Making design ‘work’ for all user groups

Healthcare designers are increasingly focused on how people function in their environments; in how their health and work are affected. Designers are enthusiastically embracing evidence that we can truly design with a view to improving health outcomes, reducing error, and the risk of hospital-acquired infection. The evidence-based design approach should not, however, take away from architects’ fundamental training – which entails designing ‘spaces’ that facilitate everyday use. In a bedroom, as a minimum, you would expect people to be able to sleep, but how well do patients actually sleep in hospitals? When designing a corridor in an inpatient ward, if you consider patients will be told to walk up and down it in order to recover sooner, then you will provide handrails, rest stops, pictures on walls, and, with luck, a window with a captivating view at some point along the way.

A ‘refocusing’ of functional design

The rise of therapeutic design in healthcare, followed by calls for evidencebased design, have refocused functional design. A more user-centric viewpoint is developing, with greater focus on the ways in which people are affected by characteristics of a space given its intended use. Environmental psychology’s contribution to a knowledge base for design is changing both client expectations, and the way that designs are developed. Increasingly, good science – emanating from several disciplines – supports the idea that well-resolved design may contribute to reduced health service costs and improved outcomes. Evidence-based design is intended to support both. However, a great many good intentions may go to waste as design management grapples with conflicting design requirements. Person-environment interactions are not simple matters of cause and effect. Consider the short-term implications of stress in recovery from injury. While the medical fraternity has found evidence of short and long-term implications of stress for healing and pain management, studies in environmental psychology1 have shown that tolerance for noise and other stressors diminishes in people who are under stress.

Qualities of the environment

Health, in the long term, is affected by where and how we live. Qualities of the environment are known to affect learning and attention to task, as well as mood and mental health, and even our body chemistry. Figure 1 is intended to illustrate the concept of the mutual impact of the environment, experiential body, and behaviour, on the body itself. The illustration is based upon a schematic prepared for the author’s dissertation,2 which includes an EBD literature review. Patient satisfaction, pain management, pace of recovery from illness, hospitalacquired conditions, and staff productivity and satisfaction, have been associated with the environment of care. This has, for instance, justified investment in natural lighting and views to nature, i.e. windows, in patient rooms, and has also put forward a good case for single-bed acuityadaptable inpatient rooms.

A ‘user-centric’ approach

A literature review permitted Roger Ulrich et al3 to conclude that: ‘The state of knowledge of evidence-based healthcare design has grown rapidly in recent years. The evidence indicates that well-designed physical settings play an important role in making hospitals safer and more healing for patients and better places for staff to work.’ Here we propose to take the above as a given in order to focus instead on an evidence-based, user-centric approach to design management. The idea is to emphasise, during the design process, desired results in terms of how spaces are used and experienced. Furthermore, a methodology is proposed in which the value of an intended use is deliberately agreed by design teams and stakeholders. This contributes to a set of jointly owned values that can be deployed as moderators during the design process, with a view to creating hospitals that work for all user groups.

 Background

If a design brief is to be summarised in a single word, that word will define its use, be it hospital, residence, school, office, factory, temple, or theatre. There is a particular intensity to the use of hospital facilities. Symbolic value, as well as traditions or conventions, provide strong cues for the forms many buildings will take. However, in the case of modern hospital design, practical needs and functionality are the foremost drivers. Over the past few centuries, hospital design has, in some cases, glorified national and military identities; in others, it has represented religious communities’ charity and spiritual dedication. Today the hospital is definitively the province of modern medicine. Neither modernist machine nor renaissance era landmark, today’s hospital is a living environment – one where clinicians, carers, technologies, and facility management, come together to provide round-the-clock service, seven days a week, to high numbers of people endlessly passing through in a wide variety of states of vulnerability and physical dependency.

A ‘humanising’ approach

Healthcare management today places a lot of emphasis on increasing patient and staff satisfaction, as well as cost savings. Architectural design will best serve organisational efficacy if designers widen and humanise the definition of functionalism, and deliberately design for better patient health outcomes and staff productivity, based on reliable information.

Progressing towards the experiential

The way we define uses in healthcare environments, or describe the purpose of a planned space, has progressed from the mechanistic, toward the experiential. The trend dates back to post-war calls for more humane health services, and later calls for more humane health environments, as well as the 1980s’ calls for a therapeutic, uplifting, and supportive, healthcare environment. Now, the evidence-based design approach demands that we justify investments in design features with scientific rigour. Ironically, Modern Rationalism’s moral dilemma with regard to beautification of hospital buildings is resolved in an entirely rational manner. Furthermore, the 1980s’ and 1990s’ marketing-inspired investments in hospitality-style healthcare facility architecture can no longer be justified. Hospitals are no more ‘five-star hotels’ than they are factories housing production lines of diagnostic procedures and surgical interventions. The hospital is utterly unique in the nature of its use, in its complexity, and in its delicacy.

Goals, principles, ideas, and conflicting requirements

The hospital design process is complex, and frequently quite lengthy. The number of people involved, and the months and years that pass until the completion of the project, pose a challenge to the realisation of project objectives. In order to communicate and explain those overarching goals, key stakeholders may set out goals and guiding principles. Here, guiding principles are understood as means to achieve the organisation’s goals. They may include statements such as, ‘We shall provide patient and family centred care’, or ‘We shall balance clinical care, research, and education’. Guiding principles for a facility project may include phrases such as ‘Support a culture of safety’, ‘Sustainable architecture’, or ‘Encourage multidisciplinary teamwork’. The design brief is likely to list both quantitative and qualitative requirements. It will support a clinical services plan; it will suit a budget and chosen a site. It will need to respect its regulatory environment (codes and standards). In addition, it may list desirable features such as prioritising access to views of nature, providing patients with environmental controls, or designing for adaptability. Extraordinary effort will be expended in conciliating between the many, and often conflicting, requirements of the client and clinical staff, as well as those of regulatory bodies, design standards, and guidelines. When personal views come into play – and they will – clear communication is vital. Challenge can be taken as an opportunity not to despair, but rather to innovate.

Subjectivity versus objectivity

A bid for objectivity may be made. However, it will more than likely come up against the inherent subjectivity of the design process. At every juncture, choices are made; at some, options are deliberately tabled for a debate. When examining aspects of a design that cannot be compared via objective, similar measurement, subjective assessments are made. It is here that designs will be viewed through the prism of cultural, aesthetic, functional, environmental, human, organisational, and business values. These values will affect choice of direction, and guide the design process, whether or not the team is consciously applying them. Values, therefore, lead to the selection of a preferred solution when objective measurement is not possible. This article proposes that shared or deliberately agreed values can be utilised as moderators when difficult choices arise.

Considering sleep

A literature review4 leads to the conclusion that it is in the nature of major injury, surgery, and hospitalisation, to adversely affect sleep. Furthermore, it indicates that re-establishing one’s circadian rhythm may actually be a relevant part of the healing process. The evidence suggests that when hospital inpatients sleep better, they are less susceptible to infection, nosocomial or otherwise. Pain, deficient wound healing, and tumour growth, have all been associated with poor sleep. Psychological well-being and general physical disposition benefit from good sleep, as does patient satisfaction. It is clear, therefore, that, according to our knowledge today, the value of sleep to hospital inpatients is very high. Having established and accepted inpatients’ night-time sleep duration and quality as a moderating value for design, deliberate choices can be made in order to favour sleep quality.

Moderating values for subjective decision-making

Architects, as a matter of course, deal in diverse metrics, concurrently. They are obliged to deal in complex, multidimensional problems. Therefore a degree of subjectivity, and creative resolution, is inherent to the architectural design process.5 This is not to say that design is primarily subjective. Architects do, of course, deal in many aspects of design that can be, and are, separately examined and minutely detailed. This is a practical necessity; however a purely analytical, systematic approach does not lend itself to architectural design. On the other hand, healthcare design is a group effort requiring excellent communication between all contributors. To many of those, creative resolution is anathema. The analytical thought process is intrinsic to most healthcare designers’ interlocutors’ training in sciences, including the applied sciences, such as medicine. When differences arise, one would prefer to see this challenging energy channelled into a creative force. Successful innovation should be possible provided that there is clarity as to how designs and specifications are to be appraised. With a plethora of non-architects undertaking subjective architectural evaluation in decision-making roles within the design process, as well as objective detail contributions that will affect the whole, a methodology for moderating between elements that cannot be submitted to comparable measure would help to improve design resolution.

A set of joint values

A set of jointly owned, or explicitly agreed, values would allow members of a team to approach new information in a relatively consistent and harmonious fashion. Debate is not eliminated; values cannot be deployed one at a time; they constantly affect one another, systemically. In addition, values themselves colour our understanding of system relationships and fundamentals within that whole. Holistic, systemic appraisals are required because people do not experience aspects of their environment as separate phenomena. It is necessary to understand how parts of the environment affect one another. The way in which aspects and qualities of space and form are integrated creates a whole system that is something greater than the sum of its parts. Franklin Becker, who has written on the matter for many years, has lately coined the term ‘Organizational ecology’ in conceptualising the workplace as a system in which physical design factors both shape, and are shaped by, work processes. Evidence-base criteria should apply twice: ideally, evidence-based criteria will indicate the relative importance a particular type of use. Thus, clinicians and architects may reach a mutual understanding with regards to use-values. These can then be used to moderate debates arising in the design process. Evidence-based design literature conveys the knowledge as to the environmental features or characteristics that can best contribute to that use. High-value uses can be deceptively prosaic, such as sleeping or walking. :

References

1 Evans GW. Environmental stress and health. In: Baum A, Johnston M eds. Handbook of Health Psychology, London: Lawrence Earlebaum Associates, 2001. 2 Clemesha MR. The new image of the hospital, grants and guidelines for architectural design [Dissertation in Portuguese]. São Paulo: FAUUSP 2003. 3 Ulrich RS, Zimring C, Zhu X et al. A review of the research literature on evidence-based healthcare design. HERD 2008; 1 (3): 61-125. 4 Kennedy MR. Sleep as a moderating value in healthcare design. HERD 2012; 6 (1): 122-42. 5 Lawson B, Dorst K. Design expertise, 2009. Oxford, United Kingdom: Architectural Press. 6 Becker F. Nursing unit design and communication patterns: what is ‘real’ work? HERD 2007; 1 (1), 58-62.