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A holistic approach to ward design

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Built environment
A holistic approach
to ward design
Three Iranian academics examine how existing experience in inpatient and other
ward design can be harnessed to ensure the creation of comfortable, relaxing and,
as far as is possible, individually “tailored” hospital accommodation in the future.
T
his article seeks not only to examine
standards of care worldwide,
but also to highlight existing
management practice in the effective use
of healing spaces to ensure sufficient
flexibility and capacity for multi-functional
use. It also considers experience of
building new healthcare facilities, with
a strong focus on issues and practices
in Iran, and examines the treatment
methods deployed by Iranian physicians
and the prevalence of regional and local
diseases. Also spotlighted is the degree to
which the country’s existing financial and
scientific capacity will define the take-up
of technology in Iranian hospitals.
We also take into consideration the
fact that, when designing and planning
new hospital accommodation, not only
do the particular identity, culture and
customs of each region need to be
carefully considered, but also the
country’s communication systems and
requirements, and the need to create
as “patient-friendly” a healthcare
environment as possible. The latter goal
can normally only be effectively achieved
by tailoring hospital facilities to reflect
local cultures and customs. Thorough
consideration of all these areas should
Authors
Farhang Mozaffar is assistant
professor, School of Architecture
and Urban Studies, Iran University
of Science and Technology, and dean
of Isfahan Art University.
Seyyed Jamaleddin is a Ph.D. student
in architecture. Mehdi Khakzand
is a Ph.D. candidate in landscape
architecture at the School of
Architecture and Urban Studies, Iran
University of Science and Technology.
Health Estate Journal
50 June 2009
Two of the leading hospitals in Tehran – the Milad (left) and the Shariati.
Often, however, hospital
design tends only to
be examined from a
functional, and rather
general, perspective
naturally result in an improved standard
of hospital accommodation and
optimised use of hospital space.
In this article we will attempt to give
appropriate guidance on how to best
design the patient care unit and wards,
among the most important parts of any
hospital.
In Iran, hospitals are built according to
European culture and standards. Indeed
Iranian and oriental culture and customs
have not generally featured in the design
of the country’s healthcare facilities.
Studies’ impact
In recent years, architects, consultant
engineers, and different private and
governmental organisations, have taken
strong account of the data produced
in studies on hospital design. This data,
and the resulting conclusions, have
formed the content of many academic
thesis dissertations for Bachelor’s,
Master’s, and PhD degrees. In such
academic papers, the subject of
inpatient departments as one part of
an overall hospital is often debated,
and the relevant regulations, standards,
plans, and key trends examined. Often,
however, hospital design tends only to be
examined from a functional, and rather
general, perspective. This is despite
the fact that one of the most important
considerations, when designing today’s
medical environment, is the need for
sensitive and considerate treatment
towards patients and its effect on the
healing process. (Shad pour, 1993).
According to the information we have
available, there have however, to date,
been no specific studies compiled on
planning the physical accommodation
for inpatient departments (where
the patient spends most time),
and specifically the obstetrics and
gynaecology wards. This article seeks
to address this issue and to present,
finally, some patterns as an efficient plan
for obstetrics and gynaecology wards.
A brief glance through history
suggests that buildings constructed
to serve the public not only maintain
their intrinsic value over time but,
with sensitive adaptation, readily
accommodate changes that enable
them to cater for new clinical needs.
A huge amount of capital, not to mention
design input, data collection, time and
manpower, is required to build, equip
and maintain a hospital, while social,
financial, cultural, climatic and other
issues all also need to be taken into
account, all adding to the architect’s
task.
 Built environment
Table 1: Accommodation plan and fundamental facilities (minimum requirements and space areas)
for acute adult wards with 28 beds, from the UK Department of Health (UK. HBN 04, 1990).
General function of spaces Number Activity space Space area m2 Quantity Total area m2
Bed spaces 1 Single room 11.5 40 46
2 Multi-bed room – 4-bed 40 30 1200
3 Multi-bed-room – 6-bed 60 20 1200
Day spaces 4 Day space 12 50 600
5 Day room 12 10 120
Sanitary facilities 6 Shower/WC/wash (with lobby) 6.5 5 32.5
7 En suite shower/WC/wash 3 2 6
8 Bathroom/WC/wash 7 1 7
9 Assisted bathroom/wash 11.5 1 11.5
10 Assisted shower/WC/wash 5.5 1 5.5
Utilities 11 Clean utility room 9.5 1 9.5
12 Dirty utility room 11.5 1 11.5
13 Cleaner’s room 7 0.5 3.5
14 Disposal hold 3 0.5 1.5
15 Examination and treatment 12.5 1 12.5
16 Ward pantry 10 1 10
17 Flower bay 1.5 1 1.5
Storage 18 Equipment store 8 1 8
19 Linen trolley bay 1.5 1 1.5
20 Food trolley bay 3 1 3
21 Resuscitation bay 1 1 1
Offices 22 Sister’s office 10 1 10
23 Doctor’s office 14 0.5 7
Staff facilities 24 Staff base 11 1 11
25 Staff lockers 6 0.5 3
26 Staff WC 2 1 2
27 Switchgear 2 1 2
Net total 3327
Circulation area 28 150
Departmental total 3477

Risk of wasted time/resource
Paying insufficient heed to any of the
factors previously mentioned may result
in considerable expense, and waste a
substantial amount of human time and
energy. It is therefore essential that the
hospital constructor, with the help of his
project partners, begins his design work
only after carefully taking into consideration
all aspects of the plan. (Ulrich, 1991)
Today, experimental and functional
studies play a crucial role in the design
process when establishing new hospital
buildings. With the speed of medical
advances, as time passes some diseases
are eradicated while, conversely, other
new and unknown ones appear. As a
result, new facilities are needed on an
ongoing basis for specific studies and
therapies. While a modern hospital
should employ the latest technologies,
it should never ignore the patient’s
mental needs. Healthcare facilities
need to have a friendly feel at a time when
the people admitted are often feeling
dejected state. Nowhere is the impact
of hospital accommodation on the
patient more evident than in the facility’s
While a modern hospital
should employ the latest
technologies, it should
never ignore the
patient’s mental needs
inpatient wards. The patient’s room is
effectively his or her entire world, and the
focus for everything from eating meals,
studying etc., to receiving visitors.
The ultimate expectation on the
architect is for he or she to plan a
flexible space which can meet all these
requirements. Studies show that hospital
patients accommodated in comfortable
environments express more satisfaction
than others. Such individuals tend to
get to understand more about their
treatment, are more likely to be positive
about the medical staff treating them,
and tend to rate the hospital overall very
highly, although it does not necessarily
follow that they are any more impressed
with the hospital’s external appearance.
Architectural factors can, generally,
speed the healing process, although the
evidence for this is of a fairly general,
international nature, rather than being
supported by individual cases.
Alongside the building’s visible fabric,
the key factors requiring consideration
when designing new healthcare facilities
include isolation and company,
landscape, and environmental peace and
control. (Shora consultant Eng., 1998)
However, flexibility of inpatient ward
spaces and multi-functionality,
particularly where patient relaxation
areas and visitor space are concerned,
make for a dynamic and optimised
hospital environment, and provide
significant fiscal benefits, as well as
placing a high priority on patient and
customer needs.
When considering the optimal layout
for rooms and other hospital spaces,
natural daylight, attractive landscaping,
and relaxing conditions, are all
particularly important. Good design can
be achieved by locating related spaces
and areas close to one another, it being
especially important to “connect”

Health Estate Journal

June 2009 51
Built environment
inpatient rooms with nurse stations, and
to provide a suitable circulation system
so that patients feel safe. It appears,
nevertheless, that the best solution is
to use architecture with a human scale
and appeal.
‘Fantasy’ spaces
Some architects have challenged the
“traditional” hospital building and devised
fantasy spaces using natural daylight,
leafy garden scenery, or corridors filled
with trees and sky. Here hospital rooms
are not solely functional, but instead
interesting internal spaces where visitors
and patients can converse informally
away from the more formal hospital
environment. Moreover, the colours and
shapes used in the inpatient wards are
not just for decorative purposes, but
instead form a fundamental part of the
planning process.
When examining inpatient ward design,
effective planning of the physical spaces
used in obstetrics and gynaecology wards
is of great importance. As a result of very
specific conditions in such wards, the
special needs of pregnant women before,
during and after birth, the fact that
expectant mothers cannot be regarded
as “ill”, and that the way in which visitors
interact with the baby and the mother is
directly affected by their environment,
the design and planning of such ward
accommodation assumes added
significance.
The main goals of obstetrics and
gynaecology wards are to prepare and
maintain the safety of the delivery for
both mother and baby, and to provide
convenient supervision and care in a
pleasant environment (Sedghiani, 1996).
Such wards must also enable staff to:
r Promote good physical and mental
health.
Some architects have
challenged the
‘traditional’ hospital
r Prepare the mother for the physical
effort and pains of labour, delivery, and
feeding and taking care of the baby.
r Recognise and manage any medical
conditions that may bring risk to the
health of mother or baby.
r Deal effectively with any emergencies
that may occur prior to the delivery
and overcome them.
r Ensure, as far as is possible, that the
birth of the child is emotionally
pleasant for the mother and,
consequently, a positive experience
for the father of the family.
The whole philosophy of creating a
“mother’s ward” in general hospitals is
influenced by the features of the ward
and the way in which it is run. A high
percentage of the patients on such
wards are not actually regarded as “ill”,
resulting in functional differences, in
terms of the facility’s relationship with
other hospital divisions and wards. The
fundamental emphasis on the gender
of the patients accommodated, and on

Table 2: Sample of physical planning in normal inpatient ward with minimum facilities.
32-bed obstetrics and gynaecology inpatient ward with minimum facilities.
No. Subject Net level m2 Number Sum of Total sum of
net area (m2) net area (m2)
1-1 Patient spaces
1-1-1 One-bed single room with a baby cradle 11 2 22
1-1-2 One-bed isolated room 11 2 22
1-1-2-1 Sluice space of isolated room 4 2 8
1-1-3 Four-bed room with baby cradle 36 7 252
1-1-4 Shower, toilet and sink (one for each) 22 1 22
1-1-5 Shower, toilet, and sink for disabled 8 1 8
1-1-6 Therapy tub and sink 20 1 20
1-1-7* Day room 16 1 16
1-2 Support room
1-2-1 Pharmacy and clean work room 11 1 11
1-2-2 Used utilities + dirty work room + sluice 9+3 1 12
1-2-3 Service room + health service 7+3 1 10
1-2-4 Small room for cleaning tools (one for toilets) 2 2 4
1-2-5 Medical activity room 15 1 15
1-2-6 Butler room 12 1 12
1-2-7 Equipment storage 10 1 10
1-2-8 Clean cloth storage 4 1 4
1-2-9 Wheelchair and stretcher park 4 1 4
1-2-10 Serum place 1 1 1
1-2-11* Physicians and conference room 20 1 20
1-2-12 Nurse room 10 1 10
1-2-13 Nursing station 12 1 12
1-2-14 Health service of the staff 3 1 3
1-2-15 Electric table space 2 1 2
500
35% is added as the internal traffic spaces 150
Net total sum 650
6% is added as dry wall 39
Total sum of ward’s gross foundation (m2) 689
Ward’s gross foundation for each bed (m2) 21/5

Health Estate Journal

52 June 2009
 Built environment
Table 3: Recognition of the position of inpatient wards according to the internal hospital connections and links
with other divisions and regions (from Le Mandat M., ‘Tableau des Liaisons’, Le chapiter 3.4, ‘Les relations-les liaisons,’
Prevoir l’espace hospitaliers [Paris, France, 1989], p.275).
Zones No. Principal services Proximations, directions and mechanisations
for internal hospital services
Normal inpatient ICU or CCU
Wards Units/wards
Hospitalisations Rehabilitation
Internal patient care 1 Nursing and hospitalisation Easy connection type 4
2 Intensive care unit
Corpse 3 Morgue
Medical techniques 4 Explorations Physiologic (functional)
5 Laboratories Necessity of connection type 3 Necessity of connection type 3
Easy connection type 4
6 Radiology Easy connection type 4 Easy connection type 4
7 Rehabilitation and physiotherapy Easy connection type 4
Acceptance 8 General acceptance Easy connection type 4 Easy and simple connection type 4
Pharmacy preparation 9 Pharmacy preparation Necessity of connection type 3
Easy connection type 4
10 Sterilisation Easy connection type 4
Obstetric surgery 11 Bloc obstetrical Easy connection in vertical Easy connection type 4
direction or in horizontal
direction type 4
12 Bloc operation (endoscopy or surgery) Easy connection type 4 Short and easy link in vertical
direction or in horizontal
direction type 2
External patient care 13 Emergencies Preferred vertical or horizontal
mechanised horizontal
14 External consultations

preserving the women’s dignity and

safety, are two of the key basic tenets
in the creation of a “mother’s ward”.
The crux of the problem
and the research question
In obstetrics and gynaecology wards the
speed of the recovery/healing process
is closely related not only to the patient’s
physical status, but also to how
effectively she is able to relax and how
well her mind and soul are “soothed”.
These important goals throw up
problems and issues related to hospital
spaces, especially as regards inpatient
wards.
Against the backdrop of maintaining
an effective overall health service
strategy, establishing an integrated
and multi-professional system, and
appropriate space planning for obstetrics
and gynaecology wards in general
hospitals, the key question addressed
by this paper is how one can best
provide a conducive environment both
for treatment, and for the acceleration
of the healing process in line with the
culture and customs of each region
in Iran. Taken into account must be
both current trends, and the individual
patient’s mental and physical condition.
The study hypothesis
Based on what has been discussed,
in terms of theoretical approach and
Another factor to be
considered in
planning spaces is
providing adequate
room for the patient’s
relatives and visitors
research, the following hypothesis was
considered:
To properly plan for the physical space
needed for obstetrics and gynaecology
wards, a permanent and long-term
review and revision of planning and
standards should be undertaken, and
a list of “Dos” and “Don’ts” formed.
Patient-friendly and human-centered
considerations in obstetrics and
gynaecology wards markedly accelerate
the patient healing process, and improve
relaxation and calmness. This makes
it necessary to pay particular attention
to the patient’s physical, mental, and
spiritual welfare.
Because the patient effectively “lives”
in the inpatient ward for a short time,
every effort should be made to provide a
lively, familiar, and dynamic environment
via the use of colour, light, landscape,
connection with open spaces, and air
conditioning, alongside appropriate
space planning. Another factor to
be considered in planning spaces
is providing adequate room for the
patient’s relatives and visitors, in a style
appropriate to the customs, and culture,
of each region.
Definition of inpatient
care units
The phrase “inpatient ward” might be
considered to convey two different
mental pictures. The word “ward”
denotes “a containing space” and the
adjective “inpatient” within a hospital
complex implies a series of beds
arranged in different configurations
within an area or department mainly
consisting of hospital beds”. (Shora
consultant Eng., 1998)
Studying the definitions of inpatient
wards in HBN guides, the following
could be concluded: the phrase
“inpatient ward”, and the context
surrounding it, was coined in the UK
in 1990, and the etymological derivation
of the word “ward” suggests that, as a
verb, it means to protect, defend, provide
immunity against, and eliminate. It also,
of course, has a number of different
definitions in a care and treatment
context. It is remarkable, also, that the
meaning of the word “ward” partially
overlaps with that of “department”.
Based on the definitions we have cited,
in a hospital the word “ward” can only

Health Estate Journal

June 2009 53
Built environment
Table 4: Names of the hospitals studied.
Hospital name
Shavid Rajayi – Gachsaran
Alavi – Shiraz
Shahid mohammadi – Bandar Abbas
Shariati – Tehran
Hazrat-e-Rasoul-Tehran
Milad-Tehran
Hafiz-Shiraz
Dena-Shiraz
Hor-Tehran
Total
be considered in the context of being
a part of a nursing department.
The difference between the words
“unit” and “ward” is defined in the
following paragraph: “Designers and
planners suggest the solution of not
seeing the single ward, but rather a
linking together of wards with essential
complementary accommodation (ECA)
and optional accommodation and
services (OAS) as a ‘unit’. Thus it can
be concluded that the meaning of the
word “unit” is more all-encompassing
than that of a ‘ward’; a unit is a linked
complex or set consisting of some ward,
and some common, accommodation”.
In UK general hospitals, from 1990
onwards, adult wards have only been
allotted to adult patients with serious
conditions. On the whole adults not
suffering from a serious condition
will not be admitted to such wards
in general hospitals. They will usually
be released prior to them making
a complete recovery.
The common generic phrase used
for inpatient wards in the publications of
the US health ministry is “nursing unit”.
The word “unit”, with the accompanying
word or words describing their
application, function, the age of the
patients housed in them, and their
medical specialty or surgery type, are
the components of the main names of
all divisions of all types of inpatient
wards in general hospitals, as follows:
r Adult medical nursing unit.
r Adult surgical nursing unit.
r Post-partum nursing unit.
r Intensive care unit (or ICU).
r Newborn nursery unit.
r Paediatric and adolescent unit.
r Psychiatric nursing unit.
Regulations and criteria
of inpatient wards
Zoning of particular hospital areas in
“structuralism-based architecture” is not
generally undertaken purely to establish
the location used for specific hospital
activities, but equally to provide the
space and physical conditions necessary
for patient relaxation and welfare. Such
Health Estate Journal
54 June 2009
Frequency Percentage Authorised percentage
39 19.1
27 13.2
28 13.7
14 6.9
27 13.2
28 13.7
16 7.8
20 9.8
5 2.5
204 100
factors are so important as to be likely
to take priority over other areas such
as medical diagnostic equipment.
The most appropriate concentration
and layout of wards, and inpatient ward
accommodation in particular, and its
context within hospital zoning, is all
part of the administrative planning of
hospital accommodation. As previously
mentioned, it is normally undertaken
at the stage when the architect first
conceives the architectural structure
of the new hospital. (Tofighi, 2002)
Methodology
Assessment and evaluation of the effect
of the hospital environment and space
(especially as regards the inpatient
obstetrics and gynaecology wards)
is this study’s objective. In this research
a cross-section of women were
interrogated via questionnaire. The study
participants included expectant and
post-natal hospitalised women, and
women working in the obstetrics and
gynaecology ward of nine hospitals
(see Table 4). Physicians (specifically
obstetrics and gynaecology specialists),
and obstetrics and gynaecology ward
nurses, also took part. (Groat & Wang,
2002)
The questions in the questionnaire
used for the study were prepared in such
a way as to cover the varying viewpoints
of respondents on the different
environmental and layout considerations
for the hospital.
Among the key conclusions were:
r The use of attractive local landscaping
and open, green spaces can play a
significant part in the healing process.
r Providing good external views,
particularly in the inpatient areas,
Room design should
seek to provide sufficient
‘space’ around patients’
beds to cater for sudden
influxes of visitors
Association percentage
19.1 19.1
13.2 32.4
13.7 46.1
6.9 52.9
13.2 66.2
13.7 79.9
7.8 87.7
9.8 97.5
2.5 100
100
should be a key priority for designers
of new hospitals.
r Where possible, inpatient rooms
should be configured with their own
area of “open space”.
r There should be a greater focus on
designing single and two-bed rooms
than three- or four-bed rooms.
r Room design should seek to provide
sufficient “space” around patients’
beds to cater for sudden influxes
of visitors.
r Rooms containing televisions and
radios perform an important patient
entertainment function, but should
be sited so as not to disrupt everyday
hospital activities and functions.
r Light and soothing colours, with equal
attention devoted to ensuring ingress
of both adequate natural and artificial
light, are important design factors.
r Care should be taken, when designing
inpatient areas, not to provide one,
or just a few patients, with ample
natural light at the expense of others.
r The need for a degree of patient
independence, and for a relaxing
environment, are important
inpatient accommodation design
considerations.
r Adequate space for the patient’s
friends, family and relatives should
be provided
r It can be said with a 90% certainty
that, as individuals’ level of education
increases, so too does their desire,
when in hospital, for good views
and landscaping.
r The more educated people are, the
keener they are to have access to
music while in hospital.
r The older people are, the keener
they are on their accommodation
featuring a variety of colours, and
the more effect colour has on the
healing process.
r Individuals working in more “private”
occupations are less interested in
interacting with other patients.
r Housewives are generally more
interested in interaction with
others than other groups.
r While students are keener to have

access to music in the hospital
environment, it could be inferred from
our questionnaire that housewives and
civil employees are not especially keen.
r It can confidently be asserted that the
more educated patients are, the keener
they are to have access to meeting
facilities for interaction with family and
friends. This finding contrasts with the
presupposition that, the higher the
patient’s education level, the lower their
general emotional interaction with others.
Overall conclusions
Based on what we have discussed so far,
we can safely conclude that a hospital
is not solely a physical building that,
regardless of its condition, can guarantee
patient recovery, but that the whole entity
includes “services” comprising a complex
combination of purposes, goals, knowledge,
expertise, policies, programmes and
procedures based on hundreds of years
of experiments and observations.
Providing a “suitable” or “favourable”
environment, the primary goal in the
admission ward in a hospital, is closely
related to the cultural, social, economic
and political characteristics of local
and international society.
Based on all factors, and on the
questionnaire findings, it seems safe to
conclude that factors like light, a “natural
environment”, and room arrangements/
View publication stats
A hospital is not solely
a physical building
that can guarantee
patient recovery
layout, are of the utmost importance in
designing a hospital, and can significantly
affect patient recovery. ✚ Azad University, Tehran.
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Health Estate Journal
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