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Environmental Psychology and Architecture for Health Care Design
Mirilia Bonnes, Marino Bonaiuto, Ferdinando Fornara, Elena Bilotta

1. Preliminary remarks for the collaboration

between psychology and architectural
design

Psychology must be very grateful to architects, Psychologists started to study and observe sys-
because without them it would never had under- tematically spaces and environments of everyday
stood the importance of environmental psychol- life after the specific request made by architects
ogy (see Stockols, Altman, 1987; Bonnes, Secchi- and designers. This was the first step towards
aroli, 1992; Bechtel, Churchman, 2002). Without the development of theories, instruments and 35
architects, psychology would never had identi- methods that today define environmental psy-
fied architectural psychology (Bonaiuto, Fornara, chology as a specific psychological discipline. It
Bonnes, 2004; Bonaiuto, Bilotta, Fornara, 2004) assumes a social-physical specificity – place or
and it would never had get to the ecological-con- setting specificity – of human experiences and
textual turning point of the entire psychological actions and it aims at understanding the psycho-
inquiry. It is important to keep in mind that one logical processes characterizing these place or
of the main stages for the emergence of environ- setting specificities. Following the environmen-
mental psychology as a distinct discipline at an tal psychology perspective, life environments
international level was related to health care de- (or setting/places) have their own informative
sign. In particular, the work made by the research or communicative ability, which can differently
group leaded by social psychologists W. Ittelson meet people’s environmental needs (with their
and H. Proshansky at the City University of New expectations, wishes, intentions, emotions, etc.).
York at the end of the ’50s played a key role in Thus, each place/setting’s configuration can be-
that direction. The main aim of the research group come – through its isomorphism and affordances
was to analyze the role played by the architectural – on one hand a support, or a facilitator, but on
arrangement of a psychiatric hospital on patient’s the other hand also a constraint, for people/us-
behaviors and daily life (Ittelson, 1960). The term ers/actors’ environmental needs (see figure 1).
Environmental Psychology was used for the first
time in 1964 by Ittelson during a Conference or-
ganized by the American Hospital Association in
New York focused on health care design. Other
than the interest towards health care design, the
origin of environmental and architectural psychol-
ogy is related in some Countries (in particular,
United States, United Kingdom, Canada, France)
to the emergence of specific requests coming
from architectural design in general, especially
when this was related to buildings and residen-
tial environments for “special populations”, such
as psychiatric hospitals, but also residences for
elderly and students. In those cases, architects
wanted to suggest the best design solutions for
the users, especially because their expectations
were less predictable, since they were coming
from “special users” such as psychiatric patients, Figure 1: Environmental psychology and architectural
elderly, students, etc. environments for settings/places of everyday life.

TESIS InterUniversity Research Center - Systems and Technologies in Healthcare Buildings

 Proceedings of 28th International Public Health Seminar edited by Romano Del Nord
Setting’s spatial-physical configuration can be
more or less fitting both with the general pro-
gram of the setting and with the more specific
(or special) people/actors’ environmental needs.
For example, a specific spatial-physical configu-
ration of a hospital unit can meet and facilitate
or inhibit needs/behaviors of some of the prin-
cipal categories of users/actors: patients, staff,
or visitors.
Environmental psychology shows that everyday
life environments or settings tend to remain in the
unconscious background of people’ everyday ex-
perience (everyday awareness/cognition), but at
the same time environmental psychology demon-
strates also that these environments/settings are
not affectively neutral or insignificant for these
36 people who experience them. Some empirical
evidence in this direction emerged also from our
studies conducted in healthcare environments
(see Bonaiuto, Fornara, 2003; Fornara, Bonaiuto,
Bonnes, 2007). In fact a similar phenomenon of
environmental numbness has also happened in
the tradition of studies of psychology, which tra-
ditionally used laboratory settings to analyze and
understand human psychological processes, and
thus ignoring the spatial and social-physical char-
acteristics of the settings and the places where
these processes occur. Through environmental
psychology research, physical aspects are now
considered a “full figure” and not just a “back-
ground” in the research field of psychology.
Anyhow, environmental psychology needs to
develop and use new specific tools and meth-
ods in order to systematically consider and un-
derstand these human psychological processes.
Some examples of instruments used for this
purpose are the ones we developed concerning
the affective qualities of places in general (Pe-
rugini et al., 2003) and those concerning per-
ceived environmental qualities of specific places
such as residential neighborhood (Bonaiuto et
al., 1999, 2006), and also health care envi-
ronments (Fornara, Bonaiuto, Bonnes, 2006,
2007).
There are several ways environmental psychol-
ogy can collaborate with health care designers
in order to improve the realization of a good and
humanized project, depending on designers’ ex-
pectations and on the design phase taken into
account. In particular, there are three phases of
the design process where psychology can play
an important role: (1) ideation, (2) specifica-
tion, and (3) evaluation (see Bonnes, Secchiaroli,
1992; Bonaiuto, Bilotta, Fornara, 2004). During
the ideation phase, some general information
from psychological research field can give im-
portant advices for the ideation of the project. In
the specification phase, the influences of specific
spatial-physical characteristics on users’ psycho-
logical processes can be clarified (e.g., the rela-
tion between structural features of the setting
and privacy regulation, or between illumination
and comfort and/or work performance). In the
evaluation phase users assess the “building-in-
use”; this phase aims at detecting possible im-
provements that can also be useful for the next
projects, not only for the one considered in the
evaluation. The Post-Occupancy Evaluation (POE)
studies are examples into this sense. Although
this kind of multidisciplinary collaboration be-
tween architects/designers and environmental
psychologists is quite rare in Italy, many exam-
ples have been already realized by our research
group CIRPA (Center of Interuniversity Research
on Environmental Psychology) which often had
the chance of working in the field of design,
including health care design. The first occasion
in this direction came from the Concourse for
the design of the New Pediatric Hospital Meyer
of Florence; then a specific collaboration with
the group of designers from the TESIS center
of the University of Florence started and devel-
oped (see Del Nord, 2006; Bonnes, Fornara, Bo-
naiuto, 2008). In fact we not only accepted to
collaborate with the requests coming from the
TESIS group, but we also started new research
lines, into this direction (see Fornara, Bonaiuto,
Bonnes, 2006, 2007).
2. Meeting health care users’ needs:
the concept of hospital humanization
Recent developments in architectural planning
and design showed the importance of “human-
izing” healthcare contexts in order to increase
environmental quality and user’s well-being
(Schweitzer, Gilpin & Frampton, 2004). The tar-
get of “more human hospital environments”
(Nagasawa, 2000) refers to spatial, physical and
functional design attributes that health care en-
vironments should possess for both: (i) reducing
the stress level which can be very high for both
patients and staff, given their daily contact with
disease, pain and (in some cases) death; and (ii)
promoting and increasing the well-being and
the life quality of hospital users. As suggested
by many authors (e.g., Devlin & Arneill, 2003),
specific attention should be given to several
 Environmental Psychology and Architecture for Health Care Design by Mirilia Bonnes, Marino Bonaiuto, Ferdinando Fornara, Elena Bilotta
design features which could better meet users’
needs (Evans & McCoy, 1998; Pressly & Hee-
sacker, 2001). These attributes include lay-out
and spatial configuration; colors and materials
of furniture, walls and floors; artwork; type,
quantity and focalization of natural and artificial
light; kind of views inside and outside; size of
windows; cleanliness; climate – such as: spatial
and sensorial comfort in visual terms (i.e., ad-
equate lighting and panoramic views) or in audi-
tory terms (i.e., avoidance of annoying noises) or
in climatic terms (i.e., adequacy of temperature
and humidity); orientation; sense of welcome;
privacy and social interaction; perceptual con-
sistency; control over space; clear affordance;
restorativeness. In particular, with respect to
hospitals and other healthcare settings, spatial-
physical humanization represents a component
of the broader concept of hospital humaniza-
tion, which includes organizational, relational
and therapeutic aspects in addition to environ-
mental and social qualities (Fornara, Bonaiuto,
Bonnes, 2007).
Following this general framework, we decided
also to develop and to use specific tools and re-
search methods in order to verify the psychologi-
cal effects of healthcare humanization on users.
Examples of our research activity focused on
hospital humanization will be given in the next
paragraphs.
3. Pediatric hospital humanization and
perceived affective qualities: some
empirical results
Starting from the tradition of studies of envi-
ronmental psychology, highlighting the need
of carrying out empirical studies to verify the
psychological effects of healthcares’ humaniza-
tion on users, two empirical studies have been
conducted, with the general aim of evaluating
the effects of different children health environ-
ments. In particular, the main aim was to com-
pare psychological effects of different pediatric
hospitals: on the one hand those designed fol-
lowing traditional criteria, on the other hand
those designed following the recent “human-
ization” criteria, which take into account users’
psychological needs. The general aim was to
empirically verify the role played by environ-
mental humanization in facilitating users’ (staff,
patients, visitors) well-being and a positive so-
cio-physical integration in the environment of
the pediatric hospital.
TESIS InterUniversity Research Center - Systems and Technologies in Healthcare Buildings
Since “the first level of response to the envi-
ronment is affective” (Ittelson, 1973, p.16), the
attention of both empirical studies was focused
on affective responses and evaluations (posi-
tive vs. negative) that the hospital environment
– low, medium, or high humanized – provokes
among its users. In particular, two different
studies were conducted in three different wards
of the hospital: the in-patient area, the recep-
tion area, and the playroom. These are crucial
areas because they correspond, namely, to area
where the patients stay most of the time; to
the place where the first contact between the
children and the hospital occur; to a place of
amusement and socialization. In particular, the
main hypothesis of the study was the follow-
ing: the higher the degree of humanization of 37
the hospital, the higher the scores in positive
affective qualities (exciting, pleasant, relaxing,
arousing) and the lower the scores in negative
affective qualities (sleepy, unpleasant, distress-
ing, gloomy) attributed to the in-patient area
and the acceptance area.
3.1. Context, sample, instrument and data
analysis
Three pediatric hospitals of Rome were chosen
for their different degree of architectural hu-
manization (i.e., high vs. medium vs. low). Such
difference was confirmed by means of an evalu-
ation made by an expert, based on some param-
eters of objective quality.
The sample was composed by parents, staff and
external visitors (only in the second study). The
sample of the first study consisted in 205 sub-
jects (159 parents and 55 caregivers; 70 males
and 135 females; from 22 to 60 years old). The
sample of the second study consisted in 166
subjects (114 parents, 66 caregivers; 6 visitors;
73 males and 93 females; from 22 to 60 years
old). Participants were contacted in the exam-
ined areas and asked to fill in a paper and pencil
questionnaire. In order to measure the perceived
affective qualities of the hospital, the Scale of
Affective Quality (SAQ) based on the circumflex
model of affective quality attributed to place
(e.g., see Russell and Pratt, 1980) was used. The
scale was adapted and validated for the Ital-
ian contexts (Perugini, Bonnes, Aiello, Ercolani,
2002), and consisted in a list of 48 adjectives
included in 8 dimensions (6 items each), 4 posi-
tive (i.e., Relaxing, Exciting, Pleasant, and Arous-
ing) and 4 negative (i.e., Distressing, Gloomy,
Unpleasant, and Sleepy). The response scale is
 Proceedings of 28th International Public Health Seminar edited by Romano Del Nord
Figure 2: Mean scores of the 8 dimensions of positive
and negative affective qualities (range 0-6) for the
different degrees of humanization (first study: users
of the in-patient area).
38
Figure 3: Mean scores of the 8 dimensions of positive
and negative affective qualities (range 0-6) for the
different degrees of humanization (second study: us-
ers of the acceptance area).
Figure 4: Mean scores of the 8 dimensions of positive
and negative affective qualities (range 0-6) for the
different degrees of humanization (second study: visi-
tors in the acceptance area).
a Likert-type 7-step format, where subjects as-
sessed how well each adjective could describe
the target-place (i.e.: each hospital area). A se-
ries of ANOVA were run with the scores of affec-
tive quality dimensions as dependent variables
and the degree of humanization, the typology of
setting and the typology of users as independent
variables1.
3.2. Results and conclusions
Results showed that the three hospital (low vs.
medium vs. high humanized) are perceived in
different ways by their users (see figure 2 and
3): a higher degree of humanization of the in-
patient and acceptance area is associated to a
higher level of perceived positive affective quali-
ties and to a lower level of the negative ones.
Visitors sample showed the same general trend
(see figure 4), and they also showed higher
scores in perceived negative affective qualities
when asked about the low humanized hospital
(and vice versa for the medium and high human-
ized hospitals).
More in general, all the affective qualities con-
firm the trend of perceiving the different setting/
places (in-patient and acceptance area) along a
continuum of humanization, which shows how
the affective qualities profile changes depending
on the degree of humanization of the hospital:
the higher the degree of architectural human-
ization, the higher the positive affective quali-
ties and the lower the negative affective quali-
ties. Thus, experiencing an architecturally highly
humanized hospital increases positive affective
qualities and decreases negative affective quali-
ties people attribute to the place.
Our research results clearly confirm the system-
atic relationship between hospital architectural
humanization and the perception of affective
qualities of hospital setting by various users
categories (not only patients, but also medical
staff), and show how with the increase of hos-
pital architectural humanization, the positive af-
fective qualities increase and the negative ones
decrease.
4. Setting up quantitative measures for
indicators of hospital humanization
A different research line concerns the develop-
ment and the psychometric validation of instru-
ments which are adequate for measuring indica-
tors of quality of hospital settings.
These instruments are expected to be quite use-
 Environmental Psychology and Architecture for Health Care Design by Mirilia Bonnes, Marino Bonaiuto, Ferdinando Fornara, Elena Bilotta
ful both for research aims and for practical ap-
plications in hospital design activities, such as in
new designs, transformations and renovations.
In particular, for comparison aims, they were
developed both a checklist for “expert” assess-
ment (based on those quality criteria coded in
the hospital design domain) and a questionnaire
for “user” assessment (measuring indicators of
perceived quality of hospital settings).
The main hypothesis of this set of studies, is simi-
lar to the previous ones, that is: it is expected that
the more humanized the structures are, the high-
er the users’ scores of perceived quality of hospi-
tal attributes. The difference is that, in this case,
the psychological responses under analysis con-
cern the cognitive-evaluative level (whereas in the
previous case the affective level was examined).
4.1. Context, sample, instrument and data
analysis
The research contexts are represented by three
orthopaedic units of three hospitals in Rome. We
decided to select units whose differences in hu-
manization was not so great in order to verify the
discriminating power of the tool even with small
differences in spatial-physical quality. One in-pa-
tient area and one ambulatory waiting area were
taken into account for each unit. Two architects
visited all the three hospital and care units and
filled in an “expert” grid concerning the design
quality of places. On the basis of these results (see
figure 5), the three units were labelled respective-
ly as “high”, “medium” and “low” humanized.
The study participants (N = 202) were sampled
from the three main categories of hospital us-
ers (i.e., patients, staff, and visitors/companions)
and contacted directly by trained interviewers in
the in-patient and ambulatory waiting areas of
the hospital units.
A self-report questionnaire was prepared for
gathering users’ assessment. The questionnaire
contains four PHEQI scales, each one concerning
respectively one of four main areas: a) spatial-
physical aspects of proximal external spaces of
the hospital (16 items); b) spatial-physical as-
pects of the care unit (22 items); c) spatial-physi-
cal aspects of the in-patient and of the waiting
areas (22 items); d) social-functional aspects of
the care unit (20 items).
An “expert” evaluation grid (120 items covering
the same four hospital areas addressed in the
questionnaire) was compiled by two architects,
in order to measure the “objective” quality de-
gree of design attributes.
TESIS InterUniversity Research Center - Systems and Technologies in Healthcare Buildings
The sample was composed by 75 users of low-
humanized hospital units, 56 users of medium-
humanized hospital units, and 71 users of high-
humanized hospital units. Patients were 70,
visitors/companions were 65, and staff individu-
als were 67. Users of the in-patient area were
103 whilst users of the ambulatory waiting area
were 99. Females were 103 and males 99, from
18 to 70 years old.
39
Figure 5. Mean scores of designers’ judgement of
hospital sub-places design quality. (Note. Range: from
0 = insufficient to 4 = excellent).
4.2. Results and conclusions
The difference between the three healthcare
places did not turn out to be very great in the
expert judgement. In particular, the external
areas obtained similar scores in the three hos-
pitals and the waiting area of the overall medi-
um-humanized setting obtained a slightly lower
score than the overall low-humanized setting
(see figure 5). Furthermore, it is worth noting
that, for each sub-place, the more humanized
setting scored slightly above the mean point of
the response scale, except for the external are-
as which are slightly below this point. Thus, the
design quality of the three places did not show
huge differences, although the trend clearly
shows that expert quality assessment generally
increases with increasing spatial-physical hu-
manization.
Statistical processing (i.e., Principal Component
Analyses) produced 12 Perceived Hospital Envi-
ronment Indicators (PHEQIs; see Fornara et al.,
2006), respectively 4 for the external hospital
spaces, 3 for the hospital care unit, 2 for the in-
patient (or waiting) area, 4 for the social-func-
tional features.
− External hospital spaces: 1. Upkeep & Care,
2. Orienteering, 3. Building Aesthetics, 4.
Green Spaces.
 Proceedings of 28th International Public Health Seminar edited by Romano Del Nord
− Hospital care unit: 1. Spatial-physical Com-
fort, 2. Orienteering, 3. Quietness.
− In-patient/waiting area: 1. Spatial-physical
Comfort, 2. Views and lighting.
− Social-functional features: 1. Care for Social
& Organizational Relationship, 2. Privacy, 3.
Additional Services.
Internal consistency proved to be very satisfac-
tory (Cronbach’s Alphas range from.91 to.83) in
spatial-physical PHEQIs concerning the hospital
unit and the inpatient/waiting areas; adequate
in social-functional PHEQIs (in particular, Cron-
bach’s Alpha was above.80 in the PHEQIs of pri-
vacy and care for relations & organization); and
acceptable in spatial-physical PHEQIs concern-
ing external hospital spaces (Cronbach’s Alphas
40 ranged from.73 to.64).
In spite of the low level of contrast in expert
judgement of design quality among the three
hospitals investigated, the results showed an
overall increase of users’ perceived quality from
the least to the most humanized healthcare envi-
ronments in all the aspects and sub-places under
examination. More specifically, the outcomes of
the Analyses of Variance showed a better per-
ceived quality of the high-humanized rather
than the medium- and low-humanized hospi-
tals as regards indicators of the external hospital
spaces (i.e., upkeep & care, orienteering, build-
ing aesthetics). With respect to the perceived
quality of both the hospital care unit and of the
inpatient/waiting areas, the more the degree of
humanization, the better the perceived quality of
all indicators (i.e., spatial-physical attributes and
orienteering in the hospital care unit; spatial-
physical comfort and views & lighting in the in-
patient/waiting areas), except for the dimension
of quietness, whereas no differences emerged
among the three hospital care units. Finally, the
low-humanized hospital care unit received a
note
1.  In the case of visitors, a t-test for paired samples was used because of the very low number of Ss in this group.
worse evaluation than the other two units in the
social-functional indicators of care for relations
& organization and additional services, whereas
no differences emerged for privacy.
These findings provide an empirical support to the
importance of design features in the light of us-
ers’ satisfaction toward their environmental expe-
rience, therefore improving the quality of hospital
design features seems to directly foster greater
satisfaction toward health care environments.
A further interesting congruence emerged be-
tween the quality of spatial-physical features
and social-functional aspects; that is to say, the
more the degree of architectural humanization,
the better the perceived quality of relational,
organizational and functional dimensions. This
association could be due to a mutual bi-direc-
tional influence between the two levels. In other
words, the attention of heath care management
toward design features would reflect an overall
care for users’ well being, also expressed by the
organizational and relational climate; conversely,
poor attention toward design issues would re-
flect poor care for the other aspects of hospital
management. At the same time, a good design
would facilitate the functioning of the whole
health care system and, consequently, increase
both users’ well-being and satisfaction and the
quality of service provision.
In sum, this research line represents an attempt
to support the importance of the quality of de-
sign features in fostering hospital users’ satisfac-
tion, taking into account the difficulty of doing
research on this topic. The setting up of quantita-
tive instruments measuring indicators of hospital
humanization (for both “users” and “experts”)
can allow comparisons between hospital settings,
and the good psychometric qualities of these tools
can allow their use as a valid aid for investigations,
within a “user-centered” design process.
 Environmental Psychology and Architecture for Health Care Design by Mirilia Bonnes, Marino Bonaiuto, Ferdinando Fornara, Elena Bilotta

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TESIS InterUniversity Research Center - Systems and Technologies in Healthcare Buildings