consequently, modifications in visitation policies
took place and parents started to be with their child whenever they want (article 2, EACH
Charter). Furthermore, parents even started to be encouraged to stay and frequently visit
their children (article 3, EACH Charter), with hospital facilities being set up to support
their overnight stay (article 2, EACH Charter).
From the parents’ perspective, having a child hospitalised can represent a profound
dramatic experience, not only emotionally but also because it implies a lot of changes in
their routine. Dealing with work deadlines, taking care of other possible children, or only
guarantee domestic tasks done without leaving their sick child alone, became a serious
and stressful problem. A shift towards family centred care started to be practiced in order
to help family to deal with their daily life, through adequate facilities design, and also to
engage them in health care policies, evaluation of the system, provision of a closer
interaction with health providers and involvement in medical decisions (American
Academy of Paediatrics 2015).
In terms of physical dimensions, it is recommended to offer parents:
- The possibility to fulfil their basic needs, offering facilities such as bathrooms in the
rooms or floor to keep them clean and fresh (Olds and Daniel 1987);
- Adequate beds to allow proper sleep and rest (Olds and Daniel 1987);
- Family room, chapel or consult room to allow privacy for professional or religious
purposes (Olds and Daniel 1987);
- Storage room to keep personal belongings in a safe place, and be able to personalize
space and be comfortable (De Vos 2004);
- Cooking and laundry facilities to allow daily tasks such as washing clothes and
preparing meals for them and respective children (Olds and Daniel 1995).
Other facilities can be added in order to provide a better experience, since parents,
similarly to children, also need socialisation, positive distractions, access to information
and a sense of being in control.

Figure 02.5 - Health Impacts, prevention measures and design guidelines for better socialization patterns
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Children’s Hospitals

2.2.3. POSITIVE DISTRACTIONS

‘(…) second to the continuing presence of the mother or another supporting figure, play
can be an important factor in diminishing the harmful effects of stress in hospitalised
children.’ (MacCarthy 1979)

Playing is extremely important for children. It not only provides enjoyment, but also leads
to an interaction and exploration of the environment (Armstrong and Aitken 2000). This
positive activity develops children’s social, intellectual, physical and emotional growth.
Furthermore, in such a specific environment, playing contributes to a decrease of stress
and anxiety (Peterson 1989), and also helps to cope with the hospital admission process
(Delpo and Frick 1988). The change from a calm, recognizable place as home, to a busy
and huge space with a lot of strange machines and different smells, noises, and faces
can be terrifying. Playing can help at this level, improving children’s understanding and
interpretation of hospital language, sights and sounds (Haiat, Bar-Mor and Shochat
2003).
In order to encourage playing, the hospital should offer social child-friendly spaces that
could provide toys and activities. It is frequent to see a playroom or play area in wards
with toys, games, craftwork, books and other activities correspondent to each age range.
Bedrooms can also have available games and playing items to attract friends and
siblings to visit patients in hospital, enlarging the playing experience.

Figure 02.7 - Play benefits and design guidelines

Education also represents a fundamental activity in children’s development. In case of

chronic illness, children have to stay long periods in hospital, so education programs
were created for them to continue following the lecture contents correspondent to their
age. Regularly, there is a need to do some adjustments in the contents regarding the
direct effect of illness in the learning process (Thompson and Gustafson 1996).
However, the continuation of this activity seems to be of extreme importance, developing
psychosocial well-being (Sanger, Copeland and Davidson 1991), and positive distraction
from illness.
The information and research in this field is scarce, especially regarding hospital schools’
physical support. In any way, paediatric hospitals should provide classrooms that allow
access by wheelchair or stretcher, as well as, all the necessary material to take
medications while learning.

Figure 02.8 - Education benefits and design guidelines

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Art is other considered positive distraction in healthcare settings, with proved impact on
stress reduction and mood improvement, but based on adults’ researches (Ulrich,
Simons et al.1991). The lack of information about its health effects in hospitalised
children lead to the development of a new study. Eisen et al. (2008) conducted the
research with hospitalised children between 5 and 17 years old, in which was found that
all age groups present a higher preference for nature art, but without relevant
physiological differences from art stimulus. These results can be attributed to the fact
that paediatric units offer a wider range of social activities than the general hospital,
where adults suffer much higher levels of isolation (Eisen et al. 2008).
However there are much more investigation to do in this field, covering a wider range of
patients. For now, it is recommended that hospital rooms could provide an art cart, with a
majority of nature-based images, for children to choose their favourite (Eisen et al.,
2008), improving their felling of control.

Figure 02.10 - Art impact on children and design guidelines

Nature constitutes not only a positive distraction, but it also has proved health benefits,
recognised for centuries. In healthcare context, several studies have reported reductions
on stress levels and health related complaints (Ulrich 1984), with adults’ patients stating
that visiting natural settings help them to overcome stressed or depressed feelings
(Cooper-Marcus 1995). Moreover, the simple access to landscape views, rather than a
brick wall, has proved to reduce hospitalisation period, analgesic doses and postsurgical
complications (Ulrich 1984).
Children are an age group particularly affected by the contact with nature and hospital
provision of gardens (Horsburgh 1995). The stress of hospitalisation can be reduced by
offering a space less complex than hospital, with a more relaxing and familiar
atmosphere, functioning as a refuge (Whitehouse et al. 2001).
Contrary to adults who exhibit a more contemplative relation with the environment,
children are especially aware of functional aspects, i.e., about the active use of the
space and respective exploration. They normally look after elements to climb, jump over,
throw (Gibson 1979) or even places to hide, where they cannot be seen but they can
look out (van Andel 1990).
However, in Whitehouse’s et al. (2001) research, it is observed that the majority of young
garden users’ were not hospitalised children but rather healthy siblings of patients, or
outpatients. This question is of major importance in order to understand how children in
more fragile condition can also benefit from this contact with nature. Raise awareness
about the garden existence; facilitate access with regard to physically handicapped
children; or giving meaningful purposes to the garden, such as providing physical
activities for recuperation, or concentrate educational and playing activities, are in
between the measures that should be taken into account for users taking full advantage
of this facility.

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Figure 02.13 - Nature impact on patients’ well-being and potential activities

2.2.4. SENSORIAL DIMENSIONS

The human senses are active perceptual systems, which can function independently or
in combination, interacting with the surrounding environment to extract information
(Gibson 1966). The sensory experience can range from the senses of touch, smell,
taste, vision and sound.
Children are especially sensible to the sense of touch, since it is the first sense being
developed when one is just a embryo (White 2014), and throughout childhood it allows
them to identify the proximity from objects and perceive movement. Through this sense
children are able to explore materials, items and food, helping in their understanding of
the surroundings (Hall 1969). In designing facilities from this age group, different textures
can be included to enrich their tactile exploration. The range of elements with different
textures can vary from surfaces as floor, outdoors’s paths, low-level walls, moveable
objects or outdoor barriers, with the use of materials such as wood, plastic, rubber,
metal, mirrors, cotton, silk between others (Post, Hohmann and Epstein 2011).
In healthcare environments, vision and acoustics are the privileged elements. Although
there is lack of research with specific focus on young age groups, it is further recognized
the benefits of daylight on hospitalised patients. Sunlight was proven to increase the
amount of melatonin produced in the brain, which is a responsible hormone for
biorhythms regulation (Olds and Daniels 1987), and also contributes to decrease the
request for pain medication on post-surgical patients (Walch et al. 2004). Furthermore, it
was documented that patients in rooms with high levels of sunlight had shorter stays,
and both electrical and natural light have positive mood effects in both healthy and
depressed patients (Beauchemin and Hays 1996).
The importance of sunlight in patient’s recovery, represent for architects and healthcare
administrators an extremely important factor to take in consideration when it’s time to
choose building orientation and site planning of new projects (Ulrich, Zimring, Quan and
Joseph 2006). Findings show that site plans where buildings tend to block daylight from
each other, or rooms with lack of windows should be avoided.

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However, daylight is not the only light source used in healthcare settings. Normally it is
used in combination with artificial light. Both diverge in terms of uniformity, colour,
amount of UV radiation, diffusion, level of luminance and variation during the time.
Daylight can be highlighted by producing a full spectrum of visible colours, varying over
the day with latitude, meteorological conditions, and seasons (Boyce, Hunter and Howlett
2003). It also prevents the use of artificial light and, consequently, reduces electricity
costs.
On the other hand, artificial light can be fully controlled and provide the most suitable
light for each function. For example, a more intense light is required for examination
while other more comfortable provides a better homely environment. Furthermore there
are already full-spectrum electric lights that provide a similar spectrum to daylight. Thus,
some studies claim that both light sources can be considered equally satisfactory to
preform most of visual tasks (Boyce, Hunter and Howlett 2003). In addition, artificial light
can be very useful in paediatrics, since it can function as a positive distraction for young
patients when placed on the ceiling (Dutro 2007).
Independently of the light source, provide patient with control over the type of light,
intensities, or over the window blinds, can contribute to better outcomes.

Figure 02.14 - Natural and Artificial light: advantages and design guidelines

Other element of visual stimulus is colour. The impact of colour in healthcare settings
has been widely investigated, and has been found to improve satisfaction of children and
their families (Park 2007). Investigations about the most suitable colours have also been
carried. However plenty of contradictions can be noticed between existent guidelines in
literature (Tofle et al. 2004). Nevertheless, Tofle et al. (2004) states colour-mood
associations do exist, varying between different people, i.e., it cannot be concluded that
everyone will have the same relationship between a certain colour and a specific
emotion.
While a number of contradictions have been found, a number of trends have also
emerged. For example, blue presents a general preference among ages and genders;
colour-mood associations commonly consider bright colours related with happiness and
positive feelings, while dark colours are associated with negative feelings such as being
sad or bored (Park 2009).
Currently, it is emerging some colour research literature focusing on colour

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generalisations of specific age groups. For example, Park (2009) examined colour
preferences among paediatric inpatients and outpatients, and healthy children. The study
concluded that there were no significant statistical difference between the three groups
and the least preferred colour was white. In terms of gender, females seem to prefer red
and purple in relation to males.
Coad and Coad (2008) also performed a study on children’s preference for thematic
design and colour in hospitals. Contrary to what would be expected, children did not
prefer bright colours. The most preferred ones were mid blue-green colours. Single
colour preferences tended to blue accent, pastel yellow and pastel orange.

Figure 02.16 - Children opinion and perception of colour

In acoustic dimensions, Noise represents a frequent topic, generally defined as an

‘unwanted sound’ that can compromise patient and staff health. However, not everyone
perceives noise equally because the way it is analysed is dependent of personal factors
(Kam 1994). However, Kam (1994) states that continuous or background noise is
generally more accepted than intermittent sounds.
In healthcare settings, this problem has been extensively studied because of the high
levels of noise acknowledged. The WHO (World Health Organisation) established
guidelines values of 35 dB for continuous background noise during the day and 30 dB at
night, with a maximum of 40 dB for night-time peaks (Berglund et al. 1999). However,
several studies have examined the noise levels in hospitals and reported that these
standards are highly exceeded, with background noise registering 45 dB to 68 dB, with
peaks from 80 dB to 90 dB or more (Ulrich 2006). Equipments, environmental surfaces
and voices, are considered the main sources of noise.
Moreover, noise has showed negative health outcomes on patients, such as elevated
blood pressure, sleep loss and fragmentation (Yinnon et al. 1992), increased stress and
healing time (Bailey and Timmons 2005). In children specific case, NICUs (Neonatal
Intensive-Care Unit) studies detected that loud noises elevate infant blood pressure,
decrease oxygen saturation, increase heart and respiration rate, and worsen sleep
(Slevin et al. 2000; Zahr and de Traversay 1995).
Solutions to improve sound conditions in hospitals should be taken into account by
implementing appropriate design strategies, since the attempt to change staff behaviour
or organisational habits seem less effective. Provision of single bedrooms; elimination of
noise sources, such as substituting noisy equipments by silent ones; and the installation
of high performance sound-absorbing ceiling tiles or panels that avoid sound
propagation, are considered highly effective (Ulrich 2006).

Figure 02.17 - Noise impacts on patients’ health and design guidelines

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2.2.5. AGE APPROPRIATE ENVIRONMENTS

The division of children according to their age group, in healthcare settings, became a
common design solution. In this way, children of the same ward would have the same
capacity of socialisation and could accompany each other (Platt 1959). Moreover, the
study of cognitive development carried by Jean Piaget (1983) showed that children
acquire different capacities along their childhood, presenting different cognitive, physical,
emotional and social competences.
The following table shows the cognitive stage of each age group, followed by respective
age-friendly requirements for hospitalised children and design guidelines.

COGNITIVE
SPECIFIC REQUIREMENTS
DEVELOPMENTS (Piaget DESIGN GUIDELINES
AGE GROUP (Vanderbilt University Medical
theory, in: Littlefield-Cook, (Lindheim, Glaser, Coffin, 1972)
Center, 2008)
Cook, Berk and Bee, 2005)
- Importance of soft music and
Provide feeding chairs for parents or nurses
low voice
Sensorimotor - Possibility to play with soft toys
(0 to 2 years): and in front of the mirror; Provide a large playpen or small enclosed alcove for
- Knowledge of the world - Dependence of parents to live: crawling infants
only through sensory input; feeding, holding and talking;
- Start to develop - Possibility to see what the Provide tables to pull up or walk around; or boxes to
representational and others are doing; sit in, and toys
INFANCY symbolic thought, since its - Necessity of constant parental
(0-12 months) absence disable them to presence; Provide soft and warm floor
speak or remember about - Possibility to have personal
past events; belongings;
- Progress from reflexive - Importance of colours and Avoid locating electrical outlets or other hazards from
interactions with the shapes; the crawling area
environment to deliberate - Implement a routine ‘play time’
actions. in a space out of bedroom; Avoid visual barriers, enabling children to watch
- Possibility to explore the others activities and be watched by nurses
environment around by crawling. Use of textured and patterned materials
Avoid visual barriers for a better visual monitoring
Use of glazed partitions (preference for tempered
glass or unbreakable plastic)
Preoperational
- Great importance of play; Locate heaters, electrical outlets and other potential
(2-7 years):
- Possibility to ride tricycles, to hazards out of reach
- Construction and quick
jump from low heights, or to kick Avoid pointed objects and corners in the lower four
development of mental
a ball; feet
representations in language,
- Possibility to paint, draw and Provide electrical controlled cribs to avoid children to
artwork and play;
do other artwork; climb out
- Emergence of intuitive
- Possibility to play imaginative Provide ways of communication, such as telephones
thought based on personal
games;
experience; Locating windows in a position that allows children to
- Possibility to move objects and
- Inability to take another see over
create structures that symbolize
TODDLERS person’s perspective; Design low ceiling heights in alcoves and high ceiling
imaginary things, such as
AND - Idea that objects have for adults areas
animals or buildings;
PRESCHOOLE conscious life and feelings;
- Start to be able to take care of Lower windows and mirrors to a position where
RS - Notion that natural events
self-daily hygiene; children can see
(1-6 years) or objects are under the
- Importance of parental Make toilets visible and easily accessible with child-
control of people or
presence for social interaction size sinks and toilets
superhuman powers;
and positive reinforcement; Design warm, easily cleaned and textured floor,
- Inability to solve
- Necessity to set limits and which can distinguish different areas, such as work
conservation problems,
provide structure; and play
since they only focus on one
- Possibility to care personal Provide lightning near floor since children use the
aspect at a time instead of
belongings to feel safe; floor as a table
taking into account several
- Have power of choice;
aspects; Provide a private place for children to save their
- Start to get some
- Lack of reversible thought. personal belongings
independence from parents;
Connect the play area with an outdoor area, toilets
and a kitchenette for snacks. Easy to supervise
Take attention on designing different heights
because of children in wheelchairs

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- Possibility to play board games Provide electronic devices for children to keep in
Concrete Operations and videogames; touch with family and friends
(7 to 11 years): - Keep social contact with Provide a schoolroom able to accommodate a group
- Logical though is more friends become increasingly of 8 to 12 children, fully equipped to allow weakened
objective, however it is important; or handicapped patients to participate
limited to concrete and - Possibility to join group
tangible objects and activities make them feel safe; Provide a soundproofed room suitable to play music
GRADE
experiences; - Increase awareness about
SCHOOL
- Ability to solve school; Provide play areas and activities suitable for
CHILDREN
conservation problems, - Privacy; handicapped children, such as basketball, horseshoe
(6-12 years)
presenting a concrete - Chance to personalize a between others
operational thought, where space;
Include a place for studying, entertainment and
multiple aspects are - Have power of choice;
storage near each bed
considered; - Provide activities and games to
- Focus on dynamic make the environment more Provide a place for own personalisation
transformations. friendly. Provide a multipurpose room for different projects
and activities to coexist
Enable choice between single, double or four-bed
rooms
Provide a bedroom space for teenagers to
- Possibility to play board games personalize and accommodate their personal
and videogames; possessions (hanging, shelf and drawer space)
Formal Operations - Keep social contact with Design a pleasant room for socialisation with low light
(11 to 18 years): friends is extremely important; levels, soft floor and view through a quiet garden
- Start to emerge abstract - Possibility to use electronic Make bathrooms attractive places for dressing and
ADOLESCENT thought and hypothetic- devices to be in contact with self-care
S deductive reasoning; friends; Include a laundry space, since teenagers usually like
(12 – 18 years) - Emergence of egocentrism - Independence and privacy; to take care of their own clothes and personal
seen in the personal fable - Continue to follow school belongings
and imaginary audience subjects;
- Be involved in medical Design a teen space free of visual supervision, with a
responsibilities and decision- comfortable floor for siting, acoustically isolated and
making. with changeable furniture, decorations and lightning

Include a day-room for multi-purpose activities

Provide a hospital schoolroom for adolescents
Figure 02.18 - Cognitive development, specific requirements and suggested design guidelines for each age group

In general, it is noticed that over childhood, needs, preferences, dependences and

wishes change several times. The initial total dependence from parents becomes to
fade, and social activity becomes more connected with friends and new people. Spaces
for socialisation in-group or in private are needed to accommodate these requirements.
Privacy also seems to be fundamental for adolescents, since they do not need to be
monitored all the time anymore, but rather they need some time alone.
In relation to play, small children prefer to engage in individual activities, while the
following stages transform play in a more social activity, like competitive games and
sports. Therefore, it is necessary to support them with different appropriate spaces.
The different stages also present different interactions with the space. On one hand
adolescents want to feel more in control over the space and have their own place to
personalise, while little children still don’t have that ability, and are more susceptible and
receptive to the offered spatial wealth (textures or colours).
Finally, scale becomes a special issue since paediatric hospitals accommodate from
baby to adult sizes. Attributing different dimensions to spaces and objects can be useful
and comfortable. For example, reduce the heights of sinks and toilets enable little
children to go alone to the bathroom and be self-competent. Furthermore, huge spaces
with large heights can be frightening, while well-scaled spaces can provide a comfortable
experience with full perception of all dimensions. However, all spaces should be also
fully accessible by adults, since hospitalised children need to be supervised, monitored
and comply with medication schedule.

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2.2.6. SECURITY

Along with a sense of homely environment comes the dimension of feeling protected. A
strange hospital environment can bring more anxiety, vulnerability and insecurity. As it
was mentioned before, parent’s presence is one of the most important factors for
hospitalised children to feel more accompanied and supported. For parents, it is also a
safety factor, since they can assure themselves children supervision.
Other element that improves perceived security is, the already cited, possibility to keep
personal belongings with respective space for storage. Blankets, friendly messages,
drawings, books, photographs or cards are familiar objects that contribute to personalize
the space, reinforcing their identity and sense of control in the environment.
Other factors that also improve security in hospitals are related with health carers’
performance, such as the ability to frequently supervise patients, reduce patient falls or
reduce medication errors. Moreover, personal behaviour and internal rules can also
contribute to reduce infection spread and the number of transfers.

Figure 02.20 - Variables that enhance patients’ security

Staff performance is not only conditioned by personal qualifications, but also by the
surrounding physical environment. The JCAHO study (2002) reported that inadequate
workplace and poor ergonomic design contributes to an increase of nurses’ turnover and
burnout. There is also evidence that high levels of noise increase staff stress and
consequently emotional exhaustion and burnout (Topf and Dillon 1988). These elements
should be allayed to increase staff satisfaction levels and emotional wealth, and
consequently, enhance effectiveness. This user group became really important because
patients health and recuperation are dependent on their successful work.
One design factor that limits patient safety and staff effectiveness is the location of nurse
stations. Plan layouts with centralized nurse stations and supplies storage increase
nurses’ walking distances and fatigue, occupying 30 to 40% of their shift time, which
should be used in patients’ monitoring and care. Contrarily, decentralised nurse stations
and supplies located closer to patients’ rooms proved to be efficient in reducing walking
and fetching time-lost, increasing substantially observation and care time for patients
(Institute of Medicine 2004). This monitoring became especially important in paediatric
care, since children are more unpredictable and can unintentionally harm themselves or
fall. Decrease visual barriers or use transparent doors are safety measures that improve
staff monitoring, and are greatly appreciated by parents. The idea of being observed by
medical professionals reduces feelings of anxiety and alienation (Yeaple et al. 1995).
Supervision is also important in terms of hospital scale and openness. More square
meters means more entrances and exits to respect fire regulations.

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This creates a conflict between the desired hospital openness and the conservation of
the same levels of safety. Patients and parents feel safer if control over the hospital and
units’ entrances exists (Yeaple et al. 1995). Moreover patients’ constant vigilance help
parents to be more relaxed while leaving their children alone (Olds and Daniel 1987).
Medication errors are other regular aspects in hospitals that can cause harm to patients.
Evidence shows that medication errors decrease in the dispensing process when
interruptions or distractions are ceased, such as phone calls or other people’ remarks.
Appropriate light levels were found to also lower dispensing errors. (Institute of Medicine
2004). A solution can be separate dispensing spaces from the central nurse station,
avoiding noise and distractions, while light can be adjustable to the different needs
(Ulrich 2004). Furthermore, researches proved that patient transfers also increase the
possibility of medication errors, due to information lost, change of staff in charge,
frequent change of computers and system, and delays in medication administration
(Hendrich, Fay and Sorrels 2004). Providing a fully equipped single-room occupation
seems to decrease the transfers, because it reduces patients’ incompatibilities, risk of
infection and sleep disruption.
Finally infection prevention also became a security issue, since there are still people
dying as result of hospital-acquired infection. Medicine alone cannot cure all patients.
Effective design guidelines can help in the prevention and control of disease spread.
About 5% of the admitted patients acquire hospital infections, with 10% of those dying
during their period of infection and 1% die from the infection itself (Walenkamp 2006). In
terms of airborne infection, the hospital air quality and ventilation is a strong influence
due to concentrations of fungi, bacteria and other pathogens responsible of contagion
(Ulrich et al. 2004). The provision of single-bed rooms equipped with HEPA-filtered air or
laminar airflow (Passweg at al. 1998) is among the recommended measures for an
effective prevention and control. On the other hand, infection spread by contact is mainly
caused by direct human contact or contact with contaminated environmental surfaces
(Bauer et al. 1990). Studies have proved that the lack of hand washing is the principal
source of transmission. Thus, the provision of numerous well-located sinks and alcohol
gel dispensers seem necessary to increase the hand washing practice and,
consequently, reduce the infection spread (Ulrich 2004).

Figure 02.21 - Suggested design guidelines to improve patients’ security inside the hospital

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The role of architecture in children’s recovery and development!

ENGAGE USERS IN THE PROJECT. 03

Children’s Hospitals

01. PARTICIPATORY PROCESS

The desire to design a paediatric hospital that fulfils users’ requirements and
expectations is evident. However, is the designers’ work experience and good intentions
enough to achieve this end? Several authors are advocating the importance of
integrating users in the design process and in post-occupation evaluations.
Although ‘participation’ has been acquiring importance, it can be ambiguous, especially
in relation to children, due to their dependence of adults’ attitudes and interpretation of
this concept. Cutler and Taylor (2003) attribute the same meaning to ‘participation’ and
‘involvement’, defining them as taking part in the decision-making. On the other hand,
Lansdown (2001) does not attribute a definition to participation, but differentiates
consultative and participatory processes. He considers that in ‘consultative processes’
children have no control and adults preform all activities, i.e., their opinions are
considered a valuable contribution and are used to inform and evaluate the current
situation, but they do not have an active role in decision-making. On the other hand, in
‘participatory processes’ children are involved in the research and decision-making
during the design process.
Post Occupancy evaluations can be considered merely consultative or the last step of
participatory design. It is an increasingly used method to evaluate the projects’ efficiency,
which allows an easy identification of building problems and possible solutions. These
solutions can be achieved over short or long term, dependent on the number and
dimension of the changes. (HEFCE 2006)
However, listening to the users during the design process can avoid problems, instead of
correcting them. Thus, children should actively participate in decision-making due to their
unique knowledge and body experience of their condition, which leads them to have
original views and ideas, different from adults. Furthermore, a better understanding of the
democratic systems, the opportunity to be heard and the implementation of an
elementary human right as ‘the right to be listened and be taken seriously’ (Article 12 in
UN Convention on the Rights of the Child) are other important factors that contribute to a
better protection and children development (Lansdown 2001). In this way, children and
young people can influence the physical shape of spaces and create a positive impact
on services’ quality, promoting ‘user-friendly’ buildings (Crawford, Rutter and Thelwall
2003).
In spite of these beneficial results, the process of mutual power can bring problems, such
as difficulties in leading adults to take children’s ideas seriously; captivate children to
participate; try to please everyone; make sure all opinions are heard; and, deal with
unrealistic expectations that might result (Sloper and Lightfoot 2002).
The fact is that children’s opinions have not been taken seriously for a long time due to
adults’ sense of better knowledge on how to protect children’s best interests. However,
the main challenge is not to give children an adult task, but instead, give them the
opportunity to show their concerns and express their views. Moreover, it is necessary to
understand that children have different levels of competence diverging with their age, but
all of them are able to tell what they like or dislike. The appropriate support and adequate
information can allow them to express through meaningful ways, such as pictures,
poems, photographs, drama, interviews, group work or discussions. (Lansdown 2001)

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 The role of architecture in children’s recovery and development!

An example that reformulates the role of the children whether during the design process
or in a post-occupational context, is the Mosaic Approach21. This research framework
facilitates young children participation through the use of adequate activities. It seeks to
explore meanings based on individual experiences and participants’ reflections about the
information. This method is more than a data collection since the investigation course
can be adapted during the process (Clark 2010). However, this study has a main focus
on young children, which does not cover the whole age range of paediatric hospital. This
typology still lacks studies about effective methods.

1.1. LEVELS OF ENGAGEMENT IN PARTICIPATORY PROJECTS

The way children’s participation is applied can lead to different opinions. Hart (1992)
presents a model of different levels of children’s participation. The shared decision-
making degree is considered the highest level attainable, since children will always need
some adult support. The following chart represents the Hart’s ladder of participation.

Adults use children to spread their Example: Use of children’s

NON-PARTICIPATION

1. MANIPULATION ideas, while children do not drawings of a space to look like

understand the matter. children were involved.
Children participate and maybe have Example: Children do an opening
2. DECORATION an idea of the matter but are not performance of a ward but had
involved in the organisation. no part in its direction
Children have voice, but have little or Example: Selected children go to
3. TOKENISM no choice about their degree of a conference, but adults make
participation. the decisions.
Children are informed about the Example: Children participate in
4. ASSIGNED BUT project and their role. They are able to a conference but their presence
INFORMED volunteer and have a meaningful is more important than their
function. opinions
Children are informed and consulted
DEGREES OF PARTICIPATION

Example: Children have power of

about the process. Even though
5. CONSULTED AND choice to participate in a
adults handle all the initiatives,
INFORMED research and are informed about
children’s opinions are taken
the objectives and results.
seriously.
Example: Adults use 3D models
6. ADULT.INITIATED, Adults develop the original idea, but
to allow children to better
SHARED DECISIONS all the decision-making process is
understand the project ideas and
WITH CHILDREN shared with children.
criticise.
Children develop the initial idea and Example: Children build a
7. CHILD-INICIATED direct the programme. Adults’ role is playing facility, idealised and
AND –DIRECTED to identify and support children performed by their own, with
initiatives adult’s acceptance.
8. CHILD-INITIATED, Children develop the original idea, but Example: Children take initiative
SHARED DECISIONS invite adults’ to share power in of a project and it is encouraged
WITH ADULTS decision-making. by adults, who also participate.

Figure 03.1 - Hart’s ladder of participation

______________________________________________
21
The Mosaic Approach is a research framework that facilitates young children participation, trough the use of adequate
activities, such as use of cameras, child-led tours and map-making. This method seeks not only to highlight the individual
pieces of research, but also to compose an overall image of a child or group of children (Clark, 2010)

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Children’s Hospitals

However, the adaption of these definitions to a specific context, such as the children’s
participation in building conception, may change a little because projects are too complex
for children to initiate or direct. For example, Treseder’s model (1997) redesigned the
Hart’s ladder in a circular layout, where the non-participation forms were excluded and all
five degrees of participation are equally considered. Moreover, Shier (2001) also
developed a model where the right of children to be listened, supported in expressing
their views, and having their views taken into account, are the three basic levels to
respect children’s rights. The next two levels, which involve children in decision making,
as well as power and responsibility, should be questioned to evaluate the organisation
stage and openness to this degree of involvement.

1.2. PARTICIPATION CYCLE

Apart from the levels of participation, the participatory design process can be divided in
different steps to better identify the different possibilities of integrating children. This
cycle is discussed by Stephenson, Gourley and Miles (2004), in their book Child
Participation, and can be divided in the following steps:
Identification process - the information about users’ needs should be acquired directly by
them and not only through past experiences and project work. Children should be
involved since they have their own perspectives that can differ from adults. The
approaching methods should be adapted to child-friendly activities, such as daily
activities charts, drama activities, mapping, songs, focus groups, child-to-child interviews
and priorities’ rankings;
Design process – implies understanding on how users can be addressed. It is necessary
to research and collect more information about the problems identified by or with children
and its context. This stage is constituted by several phases, for which it is necessary to
understand what will be the children role and select a research team according to their
experience, age and gender. Both children and adults can set the objectives of this
research and the data collection can include surveys, questionnaires, drawings,
paintings, models, photography, video and drama. All the information should be recorded
and analysed with or by children to avoid misunderstandings;
Implementation – involves designing the project. Children should take part in the
organisation and representation of the project and also monitoring, reviewing and
identifying the impact of the project in their lives. These tasks can be carried in monthly
meetings and conferences. It is important that children can comment and ensure that
their ideas were understood, and are being correctly applied. The evaluation of the
project in a final stage can elucidate if the project succeeded and suggest different
strategies for future works.
Evaluation - all the information acquired in the process and respective results should be
documented to inform and improve future projects. This process can be achieved
through the publication of a newsletter about the project’s achievements, documentation
of the acquired knowledge about interaction adults-children and report of children’s own
experiences. Children can resort to paintings, drawings and photographs to help in their
explanation. In the end, there should be room to celebrate the project’s success and the
lessons taken from the mistakes committed.

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 The role of architecture in children’s recovery and development!

Figure 03.2 - Children’s participation project cycle

02. RESEARCH METHODS

The methods used to identify users’ needs, activities and desires can vary, since
information cannot be explicitly collected. The following chart presents an adaptation of
Sanders’ model suggested by Westerlund (2009), where the left pyramid show the levels
of users’ actions, and the right pyramid defines the correspondent type of information
that can be collected. In the middle is listed the methods that can be used in the different
levels.

Figure 03.3 - Graphic illustrative of the adaptation of Sanders’ model suggested by Westerlund, 2009

The participatory methods are based in latent knowledge so they cannot be expressed
only by words, while the conventional methods are mainly based on explicit knowledge
and observations of behaviour (Sanders 1999). These new tools focus on new ways
people can express their thoughts, dreams and feelings.
The following topics explore different activities’ tools that can be used during the design
process and in post-occupational evaluations. Even though the traditional methods
(interview and observations) continue to be useful, the use of visual methods, such as
maps, drawings, videos and photographs are recommended to use with children
(Stephenson, Gourley and Miles 2004). These methods are not only funnier, but are also
believed to enhance children’s ability to communicate their perspectives to researchers
(Hill 1997), independently of their age, size or verbal skills. After finishing their activities,
children should have the right to interpret their work and decide about the publication of
their visual material (Regional Working Group on Child Labour 2003).

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2.1. OBSERVATIONS

Observation allows researchers to learn about the people being studied through an
active look and respective documentation, by writing notes or through memorisation
(DeWalt & DeWalt 2002). The time spent in observing activities can also help the
researcher to immerse in the study environment. Furthermore, adopting this method in
the beginning of the research enables the researcher, not only to listen to children
attentively and observe their body language, but also to formulate better questions in the
following phases, and interpret children in a better way (Warming 2005).
Researchers can choose between having a participant or non-participant role. In non-
participant observations, the researcher takes a passive role, writing a narrative of what
is perceived, rather than engaging in daily activities. On the other hand, in participant
observations, the researcher is first identified and plays a more active role, allowing a
closer connection with participants in a beginning phase. When the study involves
children, a non-participant approach is more difficult to maintain for a long time, due to
their curiosity. (Clark 2010)

2.2. INTERVIEWS

‘Child-focused interviews pose a number of challenges, including differences in cognitive

and linguistic abilities of professionals and children, conditions under which children attend
interviews, and various misconceptions that children have regarding the interview process.’
(Zwiers and Morrissette 1999, 49)

Children are different and not all of them will react positively to a strange person. For this
reason, provisions should be taken to make them feel comfortable and, consequently,
more participative. Researchers should be flexible to adapt their work to the single child’s
characteristics. For example, some children are not receptive of taking a one-to-one talk
and prefer group interviews.
Regarding the location of the interview, the choice of the place should focus where
children have more control. Moreover, allowing them to play and talk at the same time
could enable them to be more at ease. Other question is the used language that should
be simplified, since children lack competence in the interpretation of the exact wording of
the questions and can give an unrelated answer (Clark 2010). Photographs and
drawings can also be used to help children in their communication (Bruner and Haste
2010).
Finally, interviews should be documented through recording, to avoid time waste,
unnecessary distractions and improve accuracy (Zwiers and Morrissette 1999).

2.3. PHOTOGRAPHY

‘Photographs are evidence not only of what’s there but of what an individual sees, not just
a record but an evaluation of the world’ (Sontag 1979, 88)

Visual methods, such as photography and video, allow participants to show their
individual perspectives, which are not possible to collect through observations or verbal

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 The role of architecture in children’s recovery and development!

interviews. This is particular important in the case of children, who have a short stature
so their field of view is completely different from an adult height (Clark 2010). In this way,
it constitutes a unique method for children to explain their point of view and criticise their
surroundings.
This tool allows researchers to use two methods: collect images from the objectives to
discuss with the participants; and, give cameras to children for them to collect their
perspective on the surrounding world according to their physical stature (Orellana 1999).
The idea of suggesting children to work as photographers is recent. This method
consists on two activities: taking photographs and consequently discuss about the data.
It is important to identify the purpose of the photographs for children not to miss the
research topic; allow them to be creative; and, prevent manipulation using examples or
other people. The instructions about the use of the camera should also be explained and
the number of photographs to be taken should be set. After the children finalise their first
activity, the researcher should be aware of the stories and experiences acquired during
the process. Finally, during the interview, the author should explain the photos to the
researcher to avoid misunderstandings (Dedding, Willekens and Schalkers 2012).

2.4. WALKING TOUR

Tours constitute an optimal tool that allows children to guide adults around the
environment (Clark 2010). It provides additional information about activities and personal
preferences that come to mind while scrolling around the spaces. This method also
provides the unique opportunity for researchers to experience and clarify children’s
points of view and wishes.
In order to obtain the best results using this method, children should be free to choose
where to go. Moreover, the researcher can ask questions about the choice of the room
and possible solutions for current problems (Dedding, Willekens and Schalkers 2012).
The tour can be done individually or in small groups, and children should document it
through photographs, tape records and/or drawings. Researchers are responsible to do
their own records and take notes. (Clark 2010)
This method is essentially used in post-occupancy evaluations, but can also be used
during the design process when researchers have a live 3D model available.

2.5. DRAWING

Drawing is becoming to be considered a successful method by many researchers due to

the children’s frequent engagement with images in their daily routine. This activity is
normally associated with funny and relaxed times, but it also triggers remembering, helps
to transform the abstract in concrete, and improves the relationship researcher-child
(Thomson 2008; Fargas-Malet et al. 2010). However, lack of comprehension about the
aim or result of the drawing can arise. As a solution, it can be asked to ‘draw and write’,
creating image subtitles (Gibson et al. 2005).
One drawing activity that can be asked is the ‘Daily Activities Chart’, which allows
researchers to understand the children’s range of activities during the day and the hours
spent in each. For design purposes, it can add data about the lack of spaces to perform
activities or problems in the existing ones.

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Children’s Hospitals

Other way to explore the potentialities of drawing is to ask for a mental map drawing.

‘The method can provide valuable insight for others into children’s everyday environment
because it is based on the features they consider important, and hence can lead to good
discussion about aspects of their lives that might not so easily emerge in words’ (Hart
1997, 165)

Children, similarly to adults, are able to construct mental maps of the spaces they use
and it can motivate participants to further interpretations and explanations. One
important thing of this activity is the inexistence of right or wrong answers. It is not
expected an accurate plan, but instead, a map where significant places are highlighted
(Clark 2010). This method can also complement the walking tour, producing a more
permanent record, of which is possible to engage other children, parents and staff in
discussions.

2.6. FOCUS GROUPS

A focus group is ‘a carefully planned discussion designed to obtain perceptions on a

defined area of interest in a permissive, nonthreatening environment’ (Krueger 1994, 6).
In this way, the researcher is allowed to understand and explore the rational and
emotional responses of participants.
The main principles of focus groups set out by the Regional Working Group on Children
Labour (2002) consists on the requirement of 8 to 15 participants with similar
characteristics; a comfortable place without spectators or interruptions; enough space for
everyone; a planned duration for the discussion; a list of topics to be covered; a skilled
facilitator; and, at least one person skilled in taking notes.
Regarding the fact that children tend to answer the way they believe the researcher
wants (Donalson 1978) focus groups can help removing this pressure of one-to-one
interviews. However, in some cases, it can increase inhibition of some children, and
induce children to repeat a theme rather than give their own opinion (Lewis 1992). The
use of different written, visual and verbal techniques can help render this method more
efficiently.

2.7. INVOLVING PARENTS AND PRACTICIONERS

Although children are the main focus of this study, it is important to also include adults’
opinions about their experiences, and perspectives on children’s experience. Interviews
with parents and practitioners allow building up a more detailed knowledge, raising areas
of consensus or disagreement, which can contribute to a better understanding of
children’s world (Clark and Moss 2005). Moreover, parents have a unique knowledge
about their children, and can help to interpret their interview results or explanations.
Practitioners and parents can be consulted in many ways. However, it is a child-centred
research, so the approach is reduced to individual informal interviews. This method
requires a conversation guideline prepared in advance, including topics about not only
children, but also adult’s experiences. However, this list should be flexible, so that order
participants feel free to add topics. Regarding a more efficient information collection, the

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 The role of architecture in children’s recovery and development!

researcher should ask permission for the interview recording. (Dedding, Willekens and
Schalkers 2012)

03. QUANTITATIVE AND QUALITATIVE RESEARCH

The majority of the methods mentioned before are used in qualitative researches. This
type of research seeks to explore and understand participants’ thoughts, perspectives
and experiences (Hiatt 1986). However, it can generate multiple ‘truths’ (Lincoln and
Guba 1985), since results are obtained by a unique interaction researcher-participant in
an open and flexible process. This means that different researchers can obtain different
results with the same participant, thus conclusions will be less generalizable.
Qualitative research is mainly used when the researcher needs insights on the theme,
identifying possible patterns, or to help in developing ideas or hypothesis for potential
quantitative research. The data collection methods used varies from unstructured to
semi-structured techniques, such as open-ended responses, interviews, participant
observations, field notes and reflections. The sample size is typically small and the
participants are carefully selected since statistical results are not aimed but rather
particular and specialised findings. (Johnson and Christensen 2008; Lichtman 2006)
On the other hand quantitative research tends to maximize objectivity, replicability,
generalise findings and make predictions. It is characterised as assuming a single ‘truth’,
independent of human perception (Lincoln and Guba 1985). The data collection methods
are mainly tests and surveys, which results in objective numbers and statics, from which
is possible to identify statistical relationships. The sample size of this method needs to
be larger and randomly selected for better-generalized assumptions. (Johnson and
Christensen 2008; Lichtman 2006)
Therefore, the choice between using quantitative or qualitative research is dependent of
the main goals of the researcher. The incidence of qualitative research in this field can
be explained because the population in study are children, and it allows an informal
approach. Moreover, there is lack of information about the field, and children’s reasons,
patterns, motives and meanings are required.

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 The role of architecture in children’s recovery and development!

CASE STUDIES IN THE NETHERLANDS. 04

Children’s Hospitals

01. METHODOLOGY

1.1. SELECTION CRITERIA AND APPLIED METHOD

In order to complement the theoretical basis, this study analyses real examples using the
current theories, and provides a comparison between the case studies. The selection of
two projects, from a universe of six children’s hospitals available in The Netherlands,
was based in the following criteria:

Figure 04.1 - Case studies’ selection criteria

First, a research about the hospitals’ projects seems necessary to identify their
architectural qualities and life-term. The requirements relapsed on the identification of
the use of new concepts referred in recent literature, such as child and family friendly
environments.
Furthermore, the information available should be consistent. This means that project
descriptions and graphic elements, such as plans, sections, elevations, photographs and
schemes, are required for a better interpretation.
Finally, a selection of children’s hospitals in connection with academic hospitals is
required, due to its recognition and predictable continuation in long-term future, as
explained before. For this reason, the children’s hospital can be physically integrated
in the academic general hospital, as a medical speciality department, or occupy a
building of its own. In terms of intervention, entirely new buildings and rehabilitation
interventions in old hospitals can be distinguished.
The selection resulted in the choice of Wilhelmina Children’s Hospital (1998), in Utrecht,
designed by EGM Architecten, occupying a separate building from the general hospital,
in a new construction; and, Emma Children’s Hospital (2015) in Amsterdam, designed by
OD205 architectuur and OPERA, integrated in the Academic Medical Centre, in a
renovated department.
From the collection of all relevant bibliographic documentation for each case study, an
analysis was carried out and it is presented on this chapter. The textual information is
supported by graphic elements, collected in the research or produced by the author, to
provide a better comprehension.
The analysis was developed based on the following parameters:

i. Formal Study: description and analysis of the architects’ intentions and project
strategies. The sequence is similar to the one used in the second chapter, starting
with a relation between hospital and city, followed by an analysis of the internal
environments.
Urban Context – Integration of the project in the surroundings;
Spatial and Functional Organisation – functional distribution, accesses and circulation
routes that give a general notion of the project;

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 The role of architecture in children’s recovery and development!

Selected Spaces – selection of four pertinent hospital spaces with description and
evaluation of strategies. This evaluation should be done comparing the strategies
applied with the ones defended in recent theory.

ii. Participatory Study: introduction of the users’ perspective, especially children.

This study is a post-occupational qualitative research in which the research methods
suggested in the third chapter are applied (observations, photography, drawings and
informal interviews). The main objective consists in attributing expression to the main
user of paediatrics – Children – and recognise the value of their role as experts of
their needs and preferences, understanding the current tendencies in the hospital
design. However, adults’ participation is also important to complement children’s
interviews and also to understand their self-experiences.
This unique environment offered by children’s hospital is also an evident universe of
restrictions that weaken a rigorous research and require a specific approach. It is
important to recognise that this study reveals weaknesses in relation to the universe
of participants inquired and data collection, due to dependency on hospital’s
openness to this research; difficulties in gathering available participants; distance to
the study object; lack of means to further explore the method; and, difference in the
native language (Portuguese – Dutch). Because of the hospital restrictions,
Wilhelmina Children’s Hospital is not evaluated in this section, and thus the target of
this study is the Emma Children’s Hospital.
Despite the evident restrictions, the collected material can be analysed using the
existent theoretical information, suggesting tendencies of the different user groups
and generating conclusions. This study is a qualitative study, which means that the
conclusions can only be applied in relation to the studied universe, and cannot be
generalised. Further conclusions or generalised proof requires a wider range of
participants, which goes beyond this master thesis framework.
Regarding the sample size, the ideal/minimum number of participants could not be
found in the research held, varying among the different authors (between 5 and 8).
For this reason, and respecting the hospital’s availability, 6 children willing to
participate in this type of interview were selected. Parental consent and a varied age
range were required. In total, the study gathered 18 testimonials – 6 children, 4
parents, 2 doctors, 4 nurses and 2 administrative.
The data collection was held in two visits to the Emma Children’s Hospital, in
Amsterdam. The first visit (17th July, 2015) allowed a first contact with the Head
Physician of the department and with the physical space and atmosphere of the
paediatrics. The second visit (20th July, 2015) had a formal nature, with interviews of
approximately 30 minutes.

Observations

The observations taken during the visits followed a ‘participant approach’. The security
system, characteristic of paediatric hospitals, prevented a more neutral and invisible
position of the researcher, who had to be constantly identified to circulate in the hospital.
The first visit involved an informal approach, including exclusively observations. The visit
was guided by the Head Physician of the department, where it was possible to get a first

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impression of the organisation of the different wards, individually and as a collective, and
also of the accommodations attributed to the different users.
The second visit allowed a general understanding of the social context lived in the
hospital, including the interactions between children-space and children-different users.

Interview

The interviews were held during the second visit with a special focus on children’s
perspectives. Due to language incompatibilities, when children could not speak English
(2 cases), parents accepted to work as translators and interpreters of children’s answers.
The methods used were generally based on images, whether photography or drawings.
Photography was used as a tool for two activities – Walking Tour and Photo
Collection. The first faced a major constraint due to the impossibility of the majority of
patients to leave their room. For this reason, a photographic selection of the hospital
spaces was carried out, in order to provide a hospital photo tour without leaving the
room, through paper cards (attachment 2). Each card included a photo, representative of
the space, combined with graphic answers to three questions: space’s feelings, level of
interaction and level of access. Children could underline more than one answer.
Other information that could be easily collected from a walking tour are functions,
activities, preferences and period of stay relative to each space, which is also collected
with this method by conversation with children or through parents.
In relation to the photo collection, it was limited to the area where the child was
restricted, i.e., if the child medical condition forbidden to get up, the pictures should be
taken from bed. Disposable cameras were provided with 10 photos available to each
participant. The main purpose was to understand what is worthy of attention in the
children’s mind, asking them to take photos of the most important spaces, furniture,
materials, views and equipments in the hospital. The photo review was not possible due
to the limitations mentioned above.
The other graphic tool used was drawings, which were included in two activities - Room
Plan and Mental Mapping. The Room Plan assignment consisted in giving a bedroom
plan or picture (attachment 2), according to the child preference, to underline with
coloured pencils the following areas: red – dislike; yellow – neutral; green – like. In this
way, it was possible to understand children’s preferences and levels of importance in the
space they spend most of their hospitalisation period.
To conclude the interview it was asked to draw a Mental Map of the paediatric
department, in order to determine which spaces remain on the children’s minds and
which characteristics or situations can contribute to it.

Involving parents and practitioners

The language barrier with children and the will to understand the adult experiences in the
hospital, which directly influence children’s well-being, led to the need of interviewing
parents and staff. These interviews were based on informal discussions following a small
guide of open-answer questions (attachment 3). Although a question guide was used,
the conversations proceeded fluently and with flexibility to change course according to
each person character and respective experience.
The type of questions focused on personal experiences but also on an adult’s
perspective of what children’s perceive and feel about the space. The main idea of these

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 The role of architecture in children’s recovery and development!

interviews was to confront adults and children’s opinions, but at the same time, evaluate
the hospital quality in serving each user groups.

1.2 SELECTED SPACES

Regarding a more profound analysis, four relevant spaces in the hospital were selected,
to provide further investigations about their functions and design specificities. The
selection was based on the importance of establishing connections, such as inside
hospital/outside world and hospital/home. The first takes place mainly when one
approaches the hospital and has the first contact with the environment (entrance), which
is also the last place crossed when leaving. Moreover, while inside the hospital a contact
with the outside can be provided through gardens, giving the option of being outside,
inside. The connection to home is provided by the space where the patients most
frequently are (bedroom), which can be considered the space where they should have
more control, link with personal belongings, and family. Finally, the last space selected
was the family living room, which represents a specific characteristic of paediatric
hospitals and at the same time presents a strong connection with the social areas of
home, where all family can be together and carry out different tasks.

1.2.1. ENTRANCE / LOBBY

The design of the entrance area is particularly important since it contributes to the
creation of the hospital’s first impression. An initial negative experience can be difficult to
forget, even after better outcomes. Moreover, users can judge the quality of clinical care
based on hospital’s appearance (NHS Estates 2004). It is necessary to provide users
and visitors with a welcoming space, prepared for arrivals and departures, offering
spaces for waiting, meeting and socialisation, and provide easy access to information
and directions (NHS Estates 2004). The efficacy of all these functions will contribute to
the overall users’ satisfaction of hospital care.
The NHS Estates (2004) published a study with the design guidelines to improve the
patient experience at the entrance level, which can be consulted in the following chart:

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Children’s Hospitals

Figure 04.2 - Design guidelines for pediatric hospital’s entrances

Other design guidelines can be added. Factors, such as scale, also play an important
role in the lobby area. Academic hospitals are, at first sight, big representative
institutional buildings, whose first visit can be frightening. Continuing this great scale into
the inside can be uncomfortable and decrease the sense of control. Children, by their
small stature, are especially vulnerable and insecure, requiring small-scaled areas where
they can feel more competent (Scott 2010). Thus, providing a comfortable ceiling height
and atrium size, could contribute to a sense of homely environment rather than
institutional.
Furthermore, a child-friendly environment in the lobby is required, where adequate
artwork and play spaces should be placed to stimulate children imagination, and make
them comfortable from the first moment. The artwork and signalisation used in the lobby
can also be used as a differentiator factor of the organisation and should be coherent
with the remaining facilities (Bamborough 2013).
Elements such as daylight, outside views and gardens are welcome to add life to this
space and foster positive feelings. Moreover, the use of different lightning and furniture
can add different sub-functions in the same space (Bamborough 2013). For example,
bright light with individual furniture can be suggestive for reading activities, while a
medium light with moveable furniture can invite groups to socialise.

1.2.2. GARDENS

Outdoor areas are seen as an escape from the hospital’s interior facilities. According to
recent research, people prefer to go outside when they face stressful or upsetting events,
whether in natural or designed settings (Francis and Cooper Marcus 1992). Gardens are
appreciated mainly due to their contrast with the experience of being inside the hospital,
offering a more domestic, natural and varied experience, rather than the institutional and
man-made hospital (Cooper Marcus and Barnes 1995). Moreover, gardens can offer a
wide range of activities, as it was mentioned before. Ulrich (1999), underlines the
importance of this facility in his Theory of Supportive Garden Design, where he states
gardens’ ability to mitigate stress through the provision of contact with nature and other
positive distractions; enhance social support; provide users with power of choice and

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 The role of architecture in children’s recovery and development!

opportunity to have some privacy; and, create opportunities to engage in physical

exercise.
However, in order to offer a wide diversity of activities and positive outcomes, several
design guidelines should be taken into account, which have been proved to satisfy the
requirements. The following chart, presents the main characteristics of this facility,
selected by Clare Marcus in her article Healing Gardens in Hospitals (2006).

Figure 04.3 - Design guidelines for pediatric hospital’s gardens

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Children’s Hospitals

The need to define the position of outdoor areas in the early phase of the project seems
essential to attribute quality to the space, rather than use leftover spaces between
buildings. This constitutes a crucial step in designing a well-positioned and efficient
facility, for further exploration of environmental specificities.
Regarding paediatric healing gardens, the first empirical research was held by
Whitehouse et al. (2001), where it was suggested that garden use improves mood and
hospital satisfaction. Based on these results, a further study was performed with the
main focus on the actual usage patterns in gardens, from which, were extracted
important design recommendations. First, it was suggested that hospitals should include
motivating programs to increase children incidence in the garden, since once there, they
use it more actively than adults. Furthermore, features that improve relations’ person-
environment and person-person should be provided, both for children and adults.
However, adults engage in more sedentary activities, such as eating, walking, socializing
and relaxing, which suggest the existence of features such as benches, tables, water-
fountains, and paths to explore. Regarding staff, separate spaces from the other users
are necessary for them to relax and restore, during the work-breaks. Privacy is also
important regarding window views, which should provide nature views without the feel of
being observed from the inside rooms. (Sherman et al. 2006)
Other studies have been carried, from which can be highlighted the one held by Shepley
and Pasha (2013). This research focuses on the relation between design characteristics
and physical activity in outdoor spaces. It was found that the presence of children
amenities, playful pathways and layout, varied planting and good shading is associated
with higher levels of physical activities.
In conclusion, apart from landscape design and environmental characteristics, it is
important to attribute appropriate characteristics and requirements for the different age
groups, whether they are more physically active, relaxed or even enclosed.

1.2.3. BEDROOMS

The patient room is one of the most important components in the hospital. It is in this
space where patients spend most of their time during hospitalisation, and consequently,
attach major complaints or approvals. Not long ago, patients were hospitalised in large
wards, which they had to share with several strangers. Since the 80’s, economic
pressures, increasing competition and the continuous rising towards patient centred care
caused a tremendous reduction in the number of patients per room.
Previously, the different influencing factors and respective guidelines were adopted, in
which, some presented the use of single bedrooms as a design guideline. It was
considered to be an advantage in improving privacy, providing better family
accommodation, reducing noise, lowering the risk of infection spread and reducing the
number of transfers and relative medication errors. However, there is no agreement
regarding the choice between single or shared bedrooms. Van Enk (2006) pointed as
potential disadvantages of single bedrooms, the increase of construction costs;
extensive space requirements; decreased ability for nurses to visually monitor multiple
patients at the same time; reduce social interaction patients-staff; and, the increased
distance between patients, which results in longer walking distances and reduced

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nursing efficiency. However, the majority of these statements are being refuted, and
single rooms are the actual trend in the hospital design.
Van Enk (2006) in the conclusion of his research suggested that the big initial investment
in construction was likely to produce a positive return, over the hospital life span, since
single rooms would reduce the operational costs of infection reduction. Moreover, Ploeg
(1988) suggested that the predicted better social support provided in multi-bed rooms
does not occur, since roommates are frequently linked with loss of privacy, noise,
worsened sleep, unfriendliness or serious illness. Lastly, research has proved that single
rooms do not require higher nursing staff number or an increase in nurse-patient ratios
(Hendrich, Fay and Sorrels 2004), and even, health care professionals seem to have
more private and focused consultations in this model (Ulrich 2003).
More research and evidence in this topic is required to draw a clear conclusion of
whether single or shared-bedrooms are the most adequate. Meanwhile, the combination
of both single rooms and bays is being discussed (Pennington and Isles 2013). The idea
of ‘one room does not fit all’ reveals the individual user characteristics, proclaiming an
empowerment of the patient, who can choose the model that suits him/her better. Along
with the power of choice and the provision of an adequate environment in the bedroom,
independently of its typology, came the design guidelines and important room elements.
The following chart presents the design provisions that are currently assumed as the
most important.

Figure 04.4 - Design guidelines for pediatric hospital’s bedrooms

Overall, a hospital room should gather safety features, adequate amenities, and provide
patients and families with comfort at the same time. It is extremely important to offer a
great quality in the space, where they are going to spend the majority of their time. The
visualisation of a layout that incorporates the mentioned measures can vary, i.e., there is
no general solution. The following image demonstrates an example of a room layout.

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However, it is important to note that the following plans are only provided to support the
evidence. They are not design solutions and should not be used as such.

Figure 04.5 - Example of a Hospital Room Design Layout with respective functional division

By differentiating user zones, it allows patients and respective families to have more
privacy, while staff can prepare medicines or clean wet areas without disturbances. This
evokes the necessity to locate the working staff and disinfection area in the first area
upon entering the room. The patient area should follow the staff area for easier access
and, in this way, be placed between the staff zone and the family zone. The following
examples show the fixed position of patient, family and staff zone and the variable
position of the toilet.

Location of the Toilet Room

The Inboard Toilet Room (fig. 04.6a, b) is characteristic by its location at the room
entrance and next to the corridor as it occurs in a typical hotel room. This approach
attributes more space to the family zone and allows a wider view of the outside, and
consequently, more daylight. Furthermore it allows a greater separation between the
patient and the corridor, which constitutes a better acoustic measure. However, the
major disadvantage is the limited staff visibility for patient supervision (fig. 04.6b), since
the bathroom forms a physical and visual barrier. The solution could be to position the
bathroom on the footwall (fig. 04.6a), but it could raise another downside, which is the
increased travel distance from bed to the toilet, increasing patients’ falls.
The Outboard Toilet Room (fig. 04.6c, d) is located along the exterior wall. The major
advantage is that all physical barriers in the entrance are removed and provide staff’ full
visibility of the inside. However, this approach represents a great decrease on patients
and families privacy, and reduces the family zone and window size. Furthermore, the
location of the bathroom in the headwall (fig. 04.6c), disables the patient’s sight of the
outside from bed and visual contact with family. The solution of locating it in the footwall

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(fig. 04.6d) brings the same problem of increased walking distance between bed and
toilet.
The Shifted Toilet Room (fig. 04.6e) presents the benefits of the Inboard Toilet Room,
while preserving an adequate staff visual connection and guaranteeing a minimal
walking distance between toilet and bed. Moreover, the path to the bathroom can be
complemented with the help of a handrail. However, this irregular layout can possibly not
fit the general shape of the building.

Figure 04.6 - a) Inboard/Footwall Toilet Room; b) Inboard/Headwall Toilet Room; c) Outboard/Footwall

Toilet Room; d) Outboard/ Headwall Toilet Room; e) Inboard/Headwall Shifted Toilet Room

An evaluation of the room purposes and users satisfaction is important to define a

solution. For example, in the critical care units it is necessary to have constant staff
vigilance, which means that the main characteristic of the room should be to provide a
great visual connection corridor-room, avoiding all visual barriers. On the other hand, in
regular rooms, patients will prefer to have more privacy and space to be with their
families, since their health status allows that.
Other design measure that should be taken into account is the way to multiply the single
rooms.

Mirrored or Same-Handed
The idea of reproducing the same room layout is widely defended, since standardisation
will allow staff to know exactly where everything is located, independently of the room or
unit they are in. This means that same-handed rooms (Fig.04.7a) could avoid errors or
unnecessary time lost.
Conversely, mirrored rooms (Fig.04.7b) allow two bedrooms to share a plumbing system
between toilets, which multiplied by all rooms means a significant cut in the construction
costs.

Figure 04.7 - a) Same-Handed Room Layout; b) Mirrored Room Layout

However, it is necessary to consider the costs of medical errors, which could be reduced
by applying same-handed layout, i.e., a major initial investment could be compensated

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during the hospital life span. Notwithstanding, further investigation in this field is
necessary to prove the correlation between standardisation and decreased medical
errors.

1.2.4. FAMILY LIVING ROOMS

The importance of family’s presence during all hospitalisation stages has already been
mentioned. In such an early period of life, as childhood, the comfort of having the loved
ones around, being able to support anytime, is essential. However, many families have
to travel long distances from home, leaving their child alone or dividing the family. For
children, the pressure of illness along with deprivation of parental love and support can
constitute a great trauma. As it was further discussed in chapter 02, the possibility to give
parents the chance to be with their children anytime, as well as having access to
adequate amenities to live inside the hospital, seems a potential solution.
Ronald McDonald House Charities (RMHC) institution appeared in 1974 as a solution to
make ‘children happier and healthier by keeping families together – giving them a place
to rest and refresh. A place that feels like home’ (RMHC 2016). It is a pioneer in family
centred care, providing Ronald McDonalds Houses and Ronald McDonalds Family
Rooms. The non-profit organisation counts with the support of McDonalds, other
important corporations and donors, volunteers, staff and friends. The RMHC offers the
opportunity for parents to live nearby for little or no cost.
However, this study focuses on a hospital capability of including parents in fulltime, i.e.,
to offer patient’s rooms already equipped for parental stay, including bed and bathroom.
So in this section, the main focus is the provision of an area, outside the bedroom, where
family can be together and parents can socialise, work or have a good time. For this
purpose, RMHC started to provide Family Rooms where parents can stay, being able to
quickly reach their sick children.
From their practice and research, it is suggested the following provisions represented in
the chart below. (RMHC 2016)

Figure 04.8 - Design guidelines for paediatric hospital’s family rooms

It is evident that recent projects are already integrating these spaces independently from
institutions, due to an increased awareness of the hospitals’ management. Furthermore,
this space is probably the one, which can provide a major connection with home, due to
its functions, and a well thought connection with rooms would enhance that association.

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02. WILHELMINA CHILDREN’S HOSPITAL

Architect: EGM architecten, Dordrecht | Design Year: 1996 | Completion Year: 1998 |
Location: Utrecht, Netherlands | Constructed Area: 35 000 m2 gross area

2.1. URBAN CONTEXT

The new Wilhelmina Children’s Hospital is located in the sub district of Utrecht, The
Uithof, in the far east of the city. This area is known by housing numerous universities,
including the University Hospital of Utrecht (UMC), which is merged with Wilhelmina
Children Hospital. This zone includes extensive green areas, but also big-scaled
representational buildings, flanked in the northwest by one of the ring roads of Utrecht. In
this ring, two major highways cross their routes (A28 and A27), improving the accesses
from the northern and southern part of The Netherlands.
In this urban context, the WKZ faces different realities on the different sides. First of all,
the creation of a sound barrier is obliged by regulation, when there are highways nearby,
which was materialised in the design of the ‘boomerang’ building. This volume faces the
north and west sides of the plot area. Connected to the ‘boomerang’, the hospital
presents the entrance volume and develops through a vertical spine connecting four
wings, elevated on slender columns. This last building set is expected to be extended to
the east. On the south, WKZ faces the UMC, sharing an underground passageway.
Overall, the hospital is more expected to be reached by car or bus, providing a wide
parking area underneath the four wings, and a bus stop right in front of the entrance
area. From the parking area it is possible to access the hospital through a secondary
entrance, while the main entrance is located in the connection volume.

Figure 04.9 - Aerial photo of Wilhelmina Children’s Hospital; Figure 04.10 - WKZ– Site Plan

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2.2. FUNCTIONAL AND SPATIAL ORGANISATION

The glazed entrance volume welcomes the users and visitors with a big-scaled hall,
conceived to enter the children’s imagination, stepping away from the hospital
environment. This space is not only multifunctional, but is also the central core and
distributor of the entire hospital. From the main hall it is possible to access the various
buildings on the ground floor or to take the vertical accesses to the higher floors. The
ground floor holds the highest amount of public services of the hospital, such as
cafeteria, child store, restaurant, cloister garden, multi-purpose room, auditorium and
business services. In addition, the perinatology clinic was strategically positioned in this
floor to avoid the contact between pregnant women and sick children. Also, the blood
bank is positioned in the opposite end of ‘the boomerang’ pointing out its separation from
the children’s hospital, with its own entrance.
From the first floor two different main accesses can be highlighted: one located in ‘the
boomerang’ and other in ‘the spine’. The first is easily found because of its materials on
the exterior façade, with blue ceramic tiles. This access is responsible for approaching
the different day care wards (four floors). For this reason it is mainly used by hospitalised
children, family and staff. In connection with these wards there are several support areas
such as a hospital school, parent accommodation, meeting and meditation rooms, info
centre, recreation rooms and an outdoor playground (attachments 4, 5).
The vertical access located in ‘the spine’ provides access to the different halls located in
each level. From these halls it is possible to access the main distributor corridor present
in the ‘spine’, which also has access to the wings. A visible detail in the first floor hall is
the visual connection with the main ground floor hall that facilitates pathway discovery. In
this area it is possible to do the medical registration and be forwarded to the outpatient
clinics, as well as some medical specialisations, such as gastroscopy, dialysis, radiology,
heart centre, pulmonology and audiology.
The upper floors continue the same functional dynamic. The second floor includes
functions such as the day care unit, neonatology, and pregnant nursing department. This
floor area also integrates the departments for surgical, post-surgical procedures and
intensive care. The third floor comprises some technical rooms, and two close functions:
the maternity ward and the NICU, allowing the recent mothers to be close to their babies
in incubators, if it is the case. Finally, the fourth floor houses the staff offices.
All the treatment areas mentioned are positioned in ‘the wings’ comprising expensive
high-tech equipment. For this reason the architects decided to use metal plating in the
lateral facades, varying in size from the different sides in order to facilitate the
orientation. Furthermore, the corridors create an idea of continuation, materialised with a
window and a top façade covered in wood.
The third and fourth floors of ‘the boomerang’ incorporate the investigation laboratories,
whose construction materials disable visual and physical connections with the care unit,
being an almost independent part of the hospital just like the blood bank.
Finally the most recent hospital project, the Ronald McDonald family room, can be
accessed in the third floor just above the main hall, located on the roof.
In terms of orientation, the hospital is placed in such a way that most of the rooms face
east and west, with the exception of the main hall that faces north and south, as well as
the blood bank and laboratories.

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2.3. CHARACTERISATION OF THE SELECTED SPACES

2.3.1. ENTRANCE

The access to the hospital is facilitated by the unique forms of the buildings that capture
first time users attention. Furthermore, the thoughtful building dispositions use the
‘boomerang’ form to enclose an area and steer the users to the opposite side, where the
entrance areas take place. The main entrance (south) is announced by the ‘U’ space
created between the ‘boomerang’, entrance and ‘spine’ buildings, which invite the
pedestrians to enter. Green areas and paths direct users to the entrance, highlighted
with an angled coverage and the hospital name above (Fig.04.11a).
However, the main entrance is not the most used, since most users access the hospital
by car, due to its localisation in the outskirts of the city. This fact makes the secondary
entrance, on the east side, the main one in practice. The route is also well signalized for
cars to enter in a wider interval between ‘wings’, where they can easily set down or pick
up passengers, and park the car nearby, underneath the ‘wings’ (Fig.04.11b).
Both entrances provide a covered space outside, creating a protected transitory space.
The building’s entrance has automatic revolving doors, but manual doors are also
provided. The transition to the inside is smoothed by the presence of glazed facades,
which avoid a sharp transition in terms of light and ambience. This transparency also
offers confidence and control, since all spaces are visible from various perspectives.
Also, the induced feeling is not that of entering a hospital, though one still feels like
entering in a big representational building.
The large scale of the entrance hall, with three-storey high ceiling (attachment 6), is felt
when entering the south entrance. It is a central location, where the reception desk is
located with a visual connection with the day care reception, enabling an easier way
finding. A glazed elevator is only used for this connection (ground to first floor).
Furthermore, the hall can be divided in two more areas, the east with one-storey high
ceiling and the west with a two-storey high ceiling, both providing access to the most
important vertical accesses of the building. The first can be considered an introduction to
the hall, being lower and holding the secondary entrance. The second is an informal
creative area, from which it is possible to access the garden, and enter the children’s
imaginary.

‘We had a program for everything, except for this hall that we found out ourselves, inspired
by boys’ books and Indiana Jones pictures. We thought in this space as a cave separated
from the outside world trough waterfalls (glazed facades). When you enter the cave you
are in a tunnel underneath the roof, and you came into a forest of columns that represent
trees. (…) This hall can be used for everything except for formal things. This is why the
coffee shop is here now. And this is the first time I am seeing this hall being used for what
it was projected, as a camping space. Because it is holiday time, children normally go
camping, so this is a way to give hospitalised children an opportunity to have a similar
experience.’ (Mario Hendrikx, 2015)

In general, the entrance hall is the central distributor of the hospital, providing access to
the most public services of the hospital located in the ground floor and to the main

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vertical accesses. It’s a large area with multifunctional sub-areas that provide spaces to
stay and passage ways, without interfering with each other. In terms of signalisation, the
hospital is very predictable without indications, though the applied signs are mainly
written.

A B C

D E F

Figure 04.11 - Outside and inside views of Wilhelmina Children’s hospital entrances

2.3.2. GARDEN

The enclosed area defined by the ‘boomerang’, entrance and ‘spine’ buildings is where
the hospital garden takes place. Even though WKZ is surrounded by green areas, this is
the formal space for the purpose. Its central location allows a connection inside building-
garden, as soon as one crosses the hospital entrance, continuing all around the ground
floor main path, constituting a cloister image. This connection continues in the floors
above both in public areas or private rooms.
The garden characteristics suggest a place to stay, more than an activity area. The
limited dimension and lack of amenities variety restrict physical activities, including
outside physical therapies. However, dimensions and possibilities are seen from other
perspective by children, who can use this space as a play area where they can run and
interact more freely. Furthermore, users can enjoy a meal or a conversation sitting in the
garden chairs provided. Also, smokers have a wooden house in the garden especially for
smoking.
Among more contemplative and social activities, users can still choose between a
sunbath and a building shade protection, or between sitting on the moveable chairs on
the stone pavement area or lying on the grass.
In terms of fauna and flora, there is no big variety. This can be justified by the urbanized
garden and artificial essence, necessary to comply the hospital requirements in terms of
contamination and bugs spread. Enclosed by all sides, the garden prevents the
possibility of seeing the horizon. However, it offers natural light and pleasant visual
connection with the inside areas, as well as a ‘romantic atmosphere’ at night with the

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light presence in the rooms. On the other hand, this high exposure reduces the privacy of
the garden users.
Finally, the art elements are a boat offered by the Princess Margarita, where children can
play and sign their names, and two big scaled statues, a person and an earth worth
worm. Even though the statues have some connection with the garden theme, they are
too big for children to interact, acting more as first image impact objects.

Figure 04.12 - Garden different views

2.3.3. BEDROOM

The care units are located in the south part of the ‘boomerang’ building, occupying the
same area in the 1st, 2nd, 3rd and 4th floors. These wards are differentiated by different
medical specialisations to which corresponds a different animal. They house hospitalised
children, providing mainly single bedrooms with amenities for a parent to stay overnight.
Moreover, each floor also offers rooms for two or four children, and a family room with a
terrace. The other rooms are meant for staff meetings and services, with a central block
to support the bedrooms. At the bottom of this central service block it is located the
reception, from which it is possible to control entrees and exits from the bedrooms, and
also, monitor the hospitalised children through the rooms’ glazed doors.
The general single room layout is represented in Fig.04.13, and it is multiplied through
mirror process. The room plan is characterised by the outboard toilet location that
decreases the outside window size but increases the glazed door entree for better
monitoring. In the sections it is possible to identify the different users’ areas, with the
lowest height in the entrance for staff, increasing in patient zone, and reaching the
maximum height in the family zone, near the window. These suspended ceilings use a
sound absorbing material (Ecophon Gedina) and allow an efficient location of ceiling
lights.
The room layout was designed in a way that staff members can work with minimum room
entrees, by providing medication lockers accessible from both inside and outside room.
However, part of their work has to be done inside the room, in which they cannot enter
without being noticed. The design strategies that contribute for this fact are the absence
of a formal division between areas apart from the ceiling heights; the curtain location, just
ahead the entrance door and the presence of the sink and workbench in the patient
zone.

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Overall, children can personalize their room with photos, postcards, or motivational
quotes, sticking them on the walls or bathroom door (Fig.04.14b). However, there is no
specific board for this use, and no artistic paintings either. In terms of personal
belongings, there is a small locker near the bed and in the sink bench shared with
personnel.

Figure 04.13 - a) Regular bedroom plan; b) Bedroom section AA’; c) Bedroom section BB’
!
Finally, the family zone is located in the headwall, just ahead the window, allowing a
visible connection between parent-child and child-outside view. The presence of a sofa
bed and the close distance to the bathroom, allows a parent to stay overnight without
disturbing the other user zones. However, the bathroom location on the footwall prevents
the use of a handrail and increases the distance. This distance problem was mitigated by
designing a diagonal entrance.

!
Figure 04.14. - a) Ward’s corridor; b) Bedroom

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2.3.4. FAMILY ROOM

The Family Living Rooms can be divided into two different categories
(Fig.04.15): care unit living rooms, distributed into the four floors and
located in the unit southeast corner; and, the Ronald McDonald Living
Room, which is the most recent hospital building update and is
located on the entrance volume roof.
The care unit’s living rooms were designed so that parents can
access kitchen facilities, a storage room, a toilet and a terrace
(Fig.04.16). Furthermore, this space is the only common room and
playing facility in each care unit floor. Thus, here converge the Figure 04.15 -
possibilities for hospitalised children to communicate and play with Family rooms’
location – plan
other patients or siblings, and also engage in a familiar atmosphere.
layout
Parents also have the opportunity to share ideas and socialise, while !
they can go to the terrace and get some fresh air.
Overall, each care unit offers space and features for parents to stay
overnight and prepare their meals. However, there are no laundry
facilities especially for them. This type of service is only accessible for
parents who are housed in the Ronald McDonald House nearby.
Other specific services, such as disease related information, working
or relaxation spaces are located outside the care unit. For these
purposes, the fourth floor of ‘the boomerang’ building offers an info
centre and a meditation room. Moreover, Internet is easily accessed
by Wi-Fi in all hospital areas.
Finally, The Ronald McDonald’s Living Room offers a space for
parents and siblings to stay, whether they are waiting for a simple Figure 04.16 -
surgery or a long treatment to end. While parents have restrictions to Ward’s family
room plan
be with their children, this space became an important space to
escape from the hospital environment, but still at a close distance.
Designed in 2011, the Ronald McDonald’s Living Room (attachment
7) stands on the main hall roof, precisely above the forest of columns,
constituting a ‘tree house’. This volume form presents a pointy rooftop
that enhances the children’s typical house design. The northern
façade is fully glazed with wooden frames, facing the hospital garden.
In the interior, the space offers a mixture of lofty heights with
comfortable corners, and combines visibility with hiding possibilities.
The materials used were essentially wood and cork that provides a
warm and friendly atmosphere. Moreover, the soundproof ceilings
allow users to rest.
In terms of activities, the RM living room offers a fully equipped
kitchen for parents to prepare their meals with further spaces to work,
Figure 04.17 -
watch TV, read or play games. In order to organise and manage this Ronald
space, there are always volunteers available that also offer support to McDonald’s living
room
parents. Thus, this building contrasts with the hospital atmosphere,
offering warmer colors and different smells and sounds, perfect to feel
outside while being inside the hospital.

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03. EMMA CHILDREN’S HOSPITAL

Architect: OD205 Architecture, Delft | Designer: OPERA Amsterdam, Amsterdam |

Design Year: 2005 | Completion Year: 2015 | Location: Amsterdam, Netherlands |
Constructed Area: 1 100 m2

3.1. URBAN CONTEXT

The new and recently renovated Emma Children’s Hospital (EKZ) is part of the
Academic Medical Centre (AMC), which is affiliated with the University of Amsterdam
and considered the largest hospital in the city. The AMC is located in the Bullewijk
district, on Amsterdam Southeast, characterised by industrial and office buildings. This
area is also characterised by its close location with the junction between A9-A2
highways, as well as the railway line Amsterdam-Utrecht.
The AMC plot area allows for future expansions and upgrades. The surrounding areas
can be categorized in: the south and east, which present a recreational green area
including a golf course; the north side, holding the offices and businesses buildings; and,
the west which houses the Holendrecht residential area. In such an accessible area, the
AMC hospital, finalised in 1983, represents more than a building, with a set of nursing,
educational and researching buildings, connected as a city. The buildings are connected
in the ground floor, by streets and squares, which provide a commercial courtyard, with
terraces, restaurants, shops and art. The EKZ is located in the central higher building
set, occupying the 8th and part of the 7th floors.
In terms of accessibility, the hospital is mostly expected to be approached by car, train or
bus, providing a wide parking area on the ground floor, and a bus and train station with a
covered path for direct entrance in the hospital.

Figure 04.18 - Aerial photo of the Academic Medical Centre; Figure 04.19 - AMC – Site Plan
!
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3.2. FUNCTIONAL AND SPATIAL ORGANISATION

The Emma Children Hospital occupies the top floors of the higher building set in the
AMC campus. It can be accessed by the vertical accesses located in the H, F and G
blocks, 8th floor, or H block, 7th floor, depending on the ward destination.
The sense of approaching the children’s department can be described as entering a
completely different atmosphere, full of light, colour and a panoramic view to the outside
world. This view escorts the users along all façade, which matched with the rooms’ walls
transparency, provides a constant connection with the outside.
As AMC is compared with a city, the Emma can also share this characteristic but in a
smaller scale. This department provides a corridor that covers the length of the hospital,
connecting different neighbourhoods and consequently homes, as if it truly was a street.
One important characteristic of this ‘street’ is its changeable width, creating different
spaces of circulation and stay, and integrating the most public functions, such as
restaurant and entertainment areas. In the elevators location, the corridor also expands
creating a hall where graphical signalisation is printed on the floor (Fig.04.21c), allowing
a child friendly interpretation and easier way finding.
Generally, the functional organisation is divided in levels of intimacy: the most public
space is the corridor, which is accessed by people of the different wards; the wards that
can be seen as a home, offering lounges, family living rooms or playrooms for ward’s
users; and ultimately the most private space, the child room.
The wards are mostly divided by age in order to obey the different age groups’
requirements, which also allow more appropriate interactions between hospitalised
children and children/health carers. This means that many children have chronic
diseases that oblige frequent visits to the hospital until late childhood, for which it is
important a confident relationship with the same professionals, for as long as possible.
The exceptions to the age rule are the oncology and intensive care wards, which due to
special medical requirements need to be isolated. In addition, the staff ward presents the
offices, and the Emma Plaza houses a great variety of functions, such as the cinema,
info centrum, psychiatry, school, sport centrum and toilets.
Physically, the wards are represented with different colours and themes, and present a
semi-public corridor, surrounded by bedrooms. In the internal part of the corridor resides
the reception and, technical and staff rooms. In the corners, small lounges can be
accessed, offering a pleasant place to stay with an exterior view.

Figure 04.20 - Functional scheme of Emma Children’s Hospital

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3.3. DESCRIPTION OF THE SELECTED SPACES

3.3.1. ENTRANCE

The Emma Children’s Hospital entrance cannot be defined as a single formal entrance.
Considering EKZ is a department of the AMC hospital, users need to enter in the
academic hospital first. One way to directly enter the hospital is through the pedestrian
passageway, which connects the train and bus station with the AMC hall.
By car, the AMC hospital can be easily seen from distance, due to its big scale and logo
position above the higher blocks. However, the decision about the most appropriate
parking lot and respective entrance can be confusing for first time users. This occurs due
to the lack of clarity about different blocks division from the outside and possible lack of
knowledge about the end place. Because the ground floor area is huge, the further away
from the end block, the more users have to walk inside. Still, the main entrance presents
an outside coverage that not only provides a transitory space, where cars can set down
and pick up passengers, but it also helps in terms of way finding.
By entering in the main entrance, a completely new reality is set out. Despite the attempt
to smooth the transition outside/inside through the use of glazed doors and roof between
blocks, the huge blocks create a more enclosed atmosphere. Also, the interstitial space
changes dimensions, creating streets and squares filled with stores, supermarkets,
cafes, restaurants and others. The induced feeling is of entering a big shopping mall.
Just in front of the main entrance is located a general reception, where a plan scheme is
given (Fig.04.21a). This necessity points out the lack of path clarity, that even makes
verbal explanations impossible without graphic notes.
From the general reception until the EKZ it is necessary to know the end ward to enter in
the right block elevators. Each block gives access to two different wards: H7 - Babies or
Staff wards; H8 - Intensive Care or Day Hospital and staff wards; G8 - Emma plaza or
Children Wards; and, F8 – Teenagers or Oncology wards.
By leaving the elevator, the user enters the EKZ, facing a completely different
environment full of colour and transparencies. These elevator halls are also a meeting
point and distributors of the users who came from the elevators, enter or exit the two
wards or run across the corridor. Even though there are no significant height differences,
a slight difference can be noticed in Fig.04.21c, where the artificial light is carefully and
dynamically positioned. Furthermore, the child-friendly graphic signalisation is also a
strength of this project, being strategically positioned by the entire corridor.
Finally, even though it is possible to define the AMC and EKZ entrance, both are public
and lack hospital purpose. The real feeling of entering the Children’s hospital happens
when entering any ward door (Fig.04.21d), in a more private and specialised area.

Figure 04.21 - a) Academic Medical Centre – ground floor scheme; b) Atrium view; c) Emma Children’s
Hospital entrance plan; d) Elevator Hall; c) Ward’s door
!
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3.3.2. GARDEN

The connection between EKZ and the exterior world is only experienced by the
panoramic windows, i.e., there is no outside space in the seventh or eighth floor. For this
reason, the possibility to experience the outdoor fresh air is restrained.
Surrounding the hospital, there are plenty of public green areas, easily accessed, which
can be used by hospital patients, workers and visitors. However, considering there are
public gardens, independent of the hospital space, supervision cannot be guaranteed.
Hospitalised children should have medical permission and professional or parental
monitoring to frequent these gardens.
The relative distance to the hospital allows the gardens to be more natural, with a wide
variety of fauna and flora, typical of the region. The proportions and extension of this
green layer, allows a great diversity of paths and activities, such as running, riding a
bicycle, walking or simply relaxing. Furthermore, recuperation physical exercises seem
to be possible to execute, as long as the therapist determines.
In terms of furniture, there are several fixed public benches, where people can sit and
socialise or have lunch. Moreover, people can freely sit or lie on the grass, in a tree
shade or in the sun. The presence of the water canal and the possibility to see the
horizon also invites to practice contemplative activities.

Figure 04.22 - Academic Medical Centre surroundings – green areas

3.3.3. BEDROOM

The care units are mainly divided by age, excluding the oncology and intensive care
wards that need a specific medical care and vigilance. Even though there is a
predominance of single rooms layout, the number of common bedrooms increases with
age, as parental dependence decreases. The single room layout is adapted to two and
four patients’ rooms, multiplying the amenities for each one. The other main difference is
the amenities dimensions that vary with the age group. For example, the babies’ rooms
need less space due to the smaller bed size, and the bathroom facilities in infants ward
are also smaller, according to children’s heights.
One important characteristic that wards have in common is the strategic placement of
the reception desk. From the corner of the central block, near the main entrance door
(closer to the elevator hall), receptionists can easily monitor entrees and exits of both
wards and rooms. The rest of the rooms in the central-block are meant for staff, meeting

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rooms and service rooms, which support hospitalised patients. Furthermore, the rooms’
glazed doors allow an easier monitoring of each patient from the ward corridor. !
The most replicated room layout is represented in Fig.04.23, and is multiplied in a mirror
manner. Overall, the room layout presents an inboard bathroom on the footwall, leaving
a free visual connection staff-patient and offering a wide panoramic view through the
outside. However, this location increases the walking distance bed-toilet and prevents
the use of handrails.
Several design strategies can also be identified in order to attribute different users’
zones. First, the sections demonstrate an increase on ceiling heights, with the lowest in
the entrance for staff area, followed by the patient zone, and the highest correspondent
to the family area. These suspended ceilings use a high absorbing material (rockfon),
also flexible to introduce ceiling lights, as the one above the bed.
However, the different heights only predict the position of the group users, being
complemented by the plan inputs about users’ action area. In Fig.04.23 it is possible to
identify two different floor colours, which divide the right and left bed sides. One side
corresponds to staff working area and the other to family stay.
Finally, the curtain is another element that contributes to the space division. Once
closed, two different spaces can be defined: the entrance area, where staff members can
prepare medication, disinfect hands or clean the wet areas (bathroom and sink), without
disturbing patient and family; and the room area is transformed in a more private space,
where family can be with their child without feeling observed.

Figure 04.23 - a) Regular bedroom plan; b) Bedroom section AA’; c) Bedroom section BB’

In terms of personalisation, there are several shelves and a wardrobe where it is

possible to keep personal belongings, and a board where motivation pictures and cards

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can be placed. The room also provides a sofa bed for a parent to stay overnight and a
table with a chair. There are no art paintings in the rooms.
Finally, one special item is the electronic device placed near the bed. This element
allows children to play, access Internet, watch TV, change the light colour, modify the
bed height and inclination, and create a personalized room input screen.

Figure 04.24 - a) Ward’s corridor – room door; b) Bedroom

!
3.3.4. FAMILY ROOM

The Family Living Rooms are neither equally distributed, nor located in all wards. Along
the main corridor, also called the ‘Ronald McDonald Parade’, some public lounges were
designed, in order to provide a space for children and their families to socialise, play, eat
or even relax together. In the absence of doors, these rooms belong to the main corridor,
which punctually enlarges and creates spaces to stay. The exceptions to this rule are the
rooms situated on both floor ends, which in order to be reached, imply crossing the
respective wards’ doors (Teen’s lounge, IC Family Living Room and The Garden Room).
Even though these lounges belong to specific wards, children from other wards can also
use them.
The teens’ lounge provide teenagers and their families a fully equipped kitchen to
prepare meals, and a great sofa area where they can watch TV, play video games,
football table or ping pong, and also several board games. This space has a unique
social spirit specially focused on the adequate age group activities. Also, it is one of the
spaces with the most familiar atmosphere, where teens do not have to leave ‘home’ to
be together. Also, The Garden Room has the same approach but focused on babies.
The IC Family Living room has a more formal approach, focused solely on parents. Due
to the IC children medical conditions, parents cannot enter the rooms for long time
periods, which require a space for them to stay. The IC lounge provides both possibilities
to prepare meals or comfortably sit on the sofas, for more contemplative or reading
activities.
Within the corridor, four public lounges take place, strategically located in relation with
the wards nearby. The Fish Lounge is near the oncology ward and offers a wide space to
sit, either in comfortable chairs or in bench seats. The playground shares the same
space, in connection with the infants’ ward. This lounge allows children to jump, hide or
climb and also offers an interactive screen. Furthermore, the sidewalls are filled with
benches for parents to monitor their own children.

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Figure 04.25 - ‘Ronald McDonald Parade’ – plan layout and respective photographs
The last lounge houses the restaurant, info centre and silence room. Even though the
restaurant is connected with the Emma Plaza, is widely used by all hospital children and
respective families. Finally, even though the silence lounge also has this public
characteristic, it offers a more meditative and contemplative space for parents to read,
think or even pray.
Overall, Internet is easily accessed by WI-FI in all hospital areas. The only facility that is
not offered in this hospital is a laundry room. These services are only available for
parents who are housed in the Ronald McDonald House nearby.
The last communal room type are the lounges situated on each wards’ tops. These
rooms provide a view to the outside from the wards’ corridor, which improves the
connection inside/outside and supplies more natural light. The main activities are
socializing, having private conversations with doctors or nurses, or simply waiting.
According to each ward, these lounges differ. For example, the infants’ lounge offers a
playing table with games while others provide a coffee machine for parents to quietly
drink something.

3.4. POST-OCCUPANCY EVALUATION

A post-occupational study was developed based on the methodology previously

described in this chapter. Succinctly, it was used visual methods with children and verbal
interviews with adults. The obtained results are described below and can be consulted in
the attachments 8 and 9. Further analyses are commented in the next sub-chapter 04,
“Discussion”.

At first glance the cooperation between the new spatial qualities and renewed policies
were clear. The new EKZ is intended to bring the outside world inside, providing an
atmosphere in which normal life can carry on, as much as possible. In this way, the
hospital allows children and their families to proceed with their homely routines.

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‘We let parents be parents. They can give a bath to their child and have no restrictions
about visiting hours (...). We want parents to be part of the healing process. For that
reason, it is important to allow them to go in and out freely. (…) We want to provide care in
a homely environment’. (Nurse)

The hospital design supports these policies and different users’ requirements, generating
different opinions and perspectives. However, it is common sense that the EKZ offers top
scientific medical specialisations in a child-friendly environment, with many activities and
a great variety of spaces.

‘We do not only cure disease, but we also see its impact on child psychological functioning
and on family.’ (Prof. Dr. Goudoever)

In terms of children perspective, the hospital image changes according to their age,
gender, maturity, disease and personality. The photo tour exercises show different
knowledge degrees in relation to the hospital spaces, which can be matched into three
major hospitalisation categories: the non-chronic patients (fictitious names: Gerrit, 15YO;
Aya, 15YO); the chronic patients with lack of mobility (fictitious names: Gwen, 16YO; Gil,
12YO); and, the chronic patients with mobility (fictitious names: Pete, 8YO; Jan, 16YO).
Both Gerrit and Aya had reversible medical problems and had been recently submitted to
surgery. Gerrit had been in a consultation before surgery, so he had a blurred image of
the hallway, consultation room and waiting room. On the other hand, Aya had had an
emergency surgery so she had no idea of the hospital spaces. Both had in common a
short hospital stay and a daily routine constrained to their bed and double bedroom.
Maybe for this reason they paid special attention to the room details, and couldn’t draw
the hospital’s mental map.
Guerrit photographed and marked as positive hospital features the electronic device to
entertain him all day, the view through the outside and the fridge to store the food his
mother brought every day. He also mentioned that the light over his bed was used in the
first day for fun, and to discover how it worked, but was never used again.
Aya was especially pleased with the close presence of plugs to charge her mobile
phone, while she was unhappy with the size and distance of the night tables from bed.
Both mentioned they were happy and comfortable with the space and hospital
environment offered.

‘When I entered the hallway, for the first time, I had mixed feelings. On one hand I was
apprehensive because I didn’t know what was going to happen, but at the same time the
colours and overall environment made me feel more comfortable.’ (Guerrit)

Pete and Jan are chronic patients with mobility, i.e. they were not limited to the bedroom
space. Pete was in a bedroom for four patients and Jan in a double bedroom. Even
though they have distinct diseases, both have to frequently visit the hospital for one day
or to be hospitalised for several weeks.
They were really optimistic about all the spaces and room furniture, and could recognise
all hospital lounges, with special focus on teen’s ward spaces.
In terms of level of intimacy, Pete showed how he had freedom to move around inside
the ward by himself, but when going outside the ward his parents and sister always

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accompanied him. Jan is older, so he felt freer to move across the hospital. Also, in his
mental map it is possible to see the representation of the ward door, which represents a
spatial barrier, even though it is glazed.
Both considered the hospital entertainment elements to be a major positive point. In the
case of Pete, he was very enthusiastic about the playground and the table games
available in the teens’ lounge. Jan was more excited with the electronic device over his
bed, the power plugs to charge his cell phone and the television provided in the teens’
lounge.
Finally, Gwen and Gil were hospitalised in the oncology department, being mainly
restricted to their rooms. Gwen seemed accustomed to the hospital facilities, considering
she had to frequently go to the hospital to do chemotherapy. Gil had only discovered his
oncological disease few months before, and has been hospitalised since then.
Gwen could recognise the majority of spaces and felt quite comfortable with them.
However, she was mainly restricted to the oncological ward where she felt a lack of a
social space to be with her friends.

‘Many times I’m obliged to stay inside the ward’s doors because I’m too weak. So, normally
I get bored to be lying on the bed all day, and I go to the ward’s corridor and reception to
walk a bit and talk with the nurses (...) I also go to the wards lounges where parents
discuss their children’s diseases and share experiences. (...). If I have visitors I normally go
to the tables near the ward’s door (fish lounge) (…). I’ve already gone to the teens’ lounge
a couple of times with my friends, but I don’t feel quite comfortable because I’m the only
patient with no hair.’ (Gwen)

On the other hand she was quite satisfied with her room, which in her opinion was more
than sufficient for her. However she prefers single rooms to have some privacy. In
relation to the electronic device, she felt that was dispensable since she preferred to use
her portable computer where she had all her documents.
Gil was the most enclosed patient interviewed. He couldn’t stand for a long time, so he
was mainly restricted to his bed in a single bedroom. For this reason he couldn’t
recognise almost any space in the hospital, except for the oncological ward and fish
lounge. He showed a great interest in the electronic device to spend his day and in the
sofa to be near his mom or dad every day. He was also the only patient who his parents
personalised the entire room walls with post cards, images, balloons and his favourite
personal objects. He felt really comfortable with his room with the exception of the
automatic tap on the entrance.

‘Sometimes I wake up scared in the middle of the night because the tap suddenly starts
working. I don’t like it.’ (Gil)

Gil and Gwen have in common the precise mental map of the ward, with the exact
location of their rooms, reception and ward’s doors. Once again, the ward’s doors work
as a barrier to the exterior world.
Overall, children seemed satisfied and comfortable with the hospital environment and
with the panoramic windows that provided a continuous relation with the exterior. Also,
all of them thought that the spaces they knew were easy to access, with the exception of
the consultation rooms and offices.

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Regarding other users, parents, doctors, nurses and administrative staff were also
interviewed. Parents had different opinions about the hospital facilities’ quality,
dependent on the number of nights they wanted to stay in the hospital, near their
children. In the case of Pete and Jan’s mothers, they were quite satisfied with the quality
of the room since they would only stay overnight in the hospital if their sons would have a
surgery. On the other hand, Gil’s father used to sleep every single night in the hospital,
switching sometimes with his wife. In this case he felt the sofa was uncomfortable and
inappropriate for a long stay.

‘He is never alone. The sofa is not comfortable but I prefer to be here rather than staying at
the Ronald McDonald house. When he wakes up he always ask for mama or papa, and it
is good that we are here looking after him’ (Gil’s Father)

Overall parents desire privacy, preferring single rooms. Also, they often need to escape
from the type of environment where they see their ill child suffering. Thus, even though
there are plenty of lounges for family purposes in the seventh and eighth floors, they
prefer to go to the ground floor or outside to feel in a completely different space.

‘Sometimes I go downstairs, to the big hall, where all the other people are. I can look at
them and it makes me relief stress. I can also sit or buy something.’ (Pete’s Mother)

‘It would be great to have a terrace on this floor’ (Jen’s Mother)

In relation to meals, they generally prefer bringing food from home or going to the
hospitals’ restaurant than preparing food in the kitchen facilities.

‘I never cook here. Instead, I prefer to go to the restaurant. About the laundry, my wife
does everything. She carries the dirty clothes home and brings clean ones. His
grandparents also help us, bringing some food’ (Gil’s Father)

Finally, Jen’s Mother underlined her relief for knowing that her son is being taken care of
for so long by the same professionals. Also, she added she felt more confident leaving
her child in the hospital alone knowing that.
With regard to staff members, they mainly preferred to go downstairs to take a break
than to use the available ‘corner lounges’. The main design disadvantage referred was
the lack of daylight in the majority of the offices (located on the inner corridor part, inside
the wards).

‘Our room is quite closed off. It’s really dark because there are no windows, and I’m always
with the feeling that I don’t know what time is it. (…) By the end of the day, I don’t even
know the hours or what the weather is like. I feel completely disconnected with the outside’
(Dr. Alice van Velsen)

Other negative point criticised by doctors was the long walking distances they had to do
to cover during their shifts.

‘I normally work through the different departments once it is divided per age and not by
medical specialities. Thus, I am always walking through the hospital to see my different
patients.’ (Dr. Tonny Bouts)

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04. DISCUSSION

The presented case studies, WKZ (1998) and EKZ (2015), cannot be extensively
compared since they have different proportions, construction year and context. Even
though the final construction years only differed 17 years, the constant advance in
technology and increased focus on users in the last years, originates big differences
every year. For this reason, EKZ should be analysed as a recent project, while WKZ
should be regarded as a pioneer project in The Netherlands where issues as single
rooms, family rooms or incorporation of electronic devices were raised for the first
time.
Furthermore, the hospitals’ information was collected from different sources, with
different methods, dependent on people availability. For example, the WKZ texts
were mainly based on the architect speech, guided visit and graphic information,
while the EKZ was mostly based on online information, printed publications,
observations and contact with the users. Thus, different information access
generates different results and strengths. However, both hospitals present
characteristics that can be highlighted and compared.

Location and spatial organisation

First, both hospitals are located on the outskirts of the city, which at first glance
represents an increased distance from residence areas and city centre. However,
their connection with academic hospitals (gathering education, high specialised
medical treatments and investigation), together with spatial qualities such as the
possibility of expansion, careful site planning and building orientation, provides a
unique set of competences that will certainly continue to be competitive in the future.
In terms of proportions and constructed area, the WKZ is larger considering it is an
entire hospital and the EKZ is solely an AMC department. Thus, not only the WKZ
offers a wider range of functions, but it also presents a more complex distribution.
Both have in common, the spatial organisation designed around a central distributor
space. In AMC, this element is the main corridor, which includes the social and
public spaces and distributes users to the different wards. Each ward is identifiable
through a specific colour and theme. In WKZ case, the central distributor element is
the main hall, but it works in a more complex grid, i.e., it gives access not only to
final destinations (wards), but also to other distributors, such as corridors, stairs and
elevators. This large number of rooms and functions prevent the constant use of
different materials and colours.

Entrance
In relation to the selected spaces, the hospitals present different approaches with
unique qualities. Considering the entrance area is the space that relates the outside
and the inside, only the AMC and WKZ entrances are considered. From the outside,
the first main difference between hospitals’ entrances is visibility. In WKZ the
buildings’ position already predicts the entrances location, while in AMC it is merely
identified with a cover element, which from other building sides is not visible.
Furthermore the entrance environment is typologically different. WKZ presents a

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glazed volume as a continuation of the outside garden, evoking a public building

proportion without directly referring to a specific typology. On the other hand, the
AMC main hall is more enclosed and offers a shopping mall style on the ground
floor. Independently of the purpose, both work as distraction areas, allowing the
users to escape from the hospital environment, which seems to work efficiently.

Garden
The garden facilities cannot be compared since the EKZ does not have a specific
garden, and both are surrounded by public green areas. The WKZ design includes
this beneficial facility, but it is still far from the possibilities contemplated in theory,
such as the provision of space diversity to encourage the practice of different kinds
of physical exercises, including therapeutic.

Unit care division

Regarding the unit care wards, the division is implemented by age in EKZ and by
medical specialisation in WKZ. The age division favour child centred care, providing
social spaces and entertainment facilities specially designed for each age group.
However, the medical specialisations’ division allows a quick and efficient medical
care, providing special treatment machines and doctors of the field, all in the same
ward.

Bedrooms
Inside the unit care wards, both hospitals’ designers decided to predominantly apply
single bedrooms. In this way, privacy and sense of control are increased, while
noise, infection spread and transfers are reduced. However, the hospitals’ bedrooms
do not present the same layout. For one, the EKZ room layout is clearly divided by
user zones, offering more privacy for both staff to work and family to be together
without interruptions. On the other hand the WKZ room layout counterbalance
occupying less area and placing the bathroom closer to patient and family. In terms
of room facilities available, EKZ essentially evolved in terms of technology, offering
electronic devices.

Family living room

Finally, the family living rooms are one of the greatest differences between the
hospitals. The family inclusion in the hospitals is evidently the most recent addition to
patient-centred care. In WKZ first plan it is already possible to see the inclusion of
bedrooms’ amenities for parents to stay overnight and extra rooms for them to cook
or relax. However, in EKZ, the family rooms became the central concept of the
hospital, which are housed in the main corridor, and offer a great variety of activities.
Furthermore, these spaces have colours, materials and furniture that simulate the
home environment. This progress was already felt in 2011, in WKZ, with the creation
of the Ronald McDonald room, which already incorporates the same homely style.

Both projects have qualities and potential, which for the majority of the cases cannot
be compared or defined as right or wrong. The challenge here is to reach the

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maximum comfort for both patients and families in the hospital facilities, without ever
losing medical qualities. The hospital building, in an ideal situation, should contribute
to improve and accelerate the healing process.
There is no doubt that both WKZ and EKZ projects are part of an evolution process
regarding patient centred care that will continue to develop. This evolution can
already be noticed in some characteristics of the recent EKZ in relation to the WKZ.
However, some conceptual decisions should not be immediately regarded as an
evolution. Further studies in collaboration with hospital users should be taken into
account in order to reach a real conclusion. For this reason, qualitative studies are
necessary to closely follow individual users and identify general areas of comfort and
discomfort, or even small details that seem to interfere with their lives. With concrete
subjects, it is possible to proceed to quantitative studies and conclude the best way
to design.

Post occupancy qualitative study

In this project a post occupancy qualitative study of Emma Children Hospital was
developed. However, it should be taken in consideration the study limitations. First, it
was held in the summer vacation period, so the hospital was not working in its full
potential. Also, the distance to the hospital and internal restrictions prevented a
higher number of visits, thus, the sample size was small (6 children, 4 parents, 4
nurses, 2 doctors and 2 administrative). Furthermore, the children sample was
deviated in view of adolescents due to their major openness and compatibility with
this type of interviews. For this reason, there are limited conclusions in regard to age
ranges.
For example, using a higher number of participants, namely children and parents
from the different wards (not only from the teens’ and oncology wards) and age
groups, would constitute an improvement. In any case, it is possible to analyse and
discuss possible solutions from the observations and interviews’ results. But only a
quantitative study could verify the impact of these results and test the solutions.
Thus, the following solutions cannot be generalised.

Among the children’s answers, some patterns were possible to identify. For example,
many common preferences and requirements were related with the hospitalisation
term, i.e., children hospitalised for few days demonstrate to need fewer amenities
than long-term patients. For this reason, the idea of room standardisation does not
seem to work. To correctly answer the long-term patients requirements it would be
necessary to reproduce all top quality rooms, which would increase a lot the costs
and construction area. On the other hand, the reproduction of average quality rooms
would probably be more than enough for short-stays and still insufficient for long-
stays.
Furthermore, the hospitalised children’s major concerns focus on two areas:
company and entertainment. Even though the interests change with the different age
groups, all enjoy having the possibility to socialise and be comforted, while having
different activities to choose to spend the day on. The little ones enjoy having their
parents permanently by their side, and also electronic and table games available to

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entertain them. On the other hand, teenagers feel more independent, preferring to be
in contact with other teens (personally, by phone or internet) playing group games or
just chilling in a social room.
Another idea revealed in this study is that hospitalised children do not often use
public spaces. These spaces are mainly used by parents, siblings, day care patients,
visitors and hospitalised children who can go out their room and ward (minority). For
this reason, public spaces should be dimensioned and designed taking into account
this fact. Thus, in a patient centred care ideal, the bedrooms assume the spotlight in
hospital design, because their use is permanent and inevitable.
Also, semi-public spaces seem to work well, standing between the extreme privacy
and the monitoring inexistence. This means that the idea conveyed is that the social
rooms located inside the wards are seen as a living room in a house and the ward’s
door as the home’s door. While the inside offers protection, the outside seems
undefined. For this reason, children are normally more willing and authorized to
frequent these spaces than public ones. In the oncology ward case, it lacks a
common space where children with the same disease can gather with each other or
with their visitors.
In relation to details, one child mentioned the use of automatic systems inside
bedrooms. This brings along the theme of sense of control. Even though automatic
systems can be practical and in the case of taps, avoid bacteria spread, patients
should have full control inside their rooms. This means, children are already in a
strange space, worried about their medical condition, and sudden noises or lights
can be momentarily scary. Thus, in the tap case, automatic systems can be replaced
by pedal systems that are, at the same time, manual and avoid bacteria spread.

Regarding adults, they present different reactions and concerns about space design.
First, parents have a higher demand for privacy than children. They are in a strong
emotional situation, so they seem to prefer single rooms to only be with their child or
even escape to a totally different environment to be alone. For this reason, when
they want to relieve stress, they normally go out EKZ, and prefer to immerse in the
shopping mall offered in the AMC ground floor or the outside garden. It’s important
for them to have a space to escape while being close to their children. Once more,
public rooms should address this fact.
Also, spaces to prepare, keep or even buy food, as well as laundry facilities seem to
be extremely important for parents to keep a normal life inside the hospital. Without
that, they will need someone going in and out the hospital and sometimes travel big
distances between home and hospital, to prepare supplies for hospitalisation stay.
Finally, staff members are the user group that seems most impaired in the design
model adopted. For a better performance, working rooms with natural and reduced
walking distances should be provided.

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CONCLUSION. 05
Children’s Hospitals

01. ACHIEVEMENTS

The global purpose of this research/thesis/dissertation was to explore the

architectural role in the conception of hospital design, as a way to improve children’s
hospitalisation quality and healing process.
The research resided in revealing design decisions that could contribute both to help
medicine in its role to cure disease, and offering the necessary physical and spatial
support for normal children development.
As an initial assessment, the hospital typology evolution was studied, revealing a
gradual necessity to use design, in order to adapt to new requirements. Moreover,
the specific case of children’s hospital was pointed out, by its delayed appearance
and unique awareness in providing spaces for children activities. Particularly, spaces
seem to affect children in a different way that does not allow comparisons with other
age groups.
The second part of this research combined the study of an actual hospital typology
with high probability to continue in the future (academic hospitals) with the possibility
to attribute a patient centred design. From the evidences collected, it was concluded
that in fact design strategies do not only directly influence the disease through an
improvement in hygiene, isolating contagious sick patients, but also indirectly
through stress. Stress seems to affect life quality and medical outcomes, which can
be reduced by offering a homely environment, together with outside facilities that
promote a continuation of daily routines.
Therefore, the present work compiles the design guidelines proposed in the most
recent studies, but in a unique combination of cause-effect. Sense of control, social
support, positive distractions, sensorial dimensions, age appropriateness and
security were analysed as the most influencing factors to hospitalisation quality,
revealing the respective health impacts and design guidelines. However, additional
research addressing exclusively children in this area is necessary to confirm the
evidences.
The third part of the project underlined the importance of including future users in the
design process, apart from the focus on theory and architects’ work experience. In
this way, the building has more chances to satisfy each user group and be used to
its full potential. Many times, architects have good design intentions that are
disregarded by users because they misunderstand how to use it.
The final part of this research links theory, practice and users’ experience through
the analysis of two children’s hospitals case studies, in the Netherlands. Even
though both cases had different information sources and the post occupational
qualitative study had deficiencies, it was possible to identify evidences that are
confirmed in theory, and other practices that need further research (automatic
systems, standard rooms, wards’ division, semi-public spaces, users’ satisfaction,
etc.)
Overall, this work contributed to spread the present knowledge, on such a recent
area, in order to balance out the development inequalities between countries.
Moreover, evolution perspectives were found from the actual state of the art.

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02. PROPOSALS FOR FUTURE DEVELOPMENTS

From the state of the art research documented in the last part of chapter 02,
“Architectural Design: The Theoretical Approach, Principles And Recommendations”,
it is possible to conclude which areas that influence children hospitalisation need
further theoretical studies, in order to achieve optimal design guidelines. Overall, all
influencing factors (way finding, privacy, personalisation, social support, family
support, play, education, art, nature, sensorial dimensions, age differences and
security) need specific and quantitative studies in order to complete the existent
evidence, since this area of research is so recent.
Moreover, chapter 04 “Case Studies In The Netherlands” also offers some theme
suggestions developed during the analysis of users’ experiences in one case study.

Therefore, this project can serve as an inspiration and a base for future
investigations, namely:

1. Explore the hospital functionality when sharing the city public facilities
(gymnasium, spa, cinema, garden, etc.);

2. Study the actual need for school facilities in children’s hospital settings and
describe clear design guidelines;

3. Compare the impact of wards’ division per age and per medical specialisation;

5. Compare the room diversity according to hospitalisation duration, with room

standardisation;

6. Study family rooms evolution and related requirements;

7. Study the introduction of new entertainment and social amenities in children’s

bedrooms;

8. Study the impact and pertinence of semi-public spaces inside hospital care units;

9. Study the impact of automatic systems on hospitalised children behaviour and life
quality;

10. Study the influence of parents’ satisfaction levels on children;

11. Explore different hospital designs in which it is possible to be in contact with

different typological environments.

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03. ENDNOTE

Hospitals are complex building typologies that not only cure disease but also
promote health and extend life. They have many different age, gender and job users
going in and out every day. Even though this study was specially focused on
children, adults could not be totally disregarded. The fact is that users inside the
hospital create a symbiotic flow. If the right environment and tools support medical
practitioners, they will efficiently do their work, which will eventually generate better
medical outcomes, and consequently influence parents’ wellbeing as well. On the
other hand, if parents are supported in their routine change, they will be more
capable to provide emotional support to their children, who can improve their
treatment and thereby the practitioners’ job satisfaction. Thus, it is essential to create
general good experiences for all age groups because they will all have
repercussions on children well-being.
In fact, nowadays there is a high demand for stress reduction and citizens’ comfort
and well-being improvement. Therefore, healthcare settings are progressing towards
patient and family centred care, offering a homely environment and facilities that
reduce the hospitalisation impact on daily routine. For this reason, the family living
rooms concept has evolved a lot during the last years, trying to create a communal
space for family activities, as if they were at home. Overall, children’s hospitals seem
to progress from a pure technical public building to a ‘second home’, where medical
care is provided.
This new awareness for emotional and psychological support revolutionized hospital
facilities. Hospitals try to offer spaces and activities for patients to forget, even for a
second, their medical condition, and feel like ‘real children’. It is important to offer
hospitalised children the opportunity to play without fear, socialise with no restrictions
and plan their future, as if they have never had a disease. Apart from healing,
hospital facilities should allow diseased children, who need to live inside the hospital,
to have similar routines and same life opportunities as ‘regular’ children. Scientific
evidence is required not only to relate spatial characteristics with patients’ healing
progress, but also with their development patterns and satisfaction inside the
hospital.
Furthermore, children’s hospitals have the particularity of involving a lot of emotions.
The dependable character of children leaves adults powerless. So, hospital design
should be friendly and supportive on such a difficult period. It can even create
situations where people experience good emotions, ‘challenging them to give
themselves the opportunity to laugh’ (Hendrikx, 2015).
When people fall in a hospital bed, victim of a disease, they need to feel loved and
important. Children need that, and so does everyone else. Maybe, the effort that is
being applied on children’s hospitals would also be welcomed by adults and old
people, who are struggling too. A pleasant, friendly and welcome environment
cannot heal diseases by itself but can be an important factor in improving the user
experience, influence life expectancies and consequently may aid recovery.
!
!

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NHS Estates Symposium. London: The Stationery Office.
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ATTACHMENTS
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ATTACHMENT 1 – EACH CHARTER

EACH Charter

Children shall be admitted to hospital only if the care they require

Article 1
cannot be equally well provided at home or on a day basis.

Children in hospital shall have the right to have their parents or parent
Article 2
substitute with them at all times.
Accommodation should be offered to all parents and they should be
helped and encouraged to stay.
Article 3
Parents should not need to incur additional costs or suffer loss of
income.
Children and parents shall have the right to be informed in a manner
Article 4 appropriate to age and understanding.
Steps should be taken to mitigate physical and emotional stress.

Children and parents have the right to informed participation in all

decisions involving their health care.
Article 5
Every child shall be protected from unnecessary medical treatment and
investigation.

Children shall be cared for together with children who have the same
Article 6 developmental needs and shall not be admitted to adult wards.
There should be no age restrictions for visitors to children in hospital.

Children shall have full opportunity for play, recreation and education
Article 7 suited to their age and condition and shall be in an environment
designed, furnished, staffed and equipped to meet their needs.

Children shall be cared for by staff whose training and skills enable
Article 8 them to respond to the physical, emotional and developmental needs
of children and families.

Article 9 Continuity of care should be ensured by the team caring for children.

Children shall be treated with tact and understanding and their privacy
Article 10
shall be respected at all times.

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ATTACHMENT 2 – CHILDREN’S QUESTIONNAIRE

Figure 1 - Card layout of the photo tour activity

Figure 2 - a) Hospital Regular Room Plan; b) Room Photography

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ATTACHMENT 3 – ADULTS’ QUESTIONNAIRE

Parents

- How long has your child been in the hospital?

- How and why did you that choose this hospital?
- Do you think this hospital is adequate from children’s perspective?
- Can you describe one day of your daily routine here?
- Do you usually sleep here?
- Do you have enough space for both of you?
- What is your favorite space in the hospital? Why?
- Is there any space that you dislike? Why?
- What do you think about the natural light in this building? Is it sufficient?
- Where do you go when you want to take a break and relief stress?
- Do you think that you and your child have enough privacy?
- Do you have any space to cook, eat and wash your clothes?
- Is there any space where you usually go when there are more family members/friends?
- How do you evaluate the quality of the internal space? Materials, light, visibilities, exterior relations,
furniture?
- What would you change in this hospital if you could?

Staff

- What is your function in here?

- In which unit do you most often work?
- Can you describe one day of you daily routine?
- What is your favorite space in the hospital? Why?
- Is there any space that you dislike? Why?
- What do you think about the natural light in this building? Is it sufficient?
- Are the surfaces (floor, walls) easy to clean?
- Is it easy to transport beds and equipment trough the units?
- In terms of walking distance, do you feel that you have to walk too much between your services’ spaces?
- Do you feel able to keep an eye on the patients all the time?
- Do you think that your work place is appropriate? What would you change?
- Where do you go when you want to take a break and relief stress? Are there also children?
- Where do you have private meetings with parents, or working discussions?
- Talking about the patients’ rooms, do you think they have enough space? Do parents have enough
conditions to sleep in the hospital? Is the light adequate? Are they appropriate for children?
- What kind of spaces and activities do you have to distract children from their illness?
- In your opinion, which space is the most child-friendly? Why do you think so?

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ATTACHMENT 4 – WILHELMINA CHILDREN’S HOSPITAL PLANS

Documentation provided in the interview with Mario Hendrikx (15-7-15), WKZ’s Architect.

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ATTACHMENT 5 – FUNCTIONAL SCHEME OF WILHELMINA CHILDREN’S HOSPITAL

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ATTACHMENT 6 – ENTRANCE VOLUME – plan and section

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ATTACHMENT 7 – RONALD MC DONALD’S LIVING ROOM PLANS

Documentation provided in the interview with Mario Hendrikx (15-7-15), WKZ’s Architect.

FLOOR 2 GROUND FLOOR

FLOOR 3 FLOOR 1

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ATTACHMENT 8 – CHILDREN’S INTERVIEWS

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ATTACHMENT 9 - CHILDREN’S INTERVIEWS RESULTS!

Method 01 – Walking Tour!

Elevator Reception Ward’s Corner Ward’s Teens Fish Silence
Offices Clinics Bedroom Playground Restaurant
hall Desk Corridor Lounges Lounge Lounge Lounge
Known XXXXXX XXXXXX XXXX XXXXXX XXXXXX XXXX XXXXX XXXX XX XXX XX
Recognition
Unknown XXXXXX XX XX X XX XXXX XXX XXXX
Happy XX XX X XXXXX XX XX XX XX XX XX XX
Confused X XX
Scared
Feelings Apprehensive X X X X
Comfortable XXXX XXXX X XXX XX X XX XX X
Sad
Alone X XX XXX XXXXXX XXXX X
Levels of With other
XX XXX XX XXXXX X X X
Intimacy! children
With adults XXXXX XXXXX XX XXXXX X XXXX XX XXXX XX XXX XX
Entrance
XXXXXX XXXXXX X XXXXX XXXXXX XXXX XXXXX XXXX XX XXX XX
Allowed
Levels of
access Entrance
XXX
Forbidden

Method 02 – Photo Collection Method 04 – Mental Mapping

Fish
Teens Lounge Bedroom Lack of spatial
Lounge Spatial knowledge
Table Kitchen Elect. Outside Medical Electric Elect. Personal Table knowledge
Fridge
Games Facilities Devices View Equip. Plugs Devices Belongings Games Ward’s
XXX XXX
XXXX recognition
Photography X X X XX X XXX X X X
X

Method 03 – Room Plan

Ceiling Table Elec. Elec. Auto. Extra

Bed Sofa Toilet Chair
Light bed Plugs Device Tap Chairs
For! each! chart,!the! participant’s!answers!or! preferences!are!
Like XXXXX XXXX X X XXX XXX XXX XXXX signalised!with!the!respective!colour:!
X - Gerrit, 15YO; X - Aya, 15YO; X - Pete, 8YO; X - Jan, 16YO;
Neutral XX X - Gwen, 16YO; X - Gil, 12YO.
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Dislike X X !

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