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A d i s c u s s i o n o n b u i l t en v i r o n m e n t
SEMINAR REPORT
SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF THE DEGREE OF BACHELOR OF ARCHITECTURE
CERTIFICATE
Certified that the thesis entitled PSYCHOLOGY IN CANCER HOSPITAL" submitted by Himanshu Tripathi in partial fulfilment for the award of the degree of Bachelor of Architecture at the School of Planning and Architecture, Bhopal (deemed to be a university), is a record of the student's own work carried out by him under my supervision and guidance. The matter embodied in this thesis work, other than that acknowledged as reference, has not been submitted for the award of any degree or diploma.
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Dr. Savita Raje Head of Department School of Planning and Architecture, Bhopal
ACKNOWLEDGEMENT
I would like to acknowledge and extend my heartfelt gratitude to the following persons who have made the completion of this report possible: Our H.O.D. Dr. Sanjeev Singh ,for his vital encouragement and for giving this subject. Dr Sukanta Mujumdar, my Mentor , for his understanding, advice, guidance and support. Dr Rachna Khare and Ar Arti Grover, subject coordinator for the constant support and much needed motivation. I would also like to extend my sincere gratitude to all faculty members and Staff for assisting in the collection of the topics for the chapters. Most especially to my family and friends. Finally, to God, who made all things possible.
INDEX
Table of Content Cover page Certificate Acknowkedgement Introduction Relationship of topic with thesis (advance objective) 1. Psychological effects of hospitalization 2. Departmental components of hospitals 3. Landscape, garden and space between buildings 4. Interior features 5. Case Study a. Dharamshila cancer hospital, New Delhi b. Jawaharlal Nehru cancer hospital and research centre 6. The designers role 7. Inference 8. Conclusion 9. Select bibliography 10. List of tables 11. List of graphs 12. List of figure Page No.
Introduction
Health care are one of the most prominent and vital industry of 21 st century. Though hospital provides vital service to humankind, it still possesses an image of fear and false anticipation. In simple words, people fear hospitals and negative psychology affects them severely. There are many reasons for the person to be reluctant from being admitted to or even going to hospital during illness. The seminar deals with the understanding of the factors responsible for making the hospital a disliked building, and effective measure that shall be taken during the planning / designing stage to eradicate the cause. And give the building a better identity. This study explores how cancer patients experience the meaning of positive sensory impressions in the hospital environment such as architecture, decoration and the interior. Data were obtained at a general hospital in Denmark by interviewing six cancer patients at two different wards. The analysis process was guided by the hermeneutical-phenomenological theory of interpretation as presented by the French philosopher Paul Ricoeur. Two main themes were identified: to preserve identity and positive thoughts and feelings. The participants experienced that positive sensory impressions in the hospital environment had a significant impact on their mood, generating positive thoughts and feelings. A view to nature also helped them to forget their negative thoughts for a while. The possibility of having a view helped some cancer patients to connect with good memories and personal life stories that enabled them to recall some of their feelings of identity. This paper adds knowledge about how cancer patients experience sensory impressions in the hospital environment. An environment that provides homeliness and offers a view to nature seems to help some patients to preserve their identity. Furthermore, positive sensory impressions and the opportunity for recreation through environmental facilities strengthen the patient's positive thoughts and feelings.
Advance objective
The main reason behind development of the report is to better design the health care facility, which tends to increase the positive psychological impact on its intended user, not only the patients but also the staff.
c. Separation from family. d. Financial problem. e. Lack of information. f. Threat of severe illness. g. Problem with medication. 3. Stress events a. Unfamiliarity of the surrounding : i. Having strangers sleep with you in the same room. ii. Having to sleep in strange bed.
iii. Being aware of unusual smells around you. iv. Being in a room that is too cold or too hot. v. Having to eat cold or tasteless food. b. Loss of independence: i. Having to eat at different times than you usually. ii. Having to wear a hospital gown. iii. Having to be assisted with bathing. iv. Not being able to get newspaper radio or TV when you want to. v. Having to be assisted with a bad pan. vi. Being fed through tubes thinking you may lose your weight. c. Separation from family d. Financial problem i. Losing income because of illness e. Isolation from society i. Having a seriously ill roommate, unfriendly, or cannot talk to you. f. Lack of information i. Thinking you might have pain because of test or procedures. ii. Not knowing when to expect the results. iii. Fear of medical jargon iv. Lack of knowledge of proper diagnosing.
g. Threat of serious illness h. Separation from family i. Not having family visit you ii. Being hospitalized far from home i. Problem with medication i. The need for attention during illness patient may use behavior pattern quite unconsciously such as cry , complain ,and display their suffering other appear to be able to tolerate complaint. great deal of discomfort without
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walls (as compared to white walls) reduce anxiety and increase cognitive and affective appraisal and even perceived service quality. Introduction Hospitalization can have a great psychological impact. A patients health is at stake, and (s)he is temporarily separated from family and friends. Under such conditions, patients display a strong need for information concerning their health and treatment (Engstrm, 1984). However, reliable information about the quality of healthcare is rather difficult or even impossible to obtain, as patients lack insight into the procedure and effects of the treatment. To reduce this uncertainty, patients will be inclined to infer their judgment of service quality from other indicators, such as the tangible environment. Therefore, physical aspects of the service environment play an important role in customers evaluation of healthcare services (Arneill & Devlin, 2002). A considerable amount of empirical evidence is available about the effects of environmental factors on a wide variety of consumer responses (Turley & Milliman, 2000). Historically, the atmosphere in clinical environments has been cold and sterile due to color, lighting and furniture. The current trend in hospital interior design is to create an attractive, relaxing atmosphere in order to relieve patients stress and anxiety, improve their emotions and hence encourage the healing process (Devlin & Arneill, 2003). Color can be used effectively for this purpose (Calkins, 2002; Marberry & Zagon, 1995). Blue has been found to be the most preferred color throughout color literature (e.g. Bellizzi, Crowley & Hasty, 1983; Guilford & Smith, 1959), and stress-reducing effects of short wavelength colors (blue, green) are welldocumented (e.g., Birren, 1979; Valdez & Mehrabian, 1994). Yet, solid empirical evidence for anxiety-reducing and affect-enhancing effects of interior color in healthcare settings is largely lacking. In this study we investigated the effects of wall color on anxiety, pleasure, evaluation of the room and perceived service quality in a simulation of a general hospital. We expected subjects exposed to a hospital room with blue walls to experience more positive emotions, and lower anxiety, to evaluate the room more positively, and to appraise the quality of the service higher than subjects exposed to a white hospital room. There's hardly a secret anymore that human behavior is highly influenced by colors. Scientific studies have proven that our emotions and mood are affected when surrounded by particular colors. Some cause us to be more aggressive, whereas others have a soothing effect on us. From psychologists to interior designers, everybody seems fascinated with the phenomenon.
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No wonder then that when it comes to paints, specialists are extremely careful to make the right choice. As their ideas come as colors do, in a wide variety, ultimately the only thing they have to consider is the appropriateness of their vision. For instance, a hospital room wouldn't be painted in the same shades as a private residence's living room. The patients would it find difficult to cope with some red painted walls instead of the usual white, green or blue ones. We all may have in contact, one way or another, with the imposing, intimidating places which are hospitals. Either as patients or visitors, we are most certainly overwhelmed by their presence. But, once inside, hospitals have this huge power of conveying a sensation of calm and peace. How do they manage to do that? It's simple to find the answer by just taking a quick look at the walls and noticing the colors they are painted in. Hospital walls are usually covered in colors such as white, green and blue. There is an explanation behind these choices and it has to do with the psychological effects these colors have. White is the most common color to be seen on a hospital wall. And that is due to the peaceful and calm mood it provides. Other reason for choosing it is the fact that it denotes cleanness. It implies sterility, which has the effect of making patients feel reassured. This is also why doctors and nurses wear white uniforms. Blue and green are considered to be the most relaxing and refreshing colors, promoting peaceful atmosphere which encourages concentration. Designers, psychologists and feng-shui experts, they all tend to consider that shades of blues and greens make us fell calmer, more balanced and less emotional. Because green has a calming effect on our nerves, hospital waiting rooms and even psychiatric wards are painted in this color. And surgeons wear green scrubs for the same reason. As for blue, it has often been noticed that children in pain are put in hospital rooms painted in light blue due to its healing effect it conveys. When coming inside a hospital, the general atmosphere must make us feel reassured and calm. Before knowing anything about the staff's professionalism, our worried look will check for visible signs that we will be well taken for. And the hospital's walls, white, green or blue, are our first impression.
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15. Administration areas: general and personal offices 16. Storage Main roadway entrance General layout Positive reassurers a large notice of the hospital name, nature and town, placed first at some distance from the main entrance with an indication for drivers that the main entrance is one hundred yards further on, and then repeated at the entrance, well lit at night. For people arriving on foot or by bus, small direction signs at bus stops and streets intersections. Clear directions as to what the visitor does next: main reception / information point, direct route to emergencies, dropping- off points for patients, disabled parking, visitors car parks. A well maintained entrance, neat verges, shrubs, flowers, litter free, with a well lit, safe route such as footpath beside a road clearly leading to the main reception / information points. Positive unreassurers small notices and small prints Information about name and nature of hospital not given Poorly lit at night Signs hidden by trees No notice for pedestrians in the streets near the hospitals Litter at the hospital entrance. A forest of signs at the hospital entrance. Notice too near the entrance to enable a driver to indicate and make a safe turning.
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A large number of signs with negative messages Subsidiary signs 1. Prohibition on parking, dogs and trespassers. 2. Cautions against theft and speed 3. Exoneration of blame should the worst occur 4. Information about closure, resting 5. Multiple and contradictory general directions Solutions Treat main entrance signs like an army; organise them according to rank, select wisely, demonstrate authority over underlining and do not keep changing your mind. The enemy muddle so make sure everyone understands what muddle looks and can recognise it; when they can see the whites of its eye, shoot to kill. Information about good signposting is available and an important part of the management of health service building is constantly checking that every effort is being made to guide people as they come on to the site or enter the main reception area will give a good picture of whether people hesitate look anxiously around and appears uncertain, or whether they move confidently and approach the destination or information desk readily. Staff who work in reception can tell you which question people ask most often and you can get expert advice on how to sign spot them in those directions, which avoids the situation whereby staff put up a handwritten notice. However handwritten notice at least indicate a well meaning attempt to make direction clearer. Signsposting systems are available to enable you to alter and add information easily and quickly. They are worth the investment. It is very easy to make people feel hesitant and uncomfortable from the first moment they enter a building ; signposting gives you an opportunity to achieve comfort and confidence. Car park and route to the main door Vehicular access
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Most people arrive by private car and the sheer numbers that have to be accommodated have led to vast car parks, confusing direction s and sometimes-unpopular parking fees. The possible landscaping of the car park to make them as attractive and welcoming as possible. If you do charge parking fees it is worth thinking about how you explain them to the public. A notice on the fee system saying that by charging fees to cover the cost of car parking more is available for patient care or for site surveillance is helpful. Pedestrian access There has been such determination to accommodate the disabled in the hospital that this is now less of a problem than formerly. Most hospitals now realise that it is essential to involve disabled people in planning access and adapting facilities, and offer a critique of existence provision. Trying out your own facilities in a wheel chair, wearing ear plugs and fogged glasses, can give the able-bodied useful insight. Some common mistakes at the entrance Rubbish impermanent skips or permanently parked wheeled rubbish bins situated besides the main entrance ar not inviting. If there are litterbins, they must be emptied before they reach overflow point. Doors expensive, highly manufactured automatic glass doors often have shabby notices stuck all over them. Smoking Hospitals that have non-smoking policies have carpets of cigarette butts outside often the main entrance, and frequently a group of furtive smokers too, sometimes in dressing gowns and nighties, attached to drips and equipment. Large communal areas Reception foyers The checklists of essential furnishing continue with these items: 1. Clarity it is clear where you go for information? 2. Signposts are they clear, logical and organised?
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3. Written instruction maps, leaflets etc, are they unambiguous in telling people what to do next. 4. Cleanliness are the premises clean? 5. Furniture is it clean, comfortable, well arranged? 6. Lavatories are they well signposted, accessible and maintained. 7. Telephone are they working and well sited? 8. Drinking and food dispenses do these offer a variety of goods, are they clean or surrounded by rubbish. 9. Refuse sacks and laundry are piles of these in views. 10. Items for repair are old chairs and broken telephone hoods left near the door for eventual collection. An aura of helpfulness This is the most important requirement. On the arrival, is there someone who would notice people in distress and help them appropriately? Are reception staff ease to identify and available? In a number of reception arrangements staffs are given other tasks to do, such as switchboard duties or typing, and it is easy for the vivitors to feel they are interruption. In one hospital the most obvious information point is staffed byy the people in charge of security and keys ; it is hard to combine these policing tasks with being available for ordinary questions. Do porters, passing management staff and visiting peripatetic staff look approachable and pleasant? Waiting rooms The best way of reducing anxiety is to provide something of the interest to compete with the anxiety. Most hospitals will have lots of different areas where people wait. Sometimes they wait and wait, apparently unnecessarily, as in a five hour wait to have a limb plaster removed in ten minutes; on the other occasions their long wait is essential while life savings procedures are performed on their relatives, people may be accompanied by small children, or someone old, sick and incontinent, so what sort of diversions can be introduced.
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Circulation areas Corridors The designs treatment of corridors is a major challenge. They are the main roads which have to carry the traffic of many people and heavy good. Long, bleak, featureless corridors are the enemies of the comfort and reassurance. So what can be done? The problem of perspective There are many architectural precedent of interior and garden perspective vistas handled with visual eloquence which rely on three basic things Vista end attraction Intersection and interval interest High quality dcor. Vista end attraction The aim of a corridor is to encourage people to progress along it. you want them to reach their destination in a good shape , avoiding exhaustion and despair. Sometimes in the visible distance, that attracts the attention is an old ruse for achieving this. Staircase Corridors and staircase are like the outside street in that they are public pathways and can suggest menace. They can also look as though their main function is an escape in the event of fire and have notices telling you so., but even the most utilitarian of fire escapesstaircase have opportunities of design delight. Specialist examination and treatment areas In any hospitals there will be several areas where the demand demands of clinical technology will dominate design unless these areas are given special attention. Anaesthetics and recovery rooms There is a difference in design requirement between these two; the anaesthetics room is where conscious patients are wheeled for their operation pre0medication and then full anaesthetics.
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There is no need for bacterial sterility while and anaesthetics is administered, so one such room was wallpapered on the ceiling and upper walls with a William Morris paper; what better way than to float off looking at his magical forest full of birds. The recovery room is where patients come round from the anaesthetics and the need for sterility is absolute. Post-operative bleeding and projectile vomiting mean the room has to be washed down with hoses; floor joint must be sealed and the curved , pre-moulded skirting boards is usually used for cleaning ease. No one, least of all the post-operative patient, cares what it looks like. Operating theatre It is surprising to those of us who regards surgeons and airline pilots as professional who are ipso facto swathed in glamour that boredom is a hazard of their profession. Therefore, although only staff see operating theatres, some Dutch hospitals have still regarded them as sufficiently important to decorate and appoint carefully. Operating theatres are traditionally green because in the colour-spectrum green is the opposite of red and blood is red. Blood and other fluids are shiny surfaces should be matt and never glossy. Management boardrooms, committee and meeting rooms It is unknown for a hospital to remove all original features, fireplaces, skirting boards, flooring and so on and lower the ceiling before inviting and interior designer to give it character; by this time the original period character is lying in the rubbish skips. We are not suggesting that everything old is beautiful and everything modern is not, for this is not the case , but older things are more difficult to replace one lost and it takes professionalism to make the two blend together. They are like the oldest child and the youngest, both valuable but different. However, it is these traditional senior-staff meeting rooms that tend to be the only interiors to have been allowed to retain the quality and dignity of their period because their function has not changed; well behaved people still meet, sir down
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flower-planting within a border boundary. All around there would have been raked gravel, the tube and urns sitting like exclamation marks in the expanse, beyond which was probably of many gardnerrs, at first for the glory of the gentry, then the pleasure of the public and perhaps eventually the hospital management committee. Such tradition garden take many hours of greenhouse and site work and this expenditure inb not the sort that many modern institutions, including hospitals , can now expect to make. However, the average public expectation of a garden is generally stuck in this time warp whereby fine gardens imply labor and, to an extent, this expectation is true, Nowadays, many of the experienced, traditional gardens have gone, retired and taken their dibbers and twine with them. Their replacement is probably contract labour that gives a basic service of mowing and chopping, strumming and spraying and spraying, and death to the aesthetic. We believe there are viable, modern alternatives but first we needed to look more specifically at the average hospital and its land. ENVIRONMENTAL ISSUE Land has become a precious commodity. Urban sprawl and our road network have grossly reduced its acreage, while intensive farming and the toll of herbicides and pesticides have diminished much of its quality. Open land in towns and cities has always been valued by urban inhabitant, which is why squares. Parks and gardens, playing fields and cemeteries are so precious; now a days, some new area such as community gardens and green-lines are developing. There is an accelerating demand for allotment and city farms and organic farmers and environmentalist urge a restricted use of herbicides and pesticides, strumming and chopping. These voices should be heard and the handling of the hospitals land has a part to play in this. CURRENT NHS LAND USAGE There are four main reasons why so many modern hospitals do not use their land better; 1. Land care is often the responsibilities of estates staff for whom it is a less urgent priority than the maintenance of the building and technical resources. 2. The old traditions of formal gardens and estates management have been largely lost and have not been replaced by any new form of garden creations and land management.
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3. Money is a genuinely constrained. 4. Low value is placed on the aesthetics benefite for the patients and staff of the quality land usage. RATIONAL FORMAL PLANTING We are not advocating that the hospitals hand no colorful, formal planting but the means of adequate maintenance is not usually available these days. Garden formality has to be a manicured. But since such borders have such a strong traditions perhaps one good outside the main entrance could be justifies and it can serve as a splendid identifier of the place if it is impeccably maintained. ALTERNATIVE USE OF COLOUR PLANTING The love of organized colors besides the available budget could be channeled instead into hanging baskets. In springs, dozens of such baskets could be prepared, fully planted, padded with moss and be ready for a summers display. TREES, SHRUBS, HEDGES, CREEPERS These are usually inherited from thoughtful gardeners who planted those decades ago and, as such , they er often taken for granted. Great trees and large shrubs might be the remains of the asylum parks, hedges may mark the edges of land ownership or have been planted simply for their aesthetics. To neglect their replacement is to I mperil our reputation with future generations; these established plants, especially trees need a steady regeneration to maintain the population. SAFTEY ASPECTS Hospitals land does present the usual possibility of attack and assault on many people who use it. Psychiatric hospitals experience their fair share of attack both by and on patients and hospitals generally attracts voyeurs, the unstable and those with a grudge. Dense shrubberies of a height to offer concealment may be felt to present an avoidable hazard so lower growth and trees above the head are alternatives, besides the usual precautions of lit pathways and camera surveillance. Shrubberies also tent to attract and accumulated rubbish underneath that trunked trees do not and the provisions of rubbish bins is another feature of environmental care.
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WATER FEATURES Water features are always being requested but it is firmly advised never to install a pond, fountain or anything to do with water for two reasons: one is that they are never, ever maintained and other is that they arouse frantic fears of danger amongst nurse. You cn drown in an inch of water, we are lugubriously warned, again and again. The poor capacity to actually accept and care for water features is a great pity, because water does prompt soothing reactions almost universally. There are good instances, award winning water gardens and so on but visualize them in ten years time after yet more reorganizationto the NHS and consider what their condition might be like them. HARD LANDSCAPE The course of path We described earlier the need for a good system that works and has visual quality, but the best way to designate paths for walking is to let peoples feet describe their course. If people are determined to take a short cut that is where the path will appear and for the estates department vainly to place no parking traffic cones on the path merely makes everyone step around them. Then the worn earth has a bulge in it like a snake that has swallowed a goat. When people have voted with their feet, it is better to accept theses determined footpaths and upgrade and pave them in some way. Stepping stone slabs in the mown grass are a neglected variant and white flowers planted along the path edges give night guidance. Native, selfperpetuating or cheap, flowers like snowdrops, alliums, alyssum, ransoms and so on traditionally lined the path to the outdoor privy to guide you in the dark and the same principles could be used to guide people to the car park, in spite of in addition to lights. Hard surfacing qualities Asphalts and concrete are unavoidable but they do not have to present unbroken sweeps; there is a great deal of landscape design expertise on the planning of minor road system and car parking; the NHS has only to consult wisely and in time.
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Suppose you wish to create a concrete courtyard for the elderly; you will think in terms of pavings to allow wheel chairs, zimmer frames, unsteady walking and an easy passage, and it is usual to have one type of constituted stone slabs, probably light in tone and laid everyehere, as many slab as possible covering and controlling as much earth as possible. On the sunny day the unrelieved slabbing will reflect light and heat directly up into old eyes; on a dim day there will be no variation in its appreances. There is no reason why two or three colors of the same composite slab cannot be used, for variety. Gaps for low flowers do not impede wheelchairs if well placed, nor do small areas of gravels, which is cheapest to lay, and intersection in the ground of cobbles and brick make all the difference. Also, to take paving right up to a wall losses opportunity for planting climbers and softening the engineering harshness of the building ,materials. Many courtyard have no relief in the form of large trees to interrupt visually the straight, hard engineering line of the surrounding roofs, but the planting of large trees, even up to twenty feet high, while a specialist job, is not difficult or even prohibitively expensive and it makes a dramatic difference. Walls, curbs and steps Walls to sit on, curbs and steps to steps off should have two features, softness and variety. The use of half nosed bull bricks is a much softer edges than an ordinary squares bricks. If you have raised borders with inches high to two feet high. Any physiotherapist wills advice that variety is what humanity needs. LANDSCPAE BUILDING / FURNITURE / EMBELLISHMENT The well-dressed landscaped A classically well-dressed will have achieved that state by careful planning; even if they have not bought their whole outfit at the same time, there will be thoughtful coordination about it from the whole image down to the details of handkerchief and shoes. An alternative is gipsy variety where assorted items are thrown together and given a sort of unity by the glamorous if eccentric style of their combination. If we transfer this metaphor of classical and gipsy to the appointing landscape, we shall understand the alternatives.
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The best thing to do is accept the varied and various existing items and combine them in a powerful design scheme, your gipsy solution. This should involve a fresh approach to planting and paving and painting abut, above all organizing. These are a few suggestion of what can be done. Organizing and painting Temporary rubbish skips are difficult to hide but they can be placed sensitively. Semi- permanent wheeled bins can be parked behind trellis screens, in the way caravans are hidden in a garden, and the screens stained greens covered with creepers. Several Russian vines and multiple other creepers can make a huge difference to a hospital site. There are likely to be different designs of railings, bollards, seats, lampposts in a typically muddled site and some unity can be achieved by painting them in relating colors but in different ways to emphasize their designs, whatever it may be; the traditional items can be painted traditionally, the modern one in hi-tech way and trashy ones in gaudy manner. Colors washes on disparate buildings an unify them, doors can be painted to a scheme and nothing softens unsympathetic architecture like creepers. The lining of window curtains can be used as color opportunity since they are what outside sees. In a modern movement block the entire outside facing curtain colors can be handled like a huge abstract painting of colored; it takes dedicated organization but this could transform a bleak building. Pavilion, sheds and huts are often interesting and reflect the hospital history. Community and specialist use of land Psychiatric hospitals have been working to take patient into the community, but the community can also be encouraged to come into the psychiatric or any other hospital site and use its land. It can be reasonably feared that thicker and lass obviously manicured vegetation may increase vandalism and likelihood of attack on the vulnerable. However, these things are controlled when there are a lot of people around; it is the desolate car park with a few unsupervised cars that spells trouble, but a well-used open track, for dog walkers, horse riders, cyclist, and other land uses, brings in people and they can be regarded as unpaid supervision. WILDLIFE GARDENS This is a more of an element than a specific place. Its features are to encourage self-seeding, noncultivated plants and so attract insects, birds and wild mammals. ;large areas are needed, not tiny
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courtyard, as it is no use encouraging insects in one small patch when they are blitzed pesticides throughout the surrounding acres. There will also need to be agreement that estates or contract staff will not suddenly mow all the seeding flowers heads and remove them to a rubbish tip a mile away in order of someone who thinks anything wildlife is untidy. PROVISION FOR CHILDERN There is a plenty of material available regarding playing fields for adolescents and adults, and playgrounds for children. The problem always arise whether such facilities should be available to the community generally or just the hospitalized and the staff. This will depend upon space expediency.
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References
1. www.mskcc.org/research/psychiatry-behavioral/research-activity 2. www.christianacare.org/cancerpsychology
3. www.tmc.gov.in/medical/departments/as/psychiatric.htm
4. www.cancer.ucsf.edu/psycho-oncology
Bibliography
1. Healing the hospital design Sarah Hosking, Liz Haggard
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