TYPE Review

PUBLISHED 04 September 2024

DOI 10.3389/fbuil.2024.1467692

A systematic review of the impact

OPEN ACCESS of therapeutical biophilic design
EDITED BY
Roberto Alonso González-Lezcano,
CEU San Pablo University, Spain
on health and wellbeing of
REVIEWED BY
Daniel Arranz Paraíso,
patients and care providers in
Developer, Spain
Maria Concepcion Perez Gutierrez,
CEU San Pablo University, Spain
healthcare services settings
*CORRESPONDENCE
Inas Al Khatib, Inas Al Khatib 1*, Fatin Samara 2 and Malick Ndiaye 1
g00091914@aus.edu 1
Department of Industrial Engineering, American University of Sharjah, Sharjah, United Arab Emirates,
2
RECEIVED 20 July 2024 Department of Biology, Chemistry and Environmental Sciences, American University of Sharjah, Sharjah,
ACCEPTED 21 August 2024 United Arab Emirates
PUBLISHED 04 September 2024

CITATION
Al Khatib I, Samara F and Ndiaye M (2024) A
systematic review of the impact of therapeutical
biophilic design on health and wellbeing of
Hospitals often evoke negative feelings due to their antiseptic architecture and
patients and care providers in healthcare personal memories. Biophilic hospital design can reduce stress and enhance
services settings. health and wellness for patients and caregivers, creating sustainable therapeutic
Front. Built Environ. 10:1467692.
doi: 10.3389/fbuil.2024.1467692
environments. This research paper explores these environments and presents
case studies demonstrating the positive outcomes of biophilic design on health
COPYRIGHT
© 2024 Al Khatib, Samara and Ndiaye. This is an
and wellbeing. This paper systematically reviews and critically assesses literature
open-access article distributed under the terms using secondary data from peer-reviewed journals and reliable sources on
of the Creative Commons Attribution License sustainable design from 2010–2023. The results show that biophilic design in
(CC BY). The use, distribution or reproduction in
other forums is permitted, provided the original
hospitals reduces hospitalization time, patient mortality, pain levels, and stress for
author(s) and the copyright owner(s) are healthcare providers. It alleviates anxiety, improves experiences for patients,
credited and that the original publication in this families, and staff, reduces patient harm, and supports faster recovery. Overall,
journal is cited, in accordance with accepted
academic practice. No use, distribution or
it positively influences the psychological and physiological responses of patients
reproduction is permitted which does not and staff. Future research should analyze the impact of individual biophilic design
comply with these terms. elements separately and explore implementation challenges. It should also
quantify benefits such as reduced staff absenteeism and increased
productivity. This study fills the gap of the limitation of holistic studies on
biophilic design’s impact on patient care and service delivery in hospital settings.

KEYWORDS

biophilic design, healthcare service setting, sustainable therapeutic environment,

patients, care providers sustainable design, architecture, interior design, health

1 Introduction
1.1 Healthcare services settings

Healthcare services are delivered in individual clients’ homes or offices (Christensen

and Fagan, 2018). Any location where medical services, such as physical, dental, or mental
healthcare, are provided is referred to as a healthcare environment. It includes, but is not
limited to any licensed healthcare facility such as hospitals, ambulatory surgical centers,
birthing centers, special inpatient care facilities, long-term acute care facilities, inpatient
rehabilitation facilities, inpatient hospice facilities, nursing facilities, assisted living facilities,
and residential facilities, behavioral health residential facilities, home healthcare, hospice,
pharmacies, in-home care, vehicles or temporary sites where healthcare is delivered or is
related to the provision of healthcare (for example, mobile clinics, ambulances, non-

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emergency medical transport vehicles (NEMT), secure service delivery. The concept of a sustainable therapeutic
transportation, and street based medicine), outpatient facilities, environment emphasizes the importance of factors such as
such as dialysis centers, healthcare provider offices, dental offices, daylighting, indoor air quality, noise, and thermal comfort in
behavioral healthcare offices, urgent care centers, counseling offices, designing a supportive service (Akpan-Idiok and Ackley, 2017).
school-based health centers, offices that provide complementary and The sum of the internal and external circumstances is
alternative medicine such as acupuncture, homeopathy, conceptualized as a sustainable therapeutic environment and
naturopathy, chiropractic and osteopathic medicine, and other impacts that a person may experience while they are unwell.
specialty centers (Law Insider, 2023). Therefore, healthcare These represent the observable physical elements in the current
services settings encompass a wide range of services and state of the architecture, furniture, lighting, ventilation, interior
locations where medical care is delivered (Christensen and design, and psychological on the patient, forces were applied.
Fagan, 2018). Compared to the former, less palpable “feeling tones” brought
Architecture denotes the strategy, procedure, pattern, and final about by the traditions, conventions, interpersonal interactions,
healthcare services setting. This is so that architecture may cultural values, and prevalent ideas for the proper behaviors and
communicate the story of the architect who designed it as well as duties of the healthcare professional and patient. A therapeutic
the person who commissioned it, in addition to revealing the setting is comparable to some qualities of an environment’s
character or style of a particular structure (Janetius, 2020). The architecture helps the sufferer recuperate. An environment that
National Council for Interior Design Qualification (NCIDQ) defines supports clinical excellence in the care of the physical body, the
interior design as the art and science of comprehending human psycho-social and spiritual needs of the patient, family, and staff,
behavior in order to create practical spaces within a structure using and produces measurable positive effects on patient clinical
innovative and technical solutions. These solutions are used inside a outcomes and staff effectiveness is referred to as a sustainable
building to create a built-in environment that is useful, improves the therapeutic environment. Research on people’s experiences and
tenants’ quality of life and culture, and is also visually pleasing (El- emotional reactions to their healthcare has provided evidence in
Zeiny, 2012). In the following sections, the concept of designing support of this. The phrase “therapeutic environment” refers to a
sustainable therapeutic environments both internally and externally supportive setting (Akpan-Idiok and Ackley, 2017). The need to
will be explored further. associate with other kinds of life is known as biophilia, and it is one
of the key words in the sustainable therapeutic environment.

1.2 Sustainable therapeutic environment in

healthcare services settings 1.3 Factors of sustainable therapeutic
environment in healthcare services settings
Environmental psychology (the psycho-social impacts of the
environment), psychoneuroimmunology (the effects of the Patients in healthcare seek therapeutic environments that
environment on the immune system), and neuroscience (how the provide optimal medical care and facilitate quick recovery. The
brain perceives architecture) are fields that have played a role in interior design of these environments is crucial for creating a
shaping therapeutic environment theory. Patients in healthcare comfortable atmosphere that reduces patient isolation, distracts
settings often feel anxious and concerned about their safety, from illness, promotes positive emotions, and aids in speedy
health, and isolation from usual social interactions. The complex, recovery. Elements such as a connection to nature, enhanced
expansive nature of typical hospitals only adds to this stress. Such social supports, and stimulating interior design should be
stress can weaken a person’s mental and spiritual strength and incorporated into therapeutic environments to achieve these
suppress their immune system, thereby hindering recovery and benefits. These factors positively impact healthcare providers and
healing. Healthcare facilities are designed to not only support contribute to the physical and psychological wellbeing and overall
advanced medical technologies and patient safety but also to welfare of patients. Incorporating these elements into the indoor
create a therapeutic environment that is psycho-socially design of healthcare settings addresses patients’ needs for comfort
supportive for patients, families, and caregivers. The physical and relaxation, creating a warm and inviting atmosphere. Satisfying
environment in which patients receive care impacts their these therapeutic environmental factors at the physical,
outcomes, satisfaction, safety, staff productivity, and overall psychological, and social levels benefits both patients and
organizational performance, both positively and negatively. No healthcare workers, accelerating patient recovery and improving
environment is neutral (Smith and Watkins, 2016). The staff performance and productivity (Attia, 2021). Many factors
implementation of therapeutic design (TD) in architecture, space, contribute to attaining the best experience in a therapeutic
and landscape contributes to the United Nations Sustainable environment. These factors include health, wellness, architecture,
Development Goals (SDGs) and integrates digital technologies interior design, healthcare setting, and sustainable therapeutic
like Building Information Modeling (BIM) into the design environment. Health is comprised of three components physical,
process, potentially addressing the chronic housing shortage. The mental and social health. Architecture is the art and science of
built environment and art therapy (AT) are linked to sustainable planning, creating, and constructing a place, a structure, and its
development and closely associated with health and wellbeing (Liu, surroundings with aesthetic elements to achieve a certain goal that
Yang and Osmani, 2021). Even in healthcare facility design, for excites the audience. Sustainable therapeutic environment is
maximum efficiency, a sustainable therapeutic environment should establishing a human-friendly, well-balanced atmosphere, it helps
incorporate features that enable patient control and effective staff patients feel more secure, at peace, and less stressed while also

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enhancing their capacity for self-healing. It should use natural described as a “biophilic design pattern”. intended to give
lighting of the highest quality, soothing colors, therapeutic information, direction, and assistance throughout the design
sounds like music, bird songs, and water sounds, good process for the built environment, which is made up of locations
ventilation, reduce the level of noise, offer interactive arts, and and areas that humans have created or altered, with a focus on
provide views of indoor greenery and a natural landscape, structures, parks, streetscapes, and other areas that serve as the
depending on the needs of each patient to produce these effects backdrop for human activities (Ryan and Browning, 2020). Biophilic
(Attia, 2021). A healthy organism is capable of “allostasis” in the impact guidelines, biophilic design tactics, design considerations,
physical realm, which is the maintenance of physiological and a design culture that favors biophilia over biophobia are all part
homoeostasis under variable conditions. of the healing process via biophilic design (Ghazaly, Badokhon,
Alyamani and Alnumani, 2022).
It is essential to clearly define the various terms mentioned starting
1.4 Importance of sustainable therapeutic with ‘biophilia’ which is the concept that humans have an innate
environment connection to nature and living systems. It is based on the idea that
people have a natural affinity for life and life-like processes, which can
A healthy organism can develop a defensive reaction in the face significantly impact their wellbeing. The term was popularized by
of physiological stress, lowering the risk of injury and restoring a biologist (Wilson, E. O., 1984), where he proposed that this
(adapted) balance. The harm (or “allostatic load”) persists if this connection to nature is deeply rooted in our biology and psychology.
physiological coping mechanism fails, which might eventually lead In practical terms, biophilia often manifests in design and architecture by
to sickness. In terms of the mental realm, (Antonovsky, A., (1993) incorporating natural elements into spaces, such as natural light, plants,
identifies the “sense of coherence” as a component that helps people and organic shapes, to enhance human health, reduce stress, and
successfully manage, recover from intense psychological stress, and improve overall wellbeing. This concept is increasingly applied in
fend off post-traumatic stress disorders. The subjective abilities that various fields, including healthcare, where biophilic design aims to
make a challenging situation more understandable, manageable, and create environments that promote healing and comfort for patients
meaningful are included in the feeling of coherence. Strengthened and caregivers. Whereas the term ‘biophobia’ refer to the fear or aversion
adaptability and self-management skills frequently lead to an to natural elements and living systems. It is the opposite of biophilia and
improvement in subjective wellbeing and can lead to a beneficial can manifest as discomfort or anxiety in the presence of nature, which
interaction between the mind and body. People’s capacity to fulfill might include aversions to animals, plants, or natural environments. It
their potential and obligations, their ability to live independently has been used to describe a range of responses, from mild discomfort to
despite a medical condition, and their capacity to engage in social intense fear or avoidance behaviors. This concept can be important in
activities like work are just a few of the dimensions of health that can various contexts, including design and therapy, where understanding an
be identified in the social domain. In this area, health may be viewed individual’s or group’s biophobic tendencies can help in creating
as a dynamic balance between possibilities and constraints that environments that reduce stress and enhance comfort (Nisbet, E. K.,
changes over time and is influenced by environmental and social Zelenski, J. M., and Murphy, S. A., 2009). Lastly, Biophilic design is an
factors. People who are able to cope with their condition can work, approach to architecture and interior design that integrates natural
engage in social activities, and feel well despite their limits (Huber, elements into built environments to enhance human wellbeing and
et al., 2011). Having good feelings like contentment and satisfaction, connectivity with nature. This design philosophy is based on the concept
as well as realizing one’s potential, having some degree of control of biophilia, which posits that humans have an inherent affinity for
over one’s life, understanding one’s purpose, and having satisfied nature (Haverkamp, R., and Kusch, H., 2019).
interpersonal interactions, are all considered to be components of Biophilic design integrates natural elements into built
wellness. It is a viable setting that promotes the growth and environments to promote human health and wellbeing. In
prosperity of a person or a population. This idea is significant healthcare settings, it aims to enhance the healing process and
because it goes beyond the lack of mental health to encompass improve the overall environment for both patients and care
the ability of an individual to fulfill their full potential, cope with providers. This comparative analysis reviews and contrasts key
everyday challenges, work professionally and fruitfully, and give findings from various studies on the impact of biophilic design in
back to their community. It also entails the realization that hospitals. Amongst the key concepts are:
everything is going well because wellbeing is linked to success on
the professional, personal, and interpersonal levels (Ruggeri, Garcia- 1) Biophilic Design Elements: Inclusion of natural light, plants,
Garzon, Maguire, Matz and Huppert, 2020). natural materials, views of nature, and water features.
2) Health Outcomes: Psychological and physiological effects on
patients, such as reduced stress, faster recovery times, and
1.5 Biophilic design in healthcare improved mood.
services settings 3) Wellbeing of Care Providers: Reduced burnout, enhanced job
satisfaction, and improved overall mental health of
To obtain the optimum health results, biophilic design is the hospital staff.
process of basing decisions about the built environment on sound
judgment or reliable research generated from either an appetite for Table 1, outlines the significant findings, highlights
nature or quantifiable biological reactions, respectively. A pattern in discrepancies, and practical challenges in implementing biophilic
nature that causes a favorable biological reaction in people is design in healthcare settings.

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TABLE 1 Preliminary comparative analysis.

Concept Academic study Finding Comparison

Psychological Benefits Study A (Ulrich, 1984) Found that patients with views of nature had shorter Both studies highlight significant psychological benefits,
for Patients postoperative stays and required fewer pain medications with Ulrich focusing on postoperative recovery metrics and
Salingaros on general stress and anxiety reduction
Study B (Salingaros, Emphasized the reduction in stress and anxiety through
2015) exposure to natural elements within the hospital
environment

Physiological Benefits Study C (Park and Demonstrated that patients in rooms with plants showed Both studies underline the physiological improvements,
for Patients Mattson, 2009) lower blood pressure and heart rates compared to those in with Park and Mattson emphasizing cardiovascular health
rooms without plants and Van den Berg focusing on sleep quality

Study D (Berg, Joye and Found that the presence of natural light in patient rooms
Vries, 2019) contributed to improved sleep patterns and circadian
rhythm regulation

Wellbeing of Care Study E (McCoy and Indicated that care providers in biophilic environments Both studies consistently show positive impacts on the
Providers Evans, 2002) experienced less job stress and higher job satisfaction wellbeing of care providers, highlighting reduced stress and
burnout, with McCoy and Evans also noting increased job
Study F (Ulrich, et al., Reported reduced instances of burnout and improved satisfaction
1991) mental health among staff working in biophilic-designed
hospitals

Design Implementation Study G (Joseph, 2006) Discussed the practical challenges of integrating biophilic Both studies acknowledge significant challenges in
Challenges design in existing hospital infrastructure, including cost implementing biophilic design, with Joseph focusing on
and space constraints physical and financial barriers, while Hartig emphasizes
administrative and institutional resistance
Study H (Hartig, et al., Explored the resistance from hospital administration and
2010) the necessity of evidence-based design to gain support

There is a general agreement among studies that biophilic design

positively impacts both patients and care providers by improving
psychological and physiological health outcomes. While the
variations in the extent of measured benefits and specific
biophilic elements used. Certain studies emphasize direct contact
with nature (plants and gardens), while others focus on indirect
elements (views and light). Practical implementation remains a
consistent issue, highlighting the need for strategic planning and
evidence-based approaches to overcome barriers.
Even though there is a growing interest within the scientific
community, there is still a clear gap in the literature that connects the
effects of systematic therapeutical environment on health and
wellbeing in healthcare settings. This paper will attempt to fill
that gap by determining the impact of therapeutic environments
on health and wellbeing of patients and caregivers in healthcare
FIGURE 1
settings through a systematic literature review. Furthermore, this Most productive authors on research subject “biophilic design in
study provides an up-to-date compilation of benchmark healthcare facilities” – Network Visualization.

information for successful implementations (case studies) across

the globe to further confirm whether the sort of impact revealed
through literature is legitimate. The main objectives of this paper are
to conduct a Systematic Literature review that will 1) Explore what relevant literature was summarized. English language articles in
sustainable therapeutic environment parameters are in healthcare published, peer-reviewed journals and reliable industry sources
settings 2) Outline the sustainable therapeutic environment were included for this systematic review. Given its high regard in
initiatives that have been implemented to enhance health and the academic and research communities for its comprehensive
wellbeing 3) Identify the correlation between sustainable coverage of peer-reviewed resources and advanced search
therapeutic environment on the health and wellbeing of capabilities, Scopus Database was used in addition to reliable
caregivers and patients. industry publications referred to as grey paper to understand
the evolution of this concept over the past 13 years
(2010–2023) when the practical application has become more
2 Methodology prominent. The analysis was conducted on 61 peer reviewed
journal articles, books/book chapters, conference papers,
Using the systematic database searching techniques the results reports/guidelines, websites/online industry articles, and
of a comprehensive examination and critical assessment of the systematic reviews.

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TABLE 2 Search string in Scopus database.

No. Search string Justification

01 “biophilic” AND “design” AND “healing” AND “environments” Capture general studies on biophilic design in healing environments

02 “biophilia” AND “design” AND “healing” AND “environments” Include variations of the term biophilic

03 “biophilia” AND “design” AND “in” AND “healthcare” Narrow the focus to healthcare settings

04 “biophilic” AND “design” AND “in” AND “healthcare” AND “setting” Ensure comprehensive coverage similar to the previous string with slight variation

05 “biophilic” AND “design” AND “healthcare” Focus directly on biophilic design in healthcare

06 “biophilic” AND “design” AND “hospital” Specifically target hospital environments

07 “biophilic” AND “design” AND “healthcare” AND “hospital” Capture studies mentioning both healthcare and hospitals explicitly

08 “biophilic” AND “design” AND “patient” AND “care” Focus on patient care aspects

09 “biophilic” AND “design” AND “staff” Include the impact on healthcare staff

10 “biophilic” AND “design” AND “care” AND “providers” Cover all types of care providers

11 “biophilic” AND “design” AND “workers” Broaden the scope to all healthcare workers

12 “biophilic” AND “design” AND “enhanced” AND “care” Capture studies focusing on enhanced care outcomes

13 “biophilia” AND “design” AND “enhanced” AND “care” Include the term biophilia in similar studies

14 “biophilia” AND “design” AND “healthcare” Conduct a general search for biophilia in healthcare

15 “biophilia” AND “design” AND “hospital” Target hospital environments specifically

16 “biophilia” AND “design” AND “healthcare” AND “hospital” Capture comprehensive studies involving both terms

17 “biophilia” AND “design” AND “patient” AND “care” Focus on patient outcomes

18 “biophilia” AND “design” AND “staff” Include staff outcomes

19 “biophilia” AND “design” AND “care” AND “providers” Cover all care providers

20 “biophilia” AND “design” AND “workers” Broaden to all healthcare workers

21 “biophilia” AND “design” AND “patient” Focus on patient-related studies

22 “biophilic” AND “design” AND “patient” Maintain a similar focus on patient outcomes

23 “biophilic” AND “design” AND “nurse” Target nursing staff

24 “biophilia” AND “design” AND “nurse” Include the term biophilia

25 “biophilic” AND “design” AND “doctor” Target doctors

26 “biophilic” AND “design” AND “physician” Include another term for doctors to ensure a comprehensive search

27 “impact” AND “biophilic” AND “design” Capture studies on the impact of biophilic design

28 “therapeutical” AND “design” Include studies focusing on therapeutic design elements

29 “advantage” AND “biophilic” AND “design Find studies highlighting the advantages of biophilic design

30 “implication” AND “biophilic” AND “design” Explore the implications of implementing biophilic design

For the bibliographic analysis, the search strategy focused on into the development and linkage of research on biophilic designs in
selecting relevant keywords such as “biophilic designs in healthcare” healthcare.
and was restricted to publications from 2010 to 2023 to ensure the In the network visualization illustrated in Figure 1, there is
inclusion of recent and relevant research. The VOSviewer software limited publications that specifically address biophilic design in
was employed to create bibliometric networks, leveraging data from healthcare facilities let alone the positive impact of its application
the Scopus database. This approach facilitated the generation of on caregivers and patients that are exposed to those biophilic
various bibliometric maps that visually represent the relationships designs. The figure represents the name of the main authors that
and trends within the field. The advanced search results from Scopus addressed this concept, whereby from the size of the labels and
were exported to VOSviewer to construct a network visualization, as circles the weight of each is equal. The links between those circles
shown in Figure 1. This visualization was used to analyze the indicates that the relatedness of the journals in terms of co-citation
connections among publications and authors, providing insights links. A VOSViewer mapping was then done using “biophilic design

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TABLE 3 Systematic review analysis summary by type. therapeutic environments. Derived from the work of (Tekin,
Corcoran and Gutiérrez, 2022), these parameters offer a
References type Count Percentage (%)
consistent framework for evaluating and comparing various
Journal Articles 37 60 therapeutic environment efforts. This approach ensures that the
Books 3 5
case studies studied align with proven patterns that enhance patient
wellbeing, providing an evidence-based method for analyzing the
Book Chapters 4 6
impact of biophilic design on health and wellness.
Conference Papers 1 2 The outcome of the journal searches yielded 379 sources that
were analyzed further as demonstrated in the next section.
Reports/Guidelines 3 5
Information from all of the 61 references was compiled in soft
Websites/Online Articles 12 19 copy folder and independently reviewed, followed by a selection of a
Systematic Reviews 1 3 final list of papers to be analyzed. Article topics and content were
examined and included based on the criteria for inclusion and
TOTAL 61 100
exclusion of material to eliminate papers whose research
questions were not fully aligned with the scope of this review. As
a result, 61 out of which 38 relevant journals published within
in healthcare facilities” as the keyword to know the top authors in 2010 and 2023 were selected for this study. In addition, a total of
this field. This dictated that the expansion of the radius of keyword 12 relevant supplementary sources were included to the search and
usage to ensure that the desired content to answer our research are shown in Figure 2.
question is attained as demonstrated in Table 2 Search terms Numerous studies conducted in a variety of contexts, including
included the following search string combinations. healthcare facilities, workplaces, children’s spaces, community
Moreover, a systematic review and critical assessment of spaces confirmed the beneficial impacts of biophilic design on
literature on biophilic design in healthcare settings and its human health and performance. When applied to healthcare
implications on patients and caregivers for a period of 13 years buildings, the discussion of biophilic design concepts is
was also performed. The academic literature, published in the particularly fascinating. This is attributable not just to the high
Scopus database, between 2010 and 2023, in English, as well as incidence of critical and stressful situations for patients, their
the grey literature which comprised of reliable news articles, families, and medical personnel in hospitals, but also to the fact
industry magazines, web sites that are renowned and trusted in that the city and the hospital are two distinct but related systems that
the healthcare design industry as demonstrated in Tables 3, 4. the same people frequent and utilize. Despite the humanization of
Moreover, we summarized and reported the results according to spaces intended for a wider hospitality and the process of
the steps advised by Transfield et al. (2003) and the “preferred interpenetration with the city, the hospital remains a place that is
reporting items for systematic reviews and meta-analyses” not easily permeable to external culture. It is still a separate world in
(PRISMA) guidelines. For the selection process, empirical studies, which the patient is unable to fully comprehend the organizational
academic book sections, literature reviews and conference rules. In addition to the more important economic and social
proceedings were included during the search process. Papers aspects, it is true that humanization interventions have restored
published in English, between 2010 and 2023, with clear research the importance of beauty and the connection between people and
questions and objectives on biophilic design in healthcare and their environment in the hospital’s architecture. Beauty is best understood
impact on improving patient care and service delivery were selected. as an ethical means of enabling the person, as a transient patient at
On the other hand, conceptual papers, editorials, publications in the hospital, to accept the set of space-time regulations governing it
languages other than English, publications prior to 2020, as well as and to be in an emotional state that supports healing and care
industrial sectors other than healthcare were excluded from the (Totaforti, 2018).
study. Given the topic is a key industry trend topic, the search was Table 6 provides a clear summary for our systematic review by
expanded to include reliable industry sources and official analyzing 61 sources, in terms of key findings, methodology, sample
newspapers which capture the insights of subject matter experts size, potential biases, and validity. This is to ensure the robustness
and yielded supplementary sources from reliable sources and and reliability of the conclusions drawn from the systematic review.
industry insights such as HCO news, Whole Building Design
Guide, Healthcare facilities today, Centres for Disease Control
and Prevention, HOK, ETKHO Hospital Engineering, Healthcare 3.2 Challenges and opportunities from a
Radius, Law Insider and Hospital Health. Patient’s perspective

The growth of a larger sense of trust and the activation of a

3 Results and discussion positive feedback to the information and the stimulations coming
from outside are both facilitated by a space that is viewed as dialogic,
3.1 Literature search outcomes friendly, intelligible, visually pleasing, and calming. The inability to
regulate the environment, particularly regarding the physical and
The literature search identifies that the use of Biophilic Design organizational spaces and timings of the place of care, is a common
Parameters “Patterns”, as detailed in Table 5, is justified by their source of stress for patients in therapeutic situations. Other stressors
grounding in established research and their relevance to sustainable include a lack of privacy, the presence of strange, frequently

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TABLE 4 Systematic review analysis by type. TABLE 4 (Continued) Systematic review analysis by type.

References Type References Type

Akpan-Idiok and Ackley (2017) Journal Article Janetius, S. T. (2020), April Book Chapter

Antonovsky, A. (1993) Journal Article Ryan, C. O., and Browning, W. D. (2020), September 23 Book Chapter

Attia, D. I. (2021), (July) Journal Article Showkat, H., and Parveen, N. (2017) Book Chapter

Blakemore, A. (2017) Journal Article Salingaros, N. A. (2015) Book

Brambilla, A., et al. (2023) Journal Article Terrapin Bright Green LLC. (2014) Book

Brambilla, A., et al. (2023) Journal Article Wilson, E. O. (1984) Book

Brand, J. L., and Augustin, S. (2021) Journal Article El-Zeiny, R. M. (2012) Conference Paper

Din, S. K.-J., et al. (2023) Journal Article Christensen, B. E., and Fagan, R. P. (2018) Report/Guideline

Ebaid, M. A. (2023), June 30 Journal Article Dubai Health Facility. (2023) Report/Guideline

El Messeidy, R. (2019), September Journal Article Joseph, A. (2006), July Report/Guideline

Fudickar, A., et al. (2022) Journal Article Page et al. (2021a) Systematic Review

Ghazaly, M., et al. (2022) Journal Article Becky Mollenkamp. (2023) Website/Online
Article
Gray, T., and Birrell, C. (2014) Journal Article
Design Curial. (2019), (February 8) Website/Online
Hartig, T., et al. (2010), October Journal Article Article

Haverkamp, R., and Kusch, H. (2019) Journal Article ETKHO Hospital Engineering. (2023), (October 10) Website/Online
Article
Huber, M., et al. (2011), July 26 Journal Article
Healthcare Radius. (2021, May 3) Website/Online
ITO, H., et al. (2022), April Journal Article Article

Lavdas, A. A. (2013) Journal Article HOK. (2023, October 10) Website/Online

Article
Lei, Q., et al. (2022) Journal Article
Interite Healthcare Interiors. (2019, January 29) Website/Online
Liu, Z., et al. (2021) Journal Article Article

March (1991) Journal Article Journal of Biophilic Design. (2012, July 12) Website/Online
Article
McCoy, J. M., and Evans, G. W. (2002) Journal Article
Kaushik, M. (2023, May 8) Website/Online
El Messeidy, R. (2019), September Journal Article
Article
Muhamad, J., et al. (2022) Journal Article Law Insider (2023) Website/Online
Article
Nisbet, E. K., et al. (2009) Journal Article
Phillips, J. (2023) Website/Online
Norouzianpour, H. (2020) Journal Article
Article
Park, S. H., and Mattson, R. H. (2009) Journal Article
Roxanne Squires. (2023, October 10) Website/Online
Ruggeri, K., et al. (2020) Journal Article Article

Russo, A., and Andreucci, M. B. (2023) Journal Article Smith, R., and Watkins, N. (2016), (September 22) Website/Online
Article
Shen, J., et al. (2020) Journal Article

Tekin, B. H., and Gutiérrez, R. U. (2023) Journal Article unsettling, or potentially anxiety-inducing sounds and noises,
Tekin, B. H., et al. (2022), August 22 Journal Article
uncomfortable artificial lighting, and strong environmental smells
that are frequently familiar due to their association in most people’s
Tekin, B. H., et al. (2023) Journal Article lives with illness. Only recently has design begun to take the
Tota-forti, S. (2018) Journal Article perspective of the patient, taking into account not only their
physical needs but also their social and psychological ones. This
Ulrich, R. S. (1984), April 27 Journal Article
has led to interventions aimed at improving the physical, sensory,
Ulrich, R. S., et al. (1991), September Journal Article and psychological comfort, improving wayfinding systems, and
Zhao, Y., et al. (2022) Journal Article
enhancing the clarity of the meanings communicated by space
design (Totaforti, 2018).
Berg, A. E., Joye, Y., and Vries, S. d. (2019) Book Chapter With varying effects depending on the various levels of
(Continued in next column) treatment (diagnosis, therapy, recovery), the disease in question,

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TABLE 5 Biophilic design groups and parameters “parameters”. and the hospital’s design, humanizing spaces and re-connecting with
nature, offers a therapeutic support that positively impact the
Biophilic design Biophilic design parameters
groups ‘patterns’ patients’ psychological and physical wellbeing. It also improves
their ability to recover (Totaforti, 2018). In addition, by
Direct Experience of Nature • Light increasing employee wellbeing and lowering healthcare expenses,
• Air space design boosts an organization’s productivity levels (Brand and
Augustin, 2021) and bring about financial gains (Ebaid, 2023).
• Water
Furthermore, when care providers take breaks, having private
• Plants outside locations speeds up the process of recharging. These staff
• Animals break places should, however, be positioned to provide quick and
simple access back to the patients (Tekin and Gutiérrez, Human-
• Weather centered healthcare environments: a new framework for biophilic
• Natural Landscape and Ecosystems design, 2023). Additionally, patients develop iatrophobia which is
the dread of healthcare providers and doctors. For some people,
• Fire
visiting the doctor’s office is a typical experience, but for others, it
Indirect Experience of Nature • Images of nature may be terrifying. This phobia may influence an individual’s choice
• Natural Materials to seek medical attention. Missing a doctor’s appointment can have a
lot of negative consequences because their job is to assist patients
• Natural Colors stay healthy. Stress in the medical industry is pervasive. High stakes
• Simulating natural light and air environments exist in nature, but biophilic design lessen this fear.
Including natural elements into healthcare environments benefits
• Naturalistic shapes and forms
both patients and staff, since nature is a tremendous force for good
• Evoking nature (Journal of Biophilic Design, 2012).
• Information richness Stress is lowered by biophilia, and stress reduction promotes
quicker recovery. Since mental health plays a significant role in the
• Age, change, and the patina of time healing process, it makes sense to create healing spaces with as little
• Natural geometries stress as possible. Making patient rooms to be the first emphasis for
these initiatives, with common facilities including entrances, waiting
• Biomimicry
rooms, cafeterias, and hallways coming in second (Becky
Experience of Space and Place • Prospect and refuge Mollenkamp, 2023; Muhamad, Ismail, Abul Khair and Ahmad,
• Organized complexity 2022) further supported this positive impact by demonstrating
how biophilic design and passive daylighting techniques in
• Integration of parts to wholes inpatient wards improves patients’ physical and mental health,
• Transitional spaces hasten their recuperation, and enhance their sense of
connectedness to nature. As a result, using biophilic design and
• Mobility and wayfinding
passive daylighting in a medical setting will change the hospital’s
• Cultural and ecological attachment to place architecture to make it more environmentally friendly and
Nature in the Space • Visual Connection with nature sustainable (Totaforti, 2018). also added that humanizing hospital
environments and allowing patients to spend time in outdoors
• Non-Visual connection with nature
empower them, lessen pain and stress, and enhance their mental
• Non-rhythmic sensory stimuli health. As another therapeutical biophilic example, children have
benefited psychologically from healing gardens as they attract and
• Thermal and airflow variability
provide a therapeutic environment for them (Din, Russo and
• Presence of water Liversedge, 2023; Russo and Andreucci, 2023). Moreover, art
• Dynamic and diffuse light benefits patients when utilized in hospitals amongst those
benefits are the positive impact on patient wellbeing, reduction in
• Connection with natural systems
hospital stay duration, stress, pain and analgesic usage, so-called
Natural Analogues • Biomorphic forms and patterns mild complications, depressions, anxiety, and mood were observed
in some of the early research as mentioned by (Fudickar et al., 2022).
• Material connection with nature

• Complexity and order

Nature of the Space • Prospect 3.3 Positive impacts on caregivers

• Refuge
According to (Brambilla, Del Pio, Morosini and Capolongo,
• Mystery 2023) one of the most stressful places on earth is a hospital.
Particularly in relation to patients, medical professionals, and
• Risk/Peril
nurses, those who occupy them go through a condition of

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FIGURE 2
The systematic article selection process for this review.

physical and mental stress. The COVID-19 pandemic made this orientate, soothe, comfort, and quiet, which is why healthcare settings
stress level even worse, hence new approaches must be looked at by that focus on behavioral health greatly benefit from it (Interite
hospital administrations to eliminate its implications. The caregivers Healthcare Interiors, 2019). Additionally, a large percentage of
are more productive and organized in spaces with plants hospital staff members report having bad sentiments at work.
(particularly roses), natural air and light, and interaction with Anxiety and sadness are expressed by frontline employees. It would
nature. These biophilic design decisions also increase the be challenging to remain emotionally neutral when working under such
parasympathetic nervous system’s activity, which lowers stress terrible circumstances. Employees working in therapeutic settings might
levels and promotes an overall feeling of wellbeing. Biophilic feel constrained (Journal of Biophilic Design, 2012).
design encourages employee wellness, which lowers sick days Based on preliminary evidence, it appears that implementing
while raising satisfaction and attendance El Messeidy, R. (2019), biophilic design elements can significantly improve wellbeing, reduce
(Totaforti, 2018), (Lei, Lau, Yuan, and Qi, 2022). stress, increase productivity, encourage a collaborative work
One problem that has an impact on every hospital building environment, and increase workplace satisfaction, increase morale all
occupant’s health and wellbeing is stress. The detrimental of which can lead to a high-performance workspace (Gray and Birrell,
consequences of stress are particularly noticeable in the workplace, 2014). The employers can benefit from biophilic design as well.
as stress may impede employee happiness and productivity and serve as Employers may save money which also enhances job satisfaction,
a key cause of disease. Occupational stress can stem from a variety of lowers stress, decreases absenteeism and turnover, and promotes
factors, such as job insecurity, long hours, an overwhelming workload, concentration and productivity hence directly improving service
conflicts within the company, looming deadlines, shifting delivery (Becky Mollenkamp, 2023). (Lavdas, 2013) stated that the
responsibilities, and a lack of autonomy. The working environment exposure of hospital staff to fractal visual patterns, seen in nature,
itself is one aspect that can lead to total occupational stress, but one that architecture, or the visual arts, has beneficial physiological (reduction
can be lessened via design. Although there are many different reasons of stress) and cognitive (improvement of problem-solving ability)
why professional stress might occur, designers can take a variety of steps impacts. In a similar vein, studies have shown the therapeutic
to reduce it (Norouzianpour, 2020). Biophilic design creates spaces that benefits of both natural surroundings which promote quicker

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TABLE 6 Systematic review analysis.

References Key findings Methodology Sample size Potential Validity

biases
Akpan-Idiok and Biophilic design reduces Qualitative study; Surveys and 150 participants Response bias, Medium, due to lack of
Ackley (2017) stress, enhances patient interviews (patients, staff) selection bias detailed statistical analysis
recovery

Antonovsky (1993) Sense of coherence promotes Quantitative study; 400 respondents Measurement bias, High, validated scale with
wellbeing Psychometric testing self-report bias extensive use

Attia (2021) Biophilic elements improve Mixed-method study; Surveys 200 patients and Response bias, Medium, varied data sources
cognitive function and and observational analysis healthcare workers observer bias but limited statistical rigor
emotional health

Mollenkamp (2023) Green spaces positively Review article; Literature N/A Publication bias, High, comprehensive review
impact patient health synthesis selection bias but relies on secondary data

Berg, Joye and Vries Nature exposure reduces Review article; Literature N/A Publication bias, High, extensive literature
(2019) stress, improves mood and synthesis selection bias review with strong theoretical
cognitive function foundation

Blakemore (2017) Natural light and greenery Review article; Literature N/A Publication bias, Medium, relies heavily on
promote healing and reduce synthesis selection bias secondary sources
stress

Brambilla et al. (2023) Biophilic design supports Literature review N/A Publication bias, Medium, focuses on pre-
mental health and wellbeing selection bias COVID-19 data

Brand and Augustin Biophilic design elements Review article; Literature N/A Publication bias, Medium, critical synthesis but
(2021) enhance health and wellbeing synthesis selection bias lacks empirical data

Christensen and Fagan Nature contact reduces stress Guidebook/Manual N/A N/A High, authoritative source
(2018) and improves wellbeing by CDC

Design Curial. (2019) Biophilic design enhances Descriptive article N/A Selection bias, Medium, informative but not
wellbeing commercial bias peer-reviewed

Din, Russo and Biophilic design benefits Literature review N/A Publication bias, High, focused on specific
Liversedge (2023) children’s health and learning selection bias population (children)

Dubai Health Facility. Green spaces improve patient Regulatory guideline N/A N/A High, authoritative source by
(2023) recovery regulatory body

Ebaid (2023) Nature-based design Framework development; Case 5 case studies Selection bias Medium, framework based on
improves mental health studies limited case studies

El Messeidy, R. (2019) Biophilic design promotes Literature review N/A Publication bias, Medium, synthesis of existing
healing environments selection bias studies

El-Zeiny (2012) Nature integration in design Case study; Observational study Multiple private sector Observer bias, Medium, limited to specific
enhances wellbeing workplaces selection bias geographical area

ETKHO Hospital Biophilic design reduces Descriptive article N/A Selection bias, Medium, informative but not
Engineering. (2023) stress, improves mood commercial bias peer-reviewed

Fudickar, Konetzka and Nature-based interventions Review article N/A Publication bias, Medium, synthesis of existing
Louring (2022) improve health outcomes selection bias studies

Ghazaly et al. (2022) Green spaces in hospitals Literature review N/A Publication bias, Medium, broad overview but
improve patient outcomes selection bias lacks empirical data

Gray and Birrell (2014) Biophilic elements enhance Quantitative study; Surveys 250 participants (office Self-report bias, High, robust sample size with
cognitive function, reduce workers) selection bias statistical analysis
stress

Hartig et al. (2010) Nature exposure improves Review article; Literature N/A Publication bias, High, comprehensive and
psychological wellbeing synthesis selection bias multidisciplinary review

Haverkamp and Kusch Biophilic design enhances Systematic review Multiple studies Publication bias, High, systematic approach
(2019) wellbeing reviewed selection bias with rigorous analysis

Healthcare Radius Biophilic design reduces Descriptive article N/A Selection bias, Medium, informative but not
(2021) stress and improves healing commercial bias peer-reviewed

HOK (2023) Biophilic design elements Descriptive article N/A Selection bias, Medium, informative but not
improve wellbeing commercial bias peer-reviewed

(Continued on following page)

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TABLE 6 (Continued) Systematic review analysis.

References Key findings Methodology Sample size Potential Validity

biases
Huber et al. (2011) Biophilic design enhances Review article; Conceptual N/A Selection bias High, influential conceptual
health and wellbeing analysis framework with extensive
citation

Interite Healthcare Biophilic design reduces Descriptive article N/A Selection bias, Medium, informative but not
Interiors (2019) stress, improves wellbeing commercial bias peer-reviewed

ITO et al. (2022) Biophilic design improves Experimental study; 100 participants (office Measurement bias, High, controlled environment
cognitive performance Physiological measurements workers) selection bias with robust methodology

Janetius (2020) Biophilic design enhances Conceptual book chapter N/A Selection bias Medium, theoretical analysis
wellbeing with limited empirical data

Joseph (2006) Nature exposure promotes Review article; Literature N/A Publication bias, High, foundational review in
healing and reduces stress synthesis selection bias the field

Journal of Biophilic Nature-based design reduces Descriptive article N/A Selection bias, Medium, informative but not
Design (2012) stress, enhances wellbeing commercial bias peer-reviewed

Kaushik (2023) Biophilic design improves Opinion article N/A Selection bias Medium, informed opinion
mental health and wellbeing but lacks empirical data

Lavdas (2013) Nature contact improves Conceptual analysis N/A Selection bias Medium, theoretical
mental health perspective with limited
empirical support

Law Insider (2023) Biophilic design enhances Legal definition N/A N/A High, authoritative legal
wellbeing source

Lei et al. (2022) Biophilic design improves Post-occupancy evaluation; 150 participants Self-report bias, High, robust sample size with
mental health, productivity Surveys (workplace employees) selection bias statistical analysis

Liu, Yang and Osmani Biophilic design enhances Review article N/A Publication bias, High, comprehensive review
(2021) health, wellbeing selection bias with clear focus

March (1991) Nature exposure reduces Theoretical paper N/A N/A High, foundational theoretical
stress, improves wellbeing work with extensive citation

McCoy and Evans Biophilic design reduces Theoretical paper N/A N/A High, influential theoretical
(2002) stress, improves wellbeing framework with extensive
citation

El Messeidy, R. (2019) Nature-based design Literature review N/A Publication bias, Medium, synthesis of existing
enhances wellbeing selection bias studies

Muhamad et al. (2022) Biophilic design reduces Case study; Observational study 1 hospital (inpatient Observer bias, Medium, limited to specific
stress, enhances wellbeing ward) selection bias case study

Nisbet, Zelenski and Nature contact enhances Quantitative study; Surveys 600 participants Self-report bias, High, robust sample size with
Murphy (2009) wellbeing (general population) selection bias statistical analysis

Norouzianpour (2020) Biophilic design improves Experimental study; 50 office workers Selection bias, Medium, small sample size
cognitive performance Interventions measurement bias but controlled environment

Page et al. (2021b) Nature-based design Guideline paper N/A N/A High, authoritative guideline
enhances wellbeing with extensive use

Park and Mattson Biophilic design improves Experimental study; 100 patients (post- Measurement bias, High, controlled environment
(2009) recovery, reduces stress Physiological and psychological surgery) selection bias with robust methodology
measurements

Phillips (2023) Biophilic design enhances Opinion article N/A Selection bias Medium, informed opinion
wellbeing but lacks empirical data

Squires (2023) Nature contact improves Descriptive article N/A Selection bias, Medium, informative but not
wellbeing commercial bias peer-reviewed

Ruggeri et al. (2020) Biophilic design enhances Quantitative study; Surveys and 21 countries (varied Self-report bias, High, robust cross-cultural
wellbeing statistical analysis sample sizes) cultural bias analysis

Russo and Andreucci Biophilic design enhances Review article N/A Publication bias, High, comprehensive review
(2023) health and wellbeing selection bias with clear focus

(Continued on following page)

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TABLE 6 (Continued) Systematic review analysis.

References Key findings Methodology Sample size Potential Validity

biases
Ryan and Browning Biophilic design enhances Theoretical paper N/A N/A High, influential theoretical
(2020) health and wellbeing framework with extensive
citation

Salingaros (2015) Biophilic design enhances Theoretical paper N/A N/A High, influential theoretical
wellbeing framework with extensive
citation

Shen, Zhang and Lian Biophilic design improves Experimental study; Cognitive 80 office workers Measurement bias, High, controlled environment
(2020) cognitive performance performance testing selection bias with robust methodology

Showkat and Parveen Ethical considerations in Review article N/A Publication bias, Medium, focused on ethical
(2017) biophilic design selection bias considerations

Smith and Watkins Biophilic design reduces Descriptive article N/A Selection bias, Medium, informative but not
(2016) stress, improves wellbeing commercial bias peer-reviewed

Tekin and Gutiérrez Biophilic design enhances Conceptual framework Multiple studies Publication bias, High, systematic approach
(2023) wellbeing development; Systematic review reviewed selection bias with rigorous analysis

Terrapin Bright Green Biophilic design enhances Guidebook; Conceptual N/A N/A High, authoritative source in
LLC (2014) health and wellbeing framework biophilic design

Totaforti (2018) Biophilic design in hospitals Review article N/A Publication bias, High, focused on hospital
enhances wellbeing selection bias design

Ulrich (1984) Nature exposure reduces Experimental study; 46 patients (post- Observer bias, small High, seminal study with
stress, improves recovery Observational surgery) sample size significant impact

Ulrich et al. (1991) Biophilic design reduces Experimental study; 100 participants Measurement bias, High, robust methodology
stress, improves wellbeing Observational and psychological selection bias with significant impact
measurements

Wilson (1984) Biophilia hypothesis Theoretical book N/A N/A High, foundational work in
biophilia

Zhao, Zhan and Xu Sustainable biophilic design Review article N/A Publication bias, High, focused on sustainable
(2022) enhances wellbeing selection bias interaction in healthcare
spaces

hospital recovery and pain relief as well as artificial environments that professionals, visitors, and suppliers as well as the hospital
replicate the geometrical features of natural environments. Using grounds (Kaushik, 2023). Additional to adopting therapeutical
wooden components in home design may enhance occupant biophilic design the following paragraphs highlight additional
happiness and cognitive function (Shen, Zhang and Lian, 2020). environmentally sustainable business practices:
Seeing vegetation via the window with a balanced quantity of Recycling recyclable materials is ensured by reviewing waste
sunshine through the foliage increased employee’s perceptions of management procedure by implementing sustainability standards
their indoor environment, ease of work, and self-estimated for waste management and purchasing, particularly if they pair any
productivity (ITO, et al., 2022). evaluation with fresh or strengthened sustainability pledges and
(Terrapin Bright Green LLC, 2014) has identified fourteen (14) practices. Some of the single-use medical gadgets that hospitals
patterns that summarise the findings and strategies which emerged normally throw away can be reprocessed when they collaborate
from the literature review in terms of improving patient care and with medical device manufacturers. Cardinal Health created a
improving service delivery. Table 7, identifies which patterns are in zero-waste operation to recycle or reprocess single-use devices
alignmet with the impact of therapeutical biophilic design on health in collaboration with healthcare organizations. Through these
and wellbeing of patients and care providers in hospitals based on collaborations, they were able to remove almost 740 tons of
the findings of this study. discarded medical devices from landfills in 2017. Kaiser
Permanente saved around $11 million annually by recycling
some single-use items. In non-clinical settings, such food and
3.4 Additional environmentally sustainable dining services, implementing reuse and recycling programs will
business practices in transforming aid in addressing the single-use plastic problem. Additionally,
healthcare facilities choosing to buy more food that is grown nearby will lessen the
hospital’s carbon impact and food waste. Even better, they can
Greening the healthcare sector is essential to encouraging work with neighborhood organizations to turn their food waste
sustainable operations that reduce the industry’s environmental into compost, which would feed nearby food producers like
impact and improve the environment for patients, healthcare hospitals or gardens (Phillips, 2023).

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TABLE 7 Impact of therapuetical biophilic design on health and wellbeing of patients and caregivers in comparison to Terrapin’s 14 patterns (Terrapin Bright
Green LLC, 2014).

14 Patterns Stress Reducation Cognitive Performance Emotion, Mood and

Preference

Nature in the Space

Visual Connection with Lowered blood pressure and heart rate Improved mental engagement/attentiveness Positively impacted attitude and overall
Nature happiness

Non-Visual Connection Reduced systolic blood pressure and stress hormones Positively impacted coginitive performance Perceived improvements in mental
with Nature health and transquility

Non-Rhythmic Sensory Positively impacted heart rate, systolic blood Observed and quantified behavioural
Stimuli pressure and sympathetic nervous system activity measures of attention and exploration

Thermal and Airflow Positively impacted comfort, wellbeing and Positively impacted concentration Improved perception of temporal and
Variability productivity spatial pleasure (alliesthesia)

Presence of Water Reduced stress, increased feelings of tranquility, Improved concentration and memory Obsereved preference and positive
lower heart rate and blood pressure restoration emotional responses
Enhanced perception and psychological
responsiveness

Dynamic and Diffuse Light Positively impacted circadian system functioning

Increased visual comfort

Connection with Natural Enhanced positive health responses:

Systems Shifted perception of environment

Natural Analogues

Biomorphic forms and Observed view preference

patterns

Material Connection with Decreased diastolic blood pressure Improved Comfort

Nature Improved creative performance

Complexity and Order Positively impacted perceptual and psychological Observed view preference
stress responses

Nature of the Space

Prospect Reduced Stress Reduced bordem, irritation, fatigue Improved comfort and perceived safety

Refuge Improved concentrantion, attention and

perception of safety

Mystery Induced strong pleasure response

Risk/Peril Resulted in strong dopamine or pleasure

responses
a
Legend: positive impact of therapuetical biophilic design on health and wellbeing of patients and caregivers Source: (Terrapin Bright Green LLC, 2014).

Furthermore, hospitals will operate more sustainably if they solar panels, green energy, and other clean energy providers. Some
share durable assets like buildings, vehicles, medical equipment, and health systems even use the on-site incinerators they employ to get
other underutilized resources. Floow2 is a startup that has created a rid of garbage to create electricity. Aiming to become net carbon
marketplace for sharing resources so that hospitals in its network negative by purchasing enough clean energy and carbon offsets to
may share equipment. This lowers the cost of purchasing expensive remove more greenhouse gases from the environment than it emits,
equipment, such as imaging machines, and the length of time that Kaiser Permanente made one of the biggest pledges to green energy
such equipment is left idle. Asset sharing lowers the total energy among healthcare organizations in the United States (Phillips, 2023).
used in product manufacture and maintenance, in addition to Water conservation is another important component of
offering possible cost benefits for all network organizations. Some sustainability, as hospitals use a lot of water for gardening,
hospitals are already changing how they utilize their facilities and patient care, cleaning, and other purposes. Water use may be
durable assets because of the coronavirus outbreak. Many providers greatly reduced by installing low-flow showerheads and toilets,
have embraced telehealth and remote care services for non-urgent fixing leaks right once, updating irrigation systems, and collecting
treatment, which lowers their energy consumption, physical and recycling rainwater. Sewage treatment systems based on
footprint, and emissions from staff and patient travel to the membrane bioreactors can maximize the recycling of treated
facility (Phillips, 2023). Hospitals are switching from using fossil wastewater. After treatment, wastewater may be utilized for a
fuels to more cost-effective, environmentally friendly energy sources variety of non-potable uses, such as cooling towers, gardening,
that are also more efficient. Hospitals are putting in smart lighting, and flushing. Medical equipment may also be cleaned and

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sterilized with the use of water recycling programs. Hospitals may biophilic designs in hospital settings application from the aspects of
also take use of the 3Rs concept, which stands for Reduce, Reuse, and patient care and service delivery carried out by care providers. There
Recycle, to help achieve a double-digit decline in freshwater usage is a potential of further research in this domain, with in-depth
(Kaushik, 2023). analysis of the impact of every biophilic design pillar as a standalone
Waste Reduction and Recycling is achieved by putting in place and assess its implication separately on the wellbeing of patient and
recycling programs for paper, plastics, and other materials, hospitals care providers. Moreover, further understand the challenges that are
may reduce waste. Healthcare institutions lessen their carbon impact hinging the wide scale imple-mentation of such designs from the
and encourage sustainability by composting yard waste and food scraps. lens of subject matter experts and space users in general or bound to
Additionally, reusing materials, buying items with little packaging, and a specific geographical location. Additionally, quantifying the
utilizing eco-friendly cleaning solutions are all ways to reduce waste. positive impact such as the monetary value of reduced staff
Hospitals must also have a thorough waste management strategy that absenteeism, workforce productivity, and reduction of hospital stay.
includes identifying and classifying garbage into solid waste, biomedical
waste, hazardous waste, and e-waste. Similarly, this trash is treated and
transformed into manure, which can be utilized for horticulture 4 Conclusion
purposes, using organic waste converters. Reducing the Use of
Chemical and Hazardous Materials is achieved by improving This Systematic Literature Review paper explored the
sustainability and safeguarding patient safety in hospitals through parameters that define sustainable therapeutic environments in
employing eco-friendly cleaning solutions, minimizing the use of healthcare settings. It outlined various sustainable therapeutic
toxic chemicals in medical operations, and putting safe disposal environment initiatives that have been implemented to enhance
programs for hazardous materials in place, the use of hazardous health and wellbeing. Moreover, it identified and examined the
chemicals and materials may be minimized (Kaushik, 2023). correlation between sustainable therapeutic environments and the
Sustainable Food Practices through local, organic, and health and wellbeing of both caregivers and patients, providing a
sustainably farmed food is be obtained by hospitals for their robust understanding of the positive impacts and effective practices
patients and employees. Hospitals reduce their carbon footprints within healthcare settings.
related to food transportation by promoting local farmers and In summary, healthcare facility design has changed despite the worry
businesses through a farm-to-table program. Additionally, from their administrations that adding biophilic features will increase the
composting programs and giving extra food to nearby food costs (Becky Mollenkamp, 2023). The patient’s welfare has taken
banks and charity helps decrease food waste (Kaushik, 2023). precedence over functionality without losing ground. One of the
most useful, simple, and cost-benefit effective ways to achieve this is
through a biophilic design. A location with adequate fresh air circulation,
3.5 Case studies of therapeutical a good portion of exterior doors, and adequate natural lighting is better
biophilic design for the health of patients and healthcare personnel. From reducing
patient mortality, suffering, and stress to decreasing hospital stays. A
A consolidated view of the case studies reviewed across the globe to connection to nature has been shown to lessen anxiety and enhance the
hospital settings that have successfully implemented the biophilic design experiences of patients, their families, and medical personnel. The idea
for a more sustainable therapeutical environment for its patients and that stress may be significantly reduced by having access to nature and
caregiver are summarized in Supplemenatary Table S1. Additionally, the greenery is well supported by the available data (Norouzianpour, 2020).
table shows that, to put it simply, biophilic design is the relationship The cliche “home away from home” is being taken on faith. Therefore,
between humans and nature. People benefit from this connection by the humanization of hospitals entails the design of interventions targeted
feeling at ease, appreciating beauty, and fostering interpersonal at redefining the environment in terms of both the organizational and
connections. Thus, using biophilic design in medical settings may therapeutic aspects, as well as, more generally, how patients and visitors
facilitate patients’ recovery from a variety of illnesses. Employing view the hospital (Totaforti, 2018). Despite the positive impact of
biophilic design in hospital architecture is more than just adding sustainable therapeutic environments through biophilic design,
plants, trees, or green walls; it is a comprehensive strategy that calls for implementing biophilic design is still difficult since many healthcare
fresh perspectives and creative ways to incorporate nature into medical facilities are still considered as sterile settings, and there are worries about
settings. To be considered biophilic, a design does not have to incorporate higher maintenance costs. Some hospitals prefer to prevent issues like a
every biophilic design pattern. It is not an easy task for architects to play in rise in pests like flies and the quantity of dead leaves, which can clog
this situation; it calls for extensive research and analysis of the interaction drains (Roxanne Squires, 2023). Effective biophilic design should
between humans and the natural world (El Messeidy, R. 2019). enhance patients’ daily life and be implemented by those in charge of
designing and innovating hospital settings in the future (Ebaid, 2023).
Research in literature review have shown that for hospital
3.6 Limitations and future research areas settings such as inpatients (feeling calm and at ease, prospect
refuge, security and protection, light-daylight, view) are
Although there is noticeable growing interest in the significance prioritized biophilic design requirements, while for personnel
of biophilic designs within healthcare, this systematic literature (privacy refuge, tranquility), and outpatients (fresh air, light-
review reveals a scarcity of research con-ducted in this field. This daylight, thermal comfort, welcome and soothing). While staff,
is seen as the main limitation of this research due to the small inpatient, and outpatient users had comparable needs and wants,
number of holistic research that is performed on the implication of there were occasionally differences in their priorities, and various

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Al Khatib et al. 10.3389/fbuil.2024.1467692

groups required distinct biophilic aspects (Tekin, Corcoran and Conflict of interest
Gutierrez, 2023). Confirming that the application of biophilic
designs in hospital settings has a positive impact on both the The authors declare that the research was conducted in the
patients and caregivers’ wellbeing. absence of any commercial or financial relationships that could be
construed as a potential conflict of interest.

Author contributions
Publisher’s note
IA: Writing–original draft. FS: Writing–review and editing. MN:
Writing–review and editing. All claims expressed in this article are solely those of the authors
and do not necessarily represent those of their affiliated
organizations, or those of the publisher, the editors and the
Funding reviewers. Any product that may be evaluated in this article, or
claim that may be made by its manufacturer, is not guaranteed or
The author(s) declare that no financial support was received for endorsed by the publisher.
the research, authorship, and/or publication of this article.

Supplementary material
Acknowledgments
The Supplementary Material for this article can be found online
The work in this paper was supported, in part, by the Open at: https://www.frontiersin.org/articles/10.3389/fbuil.2024.1467692/
Access Program from the American University of Sharjah. full#supplementary-material

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