HEALING DESIGN: A HOLISTIC APPROACH TO SOCIAL

INTERACTION IN PEDIATRIC INTENSIVE CARE UNITS IN

THE UNITED STATES AND TURKEY
Hilal Özcan
WHR Architects, Inc., Houston, Texas, USA
hozcan@whrarchitects.com

ABSTRACT
This paper explores the relationship between healing and its embodiment opportunities in
architectural design. It puts forward a method for identifying some key architectural vari-
ables which may be measured for their sensitivity toward healing design. Specifically, it
examines the impact of the pediatric intensive care unit (PICU) setting in the healing
experience of children, as well as families and caregivers. Data is collected through a
qualitative methodology including participant observations, behavioral maps, and in-
depth interviews. The meaning and value ascribed to the PICU setting in the observed
Turkish and the U.S. facilities present different care practices and philosophies. Howev-
er, field studies identify social interaction as a universal healing function transcending the
physical setting. Crowding, parental absence, and over-stimulation in a single multi-bed
unit play against healing in the Turkish model. However, staff collaboration and sense of
dedication support healing. In the U.S. model social support, family-centered-care, and
focus on patient experience are acknowledged as central concepts to healing. This study
identifies six design indicators for healing social interaction.
Keywords: Pediatric Intensive Care Unit (PICU), Social Support, Social Interaction,
Common Gathering Areas (CGAs), Healing

INTRODUCTION
This study is based on the comparison of the existing spatial organization and
design trends in two pediatric intensive care units (PICU) to emphasize their sim-
ilarities and differences, and explore how their physical environment influences
human behavior. The study calls for a holistic approach to identify the potential
for cultural healing in health facility design and promote cross-cultural under-
standing for a global context that can generate better hospitals and health care
delivery models. With this objective, the PICUs of two children’s hospitals were

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compared. The observed Turkish hospital (HCHA) is an academic non-profit

350-bed hospital established in 1958. The PICU consists of a 9-bed single room
unit and one isolation room. While their acuity is high with various disease enti-
ties, they specialize in trauma and cardiac care. No data is available for length-
of-stay (LOS) and mortality rates. The U.S. hospital (CMCD) is a private, non-
profit 406-bed institution established in 1948. (CMCD had 348 beds during the
case study period in 2002, which paralleled the bed number of the observed Turk-
ish hospital.) Caregiving is provided for patients suffering from medical, surgi-
cal, neurosurgical, traumatic and cardiac diseases. It contains four specialized
PICUs, which foster family centered care. With a total of 63 beds scheduled, it
has the largest PICU in the U.S. The average LOS in the PICU is 4.7 days, and
PICU mortality rates rank among the lowest in the U.S.

Figure 1. Observed Turkish Hospital HCHA (left) and U.S. Hospital CMCD (right)
(Image credit: Hilal Ozcan)

RESEARCH STRATEGY
In contrast to curing, healing is a psychological and spiritual concept of health. It
may not be effectively understood with quantitative and statistical studies, which
fragment analyzed concepts to single measurable criteria. To inform healing
design indicators, a qualitative methodology seemed more beneficial in this
study. The use of a holistic approach called for the provision of practical, physi-
cal and psychological needs through 1) stress reduction and relaxation, 2) social
support and positive social interaction (touch, talk, meaningful communication).
The study identified six design indicators, which are provisional, scale, location-
al, functional, symbolic, and ambient interventions for healing.

LITERATURE REVIEW
The benefits of social support and social interaction are well-established in health
design literature. However, there is only a moderate amount of research concern-
ing how facility design can facilitate or hinder access to social support and inter-
action. The six design interventions which emerged in this study support the lit-
erature regarding the healing benefits of social interaction.

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Social Support
Social support is the emotional support, caring and tangible assistance that a per-
son receives from others (Ulrich, 2000). Research in healthcare and workplace
situations found that individuals who receive higher social support experience
less stress and greater health. Socially isolated people, on the contrary, experience
higher rates of illness and less favorable recovery indicators. For example, car-
diac patients receiving higher levels of social support recover more quickly from
heart attacks and have more favorable long-term survival rates. Social support
improves recovery outcomes in myocardial infarction patients, and survival
length in patients with metastatic cancer (Spiegel et al, 1989).
The evidence showing benefits of social support across health-relevant contexts
suggests that design promoting social support will reduce stress and improve out-
comes (Ulrich, 1991). Provisional design interventions for fostering social sup-
port include comfortable, pleasant waiting areas; convenient access to food, tele-
phones, and restrooms; convenient overnight accommodations; and accessible
gardens with sitting areas that encourage socialization.
Social Interaction
Staying connected with others has important healing benefits. Social and parental
support plays an important role in helping patients recover from illness. Evidence
indicates that social interaction levels can be increased by providing lounges and
waiting rooms with comfortable movable furniture arranged in small flexible
groups (Ulrich & Zimring, 2004). Studies in psychiatric wards and nursing homes
have found that appropriate arrangement of movable seating in dining areas
enhances social interaction and improves eating behaviors (Melin & Gotestam,
1981; Peterson et. al., 1977). Research on day rooms and waiting areas has shown
that arranging seating side-by-side along room walls inhibits social interaction
(Holahan, 1972; Sommer & Ross, 1958).
Social interaction in an ICU may be influenced by: 1) floor and room layouts, 2)
physical, visual relations and spatial ordering systems between CGAs, 3) furni-
ture placement and settings, 4) interior order and transparency. For instance,
“heavy or unmovable furniture inhibits social interaction, while comfortable and
movable furniture arranged in small, flexible groups can facilitate it” (Levin,
2003). Locating support areas closer to patients may improve social support and
collaboration. Since CGAs were not present in the Turkish unit, the CMCD
model indicated the social benefits of these rooms, which facilitate interaction.

MATERIALS AND METHODS

A qualitative methodology is used to emphasize the relationship between the
knowledge sought and the methods used to reveal that knowledge. Naturalistic

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inquiry, which originated in the work of Lincoln and Guba (1985), became the
methodology of choice. Six data gathering methods were used: 1) participant
observations, 2) behavioral maps, 3) in-depth interviews, 4) measurements of the
physical environment, 5) analysis of medical records, and 6) floor plan analysis.
Both the Turkish and U.S. model were observed for six weeks each.
Participant Observations
Participant observations involved intense social interaction with people in their
own setting. Continuous-interval recording every quarter of an hour recorded a
variety of caregiver and patient behaviors and background variables from differ-
ent locations. Observation notes standardized behavioral (patient’s state, comfort,
well-being; caregiver attention, proximity to patient, tactile, visual, vocal stimu-
lation of the patient; family state, comfort, well-being, caregiver function) and
environmental categories (room layout, flexibility, patient monitoring, equipment
attached to patient, general appearance, temperature, sounds, smells, lighting).
Daily observations lasted for 4-6 hours. The researcher also spent nighttime hours
to test the validity of the generalizations emerging from daytime observations.
Behavioral Mapping
Behavior is mapped to space to determine how humans interact with space and
organize place activities. Behavioral maps were recorded from different stations
to compare the two units, which differed in size and spatial configuration (open
versus bay design), and to determine what individuals do in different areas of the
unit. The data was collected by identifying subjects and recording their activity,
path, and interactions as well as the movement of equipment and furniture every
quarter of an hour for 65 hours, which resulted in 263 data entries.
Individual in-depth Interviews
Interviews were conducted individually, audio-taped in full, and content ana-
lyzed. Fifteen interviews were conducted in Turkey, and fifteen in the U.S., which
identified needs assessment by staff members. Six categories guided the inter-
view protocol: 1) personal questions, 2) practical and psychological needs of
patients, families and staff, 3) evaluation of social practice, 4) evaluation of the
built environment and how it responds to perceived social and psychological
needs, 5) social and professional relationships, and 6) cultural diversity.
Measurements of The Physical Environment
Quantitative measurements of daylight levels and walking distances were record-
ed in all four units at CMCD. The impact of daylight and walking distances on
staff behavior was observed qualitatively.

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Analysis of Medical Records

Medical records were gathered from CMCD for the study period to identify
behavioral outcomes of patients, families, and caregivers, and relate them to envi-
ronmental variables. Medical records included patient demographics, length-of-
stay (LOS) days, and mortality rates. Information about families’ needs was
obtained from 2000-Strategic-Plan and the final report of Patient Family Focus
Group Interviews. Staff performance data included nurse quitting rates and nurs-
ing errors. Unlike the U.S. hospital, where patient admission, family evaluation,
and staff performance data was available, there was only a handful of patient
admission data, no family evaluation data and no staff performance data in the
Turkish model.
Floor Plan Analysis
This included a quantitative evaluation of plans that measured and compared
quantitative facts such as room dimensions and walking distances between them,
and a social evaluation assessing the links among the different areas of the facil-
ity. Floor plan analysis revealed six themes, emphasizing CGAs: 1) Unit spatial
configuration, 2) location and adjacency of spaces, 3) acoustic/physical separa-
tion, 4) visual control, 5) spatial organization, location of equipment and furni-
ture, 6) the numbers and size of spaces, walking distances, and proximities
between.

Figure 2. ICU Floor Plan, Turkish and U.S. PICU (Image credit: HCHA, CMCD)

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RESULTS
Provisional Intervention
Provisional intervention defines the minimum program requirements for greater
social interaction, social support and collaboration among patients, families, and
caregivers. Provisional objectives relate to the quantifiable aspects of space and
basic programming issues, such as the quantity, size, and type of spaces. Findings
revealed that the core values of family-centered-care model relate to the provi-
sion of CGAs, particularly patient room, waiting room, staff lounge, counseling
room, consultation room, as well as the provision of family space in the patient
room.
Single Patient Rooms (SPRs)
At CMCD, the oldest ICU is a single open bay environment, which is used as a
step down unit. The general, cardiac, and trauma units contain SPRs, which have
increased steadily in both room and unit size. The Turkish ICU is an open multi-
bed unit, diminishing environmental control, privacy, and family presence at
patient’s bedside. It also increases overstimulation, noise, exposure to resuscita-
tion and death. If the provision of single rooms is not feasible, double-occupan-
cy rooms or shared clusters for 3-4 patients would be more progressive than the
open bay. Providing resource centers for staff and families in close proximity to
patient areas would support healing.
It was observed that the provision of SPRs increased the opportunities for inter-
action between caregivers and families. While working in individual rooms
reduced simultaneous staff interactions, the staff station may have been perceived
to be less threatening (Figure 4). In the open bay environment, the staff station
inhibited privacy of conversations. For instance, when a nurse needed support
from colleagues, she feared to seem incompetent. In the U.S. model with single
rooms, feeling less threatened to be overheard nurses frequently invited the care-
givers at the staff station for input. In the Turkish model, double, triple or even
quadrant-occupancy rooms or clusters may increase privacy and improve staff
collaboration.
Staff Resource Center (SRC)
The provision of generous space for staff rejuvenation function impacts staff sat-
isfaction and performance, while increasing staff interaction. Turkish caregivers
reported that they had a high degree of staff interaction and collaboration when
there was a small room and kitchen in the unit, where they prepared their meals,
celebrated birthdays, and interviewed families. This room was demolished during
the 1998 ICU renovation. Four years later, nurses expressed their need for a staff
lounge and staff refrigerator proximate to the PICU, which will enable them to

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have a proper lunch break. The provision of a small break room for 8-9 caregivers
equipped with a kitchenette, refrigerator, dining table, and comfortable sofa to
meet their practical needs will increase staff performance and dedication.
Family Waiting Room (FWR)
Since the waiting room function is not present at HCHA PICU, families wait in a
public hallway, from where they can view the unit through transparent glazing.
Many of them often sabotage ICU access rules, thereby increasing cross-infection
risks. In this spatial organization, caregivers are often distracted trying to keep
families out of the unit. Alternate operational solutions were considered such as
organizing scheduled family-physician meetings and encouraging them to wait in
their homes for information so they can banish family presence in the hallway.
Family Resource Center (FRC)
A centrally located room equipped with research facilities, Internet accessibility,
business center services (fax, copier, printer), a library of medical information,

Figure 3. Patient Zone, Turkish and U.S.

PICU (Image credit: Hilal Ozcan)

Figure 4. Staff Station, Turkish and U.S. PICU (Image credit: Hilal Ozcan)

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meeting rooms for small and large groups, and adequate facilities (washer/dryer,
refrigerator, food service, a kitchen to prepare meals, sleeping arrangements) will
improve family well-being, thereby impacting patients’ medical outcomes.
Scale Intervention
Scale indicates a relative system of measure, which can range from intimate spa-
tial order to gigantic and monumental. In the history of architecture, human scale
has been a reliable source of measure, and various trends emerged to the human
scaling of a building such as anthropomorphism, which addressed the relation-
ship between architecture, human body and human sensory experience. Howev-
er, the role of the human body in informing the size and scale of the ICU has been
limited. In this study, size and scale emerged to be the most important design indi-
cators influencing the perception of an ICU and informing higher level design
interventions for healing.
Programming for the most beneficial size of CGAs may impact the curing aspects
of care through reduced LOS days. This is often linked with cultural factors and
spatial comfort that is also culturally influenced. Scale influences spatial percep-
tion through comfort and image. Particularly, a generous patient room size may
indicate the focus on healing design. However, due to the diversity in the percep-
tion of scale, 1) spatial comfort and image are by and large culturally influenced,
and 2) different cultures utilize and experience the same space in different ways.
The Turkish unit’s CGAs and department size per patient are approximately five-
fold smaller. However, whatever was perceived to be an appropriate size in the
U.S. model, Turkish caregivers found out of scale and to have lost its connection
to the people experiencing it. Neither can they imagine the size requirements
needed for the single patient room functioning efficiently with their current
resources. On the contrary, most felt comfortable with the open bay, where they
could see all patients at once.
Increased unit size increases walking distances, and reduces the chances for
social interactions. The relationship between scale, geometry and spatial organi-
zation has long interested health care architects regarding how to size each ICU
space, and configure the spatial combination most effectively. Ozcan and Caden-
head (in review) compared ten exemplary U.S. units awarded by the Society of
Critical Care Medicine since 1992. Indicating that the ICU and patient room size
increased steadily since 1960s, they claimed the design trends to increase the
patient room size will diminish in coming years, while new growth will occur in
nursing unit support (NUS) and common gathering areas.
Locational Intervention and Spatial Ordering Systems
Locational intervention relates to planning for the most beneficial locations and
proximities between spaces for promoting social interaction as well as function-

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Figure 5. ICU Patient Room with Family Space, Clarian Methodist, Indianapolis; Lega-
cy Good Samaritan, Portland, Oregon. (Image credit: WHR Architects, Inc.)

ality, visibility and privacy. Reducing walking distances between inpatient areas
and support spaces will enable nurses to spend more time with their patients.
In the Turkish ICU: 1) NUS areas outside the unit caused nurses to continually
move back and forth, causing fatigue, exposing them to families waiting outside,
thereby distracting them and reducing their performance. 2) Delayed specimen
transportation to laboratories required staff to draw more blood, causing more
pain. While the compact unit geometry saved time, it did not translate into staff-
family interaction but only staff interaction time. The circulation pattern between
inpatient areas and staff lounge indicated the more distant the lounge the less
caregivers will rejuvenate intermittently. Turkish administrators worry if the
lounge is too close, staff would use it excessively.
In the U.S. ICU, which is less compact and flexible, increased walking distances
and charting time reduced staff time spent with patients. Since increasing the unit
size increases walking distances and reduces social interactions, the U.S. model
recognized the value of locating related common gathering functions most bene-
ficially, particularly in relation to the SPR. Additionally, there is increased aware-
ness to increase human contact through informal chance meetings by offering
careful consideration of furniture and equipment.
Location of Staff Station and SPRs
The observations and interviews identified staff perception of the visual relation-
ship between staff stations and SPR. Both the central staff station and decentral-
ized stations should offer visual access to each patient, and provide direct paths
between rooms to enable caregivers to immediately react to emergencies. Partic-
ularly respiratory care practitioners, who care for patients in different rooms, will
benefit from clustering SPRs in a more compact and flexible arrangement.

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Table 1. Programmatic Intervention

Location of SRC
Proximate location of SRC to the unit may increase staff collaboration and per-
formance through increased opportunities for staff interaction. In the Turkish
model, beneficial staff functions are either missing or located outside the hospi-
tal (e.g., medical library). At CMCD, staff lounges have varying proximities to
the inpatient unit, which can be measured and correlated with the utilization of
each staff lounge, staff interaction levels, and resulting health outcomes.
Location of Waiting Room and FRC
In the Turkish unit, families can wait in other departments with the waiting room
function, yet they prefer waiting in front of the PICU to stay close. At CMCD,
waiting room proximities vary from the inpatient unit: three out of four are out-
side the unit and several floors away, therefore families in more distant rooms
visit their children less frequently. CMCD patient family focus group study con-
cluded (Strategic Research, 2000) if the FRC is too far from the child’s room,
many parents will not visit the FRC.
Functional and Technological Intervention
A functional, flexible and accessible environment is a major aspect of the critical
care setting. Functionality involves meeting complex technological innovations
and practical everyday needs, while improving the physical and technical work
environment through maximum building performance.

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Functionality and Instrumentality

Functional intervention is linked with providing important resources to support
the practical functions of staff, patients, and families, which may increase the
chances for social interaction. Some practical functions are the need for rest,
relaxation, and nourishment, having access to drinks, snacks and small meals,
having a shared space equipped with an oven, a few tables, a comfortable chair,
quiet areas for parents to relax away from their child’s bedside, overnight sleep-
ing, separate phone, laptop computer connectivity, comfortable seating, and quiet
areas for staff with a comfortable couch, recliners, or a nap room. For developing
health care delivery models, simple interventions are most effective, and can
influence staff performance tremendously. Table 2 indicates a Likert-scale meas-
ure to evaluate unit response to functionality from simple to highly complicated.
Technology and Social Interaction
Functionality in design is ultimately linked with the meaning of technology and
social interaction. Providing maximum building performance within a context of
social interaction may define functionality. Particularly ICU design must honor
human dignity by focusing on social interaction.
Functionality in the ICU relates to the utilitarian tendency of everyday human
activities, which informs a praxis approach, and a technological understanding of
the world. Martin Heidegger argued that our fundamental relationship to our
everyday world is primarily practical, and therefore that scientific knowledge is

Table 2. Functional Intervention

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to be derived from practice (Ihde, 1979; Little, 1999). While the things that are
used for practical ends (i.e., equipment) embody highest significance in our abil-
ity to know theoretically (Walters, 1995), the embodiment of common practices
of everyday life results in a quality of being taken for granted, which Heidegger
calls ready-to-hand (Little, 1999). In the ICU setting, caregivers may view tech-
nology as a conspicuous instrument, which Heidegger views as present-to-hand
since it is decontextualized. Therefore, caregivers need to transform the ICU
atmosphere driven by technology from present-to-hand to ready-to-hand through
a conscious act of familiarization and social interaction.
Symbolic Intervention
Healing could be influenced by the symbolic and communicative function of
architecture. Through symbols, a building may represent a real idea, or content.
Meaningful messages sent from the environment may impact users’ behavior,
particularly socialization. The geometry, shape, color, texture, tectonic quality,
size, scale, volume, order, and regularity of an ICU setting can support healing by
contributing to a distinctive form and meaning.
Materiality
Symbolism is linked with the choice of materials, colors, textures, furniture, and
finishes, which inform communicative value. Materiality relates to the celebra-
tion of the experiential and sensual dimensions of architecture through exterior
and interior building materials and systems. Sometimes, it can be used to domi-
nate, and impose the sterile, institutional, authoritative character of a facility. Or
it can reflect humanistic design intentions, influencing social interaction. Harris
(2000) found that family and friends stayed longer during visits to rehabilitation
patients when patient rooms were carpeted rather than covered with vinyl floor-
ing.
Transparency
Transparency in architecture refers to dematerialization of form, which is
expressed in degrees from translucent to opaque. Transparency symbolizes the
ability to distinguish between the hidden and visible content to transmit inten-
tions, ideas, meaning and even the capacity for Truth. This interplay between
emergence and hiddenness may be associated with the idea of healing. Yet it is
questionable if transparency is desirable or achievable in an environment
designed for healing.
Transparency in an ICU may signify healing by involving the family in care
rather than being invisible, inaccessible, and mysterious. Social transparency
indicators include giving families access to information, disclosure about the
diagnosis, treatment options, prognosis and control over their child’s care. Archi-

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tecturally, this translates into the way the unit reveals itself, its activities, its per-
ceivable scale, the relationships between its spaces, the use of translucent mate-
rials, and the exposition of its structural and mechanical systems.
Transparency can be played out by making shared spaces more visible and acces-
sible, which will lead to more eye contact and interaction, thereby encouraging
people to readily support one another more frequently. From an ontological view
of person, the subject in the ICU needs an environment, where comfort and well-
being do not result from incorporating the latest and greatest equipment and tech-
nology, but from an ideal of transparency, where the desire of relating meaning-
fully to others is revealed and fulfilled.
Table 3. Symbolic Intervention

Geometry
The geometry, shape, and regularity of an ICU setting can support healing by
contributing to a distinctive form and meaning. Throughout history, many people
were fascinated to work with geometries because a geometry can be isolated from
reality as a coherent organized whole, and can make one feel the perfection of
God.
Opposites in form language can symbolize the distinction between sacred and
mundane. Sacred activities involve with knowledge and meaning while mundane
functions involve lower needs, such as eating, resting, and sleeping. Through the
interplay between sacred and mundane functions, the form and geometry of an
ICU can symbolize social interaction.

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Ambient Intervention
Ambient intervention deals with creating a home-like, familiar and comfortable
environment, which is sensitive to the needs of the participants particularly in
social interaction spaces of the ICU through access to nature, extant natural light
opportunities, shapes of spaces, color, high degree of enclosure and privacy.
Comfort and Familiarity
A comfortable and familiar environment may contribute to healing through the
celebration of social interaction made possible within shared common spaces. A
sense of comfort or dwelling can enhance the full capacity of social interaction
and healing. Lawlor suggests, “like […] people coming together to celebrate the
human spirit, deepening into architectural dwelling is an everyday practice.”
Comfort in the U.S. ICU is expressed through the selection of furniture, seating
arrangements, residential-like design, comfort of family space, use of healing col-
ors and home-like materials, attention to detail to project an image of individual-
ity, exhibition of family photographs, and the general atmosphere of common
spaces. In the Turkish model, many argued expressing high levels of comfort and
personalization can destroy the institutional image of the facility.
Image and Character
Interiority refers to the interior quality or character, inner life or substance of a
place. Within the context of the ICU, image and character are more influential in
social and cultural activity settings rather than universal caregiving functions,

Table 4. Ambient Intervention

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because the place tends to become more personally expressive, unique, full of
character, and comfortable within the former. Common gathering spaces may be
expressed with the choice of colors, materials, and furniture.
Access to Nature
Nature and daylight are effective for fostering social support, social interaction,
and healing. At CMCD cardiac and trauma units, windows are maximized in
patient rooms to increase views to the outside and daylight. Access-to-nature
research focuses on human response to exposure to indoor and outdoor plants and
gardens, views of nature and daylight, indicating reduced LOS days. There is lim-
ited evidence that gardens in healthcare facilities can be especially effective for
increasing staff access to social support from other staff (Ulrich, 1999).
Resulting Social Design Intervention
Social design is linked with providing the social systems and requirements that
make the place work, and create an atmosphere supporting the facility. These
include 24-hour food service, sleeping arrangements for families, planned activ-
ities for siblings, private meetings with doctors away from the child’s bedside,
support group and educational meetings for parents, religious and spiritual serv-
ices, and the social aspects of common gathering spaces: CMCD patient family
focus groups concluded that the FRC must be accessible 24/7, as parents feel
most comfortable visiting it late at night, while their child is asleep.
Table 5. Social Design Intervention

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The lack of family space and disabling policies minimize the chances for social
support between the patient and family in the Turkish model. Particularly, fami-
lies’ low education level constitutes a barrier in adopting a family-centered care
model. Providing meeting rooms for support group and educational meetings
would increase their understanding of their child’s care: particularly chronic dis-
eases such as cancer, asthma, and metabolic disorders require knowledge to
understand the disease and adopt an appropriate lifestyle.

MEASUREMENT INSTRUMENT
This paper puts forward a method for identifying key architectural determinants
which may contribute to and be measured for their sensitivity toward healing
design. To measure the contribution of patient rooms and other common gather-
ing areas to healing design, a 5-point likert-type scale measurement instrument is
proposed, which ranges from very low through moderate to very high.

DISCUSSION
This paper explored the relationship between the healing aspects of social
interaction and its embodiment opportunities in architectural design. The study
examined how the spatial organization of the PICU affects face-to-face interac-
tions and collaborative relationships among patients, families and caregivers. For
instance, the more staff members collaborate, the better care they will deliver.
The qualitative exploration has uncovered problematic areas in the PICU envi-
ronment through analysis of social interaction function within common spaces.
Using qualitative tools for measuring characteristics of the observed PICUs, this
study demonstrated that PICUs characterized by increased provision and scale of
CGAs, where social interactions occur naturally, their increased configurational
and relational accessibility and functionality (e.g., physical and visual proximi-
ties, interrelationships, accessibility and flexibility among related spaces), provi-
sion of shorter walking distances, and higher visibility and transparency of CGAs
will exhibit higher rates of unprogrammed, unscheduled, and supportive social
interactions and collaborations. This, in turn, will increase staff performance,
relaxation, and general well-being in the unit, thereby influencing healing.
Limitations
This study was based on qualitative narratives of in-depth interviews and obser-
vations. Future studies may triangulate research findings with quantitative data to
indicate the healing benefits of positive social interaction. Fewer LOS days and
better recovery indicators may provide more convincing evidence for healing.
Average LOS days for specific units may be correlated with healing design indi-

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cators. This study claimed that increased staff interaction would increase staff
performance and collaboration, improving medical outcomes. Future studies may
collect quantitative records of staff performance (e.g., nursing errors, nurse quit-
ting rates, attrition, morale, efficiency).
Implications
An ICU navigation model may analyze social interaction function by changing:
1) walking distances, 2) scale, 3) configurational and relational accessibilities,
and 4) visibility and transparency ranges between CGAs. Analytic and statistical
tools can measure characteristics and interrelationships between shared spaces.
Simulation and visualization of research findings may demonstrate the impact of
unit configuration on face-to-face interactions, thereby improving healing. A
video clip may highlight how reduced staff walking distances as they move
around would affect the chances for interacting with patients, families and other
caregivers.

CONCLUSION
Findings indicated that design interventions that increase the rate of unscheduled
social interactions may also improve healing in an ICU, particularly through the
provision of practical everyday needs: the placement of the tea kettle, refrigera-
tor, copier, printer, fax machine, shared workstations and the staff station may
gather people in a small unit. More social encounters will create more support-
ive interactions, improving well-being and recovery.
The importance of touch, talk, and love in caregiving is well acknowledged, yet
these insights may not translate into physical design: a staff lounge may be sev-
eral floors away, which is less effective for staff interaction than having all shared
activities and the unit intermingled in a compact, flexible arrangement. This study
suggests healing results from social interaction, which is influenced by walking
distances and spatial, visual and intellectual proximities between spaces. That is,
the closer it is between different functional units the more people will encounter
with one another as they share a common space, and engage in a supportive,
meaningful conversation. Having these conversations enables a more therapeutic
caring environment, which translates into healing.
The study found clustering shared activities in a more compact and flexible
arrangement may increase socialization. Turkish caregivers recalled the benefits
of their lounge space, which enabled them to interact positively in a small space,
and involve families in care. Although compact spaces may not support generic
ICU functions, the beneficial size and location of common areas may impact
healing through meaningful social interaction.

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In summary, healing design is about the creative, festive discovery of the possi-
bilities of social support and social interaction, which can simply project from
providing lower level practical needs such as beverages. This study emphasized
the potential of common spaces in the ICU, which gather patients, families and
caregivers and stimulate meaningful interaction, care-in-situation, communica-
tion, collaboration, and love. Shared hospital spaces, where emotional care and
concern are exchanged unconditionally, may encourage a new social life resisting
against the destiny of the West, which reduces the human capacity for establish-
ing natural and unscheduled social interactions in favor of a more technological,
mechanistic lifestyle.

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