EVIDENCE-BASED HEALTHCARE DESIGN: A THEORETICAL APPROACH
TO A SUBSTANCE ABUSE TREATMENT FACILITY INTERIOR DESIGN
By
Cecilia Escobar

A THESIS
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of
Environmental Design – Master of Arts
2014

ABSTRACT
EVIDENCE-BASED HEALTHCARE DESIGN: A THEORETICAL APPROACH
TO A SUBSTANCE ABUSE TREATMENT FACILITY INTERIOR DESIGN
By
Cecilia Escobar
This thesis aimed to develop a theoretical background on two major healthcare design
theories: Nightingale’s (1859) Nursing Environmental Theory and Ulrich’s (1991) theory of
Supportive Design. Ulrich’s ideas eventually led to the development of Evidence-based design,
the practice of basing design decisions on extensive research (Hamilton, 2003). Utilizing the
theoretical background, The Supportive Design Space Assessment Matrix was developed. This
matrix was used to assess supportive design elements in two pre existing substance abuse
treatment facilities, one of which was an evidence-based design, and the other which was a
retrofit design. Based on the matrix, it was found that the evidence-based design was more
successful in providing a supportive environment for its patients. The other goal of this thesis
was to utilize the theoretical framework, case studies, and Supportive Design Space Assessment
Matrix to develop a retrofit design for a substance abuse treatment facility. The design for this
thesis project was created using the concept of a hummingbird, which symbolizes that all
obstacles can be overcome.

This is a suitable concept for this project because it

demonstrates strength and courage for teens who are undergoing a difficult time in their lives.
The proposed design for this thesis incorporates strategies that encourage social support, sense of
control, and positive distractions through nature. Proposed floor plans and computer renderings
demonstrate how substance abuse treatment facilities can successfully foster coping with stress
and promote healing.

ACKNOWLEDGEMENTS

Foremost, I would like to express my gratitude to my graduate advisor, Dr. Suk-Kyung
Kim, Associate Professor of Interior Design, for her patience, motivation, enthusiasm, and
wisdom. Her guidance helped me immensely in all the time of research, design and writing of
this thesis. I could not have imagined having a better advisor and mentor for my graduate studies.
I would also like to take this time to thank the rest of my committee, Dr. Joanne Westphal and
Dr. Young Lee for their encouragement, constructive criticism, and difficult questions. Dr.
Westphal’s interest in healing environments and her experience as both a landscape architect and
practicing physician was essential in the development of this project. Without her knowledge,
experience, and wisdom, this project would not have been as successful. Dr. Lee’s interest in
healthcare design and building information modeling in Revit was truly beneficial. Without her,
I would not have been able to successfully develop my design renderings for this project.
I would also like to thank my fiancé, Timothy Kane Jr., for his love and support
throughout this process, and for believing in me even when I didn’t believe in myself. I am not
sure how I could have completed this exciting, yet difficult process without him by my side.
Lastly, I would like to thank my parents, Fernando Escobar and Sandra Niese (DeYoung) for
their unconditional love and encouragement in the pursuit of my graduate education.

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TABLE OF CONTENTS

LIST OF TABLES ...................................................................................................................... vii
LIST OF FIGURES ..................................................................................................................... ix
CHAPTER 1. INTRODUCTION ................................................................................................ 1
1.1 Background ............................................................................................................................. 1
1.2 Problem Statement.................................................................................................................. 4
1.3 Purpose and Objectives .......................................................................................................... 5
1.4 Expected Outcomes ................................................................................................................. 7
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CHAPTER 2. REVIEW OF LITERATURE ............................................................................. 8
2.1 Introduction ............................................................................................................................. 8
2.2 Theoretical Research .............................................................................................................. 8
a) The Nursing Environmental Theory (Florence Nightingale, 1859) .............................. 8
b) The Theory of Supportive Design (Roger Ulrich, 1991) ................................................. 9
c) Stress as it relates to Supportive Design Theory .............................................................. 9
2.3 Elements of Supportive Design Theory and Nightingale’s Nursing Environmental
Theory .......................................................................................................................................... 10
2.3.1 Perception of Control ................................................................................................. 11
a) Wayfinding ................................................................................................................. 12
b) Privacy ........................................................................................................................ 12
c) Noise ............................................................................................................................ 13
d) Lighting ...................................................................................................................... 13
e) Thermal Comfort ....................................................................................................... 14
2.3.2 Social Support ............................................................................................................ 15
a) Furniture Arrangements ........................................................................................... 15
b) Social Spaces .............................................................................................................. 16
c) Accommodations ........................................................................................................ 17
2.3.3 Positive Distractions ................................................................................................... 17
a) Nature ......................................................................................................................... 18
b) Animals ....................................................................................................................... 19
c) Physical Activity ......................................................................................................... 20
2.4 Summary ................................................................................................................................ 21
CHAPTER 3. METHODS.......................................................................................................... 23
3.1 Introduction ........................................................................................................................... 23
3.2 Approach to Design............................................................................................................... 23
3.3 Case Studies ........................................................................................................................... 24
3.4 Target Site Visit..................................................................................................................... 24

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a) Target Project Site .......................................................................................................... 24
b) Location........................................................................................................................... 25
c) Exterior Conditions ......................................................................................................... 26
d) Interior Conditions ......................................................................................................... 27
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CHAPTER 4. CASE STUDIES ................................................................................................. 30
4.1 Introduction ........................................................................................................................... 30
4.2 Case Study 1 – Retrofitted Design ....................................................................................... 30
4.3 History .................................................................................................................................... 30
4.4 Site Conditions ...................................................................................................................... 31
4.5 Parking ................................................................................................................................... 33
4.6 Buildings ................................................................................................................................ 33
4.7 Staff Areas ............................................................................................................................. 34
4.8 Patient Rooms........................................................................................................................ 35
4.9 Indoor Gathering Spaces ...................................................................................................... 36
4.10 Outdoor Gathering Spaces ................................................................................................. 37
4.11 Need for Improvement ....................................................................................................... 39
4.11.1 Security ..................................................................................................................... 40
4.11.2 Interior ...................................................................................................................... 40
a) Floor Surfaces ........................................................................................................... 41!
b) Interior Rooms .......................................................................................................... 41!
4.11.2 Exterior ..................................................................................................................... 42
4.12 Case Study 2 – Evidence-based Design ............................................................................. 43
4.13 History .................................................................................................................................. 43
4.14 Site Conditions .................................................................................................................... 44
4.15 Exterior ................................................................................................................................ 44
4.16 Staff Areas ........................................................................................................................... 46
4.17 Patient Areas ....................................................................................................................... 47
4.18 Visitor Areas ........................................................................................................................ 50
4.19 Outdoor Gathering Spaces ................................................................................................. 51
4.20 Need for Improvement ....................................................................................................... 52
4.20.1 Exterior ..................................................................................................................... 53
4.20.2 Interior ...................................................................................................................... 53
4.21 Case Study Summary ......................................................................................................... 54
CHAPTER 5. PROJECT DEVELOPMENT ........................................................................... 55
5.1 Design Concept ...................................................................................................................... 55
5.2 Applying the Theories........................................................................................................... 55
5.3 Space Program and Design Guidelines Based on Theoretical Framework/Case Studies
....................................................................................................................................................... 55
5.4 Space Planning ...................................................................................................................... 57
5.5 Design Development.............................................................................................................. 61
5.5.1 Final Floor Plan......................................................................................................... 62
5.5.2 Reception Space ........................................................................................................ 64
5.5.3 Waiting Room............................................................................................................ 66
5.5.4 Atrium ........................................................................................................................ 68
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5.5.5 Patient Common Area .............................................................................................. 70
5.5.6 Horticulture Therapy Space .................................................................................... 72
5.5.7 Patient Room ............................................................................................................. 74
CHAPTER 6. SUMMARY AND CONCLUSION ................................................................... 76
6.1 Summary ................................................................................................................................ 76
6.2 Implications .......................................................................................................................... 78
6.3 Limitations ............................................................................................................................. 79
6.4 Future Research .................................................................................................................... 79
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APPENDIX .................................................................................................................................. 81
REFERENCES ............................................................................................................................ 88

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LIST OF TABLES

Table 1. Common Ideas Found in Both The Theory of Supportive Design and Nightingale’s
Nursing Environmental Theory .................................................................................................... 22
Table 2. Supportive Design Space Assessment Matrix for The Brighton Center for
Recovery ....................................................................................................................................... 39
Table 3. Supportive Design Space Assessment Matrix for The Rosecrance Health
Network......................................................................................................................................... 52
Table 4. Brighton Center for Recovery Summary ........................................................................ 54
Table 5. Rosecrance Health Network Summary ........................................................................... 54
Table 6. The new facility spaces and their Supportive Design guideline applications................. 56
Table 7. Space Assessment for Riverside Recovery ..................................................................... 62
Table 7. Theoretical Application for Riverside Recovery ............................................................ 63
Table 9. Theoretical Application for the Reception Space ........................................................... 65
Table 10. Space Assessment for the Reception Space .................................................................. 65
Table 11. Theoretical Application for the Waiting Room ............................................................ 67
Table 12. Space Assessment for the Waiting Room ..................................................................... 67
Table 13. Theoretical Application for the Atrium ........................................................................ 69
Table 14. Space Assessment for Atrium ....................................................................................... 69
Table 15. Theoretical Application for the Patient Common Area ................................................ 71
Table 16. Space Assessment for Patient Common Area............................................................... 71
Table 17. Theoretical Application for the Horticulture Therapy Space ....................................... 73
Table 18. Space Assessment for the Horticulture Therapy Space ................................................ 73
Table 19. Theoretical Application for the Patient Room .............................................................. 75

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Table 20. Space Assessment for the Patient Room....................................................................... 75
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LIST OF FIGURES

Figure 1: John Zielsel’s (2006) Model of the Design Process ...................................................... 23
Figure 2: Site Map ........................................................................................................................ 26
Figure 3: Entry (left), student mosaic (right) ................................................................................ 26
Figure 4: Flag Pole (top left), Parking lot and surrounding neighborhood (top right), community
garden (bottom left), open space (bottom right) ........................................................................... 26
Figure 5: Floor Plan (Not to scale) ............................................................................................... 28
Figure 6: West entry with window to office (top left), front entry (top right), view of media space
(middle left), concrete block and blue low-pile carpeting (middle right), brick and concrete block
in media space (bottom left), missing acoustical ceiling panels (bottom right) ........................... 29
Figure 7: Area Map ....................................................................................................................... 32
Figure 8: Site Map ........................................................................................................................ 32
Figure 9: Parking lot (left), main building entry (right)................................................................ 33
Figure 10: Chapel (left), Medical Services Building (right) ......................................................... 34
Figure 11: Sofa in break room (left), eating area (right)............................................................... 34
Figure 12: Patient room in Medical Services Building (left), patient restroom in Medical Services
Building (right) ............................................................................................................................. 35
Figure 13: Patient room window (top left), resident shower (top middle), resident storage (top
right), main building resident corridor (bottom left), detox center (bottom right ........................ 36
Figure 14: Chapel interior (top left), meeting room interior (bottom left), cafeteria in Medical
Services Building (right) ............................................................................................................... 37
Figure 15: Open space view from the north side of the main building......................................... 38
Figure 16: Gazebo view from main parking lot ............................................................................ 38
Figure 17: Walking Garden located on the south side of main building ..................................... 38

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Figure 18: Site Location ............................................................................................................... 44
Figure 19: Main Entry (top left), courtyard (top right), twelve step waterfall (bottom left),
waterfall (bottom right) ................................................................................................................. 45
Figure 20: Pond ............................................................................................................................. 46
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Figure 21: Conference room (left), office wing (right)................................................................. 47
Figure 22: Resident lounge space (left), resident room (right) ..................................................... 48
Figure 23: Gymnasium (top left), Ipsen Conservatory (top right), school corridor (middle left),
student artwork (center), classroom (middle right), cafeteria (bottom left), cafeteria serving line
(bottom right) ................................................................................................................................ 49
Figure 24: Private family gathering space (left), multidenominational chapel (right) ................. 50
Figure 25: Serenity circle (top left and bottom right), outdoor gathering space (top right), private
reflection space (bottom left) ........................................................................................................ 51
Figure 26: View from second floor corridor (left), wall does not meet ceiling in resident lounge
(right) ............................................................................................................................................ 53
Figure 27: Adjacency Matrix ........................................................................................................ 58
Figure 28: Bubble Diagram .......................................................................................................... 59
Figure 29: Block Diagram ............................................................................................................ 60
Figure 30: Final Floor Plan ........................................................................................................... 62
Figure 31: Reception Space .......................................................................................................... 64
Figure 32: Waiting Room ............................................................................................................. 66
Figure 33: Atrium ......................................................................................................................... 68
Figure 34: Patient Common Area ................................................................................................. 70
Figure 35: Horticulture Therapy Space......................................................................................... 72
Figure 36: Patient Room ............................................................................................................... 74

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Figure 37: Bedding by DesignTex (top left), bedding by Stinson (top middle), main wall color by
Sherwin Williams (top right), accent wall color by Sherwin Williams (middle left), bamboo
flooring by Morning Star (center), storage unit by Coalesse (middle right), bed style by Ikea
(bottom left), area rug by Pantone Universe (bottom right) ......................................................... 84
Figure 38: Wallcovering by Brewster Home Fsahions (top left), wall color by Sherwin Williams
(top middle), carpet tile by Interface Flor (top right), side chair by Coalesse (middle left), coffee
table by Coalesse (center), side stool by Herman Miller (middle right), lighting fixture by
VLighting (bottom left)................................................................................................................. 85
Figure 39: Ripple wall by 3Form (top left), countertop material by Compac (top middle), wood
finish by Morning Star (top right), flooring material by Armstrong (middle left), flooring
material by Armstrong (center), flooring material by Armstrong (middle right), flooring material
by Armstrong (bottom left), light fixture by YLighting (bottom right) ........................................ 86
Figure 40: Wallcovering by Brewster Home Fashions (top left) carpet tile by Interface (top
middle), wall color by Sherwin Williams (top right), upholstery by DesignTex (middle left), sofa
by Herman Miller (middle right), lounge chair by Coalesse (bottom left), side chair by Coalesse
(bottom middle), table by Coalesse (bottom right) ....................................................................... 87

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CHAPTER 1. INTRODUCTION
1.1 Background
Quality of care in a hospital environment can greatly affect patient health and wellness
(Nightingale, 1859); however, the impact of the built environment on patient health cannot be
overlooked. Roger Ulrich (1984) began researching this topic when he conducted a ground
breaking study which revealed that patients recovering from surgery who had views of nature
suffered fewer complications, used fewer pain medications, had fewer nursing complaints, lower
blood pressure readings and shorter hospital stays than recovering surgical patients who had
views of a brick wall (Ulrich, 1984). Although healthcare facilities are centered on patient care
and safety, staff wellbeing is just as vital. In 2002, registered nurses had a turnover rate
averaging 20 percent, and quality of care in many of today’s hospitals was lacking (Ulrich,
2004). This was suspected to be due to a number of reasons hidden within the confines of the
built environment, such as the lack of a variety of patient room types, poorly functioning
ventilation systems, over-crowding, excess noise, and inefficient layouts (Marberry, 2006). The
Joint Commission on Accreditation of Healthcare Organizations found that poor physical
working conditions, such as long hours, over-crowding of workspaces, and inadequate lighting
contribute to staff burnout (Ulrich, 2004). Evidence-based design practices in the design of
healthcare environments can remedy this issue, and as a result reduce staff stress and fatigue,
thereby increasing quality of care. This practice improves patient safety, reduce patient stress,
and improve overall well-being (Ulrich, 2004).
Evidence-based design is the practice of basing design decisions on research that
improves health care delivery in quantitative and qualitative ways. Evidence-based design
practices in the healthcare environment are used to create therapeutic environments that are

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physically and psychosocially supportive, economically efficient, and spiritually restorative for
staff and patients undergoing stress (Hamilton, 2003). Hamilton (2003) discussed the four levels
of evidence-based design.
According to Hamilton (2003), level-one practitioners (architects, design professionals)
make the effort to create a design based on readily available evidence. One example of a levelone project would be a design for a hospital whose concepts were based on reviews of other
evidence-based projects and interpretations of published research. Level-two practitioners not
only explore available evidence to create a healthcare environment, but they also hypothesize
expected results from the proposed design interventions. Level-three practitioners take this a step
further and report findings in the public eye through trade magazines, press conferences, etc.
This practice contributes to advances in evidence-based design and serves as available evidence
for future evidence based design practitioners. Level-four practitioners, like level-three
practitioners, publish their findings in the public arena, however level-four practitioners publish
their work in scholarly journals that require peer review.
Many healthcare facilities in the United States have successfully shown that the designs
of their facilities have contributed to the overall health and wellbeing of the patients, visitors, and
staff. Many of these facilities were constructed as part of The Pebble Project, which is “a unique
and dynamic collaborative, where forward thinking healthcare organizations, architects,
designers and industry partners work together to identify built environment designs and
solutions that measurably improve patient and worker safety, clinical outcomes, environmental
performance and operating efficiency” (Pebble Project, 2013). The Pebble Project is associated
with the Center for Health Design as the center’s main research initiative, and it strives to use
evidence-based design principles in the construction of healthcare buildings around the world.

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Design stakeholders, in conjunction with the Center for Health Design’s research consultants,
develop approaches to implement, record, and report the findings of their actions. At least 38
healthcare facilities have been constructed as part of the Pebble Project (“Pebble Project,” 2013).
The project has published at least 40 reports and papers that link the built environment to patient
outcomes. Facilities constructed as part of the Pebble Project would be considered level-4
evidence-based design projects, according to Hamilton’s research (2003).
A variety of healthcare facilities, such as hospitals, specialty hospitals, long term care
facilities, short term care facilities, and inpatient/outpatient care facilities have been constructed
around the principles of evidence-based design, and several have been featured in the public eye,
thus contributing to the overall realm of evidence based design practices. Although there are
several published evidence-based design healthcare facilities, very few publications feature
substance abuse treatment facilities utilizing this approach to design.

A substance abuse

treatment facility is a specialized facility whose programs are designed to help patients recover
from alcohol and/or drug additions. According to the Michigan Department of Community
Health, 60% of Michigan adults used alcohol in the past month, while 16% of youth between the
ages of 12-17 consumed alcohol (Fussman, 2012). In addition, 27% of adults admitted to binge
drinking within the last month, and 10% of the youth population admitted to doing the same
(Fussman, 2012).
In 2011, the Michigan Department of Community Health conducted a survey (Fussman,
2012) which suggested that the more a high school student consumes alcohol, the more likely it
is that he or she will partake in recreational and prescription drug use. The data found that bingedrinking students admitted to consuming prescription painkillers and other prescription drugs
without a doctor’s written consent. These types of behaviors have been shown to lead to long-

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term addictions to alcohol and illicit drugs. Half of all lifetime cases of mental and substance
abuse use disorders in Michigan begin by age 14 and 75% by age 24. In 2012, 50,586 people
were reported to be currently seeking treatment through one of 17 substance abuse treatment
agencies in Michigan, and only 29.3% of people were reported to have completed their treatment
programs, 24% transferred to another facility, while 28% left against staff advice.
According to the 2012 National Survey on Drug Use and Health (NSDUH), the rates of
substance addiction in the United States for persons aged 12 or older highest for the Western
region and second highest in the Midwest (National Survey, 2012). Of all participants surveyed
who admitted dependency to drug and/or alcohol abuse in the last year, 95% said that they did
not need treatment for their illnesses, while 4% believed they needed treatment but did not make
an effort to do so, and only 1% made an effort to seek treatment for their addiction. Not
knowing where to go for treatment was one of many reported reasons for not seeking treatment
(U.S. Department of Health and Human Services, 2012). !
1.2$Problem Statement!
Due to the overwhelming number of addicts who do not seek treatment for their
addictions, the National Survey on Drug Use and Health (NSDUH) discussed the need for
additional specialty treatment facilities nationwide.

These types of facilities included the

addition of inpatient treatment hospitals, drug or alcohol rehabilitation facilities (both inpatient
and outpatient), and mental health centers (U.S. Department of Health and Human Services,
2012).
Chronic stress has shown to lead to drug abuse and relapse among vulnerable individuals
(Sinha, 2001).

To better provide an environment for recovering addicts, substance abuse

treatment facilities should be designed to help patients reduce their stress levels. Westreich,

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Heitner, Cooper, Galanter and Guedj (1997) found that a lack of social support leads to elevated
stress levels among recovering addicts, which ultimately leads to relapse. While there are a
number of substance abuse services in the greater Lansing, MI area, few serve as long-term
treatment facilities that serve teenagers between the ages of 12 and 18, and even fewer show any
evidence to have been designed using any kind of theoretical background to promote stress
reduction and recovery.

Utilizing an evidence-based design approach to creating a youth

rehabilitation facility in the Lansing area could help alleviate chronic stress among patients,
thereby reducing the rate of relapse among youth in the area (Westreich et al., 1997).
1.3 Purpose and objectives
This thesis aimed to utilize theoretical framework and case studies to develop a space
assessment matrix, which was used to design a long-term substance abuse treatment facility
designed to foster coping with stress and allow for natural healing. The facility serves the needs
of youth ages 12-18 in the State of Michigan. The design of the new treatment center integrates
the ideas of Roger Ulrich and Florence Nightingale in a space that provides an optimal healing
environment that promotes coping with stress. Based on the idea that chronic stress leads to
relapse (Sinha, 2001), a facility that utilizes supportive design strategies to alleviate stress
encourages recovery and helps prevent relapse among facility residents (Ulrich, 1991; Westreich
et al., 1997). The success of this thesis project relied upon the following objectives:
1. Review Supportive Design Theory and the Nursing Environmental Theory.
This objective was achieved through a close look at existing literature. The literature
includes the findings of Roger Ulrich’s (1984, 1991) Theory of Supportive Design as
well as the findings of Florence Nightingale (1859) and her followers’ contributions
to the development of Nursing Environmental Theory.

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research, all elements of supportive design, as described by Roger Ulrich were
reviewed, while Florence Nightingale’s research served as supplemental information
to enhance Ulrich’s findings.

Ulrich’s and Nightingale’s research was used to

develop a list of supportive design guidelines to be applied to the new facility design.
2. Evaluate the implications of these theories on existing facility designs.
The list of supportive design guidelines that were developed in objective one were
used to evaluate the existing conditions of two substance abuse treatment facilities.
The Brighton Center for Recovery is a treatment facility that has been retrofitted
multiple times since the 1940’s to accommodate to the changing needs of the campus.
The Rosecrance Health Network, on the other hand, is a newly constructed facility
that was built utilizing principles of evidence-based design. The facilities were
toured, and photos of the built environment documented any evidence showing
examples of the use of Supportive Design Theory and Nightingale’s Nursing
Environmental Theory.
3. Redesign a vacant building to serve as an addiction treatment facility.
The design process for this thesis includes an in-depth literature review pertaining to
existing theories as well as design strategies known to correlate with findings in past
theoretical research. Case studies discuss existing rehabilitation facilities that utilize
theory in the design of their buildings. After this extensive preliminary research was
conducted, the schematic design phase commenced. During this process, the design
concept along with conceptual images, space planning, and ideas were implemented.
Following the schematic phase, the design development process began, where space

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planning, ideas, concepts, finishes and materials were finalized, and spatial images
were rendered using computer imaging software.
1.4 Expected Outcomes
Although this thesis was not developed as part of the Pebble Project, there are many aspects of
The Pebble Project that were considered. It is important to consider collaboration with various
key stakeholders such as healthcare directors, members of the staff, contractors, building users
and the surrounding community. The success of the development of design for this project relied
upon preliminary interviews with facility managers and staff members at existing facilities.
These conversations provided insight as to what design aspects should be considered in order for
the new facility to function optimally to promote healing. In addition, attending site visits to preexisting substance abuse treatment facilities helped explain how this type of facility is supposed
to operate, what problems are often encountered in the physical design of these facilities, and
how solutions to these problems have been achieved. By utilizing these strategies, this project
envisioned a successful, functioning design that promotes healing for patients and reduces stress
through supportive design techniques.

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CHAPTER 2. REVIEW OF LITERATURE
2.1 Introduction
Studies have shown that the built environment can have a positive and/or negative impact
on patient stress and overall health. This review of literature aimed to define the concept of
stress in a substance abuse treatment facility setting while also illustrating the importance of the
built environment in affecting patient health. Many of these findings were based on the ideas of
Roger Ulrich’s Theory of Supportive Design (1991), which is derived from Nightingale’s
Nursing Environmental Theory (1859). All elements of supportive design, as described by
Roger Ulrich, were reviewed, while Florence Nightingale’s research served as supplemental
information to enhance Ulrich’s findings; only elements directly related to the built environment
were reviewed in detail.
2.2 Theoretical Research
a) The Nursing Environmental Theory (Florence Nightingale, 1859)
Florence Nightingale’s (1859) research, although mainly focused on quality of
care, discusses the built environment’s impact on health in her Nursing Environmental
Theory. Nightingale’s Nursing Environmental theory suggests that it takes a combination
of nursing and the surrounding environment to create an “optimal setting for God to act
naturally” (Nightingale, 1859). To Nightingale, the surrounding environment was more
than just nature and built structures. She was concerned with ventilation, light, room
temperature, and mental stimulation as well as food intake, water consumption, and
medication use (Libster, 2008).

Although established in the late 1800s the theory

describes several elements that coincide with current healthcare building practices. For
example, Nightingale describes ventilation as the single most important element of a

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healthcare environment and that health care providers should provide access to natural
ventilation without affecting the thermal comfort of the patient (Nightingale, 1859). In
addition to ventilation, Nightingale also suggests a list of other canons she believed
contributed to optimal healing environments including temperature, lighting, noise,
variety, social support, diet, health of houses, and cleanliness. Roger Ulrich began
further exploring temperature, lighting, noise, variety, social support, and diet in the early
1980’s, which led to the development of Supportive Design Theory (Selanders, 2010).
b) Supportive Design Theory
Healing and patient wellness, although dependent on patient care and adequate
medication, is also greatly influenced by the built environment, as it is described in
Supportive Design Theory. Roger Ulrich, one of the main researchers in the area of the
built environment’s impact on health developed a Theory of Supportive Design, which
explains essential aspects of healthcare facilities that create the optimum environment in
which patients can heal. Although Supportive Design Theory does not encompass all
factors that might influence wellness, it focuses on how the built environment can
improve overall health.

The theory suggests that a healthcare environment will be

psychosocially supportive if it is designed to increase a perception of control in patients,
offers access to social support, and provide access to positive distractions like art nature,
art, and spaces for therapeutic activities. The theory also suggests that target groups are
not only patient-focused, but also includes visitors and staff (Ulrich, 1991).
c) Stress as it relates to Supportive Design Theory
Supportive Design Theory was developed around the concept of stress. During
his research, Roger Ulrich defined stress as, “A major obstacle to healing.” He indicated

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in his research that there are often at least two identifiable sources of stress for a patient:
the illness or injury itself and the physical environment (Ulrich, 1991). He suggests that
elevated stress levels can lead to a variety of adverse physiological effects such as
elevated blood pressure, muscle tension, suppressed immune systems, and psychological
effects such as depression, anxiety, feelings of helplessness, sleeplessness, social
withdrawal, and drug or alcohol abuse. The idea behind Supportive Design Theory is that
a healthcare facility should be designed to alleviate stress levels by limiting features that
could become stressors and by incorporating features that are designed to have stressreducing influences (Ulrich, 1991). For example, Ulrich describes an “unsupportive”
healthcare environment as a poorly designed facility that is noisy, denies visual privacy,
and presents wayfinding difficulties (Ulrich, 2000).
2.3 Elements of Supportive Design Theory and Nightingales Nursing Environmental
Theory
For the purpose of this review of literature, the Nursing Environmental Theory was used
to support the current research related to Supportive Design Theory. Advances in medicine have
eliminated many of Nightingale’s original strategies for maintaining a healthy environment, such
as utilizing fireplaces for warmth in a hospital environment. However, there are various
environment-related elements of the Nursing Environmental Theory that can be linked to the
current ideas outlined in Supportive Design Theory, such as temperature, light, noise, variety,
and social support (“chattering hopes and advices”).
Nightingale’s canon of temperature encourages nurses to help the patient maintain their
appropriate body temperature with blankets, open windows, or lit fireplaces (Nightingale, 1859).
Although a more modern interpretation of this idea, Supportive Design Theory similarly
discusses the importance of thermal comfort in maintaining a sense of control in a healthcare

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environment (Ulrich, 1991). Nightingale discusses the importance of access to natural light in the
healthcare environment. This idea can be linked to Roger Ulrich’s modern opinions about
maintaining sense of control through individual lighting control in patient rooms and providing
positive distractions through access to natural light. Nightingale’s concept of noise control can
be linked to a variety of design strategies outlined in the modern concepts of Supportive Design
Theory. For example, Roger Ulrich argues that sense of control in the healthcare environment
can maintained through increased privacy. He indicates in his research that one way to maintain
privacy in a space is to control noise levels with sound-absorbing materials or sufficient room
layouts (Ulrich, 1991). The Nursing Environmental Theory stressed the importance of variety in
a healthcare setting, which could be maintained by providing positive stimuli in the space
(Nightingale, 1859).

Supportive Design Theory similarly discusses maintaining positive

distractions to reduce stress levels among patients. Lastly, Nightingale explained that social
interaction could be beneficial to the natural healing process (Nightingale, 1859). This idea can
be linked to modern design strategies that encourage social support in Supportive Design Theory.
2.3.1 Perception of Control
Not all patients are capable of achieving control over their own bodies due to injury or
illness; it is possible, however, to provide them with control over the built environment. There
are several strategies to create an environment in which the patient has complete control.
Adequate wayfinding, increased privacy through the availability of private rooms or curtains,
personal control over lighting and room temperature, personal control over television channels,
and the availability of areas for pursuing personal interests are all positive design strategies from
which patients can greatly benefit (Ulrich, 1991).

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a) Wayfinding
Hospital occupants can easily become disoriented and stressed when there is a
lack of efficient wayfinding cues in the environment. In order to prevent disorientation
among staff, patients, visitors, etc., Carpman (1984) discusses that signage should be
placed at every intersection and major destination within the hospital environment.
However, directional cues do not stop at the written word. Environmental design cues
should also indicate a change in location. For example, changes in flooring material, wall
color, or overall theme could help distinguish varying destinations within the built
environment (Carpman, 1984).
b) Privacy
Maintaining a patient’s privacy can elevate his or her sense of control in a
healthcare setting. There are several design strategies that increase privacy for patients,
such as the availability of single occupancy rooms, privacy curtains, and acoustically
absorbent building materials. According to a recent study, the most common reason for a
room transfer request from a double-occupancy room to a single-occupancy room is a
lack of privacy (Chaudhury, Mahmood & Valente, 2005). In an attempt to increase
privacy in multi-patient room settings, privacy curtains are typically installed; however,
one study found that patients believe privacy curtains to be inadequate. Although useful
as a visual barrier, curtains are useless for filtering dialogue. Under these circumstances,
many patients expressed frustration that their respective roommates had been able to hear
private conversations regarding treatment plans and personal information (Malcolm,
2005).

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c) Noise
According to the Nursing Environmental Theory, one of the standards of nursing
is noise control (Nightingale, 1859). Nightingale suggests that excess noise can wake a
sleeping patient, which will cause more harm than good in the healing process. Although
this theory was introduced 150 years ago, today’s hospitals still suffer from excess noise.
In fact, most hospitals exceed the World Health Organization standards of average noise
levels (Ryherd & Zimring, 2010).

Uninterrupted sleep is a main source for good

physiological and psychological health, and noise is one of the main causes of disturbed
sleep, which can have adverse health effects (Berglund et al., 1999). For example,
patients who suffer from disturbed sleep as a result of excess noise may experience
extended hospital stays, the need for more medication, and the decreased ability to
communicate clearly, all of which contribute to higher stress levels (Ryherd & Zimring,
2010). One of the goals for achieving a supportive design is to diminish or filter these
unwanted sounds to allow for uninterrupted sleep. Highlighting serene sounds such as
birds chirping and rippling water can enhance the therapeutic environment (Dilani, n.d.).
Studies have shown that improvements to the acoustics in a healthcare environment, such
as the addition of sound-absorbing materials, directly correlate with medical staff’s
perception of improved noise control and enhanced patient sleep patterns (Ryherd &
Zimring, 2010).
d) Lighting
Lighting is an integral part of any building, and it can have positive or negative
effects on its occupants. It is common knowledge that certain types of lighting can cause
sensitivity in migraine-prone occupants, while natural lighting and/or broad spectrums

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can have therapeutic effects. A recent study indicated that exposure to sunlight had a
positive effect among patients who had undergone spinal surgery. 89 patients were
randomly assigned to dim or bright rooms, of which 46% had access to natural light.
According to the study, patients assigned to the brighter rooms required 22% less pain
medication and reported significant reductions in stress (Walch et al., 2005).
Exposure to sunlight also has a significant effect on the length of time patients
reside in the hospital. Beauchemin and Hays (1998) explored the effect of natural light
on mortality rates and length of stay among heart attack victims. The study indicated that
female patients exposed to sunny rooms spent a full day less in the hospital than those
assigned to a room without sunlight. In addition, mortality rates among both men and
women were higher among patients who did not have access to natural light (Beauchemin
& Hays, 1998). Other studies have linked the absence of windows to more instances of
anxiety, depression, and delirium in patients than patients assigned to a room with
windows (Parker & Hodge, 1976).
e) Thermal Comfort
According to the U.S. Department of Energy, today’s hospitals maintain high
ventilation rates to lessen the risk of microbial contamination (Taddonio, 2011).
Adequate ventilation has been a focus of hospital facilities at least since the time of
Florence Nightingale. Nightingale discusses the importance of adequate ventilation and
thermal comfort in her novel. According to Nightingale (1859), an optimal healing
environment should provide clean, fresh air to the patient without chilling him or her, and
ventilation should be provided to prevent the spread of sickness. Nightingale’s Nursing
Environmental Theory suggests that it is the responsibility of the nurse to provide a

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thermally comfortable environment.

Supportive Design Theory also suggests that

thermal comfort and adequate ventilation is an integral element to any healing
environment, but Roger Ulrich suggests that by allowing patients to control their own
thermal environment, perception of control can be increased, and stress can be reduced
(Ulrich, 1991). For example, by providing cabinets with extra storage for blankets,
patients do not have to rely on outside sources to be thermally comfortable. Also, by
providing individual thermostats within the space, patients have the opportunity to rest in
an environment in which they are thermally comfortable without affecting the comfort of
other patients (Ulrich, 1991).
2.3.2 Social Support
The Nursing Environmental Theory suggests that patients benefit from support from
friends and family (Nightingale, 1859). It emphasizes, however, that these social networks have
to provide the appropriate types of support. Nightingale (1859) discussed in her findings that
patients do not benefit from false hopes and repetitive health advice; rather, patients benefit most
from casual conversation with another human being. Roger Ulrich (1991) found in his research
that patients recover more rapidly when in the company of friends and family. Unlike
Nightingale, his research does not seem to show whether or not the types of conversations have
any effect on recovery rates among patients. Supportive Design Theory has described a variety
of design strategies that can encourage social support in healthcare facilities such as appropriate
furniture arrangements, designated social spaces and accommodations for visitors.
a) Furniture Arrangements
Sommer and Ross (1958) found in their research that certain furniture
arrangements could encourage social interaction, while others can diminish it. Upon

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observation in a geriatric ward, it was found that early in the day, chairs were arranged in
a side-by-side formation against the walls, and by the end of the day, various family
members had moved the furniture into small groupings in order to converse more
comfortably (p. 129). It was found in the study that social interaction is reduced when
chairs are arranged in a side-by-side format rather than in small groupings.

This

reduction in social interaction was even greater when chairs were placed along walls in a
space. In addition, it was also found that heavy, stationary furniture inhibits social
interaction (Sommer & Ross, 1958). Roger Ulrich utilized Sommer and Ross’ (1958)
findings in the development of the, “social support” aspect of Supportive Design Theory.
According to Ulrich’s theory, in order to encourage social interaction in a social
gathering space, it is important to incorporate small groupings that contain light,
moveable furniture (Ulrich, 1991).

Not only will light, mobile furniture promote

interaction, but it will also give visitors, patients and staff a sense of control within the
space, helping reduce overall stress levels.
b) Social Spaces
Although single occupancy patient rooms have been shown to improve privacy
among patients, the availability of multi-occupancy rooms has shown to increase social
interaction among patients and helps reduce stress levels (Chaudury et al., 2005).
Supportive Design Theory also suggests that comfortable visitor areas separate from
public waiting areas should be provided.

These spaces should incorporate light,

moveable furniture to encourage social interaction and support among visitors of
seriously ill patients (Ulrich, 1991). Ulrich emphasized in his research that outdoor
gardens and sitting areas should also be provided throughout the campus to encourage

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social interaction. In addition, he discussed that although social support is an integral
element to any successful healthcare design, designers should create a space that does not
promote interaction to the point of denying access to privacy (Ulrich, 1991). Any interior
space that provides patients with control over their contact with other patients and visitors
will ensure that social support will have stress-reducing effects rather than increasing
stress (Ulrich, 1991).
c) Accommodations
Although multi-occupancy patient rooms have demonstrated increases in social
interaction with other patients, single-occupancy rooms offer greater flexibility when
accommodating family members, thus increasing family interaction (Chaudhury et al.,
2005).

According to Ulrich (1991), healthcare facilities provide separate overnight

accommodations within the building for families of patients in order to successfully
promote social support and reduce stress among patients and visitors.
2.3.3 Positive Distractions
According to The Nursing Environmental Theory, variety and positive stimulation is
integral to the healing process. “…the degree would be quite inconceivable to which the nerves
of the sick suffer from seeing the same walls, the same ceiling, the same surroundings during a
long confinement to one or two rooms” (Nightingale, 1859). Nightingale explained that the
longer a patient is exposed to the same environment, the more he or she craves a variety of
different objects or scenery, and these cravings are often indicative of what is necessary for
recovery (Nightingale, 1859).

Roger Ulrich also discussed the importance of positive

distractions in his Theory of Supportive Design. He explained that moderate amounts of positive
stimulation can successfully promote patient well-being. Ulrich emphasized that the levels of

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stimulation in a space have to be appropriate. For example, if stimulation levels are too high due
to intense sounds, lighting, and colors, it can increase stress levels. On the other hand, if
stimulation levels are too low, boredom and depression can arise, which can diminish overall
health (Ulrich, 1991).

Wilson (1972) found that sensory deprivation in the healthcare

environment can lead to elevated levels of anxiety and depression among ICU patients. Roger
Ulrich (1991) defined positive distraction as an element that holds the interest of the patient
while creating positive feelings. In his Theory of Supportive Design, Ulrich described several
design strategies that can help alleviate stress through positive distraction. He described what he
considers to be the most effective positive distractions in a healthcare design, which includes
nature and animals (Ulrich, 1991).
a) Nature
A relatively large body of research has discussed the stress-reducing influences of
exposure to nature. Nightingale found in her studies that patient suffering was often a
result of a lack of windows or adequate views of nature in the space. She noted how
patient recovery was often elevated when the patient was sent flowers or plants
(Nightingale, 1859). She discussed the importance of plants in the interior environment
and that an interior space can never have too many plants. Nightingale (1859) discussed
the superstition that having plants in a patient room was unhealthy. She defended this by
suggesting that the presence of indoor plants creates variety for the patient, and the
oxygen produced by the plants can help improve air quality (p.34).
Roger Ulrich has heavily explored this concept in his research during the
development of Supportive Design Theory. His ground breaking study, “view through a
window may influence recovery from surgery,” found that patients recovering from

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surgery who had views of nature recovered more rapidly and took fewer pain medications
than patients with views of a brick wall (Ulrich, 1984). Several of Ulrich’s findings have
suggested that natural elements may help with recovery because they elicit positive
feelings, reduce negative emotions, and reduce stressful thoughts (Ulrich, 1991). Coss
(1990) conducted a study that explored the effects of ceiling mounted images on patient
wellness. It was found that patients who were exposed to images displaying nature and
water had lower systolic blood pressure than patients who did not (Coss, 1990). Past
research has suggested that while short-term exposure to nature has shown to have
positive effects on patient stress, individuals who experience long-term exposure to
nature in a confined setting seem to benefit more (Ulrich, 1991).
A number of Ulrich’s studies suggest a variety of design strategies that can
incorporate nature into a healthcare setting. Ulrich has discussed the importance of
indoor plants, indoor healing gardens (Ulrich, 2002), exterior views of nature (Ulrich,
1984), and art portraying natural scenes (Ulrich, 1991). In displaying art, Ulrich stresses
the importance of incorporating natural scenes that do not depict any urbanscapes. He
has theorized in his writings that the stress-reducing effect of natural content, such as
water scenes, may be due to evolutionary responses to unthreatening situations (Ulrich,
1991).
b) Animals
The company of animals in the hospital environment is said to help alleviate some
of the stresses associated with hospitalization. One study explored how canine visitation
therapy influenced perception of pain in pediatric surgery patients. The study found that
the canine visits reduced the perceived pain in children recovering from surgery. The

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findings suggest that the perceived reduction is in pain is due to the distraction caused by
the animal visitations. The pet therapy distracted children from pain-related thoughts and
was able to activate feelings of companionship (Sobo et al., 2006). Pet therapy has
shown to improve quality of life in hospitalized cancer patients by decreasing pain,
improving vital signs, providing distraction, decreasing fear, increasing socialization, and
decreasing emotional distress (Lazenby & Urbanski, 2012). Encounters with animals are
also beneficial to patients in non-hospital settings. One study observed the effects of
animal therapy on patients in a nursing home setting. The study found that nursing home
patients reported improvement in overall mood as measured by depression, anxiety, and
positive affect assessments upon interacting with therapy dogs (Johnson, 1997).
One strategy for incorporating animals into a healthcare setting, as outlined by
Supportive Design Theory, is to display artwork depicting natural settings with animals.
Ulrich stresses the importance of incorporating artwork that depicts the animals at an
appropriate distance. If an animal appears to be too close, it could lead to elevated stress
levels, and if the artwork appears to be too abstract, it could produce negative attitudes
among patients (Ulrich, 1991).
c) Physical Activity
Patients entering into a substance abuse treatment facility often experience
heightened feelings of depression or anxiety (Brown & Evans, 1997). Evidence has
suggested that regular exercise can be as effective as psychotherapy or prescription
medication in the treatment of anxiety and depression (Zangeneh et al., 2007).

Ulrich

(1991) has suggested that incorporating spaces for mild exercise such as wide corridors,

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walking gardens, and exercise rooms could serve as a positive distraction for patients
with these types of conditions.
2.4 Summary
This review of literature was conducted to gain a better understanding of the elements of
Supportive Design Theory and how these elements relate to the ideas of Florence Nightingale.
Nightingale’s Nursing Environmental Theory has a care-focused background with elements of
environmental impacts on patient well-being. Roger Ulrich further developed the environmental
aspects of Nightingale’s Theory in the development of his Theory of Supportive Design.
Although the two theories were developed in different eras and with different backgrounds, it is
quite clear that the two theories share many of the same environmental aspects of patient wellbeing, such as wayfinding, privacy, noise, lighting, thermal comfort, social support and exposure
to nature. Table 1 illustrates these common ideas found in both theories as described throughout
this literature review.

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Table 1. Common Ideas Found in Both The
Theory of Supportive Design and Nightingale’s
Nursing Environmental Theory

“Chattering”

Variety

Noise

Light

Theory of Supportive Design
Guidelines
(Ulrich, 1991)

Nightingale’s
(1859) Canons

Temperature

DESIGN ELEMENTS

Perception of Control
Wayfinding
Privacy
Noise
Lighting
Thermal Comfort
Menu Options
Social Support
Furniture Arrangement
Social Spaces
Family Accommodations

Direct Relationship

Positive Distractions
Nature/Artwork

Indirect Relationship

Animals/Artwork
Space for Physical Activity

No Relationship

Activity Spaces

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CHAPTER 3. METHODS
3.1 Introduction
Before the design process begins, two pre-existing substance abuse treatment facilities
were visited. The Brighton Center for Recovery is an example of a retrofitted facility with needs
for improvement, and the Rosecrance Health Network is an example of a facility that was built
utilizing evidence based design practices and supportive design strategies. Each of these site
visits was useful in determining how a substance abuse treatment center differs from other
healthcare facilities, and it helped contribute to the knowledge of how these types of facilities
operate.
3.2 Approach to Design
This project was completed in three phases: Predesign, Schematic Design, and Design
Development. Although this approach was followed as closely as possible, when certain design
elements were not working, other areas had to be readdressed. John Zeisel’s (2006) approach to
the design process was utilized. Figure 1 illustrates the cyclical process required during the
design process, and how theoretical information is constantly fed into the process in order to
develop a more effective design outcome.

Figure 1: John Ziesel’s (2006) Model of the Design Process

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3.3 Case Studies
The Brighton Center for Recovery is a facility that was retrofitted from an original small
farmhouse. The visit to the Brighton hospital was beneficial because this thesis utilizde a
preexisting facility for the substance abuse treatment facility redesign. After the site visit, there
was a better understanding of how a retrofitted facility encounters certain design limitations.
Chapter 4 explains these limitations and needs for improvement in detail.
The Rosecrance Griffin Substance Abuse Treatment Center is a facility that was built
keeping evidence-based design and Supportive Design strategies in mind. It displays how a
successful operation can be built with fewer limitations than that of a retrofitted facility. It
serves as an example of what a substance abuse treatment facility should offer in the design of
the building and what types of spaces should be offered in order to foster coping with stress.
Chapter 4 explains the space and program success in detail.
3.4 Target Site Visit
a) Target Project Site
This thesis aimed to utilize the existing literature and case studies (as outlined in
Chapters 3 and 4) to redesign a vacant building in the greater Lansing, MI, area to serve
as a long-term substance abuse treatment facility designed to foster coping with stress
and allow for natural healing. The facility serves the needs of youth ages 12-18 in the
State of Michigan. The design of the new treatment center unites the ideas of Roger
Ulrich and Florence Nightingale to create a space that provides an optimal healing
environment that promotes coping with stress. The functions of the space were based on
the findings from the site visits as described in Chapters 3 and 4.

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b) Location
The vacant building was previously used as a public elementary school (See
Figure 2). The property is large enough that additions can be made to the facility if
necessary. One unique feature of the new facility is that it will incorporate spaces for
public outreach programs; the proximity to the neighboring homes and community will
attract the public to participate in these programs. The property also features a large, open
green space that can be redesigned to incorporate outdoor healing gardens and places for
group reflection. To prevent substance infiltration, a hefty security program will be
implemented. Refer to Chapter 5 for more details.

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Figure 2: Site Map

c) Exterior Conditions
The exterior consists of mainly brick and cinder block construction. A studentmade mosaic and an area for a flagpole highlight the main entry into the building (See
Figure 3). The flagpole is surrounded by a garden space that currently consists of only
mulch (See Figure 4). This area provides the new facility an opportunity for a welcoming
entryway. The entry into the facility looks out onto the parking lot and neighboring
homes (See Figure 4). The existing parking lot is in need of repair. There is a large open
space behind the building to the east. It served as open space for students and included a
soccer field, baseball diamond and a vegetable garden (See Figure 4).

Figure 3: Entry (left), student mosaic (right)

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Figure 4: Flag Pole (top left), Parking lot and surrounding neighborhood (top right),
community garden (bottom left), open space (bottom right)

d) Interior Conditions
This building was vacated in Fall 2010, so it has seen some neglect and is in need
of updating and repair. Although the building was vacant for nearly three years, some
spaces in the building have been reclaimed and are currently being used for community
office spaces. The current layout features a large variety of spaces including several
classrooms with individual restrooms, cafeteria, gymnasium, administrative offices, a
staff lounge and a centralized media center (See Figure 5).
The interior walls consist of mainly painted concrete block, while the corridor
floor material is a commercial-grade, low-pile broadloom carpet.

The ceilings

throughout the entire building are 2’x4’ acoustical ceiling panels. Portions of these

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ceiling panels are missing in the centralized media center. The main entry of the building
is a small vestibule that is visible through a window in the main. Upon entry into the
building, there is an interior room with windows that look into the interior of the space
(See Figure 6).

This space could serve as a welcome reception area to the new

rehabilitation facility, or it could serve as a public space for a community outreach
program.

There are 15 classrooms approximately 500 square feet in size located

throughout the building.

APPROX. SQ. FT: 14,500

MECH/STORAGE
STAFF
RESTROOMS

CLASSROOMS

GROUP AREAS
Figure 5: Floor Plan (Not to scale)

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Figure 6: West entry with window to office (top left), front entry (top right), view of media space (middle left), concrete
block and blue low-pile carpeting (middle right), brick and concrete block in media space (bottom left), missing acoustical
ceiling panels (bottom right)

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CHAPTER 4. CASE STUDIES
4.1 Introduction
Utilizing the guidelines outlined in Supportive Design Theory, the Supportive Design
Space Assessment Matrix was developed as part of this thesis. Two existing facilities were
analyzed based on their supportive design elements in order to test the theoretical framework in a
substance abuse treatment facility setting and to clarify the difference between an evidence-based
design and a retrofit design. The Rosecrance Health Network is a treatment facility that was built
within the last decade, and was designed and constructed utilizing the principles of evidencebased design. The Brighton Center for Recovery is a substance abuse treatment facility that has
been retrofitted to accommodate to the changing needs of patients since the 1940s.

4.2 Case Study 1 - Retrofitted Design
The Brighton Center for Recovery
o Location: Brighton, MI
o Square Footage: 79,700
o Year Established: 1948
o Acreage: 92
o Latest Addition: Mid 1970s
4.3 History
The Brighton Center for Recovery is a substance abuse treatment facility located on 92
acres in Brighton, MI, as a member of Ascension Health, St. John Providence Health System.
The building that is the Brighton Center for Recovery today began as a small farmhouse

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established in the 1930s. Harry Henderson modified the building to create the Brighton Hospital
in 1948. It was the first of its kind for substance abuse treatment in the state of Michigan.
4.4 Site Conditions
The 92-acre campus is located in Brighton, MI, with easy access from I-96, a major
highway in the State of Michigan (See Figures 7-8). Although its proximity to a major highway
allows for easy wayfinding for visitors and new patients, it poses a possible threat to privacy and
security for patients undergoing treatment.

According to the Director of Operations, the

facility’s location makes it susceptible to substance infiltration.
In addition to the medical buildings on the campus, the Brighton Center for Recovery
also features a variety of outdoor spaces including open spaces, garden spaces, and an on-site
lake. Although these outdoor areas are part of the campus, many are inaccessible to residents
due to possible security breaches, such as substance infiltration, into the facility from outside
sources.

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N
KENSINGTON RD.

GRAND RIVER RD.

SITE

I-96
Figure 7: Area map

MEDICAL SERVICES
BUILDING

!

MAIN BUILDING
!

N
GARDEN

OPEN SPACE

PARKING

32

BUILDINGS

Figure 8: Site Map

!

4.5 Parking
The campus provides ample parking for visitors and events. A large parking lot is
available on the west side of the campus near the main building where large events, community
meetings, and public Alcoholics, Anonymous meetings are held (See Figure 9). There are
parking spaces available on the east side of the campus near the Medical Services Building
where inpatient and outpatient services are provided. Campus parking can be better illustrated in
the site map (See Figure 8).

Figure 9: Parking lot (left), main building entry (right)

4.6 Buildings
The Brighton Center for Recovery, with its original construction in the 1930s, is an
example of a rehabilitation facility in need of renovations (See Figure 10). The treatment facility
currently features a variety of spaces, many of which have been added onto the existing
farmhouse, which now serves as the reception and lobby area for the hospital. The facility also
features a large patient wing, with 70 beds for men or women over the age of 18 at any given
time. A large, centralized nursing station located in the main building is operated 24 hours per
day to assist patients going through recovery. There is additional space in a separate building on
the campus, The Medical Services Building, which can house an additional 29 patients (See
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Figure 10). This building also features a centralized nursing station, although smaller than the
nursing station located in the main building.

Figure 10: Chapel (left), Medical Services Building (right)

4.7 Staff Areas
Despite its large size, the director of operations discussed the need for expansion in the
nurse’s station in the main building to allow for more space for medical staff. By providing a
larger space for staff, more patients can have access to nursing care. According to the director,
the nursing station in the medical services building is more effective in administering proper care
to patients. The main building features a small wing designated for administrative offices. The
administrative hallway serves as a means of egress from the lobby area to the chapel, where
community meetings are held. The director of operations for the center discussed the need for
more privacy for administrative staff.

Figure 11: Sofa in break room (left), eating area (right)

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The facility staff also has access to a small break room located in the main building on
the campus. Despite its small size, the space serves a variety of functions. It features a small
food preparation and storage space, eating area, seating area, small restroom, and staff mailboxes
(See Figure 11). The space is not large enough to effectively accommodate all staff members in
the main building.
4.8 Patient Rooms
Patient rooms are broken up into wings. The women and the men are located in separate
parts of the main building. Patient rooms in the main building accommodate up to two patients
at one time, and each room features a shared restroom. In the Medical Services Building, patient
rooms accommodate up to three patients at one time, and each room features a shared restroom.
The patient detox center is part of the medical services building, which can accommodate up to 8
patients at a time. Patients in this area receive visual privacy through privacy curtains, but lack
privacy otherwise. Each patient room has exterior windows, many which have views of natural
elements.

In addition, each patient room features individual storage areas for personal

belongings (See Figure 13).

Figure 12: Patient room in Medical Services Building (left), patient restroom in Medical Services Building (right)

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Figure 13: Patient room window (top left), resident shower (top middle), resident storage (top right), main building resident
corridor (bottom left), detox center (bottom right)

4.9 Indoor Gathering Spaces
There area variety of indoor gathering spaces located throughout the facility. The Chapel
is the Center’s community meeting room (See Figure 14). Every week, staff members and
patients alike gather here to discuss the weekly schedule, patient progress and upcoming events.
This space is also used for public AA meetings. The campus also features a large gymnasium,;
however, it is not used very frequently. The main purpose of this space is to host community
events and banquets. The facility also features a wide variety of meeting spaces that can
accommodate up to 100 people, depending on the particular space. Each of these meeting spaces
includes light, flexible furniture, which better accommodates individual group needs (See Figure

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14). The cafeteria in the main building also serves as an interior meeting space, but only during
mealtime. The cafeteria in the Medical Services Building serves the same purpose, but differs
from the main building cafeteria in that it features a floor-to-ceiling storefront window that looks
out to the nearby woods (See Figure 14). There are no family-specific gathering spaces.

Figure 14: Chapel interior (top left), meeting room interior (bottom left), cafeteria in Medical Services Building (right)

4.10 Outdoor Gathering Spaces
The campus features very few outdoor gathering spaces. The campus features a large
open space located to the north of the main building (See Figure 15). This area can be utilized for
individual and group gathering. Group meetings can be held here, but the space does not feature
any group-specific meeting areas. The gazebo, located to the south of the main building, is
sometimes utilized for group meetings under the supervision of a counselor (See Figure 16).
Meetings here do not happen often due to its proximity to the main road and parking lot. The

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administration at the Brighton Center for Recovery believe that residents are more likely to
encounter substances from outside sources if they are provide access to areas near the main road
and/or parking lot. Another outdoor space, located to the south of the main building, features a
garden with a walking path, patio, and fountain (See Figure 17). Although this space can be
accessed for staff gathering, patients do not have access due to its proximity to the parking lot.
The cafeteria in the main building used to feature an outdoor patio, but this feature was removed;
also for security purposes. Rather than implementing design strategies to enhance security, the
administrative staff has limited the amount of spaces to which residents have full access.

Figure 15: Open space view from the north side of the main
building

Figure 16: Gazebo view from main parking lot

Figure 17: Walking Garden located on the south side of main
building

4.11 Need for Improvement

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This section evaluates the Center’s need for upgrades and offers design suggestions to
successfully improve the facility. The Supportive Design Space Assessment matrix (Table 2)
lists the main aspects of Supportive Design Theory as outlined in the review of literature
(Chapter 2). These elements were used as design guidelines when evaluating the exiting spaces
within the facility. As Table 2 illustrates, the Brighton Center for Recovery needs to see
improvement in order to meet the basic standards as laid out by Supportive Design Theory.
Table 2. Supportive Design Space Assessment Matrix
The Brighton Center for Recovery
Design Guidelines
Notes
Perception of Control
Wayfinding

Patient rooms in multiple buildings; few signs

Privacy

Administrative hallway serves as main egress

Noise Control

Acoustical ceiling panels; thin walls

Lighting

2x2, 2x4 fluorescent lighting; no ambient/task

Thermal Comfort

Temperature controlled by main source

Menu Options

Predetermined menu; no vegetarian/gf options

Available
Needs
Improvement
Unavailable

Social Support
Furniture

Light, moveable; damaged, uncomfortable

Social
spaces
arrangement
Accommodations

Small spaces; large and heavy furniture
No family accommodations; no visitor spaces

Positive Distractions
Nature

Open space available; no access to gardens

Animals

Therapy dog

Physical activity

Gymnasium and exercise therapy facility

Activity spaces

Meeting rooms; no designated activities

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4.11.1 Security
Patients have restricted access to many areas of the campus that could be
beneficial to their health. For example, a healing garden has been planted to the south of
the main building, but due to its proximity to a main road and the parking lot, patients
cannot utilize the space. This is an attempt to limit substance infiltration into the facility.
The director of operations discussed that the proximity of the campus to the main road is
cause for substance infiltration, which is an issue that needs to be addressed. In the past,
patients have received illegal substances from outside sources via cars using the main
road and an easily accessible parking lot. The Center has previously considered installing
gates at the facility entry, but has no plans to install them any time soon, according to the
Director of Operations.
In addition to substance infiltration, this facility also has a problem with theft.
Although each patient is given individual storage space for belongings, there are several
reports of theft. This could be due to a lack of lockable storage; however the Brighton
Center for Recovery does not allow lockable storage in order to monitor substance
infiltration. To help solve this problem, the Brighton Center for Recovery could
implement a program in which the staff monitors patient belongings. This could be done
through a cubby system behind the reception counter or a separate space that is only
accessible with a staff key.
4.11.2 Interior
The Brighton Center for Recovery serves as a long-term substance abuse
treatment facility that has been retrofitted from an early 1930s farmhouse. In order to
keep up with the changing needs of the staff and patients, the facility has undergone

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several renovations throughout the years. Based on the evaluation laid out in Table 2, it
is clear that the facility is in need of updating and improvements. The director of
operations discussed a variety of changes that should be made to better improve the
interior function and design of the space.
a) Floor surfaces
Commercial-grade, low-pile broadloom carpeting has been installed
throughout most of the facility, which has caused several maintenance and cost
issues throughout the years. Carpeting is susceptible to staining, especially when
installed in a high-traffic healthcare facility. According to the director of
operations, the housekeeping staff cannot keep up with spills on the carpet, and as
a result has become permanently stained. The current carpeting is broadloom and
is costly to replace. In order to better meet the needs of the housekeeping staff
and keep costs low, hard-surface flooring materials that can be easily cleaned
should be installed in high-traffic areas. In areas where carpet is desired, modular
carpet tiles should be installed.
b) Interior rooms
The interior layout of the space could be improved to increase staff
productivity, staff and patient privacy, and separation of spaces. The nursing
station in the main building needs to be increased in size in order to more
effectively serve patients on a 24-hour basis. Currently, one hallway serves as
means of egress to administrative offices as well as the community chapel. A
separate hallway to the administrative offices should be added in order to increase
privacy in those areas and designate separate spaces for staff and patients.

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4.11.3 Exterior
There is currently only one exterior space to which patients have access.
Although it is a large, open area that can accommodate all patients at any particular time,
it does not incorporate any designated spaces for healing, meetings, or individual
reflection. A walking garden has been planted on the south side of the main entrance;
however, patients do not have access to this area due to its proximity to the main road and
parking lot. Security should be improved in the parking lot area in order to allow patients
to access the healing garden. In addition, designated areas for group meetings, healing,
and reflection should be added to the open area.

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4.12 Case Study 2 - Evidence-Based Design
Rosecrance Health Network – Griffin Williamson Campus
o Location: Rockford, IL
o Square Footage: 67,000 sq. ft.
o Latest Addition: 2013
o Year Established: 2004
o Acreage: 50 acres
4.13 History
The Rosecrance Griffin Williamson campus serves 80 teenagers between the ages of 12
and 18 who are addicted to drugs and alcohol. It was built in 2004 utilizing evidence-based
design principles (Hamilton, 2003; “Rosecrance Serenity Garden,” 2007) and serves as an
example of a successful facility that features design elements outlined in Supportive Design
Theory to promote healing. Reminiscent of a modern mountain lodge, this facility’s interior
design and vast outdoor healing garden is intended to reduce stress and promote patient healing.
Rosecrance’s adolescent substance abuse treatment offers an initial psychological
assessment upon admission, which is located near the reception and administrative offices. This
space offers a private family waiting area that is separated from the public waiting area. The
facility also features inpatient treatment, outpatient treatment, gender-specific counseling
services, an onsite school and an onsite chapel. In addition, the program offers a variety of
spaces that are utilized for experiential therapies including a fitness center and a horticulture
conservatory. Each of these therapy programs serves as positive distractions to reduce stress and
promote healing, according to Supportive Design Theory (Ulrich, 1991).

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4.14 Site Conditions
Rosecrance is located in Rockford Il, among newly developing sub-divisions in the area.
The large size of the property allows for a private drive, which provides access to the facility
parking lot. The site is located less than ½ mile from a main road in Rockford, IL and 1 mile
away from I-39, one of Illinois’ major highways.

UNIVERSITY DRIVE

E. STATE ST.

SITE LOCATION

I-39
Figure 18: Site Location

4.15 Exterior
The exterior of the facility is reminiscent of a mountain lodge with modern features. It
features a variety of materials including vinyl siding, natural stone, wood, metal and glass (See
Figures 19). The building features several windows, allowing natural light into the space and
creating views of the strategically planted landscaping. The back of the building features an

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outdoor patio, which looks out onto the ponds and serenity garden. The serenity garden accounts
for only about 10% of the campus, but serves as the main focal point of the campus. The garden,
designed by landscape designer Hoichi Kurisu, has been designed to incorporate a private pond,
walking paths, gathering circles, and a twelve-step waterfall, which is symbolic of the twelvestep program that is followed to reach recovery at the facility (See Figure 19). The serenity
garden attracts a large variety of wildlife including bird, ducks, geese and other water foul. In
addition, the ponds are full of underwater wildlife including bass, perch and koi. The space has
been designed to naturally attract animals, which has shown to alleviate stress levels in
healthcare environments, according to the Theory of Supportive Design.

The idea of a

supportive environment seems to have positive impacts on the adolescents at Rosecrance.
“Whenever I am feeling sad, I walk through the gardens and all of my problems seem to go
away,” stated one patient (“Rosecrance serenity garden,” 2007).!

Figure 19: Main entry (top left), courtyard (top right), twelve step waterfall (bottom left), waterfall (bottom right)

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Figure 20: Pond

4.16 Staff Areas
There is are a large variety of spaces designated for staff use at Rosecrance. According
to Supportive Design Theory and Nightingales Environmental Theory of Nursing, staff stress
reduction is just as important as patient stress reduction in improving quality of care in a health
care setting (Ulrich, 1991; Nightingale, 1859). Upon entry into the building, there is a large
reception area that is used by staff members to greet guests, check-in new patients, and checkout
patients. Behind the reception area is a large administrative wing that can be accessed only by
staff members.

These administrative areas incorporate staff cubicles, private offices, and

conference rooms for meetings (See Figure 21). The administrative wing also incorporates a
small break area for staff in this part of the building. Another break area is located in the
cafeteria of the building. Although patients can see into the space, they do not have access to it.
This space is designated for staff use only.
The nursing unit is located on the 2nd floor of the building, and it serves all patients
undergoing treatment for their addictions. This space not only incorporates exam rooms and
consultation areas, but also private nursing offices.

Staff privacy is a key strategy for

maintaining quality of care, according to the theories. Counselor’s offices are located in each
patient wing of the facility in order to maintain a sense of community within each space.

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Figure 21: Conference room (left), office wing (right)

4.17 Patient Areas
Rosecrance assigns each new patient to one of four patient wings. Each wing offers a
variety of different spaces including resident rooms, a lounge/meeting area, a supervisory space,
kitchenette, laundry facility, and counseling offices. The lounge and meeting area features
lodge-style wood vaulted ceilings and large windows with views of the serenity garden (See
Figure 22). Each unit accommodates approximately 14 adolescents and each patient room can
hold up to three patients (See Figure 22). Each resident room features a window with a view of
the landscaping that has been incorporated on the exterior. Multiple beds in in the resident
rooms could lend to social support and alleviation of stress in patients; however, the décor in the
resident rooms is lacking, and as outlined in Supportive Design Theory (Ulrich, 1991), could
lead to emotional discomfort.
In addition to private resident areas, there are also a large variety of spaces for patients to
share throughout the facility. Rosecrance offers a variety of therapy programs including art,
horticulture, exercise and music. Each of these therapy programs has a designated space in the
building. A gymnasium is available for patients who seek exercise as a positive distraction from
their addiction. In 2013, the Ipsen Conservatory was constructed as a space for horticulture

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therapy practices (See Figure 23). Residents may use the conservatory to learn about plants and
horticulture. The idea behind the horticulture therapy program is that if a resident can learn to
take care of another living thing, he or she can learn to take care of him or her self in a healthy
way. In addition to these spaces, Rosecrance also encourages education through an in-house
school on the lower level, and religion through a multidenominational chapel on the first floor.
The school space features a bright, patterned carpet reminiscent of the landscaping occurring on
the exterior of the facility. The walls, while constructed of concrete block, are decorated with
artwork made by the adolescent residents as part of the art therapy program. The school hallway,
as well as the classrooms, features windows which provide natural light and visual access to the
surrounding landscape.
The cafeteria serves as a place for mealtime and social interaction. It is located on the
lower level with views of the serenity garden. Furthermore, residents have the options of
enjoying their mealtime on the outdoor patio, weather permitting. Supportive Design Theory
discusses the importance of maintaining a sense of control in order to alleviate stress in patients.
One strategy for maintaining control is offering a menu with a large variety of food from which
to choose. Rosecrance accommodates to the needs of a wide variety of diets including vegan,
gluten-free, and vegetarian options. While the cafeteria windows offer views to the exterior, the
interior design of the space is lacking color and texture.

Figure 22: Resident lounge space (left), resident room (right)

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Figure 23: Gymnasium (top left), Ipsen Conservatory (top right), school corridor (middle left), student artwork (center),
classroom (middle right), cafeteria (bottom left), cafeteria serving line (bottom right)

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4.18 Visitor Areas
There are several visiting areas throughout the Rosecrance Griffin Williamson Campus.
Upon entry into the building, guests are faced with a welcoming waiting area complete with
comfortable furniture, a fireplace, and windows with views to the outside. There is a large
community room available for stakeholder use. While this area is often used for Rosecrance
assemblies and guest speakers, donors and other stakeholders may utilize this space for
conferences and large meetings. Visitors also have access to the multi-denominational chapel
(See Figure 24) as well as various private gathering areas located throughout the facility. A
private family gathering area is available for family members who are supporting new patients
undergoing preliminary assessment. This area can only be accessed with a key card that is
activated by a staff member at the reception desk. Each patient wing also features a designated
private family gathering space for visitations (See Figure 24). These areas encourage family
interaction and social support, which Supportive Design Theory has explained as a design
strategy for reducing stress in healthcare environments.

Figure 24: Private family gathering space (left), multidenominational chapel (right)

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4.19 Outdoor Gathering Spaces
The serenity garden, although built for Rosecrance, is available for public use. Visitors
may check-in during business hours at the reception desk to receive a visitor’s pass before
walking in the gardens. To prevent substance infiltration, residents are heavily supervised while
making use of the gardens. The gardens feature a variety of gathering spaces, including serenity
circles that are typically designated for group meetings. Weather permitting, all group meetings
are typically held outside.

In addition to group meeting spaces, the serenity garden also

incorporates spaces for small group, one-on-one, and individual reflection.

Figure 25: Serenity circle (top left and bottom right), outdoor gathering space (top right), private reflection space (bottom left)

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4.20 Need for Improvement
This section evaluates the Center’s need for upgrades and offers design suggestions to
successfully improve the facility. The Supportive Design Space Assessment Matrix (Table 3)
lists the main aspects of Supportive Design Theory as outlined in the review of literature
(Chapter 2). These elements were used as design guidelines when evaluating the existing spaces
within the facility. Rosecrance is a privately funded substance abuse treatment facility that was
built utilizing elements of Supportive Design Theory, such as private family gathering spaces,
multi-resident rooms, spaces for horticultural and exercise therapy, and an award-winning
healing garden; however, there is opportunity for improvement.
Table 3. Supportive Design Space Assessment Matrix
Rosecrance Health Network
Design Guidelines
Notes
Perception of Control
Wayfinding

Signage easily legible

Privacy

Separation of administration/residents; noise

Noise Control

Wall in lounge does not extend to ceiling

Lighting

Overhead, ambient, and task lighting

Thermal Comfort

Temperature controlled by main source

Menu Options

Vegan, vegetarian, gluten free, and diet options

Available
Needs
Improvement
Unavailable

Social Support
Furniture

Comfortable, but not easily rearranged

Social
spaces
arrangement
Accommodations

Conservatory, lounges, garden, exercise rooms
Private family waiting and meeting rooms

Positive Distractions
Nature

Healing garden; views of nature from inside

Animals

Therapy dog and space for dog

Physical activity

Gymnasium and exercise therapy facility

Activity spaces

Horticulture, library

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4.20.1 Exterior
There is possibility for further design on the second floor. The current view out
of the second floor corridor looks out onto the parking lot and the roof of the first floor
(See Figure 26). The view from the corridor to the parking lot on the second floor would
be dramatically enhanced if Rosecrance were to pursue a small green roof as a project.

Figure 26: View from second floor corridor (left), wall does not meet ceiling in resident lounge (right)

4.21 Case Study Summary
After both of these facilities were visited, it was determined, based on the design
guidelines, that the Rosecrance Health Network was more successful in providing an
environment for patients that reduces stress and encourages healing through supportive design
techniques. As illustrated in the side-by-side comparison (See Tables 4 and 5), it is clear that the
Brighton Center for Recovery was in need of improvement in terms of supportive design.

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Table 4. Brighton Center for
Recovery Summary
Perception of Control

Table 5. Rosecrance Health
Network Summary
Perception of Control

Wayfinding

Wayfinding

Privacy

Privacy

Noise Control

Noise Control

Lighting

Lighting

Thermal Comfort

Thermal Comfort

Menu Options

Menu Options

Social Support

Social Support

Furniture arrangement

Furniture arrangement

Social spaces

Social spaces

Accommodations

Accommodations

Positive Distractions

Positive Distractions

Nature

Nature

Animals

Animals

Physical activity

Physical activity

Activity spaces

Activity spaces

!

!
Available
Needs Improvement
Unavailable

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CHAPTER 5. PROJECT DEVELOPMENT
5.1 Design Concept
The hummingbird’s wings are so small that it should be impossible for them to fly;
however, it flies anyways, which is why this bird is often referred to as, “the bird of the
impossible.” The hummingbird will be used as the concept for this thesis project because of
what it symbolizes: difficulties can always be overcome, and lost parts of ourselves can always
be recovered. This idea is relevant to overcoming major life challenges including those related
to substance abuse and addiction, which is why it serves as an appropriate concept for the design
of the new substance abuse treatment facility.
5.2 Applying the Theories
In order to create a space that meets the standards of Supportive Design Theory and
Nightingales Environmental Theory of Nursing, the new facility incorporates adequate
wayfinding cues, private areas for patients and staff, indoor and outdoor healing gardens, spaces
for social interaction, and artwork. A central Atrium encourages social interaction and provides
access to nature through indoor plants as well as a large amount of natural sunlight. Each patient
room has a window to the exterior with views of nature and/or natural sunlight. In order to help
patients foster coping with stress, the new facility encourages social interaction through private
family gathering areas, positive distractions through nature and exercise facilities, and sense of
control through maintaining patient privacy.
5.3 Space Program and Design Guidelines Based on Theoretical Framework/Case Studies
This section utilizes the theoretical framework of Supportive Design Theory and the
Nursing Environmental Theory to develop a space program that incorporates design guidelines
outlined by the theories and supporting literature. The design guidelines refer to the more

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modern concepts of Supportive Design Theory while utilizing the Nursing Environmental
Theory as a tool for validation of Roger Ulrich’s ideas. Table 4 summarizes the supportive
design guidelines that can be applied to each space in the new facility.

Table 6. The new facility spaces and their Supportive Design guideline applications

All

Resident Areas

Staff/Patient
Areas

Staff Areas

Activity Spaces

Physical Activity

Animals

Nature

Positive
Distractions

Accommodations

Social Spaces

Furn. Arrangement

Social
Support

Menu

Thermal Comfort

Lighting

Noise Control

Privacy

Space

Wayfinding

Perception of Control

Reception
Administrative Offices
Nursing Station
Staff Break Area(s)
Outdoor Staff Break Area(s)
Storage
Kitchen
Counseling Offices
Pre-Assessment Space
Cafeteria
Gymnasium
Exercise Room
Group Meeting Rooms
Resident Rooms
Resident Lounge
Resident Kitchen
Resident Laundry Facility
Horticulture Therapy
Library
Waiting Room
Atrium
Healing Garden

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5.4 Space Planning
This phase of the project incorporated an adjacency matrix, bubble diagram and block
diagram to explore separation of spaces in the existing buildings. For this phase of the project,
the existing building has been broken up into spaces designated for staff members, residents and
staff, residents only, and all users. The nursing station has been placed directly adjacent to the
private resident units in order to appropriately accommodate patients on a 24-hour basis. The
resident wing consists of resident lounges, horticulture therapy spaces, a laundry facility, a
kitchen area, counseling offices, and multi-patient rooms with private restrooms. Although
much of the literature has indicated the importance of single-patient rooms in maintaining
privacy for patients, many of those studies were conducted in hospital spaces, where the patients
studied would be spending most of his or her time in the room.
Other literature, on the other hand, has discussed the importance of multi-patient rooms in
creating relationships and encouraging social interaction (Chaudury et al., 2005). This approach
is appropriate for this type of facility because the residents will only be utilizing the patient
rooms for sleep and day preparation, rather than spending most of their time in the space. It is
more beneficial for this age group to rely on peers for support than to solely rely on privacy for
stress reduction. The layout of the patient rooms and moveable partitions provide each resident
with their own personal space, thereby enhancing privacy.
The administrative offices are located near the medical and public spaces to better
accommodate to the needs of visitors and the paperwork involved with the medical aspects of the
new facility. The residents, staff, and public have access to a healing garden space located on the
East side of the building. The multipurpose space is directly adjacent to the public spaces due to
the versatile nature of these space types. The adjacency matrix, bubble diagram and block

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diagram illustrate the space classifications for the new design (See Figures 27-29). The name for
this new facility is, “Riverside Recovery.”!

Figure 27: Adjacency Matrix

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RESIDENT
ROOMS
RESIDENT
KITCHEN

NURSE

WAI
T

GROUP

RESIDENT
LOUNGE

GYM
REC.

RESIDENT
LAUNDRY

ATRIUM

HORTICULTURE
THERAPY

EXERCISE
ROOM

ADMIN.

LIBRARY

CAFETERIA

COUNSELING

PRE
ASSESSMENT
KITCHEN

STORAGE

Figure 28: Bubble Diagram

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RESIDENT
ROOMS

RESIDENT
ROOMS
KITCHEN/
LAUNDRY

LOUNGE

LOUNGE

WAITING
AREA
NURSING
STATION

LOUNGE

STO.

FAMILY
GATHERING

RECEP.

HORTICULTURE
THERAPY

RESIDENT
ROOMS

COUNSEL
OFFICES

GROUP MEETING

ATRIUM
RESIDENT
ROOMS
ADMIN.
OFFICES

REST
ROOM

GYMNASIUM

EXERCISE
ROOM
RESTROOM

CAFETERIA
LIBRARY

PRE-ASSESSMENT
SPACE

KITCHEN

STO.

Figure 29: Block Diagram

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5.5 Design Development
This phase of the project involved more in-depth development of the building layout and
furniture plan. The final floor plan and renderings were assessed utilizing the design guidelines
matrix as used previously in this thesis. In addition, materials, furnishings and fixtures were also
finalized during this phase of the project. Computer renderings were developed to illustrate
some of the proposed spaces in the new facility. Sections 5.5.2 through 5.5.7 exhibit proposed
design options for the reception area, waiting area, atrium, patient common area, horticulture
therapy space, and a patient room. The Supportive Design Space Assessment Matrix was
readapted in this section as a checklist of supportive design elements. It was used as a tool to
follow when designing each of the proposed spaces. The floor plans and renderings are provided
in this section, while materials, furnishings and fixture information is available in the Appendix.

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5.5.1 Final Floor Plan

N

Design Guidelines

Table 7. Space Assessment for
Riverside Recovery
Perception of Control
Wayfinding
Privacy
Noise Control
Lighting
Thermal Comfort
Menu options
Social Support
Furniture Arrangement
Social Spaces
Accommodations
Positive Distraction
Nature
Animals
Physical Activity
Activity Spaces

Figure 30: Final Floor Plan

Achieved
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Table 8. Theoretical Application for Riverside Recovery

Wayfinding
• Reception easily visible from entry
• Signage clearly posted
• Waiting area located near reception
• Floor plan broken up into clear
sections

Furniture Arrangement
• Light, flexible furniture
arrangements
• Small groupings
• Variety of seating options

Privacy
• Patient wing separated from public
areas
• Private family gathering
• Administrative offices separated
from public areas
• Private administrative offices; no
cubicles

Social Spaces
• Private family gathering
• Atrium provides variety of
social gathering options
• Central patient gathering
space
• Patient “pods” encourage
social interaction
• Multi-patient rooms
Accommodations
• Private family gathering
space

Lighting
• Windows with views of nature
• Skylights throughout facility
provide natural light throughout
Thermal Comfort
• Individual thermostats

Design Guidelines

Positive Distractions

Design Guidelines

Social Support

Perception of Control

Design Guidelines

Nature
• Atrium incorporates trees and
grass while providing adequate
access to natural sunlight
• Horticulture therapy spaces
• Large windows in the waiting
area provide views of nature and
natural sunlight
• Patient rooms have views of
nature and/or natural sunlight
with skylights
• Indoor plants throughout facility
Animals
• Healing garden encourages
animals to visit
• Hummingbird concept
• Artwork throughout depicts
animals and/or nature
Physical Activity
• Gymnasium
• Fitness Center
• Healing Garden
Activity Spaces
• Private patient library
• Horticulture therapy spaces
• Group meeting areas
• Classrooms

Menu Options
• Large kitchen provides adequate
space for preparation of a variety of
food options
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5.5.2 Reception Space

Figure 31: Reception Space

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Theoretical Application of Reception Area
The proposed image of the reception area (See Figure 31) demonstrates design guidelines as shown in Tables 9 and 10.

Social Support

Wayfinding
• Reception easily
visible from entry
• Signage clearly posted
• Waiting area located
near reception
Privacy
• Separate reception
office
• Divider wall provides
more privacy, but still
allows for natural light
and visual access to
atrium
Lighting
• Natural light from
atrium and waiting area
• Adequate overhead and
ambient lighting
Thermal Comfort
• Individual thermostats

Design Guidelines

Positive Distractions

Perception of Control

Design Guidelines

Social Spaces
• Waiting area located
nearby
• Atrium located nearby

Nature
• Access to natural sunlight
• Views of nature through
waiting room window
• Views of indoor nature in
atrium
Animals
• Views of nature, including
animals
• Hummingbird logo
• Artwork depicting animals
in waiting room visible
from reception

Table 10. Space Assessment for
the Reception Space
Perception of Control
Wayfinding
Privacy
Noise Control
Lighting
Thermal Comfort
Menu options
Social Support
Furniture Arrangement
Social Spaces
Accommodations
Positive Distraction
Nature
Animals
Physical Activity
Activity Spaces

Design Guidelines

Table 9. Theoretical Application of the Reception Space

Major Elements
Secondary Elements
Not Applicable

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5.5.3 Waiting Room

Figure 32: Waiting Room

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Theoretical Application of the Waiting Room
The proposed image of the waiting room (See Figure 32) demonstrates design guidelines as shown in tables 11 and 12.

Thermal Comfort
• Passive solar heating
with large windows

Design Guidelines

Social Spaces
• Arrangements
encourage
interaction
• Access to other
spaces, such as
atrium

Animals
• Views of nature,
including animals
• Artwork
depicting animals
• Hummingbird
concept

Furniture
• Variety of options
• Flexible
arrangements
• Small groupings
Nature
• Large windows
provide visual
access to nature
• Indoor plants
• Access to natural
sunlight
• View of atrium

Activity Spaces
• Waiting area can
serve as multipurpose activity
space for large
events
• Access to Atrium,
which serves as
community
outreach space

Positive Distractions

Social Support

Wayfinding
• Waiting area located
near entry and
reception
• Atrium visible and
accessible
Privacy
• Private waiting area
available
Lighting
• Natural light through
large windows and
atrium

Design Guidelines

Positive Distractions

Perception of Control

Design Guidelines

Table 12. Space Assessment
for the Waiting Room
Perception of Control
Wayfinding
Privacy
Noise Control
Lighting
Thermal Comfort
Menu options
Social Support
Furniture Arrangement
Social Spaces
Accommodations
Positive Distraction
Nature
Animals
Physical Activity
Activity Spaces

Design Guidelines

Table 11. Theoretical Application for the Waiting Room

Major Elements
Secondary Elements
Not Applicable

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5.5.4 Atrium

Figure 33: Atrium

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Theoretical Application of the Atrium
The proposed image of the Atrium (See Figure 33) demonstrates design guidelines as shown in tables 13 and 14.

Thermal Comfort
• Large windows allow
for passive solar
heating
• Individual thermostat

Design Guidelines

Design Guidelines

Furniture
Arrangements
• Variety of
seating options
including tables
and lounge
furniture
• Flexible
arrangements
• Small groups
Social Spaces
• Furniture
arrangements
encourage social
interaction
Nature
• Skylights and
large windows
provide access to
natural daylight
• Indoor plants
• Grassy areas

Animals
• Views of
nature,
including
animals
• Artwork
depicting
animals
• Hummingbird
concept
Activity Spaces
• Atrium serves
as multipurpose
space, weekly
meeting space,
and community
outreach space

Positive Distractions

Social Support

Wayfinding
• Atrium visible from
entry
• Accessible from
reception and waiting
area
Privacy
• Serves as a space for
weekly meetings and
community outreach;
other spaces reserved
for private meetings
Lighting
• Natural light through
large windows and
skylights

Positive Distractions

Perception of Control

Design Guidelines

Table 14. Space Assessment for
the Atrium
Perception of Control
Wayfinding
Privacy
Noise Control
Lighting
Thermal Comfort
Menu options
Social Support
Furniture Arrangement
Social Spaces
Accommodations
Positive Distraction
Nature
Animals
Physical Activity
Activity Spaces

Design Guidelines

Table 13. Theoretical Application for the Atrium

Major Elements
Secondary Elements
Not Applicable
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5.5.5 Patient Common Area

Figure 34: Patient Common Area

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Theoretical Application of the Patient Common Area
The image of the Patient Common Area (See Figure 34) demonstrates design guidelines as described in tables 14 and 15.

Lighting
• Skylights
• Adequate ambient and
overhead lighting

Thermal Comfort
• Individual thermostats

Design Guidelines

Design Guidelines

Furniture Arrangements
• Variety of seating
options
• Small, flexible
groupings

Animals
• Views of
nature,
including
animals
• Hummingbird
concept
• Artwork
depicts animals
Activity Spaces
• Horticulture
therapy spaces
nearby
• Kitchen allows
for socializing
and group
events
• Laundry
facility

Positive Distractions

Social Support

Wayfinding
• Central location
• Counseling offices
visible
Privacy
• Patient use only
• Storefront window
sallow for counseling
privacy

Positive Distractions

Perception of Control

Design Guidelines

Social Spaces
• Furniture
arrangements
encourage social
interaction
Nature
• Skylights and large
windows provide
access to natural
daylight
• Visual access to
horticulture therapy
space

Table 15. Space Assessment for
Patient Common Area
Perception of Control
Wayfinding
Privacy
Noise Control
Lighting
Thermal Comfort
Menu options
Social Support
Furniture Arrangement
Social Spaces
Accommodations
Positive Distraction
Nature
Animals
Physical Activity
Activity Spaces

Design Guidelines

Table 14. Theoretical Application for the Patient Common Area

Major Elements
Secondary Elements
Not Applicable

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5.5.6 Horticulture Therapy Space

Figure 35: Horticulture Therapy Space

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Theoretical Application for the Horticulture Therapy Space
The proposed image of the Horticulture Therapy Space (See Figure 35) demonstrates design guidelines as shown in tables 17 and 18.

Thermal Comfort
• Individual
thermostats

Design Guidelines

Furniture
Arrangements
• Moveable work
tables allow for
flexibility in the
space
Social Spaces
• Access to
common patient
area
Nature
• Skylights and
large windows
provide access to
natural daylight
• Indoor plants
• Patients learn to
care for plants

Animals
• View of exterior
including animals
• Views of artwork
depicting animals
Positive Distractions

Social Support

Wayfinding
• Central location
• Counseling
offices visible
Privacy
• Patient use only
• Glass walls allow
visual access but
overall privacy
Lighting
• Skylights
• Adequate
ambient and
overhead lighting

Design Guidelines

Positive Distractions

Perception of Control

Design Guidelines

Activity Spaces
• Patients learn
about horticulture
• Patients learn to
grow and
maintain plant life

Table 18. Space Assessment for
the Horticulture Therapy Space
Perception of Control
Wayfinding
Privacy
Noise Control
Lighting
Thermal Comfort
Menu options
Social Support
Furniture Arrangement
Social Spaces
Accommodations
Positive Distraction
Nature
Animals
Physical Activity
Activity Spaces

Design Guidelines

Table 17. Theoretical Application for the Horticulture Therapy Space

Major Elements
Secondary Elements
Not Applicable
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5.5.7 Patient Room

Figure 36: Patient Room

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Theoretical Application of the Patient Room
The proposed image of the Patient Room (See Figure 36) demonstrates design guidelines as shown in tables 19 and 20.

Thermal Comfort
• Individual
thermostats

Design Guidelines

Furniture
Arrangements
• Beds are arranged
to encourage
personal privacy
• Multiple beds
encourages
communication
Social Spaces
• Multi-patient
rooms encourage
social interaction
and support from
peers
Nature
• Indoor plants
• Views of nature
• Artwork depicts
nature and/or
animals

Positive Distractions

Social Support

Wayfinding
• Patient wing
separated from
remaining
building
• Easily navigable
layout
Privacy
• Layout
encourages
privacy
• Bed frames
divide the space
• Individual storage
Lighting
• Natural light with
windows
• Overhead lighting

Design Guidelines

Positive Distractions

Perception of Control

Design Guidelines

Animals
• Artwork depicts
animals
• Hummingbird
concept
• Views of nature
encourage visual
interaction with
animals

Table 20. Space Assessment for
the Patient Room
Perception of Control
Wayfinding
Privacy
Noise Control
Lighting
Thermal Comfort
Menu options
Social Support
Furniture Arrangement
Social Spaces
Accommodations
Positive Distraction
Nature
Animals
Physical Activity
Activity Spaces

Design Guidelines

Table 19. Theoretical Application for the Patient Room

Major Elements
Secondary Elements
Not Applicable

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CHAPTER 6. SUMMARY AND CONCLUSION

This section summarizes the theoretical background and design process for this thesis. In
addition, implications, project limitations, and potential for future research are discussed.
6.1 Summary
Florence Nightingale (1859) focused her research on quality of care and the built
environment’s impact on health. This is outlined in her Nursing Environmental Theory. Her
theory suggests that it takes a combination of nursing and the surrounding environment to create
an “optimal setting for God to act naturally” (Nightingale, 1859). Nightingale focused on a wide
list of principles that she believed contributed to this optimal healing environment including
ventilation, temperature, lighting, noise, variety, social support, diet and cleanliness. Roger
Ulrich began further exploring temperature, lighting, noise, variety, social support, and diet in
the early 1980’s, which led to the development of his Theory of Supportive Design (Selanders,
2010). Roger Ulrich emphasized in his research the importance of creating spaces that are
designed to promote healing through stress reduction by increasing sense of control, social
support, and positive distractions through art and nature. Roger Ulrich’s research eventually led
to the development of an entire new design field that quickly has become known as evidencebased design, which is the practice of basing design decisions on research and is used to create
therapeutic environments that are physically and psychologically supportive.
Although extensive research has been conducted on the role of a supportive environment
in a healthcare setting, very little research focuses on Supportive Design Theory in a substance
abuse treatment facility setting. Because Supportive Design Theory is centered around the
concept of alleviating stress, and patients undergoing treatment for substance abuse are a under a

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considerable amount of stress, it is important to see if the principles of Supportive Design Theory
can be applied in a substance abuse treatment setting. Utilizing Ulrich’s (1991) guidelines of
Supportive Design Theory, a Space Assessment Matrix was developed as part of this thesis to
analyze the supportive design elements of substance abuse treatment facilities. Two existing
facilities were analyzed based on their supportive design elements in order to test the
applicability of this matrix and to clarify the difference between an evidence-based design and a
retrofit design. Based on the findings from utilizing the space assessment matrix, it was found
that the evidence-based design facility was more successful in achieving a supportive
environment for patients, visitors and staff than the retrofit design.
Although there are several published evidence-based design healthcare facilities across
the United States, very few publications feature substance abuse treatment facilities, specifically,
utilizing this approach to design. The Michigan Department of Community Health has
demonstrated with statistics the need for substance abuse treatment facilities for youth between
the ages of 12 and 18. Although there are currently a number of substance abuse treatment
facilities in the Lansing, Michigan area, few serve as long-term treatment facilities that serve this
targeted age group.
Utilizing a level-one evidence-based design approach, the purpose of this project was to
utilize the healthcare design theories to develop a retrofit design for a substance abuse treatment
facility for youth between ages 12 and 18 using an existing building in the greater Lansing, MI
area.

The design for this project was created using the concept of a hummingbird.

Hummingbirds are referred to as, the bird of the impossible.” Because of their weight-to-size
ratio, they should not be able to fly; however, the tiny bird has overcome this impossibility and
flies for the majority of its life, symbolizing that all obstacles can be overcome. This is a suitable

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concept for this project because it demonstrates strength and courage for teens that are
undergoing a difficult time in their lives.
This design was developed utilizing the principles laid out in Supportive Design Theory
as well as Nightingales Nursing Environmental Theory. The new design incorporates separate
patient, public and administrative spaces in order to enhance privacy and sense of control in the
space. In order to encourage social support, a variety of gathering spaces, including a private
family gathering area have been integrated into the design. In addition, small flexible furniture
arrangements have been incorporated. Indoor gardens, a well-lit atrium, skylights, views of
nature, horticulture therapy rooms, artwork and exercise facilities all contribute to creating
positive distractions in the space. Inspired by the hummingbird concept, the design for this
project incorporates bright colors and interesting textures. Floor plans and computer renderings
help show how the design ideas for this project create a supportive environment for healing. By
utilizing strategies outlined in these two healthcare design theories, patients, staff and visitors
can benefit. According to the theories, access to nature, social support, and sense of control in a
space contribute to a supportive environment and enhance the healing process.
6.2 Implications
The findings of this research suggest multiple implications that have potential to be
applied to real-world analysis and design of supportive environments; specifically, substance
abuse treatment facilities. The findings of this research suggest that the principles of Supportive
Design Theory can be applied to substance abuse treatment facility settings. In addition, it is
also suggested that the Supportive Design Space Assessment Matrix can successfully analyze
supportive design elements of healthcare facilities, specifically, substance abuse treatment
facilities.

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6.3 Limitations
Although several aspects of this project have shown successful results, there are also
multiple limitations. This research conceptual design focused on theoretical applications and is
ideal for students and educators since budget and construction limitations were not considered.
Because the conceptual design for this thesis was based on design theories, construction
documents were not developed. In addition, certain interior elements were repeated because this
thesis focused on the applications of theory-based design principles. For example, the same
lighting fixture was used throughout the design because it presents the researcher’s intention to
provide an aesthetically successful and energy-efficient space.
6.4 Future Research
There are several possibilities for future research and design on this project. Although
several aspects of design were considered for the proposed designs, lighting was not addressed.
Future design students could produce a lighting project as a supplement to this thesis. According
to Hamilton’s (2003) definition of evidence based design, this project currently serves as a Level
1 evidence based design project because it utilizes reviews of other evidence-based design
projects and interpretations of published research. In order to produce a Level 2 evidence based
design project, future researchers could hypothesize expected results on these proposed design
interventions. If these findings were published in the public eye, it could then become a Level 3
evidence based design project, and it could develop into a Level 4 project if the findings are
published in a scholarly journal that requires peer review (Hamilton, 2003).
In addition to design-related research, the Supportive Design Space Assessment Matrix
could be tested in other healthcare environments such as hospitals, outpatient clinics, assisted
living facilities and mental health facilities. Future researchers could use the matrix to analyze

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the supportive elements of these environment types, and make any additions or changes to the
matrix, if necessary. The matrix could be used as a tool when constructing healthcare facilities,
and it could also be tested as a type of post-occupancy evaluation of evidence-based healthcare
design projects.

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APPENDIX

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Site Visit Checklist
Location:
Square Footage:
Year built:
Lot size/acreage:
Building Condition:
• Parking conditions/location:
• Heating/AC control
• Visiting hours/location/terms:
• Visitors allowed in rooms?
• Phone use options:
• Resident lighting control options:
• Access to television:
• Access to computer:
• Types of recreation areas:
• Wayfinding strategies (signage, layout of building, etc.):
• Arrangement of furniture:
• Office areas:
• Availability of gardens/plants (indoor/outdoor/both):
• Availability of windows/ window locations:
• Type of windows:
• Window placement/views:
• Artwork (type, location):
• Menu:
• Color scheme:
• Staff offices location relative to resident and gathering spaces:
• Availability of separate staff gathering spaces:
• General noise level:

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Questions to ask
What types of treatment services does your facility offer?
What types of gathering spaces does your facility feature?
What types of users do you serve? (Gender, age range, types of addiction)
How many residential users can your facility accommodate?
Does your facility feature any unique spaces that set you apart from other treatment centers?
What types of resident rooms do you offer? (private rooms, roommate style, suite style,
combination, etc.)
Can you provide an example schedule of a typical day for a resident?
Does your facility offer any unique programs? (educational, pet therapy, art therapy, guest speakers
etc.)
What are the needs of the residents?
What are the needs of the staff?
How efficient is the building layout for productivity?
How effective are the current furniture layouts?
What is the general comfort level of the current furniture?
What building design recommendations can you offer?
What is the most effective part of the facility?
What is the least effective part of the facility?

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Patient Room Materials and Furnishings

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Figure 37: Bedding by DesignTex (top left), bedding by Stinson (top middle), main wall color by Sherwin Williams (top right),
accent wall color by Sherwin Williams (middle left), bamboo flooring by Morning Star (center), storage unit by Coalesse (middle
right), bed style by Ikea (bottom left), area rug by Pantone Universe (bottom right)

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Patient Common Area Materials and Furnishings
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Figure 38: Wallcovering by Brewster Home Fsahions (top left), wall color by Sherwin Williams (top middle), carpet tile by
Interface Flor (top right), side chair by Coalesse (middle left), coffee table by Coalesse (center), side stool by Herman Miller
(middle right), lighting fixture by VLighting (bottom left)

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Reception Area Materials and Furnishings
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Figure 39: Ripple wall by 3Form (top left), countertop material by Compac (top middle), wood finish by Morning Star (top
right), flooring material by Armstrong (middle left), flooring material by Armstrong (center), flooring material by Armstrong
(middle right), flooring material by Armstrong (bottom left), light fixture by YLighting (bottom right))

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Waiting Area and Atrium Materials and Furnishings
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Figure 40: Wallcovering by Brewster Home Fashions (top left) carpet tile by Interface (top middle), wall color by Sherwin
Williams (top right), upholstery by DesignTex (middle left), sofa by Herman Miller (middle right), lounge chair by Coalesse
(bottom left), side chair by Coalesse (bottom middle), table by Coalesse (bottom right)

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