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The future feels a lot like 1984.

Some 30 years after a groundbreaking study, the 'biophilia hypothesis' has come full circle in healthcare applications. What will this focus on the importance of natural settings mean for lighting design?

What is the purpose of modern lighting? Many would seriously question the merit of this type of inquiry, particularly when posed in a lighting publication, thinking it elementary, perhaps a bit obvious. Isn't it clear? As members of the lighting industry, we spend hours, years, decades of our lives refining the art and science of lighting various applications, using an acute sense of design and an ever-evolving toolkit of lamps, luminaires and lighting controls to promote visual acuity for occupants in the built environment. Our designs highlight the beauty of our surroundings, creating visual hierarchies and focal points for the people who use these spaces.

Although our mission seems incredibly straightforward at face value, reevaluating the purpose of modern lighting is a worthy exercise as we learn more about the nature of light and its more nuanced properties--attributes that extend beyond light's most obvious benefit, the fact that it enables us to see. In the built environment, we try to deeply understand the visual experience that should be realized, which leads us to a choice of lighting equipment. This thought process isn't only true for buildings. When it comes to the great outdoors, we instinctively think about quality and quantity of light in the context of our 24-hour day. Many of us consider the timing of sunset before embarking on an evening run to ensure that we're not trying to navigate in darkness. These are important considerations, but they are certainly not the only factors at play. The feeling of awe that washes over us when viewing a spectacular sunset has very little to do with average maintained illuminance on the running surface. Similarly, the soft, varied pattern of dappled sunlight passing through tree canopies and the feeling of pleasant refuge that accompanies this scene cannot be fully described through contrast ratios or luminance metrics.

Our affinity for these spaces can be explained, in part, by what is called the "biophilia hypothesis"--the idea that humans are predisposed to prefer nature and natural settings. Social psychologists, scientists, researchers, and architecture and design professionals have toiled for decades to understand the link between biophilia and outcomes, and the body of research in this field is growing. With continued advances in technology, the multihued sunset vistas we pause to gaze at may soon be replicated (or rendered artistically) indoors, as new, dynamic lighting systems use color, intensity and personalization to bring the outside world within reach.


In healthcare, it is impossible to discuss biophilia without citing environmental psychologist Roger Ulrich's seminal study, published in 1984 in Science, on views of nature and recovery rates of patients. In this landmark study, researchers found that patients with a view of landscape and trees recovered a day faster than those facing a view of a brick wall. The patients, who were recovering from gall bladder surgery (remember, this was 1984), required less pain medication and suffered fewer complications when they had the view of tree tops than did their sensory-deprived, brick-wall-facing cohorts. Few of us would be surprised by these findings, and in the 30 years since those conclusions were drawn, this research has informed the current practice of incorporating daylight and views into patient care spaces.

We have also learned more about the neurological mechanisms that enable access to views to support healing responses. Recent studies, most notably by Texas Tech Neuroimaging Institute, have utilized functional magnetic resonance imaging (fMRI) techniques to explain our neural responses to positive images. The fMRI-enabled studies demonstrated that brain activity, as measured by changes in blood flow, moves away from pain centers and toward pleasure centers when subjects are exposed to positive images, thereby reducing the need for pain medication.

Ulrich's findings inspired the use of restorative views, both natural and simulated, in indoor environments. In a recent iteration of their patient room of the future concept, Clemson University's Architecture + Health program utilized backlit tree canopy scenes in their full-scale patient room mock-up. These graphic ceiling images were used as a design intervention intended to boost patient mood and sense of well-being through positive distraction. Techniques like this are particularly important for healthcare institutions where patients are often alienated from natural elements, a term Richard Louv, of The Nature Principle, calls "nature deficit disorder." Simulated, image-based nature scenes can benefit patients and are an option for care settings, especially in urban environments, which lack restorative, natural vistas.


The knowledge base around the impact of views has been complemented by numerous studies that prove the therapeutic benefits of daylight, establishing links to desirable healthcare outcomes such as shorter stays, reduced agitation and depression in patients with dementia, and inhibited pain response. The findings related to patient access to daylight and briefer hospital stays are incredibly dramatic. A 1998 study by Beauchemin and Hays found that patients in a cardiac intensive care unit stayed in the hospital roughly two days when placed in a sunny room. Patients in shaded rooms stayed a full day longer--an average of three days in ICU.

Longer hospital stays are often correlated with increased prevalence of complications, not to mention the psychological, quality-of-life impacts of a prolonged hospital stay on patients and families. For hospital owners, longer stays translate to increased costs of care. The Agency for Healthcare Research & Quality estimates that the average cost of an inpatient stay in the U.S. is roughly $2,000 per day. Finally, the impact of daylight highlighted even more serious contrasts in the aforementioned study. Mortality rates were found to be statistically higher for patients in the shaded rooms, as compared to the sunny ICU rooms.

Because these studies did not establish a causal relationship between daylight and the health outcomes, we are left to infer the specific mechanisms that delivered the benefits. We do know, however, that electric lighting can be used to simulate daylight, both in intensity and spectra, and that this daylight simulation may allow us to delve deeper into the human physiology behind these attractive outcomes. Since it is impossible to ensure a preternaturally sunny room for every patient, regardless of geography or climate, we have a responsibility to seek ways to replicate these therapeutic effects, democratizing access to healthier light, irrespective of room orientation or allocation. Science may be slow to catch up on understanding our complex relationship to sunlight, but these studies show that we can have a positive impact on the care environment, even if we don't have all the answers.

In years to come, dynamic lighting systems that vary in color, spectrum and intensity may become ubiquitous, replacing static systems as the price/ performance equation becomes increasingly attractive to owners. Lighting specifiers and manufacturers know that there is a fine line between dynamic and distracting, and that the devil is in the details. Color quality and graceful, flicker-free changes in intensity should be the norm as these systems increasingly become mainstream.


If we rephrase the question about the purpose of modern lighting, especially for critical applications like healthcare, it may be better to ask instead, what is the "true calling" of light in the built environment? Can natural and electrical lighting, with its physiological and psychological benefits, deliver holistic benefits to all of a building's occupants? We have moved toward smarter buildings, without question, but what about healthy buildings?

Unfortunately, the institutional design commonplace in many healthcare buildings is anxiety-inducing, dehumanizing and rife with environmental stressors that inhibit healing responses. Connecting evidence-based design approaches with smart lighting design can aid in reducing these stressors and improving key healthcare outcomes.

For the healthcare environment, where the health and wellness of patients, caregivers and staff is paramount, there is no doubt that holistic systems that use natural and electric sources, that enable task performance but also support mood and distraction to unlock functional, emotional and physiological benefits, will drive the most value in years to come. This represents a meaningful change to the (well-meant) status quo, which is primarily focused on functional performance.

Indisputably, function and performance are the primary design goals in healthcare. Lighting systems have to deliver appropriate levels of illumination, and equipment must meet stringent safety and infection control protocols for various levels of care. We should continue to treat these as "table stakes" for lighting in healthcare, and these safety protocols should continue to evolve in conjunction with clinical and public health best practices. However, assuming that we have covered the basics, perhaps our definition of "function" should evolve beyond visual acuity, system compatibility and safety criteria. In addition to those attributes, should lighting systems be scored on circadian stimulus, visual experience, and other non-traditional metrics that are linked to patient outcomes and caregiver performance?


Given the myriad objectives of the modern healthcare institution, it's reassuring to know that lighting technology has kept pace with changing needs. Novel luminaire forms enabled by LED and OLED sources can impart a softer, more organic feel to indoor and outdoor settings, disappearing into architecture, or echoing cues from architectural and landscape features. Solid-state lighting sources continue to improve, and their digital nature allows them to be easily incorporated into adaptive environments. The ability to manipulate the color and spectrum of SSL sources to deliver beneficial wavelengths as well as positive distraction for patients and families--it's all within our reach.

It seemed infeasible only a few years ago, but pervasive connectivity and the fact that there really is an app for everything has transformed our world in ways we're only beginning to contemplate. Even conservative industries like healthcare have embraced apps as a way to tap into the "big data" captured in care environments, and as a way to influence an even larger issue: population health. The Internet of Things will certainly connect our lighting systems to wearables, healthcare apps and other smart devices. Sensory networks, large and small, are blanketing our built spaces and move with us wherever we go. The Orwellian implications of this (yet another 1984 reference) may be unsettling, but we can use the insights from our smarter systems to improve quality of life.


In the future, why wouldn't our lighting systems intuit what we need, sensing that a sleepless night may require more intense task illumination at our desk the next morning, or that an elevated heart rate may benefit from a more soothing ambient lighting scene? As more lighting tools become available, we can never forget the fundamental principles of lighting design for healthcare. However, it's clear that we're moving to a world where the lighting system must play a larger role in facilitating better outcomes in healthcare settings. From our most vulnerable neonates to those nearing the end of life's journey, an informed, holistic lighting scheme can deliver profound impacts to quality of life. The pursuit of that objective is what makes this new lighting exploration so worthwhile. ?


Karyn Gayle, Member IES (2013), is vice president of healthcare at Acuity Brands. She has delivered educational presentations, workshops and in-depth seminars on lighting and control design for healthcare facilities to hundreds of participants across North America.
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Author:Gayle, Karyn
Publication:LD+A Magazine
Date:Jan 1, 2015
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