Informing the design of hospital architecture on patients

Transcription

Arenberg Doctoral School
Faculty of Engineering Science
Informing the design of hospital architecture
on patients’ spatial experience in motion
Margo Annemans
October 2015
Dissertation presented in partial fulfilment of the requirements for the degree of PhD in Engineering Science: Architecture
THE
EXPERIENCE
OF
Margo Annemans
Supervisor:
Prof. Ann Heylighen
Co-supervisors:
Prof. Chantal Van Audenhove
Arch. Hilde Vermolen
Members of the Examination Committee:
Prof. Herman Nys
Prof. Sarah Pink
Prof. Liliane Pintelon
Prof. Tom Thys
Prof. Patrick Wollants, chair
Dissertation presented in partial fulfilment of the requirements for the degree
of PhD in Engineering Science: Architecture - October 2015
© 2015 KU Leuven, Science, Engineering & Technology
Uitgegeven in eigen beheer, Margo Annemans, Berchem
Alle rechten voorbehouden. Niets uit deze uitgave mag worden vermenigvuldigd en/of openbaar gemaakt worden door middel van druk,
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All rights reserved. No part of the publication may be reproduced in any form by print, photoprint, microfilm, electronic or any other means
without written permission from the publisher.
THE
EXPERIENCE
OF LYING
Margo Annemans
Acknowledgements
Conducting this PhD research over the past five years has been a challenging but truly
enriching experience, which would not have been possible without the help and support
of numerous others.
A special thanks goes out to all who participated in this research. First and foremost I
want to thank the patients who were willing to share their time and insights with me under
often not obvious circumstances. I would like to direct a special thanks to the people of
Gasthuiszusters Antwerpen, the volunteers, logistic assistants, nurses, and physicians at
the departments where I worked and especially Willeke Dijkhoffz and Roger Albertijn,
without your support I would never have been able to conduct this fieldwork. Also the
hospitals where I was allowed to volunteer deserve a word of thank. I thank Bernie Byrne
and Will Wimshurst for the information they provided on the Maggie’s Cancer Caring
Centre in London. Finally I would also like to thank all those who took part in the individual
and focusgroup interviews, workshop, and expert panels I organised over the years.
I want to thank Ann Heylighen for being the best supervisor one could imagine and
much more than that. She put up with all my crazy ideas and managed to keep me
focused without curtailing my enthusiasm on various side-tracks. Thank you for being as
accessible to discuss findings and difficulties as all other topics that came to my mind along
the way. My co-supervisor Chantal Van Audenhove I would like to thank for her belief
in – and passion for the aim of this research. Her more distant but always supportive and
critical remarks enriched the end result. I acknowledge the members of my supervisory
committee for their suggestions over the years. Thanks goes to my past and present
colleagues in Leuven who were always there to share both substantive discussions as
joy and laughter: Stijn Baumers, Francesca Bozza, Koen Coomans, Cathérine Elsen,
Jasmien Herssens, Dorien Meulenijzer, Ido Morag, Greg Nijs, Jeandonné Schijlen, Iris
Vansteenwinkel, Peter-Willem Vermeersch, and Lisa Wastiels.
I would like to express my sincere gratitude to the board of osar architects for initiating
and supporting this PhD research, believing in me, and giving me the freedom to define
the direction of this project. Hilde Vermolen, partner at osar and my industrial supervisor,
deserves special thanks for the extraordinary effort she put into reading through this
academic work over the years but especially in the last months. Thank you, Hilde! I
also thank my colleagues at osar, who might have asked themselves what exactly I was
doing all this time. Specific thank goes to Nabila Ryahi for being present when I needed
someone to complain to and Kathleen Verrijken for the effort she put into the layout of
the manuscript.
I recognize that this research would not have been possible without the financial assistance
of the Baekeland program of the Agency for Innovation by Science and Technology in
Flanders (IWT-Vlaanderen). and osar architects nv.
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The experience of lying
Last but not least I would like to thank my family, especially my grandmother, parents, and
sisters, for the support they provided me through my entire life. A big thank you goes to
my love and best friend, Erik who always manages to put things in perspective and who
probably visited more playgrounds than he would ever have imagined. Finally also our
wonderful daughter Laurian did her share. She provided a nice distraction and forced me
to take time off when I seemed glued to my computer. Without these people’s attention,
encouragement and support, I might never have reached the finish.
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Abstract
Hospital buildings tend to be experienced by patients from a, for architects, atypical
perspective, namely lying in a hospital bed. This altered perspective has a significant
impact on patients’ spatial experience. Gaining insight into this experience is for most
architects not trivial, but crucial if they are to design truly patient-centred hospitals.
This PhD research started from a twofold aim. The first aim was to gain insight into
patients’ spatial experience. To this end I investigated which aspects relevant to
architectural practice have an impact on patients’ experience of a hospital environment.
The second aim was to inform hospital design on this experience to anticipate the needs
of patients and other users. To this end I investigated how insight into patients’ spatial
experience can be translated in a format that is applicable for architectural practice.
Researching patients’ spatial experience in a hospital setting requires a research
approach that is sensory-rich, experience-oriented, able to address motion, and flexible.
Combining multiple methods that take into account the different sensory modalities
involved in patients’ spatial experience allowed tailoring the approach to each patient’s
particular situation. Face-to-face interviews with patients, participant observation,
accompanied walks, photo-, image-, and video-elicitation, and documentation of the
built environment, are complementary in offering insight into patients’ spatial experience
in different research settings. To select these settings criteria used in hospital logistics
to identify patient profiles were slightly adapted to the experience-oriented aim of
the research. Patients were grouped according to the length of their stay, their degree
of familiarity with the hospital, and whether or not their admission was planned. This
resulted in four research settings covering three patient profiles: long-term patients
being transported along a familiar route to dialysis; patients arriving at the emergency
department; and patients at two day surgery centres with a distinct managerial and
spatial concept.
Across the different patient profiles, patients’ spatial experience is found to be impacted
by interactions between material, social and time-related aspects. Each group of patients
interprets these aspects and their mutual relationship in a (slightly) different way. Also
being static or in motion appears to be a factor of influence. This holds for the different
components of experience, including sensory perception, personal interpretation
or meaning making, and affordance. By designing hospital buildings architects thus
influence also patients’ social interaction and time perception. The insights gained add an
experiential dimension to the aspects brought forward by Evidence Based Design studies:
whereas most hospitals tend to group patients in wards according to their pathology, from
an experiential perspective this does not seem to be the most appropriate approach.
Hospital design should also consider patients’ experience in motion: when patients are
wheeled around, they experience the hospital building as a concatenation of spaces with
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each space having a share in the overall experience. Finally the results show that the built
environment takes part in patients’ experience a hospital’s care vision.
These insights have important implications for the design of patient-centered hospitals.
Paying attention to patients’ relationships with relatives and staff and clear communication
are clearly essential elements of being patient-centred. However, as a hospital’s care
vision turns out to be enacted not only by what staff communicates explicitly or how it is
trained, but also by the built environment, the hospital building can play an important role
in the implementation of a concept like patient-centeredness. Because of the importance
of motion in patients’ spatial experience, attention should be paid not only to the patient
room or examination room, but to each space where patients pass through including
hallways, changing rooms, and elevators. Spatial and managerial organisation should thus
go hand in hand.
To inform architectural practice on patients’ spatial experience, an information format
was developed that is able to communicate 1) the different components of experience:
perception, meaning making, and affordance; 2) the aspects identified as impacting
patients’ spatial experience: material, social, and time-related; and 3) the conclusions
drawn from the fieldwork at different research settings. Five layers of information were
identified: static images, both drawings and pictures; video-material to communicate the
impact of motion; testimonies from participating patients; text explicating one or more
aspects; and articles elaborating on one of the research settings.
Architects were found to value the information for its authenticity and would like it to
become part of their tacit knowledge so that they could apply it throughout the design
process. This would allow them to speak for those who are often not heard in the design
process, e.g. when talking to hospital boards or other stakeholders. Moreover, it would be
valuable to substantiate design decisions. If a client does not pay attention to patients’
experience, results from scientific research can offer a persuasive argument to put it on
the agenda.
The PhD contains specific contributions for architects, healthcare providers, and
researchers. Apart from offering architects guidance to conduct fieldwork in care
settings themselves, it formulates explicit recommendations on how to design more
patient-centred hospitals: taking into account the altered perspective from a patient in
a bed, both physical and social; supporting visual contact between patient and staff in
all areas where patients come; providing space for an additional person to spend time
in a comfortable way; and designing spaces that communicate a focus on the care
patients receive rather than on the medical procedure. Healthcare providers are shown
how to pay more explicit attention to the impact of the built environment on managerial
organisation and patients’ experience, both in daily practice and during design briefing.
For researchers, the PhD documents a research approach specifically addressing motion,
a topic that is under-researched on a building scale. It also sheds a new light on the
impact of space on patients’ experience, static and in motion, which could add to existing
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research on patient experience, mostly from a nursing perspective. Finally the scope of
design research is broadened by adding experiential information valuable for architectural
practice. By adequately translating the insight gained into patients’ spatial experience
in motion to these three groups, this PhD contributes to realising truly patient-centred
hospital buildings.
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Samenvatting
Ziekenhuisgebouwen worden door patiënten vaak beleefd vanuit een, voor architecten,
atypisch perspectief, nl. liggend in een ziekenhuisbed. Dit alternatief perspectief heeft
een sterke invloed op de ruimtelijke beleving van patiënten. Inzicht verwerven in deze
beleving is voor architecten geen eenvoudige opdracht, maar essentieel willen zij
gebouwen ontwerpen waarin patiënten echt centraal staan
Dit doctoraatsonderzoek startte vanuit een tweeledige doelstelling. De eerste
doelstelling was om inzicht te verwerven in de ruimtelijke beleving van patiënten. Hiertoe
werd onderzocht welke aspecten, relevant voor de architectuurpraktijk, van invloed zijn
op de ruimtelijke beleving van de ziekenhuisomgeving, al dan niet in beweging. De
tweede doelstelling was om de inzichten uit het eerste luik ingang te doen vinden in
het ontwerpen van ziekenhuizen om zo beter tegemoet te komen aan de noden van
patiënten en andere gebruikers. Hiertoe werd onderzocht hoe inzichten in de ruimtelijke
beleving van patiënten vertaald kunnen worden in een format dat toepasbaar is in de
architectuurpraktijk.
Onderzoek doen naar ruimtelijke beleving in een ziekenhuiscontext vraagt om een
onderzoeksaanpak die gericht is op beleving, toelaat de verschillende zintuigen en
beweging te bestuderen en flexibel is. Een combinatie van verschillende methoden,
die elk bepaalde zintuiglijke aspecten van ruimtelijke beleving naar boven brachten,
laat toe rekening te houden met de persoonlijke situatie van patiënten. Face-to-face
interviews met patiënten, participerende observatie, vergezelde wandelingen, foto-,
beelden videobesprekingen en het documenteren van de gebouwde omgeving vulden
elkaar perfect aan om inzicht te verkrijgen in de ruimtelijke beleving (in beweging) van
patiënten in verschillende onderzoekslocaties. Om deze locaties te selecteren werd
gebruik gemaakt van criteria uit de zorglogistiek. Deze criteria werden aangepast aan
het belevingsgerichte karakter van het onderzoek wat resulteerde in patiëntengroepen
geselecteerd op basis van verblijfsduur, bekendheid met het ziekenhuis en het al dan niet
gepland zijn van de opname. Hieruit volgde vier onderzoekslocaties en drie bijhorende
patiëntenprofielen: langdurige patiënten die een vertrouwde route naar de nierdialyse
volgden, patiënten die net waren opgenomen op de spoedafdeling, en patiënten in twee
dagziekenhuizen met uiteenlopende organisatorische en ruimtelijke concepten.
Onafhankelijk van hun profiel bleek dat de ruimtelijke beleving van patiënten werd
beïnvloed door interacties tussen materiële, sociale en tijdsaspecten. Deze aspecten
en hun onderlinge relaties werden door elke patiëntengroep (iets of wat) verschillend
geïnterpreteerd. Ook of een patiënt al dan niet beweegt bleek een invloedsfactor.
Dit geldt voor de verschillende componenten waaruit beleving is opgebouwd,
zintuiglijke waarneming, persoonlijke interpretaties en betekenisgeving, en affordance.
Wanneer architecten ziekenhuizen ontwerpen hebben zij dus een belangrijke invloed
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op hoe een patiënt tijd of sociale relaties ervaart. De verkregen inzichten vormen een
belevingsgerichte aanvulling bij de aspecten die door Evidence Based Design studies
naar voren geschoven worden. Uit het onderzoek blijkt dat patiënten groeperen per
afdelingen op basis van pathologie niet noodzakelijk het meest aangewezen is vanuit een
belevingsgericht oogpunt. Bovendien is het ook belangrijk dat een ziekenhuisontwerp
rekening houdt met het feit dat patiënten ruimte beleven in beweging: wanneer patiënten
worden rondgereden ervaren zij het ziekenhuisgebouw als een aaneenschakeling
van ruimtes waarbij elke ruimte bijdraagt tot de totaalbeleving. Tenslotte blijkt dat de
gebouwde omgeving een belangrijke rol speelt in hoe patiënten de zorgvisie van het
ziekenhuis ervaren.
Deze bevindingen hebben belangrijke implicaties voor het realiseren van een
patiëntgericht ziekenhuis. Aandacht voor relaties met personeel en familie en duidelijke
communicatie zijn essentiële elementen van een patiëntgerichte werking. Aangezien
de zorgvisie van een ziekenhuis niet enkel kan worden afgeleid uit hoe het personeel
communiceert of zich gedraagt, maar ook uit de gebouwde omgeving, blijkt echter
dat ook het ziekenhuisgebouw een belangrijke rol spelen in de implementatie van zulke
werking. Gezien het belang van beweging in de ruimtelijke beleving van patiënten is
het erg belangrijk om niet alleen aandacht te besteden aan de patiëntenkamers en
onderzoeklokalen, maar aan elke ruimte waar patiënten door komen, inclusief gangen,
kleedruimtes en liften. Ruimte en organisatie dienen dus hand in hand te gaan.
Om deze inzichten ingang te doen vinden in de architectuurpraktijk werd een
informatieplatform ontwikkeld dat het mogelijk maakt om 1) de verschillende
belevingscomponenten (waarneming, betekenis en mogelijk gemaakte activiteiten),
2) materiële, sociale en tijdsaspecten van invloed op de ruimtelijke beleving van
patiënten en 3) conclusies uit het veldwerk te communiceren. Het platform voorziet
vijf informatielagen: stilstaande beelden (tekeningen en foto’s), videomateriaal dat de
aandacht vestigt op het belang van beweging, getuigenissen van patiënten, toelichting
m.b.t. de verschillende aspecten en tenslotte ook artikels die dieper ingaan op een
bepaalde onderzoekslocatie.
Architecten waarderen de informatie vooral omwille van de authenticiteit. Liefst willen
zij deze informatie tot hun basiskennis maken zodat ze deze kunnen inzetten bij het
ontwerpen; enerzijds om diegenen te vertegenwoordigen die vaak niet gehoord worden
tijdens het ontwerpproces, bv. wanneer gediscussieerd wordt met ziekenhuisdirecties
en andere belanghebbenden; anderzijds om ontwerpbeslissingen te onderbouwen.
Wanneer een opdrachtgever weinig aandacht besteedt aan patiëntenbeleving, zou
een architect dit op de agenda kunnen zetten met deze informatie als ruggensteun.
Wetenschappelijke resultaten kunnen hierbij een doorslaggevend argument vormen.
Dit doctoraatsonderzoek biedt inzichten voor zowel architecten, zorgactoren als
onderzoekers. Architecten kunnen eruit leren hoe ze eventueel zelf veldwerk in
een ziekenhuisomgeving kunnen aanpakken. Daarnaast worden ook enkel concrete
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aanbevelingen geformuleerd over hoe een meer patiëntgericht ziekenhuis kan worden
ontworpen: door rekening te houden met het veranderde perspectief van een patiënt,
zowel fysiek als op sociaal vlak; door ervoor te zorgen dat het gebouw de relatie tussen
patiënt en zorgverleners ondersteunt in elke ruimte waar patiënten komen; door
ook ruimte te voorzien voor de personen die patiënten vergezellen zodat zij de tijd
comfortabel kunnen doorbrengen; en door de ruimte zo te ontwerpen dat de nadruk ligt
op de zorg die patiënten krijgen eerder dan op medische procedures. Zorgactoren wordt
getoond hoe ze expliciet aandacht kunnen besteden aan de impact van het gebouw op
de organisatie en patiëntenbeleving, zowel in de dagelijkse praktijk als bij het opstellen van
een programma van eisen. Onderzoekers vinden in dit doctoraat een aanpak om beleving
in beweging te onderzoeken, een onderwerp dat zeker op de schaal van het gebouw nog
onderbelicht is. De focus op de ruimtelijke beleving van patiënten biedt een aanvulling
bij onderzoek naar patiëntenbeleving tout court, wat nu voornamelijk gebeurt vanuit
verpleegkundige hoek. Tenslotte wordt de reikwijdte van ontwerponderzoek verbreed
door de meerwaarde van belevingsgerichte informatie voor de architectuurpraktijk aan
te tonen. Door de verkregen inzichten uit het onderzoek naar de ruimtelijke beleving
van patiënten op een adequate manier te vertalen naar deze drie groepen, draagt dit
onderzoek bij aan de realisatie van patiëntgerichte ziekenhuisgebouwen.
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TABLE OF CONTENTS
PROLOGUE1
SETTING THE SCENE
3
Context3
State of the art
4
Aim and research questions
8
Outline of the PhD
9
Reader’s guide
11
EXPLORING THE RESEARCH FIELD
15
Introduction17
Literature review
17
Research methods
23
Findings24
Discussion and future work: The social space of a mo-ving object
VOLUME 1 - METHODOLOGICAL APPROACH
31
35
1. Design research, theory, and epistemology
2. Hospital reality from a lying perspective: Exploring a sensory research approach
3. How to research spatial experience in motion? Gaining insight into patients’ experience of hospital transports
VOLUME 2 - PATIENTS’ SPATIAL EXPERIENCE IN MOTION
39
1. In-patients’ spatial experience: Interactions between material, social and time-related aspects
2. Patients’ spatial experience at an emergency department
3. Being transported into the unknown: How patients experience the route to the operation room
4. Being wheeled or walking: A qualitative study of patients’ spatial experience in day surgery centres
5. Discussion and Conclusion: Gaining insight into patients’ spatial experience in motion
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VOLUME 3 - INFORMING ARCHITECTURAL PRACTICE
43
1. What makes an environment healing? Users and designer about the Maggie’s Cancer
Caring Centre London
2. How to introduce experiential user data: The use of information in architects’ design process
3. From designing for the patient to designing for a person
4. Being wheeled through the hospital: How can design be informed about hospital patients’ spatial experience in motion?
5. Discussion and conclusion: Informing hospital design on patients’ spatial experience in
motion
GENERAL DISCUSSION AND CONCLUSION
47
SUMMARIZING THE CONTRIBUTIONS
49
Working at an intersection of research domains
51
What is in it for you?
52
Reflections on the methodological approach
54
Lessons learned
57
Future research
59
Final thoughts
61
ABOUT THE AUTHOR
65
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PROLOGUE
I detest hospitals. Still.
A harsh statement to start this PhD, but it is true. They make me nervous. They make
me nervous because of the impressive building, the smell of disinfectant, the knowledge
that they are full of sick people who might make me sick. Because they confront me with
everything that could go wrong. And I do not like that feeling of vulnerability. From the
moment I enter, I cannot wait to leave again.
Hospitals fascinate me. More and more…
Indeed, as much as hospitals make me nervous, they attract me. Without this dislike, I
might have studied medicine. They are complex buildings and complex things are being
done inside. Many people put their best foot forward to heal people, to make people
who come in all puzzled, leave with hope. This is a noble cause in which I would like to
take part. Although, as an engineer-architect, I will never work on the foreground of what
patients experience as the healing factor of their hospital stay, I have always believed that
architecture has the potential to improve patients’ well-being.
Given my dual stance towards hospitals, my interest was immediately sparked
when, back in 2009, the people at osar architects – an architecture firm specialised
in designing healthcare buildings – mentioned that they were eager to know how a
hospital environment could contribute to improving patients’ experience. Working
at an architecture firm, conducting basic scientific research, and sitting in the first row
to introduce the results in architectural practice seemed the perfect combination for
me. The call for the Baekeland program of the Agency for Innovation by Science and
Technology (IWT) in Flanders came just in time. As is written on the IWT website: “The
purpose of the Baekeland mandates is to support basic research that […] offers added value
to the company involved in the project. However, the research should be directed towards
achieving a doctorate (PhD) diploma and meet the accepted criteria for doctoral research.
In other words, the project should fit within strategic basic research with an economic [=
practical] finality, defined as high quality research that is innovative and provides the PhD
student with ample intellectual properties. It aims to build up scientific or technological
knowledge as a basis for economic applications.”
It is within this context that my PhD came into being. Throughout my PhD research,
decisions regarding objectives, research approach and analysis were always weighed
against their applicability in architectural practice. Balancing wishes, needs, and
requirements related to academic and architectural practice has been challenging.
I sincerely hope that this manuscript will be interesting and valuable for people from
architectural practice, the healthcare sector, and the academic world alike.
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Setting the scene
In the preamble to this PhD research, while preparing the grant application for IWT,
I encountered two major issues regarding the implementation of research on hospital
environments in architectural practice. On the one hand, knowledge on healing
environments and the meaning of patient-centeredness in relation to the built
environment does not seem to be ready to be implemented in architectural practice.
On the other hand, few information formats seem to exist that inform architects on and
engage them in using insights into patients’ (spatial) experience in their design process.
Based on these issues, which constitute the context of the research, I present two central
research questions. Thereafter, I elucidate how I addressed these questions by explaining
the outline of my PhD. Finally I give some guidance to read the upcoming 4 volumes.
CONTEXT
This PhD research came into being on the initiative of osar architects. As osar has been
specialized in the design of hospitals and other care buildings for years, they were not
seeking for a broad overview of tendencies in hospital architecture over the last century,
neither did they require a typological analysis. These are tasks for which professional
architects are trained and have the necessary tools at hand. Moreover, others have
extensively conducted and published this research previously (Wagenaar, 2006). In his
book The architecture of hospitals, Cor Wagenaar (2006), a historian working on the
relationship between health and the built environment, starts with this overview and
analysis, but soon moves on to the next step. By giving voice to various researchers in
the field of hospital and care architecture, the book identifies several tendencies and
gaps in the existing research at that moment. One of the mentioned gaps is the lack of
information on patients’ opinions, ideas, and views (Malkin, 2006), thus their experience
of hospital architecture.
In line with the importance the people at osar assign to the lived experience of the
inhabitants of the care facilities they design, they were seeking solid information about
the impact of space on hospital patients’ experience. Additionally this information should
be suitable for use in architectural practice. In a small scale, private housing project
architects can simply ask their clients, who are also the (future) inhabitants, about their
views, ideas, and experiences. In complex large-scale buildings like hospitals, the most
vulnerable user groups are rarely involved in the design process (Lawson, 2006). In an
architecture competition, for the sake of anonymity, the client is even completely absent.
osar already tries to bypass this by organising quality chambers (kwaliteitskamers), a
series of meeting to which they invite various actors in the domain they are designing
for to serve as an ersatz client and reflect on the design. Yet, mostly for practical reasons,
the most vulnerable actors in each domain were never invited: no older people took part
in the meeting on residential care facilities, no youth delinquents nor their family in the
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one on a youth prison. As osar felt this was a flaw in the collected knowledge, this can be
considered the motive for this PhD research.
Even when focussing only on the most vulnerable users of a hospital, the patients, various
groups can be identified. As osar articulated the need for a broad understanding of
patients’ experience, presented in a way that could create empathy with each of these
groups, I did not want to restrict my research to one group of patients but show the wide
variety amongst them. While designing architects should be able to empathize with the
people they are designing for.
In my PhD I connect architectural practice to research and practice in other disciplines.
By combining osar’s needs with the state of the art in hospital organisation and design,
I aim to take a step forward in gaining insight into the design of truly patient-centred
buildings.
STATE OF THE ART
To inform architects on patients’ spatial experience, insights need to be gained into the
hospital environment and the use of information in architectural practice. Both are in
constant dialogue in this PhD research.
HOSPITAL ENVIRONMENTS: HEALING AND PATIENT-CENTRED?
Hospitals are complex buildings with a broad range of users (Mens & Wagenaar, 2009).
From a functional angle, the building programme consists of a list of spaces related to the
business process. The sequence of admission, diagnostics and treatment results in a need
for displacing patients and staff. Depending on the situation and the need for specific
technology, physicians might visit patients or patients are brought to them, walking, or
in a wheelchair or bed, accompanied by a staff member or not. Patients with various
pathologies or profiles make use of the same facilities, like operation rooms, recovery,
radiology, etc. As these facilities are situated at different locations in the building,
many interactions take place. Additionally some not strictly medical movements, like
visitor flows or food delivery, need to be taken into account. Accommodating all these
movements, solving the logistic puzzle, and meeting all medical-technical requirements
holds considerable challenges for the built environment.
Not all characteristics of hospital spaces are defined by their function (Mens & Wagenaar,
2009). Apart from some minimal dimensions and (often also minimal) technical
equipment, hospital spaces mostly need to facilitate the logistic structure. Even when
the spatial layout were determined only by business processes, like those underlying the
logistic structure, a broad range of design solutions would still be possible. Architecture
holds the potential to do much more than just supporting functional organisation. It
seems to have a direct and arguable influence on people’s well-being (Jencks, 2006;
Sternberg, 2009). Its effects can be experienced not only by patients, but also by hospital
staff and visitors. To improve someone’s health and well-being, two strategies can thus
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be followed. One starts from the individual, the other from the environment. Whereas
the medical profession focuses on the former and aims to solve (health) problems,
architecture and design influence the latter and can contribute to prevention.
The World Health Organisation (2006) defines health as “a state of optimal physical,
mental and social well-being, and not merely the absence of disease and infirmity.”
Historically, the main function of hospitals was indeed to improve patients’ well-being
rather than cure them, as medical knowledge was limited. Although the ancient Greeks
already acknowledged the importance of architecture in caring for the ill and wounded,
it was Florence Nightingale who halfway the 19th century put the environment’s healing
qualities on the map. In her Notes on Nursing (Nightingale, 1969) she describes the
importance of improving sanitary conditions in hospitals and pleas for a pavilion typology
so wards would be easily ventilated and patients could benefit from fresh air and natural
light. With the rise of technology, like the Röntgen machines, and the discovery of
bacteria by Louis Pasteur at the end of the 19th century, healthcare shifted its focus from
the environmental to the medical, resulting in the utilitarian and highly technical buildings
we still know today (Wagenaar, 2006). In these machines a guérir, patients are considered
as objects to be fixed rather than as people.
With the foundation of the Planetree organisation in 1978, the tone was set for a new
shift towards a more patient-centred approach of healthcare. As written on its website,
this organisation declares to reclaim for patients the holistic, patient-centred focus that
medicine has lost. Everything in the hospital setting should thus be evaluated from the
patient’s perspective, also the built environment (Planetree, 2015). Since behavioural
scientist Roger Ulrich (1984a, b) published his findings on the impact of green and
window views on patients health and well-being in leading scientific journals, the
relation between environment and clinical outcome, is being acknowledged and further
elaborated. The concept of healing environment, referring to environmental aspects
that add to patients’ recovery process, became a hot topic in publications for research
(Huisman et al., 2012; Sternberg, 2009) and practice (e.g. Dijkstra, Pieterse, & Pruyn,
2006; Mens & Wagenaar, 2009; Van den Berg, 2005). More recently, the link between
architecture and neuroscience is being explored (e.g. Pallasmaa, 2014; Sternberg, 2009).
Today patients have changed from passive care receivers into active consumers (Sermeus
& Vleugels, 2010), who are well informed and hold high expectations towards hospital care
(De Wilde & Muylle, 2012; Malkin, 2006). From their perspective, many existing hospitals
are no longer adapted to how hospital care has evolved. As more and more patients
receive outpatient treatment, the number of hospital beds is decreasing (OECD, 2012).
Most patients stay in the hospital for a shorter, but intense period. As a consequence
of this evolution admitted patients are likely to experience space during a considerable
amount of time while lying in a bed – either in their room, or when being wheeled to an
examination, operation, or treatment. If hospitals want to be truly patient-centred also
the built environment should meet patients’ expectations in these various situations.
Recent definitions of patient-centeredness focus on healthcare access, sociocultural
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practice, and patient feedback, activation and empowerment (Aboumatar & Pronovost,
2013). Older definitions rather concentrate on needs, values, and preferences: focussing
on the whole person, offering emotional support, alleviating physical discomfort,
communicating adequately, sharing information, providing education, strengthening the
patient–provider relationship, including family and friends, and coordinating care across
settings (Aboumatar & Pronovost, 2013). As none of these needs, values, or preferences
directly addresses spatial aspects, research is needed to gain insight into what designing
a patient-centred hospital building could mean (Lawson, 2010).
INFORMING ARCHITECTURAL PRACTICE
Some architects might feel that the use of scientific information will erode the intuitive
and artistic side of the profession (McCuskey Shepley, 2006). Others, like osar architects,
realize that (re)designing complex hospital buildings in light of the above mentioned
evolutions requires a solid ground to base design decisions on. Therefore, researchers
and designers should share information (McCuskey Shepley, 2006). The road to this
information sharing is paved with various obstacles ranging from the framing of the
research question, over cultural differences, to practical issues like time pressure. Each
of these, whether described as obstacles or rather as issues at stake, has been further
elaborated elsewhere (Cross, 1982; Lawson, 2010, 2013; Schön, 1983). Being aware of
them is an important first step when analysing sources of information stemming from
research and directed at practice.
Even when architects aim to base their design decisions on solid information, taking
into account users’ diversity, empathising with all of them and anticipating how they
will experience a building, is not an easy task. One of the best-known desk books for
architectural practice (Neufert, 2000) is still based on the Modulor as presented by Le
Corbusier in 1925: a healthy, 1m82 tall male who explores space by walking (de Francia
& Bostock, 2000). In the context of a hospital, however, this profile is met by only a
small number of users, especially in the group of patients. Although other reference
books provide more diversity in building users’ physical characteristics (Haak, 2005), they
mostly provide practical and ergonomic information, like dimensions needed for certain
activities (e.g. turning circles or widths of doors for beds or wheelchairs). Specific insights
into patients’ spatial experiences do not seem to be systematically collected so far. If
hospital (re)design is to take into account patients’ perspective, then architects, planners,
and hospital boards need accessible, scientifically sound information about the divergent
spatial experiences and needs of diverse patient groups.
In the past different initiatives were taken to develop instruments that provide those
involved in the design of healthcare facilities with relevant information on environmental
aspects that have a positive impact on (ill) people and improve their recovery, health,
and well-being. Most of these instruments aim to collect available knowledge on the
spatial qualities of care environments. Based on a score system an existing building,
ward, or design can be tested against the list of environmental aspects. TNO (2015),
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the Netherlands Organisation for Applied Scientific Research, developed an instrument
named OAZIS, which stands for Researching Attractiveness of Care environments
through an Impact Scan. A previous version of the Dutch tool was based on a British
evaluation system for healthcare buildings, AEDET, Achieving Excellence Design
Evaluation Toolkit (Department of Health, 2015). Both OAZIS and AEDET aim at
healthcare organisation to evaluate their building stock. The tools take the form of an
Excel file that can be downloaded from the organisations’ website. The file contains
a checklist - addressing topics like privacy and autonomy, views, comfort and control,
facilities, way finding, interior, nature, and staff - that can be filled out by a designer
or care organisation to obtain a score of the building or design. Scoring the outcome
of a building in terms of users’ health and well-being has been taken a step further by
architecture and computer-science researchers (Durmisevic & Ciftcioglu, 2010). They
developed a knowledge-modelling tool for evidence-based design in which a computer
program weighs aspects against each other and calculates the impact of this input on
patient recovery.
Apart from these instruments with a quantitatively scored output, improving design can
also be achieved by inspiring architects. In the healthcare context, a good example is
IDEAs, an online tool developed by the University of Sheffield for the British Department
of Health in 2008. IDEAs was conceived and developed as a way of utilising the latest
research evidence. IDEAs provided information on people – patients, staff and visitors –
to support the design of healthcare places and as such aimed to respond to the emotional
and functional requirements of healthcare delivery. The tool dealt with activities (arriving,
bathing, resting, circulating, consulting, shopping, socialising and waiting) rather than
individual spaces or rooms. Around each theme information was provided and illustrated
with sketches and pictures. Unfortunately the webpage has been taken down, and can
thus no longer be consulted. A website like InformeDesign (Informedesign LLC, 2003),
which has a section on healthcare, brings together content, resources, people, and tools
that offer useful evidence for design. The website is structured around three themes:
space (building types, design specialisations), issues (design topics like building materials
or personal needs), and occupants (user types according to e.g. age, gender, education).
Following each category a list of published articles can be found. Although the website
unites many sources, the provided information is not presented in a way that is directly
appealing to architects or triggers creativity.
The instruments discussed above all provide valuable (spatial) information. However, they
do not address spatial experience. Interest in informing designers on people’s experience
is mainly encountered in product design and Human Computer Interaction (HCI).
Architecture seems to be lagging behind. Psychologist Liz Sanders (2009), president of a
design research firm, claims: “I have been working [at a big American architecture firm] […],
trying to work out how to bring a human-centred approach to architecture and planning. We
are not there yet. I thought it might take a couple of years. Now, after five years, we are just
beginning to make some progress. It’s a big nut to crack.” Later she continues: “Architecture,
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in my opinion, is on the trailing edge. It has been slowest to move from ‘architects design
buildings’ to ‘architects need to be involved in designing for experience, healing and so on.’
This is the bigger context of where we’re going.” It is exactly this movement, my PhD aims
to contribute to. The insight that the use of scientific research holds potential both to
design as to convince clients, has been commonplace for quite a while (Brandt et al.,
2010). However acknowledging the opportunities is not enough, research findings also
need to find entrance into the design process on a more than sporadic basis. This could
be facilitated by suitable information formats. Inspiration for these might be found in
formats used in other design disciplines to inform and engage designers with the people
using their products or services. Yet, some additional challenges seem to derive from the
specificities of architectural practice.
As architecture is a design discipline in which artistic processes and ways of knowing are
combined with more technical engineering and scientific knowledge, theory and science
are not new to architecture (Lawson, 2010). For a long time however, it were mostly
the engineering sciences, like building mechanics and physics, that had a significant
impact on how buildings were designed. Introducing empirical knowledge about human
behaviour may be more problematic as it deals with creating and organising space, which
lies at the heart of the architectural design process. Hence a clash of artistic and scientific
ways of knowing seems inevitable. Bryan Lawson (2010) identifies three key reasons for
this: architects’ solution-focused approach, the episodic knowledge in the discipline, and
the layered meaning assigned to architecture. A solution focused approach means that
architects tend to generate ideas about possible solutions and then by evaluating these
solutions come to an idea that matches the remaining solution to the problem (Lawson,
2006). Due to the lack of an overarching theory in architecture, architects tend to base
their designs on references (Heylighen & Neuckermans, 2002). These exemplary building
are valued by combining aesthetics, organisation, and integration in the environment.
If architects are to be informed, on patients’ spatial experience insights should thus be
presented in a format that is solution-focused, is able to contain episodic knowledge, and
allows to communicate layered meaning.
AIM AND RESEARCH QUESTIONS
As pointed out above, the built environment has an important role in patients’ experience.
Yet, in a hospital it tends to be experienced from a, for architects, atypical perspective,
namely lying in a hospital bed, static and in motion. Finding information on patients’
spatial experience is not easy for most architects. Therefore the aim of this PhD is twofold.
First, it aims to gain insight into patients’ spatial experience. To this end, I will identify
and document the spatial aspects that play a role in patients’ experience of the hospital
setting. Second, the PhD aims to inform hospital design on patients’ spatial experience
to anticipate the needs of patients and other users. To this end, the insights into patients’
spatial experience are translated into a scientifically validated and applicable format for
architects.
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These aims result in two central research questions concerning the relationship between
hospital architecture and patients’ well-being. On the one hand I want to gain insight into
patients’ experience in relation to the built environment. Given the specific context of the
hospital and the unique situation patients find themselves in, the first research question
is formulated as follows:
Which aspects relevant to architectural practice have an impact on patients’ spatial
experience of a hospital environment, from a lying perspective?
On the other hand, if I want the research findings to find acceptance in architectural
practice, the insights gained should be offered to architects in a format that resonates
with their way of working. Therefore, the second research question is formulated as
follows:
How can insight into patients’ spatial experience be translated in a format that is applicable
in architectural practice?
These two questions shaped the research approach, both to study the spatial experience
of hospital patients and to study architectural practice. However, the exploration of the
hospital world, as reported in the next chapter, informed an additional, more practically
oriented research question:
How should architects design space when all daily activities are reduced to one (moving)
object?
Insight into how hospital spaces can be designed to optimize patients’ spatial experience
is expected to contribute to improving the well-being of hospital users, especially patients.
OUTLINE OF THE PHD
This first chapter situated my PhD research and set the scene for the following ones. In
the second chapter I report on my initial exploration of the hospital environment through
literature and fieldwork. The manuscript consists of 4 separate volumes.
As this introductory volume can be considered the framework for my research, it also
includes the general discussion and conclusion. In the concluding part, I come back to the
research questions and draw conclusions based on a combination of the three substantive
volumes. I highlight the contributions of this PhD research for various stakeholders like
architects and hospital boards, but also researchers in adjacent fields like people studying
motion on other scales. Finally, I point at some limitations of the PhD research and outline
directions for future research.
The reporting of the actual research is organised around the three domains to which it
contributes.
A first contribution, addressed in volume 1, is methodological. V1 Chapter 1 explains the
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methodological mire in design research and connects it to the practical epistemology
and theoretical positioning of my PhD. Subsequently, in V1 chapter 2 and 3 I discuss how
the research approach I adopted came into being and which methods it consists of. In
V1 chapter 2 I explore how and to what extent alternative ways of querying participants,
by providing them with a camera, pens, pencils and paper, can help them reflect on their
spatial experience and as such provide useful insights for researchers and architects. In V1
chapter 3 I describe the challenges I encountered when trying to expand the approach
described in V1 chapter 2 to obtain a better understanding of patients’ spatial experience
while moving through a hospital. My role as a researcher in collecting and analysing data
is addressed as well.
The second contribution, addressed in volume 2, concerns the main body of my PhD
research. Based on insights into patient types in relation to aspects of space and motion
(logistics), I defined three groups of patients, which shape the structure of the second
volume. The volume reports on the spatial experience of long-term hospital patients (V2
chapter 1) and their counterpart, patients who are just being admitted at the emergency
department (V2 chapter 2). Thereafter, I concentrate on spatial experience in motion
by studying how patients in a traditional day surgery centre experience the transport to
the operation room (V2 chapter 3) and how this differs from the experience in a walkin day centre (V2 chapter 4). The combination of this wide variety of hospital spaces
and situations results in profound insights into hospital patients’ experience, both static
and while moving through the building. In the discussion (V2 chapter 5) findings from
the different fieldwork settings are combined and discussed in light of related work and
feedback from care practice.
Volume 3 addresses how the insights gained into patients’ spatial experience (in motion)
can be made available for architects. This third contribution focuses on the introduction
of experiential user data in architects’ design process. The first two chapters study the
use of (user) information in architectural practice. By analysing the case of the Maggie’s
Cancer Caring Centre London I investigate to what extent the actual users experience
the added value of a building that has been designed based on a real person’s experience
(V3 chapter 1). Then I address the results of focusgroup interviews with architects about
how, why and when they use information while designing (V3 chapter 2). The two
following chapters report on design outcomes. I document how introducing testimony
of a real person, namely Maggie Keswick, could inspire and direct (student) architects
working on a Maggie’s Cancer Caring Centre for Leuven (V3 chapter 3). Finally, I
report on a workshop I organized in which professionals were provided with different
types of (experiential) user data, and analyse how this influenced their design process
paying specific attention to the aspect of motion (V3 chapter 4). The insights from
chapter 3.4 are synthesized in an architectural practice-oriented information format,
which is presented to and discussed with an expert panel at osar architects to appraise its
applicability and usability in architects’ design process (V3 chapter 5).
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READER’S GUIDE
By combining the context and state of the art I sketched in the first two chapters, with
the overall discussion and conclusion of my PhD in one volume, I provide an overview
of what I started from and where I took it. Although this can be considered a somewhat
unconventional approach, it allows a reader to obtain an overall understanding of the
research before embarking on the exploration of the three substantive contributions.
This threefold contribution of my PhD is purposely reflected in its layout. I hope this
helps you in navigating through the document.
The chapters of the three substantive volumes are ordered to provide a good view on how
the architectural practice-oriented format came into being. However, as most chapters
have been written as independent publications, each part can be read separately. If you
are mainly interested in the final format to incorporate the insights into your design
practice, you can just start reading at the end. By reading backwards the further you read
the clearer it will become why certain decisions were made, and where certain ideas stem
from. Also content wise, you will gain a more profound insight into certain conclusions
that are addressed in the format. The methodological contribution could provide you
with a better understanding of how, as a designer, you could gain access to the spatial
experience of the people you are designing for.
The choice to build up this PhD around individual publications implies certain curiosities
that might appear as inconsistencies.
-- Each chapter that has been published or is under review as an article or book chapter
starts with the bibliographical reference to its (upcoming) publication, an abstract and
keywords. These chapters are written in the first person plural, referring to the coauthors, my academic supervisor (Ann Heylighen) and co-supervisor (Chantal Van
Audenhove), and my industrial supervisor (Hilde Vermolen). The other parts - the first
chapter, discussions (V2 chapter 5 and V3 chapter 5) and conclusion - are written in
the first person singular. Due to its relation with the students’ design studio, V3 chapter
3 was co-authored by Elina Karanastasi, supervisor of the design studio.
-- Although I tried to limit repetitions to a minimum, some ideas or argumentations
appear more than once. This is a concession I needed to make to be able to publish
each part separately.
-- The order in which articles are presented in this manuscript does not always match
the chronological order in which the research was conducted. The three contributions
developed iteratively in parallel, one influencing the other. Also within the volumes
I sometimes chose to rearrange the order of the publications to obtain a more
streamlined story. This too is elaborated on the introduction page of each volume.
All images have been made by me, except when indicated otherwise.
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References
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doi:10.1177/1062860612453617
Brandt, R.M., Chong, G.H., Martin, W.M., 2010. Design informed: Driving innovation with
evidence-based design. John Wiley and Sons, Hoboken.
Cross, N., 1982. Designerly ways of knowing. Des. Stud., Design as a Discipline 3, pp. 221–227.
De Francia, P., Bostock, A., 2000. Le Corbusier : le Modulor. Birkhäuser, Basel.
Department of Health, 2015. Achieving Excellence Design Evaluation Toolkit (AEDET
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en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_082089
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ziekenhuisomgeving voor kinderen. Merz, Gent.
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facilities into healing environments through psychologically mediated effects: systematic
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Durmisevic, S., Ciftcioglu, O., 2010. Knowledge modelling tool for evidence-based design.
HERD 3, pp. 101–123.
Haak, A.J.H., 2005. De menselijke maat: een studie over de relatie tussen gebruiksmaten en
menselijke afmetingen, bewegingen en handelingen. DUP Satellite, Delft.
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Design Journal, 5(2): pp. 8-22.
Huisman, E.R.C.M., Morales, E., van Hoof, J., Kort, H.S.M., 2012. Healing environment: A
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Hospitals. NAi publ., Rotterdam, pp. 449–459.
Lawson, B., 2006. How designers think. Architectural Press, Oxford.
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McCuskey Shepley, M., 2006. Evidence Based Design and Architecture, in: Wagenaar, C.
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Sermeus, W., Vleugels, A., 2010. Patiëntgestuurde organisatie. Kluwer, Mechelen.
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Exploring the research field
A shorter version of this chapter has been published as a conference paper:
Annemans, M., Van Audenhove, C., Vermolen, H., Heylighen, A., 2011. Lying architecture:
Experiencing space from a hospital bed. Proceedings of Well-being 2011: The First International
Conference Exploring the Multi-dimensions of Well-being. Birmingham City University and the
Royal Institute of British Architects (RIBA), Birmingham, 10 p.
Compared to the original version of the paper, the literature has been updated and
slightly elaborated. In the part on Evidence Based Design (EBD) I focus some more on
the meaning of evidence for architects, as this relates to insights discussed in volume
3. Further I elaborate on specific aspects addressed in EBD studies based on the most
recent literature so I can put my findings against them in the discussion of the second
volume. The part on experiencing architecture is complemented with new insights
regarding the relation between sensory perception and motion.
Keywords
bed
building
hospital
lying
well-being
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Abstract
Patients experience a hospital from a particular
perspective - lying in a hospital bed - which is highly
under-researched. To gain a better understanding of
spatial experience from this perspective, we combined a
literature review with exploratory fieldwork and in-depth
interviews with various stakeholders. Through qualitative
data analysis, three major themes were identified that
characterize this perspective: a hospital bed is a material
object; it has a social dimension; and it is used to move a
patient through the building. The combination of these
three aspects suggests that the perspective of lying in a
hospital bed, with its implications for social interaction
and movement, may offer important new insights into how
hospital buildings could be designed.
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INTRODUCTION
Despite many efforts by healthcare providers, for most people a hospital stay is rarely
a pleasant experience. The hospital building as such is part of this perception. The
specific situation of a hospital stay is largely determined by the building set-up and
materialization of the organization. Once you are admitted to a hospital your perspective
changes completely. A bed is assigned to you and you turn from a visitor into a hospital
patient (Nijhof, 2006). The influence of patients’ lying perspective on their experience is
largely under-researched. By developing a profound understanding of the relationship
between patients, the objects that take part in their hospital life - especially the bed - and
the building, we hope to enable architects to design environments that add to the healing
character of the hospital building. The overall aim of our research is therefore to gain
insights into patients’ spatial experience. Ultimately, we aim to inform hospital design on
this experience to anticipate the needs of patients and other users.
This paper starts with a literature review on three main themes: Evidence Based Design,
how people experience the built environment, and the lying perspective. Findings from
the literature review are confronted with the results of explorative fieldwork and in-depth
interviews with different stakeholders. Based on the data analysis themes are identified
to develop a better understanding of the role of the bed in the hospital. By explicating
this role from a physical, psychological and sociological perspective, the spatial aspects
that interact with the use of the building come forward. These aspects, observed from a
hospital bed, may be of major importance to improve a patient’s well-being. A hospital
is not limited to the patient room, neither is our study. We follow patients with their bed
wherever they move at whatever time.
LITERATURE REVIEW
EVIDENCE BASED DESIGN OF HEALTHCARE BUILDINGS
In the literature on healing or wholesome environments, an important concept is Evidence
Based Design (EBD). EBD can be considered the theoretical counterpart of healing
environment (Huisman et al., 2012). It found its origin in the analogy with other evidence
based approaches to research and practice. When it comes to buildings for healthcare
especially Evidence Based Medicine (EBM) was a source of inspiration (Hamilton, 2003).
An exact definition of EBD does not seem to exist. Roger Ulrich, who laid the foundation
of the concept (Ulrich, 1984a, 1984b), preferred to speak of supportive design, focusing
on buildings’ importance in stress reduction (Ulrich, 1991). According to Kirk Hamilton
(2003), who frequently published on the meaning of evidence in practice, the term EBD
is used to address designs that create environments which are therapeutic, supportive
of family involvement, efficient for staff performance, and restorative for workers under
stress (Hamilton, 2003). Later he adapts the term EBD to evidence based practice. An
evidence based project is then “a project whose design is based on reliable evidence from
research“ (Hamilton, 2006). This reliable evidence can be found in various sources but
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should always be evaluated on its clinical outcomes.
Since the late 1970’s, mainly in the U.S., various studies were conducted about the
spatial experience of healthcare buildings. However, it took until the mid 1980’s before
scientifically validated research came up with evidence for the beneficial influence of
green (Ulrich, 1984a) and views from a hospital window (Ulrich, 1984b). In the following
years, the Center for Health Design was established. Since 1993, this non-profit
organization collects and finances research about the qualities of care buildings. In 1998,
a study was published based on the available literature at that time in which 20 variables
and their clinical outcomes were collected and evaluated in terms of the validity of their
conclusions (Rubin & Center for Health Design, 1998). During the next decade, every
few years a new report was published, collecting and analysing studies from the last
years (College bouw zorginstellingen, 2008; Dijkstra et al., 2006; Ulrich et al., 2004; Van
den Berg, 2005). All reports have a threefold objective: providing a literature overview,
analysing and criticizing the methodological rigour, and indicating how architects or
other designers could use the results in practice. All of them come to a similar conclusion.
Only very few studies result in clear clinical evidence and withstand the methodological
evaluation. Those that meet both criteria focus on perfectly measurable, quantitative
data, such as daylight and fresh air (ventilation). Since both the research approaches and
the results are so heterogeneous, it seems very hard to come up with concrete design
guidelines (College bouw zorginstellingen, 2008; Dijkstra et al., 2006).
The most recent review of EBD studies (Huisman et al., 2012) structures its analysis
according to the target group, patients and family or staff, and applies the so-called
pyramid of evidence (Sackett, 2001), a way of evaluating research published in a practiceoriented book on EBM. According to the book, systematic reviews are the most valuable,
then evidence from randomized control trials, followed by not randomized control trials,
finally descriptive studies, evaluation studies and all qualitative studies are at the lowest
level of the pyramid (right above those not considered scientifically valuable at all). The
review’s findings (Huisman et al., 2012) are ordered according to topics and subtopics
stemming from previous literature reviews (Ulrich et al., 2008, 2004), Figure 1 provides
an overview of which topics are addressed and how civil engineer, Emelieke Huisman and
her co-authors group them. Additionally some recommendations are made to adapt or
reorganize the ordering of Ulrich’s overview. The aspect “no errors” should be related to
staff needs as well and there is an emerging trend to create “residentiality” which could
extend the topic on privacy and single rooms (Huisman et al., 2012).
Despite the growing body of literature that examines the effects of the physical
environment on patients’ healing process and well-being, EBD studies do not highlight
the confounding of parameters and lack to consider the impact of the outcomes in a
holistic way (Huisman et al., 2012). In the end the studies’ conclusions are invariable: the
research is not ready to hand architects what they need to start designing an evidence
based building. The scientifically valuable, experimental studies cannot readily be
generalized to complex, real-life settings, as they typically focus on a selection of isolated
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USERS
PATIENTS
FAMILY/
RELATIVES
TOPICS
SUBTOPICS
1.1 no errors
identical rooms
lighting
1.2 safety & security
reduce falls
reduce infection
hygiene/ cleanliness
accessibility
indoor quality
1.3 control
STAFF
1.4 privacy
single patient room
waiting room
1.5 comfort
art
view
visual comfort
acoustic comfort
orientation
1.6 family support
materials
orientation
1.7 organisation &
functionality
way finding
lighting
1.8 technical support
ergonomics
--------fig.1
User perspectives classified in topics and subtopics based on literature reviews by Ulrich et al., 2004, 2008
(source: Huisman et al., 2012)
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features. Future research should include not only clinical but also non-clinical evidence
(Van den Berg, 2005). Indeed, as most EBD studies focus on people’s primary (clinical)
reactions that provide hard objective data, their opinions, ideas, and views are not often
addressed (Malkin, 2006). Collecting this non-clinical evidence requires a more general
understanding of how hospital architecture is experienced.
EXPERIENCING A WHOLESOME ENVIRONMENT
A wholesome environment involves more than the aspects that withstand the evaluation
of EBD studies. To develop a profound understanding of the physical environment as
a whole, we take a step back and consider how architecture in general is experienced.
Although architects are mainly visually oriented, architecture is not experienced through
vision alone (Rasmussen, 1964).
Architect and architecture scholar Juhani Pallasmaa (2005) argues that all senses take
part in the experience of architecture. The way places feel, sound or smell have equal
weight as how they look. Since the ancient Greeks, Western culture focuses mainly on the
visual. During the Renaissance a hierarchical system between the senses was established,
starting with vision, ending with touch. These priorities concerning the senses, their
relative roles and interactions had a great impact on perception in architecture. In other
cultures than the Western, smell, taste and touch do have a collective importance in
behaviour and communication. Because of the obligatory distance between spectator
and object it could be argued that vision rather separates us from the world whereas
the other senses can unite us with it. This imbalance in our sensory system provokes an
inhumanity of contemporary architecture. Pallasmaa (2005) states: “It is thought provoking
that this sense of estrangement and detachment is often evoked by the technologically most
advanced settings such as hospitals and airports” (p.22). Since a hospital is definitely a place
where lack of attention for all sensory experiences may lead to discomfort, especially here
more attention should be paid to multi-sensory design.
Yet, even the five traditionally known senses are insufficient to grasp the full complexity of
experiencing the environment (Ingold, 2000, p.243). The perceptual systems, as James
Gibson (1968) calls our five sensory organs, can be extended with the orienting system
(basic to all others). This system addresses, together with the haptic and visual system,
the experience of movement. Accordingly Yi-fu Tuan (1977) extends the five traditionally
known senses with kinaesthesia, described as the sense of movement and also related
with sight and touch. He considers these the sensory organs with a strong relation to
space and spatial qualities. When moving through a building, the views change but also
what you hear or smell can be different or you can sense a difference in materials. It is
through movement that meaning can be given to a space (Herssens & Heylighen, 2012).
As we are in motion while space remains immobile, we move ‘in’ space (Bollnow 2011,
p.55). As patients move or are moved, their spatial experience differs from what they
would experience from a static perspective. Moving makes views change (Ingold, 2000)
and the environment becomes a fluid space (Ingold, 2011).
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Also time and occurring activities play a role in how the environment is experienced.
While sitting in a waiting room time is differently perceived than when hurrying for
an appointment. Clock time differs from lived time (Lefebvre, 2004). This difference
between astronomical time (or clock time) and lived (or social) time also influences
the attention paid to the environment and its impression (Sorokin and Merton, 1937 in
Ingold, 2000). Waiting, whether in a hospital or elsewhere, is a research topic in itself
(Lofgren & Ehn, 2010). In the perceived duration of wait expectations, activities and
information provision seem just as important as the actually passed time. Literature on
waiting in the hospital addresses the concepts of occupied and unoccupied time to refer
to the difference in time experience when doing something or while anxiously waiting
in uncertainty (Nairn et al., 2004). This example draws attention to the importance of
occurring activities and personal situation for how we experience space. Rasmussen
(1964) claims that the perception of architecture depends on the person who perceives
it. Many social factors come here into play, a person’s background, education, mentality,
and mood, as well as the larger environment, both material and social. Knowledge from
previous experiences or what we learned from other people takes part in our perception.
It is thus influenced by memories of previous situations. Context plays an important part
in the interpretation of perception (Maclachlan, 1989). Only if we pay explicit attention to
movement, time, activities, and patients’ personal situation, on top of sensory perception,
spatial experience can be understood in its full complexity.
THE LYING PERSPECTIVE
Within the hospital you experience all sensory aspects, time, movement and activities
from one place: the hospital bed. From your bed you are confronted with the built
environment, not only while being in your room but also while travelling through the
corridors or waiting for an examination. The specific perspective from and the mediation
of the bed influence all these experiences. This viewpoint is not only underresearched
(van der Geest & Mommersteeg, 2006a), architects do not explicitly take it into account
either. The bed is often considered as a merely technical element, determining the
dimensions of rooms and corridors. Already midway the 18th century, Nicolai Eigtved
and Lauritz de Thurah designed the Frederiks Hospital in Copenhagen by basing all
dimensions on the hospital bed (Rasmussen, 1964). Since then, hardly anything changed;
optimizing logistic flows is still considered a more important in hospital designs than
patient experience (e.g. College bouw zorginstellingen, 2007). Although of crucial
importance and not to be underestimated, for the patient, there is more to a hospital stay
than logistics. Yet, only very few studies approach the hospital from an anthropological
viewpoint. The Dutch journal Medische Antropologie devoted an issue to the subject
of the bed in general and collected five articles about the sick bed in particular (van der
Geest & Mommersteeg, 2006b). Different articles addressed different roles of the bed
in a hospital, ranging from a practical (Gibson & Sierra, 2006) to a symbolic one (Nijhof,
2006).
In a hospital all (daily) activities take place in or around the bed. To this end many
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adjustments are made. Sociologist Myriam Winance (2006) describes the process
of trying out a wheelchair as a material adjustment, an emotional adjustment and an
(ambivalent) negotiation between individual and device. An analogue process can be
expected for a patient’s adjustment to a hospital bed. Due to the situation’s temporality,
patients’ adjustment to their hospital bed most probably differs from the one of wheelchair
users to their chair. Still, the hospital bed plays an important role in the relationship
between patient and building. In terms of materiality, it is a combination of things: the
frame with its entire technicality to move it up or down, or roll it back or forward, and the
sheets, covers and pillows. A bed is not a bed without bedding; the piece of furniture itself
cannot be called a bed (De Visscher, 2006). The difference between a hospital bed and
your own bed at home should not be underestimated. It looks different, and it certainly
feels different. The bed also symbolizes the emotional adjustment from being a visitor
to being a patient (Nijhof, 2006). It defines the person as a patient. The negotiation
between patient and world takes place at different levels. The bed, as a mediator, can
heighten one’s sensitivity to the building (Verbeek, 2005). When wheeled through
a hospital building, a patient may feel different things than when walking; an uneven
floor can be a major issue, which may be overlooked in other circumstances. Apart from
active and passive touch also dynamic touch enters the picture (Herssens & Heylighen,
2010). Jasmien Herssens and Ann Heylighen (2010) describe the three modes of touch
as follows: “We touch in an active way when we use our body directly to perceive tactile
stimuli, for example, when we follow a handrail with the palm of our hand, or when we are
looking for interior objects as landmarks. Passive touch takes place indirectly as movement
does not emanate from our own body but as a result of external sources. We feel for example
the heat of the sun, the atmospheric humidity, or the height of a balcony. Dynamic touching
occurs when we use a tool to touch with; for example a white cane used by people with a
visual impairment or a bicycle on which we feel the road when cycling.” Especially passive
touch can be a problem here - think of a draught, which makes the ventilation system
suddenly noticeable. The specificity of patients’ perspective also exemplifies how the
relation between person and technology - in this case patient and bed - can influence
interpersonal relationships. The lying perspective determines patients’ specific kind of
relation with conversational partners, just as a sitting perspective does for wheelchair
users (Verbeek, 2005).
Apart from the processes of adjustment between patient and bed, during a hospital stay
also a redefinition of the patient’s self takes place. Our identity is built on a combination
of how we see ourselves, and how others see us. On top of that our body is clearly intersubjective. We often pay little attention to it until something goes wrong (Mogendorff,
2003). The image a patient has of him/herself changes during the hospital stay. The
hospital gown transforms the individual body into a body for medicine (Gibson & Sierra,
2006) and the only place in the hospital you can call your own is your bed, you put on
the gown and get in bed once you arrive (Nijhof, 2006). Also the duration of the stay
influences how people deal with their new situation. One takes bed rest, which refers to
a limited period of rest as prescribed by a doctor or as deemed necessary because of an
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acute illness, but one is bedridden. Nursing scientist Angelika Zegelin (2008) describes
a phase model of becoming bedridden by older people. Since being bedridden has
a temporary status for most patients, the difference with taking bed rest is not always
completely clear. In our research we consider a bedridden patient as someone who, due
to a hospital stay, is assigned a bed and as a result identified with it. Each bed is allocated
to a certain ward with a specific pathology. The person in the bed is, at least for the
physicians, often reduced to a case with a certain condition (Gibson & Sierra, 2006).
RESEARCH METHODS
The main aim of the study reported here was to explore whether considering patients’
particular perspective - i.e., lying in a hospital bed - can provide new insights into the
spatial qualities of a hospital building that can benefit its users’ well-being. Therefore
we should facilitate participants to give any information that seems relevant to them.
We were looking for open-ended, emerging data with the primary intent of developing
themes from them. For this objective a qualitative approach seemed most appropriate
(Creswell, 2003). The data were collected through conducting explorative fieldwork,
by volunteering in a hospital, and semi-structured, in-depth interviews with different
stakeholders in the hospital.
VOLUNTEERING IN A HOSPITAL
The fieldwork took place in a Flemish urban community hospital. During four months,
every week half a day was spent there by the first author (henceforth referred to as
the researcher). The day was fixed on Monday mornings, a very busy moment at the
hospital. The researcher worked as a volunteer to bring patients to their room at the time
of hospital admittance. It was her job to guide them to the ward and introduce them to
the room and bed. All patients received a brief explanation about how the bed could
be adjusted, where to put their clothes, how to call the nurses etc. The close contact
with patients at their first encounter with the hospital offered valuable insights into their
reactions to the environment.
Although the hospital staff was aware of the researcher’s intentions, it was agreed that
patients should not notice any difference with other volunteers. Since no difference
was made, participants were not chosen nor assigned, and can thus be considered as
a cross section of the admitted patients. None of the participants were aware of their
participation. Therefore, the researcher could not make recordings and had only limited
possibility to take notes. Although certain highlights were written down during the
fieldwork, most notes were taken several hours after the observations.
IN-DEPTH INTERVIEWS
To gain a better understanding of the daily routines in a hospital and the role of the
building and bed therein, semi-structured interviews were conducted with various
stakeholders in the hospital. In order to recruit participants different tracks were followed.
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At the start of the research a Belgian magazine for specialists published an article based on
an interview with the researchers (Verrijken, 2010). With the article, a call for information
or possible participants was launched. A short summary was published in the magazine’s
online newsletter, which was picked up by various other medical sites. Seven persons with
various backgrounds responded. Six were contacted for an interview; the seventh was not
interviewed at this point because his work in a psychiatric centre transcends the scope of
the study. The voluntary participants were complemented with the researcher’s personal
connections. She interviewed 12 persons in total: two architects, two technical directors
of hospitals, three physicians (a general practitioner and two specialists), two nurses and
three patients.
The first part of the interview had the same structure for all participants. It started with
general questions about the spatial aspects of hospital buildings, going deeper into
patients’ reactions to them. In the second part the specific role of the bed in the hospital
was addressed, but questions differed depending on the interviewee’s role. These
questions may have a more social or a more technical focus. For example, nurses were
asked about patients’ reactions during transportation in a bed, a technical director was
asked how logistics influence the building’s design. All interviews were audio-recorded
and transcribed afterwards.
DATA ANALYSIS
After a first reading the interview transcripts were analysed according to the three themes
emerging from the literature review: EBD, experiencing architecture, and the bed. For
each theme parts of the transcripts were used as quotes to illustrate the topic as found
in literature. Since the interviews and field notes are both in Dutch, quotes used in this
paper have been translated to English by the authors. Because of the specific focus of
the research on the experience of lying, the coding was revised specifically based on the
role of the bed. At this stage, the field notes and interview transcripts were both coded
using qualitative data analysis software (ATLAS.TI). To establish a list of representative
codes, we started from terms grounded in literature (Creswell, 2003) and expanded the
spectrum by in vivo codes expressing themes that stepped forward through the process.
FINDINGS
The analyses enabled us to identify three major topics related to the bed, which
significantly shape patients’ experience of the hospital stay: the bed as a material object,
the bed as a social space, and the bed as a moving object.
THE HOSPITAL BED, A MATERIAL OBJECT
The bed’s physical appearance turns out to be a key element in a hospital’s look and feel.
A technical director of a hospital phrased the most important features as follows:
“Yes, the bed is one of the most important [things]. It has to be functionally
good. It has to be technically good. In the past it was just a steel bed,
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now it has all these trimmings: electrical, self-adjustable. Also for the
nurses, it makes things easier. When I want to put the head of the bed
a little straighter, I used to have to call the nurse, now I can do it myself.
Thus, that instrument, that’s very important. And besides that, it has to
be manoeuvrable; it has to be wide enough, long enough. Yes, it has to be
mechanically and technically right.”
It is mainly the technology which differentiates a hospital bed from a regular one. When
introducing patients to their bed, the most important thing volunteers or (in other
hospitals) nurses explain is the functioning of the arrays on the safety bars which enable
moving the bed’s head and feet, so patients can make themselves comfortable. While
the functioning of the movable bed is fairly obvious, for some patients, it is a source of
confusion and uncertainty. However, for others the possibility of adjusting their own bed
gives them a certain autonomy and lowers the pressure on the nurses’ already tight work
schedule. A technical hospital worker mentioned:
“I take it as the ability for the patient to be in charge himself, to be able to
put his bed higher or lower.”
As a patient put it, while showing the functioning of the buttons:
“… it’s more interesting, because you can adapt the bed to your needs, yes,
more flat.”
Other technical features of the bed - like the possibility to move it up and down or lock
and unlock the wheels - were mentioned only sporadically by patients, and were mainly
addressed as useful and functional by nurses and physicians. They mentioned:
“well yeah, it’s useful that you can move it up and down […] definitely back
saving”
“the ergonomics, towards the nursing, is the high and low of the bed, so they
can ride more smoothly.”
The bed’s dimensions add to its ergonomics. For patients, this results in a bed that fits.
Some patients are too long, others too short for “the standard”:
“What happens often, I find, nowadays, that the beds aren’t long enough.
There are people who are 1m90 or 2m and they complain. You can enlarge
some of the beds, but not all of them. That‘s a source of irritation.”
The opposite is just as true:
“Some people are too short for their bed and slide down.”
For the staff having to take care of patients the most influential dimension is the bed’s
width. A specialist stated:
“… but it’s mostly avoided to do an examination in bed. When you examine
someone, a patient, in bed, that’s very difficultly working, because the bed is
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too wide. You have to bend over and that’s bad for your back.”
The bed’s technical features and dimensions both influence its maneuverability too. As
this aspect closely relates to the built environment, it will be addressed later.
Besides the frame’s intrinsic aspects, also accessories define the bed. A bed is not a bed
without its bedclothes and bedding (De Visscher, 2006). This counts just as much for
a hospital bed as for any regular bed, maybe even more. The bedclothes determine
how the bed feels and make, to a large extent, the difference between your own bed
at home and an unfamiliar bed in the hospital. Most hospitals still opt for sheets and a
cover while at home most (younger) people sleep under a duvet. More than half of the
participants mention this as an important aspect that contributes to the feeling of the
bed. A physician mentioned:
“The [patients] then want a duvet or something like that. Of course because
they‘re very familiar with that.”
When explaining the difference between younger and older patients a nurse said:
“Young people they’re used to a duvet. These are things you don’t find in a
hospital so that seems something unnatural and then you just don’t feel at
home. I think that’s for young people a reason to say: ‘this is strange, I don’t
feel at home.’”
One patient explained how it felt when she had her own bedclothes on her hospital bed:
“I don’t like sleeping with sheets, and normally it are always sheets. It’s like
when you return from vacation, you get into your own bed. It’s the same, your
own little cover, even if it’s a hospital bed, your own cover.”
Apart from the bedding, a hospital bed is also equipped with an infuse standard and a
handgrip. Although useful and necessary both were frequently mentioned as not very
handy while handling patient or bed. Certain objects in a hospital room are directly
related to the extended bed stay. Both the use of a lifting device and a bedpan influence
in their own way how the bed is experienced and relates to its environment.
When a hospital building is designed, the spatial aspects addressed in EBD studies
should obviously also be taken into account (College bouw zorginstellingen, 2008;
Dijkstra et al., 2006; Huisman et al., 2012; Schweitzer, Gilpin, & Frampton, 2004; Ulrich et
al., 2008, 2004; Van den Berg, 2005). However, these cannot be studied without paying
attention to the relationship between built environment and bed. Also the hospital’s
spatial organization influences many aspects that were mentioned by hospital users when
asked about their experience of the building.
During the volunteering work the two most frequent topics of conversation were the
number of beds in a room and the bed’s location in the room. Especially when patients
ask for a single room and this is not available, it is a source of frustration. In this case,
a good explanation helps considerably. However, also the opposite is true. Patients
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who ask for a room with four beds and are assigned a double room often protest even
harder. Here the reason is not always clear, but questioning a little further reveals that
the underlying motivation is often financial. When patients are assured that it will not
be more expensive, they are mostly very pleased. Still, some refuse to stay in a single
room. They feel more comfortable when someone is around. Offering choice to people
always seems the best option. This confirms what is found in literature (College bouw
zorginstellingen, 2008). Apart from the number of beds in the room, people tend to like
the bed at the window more than the other(s). As reasons for this preference both the
view and the increased privacy were mentioned.
Beyond the patient room, the building in general may facilitate or limit the hospital’s
working and interaction between staff and patients. Although the bed is considered a
handy means to transport patients through the hospital, its dimensions can also be a
restriction. One physician stated:
“personally, I always hate it when a patient goes somewhere with a bed,
because the consultation rooms aren’t at all designed for a bed and when it
enters, there’s hardly any space left. You can hardly do anything.”
The spatial organization also influences the experience of sound, temperature, light,
and views. Especially the fact that, while lying, you observe the room from a horizontal
perspective makes the experience very different. All patients mention that they suddenly
see the ceiling. One specialist who became a patient through an accident recalled that he
hardly saw anything else, even though he never had noticed it before:
“… you look up. Actually you see the ceiling all the time, and that’s the
hospital were you’ve been working for years, and then you’re in the bed and
you see the ceiling. Normally you don’t look at the ceiling and that’s strange.”
The relationship between the bed and its environment is a physical given. Participants’
reactions reveal the shortcomings or advantages of this relation.
THE HOSPITAL BED, A SOCIAL SPACE
The meaning of the hospital bed can be explored from different angels. There is the
strategic and economic meaning that is ascribed to it. In a hospital, the term “bed” does
not only refer to the object but covers both the number of available spaces in a ward and
the patients occupying them. Often heard quotes are:
“Yes, we have ‘beds’ available.”
“a big hospital has 1100 beds, yes, while there are probably way more beds
but they only have room for 1100 patients.”
Staying in bed is generally considered as a sign of being ill, as illustrated by quotes like
“For [the patients] the bed means being in need of care, bedridden.”
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“It’s really, when you no longer need your bed this means you’re getting
better. Being bedridden always has a negative connotation.”
When asked about the meaning of the bed on a personal level, participants referred to it
in a far more positive way. The bed was described as “a little house”, “his space”, “your own
little island”, and “the only thing you have”. In these descriptions we read that the bed is
considered as a retreat from everyday hospital life. Although the bed may be the patient’s
most familiar item in the hospital, it can never stand up to one’s own bed at home.
“ you get into [the bed] and you know it’s not yours”
“that bed is always worse than your own bed, maybe even when it’s probably
better, it just gives the patients an uncomfortable feeling, I think”
The fact that patients feel the need to retreat from their environment already indicates
that interactions between patients and others can be complicated. The bed, and
possible accessories, shape interactions between people. These interactions are very
diverse. There are encounters with strangers and people familiar to the patient, and
there are different ways to connect, visually, through touch, through sound, verbally, or
even through smell. The interactions directly related to the building organization have
been discussed above. Still, this organization also influences more personal interactions.
In any multiple person room, one has to deal with snoring, visitors, or toilet visits from
roommates. Because of the limited private space also very personal actions like going to
the bathroom sometimes take place within a few meters from each other. While using a
bedpan, one is separated from the other(s) mostly by a thin curtain only. This functions
as a visible barrier but hardly as an auditory or olfactory one. Yet, to a certain extent, the
interrelation with roommates is often also mentioned as possibly distracting or making
the stay more pleasant.
On a more personal level, the hospital building in general and the bed in particular can
work as an invisible threshold between patients and people close to them. One patient
summarized:
“People have a certain reserve, for example to give a kiss or a big hug.
Especially with whom you’re not so close, they also keep the distance. They
wouldn’t easily come up to you: ‘hello, happy to see you!’ and ‘how are you?’
Yes, spontaneity, that’s a big restraint of the bed. What’s very important,
I experienced, is that you can tell people you know quite well to come sit
on the bed: ‘Come, sit on the side of the bed.’ That makes it easier to talk
because the furniture in a hospital room around the bed, a fauteuil, a normal
chair, a little stool to put your feet on, those aren’t the things people like to
sit on…”
Indeed, the bed forms a physical barrier to approach the patient, while the room rarely
provides visitors an adequate alternative. Those who actually want to connect to the
patient need to overcome this barrier. Once this is done the bed becomes the centre of
shared activity.
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Apart from family and friends, also nurses intervene within this limited personal space.
Whether changing the sheets or assisting patients to get washed or sit up, they cannot
avoid that their actions, although necessary and caring, are often felt as an intrusion of
the personal space.
Outside their own room patients are even more exposed to (unwanted) interactions with
others. At the same time they are often literally overlooked. During the volunteering
work, the researcher caught herself interacting with the nurses over a patient’s head. Her
field notes mention:
“At a certain moment I take the elevator together with a nurse who pushes
a patient in a bed. The nurse smiles at me over the head of the patient. I
realize that I look over her myself. When I look at her, I see that she’s trying
as hard as she can to be as inconspicuous as possible.”
On the other hand, a patient in a bed seems to attract stares from other people. Especially
while waiting for an examination, they are very vulnerable to these. Both physicians and
patients mentioned:
“yes, everyone is watching, …”
“and then when you’re lying there, waiting in a corridor, you’re really a little
lost, I think, with your bed. Then there are passerby’s who just walk along…”
Addressing this problem in the hospital design does not seem trivial. When a niche
is created, such that patients waiting in their bed are less visible, a frequently heard
complaint is that they are totally neglected because a visual relation is lacking.
THE HOSPITAL BED, A MOVING PERSPECTIVE
Apart from the fact that a hospital bed makes you experience the environment from a
horizontal perspective, it is not static, it moves. For this reason a hospital bed is not like
any other piece of furniture. Perhaps a wheelchair would come close. The perspective
and movement both shape the experience of the building considerably. With regard to
the hospital’s material aspects, different sensory perceptions step forward. The haptic
experience changes with the bed as a mediator. Dynamic touch becomes increasingly
important, and also passive touch has its influence. The visual impression is different too.
One patient told us:
“So, the experience of being wheeled out of the room, going out of the door,
turning into the hall, then usually waiting for the elevator, rolling into the
elevator. You have those doorsteps, the transition from the flooring in the hall
to the elevator and obviously you feel that in your bed. The elevator seems
totally different because you realize more that you’re in a cage. And when
you’re wheeled out of it, you have that vibrating feeling at your bed and then
the hall, again those rhythmic movements from the light fittings that you
pass and your temperature, the difference in temperature when you pass
from one corridor to another. It flashes by, all that’s on the side, left and right,
it flashes by, and what’s on the ceiling, yes.”
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Nurses, for their part, did not deny that travelling through a hospital in a bed can be a
bumpy ride. One said:
“We wheel them around, we bump into things at all sides with the bed,
everywhere. For us that’s only a trifle, but when you’re lying in there…”
A little later she admitted:
“We knock up against all these things till they break. As nurses we’re very,
very good at that.”
The traces of this use can be read throughout the building and can be considered an
important source of information for our research.
With movement, also speed enters the picture. Interviewed patients often have the
impression that travelling through a hospital in a bed goes extremely fast. As mentioned
above, both the ceiling as the walls flash by. Because they cannot be observed properly
patients easily become disoriented. The direction in which the bed is pushed can add
to the feeling of disorientation. When lying in the direction one travels, the patient sees,
at least more of less, what is coming up but there is little relationship with the nurse
pushing the bed. When one lies in the other direction, everything on the way is a surprise
but permanent contact with the nurse is possible. Both have their advantages and
disadvantages. Regardless of the direction, patients seem to isolate themselves from
the world around them while travelling through the hospital. One patient explained it as
follows:
“I think that I consciously don’t look. Maybe my eyes are open but maybe I
cut myself off so I don’t have to see everything, so I don’t have to visualize
everything, because that’s too much. All the flashing, that’s not pleasant for
me.”
Although dependency is probably an important aspect throughout the entire hospitalstay,
many participants pointed it out as especially important in relation to the bed transport.
Signs indicating direction or points of orientation are all aimed at people experiencing
the building from a vertical perspective:
“It’s the feeling: ‘Where am I going now?’ The signs that hang there or the
remarks that hang against the wall, you can hardly read them, so you’re
completely dependent on your bed with the person who transports you.”
Because of the loss of control, also the sense of distance and time is distorted. This holds
both while travelling and while waiting. A little more interaction with others can help in
these situations:
“Then you’re put there, without being told anything. And what are two
minutes? What is a quarter of an hour? And it can take a lot of time. Then
you say: ‘Are they forgetting about me?’ and that’s not necessary in that
state. So that’s important.”
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Interestingly all technical directors and architects mention the importance of flows while
designing a hospital. Solving the problem of separated flows is unlikely to guarantee
a genuinely wholesome environment, however. Spatial experience clearly is a complex
given that entails more than just functional aspects.
DISCUSSION AND FUTURE WORK: THE SOCIAL SPACE OF A MOVING OBJECT
EBD studies as presented from the 1980’s on mainly focus on aspects of healthcare
buildings with clinical outcomes. Moreover, they pay little attention to the different
perspectives of hospital users. To develop a more articulate understanding of how
a hospital environment is experienced, sensory perception and the experiences of
movement and time should not be overlooked. By taking these aspects into account
patients’ specific experience from the hospital bed can be more fully understood.
Although most themes emerging from the literature review do turn up in the fieldwork
and interviews, the evidence does not always point in the same direction. For example,
one aspect considered extremely important in the approved EBD studies is the presence
of ventilation and fresh air (Van den Berg, 2005). Nevertheless, draught and difference
in air temperature between rooms and corridors were mentioned by participants as
important downsides while staying in, or moving through a hospital. Obviously we do
not want to plea for the absence of fresh air. Examples like this just illustrate that there
are multiple sides of the picture. Also the interpretation of certain aspects needs to be
differentiated. For patients (and others) to feel comfortable in a building orientation is an
important element (College bouw zorginstellingen, 2008; Nijhof, 2002). How orientation
should be facilitated, however, may be completely different depending on a person’s
viewpoint. While signs and arrays may be interesting to direct a visitor to the right
department, a patient who is wheeled through the building may need different reference
points not to become disorientated.
Compared to the themes emerging from the literature review (Gibson & Sierra,
2006; Nijhof, 2006), other themes were far more prominent in our data. A frequently
occurring theme was the object of the bed itself, its bedding and accessories. Technical
possibilities enhancing the comfort were brought up and the relationship between bed
and environment was considered an important factor. Around the bed much social
interaction takes place between patients but also with staff and visitors. This interaction
can be supported or counteracted by the built environment. Since the hospital bed is the
one place were patients’ entire hospital life takes place and the object traveling through
the entire building, its trajectory is expected to provide a unique perspective to take a
closer look at the built environment.
At this stage of our research, the aim of this study was to find a way to approach patients’
experience of a hospital environment from a spatial point of view. Different spaces in
the hospital are perceived differently depending on the situation. The research question
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– “which aspects relevant to architectural practice have an impact on patients’ spatial
experience of a hospital environment, from a lying perspective?” – can be fine-tuned
based on insights into EBD, the experience of the built environment and the perspective
from the bed. As patients’ particular perspective, lying in a hospital bed, is marginally
addressed in the literature so far, our research will further investigate this perspective.
A central question in our future research will be: “how should we design space when all
daily activities are reduced to one (moving) object?” Since classic pathologies tell us little
about patients’ experience of space, we are looking for a different angle to approach the
subject. At this point the trajectory followed by the bed through the building seems most
suitable. Ultimately, gaining insight into patients’ spatial experience in motion is expected
to contribute to the well-being of hospital users in general and patients in particular.
ACKNOWLEDGEMENTS
Margo Annemans’ research is funded by a PhD grant from the Baekeland program from
the Agency for Innovation by Science and Technology in Flanders (IWT-Vlaanderen).
The Baekeland program gives researchers the opportunity to complete a PhD in close
collaboration with industry, in this case with the architecture firm osar architects nv. Ann
Heylighen received support from the European Research Council under the European
Community’s Seventh Framework Program (FP7/2007-2013)/ERC grant agreement
n° 201673. The authors thank Hospital Network Antwerp (ZNA) for the provided
opportunity to volunteer and all the participants, especially the participating patients, for
sharing their time and insights.
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VOLUME 1
METHODOLOGICAL
APPROACH
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Before I report on what I found in response to the research questions, volume 1 provides
insight into the theoretical and epistemological positioning and the methodological
approach of my research. While you read this volume it is important to keep in mind that ...
read more:
VOLUME 1 - METHODOLOGICAL APPROACH
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VOLUME 2
PATIENTS’ SPATIAL
EXPERIENCE
IN MOTION
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experience of a hospital environment, from a lying perspective? This research question
comprises different elements to be researched. Identifying aspects impacting ...
read more:
VOLUME 2 - PATIENTS’ SPATIAL EXPERIENCE IN MOTION
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VOLUME 3
INFORMING
ARCHITECTURAL
PRACTICE
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How can insights into patients’ spatial experience be translated in a format that is applicable
in architectural practice? In this volume I address this research question in four steps, each
corresponding to one chapter. First I explore the effect ...
read more:
VOLUME 3 - INFORMING ARCHITECTURAL PRACTICE
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AND CONCLUSION
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Conclusion
GENERAL DISCUSSION
My PhD research started from a twofold aim. On the one hand, it aimed to gain insight
into patients’ spatial experience. To this end I addressed the research question: which
aspects relevant to architectural practice have an impact on patients’ spatial experience of
a hospital environment? This question is addressed in volume 2. On the other hand, the
PhD aimed to inform hospital design on this spatial experience to anticipate the needs
of patients and other users. The corresponding research question was: how can insight
into patients’ spatial experience be translated in a format that is applicable for architectural
practice? This question formed the basis for the research presented in volume 3. The
exploration of the hospital context (chapter “Exploring the research field”) informed an
additional, more practically oriented question: how should architects design space when all
daily activities are reduced to one (moving) object?
SUMMARIZING THE CONTRIBUTIONS
To gain insight into patients’ spatial experience, I developed a, sensory-rich research
approach. This approach combines different methods that allow addressing the different
sensory modalities involved in patients’ spatial experience, and that can be tailored to
each patient’s particular situation:
-- face-to-face interviews with patients,
-- participant observation,
-- accompanied walks,
-- photo- and image-production (asking patients to document their spatial experience
by taking photographs or making drawings),
-- video-elicitation (showing patients a video of the route they took and asking to provide
subtitles).
By applying this research approach I gained nuanced and in-depth insight into how a
hospital building is experienced from the perspective of different groups of patients.
Across different patient profiles this experience turns out to be shaped by interactions
between spatial/material elements, social aspects and time-related issues. Three general
conclusions are drawn:
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Conclusion
Although presented as three separate volumes, the contributions of this PhD are
intertwined and have been developed in constant mutual interaction. To illustrate this
relationship between the methodological contribution, the contribution on patients’
spatial experience in motion, and the one on informing architectural practice, I start by
summarizing the conclusions from the previous volumes. Then I sketch how my PhD
took shape at the intersection of multiple research domains. I highlight what my research
has to offer to different audiences, and reflect on the methodological approach. After
identifying directions for future work, I finish like I started with a short personal note on
what working on this research topic has meant for me.
-- Patients with different profiles have different expectations towards the hospital building.
Whereas most hospitals tend to group patients in wards according to their pathology,
from an experiential point of view this does not seem to be the most appropriate
approach. The small group of long-term in-patients long for a comfortable place to
reside, whereas most other patients consider the hospital as a transit space; for the
latter, the hospital building does matter as well but plays a rather supportive role in
their treatment.
-- The hospital building tends to be experienced by patients in motion. Only for a
minority of patients the lying perspective is a static one. For most patients being
wheeled around takes up a considerable amount of the time they spend at the hospital.
-- In patients’ experience a hospital’s care vision is enacted by the built environment, not
only by what the staff communicates explicitly or how it is trained.
These conclusions hold certain implications:
Conclusion
-- A traditional subdivision of the hospital population according to pathologies may not
be the most appropriate way to take care of patients based on their spatial experience
and corresponding needs.
-- Hospital design should pay attention not only to the patient room, or the examination
room, but to each space where patients pass through including hallways, changing
rooms, and elevators.
-- Spatial and managerial organisation should go hand in hand. Changing a care concept
does not happen overnight. Only with a suitably designed built environment can a
new concept be fully experienced by patients as an improvement.
As to informing hospital design, I found that architects found the insights into patients’
spatial experience valuable both for designing and for communicating with clients. To
consult the information they prefer it to be visual for easy use during the design process,
and they like it to be easily accessible - for example online. The prototypes I developed of
various information formats showed how the format impacts the transfer of information
on patients’ spatial experience to designers (chapter 3.4). Based on the insights gained
regarding the provided information (format) in relation to the design outcome, a set of
requirements was formulated. The relevance of the information and the validity of the
requirements were tested by presenting a proof-of-concept of an interactive video to an
expert panel and discussing its strengths and weaknesses. The expert panel’s comments
addressed different aspects of the format, the most important of which were its added
value for architectural practice, the character of its content, the structure, the information
layers, and the attractiveness and accessibility. The architects in the panel valued the
information provided for two main reasons:
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-- insight into patients’ spatial experience offers architects a basis to build up knowledge
on designing hospital buildings. This knowledge can be of importance when talking to
hospital boards or other stakeholders in that it enables architects to speak for those
who are often not heard in the design process.
-- architects can use the information to substantiate design decisions. If a client does not
pay attention to patients’ experience, architects can put it on the agenda. Results from
scientific research can then offer a persuasive argument.
In this format experiences from patients are directly shared with architects, and additional
information can be consulted through hyperlinks. The format reflects the insight I want
to communicate - insight into patients’ experience in motion – and to meet architects’
preference for information formats that are interactive and easily consultable online.
WORKING AT AN INTERSECTION OF RESEARCH DOMAINS
Positioning my research in just one domain is neither possible nor desirable. On the
contrary, it is rather positioned in between science and technology - because of the focus
on architecture - , humanities and social sciences - because of the research on experience
- , and health services and nursing research, classified under biomedical sciences because of the hospital context. Finding inspiration in one to inform the other(s) has
been a recurrent strategy throughout my research.
Architectural practice combines designerly ways of knowing with engineering and
scientific knowledge; making use of numbers, technical information and norms is thus
not new to architecture (Lawson, 2010). Yet architects have to do more than simply
implementing facts and figures. As their task is to design buildings where people can live
their life, the information these designs are based on should ideally stem from research
conducted in real-life situations. For the first aim of my PhD, following a social science
based reasoning therefore seemed the most valuable. Economic geographer Bent
Flyvbjerg (2012) who’s research focuses on planning and infrastructure, states that in
the social sciences the emphasis lays on contextualized studies involving field research
which produce intimate knowledge of localized understandings of subjective human
relationships, whereas the natural sciences rather excel at conducting decontextualized
experiments to understand abstract and generalizable law-like relationships. With this
contrast in mind, he argues that social sciences can make a difference in practice. My
research intended to do this on the scale of a building. To make this difference, only
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Conclusion
Providing architects an in-depth, scientifically sound understanding of the relationship
between patients, the building, and the objects taking part in their hospital life (e.g. the
bed), is expected to contribute significantly to the realization of truly patient-centred
hospitals. To provide architects and other actors involved in hospital design with sufficient
evidence to design healthcare buildings that adequately anticipate the experiences of
patients and other hospital users, my PhD took a first step in unravelling how hospital
buildings are experienced.
revealing interesting results is not enough, they should also be introduced to those
working in architectural and hospital practice.
Reality is not uni-dimensional. The insights gained through the hospital fieldwork address
three components of experience - sensory perception, memory and meaning making, and
afforded activities - and bring up material, social, and time-related aspects. As architects
mainly appreciate the richness and authenticity of the information on patients’ spatial
experience, I opted to describe my findings on this experience as closely as possible to
the raw data.
Conclusion
In the complex context of a hospital, a broad range of actors are involved. Management,
nursing, and hospital logistics amongst others contribute to the design and planning of a
hospital building from their perspective and according to their vision, while patients’ say
remains rather limited. Each of these domains has its own body of research in which the
built environment is addressed only marginally. When discussed, it is considered a static
given rather than a variable. With my research, which aimed not only to gain insight into
patients’ spatial experience, but also to inform architects on this experience to improve
future hospital design, I hope to have laid a foundation to consider space as a variable
when analysing a hospital context.
WHAT IS IN IT FOR YOU?
AS AN ARCHITECT
Due to the complexity of a hospital building and the pile of paperwork required to obtain
permission to do fieldwork there, a hospital may not be the easiest context to conduct
research. In this respect the research for design approach that was adopted in my PhD
may be the most appropriate. However, especially for more manageable, smaller scale
projects the research methods proposed in volume 1 could be a source of inspiration
for architects to conduct fieldwork themselves. By no means do I pretend to present an
exhaustive list of methods applicable in a hospital context (V1 §3.3). Yet by documenting
my experiences with a possible methodological approach I hope to help architects who
are interested in gaining knowledge on user experience getting started.
Furthermore, the approach focussed on the impact of motion and people’s spatial
experience. Although many architects may be aware of the importance of afforded
activities, it could be an eye opener to explicate this impact and specify where exactly
the added value of an alternative perspective can be found - be it just lying in a bed or
also being wheeled. The meaning and affordance of the built environment are related
not only to spatial aspects but also to social and time-related ones. By designing space
architects thus also strongly influence people’s time perception and interactions (V2
§3.5). Drawing architects’ attention to the extended repercussions their design decisions
could have, may motivate them to take into account patients’ perspective based on
real-life information rather than starting from their own interpretation or imagination of
patients’ experience. In response to the question: how should architects design space when
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all daily activities are reduced to one (moving) object?, some explicit recommendations for
architectural practice can be formulated:
-- take into account the altered perspective from a patient in a bed, both physical and
social (V2 §1.4.4, §3.5);
-- support contact between patient and staff in all areas where patients are awake (V2
§3.5, §4.6);
-- provide space for an additional person to spend time in a comfortable way (V2 §2.5,
§4.6);
-- communicate a focus on the care patients receive rather than on the medical
procedure (V2 §4.6).
To implement these recommendations architect and client should work towards a
common goal (V3 §1.6). This could be achieved by starting from a clear design brief,
appealing to architects’ creativity (V3 §2.5, §3.6). Despite architects’ preference for visual
information (McGinley & Dong, 2011), listening to people’s stories with an open mind and
without an architectural bias could be valuable for them to gain a good understanding of
patients’ spatial experience (V3 §4.4).
Being patient-centred is a common aspiration in healthcare practice. Hospital boards
tend to approach it from a managerial angle, with a focus on streamlining patientcenteredness with care processes and efficient staff employment. With my research I
point at the importance of a consistent policy with regard to space. To this end, new
insights regarding patients’ spatial experience are valuable. Whereas the methodological
approach offers an understanding of how these insights can be gained, the main gain can
be found in volume 2. While efficiency is highly valued in planning a hospital building,
hospital boards and architects should be aware that moving patients implies more than
hospital logistics. Paying more explicit attention to the built environment’s impact on
patients’ experience could add to an improved non-linguistic communication.
As illustrated in volume 3, how the design briefing is approached, has a significant impact
on the design outcome. In their role as a client, hospital boards play an important role
in supporting architects, hospital planners and technical services, to achieve a building
design that takes into account patients’ experience static and in motion. When drafting
an architectural brief, hospital boards should be aware that both the content and the
format influence the final building that will be constructed. Practicing more engaging
ways of briefing, based on sound research, has the potential not only to benefit the
collaboration with the architect during the design phase but also the realised building.
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Conclusion
AS A HEALTHCARE PROVIDER
AS A RESEARCHER
Throughout my PhD the research methods I applied were constantly subject to change
due to ethical, practical, or substantive considerations. Developing a methodological
approach in dialogue with the needs and restrictions of both a complex and sensitive
research setting like a hospital, and architectural practice, challenged the use of a
preconceived approach. Based on concrete needs from architectural practice, which I
identified in volume 3, I present in volume 1 a research approach based on a collection
of methods. This approach allows to flexibly apply and combine the methods proposed
depending on the specificities of the situation or the spatial experience one wants to gain
insight into.
Conclusion
The core of my research in the hospital has been to identify aspects that are of importance
for patients’ spatial experience. Gaining insight into this experience (volume 2) adds to
the existing body of research in nursing studies which addresses patient experience in
general and only marginally addresses spatial elements. It also points at the interrelation
between managerial organisation of care processes and spatial organisation, which could
be interesting when studying hospital policy.
Identifying motion as a determinant in (patients’) spatial experience draws attention to
the role of motion in architectural design. As I explored how to inform architects on this
determinant, the relevance of a suitable information format came to the fore. The interest
of architects in the video material and their suggestion to provide more information on
motion in buildings, e.g. a map displaying people’s routes, seems to point at a lacuna in
the information that is commonly available to architects. A useful next step thus seems
to be to develop an information format specifically aiming at transferring insights into
motion on a building scale to architectural practice.
REFLECTIONS ON THE METHODOLOGICAL APPROACH
METHODOLOGICAL APPROACH AND PATIENTS’ SPATIAL EXPERIENCE IN
MOTION
The main methodological challenge laid in finding research methods that allowed me to
gain access to participants’ spatial experience, static and in motion, and were applicable
in a hospital context. To get a grip on the spatial complexity of a hospital in a way that
does justice to the diversity of hospital patients’ (spatial) experience I derived patient
profiles from parameters used in hospital logistics – length of stay, standardization of
the admission and care process, and the possibility to plan the admission (CBZ, 2007).
These parameters were slightly adapted to make them more experience-oriented, which
resulted in the three groups of patients at the four research settings discussed in volume
2:
-- in-patients at a nephrology ward who were staying in the hospital for a long time and
where wheeled to dialysis and back;
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-- patients at the emergency department (ED);
-- and patients at a day surgery centre a) who were wheeled from their room to the
operation room (OR) and back and b) who walked to and from the OR.
Although material, social, and time-related aspects could be identified as relevant to
patients’ spatial experience regardless of their profile, deviating from a traditional hospital
division based on pathologies proved to be valuable in distinguishing subtle variations in
interpretation between the groups.
To study patients’ spatial experience as closely as possible to their actual lived experience,
methods for on-site questioning and data collection were developed. Patients were
asked to participate and interviewed during their stay, often between their admission
and treatment or after treatment before being dismissed. Interviews were conducted in
participants’ room, cubicle, often with others within hearing distance. These are not ideal
circumstances for a profound and relaxed conversation. Since the hospital’s ethical board
prescribed a high degree of anonymity of the participating patients, even expressing their
concerns over me knowing their full name, as little information as possible was exchanged.
No telephone numbers or email addresses could be collected, excluding the possibility
of follow up interviews that could have taken place in a more relaxed atmosphere. Yet, the
collected data are directly related to patients’ lived experience while in the hospital and
not influenced by later reflections, which has been shown to be the case with follow-up
interviews conducted several weeks after patients are dismissed (Radley & Taylor, 2003a,
2003b). Because I chose to interact with participating patients only during their hospital
stay, severely ill patients, like those at the intensive care, were excluded from the research.
However, as the duration of a hospital stay in decreasing (OECD, 2012), this group will
gain importance within the hospital population, the expert panel pointed out. Despite the
methods’ flexible applicability for researching patients’ spatial experience in motion, most
of them are not suited to employ under intensive care circumstances.
1 In 2013-2014 a master thesis was made by Laure Verschoren on child-friendly hospital architecture. This resulted in two publications (Verschoren et al., 2015 a&b).
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Conclusion
However, the proposed division was not exhaustive, as was brought up by the expert
panel. Generational and age related differences were not sufficiently taken into account.
As a basic decision at the start of the project was to exclude children from the research,
the specificities of this group were not considered.1 Also geriatric patients were not
specifically addressed. Although at the ED half of the participants were over 60 and
all participants at the nephrology ward fell in this category as well, the research indeed
did not gauge for nuances of variations amongst patients’ experiences based on age
difference. By neglecting the traditional division based on pathologies, I did not diversify
in terms of diagnosis. An expert panel member pointed at the different state of mind,
needs and experiences of a mother who recently gave birth and someone waking up in
the recovery. Dividing patients according to pathology does not necessarily reflect the
sensitivities of personal circumstances, however; think of women with a miscarriage who
are also treated at a mother and child ward.
How spatial experience is defined had an impact on the methodological approach and
vice versa. The research approach supports to research three components of experience sensory perception, memories and meaning making, and afforded activities- for different
patient profiles, at different locations. Therefore, a broad spectrum of methods was
brought together resulting in method collection rather than an actual concise research
approach.
Conclusion
METHODOLOGICAL APPROACH AND INFORMING ARCHITECTURAL PRACTICE
The applied methods needed to provide data that were both informative and attractive
to architectural practice. Therefore certain methodological decisions were based on
insights into architects’ design process. As most designers have a preference for visual
information (McGinley & Dong, 2011, volume 3) and a mistrust of data processed
by researchers (Restrepo, 2004), applying visual methods has the advantage that
the empirical material could be used in its original form. This implies that real data,
directly from the patients, could be employed in architectural practice. Evaluation of
the focusgroup interviews (V3 §2.3.2) and workshop (V3 §4.3.1) suggests that showing
designers the videos made during the fieldwork accompanied by patients’ testimonies is
promising to integrate both real users’ testimonies and the experience of motion into the
design process. However, according to the expert panel, the combination of (moving)
images and audio testimonies appeared to offer too much information at once (V3 §5.3).
If all three components of experience are to be communicated, the shown (moving)
images may need to be more thought through to address each component.
Since reviews of Evidence Based Design (EBD) studies mostly conclude that the results
so far are not ready to be converted to real life yet (College bouw zorginstellingen, 2008;
Dijkstra et al., 2006; Huisman et al., 2012; Rubin & Center for Health Design, 1998; Ulrich
et al., 2008, 2004), it was worth investigating whether a different kind of empirical material
could be used to inform architectural practice. Most EBD studies focus on people’s
primary (clinical) reactions which provide hard objective data; persons’ opinions, ideas,
and views are not often addressed (Malkin, 2006). Although some scholars argue that
future research should necessarily include not only clinical but also non-clinical evidence
(Van den Berg, 2005), the evaluation of EBD studies qualitative research positions quite
low in terms of its trustworthiness as no control trials are included (Sackett, 2001). If I
consider architectural practice as I made acquaintance with it, what architects are longing
for are either very concrete solutions to design problems (V3 §2.5) or information that
triggers their creativity without forcing them in certain direction. EBD studies cannot
(yet) provide the former but certainly not the latter. In reality I notice that many architects
are happy to work with qualitative research results among others and value it for its
inspirational and informative character without restricting their creativity in the design
process (V3 chapter 2, 4, Eijkelenboom, 2015).
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METHODOLOGICAL APPROACH, PATIENTS’
INFORMING ARCHITECTURAL PRACTICE
SPATIAL
EXPERIENCE,
AND
To be able to inform design research and practice on patients’ spatial experience, I
needed to develop new ways to understand this experience in relation to the built
environment. First the patient population was unravelled based on spatial experience
oriented parameters rather than the traditional division in pathologies. Then, to maintain
a good understanding of the hospital as whole, each group’s experience was explored
through a mixture of qualitative methods partially selected based on the applicability of
their outcome for architectural practice. Finally, after studying architects’ design process,
I actually tested the effect of introducing the collected experiential user information in
this process. Implicitly my aspiration was to make architects realise that how they perceive
and evaluate a building is not necessarily how patients experience the built environment.
A similar intention is described in the work of sociologist Christina Lammer (2009),
who uses ethnographic research data on patient experience to inform physicians and
create empathy with their patients. She calls this empathograhies. Although my research
approach is not a truly ethnographic one, I also aim to relate identification (understanding),
pathos (feeling) and the narrative or pictorial (writing or portraying) and consider these
categories as equally important for the approach (Lammer, 2009, her emphasis).
LESSONS LEARNED
Unlike other disciplines architecture does not have a tradition of consequent reflection
and follow up of realised projects, nor of user involvement throughout the design process
(Sanders, 2009). With my research I seek and demonstrate new ways of generating
understanding of and empathy with patients during their hospital stay. Throughout my
PhD I was constantly working simultaneously on the methodological approach, patients’
spatial experience, and informing architectural practice. Keeping an overview of how one
relates to the others was a key concern. Adopting such a broad approach has its benefits
but also its limitations.
I connected qualitative, ethnographic, design and architectural research in such a way
that one could fertilize the other. This yielded the following benefits:
-- Due to the broad scope of my research the need emerged to divide the patient
population, which resulted in the insight that a traditional division according to
pathologies has little relation with space. Thanks to this insight a novel perspective on
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Conclusion
A profound understanding of patients’ (spatial) experience most probably strengthens
the design of a truly patient-centred building. With my data and analysis I seek to support
architects in obtaining this understanding and building up tacit knowledge so that they
could constantly have a patient perspective in mind to test their design decisions against.
This acknowledgement of the role of the built environment should not be limited to the
patient room, but expanded towards each space in a hospital where patients possibly
pass or reside.
patients’ spatial experience of the hospital environment was developed.
-- Working with a broad range of hospital patients instead of focussing on just one group
or research setting allowed to bring forward the richness and diversity of patients’
experience. Aspects brought up by one group could broaden how data from another
group were analysed.
-- By introducing the insights gained in volume 2 directly in architecture practice, I
could closely follow up what was picked up and what not. How and why designers
said they would use or used the collected information partially influenced my focus
in the analysis of the data in volume 2. This is illustrated by the attention paid to the
importance of managerial organisation in relation to space.
-- To keep an overview of issues at stake in each volume I needed to broaden my view.
This raised my interest in the connection between the spatial insights I gained with
nursing studies and raised the need to address a broader public than architects only.
Conclusion
Apart from benefits also certain limitations can be identified:
-- Given the rather small number of participants at each research setting the individual
studies may be hard to generalize from. Rather each of them founded a basis for a
new research topic.
-- Due to the broad approach, I did not spend as much time at each setting as would be
needed for an in-depth ethnographic study. The results are thus not a deep as those
of a single study could have been.
-- The overview approach does not allow formulating clear-cut solutions. The
recommendations are rather strategies and points of attention, which could inspire
and direct future research and design.
-- In an attempt to draw more general conclusions I closely followed the structure of
analysis set out in the explorative phase. Considering the studies at the different
research settings as independent instead of part of one overall research project, as I
did, may have shifted my attention to more subtle interpretations of the data at hand
for each setting.
-- The broad approach makes it difficult to position my research. When opting for
one domain over another the research sometimes seems to fall short due to its
interdisciplinarity, which appears not yet to be truly established.
Despite these limitations, I would still recommend adopting such a broad overview
approach if the research question demands it. Yet, when adopting one it is important
to be self-conscious of how you do it and what its implications are. It is also necessary
to be realistic in what outcomes you can expect and pay specific attention to how you
communicate them. When doing so, a broad, interdisciplinary approach is inspiring and
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fruitful for each of the covered domains. It brings research in different domains forward
because it forces the researcher to think out of the box and explore new ways of dealing
with familiar problems.
FUTURE RESEARCH
My PhD took place at the intersection between scientific research and architectural
practice. More research could be done at either side. The collected data hold potential
as a basis for more profound theory development. Certain topics that came forward in
the data deserve an entire research project of their own and could be analysed at a higher
level of abstraction than I did with architectural practice in mind. I think of:
-- the notion of the extended body (Winance, 2006) and the embodied experience of
the built environment through this extended body;
-- the symbolic meaning attached to horizontal versus vertical relationships (between
staff and a lying patient, but also between being able to walk or being bedridden) in
the hospital;
-- the role of space in how hospitals enact hospitality or hostility;
-- how different types of waiting (Lofgren & Ehn, 2010; Maister, 1985) can be supported
by or relate to the built environment.
By opting to study how to inform architectural practice, I focused on research for design.
I did not propose actual design solutions. Adopting a research through design approach
would allow to concretize the results of my research on a level that is more solutionoriented and ready to be implemented in practice. The following topics would be worth
researching through design:
-- exploring different ways of interacting with patients in designing a hospital building.
This would offer insights into the extent to which co-design is achievable in a design
process with the turnaround of a hospital building. Additionally I could explore whether
certain types of information worked better than others (for me as an architect);
-- testing to what extent design solutions with different levels of abstraction are
appreciated by architects as a reference for future projects or are considered a
limitation of their creativity.
Embedding video in the design process is a whole research domain in itself. It would be
interesting to further develop this aspect of my PhD research with regard to
-- the characteristics of the video material;
-- the relation between video and communicating insights into (spatial experience in)
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Conclusion
-- the relation between “land”scape and “time”scape (Ingold, 2000) in a hospital context.
motion to architects;
-- the use of video as part of design briefing.
Making choices always means excluding other options. However the research conducted
gives hints towards other courses of action to take:
-- other design disciplines could be a good basis to explore different information formats
to be used in architectural practice;2
-- the study population was now limited to “general” adults. It would be interesting to
focus future research on more specific patient groups like older people or children, or
to broaden the perspective on being wheeled through the hospital by considering it
from a different perspective like the staff; 3
Conclusion
-- the results gained in volume 2 hold information that is not only relevant for architectural
practice but could also be interesting for other audiences like product or service
designers manufacturers, and hospital boards.
Throughout my research the client’s role has frequently been mentioned as a key factor to
successfully realise a patient-centred (hospital) building. As mentioned in V3 chapter 2,
architects experience that even if patients’ perspective is the starting point for a hospital’s
(re)design - which is increasingly the case - during the design process it often has to lay
thumbs against aspects that are easier to ‘prove’ or calculate as these aspects are more
decisive in clients’ decision making. Introducing and widely spreading volume 2’s results
not only among architects but also among hospital boards and other healthcare actors,
could help to create more engaged clients, which could result in a more balanced focus
throughout the design process. Studying the prolonged impact of this changed mind-set
during the construction process would be a necessary addition to the study of the impact
on the design process, if one wants to substantially broaden the priorities in designing
and constructing (hospital) buildings.
Finally, although I am aware of the objections to interdisciplinary research (Jacobs &
Frickel, 2009), I strongly believe that studying patients’ spatial experience in motion is
an example of research that unites aspects from so many domains that more profound
interdisciplinary research on this topic could certainly provide an added value, whereby
disciplines like geography, sociology, anthropology, design research, and engineering
bring in their own expertise and point of view to come to a mutual methodological
approach and framework to describe the results. This presupposes not only close contact
between the research domains, but also a wider acceptation of research that may not
exactly fit the pigeonhole. Therefore open communication about interdisciplinary work
(in progress) with do’s and don’ts, successes and failures is needed.
2 This topic is explored in the PhD of Valerie Van der Linden.
3 Cf. Master thesis and publication Laure Verschoren (Verschoren et al., 2015 a&b). In 2015-2016 two master theses will focus on revalidation
centres and staff’s spatial experience.
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FINAL THOUGHTS
This PhD has become three volumes and almost 300 pages. Yet, I still feel like I have not
told half of what is hidden in the data I collected. With every thought I developed and
every sentence I typed, a new seemingly undisclosed element came to the surface and
invited me to wander in a new direction. Sticking to one line of thought was a challenge.
Maybe that is why I enjoyed working on it so much, the followed route has never been
boring, not substantively nor practically.
My work in the last five years opened my eyes in various ways. The hospital environment
for sure is an interesting research context of which I discovered just the tip of the iceberg.
Being an engineer-architect, without medical background and having only a limited
training in the humanities and social sciences certainly has had its implications for the
choices I made, both methodological and contentwise. The context of the Baekeland
program, urged me to tackle obstacles in a practical and sometimes pragmatic way.
Taking the time to consider certain themes on a more abstract level might have added
additional depth. However, it is exciting to know that there is more to discover and new
routes to take.
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Conclusion
Although I was not involved in actual design work, working parallel in a design and
research environment made me keep a finger on the pulse of architectural practice while
studying it. The different speeds and different motivations to embed research or design
in architectural and academic practice makes truly combining them not something that
goes without saying. Yet, I remain a strong believer of the added value that can be found
in a close collaboration between “industry” and “the academic world”. Nevertheless, I
will be the first one to admit that it asks from researchers a strong personal idea about
what their research should and should not be about. I hope to have managed this in a
straightforward and down to earth way that is valuable to both architectural and academic
practice.
Conclusion
References
Annemans, M., Van der Linden, V., Karanastasi, E., Heylighen, A., 2015. Learning to Shape
Places of Care by Empathising with Patients and Caregivers, in: Proceedings of Engineering
4 Society. Leuven, 9 p.
Bate, P., Robert, G., 2006. Experience-based design: from redesigning the system around
the patient to co-designing services with the patient. Qual. Saf. Health Care 15, pp. 307–310.
doi:10.1136/qshc.2005.016527
Bowen, S.J., 2009. A Critical Artefact Methodology: Using Provocative Conceptual Designs to
Foster Human-centred Innovation (PhD dissertation). Sheffield Hallam University, Sheffield.
College bouw zorginstellingen, 2008. Kwaliteit van de fysieke zorgomgeving : stand van zaken
omgevingsvariabelen en de effecten op de (zieke) mens. College bouw zorginstellingen,
Utrecht.
Eijkelenboom, A., 2015. Presentation at Congress VTDV (Vereniging voor Technische
Diensthoofden van Verzorgingsinstellingen): Totaalbeleving van onze ‘klant’: zijn we er klaar
voor ? Antwerp.
Flyvbjerg, B. (Ed.), 2012. Real social science: applied phronesis. Cambridge Univ. Press,
Cambridge.
doi:10.1016/j.buildenv.2012.06.016
Routledge, London.
Lammer, C., 2009. Empathographies: Using body art related video approaches in the
environment of an Austrian teaching hospital, International Journal of Multiple Research
Approaches, 3(3), pp. 264-275. doi: 10.5172/mra.3.3.264
Löfgren, O., Ehn, B., 2010. Waiting. In The secret world of doing nothing. Univeristy of
California Press, Berkeley.
Maister, D.H., 1985, The Psychology of Waiting Lines, Retrieved from www.davidmaister.com
on 09.09.2015, p.9.
259–265.
Matthews, B., Brereton, M., 2015. Navigating the methodological mire, in: Rodgers, P.A., Yee,
J. (Eds.), The Routledge Companion to Design Research. Routledge, New York, pp. 151–162.
McGinley, C., Dong, H., 2011. Designing with Information and Empathy: Delivering Human
Information to Designers. Des. J. 4, pp. 187–206.
OECD, 2012. Length of hospital stay. OECD Publishing.
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Conclusion
Radley, A., Taylor, D., 2003a. Images of Recovery: A Photo-Elicitation Study on the Hospital
Ward. Qual. Health Res. 13, pp. 77–99. doi:10.1177/1049732302239412
Radley, A., Taylor, D., 2003b. Remembering One’s Stay in Hospital: A Study in Photography,
Recovery and Forgetting. Health (N. Y.) 7, pp. 129–159. doi:10.1177/1363459303007002872
Restrepo, J., 2004. Information Processing in Design. Delft University Press, Delft
Sackett, D.L. (Ed.), 2001. Evidence-based medicine: how to practice and teach EBM. Churchill
Livingstone, Edinburgh.
A Review of the Research Literature on Evidence-Based Healthcare Design. HERD.1, pp.
61–125.
Verschoren, L., Annemans, M., Van Steenwinkel, I., Heylighen, A., 2015a. How to design childfriendly hospital architecture? Young patients speaking. Design4Health 2015. Design4Health.
Sheffield, 9p.
Verschoren, L., Annemans, M., Van Steenwinkel, I., Heylighen, A., 2015b. Designing childsized hospital architecture: Beyond preferences for colours and themes. ICED2015 Design for
Life. International Conference on Engineering Design 2015 (ICED 2015). Milan, 9p.
Ylirisku, S., 2007. Designing with video: focusing the user-centred design process. Springer,
London.
About the author
Margo Annemans is a researcher at osar architects nv and the University of Leuven,
Faculty of Engineering Science, Department of Architecture, Research[x]Design group,
Belgium. In 2005, she graduated as Master in Engineering Science: Architecture at KU
Leuven. Parallel to her internship as an architect, she completed the additional course
in Social and Cultural Anthropology at KU Leuven. In 2008, she started working as a
researcher at osar architects, an architecture firm based in Antwerp, Belgium, which is
specialised in public buildings, focussing on healthcare.
Based on her background and training in both architecture and anthropology, Margo’s
PhD research gains insights into patients’ spatial experience and into how architectural
practice can be informed about this. Her research is supported by a Baekeland research
grant from the Agency for Innovation by Science and Technology in Flanders (IWTVlaanderen).
Margo conducted her PhD research in an 80% regime, the remaining 20% she devoted to
the coordination of research projects which osar architects nv undertakes in cooperation
with external partners and on research support for the design team.
At KU Leuven Margo was ‘representative of the junior researchers’ in the board of the
Faculty of Engineering Science in 2011-2012 and is currently researcher’s representative
in the bureau and board of the department of Architeture.
Publications
Article in internationally reviewed academic journal
Van der Linden, V., Annemans, M., Heylighen, A., 2016. Architects’ approaches to healing
environment in designing a Maggie’s Cancer Caring Centre. The Design Journal. 16 p.
(forthcoming)
Articles in academic books
Annemans, M., Van Audenhove, C., Vermolen, H., Heylighen, A. 2015. Being wheeled
through the hospital: How can design be informed about hospital patients’ spatial experience
in motion? In: Spinney J., Reimer S., Pinch P. (Eds.), Designing Mobilities. Routledge, London,
17 p. (forthcoming)
Annemans, M., Karanastasi, E., Heylighen, A., 2014. From Designing for the Patient to
Designing for a Person. In: Langdon P., Lazar J., Heylighen A., Dong H. (Eds.), Inclusive
Designing: Joining Usability, Accessibility, and Inclusion Springer-Verlag, London, pp. 189-200.
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Annemans, M., Van Audenhove, C., Vermolen, H., Heylighen, A., 2014. Being Transported
into the Unknown: How Patients Experience the Route to the Operation Room. In: Langdon
P., Lazar J., Heylighen A., Dong H. (Eds.), Inclusive Designing: Joining Usability, Accessibility,
and Inclusion. Springer Verlag, London, pp. 131-141.
Annemans, M., Van Audenhove, C., Vermolen, H., Heylighen, A., 2012. Hospital Reality from
a Lying Perspective: Exploring a Sensory Research Approach. In: Langdon P., Clarkson P.,
Robinson P., Lazar J., Heylighen A. (Eds.), Designing Inclusive Systems, Chapt. 1. SpringerVerlag, London, pp. 3-12. (Awarded with CWUAAT2012 Best paper award)
Articles in professionally oriented books
Annemans, M., Karanastasi, E., Poponcini, M., Heylighen, A., 2015. A Maggie’s Centre for
Leuven. Shaping Places of Care by Empathizing with Patients and Carers. In: Jencks, Ch.,
The Architecture of Hope (2nd edition), Frances Lincoln, pp. 224-229.
Annemans, M., Heylighen A., 2014. Het bed, een alternatief perspectief op het verpleeghuis.
In: Hoof, J. van, Wouters, E.J., Het verpleeghuis van de toekomst is (een) thuis. Bohn Stafleu
van Loghum, Houte, pp. 139-140.
Papers in international scientific conference proceedings
Annemans, M., Van der Linden, V., Karanastasi, E., Heylighen, A., 2015. Learning to Shape
Places of Care by Empathising with Patients and Caregivers. Raising Awareness for the
Societal and Environmental Role of Engineering and (Re)Training Engineers for Participatory
Design (Engineering4Society). Engineering 4 Society. Leuven, pp. 8-16, IEEE.
Verschoren, L., Annemans, M., Van Steenwinkel, I., Heylighen, A. (2015). How to design childfriendly hospital architecture? Young patients speaking. In Christer, K. (Ed.), Design4Health
2015. Design4Health. Sheffield, pp. 1-9, Design Society.
Verschoren, L., Annemans, M., Van Steenwinkel, I., Heylighen, A., 2015. Designing child-sized
hospital architecture: Beyond preferences for colours and themes. ICED2015 Design for Life.
International Conference on Engineering Design 2015 (ICED 2015). Milan, pp. 1-10.
Van der Linden, V., Annemans, M., Heylighen, A., 2015. “You’d want an energy from a
building”: User experience of healing environment in a Maggie’s Cancer Caring Centre.
In Christer, K. (Ed.), Proceedings of the Third European Conference on Design4Health 2015.
Design4Health. Sheffield, (art.nr. 56) Design Society, 9p.
Annemans, M., Van Audenhove, C., Vermolen, H., Heylighen, A., 2014. How to Introduce
Experiential User Data: The Use of Information in Architects’ Design Process. Design’s Big
Debates. The Design Research Society’s 2014 conference. Umeå (Sweden) pp. 1226-1237,
Design Research Society & Umeå Institute of Design.
Annemans, M., Van Audenhove, C., Vermolen, H., Heylighen, A., 2012. What makes an
environment healing? Users and designer about the Maggie’s Cancer Caring Centre
London. In Brassett, J. McDonnell, J. , Malpass, M. (Eds.), Out of Control. Proceedings of the
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8th International Design and Emotion Conference. London, pp. 1-8, Design & Emotion.
Annemans, M., Verhaegen, M., & Debacker, W., 2012. Life Cycle Assessment in Architecture
Practice: The Impact of Materials on a Flemish Elderly and Care Residence. Proceedings
of International Symposium on Life Cycle Assessment and Construction. Nantes, France:
IFSTTAR, nr. 12124, 19 p..
Vermolen, H., & Annemans, M., 2012. Keeping up Quality: Research as a Basis for Qualitative
Architectural Design. Proceedings of International Conference on Hospital Planning and
Building. Oslo, 6 p..
Experiencing space from a hospital bed. Proceedings of Well-being 2011: The First International
Conference Exploring the Multi-dimensions of Well-being. Birmingham, Birmingham City
University and the Royal Institute of British Architects (RIBA), 10 p..
Debacker, W., Annemans, M., Van Holm, M., Spirinckx, C., et al., 2011. Improving the
environmental impacts of a typical Flemish retirement home: a life cycle approach.
Proceedings of World Sustainable Building Conference. Helsinki, 17 p..
Press coverage
Verrijken, G., 2013, Liggend (be)leven, hoe ervaren patiënten het ziekenhuis? Healthcare
Executive (71), 6-9.
Verdoodt, W., 2012, May. Architectuur voor de Liggende Patiënt: Onderzoek naar een meer
menselijke architectuur voor ziekenhuizen. Zorgwijzer, (4-28), 26–27.
Verrijken, G., 2010, October 5. Zorggebouwen andere bekeken. de Specialisten, Roularte
Medica, (42), 8.
Presentations
At international scientific conferences and symposia
“Learning to Shape Places of Care by Empathising with Patients and Caregivers.” Engineering
4 Society. Leuven, 18-19 June 2015.
“Being Wheeled through the Hospital: How can design be informed about hospital patients’
spatial experience in motion?” Designing Mobilities Workshop, London, (UK), 14-15 April
2015.
“How to Introduce Experiential User Data: The Use of Information in Architects’ Design
Process.” The Design Research Society’s 2014 conference. Umeå (Sweden), 16-19 June 2014.
“Being Transported into the Unknown: How Patients Experience the Route to the Operation
Room.” & “ From Designing for the Patient to Designing for a Person.”
Cambridge Workshop on Universal Access and Assistive Technology, Cambridge (UK) 2427 March 2014.
“What makes an environment healing? Users and designer about the Maggie’s Cancer
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Caring Centre London.” International Conference on Design and Emotion. London (UK),
11-14 September 2012.
“Hospital Reality from a Lying Perspective: Exploring a Sensory Research Approach.”
Cambridge Workshop on Universal Access and Assistive Technology, Cambridge (UK) 2629 March 2012.
“Life Cycle Assessment in Architecture Practice: The Impact of Materials on a Flemish Elderly
and Care Residence.” International Symposium on Life Cycle Assessment and Construction,
Nantes (France), 10-12 July 2012.
“Lying architecture: Experiencing space from a hospital bed.” Well-Being 2011: The First
International Conference Exploring the Multi-dimensions of Well-being. Birmingham (UK),
18-19 July 2011.
“Improving the environmental impacts of a typical Flemish retirement home: a life cycle
approach.” World Sustainable Building Conference, Helsinki (Finland), 18-21 October 2011.
At professionally oriented symposia and science popularization events
“Wat heeft onderzoek naar patiëntenbeleving te bieden?” Kick-off event Van Zorg(zaam)
Onderzoek naar Zorg(zaam) Ontwerp, R[x]D KU Leuven, Leuven, 1 October 2015.
“Duurzame zorginfrastructuur: Omarmd door gebruikers” Duurzame zorginfrastructuur in
de Lage Landen, Probis, Elzenveld, Antwerpen, 17 September 2015 (combined presentation
with Ann Heylighen and Valerie Van der Linden).
“Liggend (be)Leven: betekenis voor oriëntatie?” Customer experience in de zorgarchitectuur,
Kenniscentrum 60+, AZ Groeninge, Kortrijk, 08 June 2015.
“De ruimtelijke beleving van het ziekenhuis door ouderen” Seniorvriendelijke ziekenhuizen in
Vlaanderen: utopie of werkelijkheid?, UZ Leuven, 27 May 2015.
“Ruimtelijke beleving: een totaalpakket” Totaalbeleving van onze klant: Zijn we er klaar voor?,
Congres VTDV (Vereniging voor Technische Diensthoofden van Verzorgingsinstellingen),
Antwerpen, 8 May 2015.
“GZA in beweging: Inzichten vanuit Liggend Perspectief.” Naar een Totaalbeleving van
Patiënt en Bewoners. Interne tweedaagse voor leidinggevenden, Gasthuiszusters Antwerpen,
02 October 2014.
“Ruimtebeleving vanuit liggend perspectief - Bouwt de zorgsector vraaggestuurd?”
Investeren in algemene en psychiatrische ziekenhuizen, Zorgnet Vlaanderen, Genval, 01
June 2012.
“Meten is Weten.” Expo 60+, Mechelen, 05 October 2011.
“Duurzaam materiaalgebruik.” Duurzame Bouwtechnieken, Healthcare 2010, Brussel, 15
October 2010.
“Online Communities.” Maak uw projecten efficiënter met online communities, Sirris &
Agoria, Brussel, 22 April 2010.
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Master thesis guidance
(all at KU Leuven, Faculty of Engineering Science, unless mentioned otherwise)
Flamang, L., 2014-2015.
Schreurs, L. & A. Rams, 2014-2015. “De (aan)gepaste woning op latere leeftijd: op zoek naar
zelfstandigheid en levenskwaliteit”. A. Heylighen (supervisor).
Anwar, F., 2014-2015. “Shared space and visually impaired persons”, M. Berta (Politecnico di
Torino) & A. Heylighen (supervisors). Politecnico di Torino.
Verschoren, L., 2013-2014. “Ziekenhuisarchitectuur op kindermaat. Case UZ Leuven”, A.
Heylighen (supervisor). (Awarded with the CFE - DEME master thesis prize)
Byns, N., 2012-2013. “Maggie’s kijk op het ziekenhuis: een planstudie van Maggie’s Cancer
Caring Centres met het oog op ziekenhuisontwerp”, A. Heylighen (supervisor).
Van der Linden, V., 2012-2013. “Maggie’s: ‘Healing Environment’ in ontwerppraktijk en
gebruikerservaring”, A. Heylighen (supervisor).
Van de Voorde, K., 2012-2013. “Bewogen door de ruimte. Ruimtegebruik en –beleving in de
Leuvense stationsomgeving”, A. Heylighen (supervisor).
Huyge, N., 2011-2012. “Thuis op kot? Analyse van compacte woonvormen in
studentenresidenties”, A. Heylighen (supervisor).
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THE EXPERIENCE OF LYING
Margo Annemans
Supervisor:
Prof. Ann Heylighen
Co-supervisors:
1
VOLUME
METHODOLOGICAL
APPROACH
Margo Annemans
Supervisor:
Prof. Ann Heylighen
Co-supervisors:
Prof. Herman Nys
Prof. Sarah Pink
Prof. Tom Thys
VOLUME 1
METHODOLOGICAL
APPROACH
Methodological approach
-
V1
TABLE OF CONTENTS
1. DESIGN RESEARCH, THEORY, AND EPISTEMOLOGY
3
1.1 Finding a way out of the methodological mire
3
1.2 Theoretical positioning and practical epistemology
5
2. HOSPITAL REALITY FROM A LYING PERSPECTIVE: EXPLORING
A SENSORY RESEARCH APPROACH 9
2.1 Real buildings, real experiences
11
2.2 Sensory reality 11
2.3 Insight/inside spatial experience 12
2.4 “Talking” patients, “speaking” hospitals 16
3. HOW TO RESEARCH SPATIAL EXPERIENCE IN MOTION? GAINING INSIGHT INTO PATIENTS’ EXPERIENCE OF HOSPITAL TRANSPORTS 23
3.1 Introduction
25
3.2 Space and motion in qualitative research
26
3.3 A research approach in motion
28
3.4 Methodological challenges
36
3.5 Ethical challenges
37
3.6 Conclusion
38
2.4.1 2.4.2 2.4.3 3.3.1 3.3.2 3.3.4 3.3.5 Who is talking
How patients “talk”
What hospitals “say”
Selecting research settings
Observing Interviewing
Analysing and representing
16
16
17
29
29
32
35
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Before I report on what I found in response to the research questions, volume 1 provides
insight into the theoretical and epistemological positioning and the methodological
approach of my research. While you read this volume it is important to keep in mind that
I constantly weighed decisions against the twofold aim. I aimed both to gain insight into
patients’ spatial experience and to inform hospital design on this experience to anticipate the
needs of patients and other users. Therefore I needed a research approach which supports
participating patients in expressing their spatial experience and yields results suitable to be
introduced in architectural practice. Moreover, the approach should be suitable to apply
while in motion.
The theoretical and epistemological positioning was derived from the decisions I took during
the research process. However conversely this may sound, the first chapter of this volume
explains why following this path is valuable in design research.
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1. Design research, theory, and
epistemology
Design research is a relatively new research field with many diversities and challenges.
Design researchers Ben Matthews and Margot Brereton (2015) argue that, although no
research is free of theory and epistemology, they may be present only implicitly. In such
case, they can be derived from the decisions researchers take during the research process.
As this is the case in my PhD, I will start this chapter by discussing what Matthews and
Brereton call the ‘methodological mire’, and then explore the path I took to escape from
it.
1.1 FINDING A WAY OUT OF THE METHODOLOGICAL MIRE
Research and practice, thus also (architectural) design practice, can be related in different
ways: research can be about practice, for the purpose of practice, or through practice
(Archer, 1995). Whereas gaining insight into patients’ spatial experience in motion can be
considered research for the purpose of design, informing hospital design on this experience
would rather be called research about design. Both research for the purpose of – and
about design are placed under the common denominator of design research (Matthews &
Brereton, 2015). Matthews and Brereton (2015) argue that listing all disciplinary allegiances
and methods in design research seems impossible even when ignoring the possibilities
of philosophical stances, like constructivism, pragmatism, positivism, hermeneutic
phenomenology to name a few. This broad spectrum of allegiances, possible methods,
and underlying philosophies, is what they call ‘the methodological mire’, meaning the
mire of methods, methodologies, theoretical positions and epistemologies that can, but
not necessarily do, shape design research.
Matthews and Brereton (2015) also propose a way out of the mire: escaping is possible
along two paths starting with either the purpose or the claim of the research. In what
follows, I focus on the first path starting from the purpose. This path defines the concrete
decisions a researcher takes about what aspects of the world will be collected as data
and presented as evidence of the phenomenon under research. Epistemology is then
approached in a practical, down-to-earth manner: “Epistemology becomes plainly visible
in the actual decisions researchers have taken in order to show us slices of the world that
illuminate a phenomenon of interest. We do not need to attend to foundational philosophical
assumptions, but only to those assumptions that are relevant to the problem at hand. And
the relevant assumptions are manifest in the evidence that researchers collect, assemble
and display in producing research” (Matthews & Brereton, 2015, p. 154). Such an approach
should not lead to rigour in research: “Rigour consists only of being able to show your
peers that the material you have gathered is reasonable as a response to the purpose of the
investigation, and of sufficient quality and volume to make a contribution to your particular
scholarly audience” (ibid, p.155).
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I first illustrate this path out of the mire for the research presented in volume 2 in
which I focus on gaining insight into patients’ spatial experience. Based on a profound
reading of the existing reviews of Evidence Based Design studies, I opted to study
how patients experience space from a different perspective, and decided to follow a
more anthropologically inspired approach, making use of methods stemming from
ethnography, as further elaborated in the next chapter. To describe my escape from the
methodological mire I follow the steps Matthews and Brereton (2015) propose:
Identify the purpose: For the research presented in volume 2, the purpose is to identify
and document the aspects that play a role in patients’ spatial experience in motion.
Examine the data: To gain insight into patients’ lived spatial experience I opted to
collect data directly from patients during their hospital stay. This approach had certain
implications for the applied methods, which are discussed in the next two chapters. The
collected data are presented to the readers as quotes from interviews with patients,
complemented with visual material collected during fieldwork and observations made
regarding my own embodied experiences and patients’ reactions during the accompanied
walks we undertook through the hospital. This is done for different patient profiles: longterm in-patients, patients at an emergency department, and day surgery patients at an
in- and out-patient centre.
Consider evidence in relation to purpose: When possible, the purpose to identify
aspects of patients’ spatial experience in motion is pursued by following them along
the routes they took through the hospital, and subsequently interviewing them about
their experiences during this transport, whether or not supported by video-recordings
of the route under consideration. For the data to be considered adequately evident,
patients should be considered capable of expressing their experiences, or at least of
talking about their hospital stay. Also my personal observations as researcher should
be recognized as valuable data to be analysed. Although some attempts were made to
record “objective” physical aspects (like movements of patients’ beds), these were not
taken into consideration in the final analysis as no connection with patients’ responses
could be found.
Also the research in the third volume on informing hospital design on patients’ spatial
experience could be evaluated along this path. The same procedure is followed:
Identify the purpose: The purpose of the research presented in volume 3 is to find a
scientifically validated and applicable format to introduce insights into patients’ spatial
experience in motion in architectural design practice.
Examine the data: As I am interested in which type and content of information architects
use during their design process, I wanted to collect a broad range of voices on the topic.
Therefore the data are mostly collected through focusgroup interviews and document
analysis. They are presented to the readers through quotes and images.
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Consider evidence in relation to purpose: The purpose to find a suitable approach
to introduce insights into patients’ spatial experience in motion in architectural design
practice is reached step by step by building up insight into the use of experiential user
data and information on experience in motion in architects’ design process. A first
focusgroup interview with users of a Maggie’s Cancer Caring Centre aimed to identify
the role of architecture in users’ experience and put this against the intentions of the
architect collected through a semi-structured interview. I thus learned about the value
of different information formats with regard to the presence of the user as a person in
the design process. How users appear in architects’ designs was analysed in students’
projects and further explored through focusgroup interviews with professional architects.
Finally insights gained into both the relevant content and the character of the desired
format were assimilated into diverse information formats. These were then introduced
to voluntary participants in a design workshop. The participants’ design proposals
were analysed with regard to patients’ experience and the role of motion therein. The
considered adequacy of the data is thus based on how well architects are considered
capable of reflecting on their design process and how the researcher’s role is assessed in
analysing the documents with different design outcomes.
Following this path out of the mire is considered a good basis to situate one’s research
and to create methodological transparency without explicitly mentioning theoretical
positioning or epistemology. As illustrated by my PhD’s twofold position towards research
and design, design research can be diverse. Following this path (or the one starting from
the claims made by the research) makes it possible to compare different kinds of research
with regard to the kind of data, evidence, purpose, and claims without necessarily digging
into philosophical paradigms.
1.2 THEORETICAL POSITIONING AND PRACTICAL EPISTEMOLOGY
According to Matthews and Brereton’s (2015, p. 154) stance towards theoretical positioning
and epistemology, my allegiance in both may not be essential. Still, the knowledge I
produce depends on the theoretical positioning of me as a researcher (Archer, 1995) and
my interpretation of the research findings, which I obviously did not develop in a vacuum.
Let me thus follow Matthews and Brereton’s (2015) reasoning and derive my theoretical
position and epistemology from the decisions I took throughout the research process. In
his book on the foundations of social research Michael Crotty (1998) points out that there
is a close relationship between research methods, methodology, theoretical position and
epistemology, where one can be derived from the other. Ontology is not considered
separately but seen as confluence with epistemology (Crotty, 1998, p. 10). Crotty reasons
that the later informs the former. However, when describing how to outline a research
proposal in these terms, he starts with the methods and works towards epistemology
(Crotty, 1998), which better accords with the chronological succession of a research
project.
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I could describe my research, at least in volume 2, as a study and analysis of patients’
experience of hospital architecture. Phenomenology is defined as the exploration and
description of phenomena, with phenomena referring to “things or experiences as human
beings experience them” (Seamon, 2000, p. 158). I can thus state that the origin of my
theoretical position for this part lays in phenomenology. Phenomenologists like Martin
Heidegger or Maurice Merleau-Ponty have set out the foundations of basic insights
concerning the unity of people and world (Heidegger) or embodiment and the role of
perception therein (Merleau-Ponty). Both Heidegger and Merleau-Ponty spoke about
being-in-the-world.
Experienced objects are not considered apart from the subject, object and subject
are in constant interaction with each other. These interactions form the basis of
phenomenologists’ concepts of the world (Crotty, 1998). In these interactions between
subject and object, or subject and world, something seemed to be missing to fully
understand patients’ spatial experience from a lying perspective. It soon became clear that
the role of the bed was far more than just that of a silent object. The traditional subjectworld unity needed to be expanded. Through the concept of mediation, introduced by
philosopher of technology Pieter-Paul Verbeek (2005), based upon the philosophy of
Don Ihde (1995), I came in contact with post-phenomenology. As Verbeek describes:
“Post-phenomenology can be viewed as an offshoot of phenomenology that is motivated
by the postmodern aversion to context-independent truths and the desire to overcome
the radical separation of subject and object, but that does not result in relativism. From the
post-phenomenological perspective, reality cannot be entirely reduced to interpretations,
language games, or context. To do so would amount to affirming the dichotomy between
subject and object, with the weight merely being shoved to the side of the subject. Reality
arises in relations, as do the human beings who encounter it. Only in this sense is postphenomenology a relativistic philosophy – it finds its foundations in relations.” (Verbeek,
2005, p.113)
Verbeek (2005) agrees with Heidegger’s idea that tools give shape to the encounter
between humans and their world (Heidegger, Macquarrie, & Robinson, 2008), but
asks the additional crucial question in which ways things play a role in the human-world
interaction. Things, according to Verbeek, are not neutral “intermediaries” between
human and world but mediators; they actively mediate this relation. Verbeek illustrates
this with the example of a train that coshapes how a landscape is present to a human
being. Similarly, in my research I investigate how the bed coshapes how the hospital
building is present to a patient.
Also in volume 3, on architectural design practice, a post-phenomenological logic can be
found. The tools architects use in the design process are not neutral either, but coshape
the buildings and spaces they design (Vermeersch, et al., 2011). Indeed, different design
media and information formats may lead to different design results.
However, given the aim to inform hospital design on patients’ spatial experience in
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motion my research intends not just to gain knowledge as such, but also to initiate a
change in architectural design practice. Therefore some parallel with critical inquiry
can be identified. Critical inquiry finds it origin in the work of theorist Max Horkheimer
that is based on the neo-Marxist philosophy of the Frankfurt School1 from the 1930’s.
In a landmark article from 1837, “Traditional and critical theory” he describes how critical
theory is not just a theory in itself. It should rather be interpreted as a conceptualization of
theory, as a theory that encourages some kind of action. Crotty explains this difference as
follows: “It is a contrast between a research that seeks merely to understand and a research
that challenges... […] between a research that accepts the status quo and a research that
seeks to bring about change” (Crotty, 1998, p. 113). With the development of a format
suitable to inform hospital design on patients’ spatial experience in motion, I indeed aim
to challenge architects to take into account user experience (in motion) in their design
process to realize designs, and subsequently buildings, that are truly patient-centered.
In post-phenomenology specific attention is paid to the context in which knowledge
comes into being. Moreover, it desires to overcome the separation between subject and
object. By emphasizing that subject and object constitute each other (Verbeek, 2005), it
takes the construct of meaning and the value of people’s life world as a starting point of
its reasoning. Patients’ experience of the built environment is personal and constructed
through their interactions with others and the environment. Also the design process
and how it is approached by architects is a social construct, from the point of view of
both post-phenomenology and critical enquiry. A parallel can be drawn with Crotty’s
(2003) description of constructionism: “constructionism is [..] the view that all knowledge,
and therefore all meaningful reality as such, is contingent upon human practices, being
constructed in and out of interaction between human beings and their world, and developed
and transmitted within an essentially social context” (p. 42). In this view, meaning is thus
socially constructed in our interactions, between ourselves, mediating objects, and the
physical world.
By identifying my research purpose and explicating a philosophical stance related to postphenomenology and critical enquiry, and a constructionist theory of knowledge, I roughly
sketched the context for the development of my research approach. In the following
chapters I explore the value and applicability of a sensory rich research approach to
gain insight into patients’ spatial experience. Subsequently I reflect on the methods I
combined to be able to study motion on the scale of and within the context of a hospital
building. Throughout my methodological explorations, the character of the raw data and
the outcomes were constantly evaluated in terms of their applicability in architectural
design practice.
1 Although much debated, there seems to be a general agreement that the Frankfurt School begun with the writings of the Institute for Social
Research formed in Frankfurt in 1924. Amongst others the main scholars were Max Horkheim, Theodor Adorno, Herbert Marcuse, and Walter
Bejamin. The most renown ‘second generation’ theorist is Jürgen Habermas (Crotty, 1998).
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References
Archer, B., 1995. The Nature of Research. CoDesign 2, pp. 6–13.
Crotty, M., 1998. The foundations of social research: meaning and perspective in the research
process. Sage Publications, London.
Heidegger, M., Macquarrie, J., Robinson, E., 2008. Being and time. HarperPerennial/Modern
Thought, New York.
Ihde, D., 1995. Postphenomenology: essays in the postmodern context, Northwestern University studies in phenomenology and existential philosophy. Northwestern University Press,
Evanston.
Matthews, B., Brereton, M., 2015. Navigating the methodological mire, in: Rodgers, P.A., Yee,
J. (Eds.), The Routledge Companion to Design Research. Routledge, New York, pp. 151–162.
Seamon, D., 2000. A Way of Seeing People and Place: Phenomenology in Environment-Behavior Research, in: Wapner, S., Demick, J., Yamamoto, T., Minami, H. (Eds.), Theoretical Perspectives in Environment-Behavior Research: Underlying Assumptions, Research Problems, and
Methodologies. Kluwer Academic/Plenum Publishers, New York, pp. 157–178.
Verbeek, P.-P., 2005. What things do : Philosophical reflections on technology, agency, and design. Pennsylvania State University Press, University Park.
Vermeersch, P.-W., Nijs, G., Heylighen, A., 2011. Mediating artifacts in architectural design: a
non-visual exploration, in: Leclercq, P., Heylighen, A., Martin, G. (Eds.), Designing Together CAADfutures 2011. Les Editions de l’Université de Liège, Liège, pp. 721–734.
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2. Hospital reality from a lying
perspective: Exploring a sensory
research approach
An earlier version of this chapter has been published as a book chapter:
Annemans, M., Van Audenhove, C., Vermolen, H., Heylighen, A., 2012. Hospital Reality from a
Lying Perspective: Exploring a Sensory Research Approach. In: Langdon P., Clarkson P., Robinson
P., Lazar J., Heylighen A. (Eds.), Designing Inclusive Systems, Chapt. 1. Springer-Verlag, London,
pp. 3-12.
Keywords
hospital environment
experience
sensory methodology
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Abstract
Our research investigates what spatial aspects influence
patients’ well-being in a hospital setting through an improved
understanding of people’s spatial experience from a lying
perspective. A key question is how this particular experience, i.e.
lying in a hospital bed, can be documented. The paper reports on an
exploration of research methods that yield sensory rich material.
Based on literature about various research approaches, we asked
patients to document their experience through photographs and
drawings and used these as a basis for semi-structured interviews.
Both the choice of medium and the aspects documented provide
important insights into how hospital patients experience their
environment. The addition of illustrations, generated by the
participants themselves, clearly adds an extra dimension to the
interviews. Both the interviews as the findings are deepened.
This research approach also stands closer to a sensory rich way
of questioning. The collected images reveal insights on three
different levels. There are images that literally represent visual
elements in the environment. In addition some images are not
taken for what they show but have an iconographic meaning,
telling us about other sensory experiences than visual. Finally, the
produced images can be a representation of what could be, giving
the participating patients a voice to express how they would change
the spatial situation they are in. Overall, this alternative way of
questioning people definitely provides an additional value to the
richness of the research results. In the future this approach will be
further elaborated to come to a more generally applicable research
approach, which could, at least partially bypass the problem of
articulating spatial experience. Given the rich character of the
collected material, the real-life data produced by the patients
might even serve to directly inform the design process of architects
designing healthcare buildings.
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2.1 REAL BUILDINGS, REAL EXPERIENCES
Despite many efforts by healthcare providers, for most people a hospital stay is rarely a
pleasant experience. The hospital building as such is part of this perception. Moreover,
the specific situation of a hospital stay is largely determined by the materialization of the
organization. Studies on hospital environments tend to single out one particular aspect e.g. the view through the window, or presence of green (Ulrich 1984a, 1984b) - and try to
prove its clinical outcome. Yet, they fail to translate their results to the design of real-life
settings (Rubin & Center for Health Design, 1998, College bouw zorginstellingen 2008).
Moreover, the influence of patients’ peculiar perspective, i.e. lying in a hospital bed, on
the way they experience the reality of the hospital is largely underresearched.
The overall objective of our research is therefore to investigate what spatial aspects
influence patients’ well-being in a hospital setting through an improved understanding
of people’s spatial experience from a lying perspective. By developing a better
understanding of the relationship between the patient, the objects that take part in his/
her hospital life - especially the bed - and the building, we hope to enable architects to
design buildings that add to the healing character of hospital environments. Ultimately,
we aim to provide architects with sufficient evidence to design healthcare buildings that
can better anticipate the needs of patients and other users.
Since our research aims to gain insight into how patients experience a hospital from
a lying perspective, we need a manner to make their spatial experience more explicit.
Therefore, we explored different ways for patients to document their spatial experience.
In this paper, we report on a pilot study, which explores how three patients with a very
different profile each deal with this task in their own way. The empirical material collected
is not only very rich in itself, but also inspires the participating patients to talk about those
aspects of the building that affect them most. Certain themes frequently return in the
conversations, yet the goal at this stage in our research is not so much to obtain a general
validity, but rather to explore the possibilities of using participant-collected-material to
facilitate the interviews.
2.2 SENSORY REALITY
Research about healing or wholesome environments in healthcare settings is mostly
conducted in the field of Evidence Based Design (EBD). This field found its origin in
the analogy with other evidence based approaches to research and practice. When it
comes to buildings for healthcare especially Evidence Based Medicine was a source of
inspiration. In EBD studies evidence for the healing outcome of building aspects is being
collected (Ulrich et al., 2004). Mostly individual aspects are investigated and clinical
output is highly valued (Rubin & Center for Health Design, 1998). However, almost all
reports that collect and evaluate the results of the conducted studies, have to conclude
that the evidence is not ready to be transposed to the real world: to start with, the settings
in which the trials are carried out single out individual aspects and, as such, are not
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representative of real-world hospital settings; secondly the studies do not provide insight
into how the different aspects relate to each other (Rubin & Center for Health Design,
1998, Berg 2005, CBZ 2008).
However, a wholesome environment involves more than the measurable aspects that
withstand the evaluation of EBD studies. After all, architecture is experienced through
the senses (Rasmussen 1964, Pallasmaa 2005), thus our impression of a place is defined
by how it feels, smells, sounds, and. In this multi-sensory experience of the environment,
time, movement and activities play a major role. The senses are indeed part of human
life through one’s involvement in the world (Ingold, 2000). Thus, they are a key factor
in the experience of everyday reality. If we are to develop an articulate understanding
of patients’ actual experience from a lying perspective, as is the aim of our research, we
thus need to collect firsthand information about what they feel, sense, and think during
their hospital stay, not only while being in their room, but also while travelling through the
hospital building.
2.3 INSIGHT/INSIDE SPATIAL EXPERIENCE
In studying patients’ spatial experience from a lying perspective, we explore and develop
a research approach that respects the interrelatedness of things in how they experience
the reality of the hospital, addressing different aspects of the built environment as well as
their complex interaction. To obtain a broad spectrum of empirical material, participants
should be challenged to interrogate all their senses. The method to collect material
should also be appealing to a very diverse group of patients within the hospital, making
them feel at ease with their participation. Only when these criteria are met, the material
will be rich enough to gain a nuanced understanding of the complex reality of everyday
hospital experience.
In the first months of our research we conducted interviews with various actors in the
field (medical staff, patients, technical directors of hospitals, hospital architects) to obtain
a profound understanding of the meaning of the bed in the hospital (McDonald, 2011).
Each interviewee sheds light on the topic from his/her specific perspective. This resulted
in a good understanding of the complexity of hospital design. Although our research
focuses on the experience of (lying) patients, this background makes us aware of the
importance of reflecting on and taking into account certain undeniable technical and
organisational realities. During these interviews it became clear that people find it hard
to talk about their spatial experience, especially those unfamiliar with the design and
construction process. This lack of conversation skills about the research topic makes it
hard to obtain the rich empirical material we are looking for. Part of the difficulty can
be explained by people’s lack of vocabulary when talking about space (Franck, 2009).
Additionally, due to the complexity of experience, it is not easy to ensure that it is
explored throughout the entire range of its various articulations (Throop, 2003). These
obstacles force us to look for a suitable research approach that can give us access to
patients’ personal way of experiencing a hospital environment.
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For this reason we decided to explore alternative interviewing techniques. Aware of the
difficulty for patients to express their spatial experience and given the explorative phase
of the research, we opted to ask the participating patients only one, very broad question:
“Can you document the hospital experience from a lying perspective?” After a short
introduction patients are then invited to document their spatial experience in any way
that pleases them. They are provided with pens, pencils, note block, drawing paper and
a camera (with the possibility of recording sound and movies) - or they can use their
own camera. Afterwards the material produced during this process is used to facilitate a
semi-structured interview with the participating patient about the spatial qualities of the
building
As already pointed out, we experience the built environment through our senses. For
this reason we looked into the use of sensory methods. Visual techniques like photoelicitation where people are interviewed based on photographs are not new (Collier,
1967). Over the years the technique has gained popularity in various fields such as visual
ethnography, visual anthropology, visual sociology, and visual cultural studies (Pink,
2007). A sensory method does not guarantee access to sensory realms; for example,
the visual is not necessarily best accessed by a visual method (Mason & Davies, 2009).
Nevertheless, introducing photography can be considered as a first contribution to a
more ‘sensually complete’ methodology (Warren, 2002). In order to capture the real-life
experience instead of a fictive reality constructed by the researcher, however, we shifted
our focus beyond photo-elicitation to photo-production (Radley, 2010). In line with the
work of other researchers (Herssens & Heylighen, 2009, Radley, 2010), our interest lies
not so much in the meaning of pictures; we want to gain a good understanding of what
has been made visible, but also why, and how.
Indeed, also how images are recorded may tell us something about the hospital experience
of the participating patients. As taking pictures in hospitals is not always appropriate or
allowed (Radley & Taylor, 2003a), we did not provide the patients with a camera only, but
also gave them the opportunity to take notes or make a drawing. This approach yields
richer empirical material, which initiates different topics in the interviews. In the elicitation
process, there is no reason why the drawings and plans should be treated any different
than the photographs (Harper, 2002).
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---------
---------
fig. 2-1
fig. 2-2
What you see through the window when
What you see through the window when
lying down
sitting in bed
--------fig. 2-5
Drawing of existing situation
--------fig. 2-7
Nurse connecting a patient’s bed to a wagon, a view on the ceiling while travelling through the hospital,
set-up of how the bed is transported through the hospital
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---------
---------
fig. 2-3
fig. 2-4
Window illustrating the sound that enters
The presence of a table changes the
through it
perception of visitors on the chairs
--------fig. 2-6
Drawing of how Mr. C would organize the ward
--------fig. 2-9
Opening the bathroom door can create a
second barrier without closing the door of
the room
--------fig. 2-8
Open doors, giving insight into the room at
the other side of the hall
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2.4 “TALKING” PATIENTS, “SPEAKING” HOSPITALS
2.4.1 WHO IS TALKING
To explore the research approach’s possibilities and limitations we try it out with three
very different, pragmatically chosen patients. Because of the explorative stage of the
research the validity and generalisability of the obtained results was subordinate to the
test of the methodology and the participants’ engagement. The three of them are in the
hospital for different reasons while documenting their stay. Although all are provided with
the same equipment, they each choose very diverse ways to document their experience.
Mrs. A. stays a few days in the hospital for rather serious surgery. Through photographs
she elaborately documents her experiences in two rooms, a double room before the
operation, a single room afterwards. Despite her commitment to the task, she admits
not to feel comfortable or be able to take the camera into the corridor or to treatment.
Mrs. B. has a long history of hospital visits, and participates in this study when going for a
check-up in a hospital where she has been a regular patient. Since she is not lying herself
while travelling through the hospital this time, she interprets the question as illustrating
what she remembers from previous visits and uses it to signal points of improvement
in the treatment of patients. Depending on what she feels is appropriate, she switches
between taking pictures and drawing sketches of what she observes. Even a small story
emerges.
Mr. C. is on dialysis, making him visit the same part of the hospital several times a week.
He sketches a plan of the current situation to explain to the researcher how it is and resketches it to illustrate how he would alter it to improve most of the disadvantages he
experiences today..
2.4.2 HOW PATIENTS “TALK”
How patients choose to document their experience tells us a lot about how they
experience certain situations. The pencils and papers, for instance, initially were
introduced as a pragmatic solution to the problem that taking pictures in hospitals is not
always appropriate or allowed. However, they turn out to provide insights that would
have stayed undiscovered had only a camera been used.
As one patient points out, sketching an awkward situation afterwards is much less
confronting for the people involved than taking a picture as it unfolds. Another patient
does not see the point of taking pictures of a building that the researcher can observe
herself, however he does have some suggestions on how a future hospital setting should
be designed. Whereas, for him, a photograph just shows an existing situation, drawing
provides the opportunity to manipulate reality.
Since we use the recorded images as a basis for interviews, it does not come as a surprise
that this material formed the basis for the participating patients to reflect on how they
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perceived the hospital. Often just starting the conversation is enough to divert to
aspects not, or only slightly, related to the collected material. As if enabling participants
to start the conversation from their viewpoint is enough to open the door to unexpected
insights.
2.4.3 WHAT HOSPITALS “SAY”
Pictures of the windows or the ceiling are fairly straightforward in what they indicate (fig.
2-1, 2-2). Fresh air and a view on the outside world are generally considered important
aspects of a healing environment (CBZ, 2008; Devlin & Arneill, 2003; Dijkstra et al.,
2006; Rubin and CHD 1998). It is thus no surprise that someone who wants to discuss
these topics pictures windows. When lying in a hospital bed your perspective changes.
Lying or sitting in bed has a great impact on what, or whether, you see through the
window.
The indexical meaning can be discovered only when the image and the narrative are
combined. Indeed, the same object can be pictured for a completely different reason.
One of the pictures made by Mrs. A. shows a window as well (fig. 2-3). However, this
window does not represent fresh air or daylight. The window in the picture is located in
an inner wall around the atrium accommodating the cafeteria. Through the window the
sound of chattering people and laughing children enters the room. Although Mrs. A.
indicates this as a pleasant sound being in a different setting, she finds it quite disturbing
while being in the hospital and trying to recover from surgery.
Fairly banal objects can be icons of less tangible aspects that have a severe impact on
experience of the hospital. Mrs. A. photographs the little table and the chairs in her room
while having visitors (fig. 2-4). Because of the table’s presence, the people in the chairs
do not seem to be visiting in a hospital so much as just being at home. As she puts it:
“I think it has a more homelike atmosphere when people can be sitting on a
chair, at a table, where you can put something on, than when you’d just have
a row of chairs, then it would feel like they were watching me.” (Mrs. A.)
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Conclusion
Through the material collected by the participants, the hospitals tell us both about
their organisation and about the building and its interior. The collected images and
accompanying narratives give us a good overview of what kind of material can be
expected. Obviously there are images that literally represent visual elements in the
environment, such as the ceiling. However mostly, here too, the explanation why the
image is recorded reveals supplementary useful insights. In addition some images are
not taken for what they show but have an iconographic meaning, telling us about other
sensory experiences than visual. Finally, the produced images can be a representation
of what could be, giving the participating patients a voice to express how they would
change the spatial situation they are in. Sometimes the same picture can be placed in
different categories because of the multi-layered explanation that comes with it.
Mrs. B. made a set of two photos and a drawing, picturing the transportation of an
unknown patient in bed (fig. 2-7). In this trilogy she combines a reflection on her own
experiences while transported through the hospital in a bed and the observations from
the bed.
The first picture shows the corridor in the basement of the hospital. Mrs. B. mainly wants
to point out how she felt when she was transported through during an earlier stay. It is
a very functional corridor, used as storage space for carts, bicycles, obsolete beds and
so on. It seems as if no one ever thought about the fact that patients who have to go to
the nuclear department are transported through this corridor. As Mrs. B. explains, “the
lighting is not pleasant, and all the stuff that is stored there makes you feel uncomfortable”.
The nurse in the picture is attaching a bed to a cart, used to pull the beds when large
distances have to be covered. Mrs. B. reflects on how the patient in the bed must feel,
being handled like that. Since she did not feel comfortable taking a picture while the
patient could see her, she drew the set-up, explaining how the bed is attached to the cart,
how the patient does not have any contact with the nurse involved, and what she must
perceive and feel while being towed like that. To illustrate that, Mrs. B also took a picture of
the ceiling a little further down the hall and concluded that seeing all those pipes, and the
rags in between, is not how a disconcerted patient is comforted. The dust between the
technical equipment on the ceiling makes her wonder about hospital hygiene. Although
these pictures might seem a little banal at first, how they come together and are used as
a backbone for the narrative provides new opportunities to talk about spatial experience.
We do not just learn about Mrs. B.’s experience while visiting the hospital this time, but
are also provided with a reflection on previous visits and when and why you feel most
vulnerable as a patient, which she uses to explain her reluctance to take a picture. Even
movement and time are touched upon during the conversation. The length of the travel
through the hall, how the patient must undergo the transportation not knowing where he/
she is going, it all adds to the experience of the building without being necessarily related
to visual perception.
In addition to the simple question to documents their spatial experience we asked the
patients to also express their view on how the building could be improved (fig. 2-5,
2-6). For Mr. C. drawing a plan of the ward gives him the opportunity to point out the
shortcomings of the current set-up, while by sketching how he would organize it, he
brings up spatial aspects that he thinks are important. More acoustic barriers, more visual
transparency, and a reduction of the passage to create a quiet atmosphere are only some
of the aspects mentioned.
Suggesting alterations to the hospital building is not restricted to drawing plans. Mrs.
A. documents how she improved her privacy by opening a second door to block the
view from the corridor (fig. 2-8, 2-9). When both her door as the one at the other side
of the hall were fully opened, she could see right into the other room. Since she did not
want to close her door completely, preferring some connection with the rest of the ward,
she opened the door of the bathroom to block the view. The conversation about these
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pictures first focuses on the privacy but soon broadens to interactions with other patients
and staff, feelings of safety and even how bed transport could be improved so there
would be fewer obstacles on the way.
2.5 CONCLUSIONS AND FUTURE WORK
Given the promising results of this exploratory phase, the approach will be
further elaborated in future phases into a more generally applicable research
approach that can, at least partially, bypass the difficulty of articulating
spatial experience. The motivation of the participating patients is of crucial
importance to the success of the approach. As such, finding patients
willing to participate is a key concern. Although part of the strength of the
approach lies in its flexibility, a balance should be found between freedom
and guidance. In future research, when the key concern is the outcome of
the interviews and not the followed research approach, the selection of the
settings and participants will need to be better balanced to obtain more valid
and transferable results.
When thinking about the translation of the research results to inform
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Conclusion
Developing a better understanding of how patients experience the complex
reality of a hospital building from a lying perspective, asks for a sensitive
methodological approach that addresses all senses and facilitates reflection
on experience. Although we do not wish to push forward a single method,
the approach explored so far seems to fulfil the requirements. By asking
patients to document their spatial experience and providing them with
multiple media to do so, we gain insights from the inside out, not only from
the material they collect, but also from why and how they collect it. Using
the illustrations, generated by the participants themselves, clearly adds an
extra dimension to the interviews. Both the interviews as the findings are
deepened. Even though the material collected is mostly visual, it can also
illustrate auditory or haptic qualities, like the window through which a lot of
noise enters. The images, complemented with the accompanying narratives
serve as a source of information about all senses, movement and time,
illustrating the intangibility of sensory experience. Overall, this alternative
way of questioning people definitely provides an additional value within the
aim of our research.
Conclusion
architects’ design process, we might even consider using the empirical
material in its original form. This would imply that real data, directly from the
patients, are used by those designing environments for them. Especially in
healthcare buildings, the highly complex reality forms an important threshold
for designers to acknowledge the needs of the primary users. Since the
evidence provided by EBD studies conducted so far is not ready to be
converted to real life yet, it is definitely worth investigating whether different
empirical material can be used to inform the design process.
ACKNOWLEDGEMENTS
collaboration with the industry, in this case osar architects nv provided this opportunity.
Ann Heylighen received support form the European Research Council under the
European Community’s Seventh Framework Program (FP7/2007-2013)/ERC grant
agreement n° 201673.
The authors thank the participating patients, for sharing their time and insights.
All images in this chapter were made by participating patients.
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References
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3. How to research spatial
experience in motion? Gaining
insight into patients’ experience
of hospital transports
This chapter has been submitted as a journal article.
Keywords
built environment
healthcare
hospital logistics
user experience
research design
visual methods
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Abstract
From an engineering perspective patient transport
is typically classified under hospital logistics, aiming at
optimal organisational and spatial efficiency. Valid as this
aim may be, moving people means more than bringing them
from A to B. Patients’ spatial experience in motion should
be considered as well. Providing engineers and architects
an articulate understanding of this experience would allow
them to explicitly take into account patients’ particular
perspective when designing a hospital building. If we want
to study patients’ spatial experience in motion, however,
this requires a research approach that acknowledges the
role of embodiment and sensory and time perception in
their full richness. After reviewing related research on
the relation between the built environment and motion,
we describe how we developed a sensory-rich research
approach to study patients’ spatial experience while moving.
Methodological and ethical challenges are clarified and
commented upon. We conclude by pointing out the necessity
of combining different sensory registers when studying
spatial experience in motion and point at the importance
of a research approach that is flexible enough to adapt to
changing research locations and situations as is the case
while moving through a large scale and complex building
like a hospital.
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3.1 INTRODUCTION
From an engineering perspective, the design of hospital transport centres around optimal
organisational and spatial efficiency (College bouw zorginstellingen, 2007). As a patient,
you experience the transport from a totally different perspective (Annemans et al., 2011).
Once you are admitted and assigned a bed, this becomes the centre of your personal
space - not only stationary in your room, but also while moving through the hospital.
For most people, being wheeled through a building in a bed (or wheelchair) is a rather
a-typical way of experiencing the building. Only limited knowledge is available on how
this altered perspective impacts patients’ experience of the built environment. Therefore
our research aimed to obtain a better understanding of patients’ spatial experience while
moving through a hospital building with an eye to informing hospital boards, architects,
and engineers involved in hospital planning and design.
The research methods applied to study this experience need to provide data that are
both informative and attractive to architects and engineers. For a long time however,
building design was impacted mostly by engineering sciences like building mechanics
and building physics. Introducing empirical knowledge about human behaviour could
be more problematic as it deals with creating and organising space, which lies at the
heart of architectural design (Lawson, 2010). However, in recent years, raising awareness
about the societal value of engineering in general (Unesco, 2010), and designing patientcentred hospital in particular (Aboumatar & Pronovost, 2013), has gained significant
importance.
As most designers prefer visual information (McGinley and Dong 2011; Annemans et al.,
2014a) and mistrust data processed by researchers (Restrepo 2004), applying qualitative
research methods that emphasise the visual has the advantage that empirical material
(testimonies, images, comments from patients) can be used in its original form to inform
design practice. By reflecting on how the challenges of studying a moving research
subject were dealt with in our fieldwork and analysis, this article offers insight into how a
sensory-rich research approach can be developed to study people’s spatial experience
while moving, henceforth referred to as spatial experience in motion. We use motion
to emphasize the experiential aspect of being moved and distinguish it from transport,
which refers to the act of being brought from one place to another.
We start with a literature review that explores which aspects come into play when trying
to research people’s spatial experience in motion. Given the context of our research we
relate these aspects to the specific experiences of patients being moved in a hospital
bed. Subsequently, we explain how we approached the development of a research
approach in our study and substantiate it with insights from literature. We pay specific
attention to the methodological and ethical challenges we confronted, and how these
were handled. Finally we reflect on what our research approach can add to the existing
body of knowledge on embodied, sensory research approaches and their applicability in
hospital design.
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3.2 SPACE AND MOTION IN QUALITATIVE RESEARCH
The experiences of space and motion are closely interrelated: how we experience space
is influenced by the way we move through and in a building (Latour & Yaneva, 2008)
and vice versa, the built environment largely defines how we move and experience our
journey (Fitzsimons, 2012). Whereas various studies in (human) geography show interest
in people’s experience of moving on an urban scale (Jensen 2010; Pink 2008a; Røe
2000; Ross et al. 2009), the experiential aspects of motion on a building scale are largely
under-researched. In hospital design, for instance, patients’ movement is often reduced
to organisational matters concerning logistics (College bouw zorginstellingen, 2007) and
ergonomics (Kim et al., 2009; Mehta et al., 2011; Petzäll & Petzäll, 2003).
Studying spatial experience in motion differs from studying it from a static perspective
(Bollnow 2011, p.55). While you move along a trajectory, views change gradually,
smoothening the boundaries between the different places you pass (Ingold, 2000). The
environment becomes a fluid space (Ingold, 2011). As we are interested in motion, our
focus lies on studying the lines along which patients travel, instead of the place these
lines connect. Rather than the network, we aim to study the meshwork (Ingold, 2011) of
entangled lines of experience and movement.
Whereas all senses partake in the experience of architecture (Pallasmaa, 2005), the five
traditionally known - sight, hearing, touch, smell, and taste - are inadequate to account
for our spatial experience in motion. James Gibson (1968) speaks of perceptual systems
rather than sensory organs, and distinguishes between five interrelated subsystems: the
orienting (basic to all others), the auditory, the haptic, the taste-smell and the visual,
in no particular order. The orienting system relates most closely to the experience of
movement, yet also the haptic and visual systems can provide us with information on this
matter. Yi-fu Tuan (1977) extends the five traditionally known senses with kinaesthesia
(the sense of movement), which he considers as a sensory organ with a strong relation to
space and spatial qualities, together with sight and touch. More recently, Caroline Potter
(2008) argues that the majority of the literature indeed focused on the traditional five
senses, which she calls the Euro-American classic senses, at the expense of other equally
viable senses such as kinaesthesia, heat, and pain.
With this extended range of senses in mind, we aim to identify experiential aspects related
to the way of moving. People move (or are moved) in a certain position (proprioception),
in a certain direction, at a certain speed, experiencing haptic sensations (like shocks or
wind) and orient themselves through visual, auditory, and olfactory sensations. People
either control their movement or are moved by someone else, possibly supported by
technology. All these aspects and their interrelations shape the experience of motion and
can be impacted by the built environment.
When moving towards a certain goal, like during a hospital transport, people orient
themselves in relation to their physical environment: gravity from the earth, events and
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objects like a sudden noise or a person or thing one perceives (Gibson, 1968). One’s
posture is related to the gravitational frame of reference, it implies certain axes: headfoot (versus up-down), left-right, and front-back. What seems to distinguish our research
from most other studies on movement is patients’ different, namely horizontal bodily
position. While sitting in a wheelchair, your body’s head-foot axis is in a vertical position.
When a patient lies in bed, however, this axis becomes horizontal, thus changing your
entire perceptual system. Your head is no longer automatically up and your feet down,
the top of your head or the bottom of your feet may face forward or backward. Changing
your posture from upright to lying down implicates letting go of things, both literally and
figuratively (Bollnow 2011).
How movement through space is experienced indeed closely relates to the control people
exercise over how and where they move. Actively moving - whether as a pedestrian
(Lorimer, 2011), a walker or wanderer (Bollnow, 2011; Lund, 2005; Paterson, 2009), a
driver (Laurier, 2011; Sheller, 2004) or a wheelchair user (Winance, 2006) - is completely
different from being passively moved as a passenger in a car or train (Bissell, 2010), or
being pushed in a wheelchair (Winance, 2006) or bed. Whereas in a train the driver
is not actively influencing the smoothness of the ride, the person pushing a wheelchair
(Winance, 2010) or bed plays an active role in how the ride is experienced. As a hospital
patient in a bed or wheelchair, you largely lose control over where you go and what is
going to happen to you. An upright position gives you freedom and puts you at a clear
distance from things in the world (Bollnow, 2011). When you are lying down, however,
the far perspective (along a corridor, for example) changes; you cannot see any further
than the ceiling, which illustrates the intertwining of the orienting and the visual system.
As only transitions in movement (starts, stops, accelerations) can be perceived, uniform
motion in a straight line cannot be felt (Gibson, 1968). When everything goes smoothly
in an airplane, passengers do not feel they are moving, only when looking out the window
in relation to the ground, or when there is turbulence they notice the plane’s movement.
Similarly, a perfect bed ride without any bumps would go by unnoticed. Yet, patients
see their environment passing by and feel unevenness in the floor or bumps against
doorways. David Bissell (2010) explores the experience of movement through the
event of vibrations. These are rhythmic movements, which can take place while moving
independently of the direction one moves in. Bissell elaborates on the duality of the
mobile, actively vibrating train that encloses and transports the static body (passively
undergoing the vibrations). Indeed, not all movement implies a smooth experience.
For example, vibrations often distort what you see, which can cause a sensory overload
(Bissell, 2010). During patient transport, for instance, the lights flashing by while being
wheeled through the hospital can have a disorienting effect on patients (Annemans et
al., 2011).
When moving, you experience the length of things as distance, which is not just a spatial
concept, but implies also time (Tuan, 1977). Travel time is associated with movement
along a trajectory, going from A to B. The process of travelling involves multiple kinds
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of place and time, not just measured clock time (Watts & Urry, 2008). Although this
insight stems from research on train travel, parallels can be drawn with hospital transport.
Here too, the time spent relates to various socio-material practices, hospital staff, views,
the bed, etc. Moving time is often understood as valueless with little happening, unlike
stationary time, which is considered to hold economic value. Whether or not this counts
for hospital patients’ time experience is unclear. For them the transport might as well be
a welcome distraction from the boredom of spending time in their room. Yet, even then
this distraction might relate to the destination rather than to the travel time. Moving
towards a destination or goal can lose its relevance.
To understand the interaction between time, movement, and space, rhythms are essential
(Lefebvre, 2004). Under the influence of rhythmic sound, space and time can disappear
in the background (Tuan, 1977). This once again illustrates the intertwining of Gibson’s
perceptual subsystems. Rhythm, in relation to time, can be interpreted differently
depending on the scale: there is the rhythmic movement related to vibration (Bissell,
2010) as well as the rhythm of the day or of certain activities (Edensor, 2011; Lorimer,
2011).
To summarize, a research approach addressing space and motion should allow focusing
on: locomotion (or direction), proprioception (body position), speed, rhythms, haptic
sensations (such as temperature and wind), and visual, auditory, and olfactory orientation
points. Moreover it should take into account social and time-related aspects mostly
influencing experience through meaning making and afforded activities.
3.3 A RESEARCH APPROACH IN MOTION
Since spatial experience in motion involves a broad spectrum of sensory, social and timerelated aspects, adopting just one, generalizing research approach to study patients’
experience could possibly limit the potential richness of the data being collected. Given
our focus on the hospital building, and our attention for the subjective nature of human
life - both the subjective experiences of the patients studied and the subjectivity of us,
researchers - a qualitative approach seemed the most appropriate for our study (Esterberg,
2002). The specificity of our research aim lead to some additional constraints: involving
experience of space and motion, the diversity of bodies, and the difficulty people have
to express spatial impressions verbally all challenged our research design. Techniques
and methods from various research domains were inventoried and explored as a source
of inspiration. Based on the sensory aspects relevant for patients’ experience of space
mentioned above, we analysed a broad spectrum of research methods addressing the
senses, to select those methods that supported the development of a mobile research
approach. For each phase in developing our research approach, we will discuss which
aspects we took into consideration to bring forward participants’ full multi-sensory and
embodied spatial experience in motion.
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3.3.1 SELECTING RESEARCH SETTINGS
Selecting research settings and groups of patients go hand in hand. To identify selection
criteria in which motion stood center stage, we decided to have a look at hospital
logistics. Hospitals tend to group patients according to their (care) profile in order to
optimally organize care and transport. This profile is based on parameters like length
of stay, standardization of the admission and care process, and possibility to plan the
admission (College bouw zorginstellingen, 2007). These criteria derive from statistically
founded profiles, and often seem fairly remote from experience (Adey, 2008). Still, the
defined categories seemed to hold potential value to select groups of participants who
could inform us about spatial experience in motion. We adapted the parameters slightly
to be more experience-oriented and grouped patients according to their length of stay,
whether or not their admission was planned, and their familiarity with the hospital. As
also the way of moving impacts patients’ spatial experience in motion, this was added
as parameter to differentiate patients’ profiles. According to these parameters research
settings can be selected that are suited to gain insight into patients’ experience regarding
space and motion.
Length of Admission
stay
Familiarity
Way of moving
Selected setting and
route
> 1 week
Both planned Very familiar with Wheelchair (or bed)
and unplanned hospital
Nephrology
dialysis
1 day
Planned
Mostly not familiar
Bed
In-patient day ward to
operation room
1 day
Planned
Mostly not familiar
Walking
Out-patient day surgery
centre
Yet unknown
Unplanned
Some are familiar,
some are not
Walking,
stretcher
wheelchair,
ward
to
Arriving
at
the
emergency department
Table 3-1: Criteria to select research settings and participants
3.3.2 OBSERVING
The researcher
Since the experience of space and movement is embodied in nature, an obvious research
instrument to study spatial experience in motion is the body. Yet, whose body are we
talking about? Here the relationship between researcher and researched becomes an
important point of consideration (Crang, 2003). The researcher’s perceptual registrations
can add to a deepened understanding of the embodied experience under study (AllenCollinson & Hockey, 2011; Longhurst, Ho, & Johnston, 2008). To be able to understand
patients’ spatial experience in motion, the first author - henceforth referred to as ‘the
researcher’ - underwent the hospital transport in the same mode(s) the participating
patients would. While being moved through the building she paid specific attention to
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sensory aspects. The entire transport was audio-recorded and the researcher talked out
loud about what she perceived: smells, warm or cold air streams, (rhythmic) vibrations
from ridges, a light feeling in the stomach when the elevator started, visual disturbance
from lights, or the limited view on the environment due to her bodily position. Afterwards
she took notes about how she experienced the transport, addressing topics like feeling
vulnerable and looked at or interacting with the nurse pushing the bed or wheelchair.
The route was videotaped with a camera on the researcher’s head, as such representing
the viewing angle from the position of a patient sitting in a wheelchair, lying in a bed,
or walking. By making use of video she captured the direction and duration of her own
route from the specific position, but also grasped interactions along the way, both with
the environment and with others when hers crossed others’ path, thus pointing at the
meshwork (Ingold, 2011) created through hospital transports.
Participants
The actual transports of the participating patients were observed closely. The researcher
accompanied each participant on his/her route through the hospital. Although the
researcher’s experiences by no means could be considered equal to the participant’s
- due to the different state of mind and physical condition - being able to register
what participants saw, heard or smelled while moving, or just spending time with them
forms the basis to obtain valuable (spatial) information (Pink, 2008a; Ross et al., 2009).
Accompanying patients seems to hold potential especially for studying the notion
of time in relation to the experience of places while moving (Watts & Urry, 2008).
Moreover, keeping participants company during the route, including waiting time, seems
to stimulate encounters and communication with them, which contributes to a more
nuanced understanding of their lived experience and provides access points to some
sensitive topics (Ross et al., 2009), like feelings of vulnerability or neglect. To capture
as much information as possible participants were asked to talk out loud while being
transported. This was only successful with the nephrology patients who were at ease
during the route, however. They reflected on how long it took to get there, how cold the
corridor was, where they felt a draught, or the ridges when entering the elevator. The
entire route was audio-recorded. As participants often kept silent, mostly background
noise was documented. Occasionally we captured a curse when a bump hurt a patient’s
injured foot. After each transport the researcher took extensive field notes addressing
circumstances encountered during that specific route: an avoided collision with another
patient, the smell of a soup chart in the corridor or a remark by a nurse or family member.
For a patient, small events like these can be main points of orientation. Finally we aimed
to record the movement of the bed or wheelchair by attaching an iPod to the respective
vehicle and making use of the built in gyroscope meter and the app Accelerometer Data
Pro. We then retrieved the raw data of the movement along the X, Y, and Z-axis, which
holds the potential to derive the route, speed, accelerations and shocks. We were not so
much interested in the exact measures but wanted to be able to distil which magnitude
of vertical movement was relevant to patients’ experience.
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Built environment
Apart from the participants’ experiences, the researcher documented also the built
environment in terms of sensory information and traces of motion. Each route was
photographed according to a pre-established protocol. Rooms were pictured from each
corner. Floors, ceilings and viewpoint from the bed were documented. Every time the route
took a turn a photo was taken. Along a long corridor, every ten steps a photo was taken.
This resulted in very extensive sets of photographs for each route. Additionally building
elements along the route were inspected for signs of wear and tear related to (bed)
transport: damaged corner protection and doorframes or streaks on flooring material.
Moreover, the researcher also tried to capture some general environmental parameters like
air temperature (only indicatively measured with a room thermometer) or typical smells,
resulting in sensory maps where all these perceptions of the researcher were noted (fig. 3-1).
This was done each fieldwork day prior to meeting the participating patients.
T: 22,2°C at the window / 22,4 °C on the bed / 22, 5°Con the table
sound: constant zooming of th air-conditioning unit on the roof outside (rec. 1)
smell: nothing noticeable
sound: cleaning cart
(distant)
T: 22,7°C
smell: chemical (like gum?)
T: 23,3-23,6°C
(on the desk of
the nursingstation)
T: 23,7°C
(on sidetable)
sound: new cart
being added in the
corridor
T: 23,8°C
(on the floor)
smell: fresh air
haptic: draught/breeze
(room with open window)
smell: flowers
(subtle)
T: 22,8°C (on the floor)
smell: full diaper
direction
sensory perception
building joint
--------fig. 3-1
Sensory map
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T: 23,8°C
(on the floor)
T: 23,8°C (on the floor)
23,7 °C (on a cart)
3.3.4 INTERVIEWING
Given the embodied nature of spatial experience in motion, we needed interview
techniques that addressed both the senses and the (built) environment. Our interview
method was based on insights from research on qualitative interviewing with a focus
on sensory awareness (Harris & Guillemin, 2012) and an experience-based and
body-anchored approach (Stelter, 2010). Reinhard Stelter (2010) brings forward
two methodological cornerstones of qualitative interviewing. First, as a researcher
and interviewer, you should think about how you could help participants to focus on
experience-based, body-anchored aspects of specific situations. Second, you should
take into consideration how to guide participants in the process of meaning making and
shaping stories. Therefore, the interviewer should aim for descriptive questioning which
means that s/he phrases the questions in a way that the participant responds through a
description. The focus is thus on the “what” and “how”, not on the “why”, describing an
actual situation and not trying to find an a-posteriori explanation for it.
With these insights in mind, we developed a space/motion oriented interview guide.
As we aimed to allow participants as much freedom as possible in what and how they
responded, we started with a very broad question: “Can you describe the spaces you
came through going from X to Y?” To offer some guidance, the researcher could ask
to attach three to five words to each space and to ask what these words mean to them.
When patients could not recall each space or how they got from one place to another,
the mutual experience of researcher and participant came in handy to address some
key events to attract attention to specific situations or sensory aspects. Regarding
motion, the interview guide focused on how the way of moving influences participants’
sensory experience, resulting in questions like: “What did you see/hear/feel when you
were wheeled from X to Y?” or “How did being wheeled there influence you spatial
experience?” Once again the researcher’s own embodied experience appeared valuable
to pose nuanced questions, relate to the participants’ answers and ask revealing additional
questions. Indeed, the interviews were not one-sided processes: both participant and
interviewer were involved in making sense of the context, the events and the situations
the participant brought up (Stelter, 2010).
As spatial experience in motion is part of our implicit knowledge base, verbalizing it is
not always easy. Part of this difficulty can be explained by a lack of vocabulary when we
talk about space (Franck, 2009). Therefore, we explored alternative entrance points into
the participants’ experiential, sensory realm (Annemans et al., 2012). Since the senses
are intertwined (Ingold 2000; Pink 2008a; Pink and Servon 2013) addressing one sense
can bring the others to the fore (Harris & Guillemin, 2012). Although we are aware that
sensory methods do not necessarily guarantee access to sensory realms (Mason & Davies,
2009), we agree that introducing photography can be considered as a first contribution
to a more ‘sensually complete’ approach (Warren, 2002). Various techniques involving
photographs and images have been used in other studies some in healthcare context
(Guillemin, 2004a, 2004b; Radley & Taylor, 2003a, 2003b; Riley & Manias, 2004), some
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elsewhere (Collier, 1967; Fleury, Keller, & Perez, 2009; Harper, 2002; Pink, Kürti, & Afonso,
2004).
In a pilot study, we scrutinized the opportunities, setbacks, and challenges of developing
a research approach that respects the interrelatedness of spatial elements, addressing
different aspects of the built environment as well as their complex interaction (Annemans
et al., 2012). We explored an open interviewing technique which has been proven to
be successful in a different context (Warren, 2002), namely starting from the question:
“Can you document your hospital experience from a lying perspective?” To answer
this question participants were provided with pens, pencils, note block, drawing paper
and a digital camera (allowing to record photo’s, sound and movies). We opted for this
approach based on the success of photo production in a similar setting (Radley & Taylor,
2003a). However due to extra obstacles related to some patients’ vulnerable position and
limited photography skills, we expanded the approach from photo production to image
production (Annemans et al., 2012). Afterwards the material produced by the patients
was used to facilitate a semi-structured interview with them, based on the requirements
for the interview guide described above, about the hospital’s spatial qualities.
Also while moving or being moved, our senses play an important role in our experience
(Crang, 2003; Paterson, 2009). The question thus arose to what extent the explored
methods could be valuable to study spatial experience in motion. The results from
the pilot study seemed promising. The indexical use of pictures and the reasons why
participants opted for taking pictures or drawing addressed issues concerning motion
(Annemans et al., 2012). However, when applying the approach on the larger scale, no
information was retrieved on the transport part of patients’ experience. The participating
patients took pictures of (objects in) their room or wrote notes about their stay, but none
of them took the camera along on the route through the hospital. A possible explanation
could be found partially in patients’ state of mind when being wheeled to the OR and
partially, for the older participants at the nephrology ward, in not feeling comfortable with
taking pictures in general.
Given the limited success of visual methods using pictures or drawings to gain access
to patients’ spatial experience in motion, we needed to find other ways to bypass the
difficulties some participants had explicating their perceptions. Literature pointed at
the potential of videography to pave the way for a multi-sensory research approach
(Merchant, 2011). Moreover, video-recordings, unlike photographs, show the flow of
movement (body position, direction, time lapse, orienting elements). Therefore the
researcher explored the use of the video-recordings originally made for our own benefit,
as a basis for the interviews, thus bypassing some participants’ difficulties to explicate
their tacit knowledge on spatial experience (fig. 3-2). Participants were asked to provide
“subtitles” to the video they saw, which appeared to be a successful alternative to
provide an entrance point into their spatial experience in motion. As Forsyth, Carroll,
and Reitano, (2009) argue, using video data reflexively supports the development of a
dialogue between researcher and participant.
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04:14
04:15
04:47
05:27
05:39
05:54
--------fig. 3-2
Video as an entrance point into participants’ experience in motion (original recording 16.07.2012)
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3.3.5 ANALYSING AND REPRESENTING
To provide insight into embodied and multi-sensory experience, data need to be analysed
using appropriate theories (Harris & Guillemin, 2012). Particularly relevant in this respect
are phenomenological and interpretative theories of perception and embodiment, or
nonrepresentational theory. Also during the analysis a sensory awareness should be
kept in mind. Video and audio-recordings provide visual information, soundscapes, and
information on kinaesthetic and auto location. Pictures of the environment (be it the
building or objects), but also drawings can offer insights into movement and can tell
something about the maker and the context (Annemans et al., 2012). Interview transcripts
should obviously be read with a sensory realm in mind. What participants do not tell can
provide as much information as what they do tell. When patients reflected on the route
they took, some spaces were neglected. This too could provide the researcher with a
better understanding of patients’ spatial experience while moving through a hospital
building; for example, few sensory points of orientation could reduce patients’ ability to
reflect on a certain room.
Analysing qualitative data means distilling the meaning that is hidden in them. This
process does not start after the data have been collected but takes place throughout the
research in a continuous dialogue between researcher and participant. It is important that
the researcher supports participants in the process of meaning making to truly explore
their understanding of their experience based on past, present and future (Stelter, 2010),
which can shape expectations and interpretations. Creating meaning is done when
interpreting spoken data but also while observing. Just like dancing can be a research
method of which the findings are described and analysed (Cancienne & Snowber, 2003;
Ylönen, 2003), in our study moving is a way of doing research and documenting it is part
of the analysis. Considering how to note down where and how people move is thus a key
issue. As we mostly knew in advance which routes patients at a certain setting would take,
these were documented on a plan. In some situations, however, the representation of
specific patterns of moving could be part of the field notes (Heylighen, 2013), as a piece
of data that should be analysed rather than a way of analysing and synthesizing data.
How data are analysed and represented forms the basis for their communication. Until
now we mostly subscribed to the traditional scientific approach of publishing our findings
in a written format. Various researchers have explored different formats to present their
research to the public, like film, poetry, theatre, or dance (Bagley & Cancienne, 2001).
Research on motion asks for such an alternative way of communicating (Forsyth et
al., 2009). Recently we took the first steps in disseminating our findings through short
movies supported by quotes from participating patients and remarks from the researcher
undergoing the shown transport (Annemans et al., 2014).
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3.4 METHODOLOGICAL CHALLENGES
The research approach for our study was not developed straightforwardly. Frequently
adjustments had to be made to match the pre-established approach with the specificities
of certain situations and patient profiles. Also insights gained into architects’ design
process called for adjustments to the approach (Annemans et al., 2014). The relatedness
between different settings and routes asks for techniques tailored to the situation (Pink
et al., 2010). The specificities of the hospital context entailed some challenges and
adaptions along the way. Unlike the promising results from a pilot study (Annemans
et al., 2012), participants made use of the possibility to make drawings or pictures only
sporadically. Moreover, no data on experience in motion were produced. Therefore, we
used the video-recordings of the researcher’s transport through the hospital as a point of
entrance to participants’ tacit knowledge. Recordings of similar activities made by others
can indeed trigger participants to reflect on their own actions and experiences (Mollo &
Falzon, 2004) and evoke reflections on a previously embodied experiences (Merchant,
2011).
To address the broad spectrum of aspects involved in spatial experience in motion, not
just one method can be applied. Neither can one method be connected to uncovering
one aspect. As the senses are intertwined (Ingold 2000; Pink 2008a; Pink and Servon
2013), so are our perceptions. Especially when trying to gain insight into aspects related
to motion, kinaesthesia and haptics are considered the dedicated senses (Tuan, 1977).
Moreover, visual, auditory, and olfactory features can define points of recognition that
stimulate orientation. Sharing time between research subject and researcher during
transport definitely adds to a common basis for communication (Ross et al., 2009).
Judging from our fieldwork, both reflecting on haptic perception while moving, and
registering the physical elements involved in experience in motion remain difficult. One
way to try and bypass this obstacle was combining audio-recordings during the transport
with the varying approach to gain access to the participants’ reflections - during the walk
versus afterwards based on video material. Although combining objective measures (like
the data of the gyroscope meter) with experience seems to hold great potential (Andrews
et al., 2012), interrelating them with subjective accounts is challenging (Zimring & Dalton,
2003). So far, we did not manage to relate patients’ narratives about their experience to
actually measured vibrations of the route they took.
If one conducts research in a hospital context, there is often a third person present,
especially during transport. Logistic caregivers push the bed or wheelchair and take
a major part in patients’ experience (Winance, 2010). Their skills largely influence
the kinaesthetic experience and their opinion becomes easily intertwined with the
reflections expressed by the patient. Moreover, the process of meaning making during
the discussion often unfolded not between participant and researcher but between
participant, accompanying relative and researcher. Defining where the responses of the
patients stopped and those of the relatives begun was not always easy. We could say
that the captured experiences are co-created not just between patient and researcher
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(Fischer, 2009), but also with accompanying caregivers and relatives. This does not mean
that they could not be valuable, however.
3.5 ETHICAL CHALLENGES
When one opts for a visual method in which a camera (photo or video) is used, it is
important to be aware of the power relation between researcher, participant and camera
that comes with it (Forsyth et al., 2009). Not every situation is suited to take pictures:
as the pilot study shows, participants were withheld from taking pictures in certain
situations by their own vulnerability, but even more by the vulnerability of others. In these
situations offering the possibility to draw proved valuable (Annemans et al., 2012). In
recent years, however, people have become increasingly accustomed to having their
daily lives (video-)recorded (Forsyth et al., 2009). Where a few years ago we agreed
with a hospital’s ethical committee not to show any pictures of patients, in a more recent
study the hospital decided that it did not have to pass the ethical committee since visual
methods would be applied only in public parts of the building.
In the design of complex projects like healthcare buildings, acknowledging the needs of
the primary users is an important concern. Providing designers of hospital buildings with
real-life data, directly produced by patients, may (help to) bypass this threshold. Despite
their potential for design practice (Annemans et al., 2012), communicating (raw) data
raises some ethical issues. The traditionally used informed consent forms mention that
all data will be destroyed after the study has been completed. Since we want to keep the
possibility open to use original material, like pictures or drawings made by participants,
but also pieces of interviews, this phrase had to be adapted. Instead we guaranteed to
anonymize all data when used in external communication, but also explicitly mentioned
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Conclusion
Many ethical challenges concerning sensory-rich research methods have already been
documented elsewhere (Allen-Collinson & Hockey, 2011; Harris & Guillemin, 2012).
Here we draw attention to challenges that arose when following our research approach.
As the approach employs the body of researcher and participant as an active agent
in knowledge generation (Crang, 2003), it provides the researcher with experiences
similar to the participants’. As a result the line between being the research subject and
being the researcher becomes thin and the researcher’s personality and background
gains importance. Throughout the use of this kind of research approach we should be
aware of bracketing, not for the sake of gaining objectivity, but rather to acknowledge
the researcher’s engagement in the ongoing process of co-creation of meaning
(Fischer, 2009). The researcher’s background in architecture has certainly directed her
focus towards spatial aspects, whereas the data may contain just as much information
on other aspects. Also her assumptions and interests most probably have inspired the
clarifying questions during the interviews. Even the choice for visual methods could be
stemming from architects’ preference for the visual (Pallasmaa, 2005). Being reflexive
and consciously reporting enables others to examine our data and findings, adding to the
study’s validity (Fischer, 2009).
the possibility of this use. Immediately after the informed consent forms had been signed,
they were given a code, which was used in all fieldnotes, transcripts and during analysis. In
this way, names were completely detached from the data.
3.6 CONCLUSION
Conclusion
The literature review revealed that the experience of motion does not relate
to one sense organ. Neither can the various aspects of motion - locomotion
(or direction), proprioception (body position), orientation, speed, rhythms,
and haptic sensations - be linked with just one sense. Only complementing
different sensory registers allows obtaining a nuanced understanding of
the impact of motion on our experience of space and vice versa. Studying
spatial experience in motion in all its aspects requires developing a research
approach in which multi-sensory embodied experience is addressed rather
than just individual sensory perception.
The development of our research approach started from an investigation
of aspects relevant to the experience of motion. The approach covers the
entire research process starting with defining experience based selection
criteria for the research setting, covering different methods to collect data
about spatial experience in motion, and discussing how to approach data
analysis and communication to fully address the experience of motion.
Additionally we believe that by consciously documenting how the research
approach came in to being and reflecting on challenges and opportunities,
this work makes an important contribution to the study of motion. Although
the approach has been set up, analysed and evaluated with the results’
applicability for architects in mind, the methods used could be useful also for
engineers working on people transport, in a hospital setting but also in other
complex situations. Broadening the perspective on (hospital) logistics with
insights into people’s spatial experience in motion could enrich architectural
and engineering practice and has the potential to make future buildings and
maybe even transport systems more people oriented.
Although our approach is applicable to study motion in itself, the focus of
our study was patients’ spatial experience in motion in a hospital. The aspects
addressed were continuously evaluated in terms of their relevance on an
architectural scale, whereas the methods were judged on their applicability in
a healthcare context. The research approach we developed is flexible enough
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Margo Annemans
Supervisor:
Prof. Ann Heylighen
Co-supervisors:
2
VOLUME
PATIENTS’ SPATIAL
EXPERIENCE
IN MOTION
Margo Annemans
Supervisor:
Prof. Ann Heylighen
Co-supervisors:
Prof. Herman Nys
Prof. Sarah Pink
Prof. Tom Thys
VOLUME 2
PATIENTS’ SPATIAL
EXPERIENCE
IN MOTION
Patients’ spatial experience in motion
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V2
TABLE OF CONTENTS
1. IN-PATIENTS’ SPATIAL EXPERIENCE: INTERACTIONS BETWEEN MATERIAL, SOCIAL AND TIME-RELATED ASPECTS 3
1.1 Introduction
10
1.2 Background
10
1.3 Context and methods
12
1.4 Findings
15
1.5 Discussion and conclusion
26
2. PATIENTS’ SPATIAL EXPERIENCE AT AN EMERGENCY DEPARTMENT
31
2.1 Introduction 36
2.2 Background
36
2.3 Methods 38
2.4 Findings 39
2.5 Discussion
45
2.6 Conclusion
46
3. BEING TRANSPORTED INTO THE UNKNOWN: HOW PATIENTS EXPERIENCE THE ROUTE TO THE OPERATION ROOM
49
3.1 Travelling through the hospital
54
3.2 A mobile experience
54
3.3 Towards a mobile research approach
55
1.3.1 1.3.2 1.3.2 1.3.3 1.3.4 1.4.1 1.4.2 1.4.3 1.4.4 2.3.1 2.3.2 2.3.3 2.4.1 2.4.2 2.4.3 2.5.1 2.5.2 3.3.1 3.3.2 Context
Ethical considerations
STUDY Set-up
Participants
Data analysis
12
12
13
13
14
Material aspects
Social aspects Time-related aspects Interactions
15
17
19
21
Data collection
Data analysis
Ethics
38
39
39
Time in space
Social space
Material space
39
40
44
On the method
On the findings
45
45
Researching motion
In the field
55
56
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V2
3.4 Unravelling mobile experience
57
3.5 Discussion 61
3.6 Concluding remarks
64
4. BEING WHEELED OR WALKING: A QUALITATIVE STUDY OF PATIENTS’ SPATIAL EXPERIENCE IN DAY SURGERY CENTRES
67
4.1 Introduction and aim
74
4.2 Literature review
74
4.3 Context: two concepts of day surgery centres
77
4.4 Methodology
80
4.5 Results
81
4.6 Discussion and recommendations
87
4.7 Limitations of the study
89
4.8 Conclusion
90
5. DISCUSSION AND CONCLUSION: GAINING INSIGHT INTO PATIENTS’ SPATIAL EXPERIENCE IN MOTION 93
5.1 Experiencing hospital architecture 94
5.2 Aspects relevant to architectural practice
96
5.3 Conclusion
3.4.1 3.4.2 3.4.3 4.2.1 4.2.2 4.4.1 4.4.2 4.4.3 4.5.1 4.5.2 4.5.3 5.1.1 5.1.2 5.2.1 5.2.2 5.2.3 5.3.1 5.3.2 5.3.3 Space
Time
People
Patients’ experience from a nursing perspective
Patients’ experience from a spatial perspective
Study Design
Data Analysis
Ethical considerations
Spaces
People
Time
Patients’ spatial experience Patients’ spatial Experience in motion
Material aspects
Social aspects
Time related aspects
Variation amongst patient profiles
Focussing on the patient in motion
Patient-centeredness enacted through space
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experience of a hospital environment, from a lying perspective? This research question
comprises different elements to be researched. Identifying aspects impacting patients’
spatial experience of a hospital environment entails that there should be a consensus on
who these patients are what their spatial experience of a hospital environment is. Neither is
the case.
To provide insight into the richness, depth, nuance, and diversity of patients’ spatial experience,
three patient profiles at four research settings were studied. Combining the insights gained at
the different settings offers a novel perspective on the hospital environment that transcends
what could be achieved by deepening the study with only one patient profile at one setting.
The order in which the chapters are presented is not the order in which the research took
place. This explains the somewhat unconventional literature background in some parts.
Chapters 1 and 3 address the topics put forward in the literature study that shaped the
methodological approach, focussing on the impact of sensory perception, meaning making
and affordance in relation to space and motion, from an a-typical perspective. Chapters 2
and 4 position the research on the impact of space as an addition to the existing body of
knowledge on patient experience in nursing studies, be it at an emergence department (ED)
or day surgery centre.
Presenting the chapters in this way better supports the build-up of the argument in response
to the research question. First the group that forms the archetype of the hospital patient
is studied, people who are staying in the hospital for a longer period. Then I focus on its
counterpart, patients who just entered the building at the ED. In the last two chapters more
explicit attention is paid to the impact of the way of moving, being wheeled or walking, on
patients’ relation to built environment.
Despite the diversity in spatial experience between the different patient profiles, on a
more abstract level certain similarities can be identified. These are formulated as practical
recommendations, which were discussed with an expert panel of healthcare actors.
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1. In-patients’ spatial experience:
Interactions between material,
social and time-related aspects
This chapter has been submitted to a journal.
Keywords:
design
hospital building
in-patients
patient experience
qualitative research
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Abstract
For in-patients who spend a longer time in the hospital, the
built environment plays a significant role in their experience.
While many hospital boards aim to create a patient-centred
hospital, few have a specific idea about what this means in
terms of spatial qualities. This creates a major challenge for
those involved in designing hospital environments. Therefore
we aimed to identify which elements play a role in inpatients’ spatial experience, and how these elements relate
and interact. Patients were followed during transport and
afterwards interviewed. In this way we gained insight into
their spatial experience, static and in motion. This experience
turns out to be shaped by material, social, and time-related
aspects. An analysis of the interactions between these
aspects yields a nuanced understanding of how in-patients’
experience of the hospital environment is shaped by the
spatial and social organization, movement, and perspective.
This understanding should allow informing hospital boards,
architects, and staff to start designing hospital buildings in a
more patient-centred way.
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+2
+1
/
bed/chair
route on second floor
reference cf. fig.’s
(going)
route on first floor
reference cf. fig.’s (returning)
presence of green outside
--------fig. 1-1
Hospital plan with patients’ route from the ward to
dialysis (switch from level 2 to 1)
01:00
01:07
03:75
04:00
04:50
05:75
06:00
06:25
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02:25
03:25
03:50
04:75
05:00
06:75
07:52
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07:50
08:00
08:50
10:00
10:25
11:25
13:25
13:75
14:75
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09:00
09:50
12:00
12:50
--------fig. 1-2
Videostills of the route from the ward to dialysis
(recording 25.07.2012)
16:00
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1.1 INTRODUCTION
In conversations about hospital experience, the relation with space is often not the first
that comes to mind (Annemans et al., 2011). When building or refurbishing a hospital,
hospital boards (cl)aim to create a patient-centred healing environment (Bromley, 2012).
For architects it is not always clear how to live up to these expectations (Devlin & Arneill,
2003). Therefore it seems important that architects and boards involved in (re)designing
a hospital know how patients experience it. The study reported here aimed to identify
which elements play a role in patients’ spatial experience, and how these elements
interrelate.
The study started from the observation that architecture is experienced through the
senses (Pallasmaa, 2005; Rasmussen, 1964). The specificity of the activities taking place
in a hospital context extend this experience: your relationship with the environment is
determined by moving or being moved and by the people accompanying you. As we
aim to relate patients’ experience to these context-specific circumstances, we consulted
patients who are very familiar with this context, considering them as ‘user/experts’ in
relation to the hospital building. Elaine Ostroff (1997) introduced this term to denote
“anyone who has developed natural experience in dealing with the challenges of our built
environment”. Four dialysis patients admitted to the hospital at the time of the study
were followed. By analysing their verbal and bodily reactions to the environment, we
delineate how patients’ spatial experience is determined by material, social, and timerelated aspects. We conclude by discussing where and how these aspects come together,
intertwine, and shape people’s spatial experience.
1.2 BACKGROUND
As architecture is experienced through the senses (Pallasmaa, 2005; Rasmussen, 1964),
architects should pay specific attention to sensory perception, through passive and active
reception of stimuli, and how the senses intertwine (Gibson, 1968). The five traditionally
known senses are, by themselves, inadequate to account for our (spatial) experience.
Ecological psychologist James Gibson (1968) partially bypasses this inadequacy by
considering perceptual systems instead of the sense organs. He distinguishes between
five interrelated subsystems: the orienting (basic to all others), the auditory, the haptic,
the taste-smell and the visual system, in no particular order. Not prioritizing them does
not imply all senses are equal. Regarding spatial experience, a distinction is made
between distant and immediate receptors (Hall, 1982). Eyes, ears and nose can receive
stimuli from a distant source; touch is perceived directly through the skin and muscles.
Skin sensations can relate to the tactile experience of physical objects - like contact with
a wheelchair - or the built environment. These sensations can be perceived directly,
through the chair or skin - like wind or heat.
We experience the built environment statically but also while in motion (Latour &
Yaneva, 2008). To explore spatial experience in motion, geographer Yi-fu Tuan (1977)
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extends the five traditionally known senses with kinaesthesia (the sense of movement),
which, combined with sight and touch, he considers strongly related to space and spatial
qualities. In experience in motion the senses’ intertwining becomes even more important.
While you travel along a trajectory, views change, smoothing the boundaries between
different places (Ingold, 2000). Additionally experience in motion closely relates to
the control people exercise over how and where they move. Actively moving - walking
(Bollnow et al., 2011; Lorimer, 2011; Lund, 2005 in Paterson, 2009; Laurier, 2011; Sheller,
2004) or using a wheelchair (Winance, 2006) - is completely different from being
passively moved as a passenger in a car or train (Bissell, 2010), or being pushed in a
wheelchair (Winance, 2006) or bed. Since our kinaesthetic organ only registers transitions
in movement (accelerations), we are unable to actively experience a uniform motion in
a straight line (Gibson, 1968). Therefore, vibrations of an actively moving object (like a
train (Bissell, 2010), a wheelchair, or a bed) that transports a static body, can serve as an
important point of entrance into experience in motion.
Moving, in a certain direction, at a certain speed, connects space and time (Prior, 1988;
Tuan, 1977). The experience of this connection is strongly affected by the body-axis
along which this movement occurs. Travel time is associated with movement along a
trajectory, going from A to B. To understand the interaction between time, movement,
and space, rhythms are essential (Lefebvre, 2004). Philosopher and sociologist Henri
Lefebvre (2004) uses rhythms as an analytic tool to examine daily life in relation to
the built environment. Rhythms concern repetition (of movements, gestures, action,
situations, differences), interferences of linear and cyclical processes, and phases of life,
like birth, growth, peak, decline, and end (Lefebvre, 2004, p.15).
Vibrations (Bissell, 2010), taking place while moving along a trajectory or not, can be
considered a repetitive rhythm, independent of goal oriented movement. Multiple factors,
i.e., speed, location, emotion, touch upon our experience of travel time, disconnecting it
from measured clock time (Watts & Urry, 2008). Clock time indeed differs from lived
time, time as it is experienced (Lefebvre, 2004). Although this insight originates from
research on train travel, parallels can be drawn with hospital transport. Here too, the time
spent relates to various socio-material practices, hospital staff, views, et cetera. Under the
influence of these rhythms sound, space and time can move to the background (Tuan,
1977), which once again illustrates the intertwining of the perceptual subsystems. Rhythm,
in relation to time, can be differently interpreted depending on the scale and process: the
cyclical repetitions of days and seasons define the length of a hospital stay, linear series of
activities define daily patterns (Edensor, 2011; Lorimer, 2011).
Focusing on sensory sensations, time and movement in relation to the built environment
puts forward the need to clarify our role as embodied beings in the world (Pink, 2008).
As these sensations cannot be perceived without the body, body-specific and personal
elements strongly impact spatial experience. A hurt body perceives the nature and
intensity of sensory input differently (Paterson, 2009). People reflect differently on the
environment depending on the phase of life they are in (Lefebvre, 2004). A body-in-
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a-wheelchair uses and perceives space differently than a walking body. The ‘vehicle’
itself, but also the one pushing it, plays a crucial role in how the journey is experienced
(Winance, 2010). Therefore, the research subject is not just a ‘person-in-a-wheelchair’,
but a ‘person-in-a-wheelchair-pushed-by-someone”. In a hospital context this subject is
often supplemented by extra people, be it a trainee, researcher or passer-by, widening
it to a ‘person-in-a-wheelchair-pushed-by-someone-and-accompanied-by-someoneelse’. Each of these actors, whether actively involved in the on-going action or passively
observing at the side, likely plays a role in patients’ spatial experience.
For in-patients, their entire life takes place within one building, where experience in
motion is largely restricted to controlled, passive movement. Moreover, the perspective
from which patients experience their surroundings is frequently limited to being seated
or lying down. Therefore, we decided to explore hospital architecture from this particular
angle.
1.3 CONTEXT AND METHODS
1.3.1 CONTEXT
The study was conducted at a middle-scale hospital (610 beds) in a suburban area. At
the time of the study, the building had recently undergone major reconstruction works,
with parts being refurbished and others added. The dialysis department is situated in a
new part of the hospital. As the department moved only a few weeks before the study
took place, the memory of the old location was still very fresh. The nephrology ward,
where in-patients with kidney problems are admitted, is situated in an older part of the
hospital. The route between both takes around 10 minutes, travelling through corridors,
taking different elevators and passing different hospital parts. As we are interested
in in-patients’ spatial experience, both static and in motion, this was considered as an
advantage.
1.3.2 ETHICAL CONSIDERATIONS
The study passed the hospital’s ethical board. Due to the fieldwork’s nature, it required
some creativity to guarantee patients’ privacy while being able to fully inform them and
receive informed consent. Patients should be able to participate in the study completely
anonymously. However, they should also sign an informed consent form before anything
could be recorded or used as data. This obstacle was bypassed by coding each form, and
from that moment on using only this code to refer to the particular participant. Signed
forms are kept separately from the collected data.
As agreed with the ethical board, the first author (henceforth referred to as the researcher)
was not allowed to enter a room without the patient’s permission. A volunteer from the
hospital made the first contact. Only after being introduced by this volunteer, and given
permission by the patient, the researcher could enter and provide additional information.
Finally, an agreement was made that all data collected during the fieldwork would be
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made anonymous. Since in a later phase of the research, we would like to use the data to
inform hospital designers, destroying the data or keeping them only within the research
group was not an option.
1.3.2 STUDY SET-UP
As an introduction to the site and fieldwork the researcher first documented the
architectural elements. While she was wheeled from the ward to the dialysis department
and back, she made video- and audio-recordings of the route from a lying and seated
perspective. As patients have unique, experience-based knowledge about their own
situation, they are the number one source of information (Wibe et al., 2011). Interaction
with them took place over a period of six weeks. Each week the researcher visited the
ward and dialysis department on one day to be introduced to patients, and returned two
days later for further observations during the transport and the actual interview. Since
participants’ engagement and motivation appeared to be a key factor for the study’s
success, special attention was paid to the introduction talk. Also the administrative
procedures needed in the hospital, like fulfilling the informed consent were taken care
of at this moment.
On the day of the interview, the researcher walked along when patients were transported
from the ward to the dialysis department. During the transport patients were asked to
describe what came to their mind. The same was done for the way back. A follow-up
interview was conducted during the dialysis, or once the patient had returned to his/
her room, depending on personal preferences and practical restrictions. Interviews
were semi-structured around open questions, which addressed both spatial and time
experience. Interviews took between 15 minutes and 2 hours. In some cases more informal
conversations continued to take place in the weeks following the formal interview.
1.3.3 PARTICIPANTS
The route was chosen because of its length and the spaces’ character. Even more
important was the profile of the patients frequently taking it. We were specifically looking
for patients staying in the hospital for a longer period, already familiar with its organization
and building, with the dialysis department, but possibly also with the (nephrology)
ward. Over the course of six weeks, six people were found meeting these criteria; four
of them, one man and three women, were willing to partake in the study. Due to the
researcher’s extended contact with them, we believe that these four cases can provide us
with significant insights into in-patients’ spatial experience. Apart from all suffering from
kidney failure, the four participants - referred to as John, Mary, Jane, and Louise - each
provided an added value to the study from their own background and personality.
John is a folksy man in his seventies. At the time of the study, his foot was injured so
he could barely walk and even the slightest movement left him in pain. On the day of
the interview, he would be discharged from the hospital. He was looking forward to his
daughter picking him up after lunch.
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Mary had been admitted to the hospital after losing consciousness and falling at her
home. At the moment of the interview she felt almost recovered. Although she lived
by herself since her husband died a few years ago, she was now not allowed to go home
alone anymore. She was spending some more time in the hospital while her children were
searching for a vacant spot in a care residence.
Jane is the youngest, but due to a lifelong illness she has been in and out of the hospital
multiple times. This time she had been there almost three months. She probably is not
able to go home anymore. Being only in her sixties, she still feels way too young to go
to a nursing home, yet there is not much choice left. Participating in the study was very
important to her. It made her feel useful, whereas she normally has to rely on others.
Louise is a retired pharmacy assistant. She suffers from side effects of her diabetes,
which make her lose consciousness and fall easily, being in and out the hospital and the
revalidation centre frequently.
When not admitted to the hospital all four participants visited the dialysis department
by taxi. For John and Mary coming to the department from the ward is rather a new
experience, which they became familiar with in the last few weeks. For Jane and Louise,
not only the dialysis department, but the entire hospital is a familiar place.
1.3.4 DATA ANALYSIS
The interviews were all transcribed verbatim. The field notes from the researcher’s
exploration of the route and the transcripts were coded first according to the sensory
experiences. Then the coded excerpts were assigned on a map to specific places along
the route. However, as we know from literature and earlier research, sensory experience
does not entirely cover patients’ experience of a hospital building (Annemans et al., 2011,
2014; Pols & Moser, 2009; Watts & Urry, 2008). Therefore we coded the transcripts also
according to aspects that impact experience. These could be of material, social or timerelated nature. In each of these categories certain attributes of the particular aspect (be
it an actual space, person or aspect of time) were identified and linked to related sensory
experiences and on-going activities.
Initial coding was done on printed transcripts. In a second round we used qualitative data
analysis software (ATLAS.TI) to define interrelations and explain possible missing links.
The defined categories were compared across the different transcripts, both in this study
as in parallel studies on different patient profiles (Annemans et al., 2014).
The interviews and field notes are in Dutch. Quotes used in this article have been
translated to English by the authors.
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1.4 FINDINGS
As ‘spatial experience’ seems hard to define, most interviews do not provide a
straightforward answer to the questions which elements add to patients’ spatial
experience, and how these interrelate. Most closely related to physical space are
elements of the material environment, ranging from the building as a whole to individual
objects. Most participants considered the interaction with others, the hospital’s social
environment , as most important. The experience of time turns out to change due to
the context’s specificity and vice versa. Obviously these three themes closely interrelate,
work together and are hard to separate in real-life situations.
1.4.1 MATERIAL ASPECTS
The hospital’s material environment covers different scales. The building as a whole is
what defines people’s overall perception when arriving or just passing by. Although “for
being a hospital” the building is generally appreciated, the connotation of a hospital is
hard to disconnect from it. Especially Jane seems sensitive to the feeling the building
generates. When introduced to the research topic, she mentioned:
“When you enter a hospital, wow, that falls down on me.”
In the interview she put it even more firmly: “I hate hospitals,” but then nuanced her
statement when a nurse seemed surprised:
“Not the people, but the hospitals in themselves. Well, I hate being ill, that’s
what it comes down to.”
When being used, the hospital building breaks apart in different spaces and places, of
which some hold major importance and others do not seem to partake in a patient’s
experience. Depending on his/her own specific situation, each patient perceives a
slightly different building. Still, similar building elements contribute to this perception.
A topic of conversation was the presence or absence of certain spaces in general. The
three participating women mentioned the presence of a garden as the most valuable
spatial element. The importance of the view from the window was also referred to in the
interviews:
“I think it’s nicer here. There [in the old dialysis department] I lay at the
window. That was downstairs, then you only see a little. There was a wall
and then a little further apartments or houses, but I like looking outside, even
though there’s no movement, or like here just the tops of the trees. I find that
a major advantage.”
Actually going outside (fig. 1-10) is obviously even better. Jane later on mentioned:
“I have the luck that when my daughter comes, every day, I can go sit outside
in the evening for half an hour […] but when you then come outside, that air, I
would bite it, seriously.”
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Also Mary and Louise, both capable of going outside independently, spent the afternoon
in the garden when possible. Louise explained:
“When I don’t have visitors and the weather is good, I go sit outside, with a
magazine or so. [....] Or sometimes I’m sitting there and just enjoy nature. I
can enjoy that very much actually.”
Jane, who cannot leave her bed without help, would highly appreciate some outside
space closer by (fig. 1-7):
“You know what I find the most interesting about the rooms? Some rooms,
not many, have a small balcony. […] That I’d find luxurious!”
Besides outside space participants also mentioned the size of the room, the presence of a
(spacious) bathroom with shower and toilet, and the look and feel of the corridors. None
of these seem so overly important as the possibility to go outside, however.
Often participants’ perception of hospital spaces closely relates to more punctual
design decisions. Which constructive decisions were taken, or what design solutions
were implemented, is often hidden in additional objects, but contributes to people’s
perception of the building. Sometimes, small elements can be a source of disturbance. A
simple ventilation tube always catches Mary’s eye. It innerves her that she does not know
what it is for. On the other hand participants seemed very forgiving toward situations
they do understand. During the study parts of the hospital were still under reconstruction.
Although all four mentioned the wood and other materials applied in the corridors, none
of them really bothered. Two participants mentioned the number of doors on the route
(fig. 1-8), mostly wondering what was situated behind them. Imagining that triggered
associations, like Jane reflected:
“What also impresses me is, like here when you enter, see what a number
of doors! How many doors would there be in the hospital? That’s a huge
number, I think. […] That are a lot, and behind every door there’s a little bit of
misery.”
Explaining that half of the doors were not entries to rooms but just closets seemed to
make their presence somewhat more acceptable to her. When walking through the same
corridor again a few days later, Jane explained that half of the doors were not rooms,
but closets, and that depending on the colour you could identify them (something the
logistic assistant had told during a previous walk).
Equally important as the presence of building elements seem to be missing elements. At
the former dialysis department, some system of curtains sheltered patients when having
to go to the bathroom, in the new department this is still missing. Nurses try to solve
this by using a movable screen, however, for patients little things like this influence their
experience considerably.
Apart from building elements, spaces are filled with objects that co-create the material
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environment. Medical equipment or objects like a wheelchair or walker emphasize
patients’ situation of being ill. Both Jane and Louise have a hard time accepting that.
Louise said:
“In the beginning I had a hard time seeing that wheelchair, that walker. Those
are all attributes that I don’t like to see, but settled, because I have no choice,
but…”
Many of these objects in themselves consist of multiple objects that mediate between
patients and their material environment. At the dialysis department, some patients sit in
a chair, others lay in bed. Louise used to have a bed, but is now positioned in a chair, a
decision made by the physicians. She prefers the bed, mainly because of the material the
chair is made of:
“You know what, that [chair] is covered with some kind of plastic. Everything
sticks to it. Therefore I have the sheet completely underneath [my body],
otherwise it sticks and if you have to pull loose, it hurts. […] I prefer the
comfort of a bed, even more because a person rests a lot here and I don’t
find it comfortable to try to sleep in such a chair, a bed is much more
comfortable.”
1.4.2 SOCIAL ASPECTS
The participating patients unanimously agree it is the people who make the place. Like
the material environment, the social environment is not one-dimensional either. Many
people play a role in how the hospital is perceived. The emphasis participants lay when
discussing the environment is influenced by their personality, state of mind and current
situation. At one point during the fieldwork, Jane just heard she could probably not
return home anymore and would need to move to a residential care home. Obviously
this influenced how she looked at the built environment. Letting go of her own things
surrounding her, and comparing her situation with that of others of her age made the
verdict even harder. However, just at this point she found strength in participating in our
study. As she said:
“I find it very pleasant to talk to you [the researcher], to have the feeling
that I can do something small for someone else. I find that important and
often you don’t have that here, because they [family and staff] have to do
everything for you.”
Also Louise explained how sometimes she relates differently to the environment than
under usual circumstances:
Then [after an operation] you’re so muzzy, yes muzzy let’s say. And you’re
only occupied with your pain, trying to do your thing, but that’s not that easy.
And then someone comes to do something and then someone else. And
that’s sometimes a little annoying.
Patients do not experience the hospital in isolation. Throughout their stay they get into
contact with many others, whom they may be more or less familiar with. Close family
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and friends give their opinion, or tell stories from their own experience, thus shifting
patients’ focus to certain aspects of their stay and accommodation. Even though Louise
personally does not have any negative experience with it, she highly values the presence
of a safe in the room. She recently heard a story of someone whose purse was stolen from
the hospital room, leaving her with an uncomfortable feeling on having any valuable or
even just personal things in there.
Apart from what people hear, an even more important factor of influence are occurring
activities. Visitors make patients use different spaces in the hospital. Think of Jane who
could use the garden only when her daughter came and took her outside. Mary and
Louise mentioned taking their visitors to the cafeteria, a place where they would not
come by themselves. When staying in the room, the space changes due to the presence
of outsiders. Jane stated:
“What else is important? That, when you have visitors that the atmosphere
between people is prior to the room.”
Later she continued:
“When you have company, you can forget about the room for a while.”
The role of those maintaining a professional relationship with patients may be of
a different kind, yet should not be underestimated. Going to dialysis creates a whole
network of people around the patient who all contribute to his/her experience of the
hospital. Although at the time of the study participants did not use the taxi service, when
asked about the (new) dialysis they unanimously described the taxi drivers’ parking
problems and the lack of space for them to be waiting for the taxi after the dialysis. Now
they were admitted to the hospital, the driver’s role was taken over by logistic assistants.
They too influence patients’ experience of the hospital. During the journey from the ward
to the dialysis department, remarks about the cold corridor were frequently heard, yet it
is unclear whether patients actually experienced it as cold or heard the logistic assistants
refer to it. What is clear is that the temperature in this corridor was an important topic of
conversation during the transport. Contact with staff seemed generally valued, however
to what extent depended largely on the patient. The contact can be just visual and/or
auditory or also personal. Mary described how the new dialysis department affects her
relation with the nurses:
“You see more passage here, the cupboards are here, so they have to come
here to get something, but besides that [I have not much contact with the
nurses]”
Also John identified this difference with the previous situation:
“But there are no walls anymore in between, only half of a wall so the nurses
can see each other. […] Before they walked from one room to another. They
went to help here, they went to help there, but now you don’t have to call for
help anymore, or it should be really bad.”
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Due to the new organization of the department the staff changes more frequently. Jane
explained:
“Here in the new department, the staff operating the [dialysis] machines
changes a lot, the nurses. That has advantages and disadvantages
maybe. I’d like to have the same more frequently because, well, I have a
more comfortable feeling with that. […] On the other hand, change has
advantages and disadvantages, like most things.”
As she finds some nurses friendlier than others, she is happy that they are not always
the same, yet regrets that it cannot always be the nurse she knows since her first dialysis.
Similarly, participants also get in contact with fellow patients. Here too, some feel more
need to connect than others. John seemed the most talkative of the four. He really
puts an effort in chatting with new patients at the dialysis, even when they are not that
interested. Also when coming and leaving he is the first to say “hi” and “goodbye.” The
others mentioned some sporadic contacts, but especially stressed the lack of contact
among dialysis patients. Mary said:
“I’ve been lying at different places […] at four different spots, and even then
at none of the four people were talking.”
Jane saw a relation with the spatial organization, but directly nuanced:
“The rooms are in that sense positive, they are not super small. Maybe the
old dialysis was a little cosier when you want to talk, but for me that doesn’t
count, I like it just as much to lay in silence for four hours.”
At the ward, none of the participants shared a room. Contact with other patients seemed
to be limited so small irritations caused by different people living on a small surface - a
TV playing too loud at night or visitors talking with the door open.
1.4.3 TIME-RELATED ASPECTS
Already when recruiting participants, we considered their hospital stay’s frequency,
sequence, and duration as defining elements for patients’ (spatial) experience and thus
as a criterion to select them. All these elements are time-related. Also the participating
patients referred to a relation between time-related elements and their hospital
experience. Especially the duration of activities was frequently mentioned as a reason
to pay particular attention to space. All four expressed the distance from ward to dialysis
department in terms of time. John was the most direct about it, he asked the researcher
whether she was in good shape since
“it’s a serious journey. You’re on your way for a long time.”
A returning conversation topic between the logistic assistant and the patients was the
duration of the dialysis. Participants referred to this duration and the waiting time before
and after, as a reason to pay specific attention to the material environment. The same
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counts for the hospital stay in general. The longer participants have to stay, the more
important their room, and the provided accommodation seemed to become. According
to Jane that is
“because you’re constantly lying looking at it.”1
Jane sighed about corridors with the enormous number of doors (fig. 1-8):
“(…) and in those corridors, maybe it’s indeed because of the time duration
and how often you pass through them.”
Besides the duration of the journey, she points at the frequency of getting in contact
with certain spaces. Also the frequency of hospital admissions determines the spatial
experience, as Louise told us.
“Sequences repeating daily, like the strict routine imposed by the hospital
regime, structure patients’ day.”
Both Mary and Jane mentioned how sensory perceptions indicate time. Mary stated:
“Sometimes it’s more busy in the evening. Then you hear a lot of rumor, they
are preparing the food.”
For Jane also the smell adds to her experience of the hospital (building):
“What is positive is that it doesn’t smell so hospital-like here. And around
lunch, in the morning, or at night, I first smell the coffee or the soup or the
food. Maybe there are people who don’t find that pleasant, but for me it is.”
However, a strict day rhythm also triggers certain expectations, which can cause a shift
in perception depending on the time of the day. At a different moment of the day, what
someone sees, hears, or smells can be experienced completely differently, although it
may be the same scene, number of decibels, or odour. While Louise likes to watch TV
herself, she does this to a limited extent, between seven and ten o’clock in the evening.
She also likes to leave her door open to get some fresh air. Both habits, combined with
fellow patients following different rhythms, generate irritations. She explained:
“What also bothers me, in the past is was 10 pm that there had to be silence.
Now the television is still playing there, and there. Then I think, come on,
that shouldn’t be possible (…) we’re actually here to recuperate! Maybe I’m
wrong but I don’t want to have to close my door for the sound you hear from
outside.”
Jane is not so much bothered by her fellow patients, however, the moment of the day
defines very much how she feels about the hospital environment. She said:
“At night, it’s horrible, really. I can’t sleep hours and hours. I have to wake up
once in a while to go to the bathroom, at least twice. Then I find the night
1 Typical way of phrasing it in Dutch, which connects lying down with continuously looking at something.
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horrible, the room most of all, then I wished I was home, at night even more
than during the day.”
As the biggest difference between night and day she mentioned the duration of time:
during the night everything seems to last longer.
1.4.4 INTERACTIONS
Clearly spatial experience cannot be reduced entirely to material aspects. Social and
time-related aspects affect our awareness of space just as much. Moreover, none
of the three can be considered without the other(s). Interaction between and within
the different aspects is what defines our real-life experience. Our attempt to unravel
in-patients’ experience revealed its multi-dimensionality, but also pointed at how the
multiple dimensions interrelate.
Organization is all about interaction. A common practice amongst architects is to start a
design by making an organizational diagram of how different spaces relate to each other
(Lawson, 2004). This can be based on functional criteria (e.g., the order of preparation
rooms in front of the operation room reflects the sequence of actions taking place there),
but also experiential aspects relate to spatial organization. The presence of green on the
hospital site, or even within the building is, as illustrated, greatly appreciated by patients.
Through certain design decisions this green can be brought closer to patients, changing
it from something to look at into something to truly interact with. Spatial organization, or
the perception that the building is missing it, affects patients’ idea of the building’s quality.
Mary told us in disbelieve:
“There used to be chairs [in the corridor] for the people that had eaten,
where they could wait before they went to dialysis and they had to be
removed. The fireguard had come, and that space was not meant for it. Yes,
these chairs are now gone. […] The passage was too narrow.”
Apart from ordering space, architects can do much more. The material environment
impacts how social interactions take place and vice versa. As mentioned by Jane, the
new dialysis department stimulates even less social interaction than the previous one
due to the larger space and less cosy atmosphere. She made this change very concrete:
“Before you had more contact with your neighbours because you were lying
with 8 or 9 in a room. They could close a curtain when it was needed, but it
made it easier to talk to someone next to you, or you’d say a couple things.”
At the dialysis, the nurses now pass by more frequently but seem less approachable, John
indicated. Also the organization of the hospital staff influences patients’ spatial experience.
As illustrated, the staff at the new dialysis department changes more frequently; for Jane
this reduces her acquaintance with the place, which makes the experience less pleasant.
Movement. Moving means travelling a certain distance over time. You move or are
being moved toward another place, at a certain speed, which largely affects how you
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experience the environment. Where you go is important. When leaving the dialysis
department, Jane sighed:
“It’s a whole relief when I ride away through these doors. That I enjoy that
beautiful tree …” [the first corridor after the dialysis is completely in glass
and outside stand big old trees. (fig. 1-9)]
The movement’s passive character, implicating no control over speed or destination,
defines her engagement with the environment. “It goes all so very fast,” Louise said about
being moved in a bed. She then continued:
“Because you’re so, pff, you’re just lying in bed, a little bit apathetically so to
say. I don’t call that interesting. Okay, here, I walk around here, or I go look at
the paintings, but from the moment you lay i in bed, then all of that doesn’t
interest me anymore.”
While moving, the interaction between different elements of the material environment
becomes even clearer. When they are transported in a wheelchair along the corridors,
patients feel the building through the chair. The wheelchair mediates between patient
and built environment. This experience is co-shaped by the person pushing the chair.
Many insights concerning spatial experience are hidden in what happens during transport.
Although John is not very talkative when it comes to expressing his experiences, his
reactions during the trip from ward to dialysis speak for themselves. When leaving the
elevator, the logistic assistant by accident hit the side of the door with one of the chair’s
wheels. Although not touching John at all, this small bump incited him to curse. Each
movement of the chair over an uneven surface, he felt in his hurt foot. Bumping into the
door side thus left him in even more pain.
Perspective. A change in perspective also changes the way a building, in particular a
hospital building, is experienced, literally and figuratively. Literally, participants identify
an important difference between their perception of the environment while lying in bed,
being seated in a chair and standing up, both static and while moving. Jane reflected on
the difference in what she perceives when travelling in a bed or a wheelchair:
“[When being transported in a wheelchair] you look at it [what goes on
around you] more. Otherwise [when being transported in a bed] it’s the
ceiling and a little bit of the sides, while sitting you have more direction, or
more surface.”
The researcher suggested that you have a broader viewing angle. Jane agreed that is the
best way to express it.
Apart from the view on the environment, Mary, Jane and Louise agreed that lying in
bed versus being seated in a chair makes you feel different as a person. For Jane the
difference lies in the feeling of dependence:
“[…] in the beginning I had to come in bed [to the dialysis] and then it
seemed as if I were completely knocked out, put aside. That’s the feeling you
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have when you’re wheeled in a bed through the corridors. These are my last
rides, you know you will die here, I know that, but… With the wheelchair it’s
more pleasant, the moving space, it seems. Now I have problems keeping
my head straight, but when in bed you seem to be more depending on
everything.”
Louise put a nuance in her explanation, for her it has more to do with control:
“Not with a bed, I find it horrible that they put me in a corridor in a bed; no I
don’t find that pleasant. With a wheelchair that’s not a problem, no that’s ok
because you have control yourself. With a wheelchair you can say a little to
this side or to that side.”
Indeed, the figurative angle, or the perspective, from which people experience a hospital,
largely determines their image of it. Staff certainly perceives the hospital differently than
patients, however, as we noticed in earlier studies (Annemans et al., 2012; 2014), also
amongst patients, variety in perception exists. Particularly for the participants in this study,
the material and social environment gained importance due to the duration of their stay,
as illustrated. Patients’ perception of the hospital can concern the built environment as
a whole, but just as well focus on particular objects i, or be based on social interrelations.
We mentioned that Jane said to hate the hospital, but actually meant she hated being
ill, using the building as a metaphor for her health. Similarly, a wheelchair or walker in the
room constantly confronts Mary, Jane, and Louise with their condition and dependence
on assistance, both material and social. Finally, on the opposite side, patients’ perception
can also touch upon their use of space. Although Jane is an avid smoker, she refuses to
go sit in the smokers lounge, because of its location at the entrance of the hospital.
“That kiosk at the front, […] I don’t want to go sit there, because I find that
so ugly. Someone in his pyjamas, with a stick with an infusion, and then
smoking, I find that an ugly view really.”
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--------fig 1.3
Room where in-patients reside
--------fig 1.4
Corridor at the ward
--------fig 1.5
Corridor going to the elevators
--------fig 1.6
Glass corridor with view on green, considerable
temperature difference over the course of the day
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---------
---------
fig 1.7
fig 1.8
View on the few rooms with a balcony
Corridor with numerous doors
--------fig 1.9
View on the trees when leaving the dialysis
--------fig 1.10
Courtyard where patients are allowed
going outside
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Conclusion
1.5 DISCUSSION AND CONCLUSION
To explore the specific angle from which in-patients experience space we
combined literature focusing on the experience of the built environment
through the senses, expanded the sensory realm with motion, and introduced
perspective and time. Although we initially did not focus on rhythms as
an analysis tool, the findings’ character resonates with that of Lefebvre’s
rhythmanalysis of a Paris junction (Lefebvre, 2004). Documenting the
hospital building with a multi-sensory focus, combined with closely listening
to the participating patients, is very similar to the approach of the envisioned
rhythmanalyst, who should “be attentive, but not only to the words or pieces
of information, the confessions and confidences of a partner or client. He will
listen to the world and above all to what are disdainfully called noises, which are
said without meaning, and to murmers [rumeurs], full of meaning – and finally
he will listen to silences” (Lefebvre, 2004, p. 19, his emphasis). The richness of
the data can indeed be considered a direct result of the researcher spending
a considerable amount of time with the patients, talking and being silent in
their company, in their room and during transport.
Analysing the collected data resulted in three themes that offer a basis to
inform hospital boards’ decision making and architects’ design process. The
material aspects brought forward quite obvious themes, like what you see
from the window, confirming the importance of a view on green instead of a
building (Ulrich, 1984b), but also less straightforward themes were addressed.
Poor legibility of building elements, like the numerous doors, led patients to
interpret them in their own way.
The social aspects draw attention to patients’ relationship with others.
Although we did not address this topic in our background reading prior to
setting up the study, we are aware of the literature on patients’ interactions
with staff (Hindmarsh & Pilnick, 2002; Mikesell & Bromley, 2012), and fellow
patients or relatives (Wilson & Luker, 2006). Each of these topics is worth a
study in itself and could form the basis for a specific design challenge. Within
this article we chose to consider them under one common denominator.
Time most definitely affects in-patients’ hospital experience. The link with
space is often indirect. Repetitions like the vibrating rhythms (Bissell, 2010)
described as time-space related elements, were mentioned infrequently.
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Closer related to participants’ lived experience seemed the cyclical rhythm
(Lefebvre, 2004) of night and day (Edensor, 2011; Lorimer, 2011), the linear
process (Lefebvre, 2004) of the hospital regime, and the difference between
clock time and experienced time (Watts & Urry, 2008).
Designing hospitals with these interactions in mind will be a major challenge
for architects and hospital boards. Spatial organization, like sequences of
rooms, but also sequences of activities or moments could be considered a
starting point, combining material, social and time-related aspects. How to
inform decision and design processes with these insights is subject to future
research.
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As material, social and time-related aspects interrelate, the core of our
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2. Patients’ spatial experience at
an emergency department
This chapter has been submitted to a journal.
Keywords
emergency department
patient experience
semi-structured interviews
spatial experience
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Abstract
Patients’ experience of an emergency department
(ED) is shaped by their state of anxiety and stress. Little
is known about how the physical environment impacts
their experience in this situation. Our study aims to gain
insight into ED patients’ spatial experience. Through
semi-structured interviews with 22 ED patients, we found
that their spatial experience is intertwined with their
experience of time and social interaction, and is shaped by
the transit character of the ED. These insights highlight the
potential of small spatial interventions that support staff in
emphasizing a human approach without counteracting the
medical-technical aspect of emergency care.
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bed/stretcher
route stretcher
reference cf. fig.’s
route walking
zone under construction
--------fig. 2-1
Hospital plan with patients’ route when visiting the ED (by
ambulance and walking)
01:00
01:07
03:75
04:00
04:50
05:75
06:00
06:25
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02:25
03:25
03:50
04:75
05:00
--------fig. 2-1
Videostills of the route followed when being brought
into the ED on a stretcher (recording 09.04.2013)
06:75
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2.1 INTRODUCTION
For a patient, a visit to an emergency department (ED) is not planned. For care
professionals, the procedure is fixed. Patients do not know the rules of the game,
physicians and nurses only play by them. This creates conflicting situations (Elmqvist,
Fridlund, & Ekebergh, 2012). When admitted to an ED, patients are often in great
need of human care, staff rather focuses on care’s medical-technical aspects (Gordon,
Sheppard, & Anaf, 2010). Patients do not want to be considered as objects (rather
than people), staff has work to do on the medical body (Kihlgren et al. , 2004). When
an ED is built or refurbished, staff is increasingly involved in the design process as the
workflow is a key aspect in the spatial organisation (Finefrock, 2006). Although patient
experience at an ED has already been studied extensively, research specifically aiming to
understand ED patients’ spatial experience seems to be rare. Studies conducted in other
hospital departments show that the material environment impacts patients’ experience
significantly and relates to more than just the spatial. Spatial interventions can also
address social and time-related issues (Annemans et al., 2014). The study presented here
therefore aims to describe and understand ED patients’ spatial experience and how this
relates to their overall experience of the ED.
2.2 BACKGROUND
The experience of patients visiting an ED is shaped by their often vulnerable, anxious,
stressed and fearful state (Gordon et al., 2010). Studies on ED patient experience
(Gordon et al., 2010; Nairn et al., 2004; Wellstood, Wilson, & Eyles, 2005), and satisfaction
(Boudreaux & O’Hea, 2004; Taylor, 2004) identify factors that are most important
to patients under the given circumstances. These include waiting time, information
provision, and interaction with staff, but also the emergency environment. The basis of
patients’ experience is their personal situation. Someone’s past, present, and future form
the foundation of the encounter with the ED (Elmqvist et al., 2012). The urgency of a
visit influences whether patients perceive their stay positively or negatively (Wellstood et
al., 2005). Also specific groups like older people (Baraff et al., 1992; Grief, 2003; Kihlgren
et al., 2004; Richardson, Casey, & Hider, 2007; Watson, Marshall,& Fosbinder, 1999) or
chronically ill patients (Moss et al., 2014) can have an altered perception. As many of
these factors could also apply to ED patients in general (Watson et al., 1999), studying
these groups provides a more nuanced understanding due to their increased vulnerability
or familiarity with the ED. Especially older people are said to be more sensitive to the
physical environment (Baraff et al., 1992; Watson et al., 1999).
Actual waiting time and length of stay seem relatively unimportant for ED patients’
satisfaction, what counts is the subjective experience of it (Boudreaux & O’Hea, 2004).
From a psychological perspective, unoccupied time indeed feels longer than occupied
time, planned time differs from unplanned time (Löfgren & Ehn, 2010) and anxiety and
uncertainty make waiting less endurable (Nairn et al., 2004). This might explain why staff
considers waiting time far less important than patients (Holden & Smart, 1999). How
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the latter experience it is defined by six aspects (Kihlgren et al., 2004): the typical ED
milieu makes it often unpleasant (1); patients consider waiting for test results or repeated
examinations unnecessary (2); a lack of good routines during the waiting time (3) leaves
them in uncertainty as to what to expect next; while waiting, patients are often suffering
(4); together these aspects generate bad feelings (5), complaints about which are
directed mostly to relatives, seldom to staff; when nurses interact with waiting patients
(6), signs of patience and kindness are highly appreciated, however, most interactions are
initiated by medical and technical demands. Since patients’ satisfaction seems to hinge
not on how long they actually wait, but on how well this length matches their expectations
(Boudreaux & O’Hea, 2004), providing information on the estimated waiting time could
make a difference in their experience of the ED (Göransson & von Rosen, 2010).
Many of the aspects influencing ED patients’ experience relate to interpersonal relations
between patient, staff and accompanying relatives (Coughlan & Corry, 2007; Olthuis
et al., 2014). A visit to the ED alters how patients experience their own body, but also
how they interact with others. Their connection with the nurses is often motivated by the
quality of care they want to receive. Since they do not want to be regarded as unpopular,
they show a large understanding for busy staff and often feel guilty about complaining
(Coughlan & Corry, 2007). They appreciate it when staff pays attention to them and
provides information on expected waiting time or on-going medical procedures (Nairn
et al., 2004; Thompson, et al., 1996). A human approach, rather than solely focussing on
the medical-technical aspect of care, is highly valued (Coughlan & Corry, 2007; Frank,
Asp, & Dahlberg, 2009). Staff using humour or having a positive attitude results in a
positive perception amongst patients (Watson et al., 1999). Staff recognize this need for
a human approach (Elmqvist et al., 2012). As relatives can complement the staff’s role,
they are encouraged to stay with the patient (Baraff et al., 1992). Their perception colours
patients’ experience of the ED as well (Ekwall, Gerdtz, & Manias, 2008; Welch, 2010).
The emergency environment is obviously more than just its physical aspect. Nevertheless,
material objects and built space shape patients’ multisensory perception. The typical ED
stretchers on which patients are wheeled from the ambulance into the ED and are left
to wait, are hard and many patients feel cold due to a lack of covers, creating discomfort
especially for older patients (Baraff et al., 1992). The examination room looks sterile and
dull, offers little relief or few things to divert patients’ thoughts (Elmqvist et al., 2012). At
busy moments patient and stretcher are frequently parked in the corridor, under bright
lights, with much action going on around (Coughlan & Corry, 2007). This situation
contrasts sharply with the high value patients assign to privacy and patient integrity in the
waiting room (Göransson & von Rosen, 2010). All kinds of noises resound. These can just
be disturbing (Baraff et al., 1992), or raise expectations and create disappointment, e.g. feet
approaching and moving away (Elmqvist et al., 2012). We did not find any literature on the
role of smell (or taste). The presented insights are generated from studies focussing on
general ED patient experience. Research specifically focussing on the relation between
patient experience and the ED’s built environment does not seem to exist.
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Studies that do mention the built environment focus on how spatial layout impacts quality
of care (Hall et al., 2008) or reflect on examples of recently built EDs and how these
increase the efficiency and effectiveness of the care process (s.n. 2013; Finefrock, 2006).
The former study highlights the need to balance experience related factors, like patients’
need for privacy, with the finding that patients who are within eye sight and easier to
reach receive better treatment (Hall et al., 2008). Pursuing this balance seems to be
even more important knowing that patients value experiential aspects more than clinical
elements (Holden & Smart, 1999), whereas from a medical perspective the emphasis lays
on the clinical. The latter studies stress the impact of a new layout on the fluency of the
care process and the spaces where patients reside throughout this process, thus relating
time perception with spatial interventions.
By gaining insight into ED patients’ spatial experience, our study aims to link elements
of patient experience - waiting time, interaction with staff, presence of relatives - to the
physical environment to document how they interrelate and what this means for the
design and building of an ED.
2.3 METHODS
2.3.1 DATA COLLECTION
The study was conducted at the ED of a middle scale hospital (610 beds) in a suburban
area. At the time of the study, the hospital was finishing the refurbishment of the ED. As
its entrance was still under construction, we opted to leave comments on arriving at the
ED out of the study.
To capture ED patients’ spatial experience as adequately as possible, we chose to collect
data in the hospital setting itself. The first author (henceforth, the researcher) conducted
interviews with patients waiting in a cubicle or room for further treatment or admittance
to a ward. Participants were selected based on the nursing staff’s advice. The interview
started with the question: could you describe the spaces you came through today? This
was purposely a broad question in order to let participants address those aspects of the
built environment most relevant to them and not a priori steer them in a certain direction.
Follow-up questions asked for clarification or addressed certain aspects regarding sensory
perception and motion. A video-recording of the route patients had taken from the ED
entrance to the room or cubicle they were in at the time of the interview supported the
interviews. The interview concluded with a question on what participants would change
at the ED.
Of the 24 patients who agreed to take part in the study, 22 were actually interviewed.
The interview with the other two was never finished due to an interruption for medical
treatment. The participants constitute a heterogenic sample, aged between 18 and over
90, 9 men, 13 women. Half of them were over 60 years old. The interviews took between
two and a half and 30 minutes.
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Prior to the interviews the researcher was guided through the ED by the head nurse and
took pictures to document all spaces patients could encounter when admitted to t the
ED. The most common routes (e.g., from the ambulance station to the ED, or from the
waiting room to the triage to a cubicle) were video-recorded from a patient’s perspective,
i.e. walking, in a wheelchair, or on a stretcher. These recordings supported some of the
interviews.
2.3.2 DATA ANALYSIS
All interviews were audio-recorded, transcribed verbatim, and analysed using qualitative
data analysis software (QSR NVIVO 10). The transcripts were submitted to a thematic
analysis. To identify common themes, and corresponding codes, we based us on studies
conducted in other hospital departments (Annemans et al., 2011, 2014). During the
analysis, the list of codes was refined with in vivo codes related to the ED context. The
ED’s transit character changes what patients expect and demand of the use of space, the
passage of time, and the interaction with others.
2.3.3 ETHICS
Ethical approval for the study was given by the hospital’s ethical committee based on a
written research outline and an oral defence. Prior to the interview all participants signed
an informed consent form explaining the aim of the study and its set-up. Participants
were informed that they could withdraw at any time without jeopardising their treatment
or care.
To guarantee participants’ anonymity each form was immediately given a code, which
was used throughout all further data processing. Informed consents and data have been
stored separately.
2.4 FINDINGS
How the participating patients perceived the ED environment is largely determined by
their state of mind at various moments along their admittance. Most participants mention
that the building is the least of their worries. Some just did not attend to the environment
they came through. Others judge that, given the circumstances, it is not the time to be
discussing trivial matters like the building. When exactly the built environment starts to
gain importance varies from person to person. Some participants claim that their altered
state of mind makes them more sensitive to their environment, right from the moment
when they are assigned a box or room, just because of the unfamiliarity with the situation.
Others refer to previous hospital stays to illustrate the increased relevance after a few
days. These previous experiences and the corresponding expectations impact patients’
perception of their present ED visit considerably.
2.4.1 TIME IN SPACE
For ED patients the most important activity seems to be waiting. Unlike what is suggested
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by the spaces’ naming, the waiting does not stop after the waiting area. According to
the participants, they wait throughout their time at the ED. Therefore, defining only
the designated waiting area as “waiting room” may be somewhat short-sighted. This is
illustrated by a patient who was wheeled on a stretcher right from the ambulance (fig
2-3) to the cubicle (fig. 2-10).
Interviewer: So you didn’t have to wait, you could come here straight away
Patient 15: But here I have to wait […]. This for me is the waiting room.
Some places are more suited for waiting than others. A changing room at the radiology
department is certainly not intended to spend unoccupied time, yet it happens:
Patient 8: Yes, those spaces are all small. That I find scary. Like the little
hutch where you have to wait before they take X-rays. That’s all so - I’m not
claustrophobic - but when you have to wait long that’s just scary.
Most participants show understanding for the waiting time and even condone it by
the staff’s busy schedule and the time needed to run tests. Still, when magazines or a
television facilitates the waiting, this is largely appreciated. Without them patients feel
neglected.
Throughout their time at the ED, participants were fully aware of the department’s transit
character. As only limited time is spent here, the requirements for the accommodation
differ significantly from those for other parts of the hospital. Many participants explicitly
make the comparison:
Patient 13: You can’t compare this with a room, another room [at a ward]. […]
This is just a passage.
Patients see the ED as a transition zone before going to a ward or until they can go home
again.
Both the continuous waiting and the ED’s transit character impact how ED patients relate
to the social and the physical environment.
2.4.2 SOCIAL SPACE
The transit character is emphasized by the continuous flow of people ED patients meet.
Each space seems to be populated by someone else: a secretary at the registration desk,
a triage nurse at the first examination, different physicians and nurses coming and leaving
once assigned a room or cubicle, and others when going to the radiology department or
an examination. Patients never know what and whom to expect, at which moment. They
lie waiting in their room, ears pricked to collect a sound of an upcoming intervention.
Patient 24: I’m just staring, I can’t do anything else, I’m hanging here. [attached
to some medical equipment]. I hear people walking around. Sometimes you just
have a cautious attitude, like are they entering now to tell me something or not?
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At the ED the presence of fellow patients in an undeniable fact. As patients are fully
aware that the cubicle or room is just a transit space, they also acknowledge that others
came before them and will come after them. A participant observes the fingerprints on a
cabinet, for him an indication of being just another person in the row of room occupants.
Space at the ED constantly has to be shared with others - staff, fellow patients, and
(their) relatives. Sounds easily travel from one space to another. Whether purposefully
or accidently, people are curious and tend to stare at a patient on a stretcher or in a bed,
or try to catch a glimpse from the corridor to find out what staff is up to. For patients,
nurses and physicians are those who are in charge. They know what is going on and what
to expect. They can provide information about people, places, and procedures.
Patient 17: They [staff] accompany you the entire time. That’s very
important of course. They come in, they tell you what they’re going to do,
they accompany you there, and then you have to wait there, in that area.
Participants attribute high importance to the spaces’ functionality so the staff can do
their job, even if this means that they may lose some spatial qualities.
Patient 16: “I think it’s logical that [the nurses] should be able to do their job.
They have to run around, especially when it’s crowded. If you want you can
close your door, that it doesn’t bother you either. […] It’s difficult to make it
different […] then they might have to make a detour to get here, only not to
bother [the patients], but it’s not good for doctors and nurses, no that’s not
good.”
According to the participants, space should be designed such that it supports the staff to
improve patients’ well-being. Some of the cubicles have a window, allowing daylight to
come in, yet the spatial organisation allows patients to enjoy the advantages only partially
(fig. 2-10).
Patient 22: “You can’t experience anything from outside, since you’re lying in
the wrong direction. Obviously they can’t be occupied with these things, I
understand, you have to make sure that the space stimulates that. You can’t
expect it from the staff.”
When patients are accompanied by relatives, an ED visit becomes a collective experience.
Relatives use of and reflections on the ED influence patients’ spatial experience. Patients
are concerned with their relatives, whether they are with them and can spend the time
in comfortable circumstances or whether they are not yet aware of them being in the
hospital and might be worrying. The presence of relatives emphasizes different aspects
of the ED.
Relative 10: You know what I miss, a coffee machine actually […]
Patient 10: Yes, I think so too […]
Relative 10: I think when you have to wait for a long time, isn’t it [name].
We’re sitting here since half past one, we’re longing for some coffee.
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--------fig 2.3
Entrance
for ambulances
--------fig 2.4
Entrance for patients at the drop-off zone
--------fig 2.5
Corridor towards the waiting area
--------fig 2.6
Waiting area
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---------
---------
fig 2.7
fig 2.8
Corridor after the waiting area
Triage where patients undergo a first
examination
--------fig 2.9
Corridor with cubicles at both sides
--------fig 2.10
Cubicle with stretcher
and blinded window
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2.4.3 MATERIAL SPACE
With material space we refer to the built environment, made of building elements like
walls, ceilings, floors, doors, windows, ... but also its interior and the objects it contains,
both specific ED equipment and general interior elements. Each of these shapes the ED’s
spaces. What patients see, but also what they hear, smell, and feel adds to their spatial
experience. The unoccupied time seems to increase patients’ awareness of the material
environment. Although many participants claim not to be in the mood to attend to the
environment, many others argue that because they have the time they start looking
around, judging what they see. Especially the cleanliness of the spaces is a key concern.
Patient 22: What strikes me most, when you lie down everything is striking,
little papers on the floor, streaks. You see it much more than that you’d notice
it otherwise just because you have nothing else to do, you just are.
Wear and tear on corner protectors and plinths are interpreted as signs of the level of
care and attention at the ED. Other interior aspects like the wall’s colours or possible
decoration are also mentioned. However focussing on patients’ multisensory perception
reveals the impact of more structural architectural choices.
Patient 22: You indeed have a window to the outside, but it’s blinded so you
have very little- very much the feeling of a basement, low ceiling and little
light.
Patient 17: Whether they hear you or we hear them, that doesn’t bother me
at all. You’re here with your own pain and problems. You never come here as
a hobby, so you’re always the victim of something that goes wrong. […] All
the sounds you register, they can be – relaxing, I wouldn’t call it – but it can
be calming.
Patient 16: You’re always cold in the corridors. […] I think that’s because of
the wind you make yourself, since when you’re walking there it’s not like that,
it’s not so cold. I think it’s the wind you make, the wind, the air movement.
Not only haptic sensations are broadened when moving; this last quote illustrates that
the entire perception of the built environment changes continuously. Visually participants
often recall only key elements like a red door or sequence of lights. Moving, walking or
being wheeled on a stretcher or in a wheelchair is pre-eminently an embodied experience.
For patients entering the ED walking, fluency and speed are determined by their physical
shape. Especially older participants often mention aspects of the built environment that
formed a burden on their route to the ED: a staircase between parking lot and entrance,
a long corridor, poor signage.
Unfamiliar objects like medical equipment catch patients’ attention and raise questions.
Deploying a stretcher or wheelchair alters patients’ perspective on the built environment.
One participant describes a typical hospital ceiling as a white, suspended ceiling with
many gratings and unpleasant light; at least two others point out the contrast between
experiencing the room standing up and lying down.
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Patient 9: When you’re walking upright, it seems smaller. When you’re lying
down it becomes larger. Suddenly you see the entire ceiling.
Patient 17: When you enter standing up, walking, then, yes, then it’s a small
room and then when you lie down then it becomes a relaxed and quiet
room. The ceiling is peacefully white. When you look down, it’s much more
crowded, when you look up it is more peaceful.
Besides the fact that their perspective alters, patients on a stretcher have to let go of
control. Participants mention being put in the middle of the corridor to wait, feeling to
be in the way, and being unable to do anything about it. Frequently addressed is also the
smoothness of the journey, and whether or not they hit walls or doorways.
2.5 DISCUSSION
2.5.1 ON THE METHOD
By deciding to interview ED patients at the actual location of their spatial experience
we restricted ourselves in the choice of participants. Seriously ill or injured patients were
not included in the study, as they could not be interviewed while being admitted to the
ED. However, the collected data suggest that the material environment attracts patients’
attention only when they have time to realize what is going on. As we approached
patients who were admitted at the time of the study, we did not consciously differentiate
between specific groups like older or chronically ill patients. Nevertheless we believe
that our sample, although rather limited, gives a good indication of the ED population’s
spatial experience and the way of working allowed us to study this experience in depth.
Taking part in the study might have changed participants’ perspective slightly. While they
were interviewed, unoccupied time became occupied thus altering their perception of
the wait. Moreover, the researcher’s role was not always clear. Giving social support often
became part of the deal. Stressed or anxious participants seemed to appreciate someone
to talk to.
2.5.2 ON THE FINDINGS
Unoccupied time indeed is important in patients’ experience of the ED. Waiting with
nothing to do increases their sensitivity to environmental defects. Most of the time spent
at the ED is perceived as waiting time, much more than what staff and management
usually consider as such b. Not just the waiting room and the room or cubicle should be
suited to do so, but all spaces where patients stay during an unknown period. Although its
possible impact on actual waiting time could not be derived from this study, the material
environment can thus change waiting time perception (Boudreaux & O’Hea, 2004).
How people act, or do not act, affects patients’ relation with the built environment.
Accompanying relatives can distract patients (Baraff et al., 1992; Ekwall et al., 2008) while
waiting, but can also attract their attention to spatial defects or misfits. As patients and
relatives have no control over what happens around them and do not know what staff is up
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to, they tend to evaluate the staff on the small details they can observe like fingerprints on
a cabinet or doorways’ wear and tear. Participants showed a great understanding for staff
and emphasized the importance of a functional environment. This could be understood
in light of the desire to be a good patient (Coughlan & Corry, 2007). Moreover, the ED’s
transit character seems to alter patients’ expectations, preferring it to be supportive to
staff rather than pleasant to reside. This does not mean that space should not foster
their well-being. The spatial organisation should guide staff towards a better usage. Small
interventions like affording a different placement of the bed might be sufficient.
Most topics concerning the material environment mentioned in studies on ED patient
experience were confirmed. The ED is indeed a dull environment, patients feel cold, and
it could be more quiet (Baraff et al., 1992). However, our study added nuance to most of
these insights. Apart from discussions on the colours or look of the interior, participants
addressed more structural matters. The lying perspective highlighted the added value of
an “empty” non-disturbed ceiling, to create spaciousness, but also the need for adequate
lighting. Only one participant mentioned feeling cold while waiting in the cubicle, and
was provided with a blanket. Various others indicated the air movement during transport
as the one to blame. Hearing noises from the corridor raises expectations that staff is
approaching, but can, as someone mentioned, also distract patients from their worries.
Conclusion
2.6 CONCLUSION
Studies on ED patients’ experience stressed the importance of waiting time,
interaction with staff, relatives’ presence and some elements of the material
environment. Our study suggests that these aspects interrelate and come
together in the built environment. The presented evidence seems to indicate
that scrutinizing ED patients’ experience from a spatial angle yields a more
nuanced understanding of certain experiential aspects. Addressing spatial
experience apparently asks for the explication of embodied perception,
raising awareness about the ED experience’s multisensory nature. Judging
from our study, the challenge for hospital designers and planners lies in
supporting staff in emphasizing a human approach through small spatial
interventions without counteracting the medical-technical aspect of
emergency care. This should enable both staff and patients to benefit from
an improved ED environment.
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3. Being transported into
the unknown: How patients
experience the route to the
operation room
An earlier version of this chapter has been published as a book chapter:
Annemans, M., Van Audenhove, C., Vermolen, H., Heylighen, A., 2014. Being Transported into the
Unknown: How Patients Experience the Route to the Operation Room. In: Langdon P., Lazar J.,
Heylighen A., Dong H. (Eds.), Inclusive Designing: Joining Usability, Accessibility, and Inclusion.
Springer Verlag, London, pp. 131-141.
Keywords
built environment
daysurgery
motion
patient experience
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Abstract
When you are admitted to a hospital, you enter an oftenunfamiliar environment. You suddenly become a patient.
Especially when being transported in a bed, you lose control
over where you go and how you interact with the space
around you. Many people feel anxious and vulnerable under
these conditions. Often the built environment adds to this
confusion, whereas it should support patients during their
hospital stay. To explore the relation between motion and
space, we present a concise literature review on motion and
spatial experience, and sketch the theoretical background
on researching motion. To actually study the impact of space
and spatial elements on patients’ experience in motion, we
interviewed 12 patients admitted to the day ward of a general
city hospital. The interviews were supported by videos we
had made of the transport. Studying the role of motion in
patients’ spatial experience of the hospital appeared not to
be an easy task. Both methodologically and content wise,
we encountered some challenges in bringing to the surface
and unravelling those experiences linked to spatial aspects.
Despite what one might expect, being moved in a bed does
not reduce but rather expands patients’ sensory perception.
An important interrelation between space, time and people,
especially during the transport, was found. By designing
space architects thus may have a strong influence on people’s
time perception and interactions.
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0
level 0
level 4
+1
bed
route (returning)
reference to fig.’s
route (going)
--------fig. 3-1
Hospital plan with patients’ route from the day surgery
ward to the OR (from level 4 to 0)
01:00
01:07
03:75
04:00
04:50
05:75
06:00
06:25
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02:25
03:25
03:50
04:75
05:00
--------fig. 3-2
Videostills of the route from the day surgery ward to
the OR (recording 16.07.2012)
06:75
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3.1 TRAVELLING THROUGH THE HOSPITAL
When you leave [the ward], and are [in the waiting area at the OR], you’re
mostly so nervous that you hardly notice anything, that you don’t see things.
There I was so nervous, I had never done this. [I thought:] “Ooh, what can I
expect? What am I going to feel?”
(young woman about the route to the operation room)
When undergoing a hospital admission, examination, or operation, many people
experience nervousness, agitation, and uncertainty. This state of anxiety apparently
increases once you are picked up to be transported to the operation room (OR).
Buildings can influence people’s experience positively or negatively (Day, 2002), yet
what does this mean in the context of hospital transport? What is the role of motion in
your (spatial) experience of the hospital? Who and what plays a role in this experience?
To start addressing these questions, we conducted a study at the day ward of a general
urban hospital. Since the length of hospital admissions is constantly diminishing, more
and more patients undergo treatment during a short, planned admission. Despite the
diversity of this growing group of patients - some familiar, others unfamiliar with the
hospital - they share a main concern with their health and the upcoming operation,
combined with limited time for contact with staff. Therefore we explored how we could
make these patients reflect on their experience in motion both during and after the
transport, to and from the OR, while respecting the possible variation in their sensory,
cognitive, and physical capabilities and awareness. Reflections from this diverse group
are expected to provide insight into how to design future hospital buildings that address
hospital patients’ needs before, during, and after transport by focussing not only on
functional and ergonomic aspects but also on people’s personal experience related to
their mindset under the given circumstances.
3.2 A MOBILE EXPERIENCE
While patients are transported through the hospital, to the OR, the bed is an important
mediator between the patient and his or her environment (Annemans et al., 2011). Still
the role of the bed in the general hospital experience is largely underresearched (van der
Geest & Mommersteeg, 2006a). Research on beds and transport seems often restricted
to functional matters such as organization (College bouw zorginstellingen, 2007) and
ergonomics (Kim et al., 2009; Mehta et al., 2011; Petzäll & Petzäll, 2003). Very little is
known about patients’ mobile experience in the bed.
When considering mobile experience it is important to distinguish between active and
passive movement. Moving actively - whether as a pedestrian (Lorimer, 2011), walker
or wanderer (Bollnow et al., 2011; Lund, 2005 in Paterson, 2009), driver (Laurier, 2011;
Sheller, 2004) or wheelchair user (Winance, 2006) - is completely different from being
passively moved as a passenger in a car or train (Bissell, 2010), or being pushed in a
wheelchair (Winance, 2006) or bed. Since we can only feel transitions in movement
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(starts, stops, accelerations), we are unable to register a uniform motion in a straight line
(Gibson, 1968). If everything went perfectly smoothly the patient would not notice; what
(s)he does notice is the change in direction or speed, resulting from bumps or starts and
stops.
The negotiation between patient and world takes place at different levels, spatial, social,
and timewise. The bed mediates this relationship, thus heightening one’s sensitivity to
the building (Verbeek, 2005). While you are lying in a bed different relations to space
change (Annemans et al., 2011). Your head-foot axis becomes horizontal, altering your
entire system of perception. Your view on the environment is directed towards the upper
part of the room and you register different haptic sensations through the bed’s wheels,
frame and mattress. Changing your posture from upright to lying down implicates letting
go of things, both literally and figuratively (Bollnow et al., 2011). When you are lying in a
hospital bed, this letting go is even more emphasized by your loss of control on where you
go and what is going to happen to you. As mentioned above, this interaction does not
come into being because of the bed alone. As Myriam Winance (2010) illustrates for a
wheelchair, the ‘vehicle’ itself, but also the one pushing it, play a crucial role in how the ride
is experienced. Therefore, the research object is not just the ‘person-in-the-bed’, but the
‘person-in-the-bed-pushed-by-someone-and-accompanied-by-someone-else’. Besides
spatial and social aspects, an important element in experience in motion is the duration
of the route. Speed is the distance travelled divided by the time of travel. However, in
the process of travelling multiple kinds of time and place are involved, socio-material
practices are a major influence (Watts & Urry, 2008). In a hospital, these practices could
be fellow patients, spatial aspects like views or haptic sensations during transport, or the
sheets on the bed.
3.3 TOWARDS A MOBILE RESEARCH APPROACH
3.3.1 RESEARCHING MOTION
Motion is intrinsically connected to space. Therefore, we looked for a way to gain a
nuanced understanding of their meaning and mutual interaction. The key role of the
environment and the attention to the subjective nature of human life - both the subjective
experiences of the patients studied and the subjectivity of us, researchers - make a
qualitative approach most appropriate for our study (Esterberg, 2002). The specificity
of the research adds some additional constraints. Involving experience and motion, the
key role of the body, and the difficulty to verbally express spatial impressions all present
challenges to our research design.
Gaining insight into the embodied perception of patients being transported in a hospital
bed demands a suitable research approach. Grasping all sensuous dispositions of their
movement requires an extension of traditional reflexive ethnography (Paterson, 2009).
Mobile research methods (doing research while being on the move) can stimulate
encounters and communication (Pink, 2008b; Ross et al., 2009). Combining a thick
description of one’s own experiences as a researcher, with the participants’ stories, and
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with photographs, audio en video-recordings made by and alongside the participants,
generates very sensory-rich data, providing nuanced insights about both experience and
physical aspects.
Due to ethical or other restrictions, not all contexts are suited to actively engage
participants in the making of photos or videos (Annemans et al., 2012a). However,
also videography recorded by the researcher can evoke in people clear reflections on
a previously embodied experience (Merchant, 2011). Therefore we should not feel
restricted to one on one recording, i.e., showing participants an actual recording of their
own activity. Also recordings of similar activities made by others may trigger them to
reflect on their own actions and experiences (Mollo & Falzon, 2004). Based on these
insights we modelled our research approach, adapting it to the hospital context and
balancing the stimulation of reflexivity in the participating patients with the recording of
situation specific, momentary data.
3.3.2 IN THE FIELD
Whereas a pilot study predicted promising results for the use of interactive visual
methods (Annemans et al., 2012a), the specific context in the day ward and the focus
on the mobile aspect forced us to flexibly adapt the research set-up. Compared to
other hospitalised patients, patients at the day ward spend little time in their room. Only
very few turn out to find the motivation to consciously reflect on their environment and
document this for use in a later conversation, possibly because of the unfamiliarity with
both the location and circumstances. Therefore, although the objective of the research
remained untouched, the research approach was adapted along the way.
Beforehand, a researcher (the first author) documented various aspects and spatial
elements of the route. In an attempt to connect the researcher’s and the researched
embodied experience, a scenario was mapped out for registering visual, thermal, and
olfactory stimuli. As a start, the researcher herself took place in a bed and was wheeled
through the corridors to the OR and back. This trip was video-recorded with a head
camera and sensory perceptions were spoken out loud and audio-recorded. For the
entire route photographs were taken every five meters and every time the direction of
the route changed or a new room was entered. At each point we planned on measuring
the temperature. Every morning before starting the fieldwork, the researcher walked
the route indicating clues to make up a smell map. Wear and tear in the hospital was
photographed and indicated on a map.
The research was conducted over the course of six weeks, one day a week, at the day
ward of a general hospital. During this period 12 patients were found willing to partake in
the study. As agreed with the hospital’s ethical board, a standard procedure started with a
staff member asking a patient whether (s)he would like to participate in a study on spatial
experience. If they agreed the researcher entered the room, and explained in more detail
the content and goal of the research and what the participant could expect. If (s)he still
agreed, an informed consent form was signed by both parties. Then the participants
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were given a photo camera, pen, pencils and paper, and asked to document their stay
at the hospital, while they were waiting to be brought to the OR. Although some did,
many responded that they were not in a state of mind to do so. Also depending on the
patient’s psychological state, a short interview about the first impressions of the hospital
was already conducted. Then the researcher left, until the patient was picked up by a
logistic assistant to be wheeled to the OR. These transports were accompanied by the
researcher, by analogy with guided walks (Pink, 2008b; Ross et al., 2009) and audiorecorded. No specific questions were asked but it was made clear by the researcher
that patients were free to comment on their trip (talk out loud) or stay silent. The
same was done for the route back to their room. When they were well awake again, the
actual interview took place. The initial intention was to base this on the documentation
provided by the patients. However, due to both personal and practical reasons only a
limited amount of this information was available. Additionally, as they were preoccupied
with the upcoming operation when going, and sometimes quite sleepy when returning,
few had a good memory of the transport. It soon became clear that watching the video
of the researcher’s transport helped them to reflect on theirs as well. As such, this video
material became an important element in the interviews.
The audio-recordings of both the accompanied transports and the interviews were
transcribed verbatim. The transcripts complemented with visual material when available,
were analysed through coding them using qualitative data analysis software (ATLAS.
TI). To establish a list of representative codes, we started from previously established
categories grounded in literature (Creswell, 2003) and expanded the spectrum by in vivo
codes expressing topics stepping forward through the process.
3.4 UNRAVELLING MOBILE EXPERIENCE
3.4.1 SPACE
Some sensory perceptions can be directly linked with spatial elements like lights, joints,
ceilings, walls, or furniture. Several patients experienced the sequence of the lighting
combined with the dull ceiling as very unpleasant. As one stated:
“From the moment I left here I saw those lamps pass by one after the other.
That was the worse. I hate that. It’s like a movie that you see when you go to
the OR, where you can’t get out.”
Others express the view from the bed during transport in a more positive way, suggesting
changes to the ceiling, or the upper part of the wall (fig. 3-6).
“Yes, they could probably do something about that, I don’t know, maybe the
colour or something like decoration, so that it would be a little more pleasant
to ride there.”
Besides the visual also the haptic experience was discussed frequently. The bed itself is
mostly considered comfortable and received many compliments on its possibilities to
be adjusted to one’s personal needs. However, when being transported in a bed, each
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unevenness during the transport is felt. Bumping into things can cause these interruptions
but also joints in the floor, a door profile, and the entrance of the elevator interrupt the
smoothness of the ride. It all adds to a participant sighing:
“It seemed like a cobble stone street, all those bumps.”
Other sensory perceptions, like temperature and sound, are a more indirect consequence
of spatial or material aspects. The temperature in the building is influenced by basic
architectural decisions, e.g., the ward’s orientation, the floor on which a room is situated or
the presence of (open) doors and windows. At the time of the fieldwork the weather was
fairly warm, so the difference in temperature between the ward and corridor downstairs
close to the OR was significant. However, this was not necessarily experienced as
negative. When talking about the difference between active and passive movement, a
patient mentioned:
“[what I never noticed when actively moving is] the difference in
temperature. When you go downstairs it’s colder again. [On the way to the
OR] we passed by a door and that [the presence of fresh, cool air] stays with
you. It gives some variety. [That’s important] because when you’re lying, you
don’t see these things.”
This illustrates the complementarity of different senses: while being transported in
a bed, your visual perception may decrease, whereas your sensitivity to other sensory
perceptions, like feeling the fresh air, could increase. A material element can also have a
direct and indirect impact. The bumps mentioned above result in a disturbing feeling, yet
also the generated sound is found “typical” for hospital transport. The audio-recordings
of the transport confirm the presence of this sound. Frequently heard in the interviews
were quotes like
“It’s like that when you’re brought there, over all those bumps tum, tum, tum,
tum, yes that is”
“those ridges here, that’s not pleasant when you go that’s not a problem, but
when you return, with that head, constantly the click, click, click, click. That’s
not pleasant.”
The way participants phrase their answer already highlights the distinct rhythm as a
very specific attribute of the transport. Also distance and direction fit in this segment.
The trajectory’s length is perceived differently because of the lack of control and the
difference in speed. The direction in which a patient is transported, head first or feet
first, depends on the type of bed and the preference of the person doing the transport.
Although related to space, both are tightly connected with time and/or people, discussed
in the following paragraphs.
3.4.2 TIME
How far one place is from another is clearly a spatial matter. How far it is experienced,
however, has much to do with how smoothly and, even more importantly, how fast the
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ride goes. Whether you like being transported apparently is a very personal issue. Still,
the speed of the ride seems to be a significant factor in the appreciation. Some patients
were really bothered by the rhythm generated by the moving bed related to the spatial
aspects discussed above. Others said things like:
“Now I have to rest. I found that a nice distraction, being wheeled in the bed,
they should have moved around some more with me.”
When the interviewer asked whether the route should have been longer, the answer was:
“Yes, but sometimes they rode pretty fast. I liked that. I’m lying in this bed, so
nothing can happen to me.”
This man considered the transport a nice distraction. Its speed contrasts with the rest of
the time spent in the day ward where you are actually just waiting for the next thing to
happen. At the same time, the bed’s presence provides a feeling of safety. Although as a
patient you are well cared for, you spend much time alone, whereas during the transport
there is always someone accompanying you. Apparently this gives the feeling that
nothing can go wrong.
The value of the moving time becomes even clearer when we take a closer look at its
counterpart, the waiting time. While waiting you are not actually moving, yet it can be
considered an important part of the route to and from the OR that is studied here. How
long patients had to wait in a certain place or at a certain point along the route was
frequently mentioned. A couple of which both were admitted for an examination held
the following conversation:
“I had to wait a long time there before it was my turn. Did you? Yes I did,
yes.”
Then she turned to the researcher saying:
“That’s because he was the first and I was the last one, and then you don’t
know anything of him and ooh, I’m then a little … [nervous].”
The lack of control over the situation and not knowing what to expect next seems to add
to the feeling of time passing very slowly.
3.4.3 PEOPLE
During the entire route from the ward to the OR, you are hardly ever on your own. Various
people interfere with you in different stages of the trajectory. When coming to the hospital,
a parent, child, partner, or someone else may accompany you. In the hospital room, you may
have a roommate. Even if you do not, nurses come in every now and then to check on you or
prepare you for your examination. Once a logistic assistant picks you up, you leave the people
familiar to you but are still with someone. Along the transport, others pass by in the corridor
and once your bed is parked at the waiting room in front of the OR, many others stand next to
you. All these people influence your experience, whether physically or through oral interaction.
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Obviously, the logistic assistant pushing the bed has a direct influence on the experience
in motion. (S)he decides whether to push the bed from the head or the feet, depending
on the type of bed, own preference, possible obstacles on the route, and general
instructions. As such, (s)he also determines the direction in which you will travel, head
first or feet first. One participant said:
“[…] because they ride with your head first, if they’d ride with your feet first,
but now you think: Ooh, what will be coming? What will be coming?”
The video material was recorded moving feet first, while most patients were transported
in the opposite way. Many comments about what they saw related to the difference
between both perspectives, mostly stating that they saw much less. When not knowing
what will come or what is happening around you, you have to let go of the control you
have when moving actively. A woman addressed the difference as follows:
“It’s nicer, when you walk, you have more control. It’s always like that. When
you lay in a bed then you’re entirely in the hands of the [nurses] […] and then
you have to … yes, follow. That’s different from when you walk, then you
determine your own rhythm and you see different things too.”
There seems to be a permanent interaction between how you experience others’
presence around you and how you experience space (or spatial aspects). In the (multiple)
patient rooms, in the waiting room and in the recovery, curtains between beds provide
at least some visual privacy. However, when they are closed, the patient at the side of
the corridor is left in the dark, especially in the rooms. In the waiting room and recovery,
open curtains leave other patients and possible medical interventions in full view. As a
participant said:
“[…] it can be that you’re afraid of the operation or the unknown. Then it can
be a little frightening when you’re standing there in the waiting area, because
you’re there with other patients, and you see all those people, although
there’s a little curtain, but you see them pass by and if someone comes there
for the first time. You see the doctors and the nurses with their mask and
their head and the OR clothes. Yes then it’s possible that you say ‘Ooh, no,
what is happening here?’”
Closing the curtains in the waiting room or recovery implies no or less visual control of
the nurses over the patient, but also less contact of the patient with the staff. Apart from
a possible visual separation, neither patients nor staff have much privacy, especially in the
waiting area. Sometimes overheard conversations can cause irritation. A former nurse
who now participated in our study as a patient testified:
“When I entered the waiting area of the OR, I thought it was horrible. It
was like a nice clique. They were making paella and someone had holiday
pictures with her. It’s allowed, but as a patient I find that disturbing.”
In situations like this rethinking the spatial organisation could contribute to decreasing
unnecessary but very human irritations.
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3.5 DISCUSSION
The study presented here is part of a broader research project. Also the fieldwork
conducted at the day ward covered a much wider spectrum of experiences of the hospital
stay. For the analysis reported here we focused on the part of the transport. Spatial
aspects related to the hospital stay in the ward or a treatment room are not addressed,
if not related to the followed route. This does not mean that the participating patients
limited their responses to this route, however. Many of them reduced the importance of
the spatial experience by pointing at the limited duration of their stay. Yet, all of them
agreed that a supportive environment would be much more valued when they had to stay
longer than a day. This is being investigated in another part of our research.
Various patients also questioned the necessity of being wheeled to the OR while being
perfectly capable of walking there. Although not all agreed that it would be better,
comparing the experiences of the patients participating in this study with those of patients
in a walk-in dayward could be interesting, and is taken up in the further development of our
project. The participants in this study confirmed a significant difference between actively
moving, while walking, and being transported in a bed. As the literature on experience
in motion largely focussed on active movement, the insights collected here add to the
knowledge on its passive counterpart. Since most of these studies look at mobility on an
urban scale, translating their results to a building scale presents a major challenge. Still,
we could also draw significant parallels. Socio-material practices (Watts & Urry, 2008)
are indeed a major influence, relating the three aspects of space, time and people. Also
the extended research object (Winance, 2010) is confirmed and even further extended
into the ‘person-in-the-bed-pushed-by-someone-and-accompanied-by-someone-else’.
However, whereas in the case of a ‘wheelchair-user-unity’, the unity is (mostly) fixed and
familiar, in the case of the bed, none of the actors are familiar with each other, which
could add to feelings of uncertainty and loss of control. As the analysis shows, clearly
distinguishing between the aspects is hard. All are intertwined and constantly interacting.
Unravelling them is challenging.
Also the adopted research approach deserves a closer look. Reflecting on your spatial
experience is not easy. Additionally, the patients experience was influenced by many
others interacting with the transport. Accompanying relatives, commenting during the
interview, or pointing at different things, or logistic assistants warning the patient to cover
up well because of the difference in temperature, may have influenced the responses.
As we made use of the video material the researcher’s perspective sneaked in as well.
Although we aimed to make the recording as neutral as possible, the researcher looked
at certain things, and the one pushing the bed did so in a certain way, feet first, sometimes
trying to avoid obstacles that were absent when the participants passed the same place.
However, most participants were able to make abstraction of these differences and relate
the recording to their own experience, pointing at parallels or differences and as such
providing additional data and confirm earlier research (Mollo & Falzon 2004). Also the
extra information, unasked for, given by others, can be understood in this perspective.
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--------fig 3.3
Patient room at the day surgery ward
--------fig 3.4
Bed and operation gown as symbols
of being a patient (picture taken by
participant)
--------fig 3.5
Beds named according to colour rather than numbers
would make this patient feel more like a person than
a number (drawing by participant)
--------fig 3.6
Proposal to pay more attention to the ceiling
(drawing by participant)
--------fig 3.7
Corridor at the day hospital ward
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--------fig 3.8
Corridor approaching the elevators
--------fig 3.9
A patient’s view
on the ceiling
---------
of the elevator
fig 3.10
Corridor downstairs
approaching the
OR
--------fig 3.11
Entrance to the waiting area
in front of the OR
--------fig 3.12
Elevators with arrows, symbolizing “ups” and
“downs” according to participant
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As illustrated, a real-life hospital experience is shaped by many. All in all, we believe that,
given the specific circumstances, the adopted approach found a good balance between
giving people the freedom to respond at the moment they feel most comfortable and
address the topics relevant to them and relating their responses to the actual environment.
3.6 CONCLUDING REMARKS
Studying the role of motion in patients’ spatial experience of a hospital is
not easy. Both methodologically and content wise, we encountered some
challenges in bringing to the surface and unravelling this experience.
Although at first sight, one could expect spatial aspects to disappear to
the background when being transported in a bed, e.g. due to the reduced
view on the environment, this study shows the opposite. Indeed, the sensory
realm is broadened by new perceptions. A great challenge for architects lies
in translating this kind of findings into an improved patient experience.
Conclusion
Spatial aspects cannot be studied isolated from the activities going on
in the spaces considered. Depending on what is happening and who is
involved, each experience is shaped differently. Also during transport, we
encountered an important interrelation between space, time and people.
As such, architects designing space also strongly influence time perception
and people’s interactions. Since singular spatial elements can have only a
punctual impact on these fields, the design of healthcare buildings should
be approached in a more general way, where architecture and organisation
go hand in hand. Although studying organisational matters transcends the
scope of this research project, we are convinced that, due to the connecting
character of motion, interesting insights concerning spatial relations could
be derived, especially when broadening our horizon, not just focussing on
one route, but combining the research on different routes and modes of
transport.
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ACKNOWLEDGEMENTS
Margo Annemans’ research is funded by a PhD grant of the Baekeland program of the
Agency for Innovation by Science and Technology in Flanders (IWT-Vlaanderen), which
gives researchers the opportunity to complete a PhD in close collaboration with industry,
in this case osar architects nv. Ann Heylighen received support from the European
Research Council under the European Community’s Seventh Framework Program
(FP7/2007-2013)/ERC grant agreement n° 201673. The authors thank the participating
patients, for sharing their time and insights and the hospital board for their support.
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4. Being wheeled or walking:
A qualitative study of patients’
spatial experience in day surgery
centres
This chapter has been submitted as a journal article.
Keywords
built environment
day surgery
patient experience
space
qualitative research
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Abstract
In this article we explore what a different way of moving
- being wheeled versus walking - means for the spatial
experience of day surgery patients. Day surgery centres can be
conceived in very different ways. Some are organized similar
to traditional hospital admittance; others are located in a
specifically designed part of the hospital, and receive patients
as guests who walk through the entire procedure. We conducted
semi-structured interviews with 37 patients at two distinct
day surgery centres. Despite the different managerial concepts
and corresponding spatial designs, in both centres patients’
spatial experience is shaped by the interrelation of material,
social and time-related aspects. However, different concepts
result in a different experience throughout patients’ journey.
Based on an analysis of the different journeys we conclude that
patients’ interpretation of a hospital’s care vision is influenced
not only by what the hospital communicates explicitly or how
it educates its staff, but also by what is implicitly told by the
built environment.
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--------fig. 4-1
Hospital plan with patients’ route through the out-patient
day surgery centre
/
bed / walking
route to the OR
reference to fig.’s
route from the OR to the
room or lounge
P
02:00
00:00
01:07
02:25
01:07
02:25
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04:50
06:25
03:25
03:25
03:25
03:25
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01:00
01:07
01:07
02:25
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02:25
03:25
--------fig. 4-2
Videostills of the route through
the out-patient day surgery
centre (combination of recordings
28.05.2014 and 04.06.2014)
03:25
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4.1 INTRODUCTION AND AIM
In day surgery centres, patients often question the necessity of being wheeled to the
operation room (OR) while being perfectly capable of walking (Keegan-Doody, 2007;
Nagraj, Clark, Talbot, & Walker, 2006; Turnbull, Wood, & Kester, 1998). Given our interest
in the role of architecture in how patients experience a hospital stay, the question arose
what this different way of moving - being wheeled versus walking - would mean for patients’
spatial experience. To address this question, we start from the analysis of a traditional
day surgery ward where patients are wheeled in bed to the OR and add insights from a
recently opened day surgery centre of the same hospital group. The latter is separated
from the main hospital and conceived as an out-patient centre where patients walk to the
OR. Despite different managerial concepts and corresponding spatial designs, in both
centres patients’ experience is found to be based on the interrelation of material, social
and time-related aspects.
A managerial decision to opt for a day surgery concept where patients walk or are wheeled
to the OR directs the experience of each of these aspects. Despite undergoing the same
medical treatment and being exposed to similar pressures, patients in a traditionally
conceived day surgery centre, henceforth called in-patient day surgery centres, are likely
to instigate a different experience than those in out-patient day surgery centres where
walking is the main mode of transport. Exploring how these different concepts impact
patients’ spatial experience is the aim of the reported study.
4.2 LITERATURE REVIEW
4.2.1 PATIENTS’ EXPERIENCE FROM A NURSING PERSPECTIVE
Studies on patients’ experience when being admitted for day surgery abound. The
majority of these are conducted from a nursing perspective and address aspects of
patients’ experience ranging from preoperative anxiety to postoperative pain and
psychological follow-up (e.g. Mitchell, 1999; Stevens, van de Mortel, & Leighton, 2001;
Costa, 2001). Given our interest in the role of architecture in how patients experience a
hospital stay, we focus in our research on the relationship between spatial organization
and patients’ experience, and thus on those parts of the treatment that take place within
the premises of the hospital.
After a patient is admitted to the day surgery centre, preoperative waiting starts,
often leading to anxiety (Mitchell, 1999). Several patients feel abandoned at this stage
(Gilmartin & Wright, 2008). In such situation small spatial interventions hold the potential
to make a difference (Rhodes, Miles, & Pearson, 2006). As a hospital gown transforms
the individual body into a body of medicine (Gibson & Sierra, 2006), changing into this
gown and leaving personal belongings behind is a physical reminder of one’s role, which
can heighten the ongoing anxiety (Markovic et al., 2004). A dressing room that is not
explicitly separated between the sexes (Gilmartin & Wright, 2008), or having to wait in
a room which is not suited, compromises patients’ dignity and privacy and gives them a
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sense of powerlessness, which once again increases vulnerability and anxiety (Rhodes et
al., 2006). Privacy also seems an important issue in the preoperative room. Discussing
health issues with other day surgery clients or even their relatives in the room makes
patients feel uncomfortable (Stevens et al., 2001).
Arriving at the OR has been identified as the most stressful event of a day surgery
visit (Mitchell, 2008). Depending on the centre’s concept, patients enter the OR either
walking or being wheeled on a bed or trolley. Being allowed to walk into the OR can
give patients a sense of being physically in control of the situation (Costa, 2001). When
surgery takes place under local anaesthesia, the OR is experienced consciously: patients
are continuously aware of their environment while being operated, and can feel distressed
by being naked and visible during the procedure (Stevens et al., 2001) or hearing the
sounds of the OR (Mitchell, 2008). Concerning the recovery room, patients testify
witnessing care of an unconscious fellow patient and feeling ashamed about being sick
themselves (Stevens et al., 2001). Since only curtains separate one patient from another,
privacy is rather limited at this stage (Stevens et al., 2001). Finally after a last checkup patients are dismissed. Here most studies focus on pain management and aftercare
(Gilmartin, 2007; Mottram, 2011a).
Overall day surgery patients’ experiences seem to relate closely to their expectations
(Costa, 2001). Unanticipated events — waiting time, having to walk into the OR, pain
— shape patients’ perception of the hospital visit. Patient management is often based
on the trajectory a day surgery patient is supposed to follow and on the average time
spent at each stage. Any deviation jeopardizes the streamlined plan. The organizational
sequence of the nursing process should be supported by the spatial sequence. Although
on one hand, this approach makes patients feel like a number or compare the day surgery
centre with a production line (Markovic et al., 2004), on the other hand, saving and not
wasting time is a prime reason to opt for day surgery (Mottram, 2011b).
4.2.2 PATIENTS’ EXPERIENCE FROM A SPATIAL PERSPECTIVE
Clinical nurse consultant Dani McKenna (1997) wrote about the importance of the
senses in the experience of day surgery patients. She mentions the built environment
explicitly only with regard to the visual, e.g., closed doors, ceilings, and walls. However, as
architecture is experienced through multiple senses (Pallasmaa, 2005; Rasmussen, 1964),
patients’ spatial experience is multisensory too. Spatial organization impacts much more
than the visual. The sounds people hear in the OR (Mitchell, 2008) or recovery (Stevens
et al., 2001) closely relate to the materialization of physical boundaries. A curtain does
not block sounds as effectively as a wall. Haptic qualities of objects add to patients’
comfort and thus to their general well-being. Comfortable chairs in the waiting area are
mentioned as important elements to feel less stressful (Rhodes et al., 2006). Another
important issue in day surgery centres is cleanliness, both visual and physical (Mottram,
2011b). It is considered as a measure for both the commitment to the patient and the
managerial focus on quality (Keegan-Doody, 2007; Mitchell, 2010).
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Besides seating arrangements and interior design like natural murals, a study on patients’
experience of preoperative wait also mentions spatial layout as having a positive effect on
promoting privacy and calmness (Gilmartin & Wright, 2008), linking spatial elements with
social interactions and waiting time. Physical elements, like comfortable chairs, a suitable
room temperature, adequate lighting and pleasant décor, complemented with items of
distraction like magazines or a television make a calming interior (Rhodes et al., 2006). A
managerial focus on quality and commitment to the patient can be communicated not
only by the attention paid to cleanliness, but also by the spatial layout. When patients
refer to the concept and set-up of a day surgery centre as an assembly line (Mitchell,
2010), or a conveyor belt (Mottram, 2011b), this impression is likely reinforced by the
built environment. The materialization of the spatial layout can support or hamper social
interactions. Direct contact with others, presence of and communication with caregivers
and relatives is considered by patients as comforting (Markovic et al., 2004; Rhodes et al.,
2006). The hospital building should support relatives to accompany a patient throughout
the day surgery trajectory. When permanent physical presence is not possible, a visible
connection can be reassuring too. It makes patients feel empowered and less abandoned
(Rhodes et al., 2006). Paying attention to patients takes time from an already very busy
nursing staff. Lloyd (2003) calls this the ambulatory paradox: day surgery centres want
patients with them for less time, but what patients want most is for care givers to spend
time with them. Just because of patients’ specific journey through day surgery, one can
distinguish different dimensions of time: time considered wasted, useful, or efficiently
spent (Mottram, 2011b).
Patients’ perspective on the built environment is influenced by whether and how they
move (Annemans et al., 2014). Being wheeled to an operation or examination affects
their experience (Mitchell, 2003). As the loss of control is an important cause of fear,
being allowed to walk into the OR can be very consoling to patients: it gives them a
sense of being in control of the situation at least physically (Costa, 2001). Although it
might not be what patients expect when going to the OR (Mitchell, 1999), walking is a
normalized, everyday life experience (Markovic et al., 2004) and thus makes the hospital
experience less a disruption of patients’ life. Walking does not allow patients to block out
the medical setting by closing their eyes, like they could on a trolley or wheelchair, it even
heightens their awareness of the environment (Markovic et al., 2004).
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4.3 CONTEXT: TWO CONCEPTS OF DAY SURGERY CENTRES
To investigate how different concepts of day surgery centres impact patients’ spatial
experience, we selected as research setting two hospitals within the same hospital group,
with the same staff policy and overall care vision.
At the inner-city campus (302 beds), day surgery is organized like long-term admission.
Only the length of stay differs. Patients arrive in the morning, are registered, go to the
ward (identical to any other ward), and are assigned a room and bed (fig. 3-3). From
there they are wheeled in bed downstairs to the OR (fig. 3-11) where the surgery or
examination takes place. After the intervention, patients stay at the recovery before
being brought back to their room where they wait for the doctor to stop by before being
dismissed (fig. 4-3 left).
On the peripheral campus (610 beds) day surgery takes place in a part of the hospital
building specifically designed for this purpose. The centre has its own entrance and
patients register at a desk next to the front door (fig. 4-4). They wait seated in a waiting
room (fig. 4-3) before being called by a nurse to start their journey through the centre.
They are first brought to a changing room with moveable lockers (fig. 4-6). After a short
wait they are brought to the preparation room to measure their blood pressure and
prepare them for surgery. Depending on the type of surgery and their condition, patients
walk or are wheeled in a wheelchair to the OR. After surgery they are (briefly) brought
to the recovery before being accompanied to a single or multiple patient room or the
lounge, depending on personal and medical requirements. From here they are dismissed.
(fig. 4-5 right)
IN
OUT
room
IN
corridor
waiting room
changing room
recovery
corridor
preoperative room
operation room
preoperative
waiting area
operation room
recovery
room/lounge
preoperative
room
OUT
--------fig. 4-3
Patient trajectories in day surgery centres with an in-patient (left) and outpatient (right) concept
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--------fig 4.4
Entrance to the out-patient day surgery
centre
--------fig 4.5
Waiting area at the out-patient day surgery centre
--------fig 3.6
Locker and changing room at the out-patient
day surgery centre
--------fig 3.7
Corridor in the preoperative area
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--------fig 3.8
Preoperative room where patients are
prepared before going to the OR
--------fig 3.9
View when leaving the recovery at the
out-patient day surgery centre
--------fig 3.10
Patient chairs in the lounge at
the out-patient day surgery centre
--------fig 3.11
Area for accompanying relatives in the lounge at the
out-patient day surgery centre
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4.4 METHODOLOGY
4.4.1 STUDY DESIGN
To explore how different concepts impact patients’ spatial experience, the study design
should allow addressing the role of architecture. Studying this role is challenging due
to the difficulty people have to express their spatial experience, and the role of motion
therein. In order to gain insight into this experience without bothering patients with
seemingly unsolvable questions, we opted for ethnographic methods, like image
production (making drawings and/or pictures) (Harper, 2002; Pink, 2007; Radley, 2010),
accompanied walks (Collier, 1967; Harper, 2002; Orobitg Canal, 2004; Pink, 2007; Pink,
Kürti, & Afonso, 2004), and the use of video as a basis for reflection (Merchant, 2011;
Mollo and Falzon, 2004; Pink, 2007). Additionally semi-structured interviews were
conducted. The structure derived from the sequence of spaces along the followed
trajectory.
The study’s methodological approach was explored in a pilot study (Annemans et al.,
2012a), and slightly adapted to situation-specific aspects. In the in-patient day surgery
centre, a nurse asked patients whether they agreed to partake in the study. Then the
researcher (the first author) entered the room, gave some additional information and
explained the study’s aim and approach. To explore the role of motion in patients’
experience the researcher accompanied them when they were wheeled to the OR and
back. When patients returned to their room, the actual interview took place, supported
by a video recorded of the route to the OR when needed. The fieldwork was conducted
during six consecutive weeks, one day a week, which resulted in 12 participants.
At the out-patient day surgery centre the researcher approached people sitting in the
waiting room. After she explained the aim of the research, those agreeing to participate
where asked to pay specific attention to the built environment while going through the
hospital procedure. After surgery, the researcher conducted the interviews, once again
supported by previously recorded video material when needed. As the mode of transport
of these patients could vary - being wheeled in a bed or wheelchair, or walking - the
conversations specifically addressed this mode. Interviews at this location were generally
shorter but more numerous: 30 people agreed to partake in the study and signed an
informed consent, 25 were actually interviewed. The fieldwork took place two days a
week, during three consecutive weeks.
At both locations participants turned out to be a heterogenic adult group, consisting of
men (6 in-patient, 8 out-patient) and women (6 in-patient, 17 out-patient), young and old
(60+; 6 in-patient, 7 out-patient).
4.4.2 DATA ANALYSIS
The audio recordings of all interviews and accompanied transports were transcribed
verbatim. The transcripts were analysed thematically to identify common themes
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amongst patients’ experiences at both locations. To establish representative themes,
and corresponding codes, we based the analysis on previous findings (Annemans et al.,
2014). The defined themes are grounded in literature (Creswell, 2003) and expanded by
in vivo codes expressing topics stepping forward during the analysis. All quotes used in
the findings have been translated to English by the authors.
4.4.3 ETHICAL CONSIDERATIONS
The study design was submitted to the hospital group’s ethical committee. After an
oral presentation of the project and profound dialogue on how the research should be
approached (concerning permission to enter rooms, participants’ anonymity, data use),
approval was obtained. All participants signed an informed consent when they agreed
to take part in the project. This document explained the aim of the study and its set-up.
It informed participants that they could withdraw at any time without jeopardizing their
treatment or care. Participants’ anonymity and confidentiality were guaranteed. However,
since in a later phase the collected data should be used to inform architects, destroying
the data or keeping them only within the research group was not feasible. Therefore,
informed consent forms were immediately given a code, which was used throughout all
further data processing. Informed consent forms and data have been stored separately.
4.5 RESULTS
Despite patients’ different mode of transport, their spatial experience while moving turns
out to be shaped by the same elements: the spaces they travel through, the people they
meet, and how time is passed.
4.5.1 SPACES
Given the short admittance, day surgery patients spend a relatively large part of their
hospital stay moving from one space to another. Different types of spaces can be
distinguished: those with a more residential character and those intended pass through.
In the in-patient centre, patients stay in their own room. Immediately, they are asked to
change in a hospital gown, put their clothes in the closet, and wait in bed (or the chair
next to it) until they are wheeled to the OR. Also the preoperative care, like taking blood
pressure is done in the room. Patients in the out-patient centre can check in at the front
desk and are then asked to sit down in the waiting area (fig. 4-5), at their turn they are
called and taken to the clothing room to get changed in a hospital gown, a bathrobe,
and slippers. The room is shaped as a hall with small changing cabins at the side and
moveable lockers to put away personal belongings (fig. 4-6). Many patients find this
confusing, not knowing where to get undressed, where to wait, or what to do:
“I didn’t know whether to get changed here [in the main room] or the toilet
[not even seeing the changing cabins]” or “it was a little chaotic, messy [in
contrast with the waiting area].”
They consider the room functional but cheerless, describing it as “a swimming pool”,
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“factory-like”, or “a conveyor belt.”
Once in the operative area, this perception changes. In the in-patient centre the waiting
area before the OR is a large room with curtains between the beds in which patients wait
to be brought to the preoperative room (fig. 4-7). At least two patients found it a corridor
rather than a place to pass time while waiting:
“[…] it bothered me that it was a corridor, not a room, a little bit disrespectful
to lay people there. It seemed to serve multiple functions at once.”
At the out-patient centre, each patient is assigned a private preparation room, where
some preoperative treatment is provided and they can quietly wait before being taken to
the OR (fig. 4-8). This is highly valued by the participants.
The experience of the OR and recovery are fairly similar at both locations. The machinery
at the OR impresses and fascinates patients. A patient at the in-patient centre said:
“At the OR […] you have all these things, equipment, […] you have to wait
there, and everywhere you see needles etc. Can’t they hide that a little?”
whereas one at the out-patient centre formulated it as follows:
“The OR, that’s technical obviously. It’ s full of things.“
Patients consider cleanliness and efficiency very important.
Finally patients return to their room or are brought to a private room, stay in a large
space with only curtains between the beds, or can sit down and relax in the lounge.
Even if patients in the out-patient centre can recover in a single person room, this is not
perceived as completely private because of the linear approach. One patient makes the
comparison:
“But why? Why do you have to wait in a waiting room? Then you go to the
dressing room, there you have to wait again, then they bring you further,
then you’re being- [‘processed’]. In [name of the in-patient centre] they are
helping you. They assist you to your room, your bed, your husband can be
with you.”
For this woman having her own room, her own bed and being assisted were important
elements of feeling taken care of. She felt that the out-patient centre processed her like
an object that had to be fixed instead of a person needing treatment.
How patients experience the hospital building seems to be impacted notably by whether
they are being wheeled, in a bed or wheelchair, or are walking. Sensory perception differs
significantly in both cases. Whereas walking participants never referred explicitly to the
lighting nor the uneven floor, those being wheeled frequently mentioned lamps flashing
by while riding through the corridors and bumps at doorsteps as disturbing (Annemans
et al., 2014). When the mode of transport changes, the use of typical hospital equipment
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might need to be reconsidered too. As one participant in the out-patient centre mentions:
“I thought the nurse [who was holding the drip] was walking very fast. I
thought, oh no, if she’s walking that fast with this drip, that’s not easy to
follow.”
Technical features, specifically aiming at facilitating movement can be perceived totally
differently depending on how one moves. The patients wheeled around in bed mention
automatic door openers as important to smoothen the journey for nurses and patients:
“Here she has to go push a button [to open the door], why can’t they have a
rope or something, so you wouldn’t have to wait and she wouldn’t have to go
to that button to open it.“
For a walking patient not used to the hospital environment, an automatically closing door
can be a threshold:
“Those sliding doors were really not pleasant. […] I had to enter there and I
felt those sliding doors squeezing me. I was stuck between them, because
they closed behind [the nurse].“
Giving patients more control over their situation is an important reason for making them
walk, however, this can have a reversed effect. A young girl explains:
“When you’re walking into your own operation room, you can see all these
instruments that made me very anxious.”
She would have preferred to be able to close her eyes and be taken care of.
While on the move an important aspect of keeping control is being able to orient
oneself. The materialization of the interior, and the corresponding atmosphere structures
patients’ trajectory and creates points of recognition based on sensory perception. Eyecatching elements, like a green desk at the nurse station in the in-patient centre or a wall
with a design of oranges in the hall of the out-patient centre (fig. 4-9), define a certain
atmosphere. Yet, also non visual elements, like a difference in temperature can make a
distinction between spaces:
“When you go downstairs it’s a little colder when we rode by a door […] that
gives some variety because when you’re lying down, you don’t see such
things.”
Apart from specific sensory elements, one’s ability to orientate is affected by how one
moves. Like a participant says:
“When you walk you’re more concentrated on where you go. […] I have the
same in a car, when I’m sitting next to the driver, I have no clue where I am,
compared to when I’m driving myself.”
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4.5.2 PEOPLE
Managerial choices, like conceiving a day surgery centre as in-patient or out-patient,
turn out to impact not only patients’ spatial experience, but also their social interactions,
and this at different levels. On an individual level managerial decisions concerning
organisation and space can support or thwart self-control. At the in-patient centre, many
participants expressed the desire to be able to walk to OR:
“What I found annoying when going is that I wanted to walk and then when
necessary doing everything else. I don’t want to be wheeled there and then
having all these people passing by. That’s simply disturbing.“
However, this desire seems to be situation-specific. At the out-patient centre a participant
thought the opposite:
“The walking was a little annoying with that drip, [they should just have put
me in a bed].”
Sometimes being wheeled can indeed be comforting:
“Sometimes it’s nicer to be sitting […] because it gives a safer feeling.“
Often the hospital environment in itself, and the presence of the bed in particular limits
patients’ ability to make their own decisions. One participant said:
“I don’t find it that important to be able to walk yourself. What was
disturbing, I was standing downstairs [in the waiting area in front of the OR,
in bed] and I had to go to the toilet, and I didn’t have a bell, so I couldn’t. I
had to wait till a nurse came.“
On the other hand, letting go of control can be comforting in the given circumstances.
Patients sometimes find the transport in the bed a positive distraction from the rather
boring time at the in-patient day surgery centre.
A building can create a very specific image, which influences people’s - c.q., patients’
- self-esteem (Annemans et al., 2012b). At the in-patient centre participants mostly
appreciate the hospital environment for being a hospital, using quotes like “it’s not a hotel”;
at the out-patient centre many participants make the same comparison with a different
incentive. They positively refer to the centre as “not a hospital-hospital,” or “homelike.”
One patient even compares it to a holiday resort:
“I’d say I’m not going on holiday, I’m just coming here.”
Especially the lounge with comfortable chairs, side tables, plants and semi-transparent
separation screens, where patients are brought in their bathrobe to drink a cup of coffee
and recover accompanied by their relatives before going home, is compared to a
restaurant, a bistro, or a wellness centre. This sharply contrasts with the connotation given
to the clothing room being “industrial” and “a conveyor-belt.” Patients’ appreciation for the
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created atmosphere seems to relate strongly to the associations they make:
“The waiting area I find gushy. That’s something I expect in a hotel at the
Mediterranean Sea, not here.”
When the environment does not match patients’ expectations, a rather negative
connotation seems more common.
Being in a hospital means interacting with others. Neither patients’ experience of the
way of moving, nor their perception of the building, is an individual construct. Spatial
organisation can make people feel alone. At both centres the preparation room before
the OR generated these feelings of loneliness. As a patient at the out-patient centre says:
“I was left alone for ten minutes, no one was looking after me, that was
definitely not pleasant.”
Similar comments could be heard in the in-patient centre. On the other hand, spatial
organisation can also support social relations even without direct contact. One participant
compares the recovery room with the preoperative rooms:
“This is indeed nicer than being in such a hutch, then you’re completely
isolated […] but here, at least you see some movement.”
Several others confirmed this appreciation for seeing staff move around. Indeed, the
interaction between patient and staff is shaped through managerial and corresponding
material interventions. One patient who was treated under local anaesthesia was telling
about the tent that was put over his head so he was unable to see the doctor. However,
he felt very reassured as he explained:
“Then the surgeon came in, the only contact I had with him, and that gave a
very good feeling, was that he was constantly humming. I thought, as long as
he’s humming, everything is going well.”
Managerial and spatial decisions also influence the staff’s role. In the lounge, patients
are served coffee and cookies by the same nurses who accompanied them along their
trajectory and provide medical support. For those in a room, both at the in- and at the
out-patient centre, nurses clearly fulfil a medical role, whereas in the lounge they take part
in the creation of the “wellness” atmosphere. The lounge also foresees a separate area for
relatives (fig. 4-11). Several patients mention that the hospital’s attention for their relatives
reassures them as well.
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4.5.3 TIME
Through motion space becomes related to time. Moving or being moved means
travelling at a certain speed. When participants actually mention speed, this can relate to
the speed at which they move or the speed of the procedure. Some participants dislike
the lack of control over the speed when being wheeled, others precisely appreciate this:
“sometimes they rode pretty fast. I liked that. I’m lying in this bed, so nothing
can happen to me.”
When patients are walking, however, the speed suggested by nurses can be too fast,
leaving patients uncomfortable following them.
Regarding the speed of the procedure, participants reflect solely on the time it took to
go through the entire process:
“The clothing room, that’s fine yes you have to wait there a minute or two
minutes till they come and get you. […] Then the preoperative room, also
two minutes, not even. […] The recovery for a moment, there I was only five
minutes then I came here. […] It was the fast track, all together 25 minutes I
think, that’s fast!”
Efficiency is highly valued. Estimating the route’s physical length seems hard for
participants, but also judging the duration of the trip is a challenge. A patient at the outpatient centre notices this difference in time experience himself:
“it lasted at the most ten minutes, […] then they brought us down, that
seemed to be much shorter.”
Travel time seems to last longer when being wheeled. As one participant at the in-patient
centre said:
“When you’re lying, you look around more […] it’s not that other things stood
out, but rather that you have more time to look around, compared to while
walking.”
The travel speed affects the rhythms one experiences. Some rhythms directly relate to
spatial elements like ridges, imitated by participants as “tum, tum, tum” or “click, click, click”
or referred to as “a coble stone street” (Annemans et al., 2014), others relate to the rhythm
of the journey, alternating different activities. During transport through the hospital,
patients’ spatial experience is built up by stringing together spaces along the route. In
a day surgery centres the ongoing activities strongly relate to time: the patient is either
being treated or waiting for the process to continue. As mentioned, hospital spaces can
be intended to reside in or to be passed through. In reality, however, we noticed that there
is no one-on-one match between the places where patients wait and those intended to
stay, or between those where they undergo treatment and those meant to do so. This
mismatch between the character of a space and the time spent there results in awkward
situations. In their perception, patients wait a considerable amount of time at the day
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surgery centre. When the places where they have to wait do not seem to be designed
for it, like the dressing room of the out-patient centre, it strengthens their impression of
being subordinate to the procedure. Like one participant at the out-patient centre said:
“As a patient you don’t have the feeling to be an individual.”
Someone there claimed about the route:
“The general impression I got is that of the waiting room.”
Despite the waiting time, however, the design and concept of both the waiting room and
the lounge at the out-patient centre make people not feel in a hospital. One patient even
mentions the absence of a clock as a good thing. It withheld her from counting time. The
sequence of spaces also communicates to patients the followed procedure. A patient,
who was coincidentally brought to the children’s corner of the recovery, mentioned the
drawings on the wall. When asked whether she considered them a point of reference, she
answered:
“Yes, I think so. It adds to the impression that everything went well. Since I’m
now lying here. I’m not where I was at first anymore.”
Finally patients’ time perception relates to interaction with others. In the waiting room of
the out-patient centre patients see others who are called faster despite having entered
later. Although perfectly explainable by the presence of different surgeons operating in
different OR’s, for patients this can be confusing. Here too patients like a sense of control.
One participant proposes a system with numbers so you can at least see how many
people are ahead of you:
“That wasn’t very pleasant […] because you’re all waiting and you don’t have
a number, so you don’t know when it’s your turn. I like clear appointments. I’d
put there a number, so you know that you’re next, and you know how long
you still have to wait.”
Another participant confirms that not knowing is the worst:
“When is the doctor coming? It’s always like that, when the environment
is cosier that’s more pleasant than when you’re standing in a corridor for
example.”
4.6 DISCUSSION AND RECOMMENDATIONS
Comfort and cleanliness have been identified as important factors through which hospital
management exposes its commitment to the patient and focus on quality (KeeganDoody, 2007). Our findings expand this insight by showing that the entire material
environment co-constructs patients’ impression of the care organisation. Making patients
wait in an environment that is not designed as a place to reside, like the clothing room, is
interpreted by participants as a focus on the procedure, and a neglect of the patient as
an individual. As a result participants characterize the day surgery centre as industrial or
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compare it to a conveyor belt. When patients are cared for as if they are guests in a bistro
or wellness centre, a completely different connotation is made.
Our findings suggest that motion impacts patients’ spatial experience in two ways,
by concatenating spaces and through the way of moving. As one moves, the built
environment becomes a concatenation of spaces, whether actual rooms or a personal
cocoon. The type of space one needs to be covered from others could thus be different
when walking than when being wheeled. Unlike patients in a bed, walking patients waiting
along the route in an unsuitable space are not protected from passer-by’s by the two
square meters of the bed. As expected, the way of moving - being wheeled or walking has a significant impact on patients’ spatial experience. Walking gives them an active role
in the care process and more control over the situation, whereas being wheeled makes
them passively undergo what is happening. The advantages and disadvantages of each
should be nuanced. The former leaves patients no choice: whether they like to or not,
they are aware of their environment. Seeing all hospital equipment when walking into
the OR is not for everyone reassuring. Despite the fact that patients in the traditional
centre asked to be able to walk to feel more in control, our findings suggest that this is
not necessarily the case. The participant who could not follow the nurse pushing her drip
in front of her definitely did not feel in control.
Comparing our findings to the insights from a nursing perspective reveals additional
insights. The data confirm that preoperative wait increases anxiety. Managerial decisions
shape waiting time and space. A suitable environment and insight into the care process
help to make patients feel more in control and thus reduce anxiety. What a suitable
environment is, is difficult to answer in a straightforward way. An in-patient concept where patients are assigned a room, which they return to after treatment - confirms their
status of patienthood. When wearing the typical hospital gown, these patients are covered
up and protected by their bed that travels with them to the OR. On the downside, their
role as patient is clearly established by the material and social environment whereas in
the out-patient centre the situation is normalized as far as possible. However, here some
participants mention a feeling of numberhood.
Patients’ expectations about what is going to happen are just as important as what
they actually experience. More extreme experiences, positive or negative, seem to
leave a more profound impression on patients. As the in-patient centre meets patients’
expectations of a hospital stay better than the out-patient centre, the latter evokes more
extreme reactions. Participants at the in-patient centre manage quite well to describe
the atmosphere, at the most they make use of an expression as “hospital-like” or not.
Participants at the out-patient centre struggle when talking how they feel about the
centre. Neither the waiting room, nor the clothing room, or the lounge matches their idea
of a hospital environment. To express their appreciation or disappointment, participants
frequently used metaphors, positively or negatively. These create a vivid image of the
place.
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Design recommendations concern the interrelation of spaces, people, and time. To solve
or at least address the ambulatory paradox (Lloyd, 2003), social interactions should be
supported to compensate for the limited personal time nursing staff can spend on each
patient. When one thinks about the spatial design of a day surgery centre, whether in- or
out-patient, a first step could already be to support visual contact with the staff in all areas
were patients are awake. Enabling accompanying relatives to be with the patient through
the entire trajectory could be reassuring as well. Therefore, the material environment
should be suited for an additional person to spend time in a comfortable way. This serves
a double purpose: not only are patients’ experiences influenced by the opinion of others,
many participants also mention their loved ones being taken care of as reassuring during
their treatment.
Whereas efficiency is highly valued and patients appreciate a smooth process and little
wasted time, hospitals should consciously guard not to pass on too many responsibilities
to patients and relatives just to optimize the procedure for staff (Mottram, 2011a). Spaces
that communicate a procedure focused approach are least appreciated. By giving
patients insight into the ongoing activities of nurses and doctors, they can make their
own judgment of their time use. Each space where patients reside should be suited for
this, regardless of the staff’s activities in there.
4.7 LIMITATIONS OF THE STUDY
To be able to study how the way of moving impacts day surgery patients’ spatial
experience, the two locations ideally should be as similar as possible, only differing in
the mode of patient transport. In reality, this can be studied only at two locations, as a
different starting point concerning managerial and spatial organisation plays a key role in
the choice for an in- or out-patient day surgery centre. To partially bypass the occurring
differences, we studied two centres of the same hospital group. As such at least the
overall care vision was identical.
As we aimed to follow patients throughout their journey through the hospital and
spend enough time with each participant, the number of participants was rather limited.
Nevertheless, the study seems to reveal significant insights into how the way of moving
impacts patients’ spatial experience.
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4.8 CONCLUSION
Conclusion
This study investigated what a different way of moving - being wheeled versus
walking - means for patients’ spatial experience. This question was induced
by the results of a study at a day surgery centre (Annemans et al., 2014) in
which various participants questioned the necessity of being wheeled to the
OR while being capable of walking there. Therefore we investigated what
a different managerial concept, aiming at making patients walk to the OR
instead of wheeling them, means for patients’ spatial experience, given that
the type of patients and the hospital ‘s care vision were largely similar.
By analysing patients’ spatial accounts in two distinctly conceived day
surgery centres, we gained insight into the relation between managerial
and spatial organisation on the one hand, and patients’ experience on the
other hand. Whereas the in-patient centre considers patients as guests who
reside with them, be it only a short time, the out-patient centre treats them
rather as visitors or clients. What is most suitable depends on each patient’s
personality, physical state, state of mind, and expectations. Regardless
of personal preferences, key to creating a positive patient experience is a
consistent communication through all aspects of the hospital visit, through
oral and written communication, treatment by staff, and spatial design.
The presented evidence indeed helps to demonstrate that patients’
interpretation of a hospital’s care vision is influenced not only by what the
hospital board communicates explicitly or how it educates its staff, but
also by what is implicitly told by the built environment. Regardless of how
patients’ trajectories are organized, each step should resonate with what
a hospital wants to communicate to its patients. Most striking in patients’
overall perception are elements that do not meet the expectations raised.
Because managerial and spatial organisation are entangled, changing a day
surgery centre’s concept is not an overnight decision. Only with a suitably
designed environment can a new concept be fully experienced by patients
as an improvement.
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ACKNOWLEDGEMENTS
The authors thank the participating patients, for sharing their time and insights and the
hospital board for its support.
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5. Discussion and Conclusion:
Gaining insight into patients’
spatial experience in motion
Volume 2 aimed to gain insight into patients’ spatial experience. To this end, I asked
the research question: which aspects relevant to architectural practice have an impact on
patients’ spatial experience of a hospital environment, from a lying perspective? To answer
this question I conducted fieldwork at four research settings in which 62 patients took
part:
-- at a nephrology ward 4 patients who were staying in the hospital for a long time and
where wheeled to dialysis and back participated (V2 chapter 1);
-- at the emergency department 22 patients took part in the study (V2 chapter 2);
-- at a traditionally approached day ward, I followed and interviewed 12 patients who
were wheeled from their room to the operation room (OR) and back (V2 chapter 3);
-- to specifically address the impact of the way of moving on patients’ spatial experience,
I studied 25 patients at a day surgery centre where patients walk to the OR and added
the insights gained to those of the traditionally approached day surgery centre (V2
chapter 4).
In this chapter the insights from the fieldwork are confronted with findings from the
literature. The literature review on experiencing (hospital) architecture showed that
people’s experience relates to the sensory aspects they perceive, the memories and
meaning they attach, and the activities they (can) undertake. Both patients’ perspective
and whether they experience their environment static or in motion add to nuanced and
varied insights into their spatial experience. Under these diverse circumstances, the
findings show how patients’ experience of the hospital building involves a combination of
spatial, social, and time-related aspects that are affected by decisions concerning spatial
organisation or building elements.
To increase their validity, the research results were presented to an expert panel at a
university hospital, unrelated to the hospital where the fieldwork was conducted. The
members of the panel - four patients, a doctor, two nurses, a physiologist, the head of
logistics, and the head of spatial planning - were asked to discuss nine statements. The
first six summarise the findings:
-- For long-term in-patients it is important that the hospital allows them to reside.
-- When patients do not understand a space, this results in a feeling of unease.
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-- A building that pays attention to those accompanying a patient takes care of the
patient.
-- A hospital building should support social interaction between patients, visitors, and
staff.
-- Activities define the rhythm of the day, also in a hospital.
-- The duration of time is a relative concept, depending on environment and situation.
The last three refer to conclusions presented below:
-- By moving through the building each patient experiences his/her own hospital.
-- A hospital should be built based on the specific needs of different patient profiles (e.g.
spacious rooms with a balcony for long-term in-patients, smaller functional rooms for
short-stay).
-- A hospital communicates its care vision not only through documents and actions,
verbal and written, but also through the building.
The group members’ comments were used as a validity check of the results and are
presented as part of the following text to confirm, contradict, or nuance them.
5.1 EXPERIENCING HOSPITAL ARCHITECTURE
The first objective of this PhD was to identify which aspects relevant to architectural
practice have an impact on patients’ spatial experience of a hospital environment
from a lying perspective. Given the apparent role of transport in many patients’ spatial
experience, the focus of my research soon shifted towards patients’ spatial experience in
motion.
5.1.1 PATIENTS’ SPATIAL EXPERIENCE
Defining experience, and by extension spatial experience, is not easy. The components
of experience that have been addressed when describing the experience of a wholesome
environment in the second chapter (V0 Experiencing a wholesome environment) are also
encountered in the findings from the fieldwork (V2 §1.4, §2.4, §3.4, §4.5). Architecture is
experienced through the senses (Pallasmaa, 2005; Rasmussen, 1964). Visual elements
are the first that patients’ mention when talking about space but also haptic aspects,
sounds, and smells are addressed. However, as Ingold (2000) argues, the five senses are
not enough to grasp the full complexity of experience. How architecture is experienced
depends on the person who experiences it (Rasmussen, 1964). As shown in the
previous chapters, some of the factors at play include patients’ personal characteristics,
the circumstances under which they come to the hospital and the outlook they have.
The previous chapters also illustrated that social factors, as well as the larger context,
both material and social, add to patients’ interpretation of a situation and environment.
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Associations were easily made when describing spatial experience. Memories of previous
experiences and situations have an important role in this (Maclachlan, 1989). Activities like
eating, sleeping, waiting, or moving, whether or not supported by the built environment,
define spatial and time experience (Sorokin & Merton, 1937 in Ingold, 2000).
In patients’ spatial experience three components of experience can be encountered:
sensory perception, personal interpretation or meaning making, and afforded
activities. This finding is in line with a classification based on a literature review in product
design which identifies information from the senses, values (or meaning), and affordance
as the components adding to human centred design (Vaes et al., 2014, p. 28). As this
PhD aims to identify aspects relevant to architectural practice with an emphasis on a
patient’s perspective, these three components of experience seem relevant to explore in
more detail.
5.1.2 PATIENTS’ SPATIAL EXPERIENCE IN MOTION
My PhD research soon developed from studying patients’ spatial experience in a bed to
patients’ spatial experience in motion. Since people are in motion while space remains
immobile, they move ‘in’ space (Bollnow, 2011). Thinking about moving through a
hospital building, is easily associated with hospital logistics. How moving through the
building impacts patients’ spatial experiences is largely underresearched (V1 §3.2). The
lying perspective, which I took as a starting point for my research, turns out to be static for
only a minority of patients. As my fieldwork at the different settings shows, hospital space
also tends to be experienced by patients in motion. For short-term patients like those at
the in-patient day surgery centre, being wheeled around takes up a considerable amount
of the time spent at the hospital. With a significant increase in out-patient treatment
(Masseria et al., 2009), day surgery patients are most probably a growing group within
the hospital. Paying attention to patients’ spatial experience in motion is thus well worth
in designing future hospital buildings.
I dare to state that patients corresponding to different profiles, and thus following different
routes through the hospital, experienced and used a different hospital. The building’s
address and exterior might have been the same, but the concatenation of spaces they
visited and how these were perceived differs significantly, confirming Rasmussen’s (1964)
claim that the perception of architecture depends on the person who perceives it. The
way patients move or are moved is shown to have an important influence on their
spatial experience in motion. Patients hardly ever move by themselves. They are moved
in a bed or wheelchair, pushed by a staff member and often accompanied by a relative.
When walking they are accompanied and maybe even supported by a staff member, who
might push or carry an infusion literally connecting him or her to the patient. Studying
patients’ spatial experience in motion thus means taking into consideration an extended
body (Winance, 2006) consisting of the patient and the “vehicle” but also a staff member,
and possibly accompanying relatives.
The role of the bed or wheelchair in patients’ spatial experience, static or in motion,
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should not be underestimated. In adapting to their use, patients go through different
levels of adjustment: material adjustment, emotional adjustment, and the consequential
adaptations of patients’ world(view) (Winance, 2006). Not surprisingly this is the
strongest with the long-term patients, however some similarities are found in the other
groups. The material adjustment is most clear in the appropriation of the bed and the
bedside table, but also the beds and chairs at the dialysis are provided with an extra
pillow or cover that patients bring (fig. 5-5). One participant even took her own pillow
for the ride in the wheelchair. Especially the patients in the expert panel recognize these
small adaptations patients make. The emotional adjustment is one that is found amongst
all groups. Being assigned a bed (Nijhof, 2006) or a stretcher for that matter changes
a person into a body of medicine (fig. 5-1). The same can be said about being given
an operation gown (Gibson & Sierra, 2006). The ambivalent negotiation between
individual, device, and the built environment (fig. 5-2) is also striking. Although the bed
is sometimes detested for its connotation of being sick, it is also considered a safe place,
even when being wheeled at high speed (V2 chapter 3 and 4).
5.2 ASPECTS RELEVANT TO ARCHITECTURAL PRACTICE
If one research domain aims at identifying spatial aspects that are important in the design
of a hospital environment it is EBD. As concluded in various reviews of EBD studies, the
impact of the clinical outcomes that are required to withstand the reviewers’ evaluation
criteria is not considered in a holistic way (Huisman et al., 2012). The research is thus not
ready to hand architects what they need to start designing a real-life evidence-based
building in all its complexity. With my research I would like to add to the much-needed
non-clinical evidence (Van den Berg & Wagenaar, 2006), which can provide insight into
people’s opinions, ideas, views (Malkin, 2006), and experiences. With experience I refer to
three components, sensory perception, personal interpretation or meaning making, and
afforded activities. Each of these components is to some extend reflected in the aspects
discussed below. The themes that came forward in the exploration of the research
field, structured the analysis of the findings from the fieldwork at the different hospital
settings. Across the different patient profiles, patients’ experience seems to be shaped
by interactions between material, social and time related aspects. As stated previously,
architects designing space thus also strongly influence time perception and people’s
interactions (V2 §3.6). Each group of patients gives a (slightly) different interpretation to
these aspects and their mutual relationship. Also being static or in motion appears to be
a factor of influence. The insights gained add an experiential dimension to the aspects
brought forward by EBD studies.
5.2.1 MATERIAL ASPECTS
The material aspects that have an impact on patients’ spatial experience mostly relate
to sensory perception. Yet, their experience was shaped also by the meaning patients
attach to what they perceive and what these material aspects afford. Which aspects step
forward depends on whether patients experience them statically or in motion.
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Simple window views ( e.g. fig. 5-3) can bring patients joy. A tree outside the window in
the corridor or a view on the trees from the dialysis ward or room brightened participants’
day. These observations are in line with Ulrich’s early studies on the effect on patients’
health of the presence of green (Ulrich, 1984a) and the view from the window (Ulrich,
1984b). Although the view on green is largely appreciated, seeing some movement from cars, busses and people - makes patients feel part of daily life (Verschoren et al.,
2015), a patient in the expert panel pointed out. If the building would afford to go outside
it is considered even better.
As patients perceive the built environment differently while moving, different elements
take part in their spatial experience. Visual elements, like a brightly coloured door or wall,
sounds, e.g., from a nursing station, or tactile sensations, like a draught, can function
as orientation points (fig. 5-4). Whereas the exploratory study points at draught as
a problematic element, the actual fieldwork adds a positive association to the same
phenomenon. Also kinaesthesia plays a crucial role in how the continuation of spaces
is experienced. Depending on one’s way of moving, being wheeled or walking, different
haptic aspects can come to the foreground. For a patient in a bed, ridges between
a corridor and an elevator or expansion joints in the flooring material can be highly
unpleasant, whereas automatically opening doors reduce the number of starts and stops,
and thus increase the comfort (V2 §3.4.1). For a patient walking with an infusion standard,
by contrast, following a nurse through automatic doors was so challenging that these
small unevennesses in the floor might not even be noticed (V2 §4.5.1). These insights
provide new illustrations of the different modes of touch (Herssens & Heylighen, 2010).
Active touch might be related mostly to bedding materials, as discussed below, but the
draught which functions as an orientation point can be considered an example of passive
touch, whereas experiencing the ridges of the flooring material is an example of dynamic
touch.
Patients with different profiles attach a different meaning to the hospital environment. As
the long-term patients are familiar with the ward, the route to the dialysis, and the dialysis
department, for them the hospital is mainly a place to reside. They like to appropriate
their environment (fig. 5-5), be it their room, or just their bed. The specialist in the
expert panel testified that she often saw patients, mostly women, come in and the first
thing they would do is put up a picture, or a table cloth, sometimes even their own
bedcover. As these patients consider their experiences as highly predictable, how they
experience the built environment is indeed co-constructed by knowledge from previous
experiences and interpreted based on memories (Maclachlan, 1989). A patient from the
expert panel even stated that the hospital a patient experiences is not static but dynamic,
each new experience is shaped by previous ones. They remember what happened last
time and look forward to it or not, which impacts how they perceive space along the way.
Unknown elements or objects that confuse patients can be experienced as disturbing.
The large number of doors, which symbolize (fig. 5-4) the amount of misery for a
patient but actually are just closets (V2 §1.4.1), or a ventilation pipe running across the
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corridor (V2 §1.4.1) are visual examples of this. A nurse of the expert panel added another
example by telling of a patient being worried something would be wrong with him as
he was hearing beeps, which turned out to be the bell of other patients. Patients at the
emergency department (ED) specifically point at the transit character of the place (fig.
5-2). Elements that symbolize being taken care of might be unfamiliar to them, but are
in a way also reassuring or at least fascinating. These patients are not longing for an
environment that affords them to relate to it.
Whether patients are wheeled or walk, most of them pass through a sequence of
rather unfamiliar places. As a patient in the expert panel added, the followed routes
often depend on the one wheeling the bed, the moment of the day, or other unknown
organisational matters. This could make that the route is longer than expected or shorter,
but runs through spaces which are not intended to accommodate patient transport,
like a basement or corridor with dirty laundry. If the environment does not live up to
patients’ expectations or is not intended for patient transport, it may leave patients
puzzled. Under these circumstances, patients’ experience is shaped primarily by the
unexpectedness of locations, not so much by the qualities of the spaces as would be the
case for spaces to reside in.
--------bed, hospital gown and infusion standard (pictures taken by participant)
--------presence of
wheelchair and
walker in the room
--------cabinet with hospital
clothing at the outpatient day surgery
centre
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5.2.2 SOCIAL ASPECTS
In the scheme structuring EBD studies, family is discussed together with patients, while
staff is considered a separate user category (Huisman et al., 2012; Ulrich et al., 2008,
2004). My findings partially confirm this distinction, but also add some nuance to it.
Regardless of their profile, participants highly value contact with relatives and staff. What
does vary between the different profiles is the desired nature of these contacts.
In relation to social aspects participants emphasized the activities the hospital building
affords. However, also sensory perception and the meaning patients address to the
building turn out to play a role. Visiting relatives can alter the sensory perception and
meaning of a familiar place, mostly the patient room. A patient told that the presence
of her relatives made the room’s physical appearance less important (V2 §1.4.2):
through their presence she considered it a nice place anyway. How patients and those
accompanying them experience the hospital is co-constructed. This does not mean that
experiences are identical. Patients quite frequently mention spaces’ usability by staff as
influential in their spatial experience. Relatives rather focus on comfort and efficiency of
the procedure.
--------medical equipment in box (left) and room (right) at the ED
--------medical equipment
at the out-patient day
surgery centre visible
to patients when they
enter walking
--------fig 5.1
material elements changing a
person into a body of medicine
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The presence of others, be it relatives or staff, affords a different use of the hospital
building. For long-term patients, visits from relatives can add a place to the concatenation
of spaces to linger in, think of patients going to the cafeteria with their visitors, or visitors
taking a patient outside to enjoy the sun in the courtyard (V2 §1.4.1). A patient in the
expert panel added an important nuance to the findings of the fieldwork. Some longterm patients do not have family or friends who frequently come to visit. Apart from
their medical problems, these patients encounter some additional (practical) worries (for
example, how to get their laundry done).
For patients at the ED and day surgery centres, an important concern is the
accommodation of their relatives while they are being treated. Here, more than at the
wards, it seems to be the patient-and-the-accompanying-relative who should be taken
care of, especially since the presence of relatives comforts patients and thus possibly
reduces pressure on staff (Baraff et al., 1992). A member of the expert panel confirmed
this. When she recently visited the ED with a young son whom she did not want to leave
by himself, the ED did not seem to be prepared for this, most probably quite common,
situation. There was no cell phone reception, or Wi-Fi access inside. She thus had to
choose between leaving the ED to inform her husband or staying with her son. Moreover,
the space was not accommodated to be waiting for a long time. As we found that patients’
experience is co-constructed by the experience of accompanying relatives (Ekwall et al.,
2008; Welch, 2010), such a testimony from a relative could be relevant as well.
Patients’ interaction with the staff also varies between the profiles. Not surprisingly
long-term patients build up a relationship with nurses, logistic assistants, and physicians,
especially at a location like the dialysis, which they visit three times a week (V2 §1.4.2,
§1.4.4). As I learned from the fieldwork, space can facilitate or hamper these relationships.
At the ED and the day surgery centre, patients have a more professional relation with
staff, relying on them mostly for treatment, less for social contact. Both literature (Baraff
et al., 1992; Elmqvist et al., 2012) and the expert panel point at the role of spatial solutions
to accommodate these interactions: thin curtains are insufficient as sound barriers for
sensitive conversations. As the ED where the fieldwork took place had boxes and no
curtains, I cannot confirm this from my findings. However, similar results were found
about the waiting area in front of the OR and the recovery (V2 §4.3.4, §4.5.2). Whereas
at the ED staff fulfils the role of information provider and has to relieve patients from
uncertainty, at the day surgery centres, they are also expected to provide additional
services. Especially at the out-patient centre, their role changes throughout the process
from medical caregiver to service provider according to the managerial concept.
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corners and doors with bump marks
cracked chair seat as a sign of
fingerprints of previous ED visitors on cabinets
previous patients
--------fig 5.2
wear and tear as an image of (non-)afforded activities
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5.2.3 TIME RELATED ASPECTS
Time related issues are not addressed in Ulrich’s review of EBD studies (Ulrich et al.,
2008). Literature on the experience of architecture, however points at the importance
of time in relation to occurring activities in how the environment is experienced (Ingold,
2000; Lefebvre, 2004; Nairn et al., 2004; Rasmussen, 1964). This is confirmed by my
findings. In the spatial experience of patients with the different patient profiles, an
important role seemed to be played by rhythm and duration. There mostly meaning
making and afforded activities are at stake.
Apart from the rhythmic sensation of being wheeled over ridges, which is a direct
sensory experience, most sensory experiences pointing at a certain rhythm are a basis for
meaning making. For long-term patients their hospital stay, and thus their experience, is
structured mainly by the rhythm of the day. Meaning attached to sensory perceptions
point at a particular part of the day: the first sounds of the shift change in the morning
with nurses coming to wash patients and bring breakfast, the smell of soup when patients
return from dialysis and know that they can eat and relax, talking and laughing from other
rooms during visit hours, TV’s playing too loud at night, or the quietness of the night
when time seems to go by very slowly. A long-term patient in the expert panel told of his
desire to break through this routine. The daily rhythm can be broken by activities. Being
wheeled through the hospital, to dialysis, an examination, or treatment can be considered
a distraction, giving a different meaning to the spaces.
For day surgery patients, especially those at the in-patient centre, rhythms were
addressed mainly with respect to the route taken to the OR. Sensory perceptions, like a
draught at an open door, functioned as orientation marks and structured the route. At the
ED, aspects regarding orientation did not seem to come forward, maybe because of the
unpredictable character of the situation.
The duration of the stay obviously impacts how patients experience the built environment.
Long-term patients elaborated far more on the places where they reside and spend hours,
like their room or the dialysis department, than on the route. For patients at a day surgery
centre, whether organised as in- or out-patient centre, travelling through the hospital
takes up a considerable portion of their hospital stay and is frequently commented upon.
Patients at the ED are very well aware of the space’s transit character and expect (or hope
for) a short stay. This makes that the time they spend waiting is considered unoccupied
time. They just wait for news so they can move on, whether that means going home or
being admitted to a ward.
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view from a hospital bed (left) versus view through the window (right) - ward at the in-patient day surgery centre
view from a hospital bed (left) versus view through the window (right) - ward at the in-patient day surgery centre
view from a hospital bed (left) versus view through the window (right) - room at the ED
--------fig 5.3
(window) views depending on perspective (to be continued)
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view from a lying perspective (left) versus standing up
(right) - box at the ED (window behind patient’s back)
view from a lying perspective (left) versus standing up (right) - preoperative waiting room at the out-patient day
surgery centre
view from a lying perspective (left) versus standing up (right) - operation room at the out-patient day surgery centre
--------fig 5.3
(window) views depending on perspective (continuation)
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three indicating that patient is almost back at the ward
after dialysis (orientation point)
outside space proving fresh air on the way to the OR
(orientation point)
red door as entrance
to the ED, only point
remembered by patient
along the route
wall with oranges at
the main corridor of the
out-patient day surgery
centre indicating the
operation is over
arrows next to the lift, symbols for ups and downs at the
cross above the door in a patient room, symbol for each
hospital
patient wearing his/her own cross
--------fig 5.4
meaning making: orientation points & symbols
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objects needed at hand
pillow for personal
(e.g. water bottle)
comfort
support from others
decoration & personal
belongings
--------fig 5.5
appropriation of the environment
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how the material
environment could
support how patients are
referred to in terms of
colours
(instead of numbers)
most colourful object in the
room communicating an
unsympathetic message
--------fig 5.6
communication by the
material environment
readability of the built environment
sequence of space communicating a distinct atmosphere
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5.3 CONCLUSION
The World Health Organisation (2006) defines health as “a state of optimal
physical, mental, and social well-being, and not merely the absence of disease and
infirmity”. This definition resonates perfectly with the conviction that the built
environment has an impact on people’s health (Jencks, 2006; Mens & Wagenaar,
2009; Sternberg, 2009). In writings and discourses on hospital architecture and
patients’ health a frequently mentioned concept is patient-centeredness. Elements
from the definitions like communicating adequately and supporting the patient–
provider relationship, including family and friends, and coordinating care across
settings (Aboumatar & Pronovost, 2013) relate to the aspects discussed above.
By looking at the hospital building from a patient perspective and exploring how
patients may differ in terms of their spatial experiences, I aimed to identify to what
extent and how the building could add to patient-centeredness.
Conclusion
5.3.1 VARIATION AMONGST PATIENT PROFILES
Most hospitals tend to group patients in wards according to their pathology.
This implicates that long-term patients staying for over a week share the same
accommodation with the large group of patients who stay only a few days,
or even just a day. The presented research shows however that long-term
in-patients long for a comfortable place to reside, whereas the majority of
patients consider the hospital as a transit space. It thus seems inappropriate
to accommodate both with the same type of spaces. A long-term patient
in the expert panel confirmed this. She really appreciated the presence of
group facilities to be able to leave the small individual room at a rehabilitation
centre. Residing in an appropriate space should thus not necessarily mean
that one could reside only in a patient room. For long-term patients, the
hospital is the place where their every day life takes place and thus should
be able to support their daily activities. For day surgery patients or patients
at the ED the built environment does matter but plays a rather supportive
role in their treatment. Most of the reviews on EBD do no take into account
these differences amongst patient groups, thus drawing conclusions which are
supposed to count for all patients (Dijkstra et al., 2006; Huisman et al., 2012;
Rubin & Center for Health Design, 1998; Ulrich et al., 2008, 2004). If hospital
(re)design is to take into account patients’ perspective architects, planners,
and hospital boards also need information about divergent spatial experiences
of diverse patient groups.
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Hospital buildings should support patients’ mental and social well-being. In
my research I identified certain experiences related to mental and social wellbeing, which varied amongst patient profiles. From an architectural point of
view providing specific spaces that respond to the experiences of patients with
different profiles thus seems logical. Members of the expert panel considered
choice and diversity important issues in this respect. This is now partially met
by giving patients the choice between a single or multiple person room, at
least upon availability.
Patients who were admitted in for a short period rarely wanted to appropriate
the environment. This does not mean that these patients do not want to be
recognized as a person during their stay. Yet, they tend to focus more on the
efficiency of the medical procedures and expect from the building to do the
same. My plea for an environment more suitable to reside for a small number
of long-term patients does not imply that the majority of the patients do not
need appropriate spaces. On the contrary, since this is usually a big group, it is
essential to create a building that enables the staff to treat them as comfortably,
efficiently, and personally as possible. When a patient is wheeled into a room
with a window, the space should be organised such that the position of the bed
allows the patient to look outside (V2 §4.5.1). For hospital rooms this might be
common knowledge, however, the same counts for every other space where
patients are positioned, or wheeled through.
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Conclusion
Most long-term in-patients are longing for a place to reside. These places
should be equipped to care for them while trying to maintain continuity with
daily life (V2 §1.4). Being able to appropriate space thus seems a key concern.
Also differentiating between spaces can be important. Being able to go
outside, for example was the highlight in the participating long-term patients’
day (V2 §1.4.1) as was confirmed by the patients in the expert panel. However,
not all of them could do this unaccompanied. Providing an accessible outside
space would thus make a considerable difference for these patients. According
to their testimonies being able to go outside did more for their well-being than
any medicine could do. The advantage of diversifying patients’ environment
during the day was confirmed by the patients in the expert panel, who pointed
at the importance of variety. Ideally long-term patients should be able to go
home during the weekend. When this is not an option, these patients should
at least be able to leave the room, for example by going to a group facility.
As a spatial solution to these diverse experiences, I proposed to the expert panel
to provide a few rooms for long-term patients, maybe with a balcony or extra
corner, that would better support them in diversifying where they spend their
day, without putting extra pressure on staff. Most members could agree with this.
The doctor in the panel had some objections. She pointed at the need to have
all patients with the same pathology at the same ward, which I do not consider
contradictory. Moreover, she was afraid that it would be difficult to draw the
line between who could and could claim such a room. Although this kind of
concerns from the field should certainly be taken into account, this should not
limit architects’ creativity in dealing with diverse spatial experiences. I believe
that even within an existing building or ward a distinction could be made.
Conclusion
5.3.2 FOCUSSING ON THE PATIENT IN MOTION
While moving, people experience a building as a concatenation of spaces.
This concatenation should be understood as a fluid space, a continuum
(Ingold, 2011) rather than a series of separate spaces a patient travels through.
Patients’ spatial experience of a hospital environment thus depends on how
well spaces work together. This means that attention should be paid not only
to the spaces that are traditionally associated with patient experience, like the
patient room, or the examination room, but to each space where patients pass
through including corridors, changing rooms, and elevators. A route going
through emergency exits which do not seem meant to be passed, or passing
by a pile of garbage bags, as patients in the expert panel described, may be
remembered by patients as unsuitable even though the majority of the spaces
they passed through were designed to wheel patients’ through.
For each of the aspects - material, social, and time related - being in motion
added to patients’ spatial experience. A draught along the route, not having
control over whom one encounters, or points of orientation that give rhythm
to a route are just a few illustrations. Each of these additional aspects relates
to sensory perception, to meaning making, and/or to affordance. When being
wheeled through a corridor a patient can feel the ridges at the sealing of the
flooring material. This perception can trigger the association with a cobble
stone street, but can also serve as a point of orientation that one is almost
back in the room. Moreover, it can make the accompanying nurse ride slower,
making the journey longer. Being moved thus connects the different aspect
of patients’ spatial experience in motion, maybe even more than experiencing
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the built environment in a static way.
When patients are wheeled in a bed or wheelchair, additional nuances like the difference in haptic sensation of material elements like ridges, altered
social relations and different time perception when passively being moved are added to the aspects relevant to architects. In many situations, the bed
condemns patients to passively undergo what is happening especially while
in motion. Taking into consideration the role of the bed (or wheelchair) in
their spatial experience in motion, in all its facets, is thus not a side issue but a
necessity when designing a truly patient-centred hospital. Taking into account
this extended entity and its possibly altered perspective when designing the
built environment, would avoid often heard situations of patients parked in the
corridor or, as a patient of the expert panel testified, patients in pain being hit
by another bed passing by.
5.3.3 PATIENT-CENTEREDNESS ENACTED THROUGH SPACE
Hospitals have long been perceived as institutes. Only recently efforts
are made to change this perception towards a more patient-oriented one.
However, the old hospital buildings remain and often still express this idea
of strictly organised healing machines, rather than supportive environments
(Wagenaar, 2006, p.31). When asked about their care vision, many hospital
boards will respond that they put the patient centre stage (Sermeus &
Vleugels, 2010). This refers in the first place to new services brought into
being: providing information through websites and poster campaigns, offering
choices in meals, or educating staff. More recent managerial concepts, like the
introduction of an out-patient day surgery centre where patients walk to the
OR, brought up the need for new spatial configurations.
Although most patients at the out-patient centre (V2 §4.5) were positively
surprised by the new day surgery centre’s configuration, it was not what they
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Conclusion
The implications of patient-centeredness for hospital design should be
considered in a broader perspective than painting the walls or providing an
extra shelf for personal belongings. Although this kind of interventions might
add to a positive patient experience (Yildirim, Akalin-Baskaya, & Hidayetoglu,
2007), the building seems to play a more structural role in enacting a patientcentred vision.
Conclusion
had expected. They were clearly lacking a frame of reference to be able to
describe its atmosphere. Striking was patients’ frequent use of metaphors:
they relied on comparisons with other building types or contexts to address
both positive and negative elements. In this kind of unfamiliar environment,
clear communication with patients seems important, especially through the
built environment itself (fig. 5-6). Whereas the general message for patients
was that they were considered customers who should be well cared for, as was
clearly communicated by the waiting area and lounge, other parts like the locker
room focused on process efficiency. The presence of technical equipment,
which could be considered as scary by some patients, was perceived by others
as a sign of good care. A patient in the expert panel explicitly mentioned that
for him having modern equipment was the basis to receive optimal care. Many
patients mentioned this contrast between clinical and non-clinical spaces even
though not all found it disturbing. Also at the ED spaces not suited for what
patients actually had to do there, attracted attention. A changing room is not
a waiting room. Still waiting is what patients are expected to do there. Longterm patients mainly mentioned their desire to be able to dwell in their room,
which was obviously not what the room was designed for.
Generally speaking, I can conclude that hospital boards communicate their
care vision to patients, not only by what they say explicitly or by how they
educate their staff, but also by what is implicitly told by the hospital building.
The expert panel broadly agreed with this statement. One of the members
mentioned a hospital in which many inside walls were replaced by glass,
giving the hospital a much more open atmosphere, which she interpreted
as the hospital organisation being transparent towards patients and visitors.
Managerial and spatial decision-making and organisation should thus go
hand in hand. When a care concept is changed, the built environment should
be changed accordingly.
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Margo Annemans
Supervisor:
Prof. Ann Heylighen
Co-supervisors:
3
VOLUME
INFORMING
ARCHITECTURAL
PRACTICE
Margo Annemans
Supervisor:
Prof. Ann Heylighen
Co-supervisors:
Prof. Herman Nys
Prof. Sarah Pink
Prof. Tom Thys
VOLUME 3
INFORMING
ARCHITECTURAL
PRACTICE
Informing architectural practice
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V3
TABLE OF CONTENTS
1. WHAT MAKES AN ENVIRONMENT HEALING? USERS AND DESIGNER ABOUT THE MAGGIE’S CANCER CARING CENTRE LONDON
3
1.1 Introduction
5
1.2 Healing through the environment?
6
1.3 Maggie’s
7
1.4 Research approach
9
1.5 The users and the architect
1.3.1 1.3.2
1.5.1 1.5.2 1.5.3 Maggie’s cancer caring centres
Maggie’s London
7
8
10
The building
Image building
Social network building 10
12
13
1.6Conclusion
15
2. HOW TO INTRODUCE EXPERIENTIAL USER DATA: THE USE OF INFORMATION IN ARCHITECTS’ DESIGN PROCESS
19
2.1 Introduction
21
2.2 (User) informed design in literature
21
2.3 Researching architects’ information use: Methods
2.3.1 2.3.2 Focusgroup interviews: Aim and set-up
Data collection and analysis
22
2.4 Architects on experiential user data: Findings
27
2.5 Discussion and critical remarks
31
2.6 Conclusion
33
3. FROM DESIGNING FOR THE PATIENT TO DESIGNING FOR A PERSON 37
3.1 Introduction
39
3.2 (User) experience in design
39
3.3 Maggie’s world
40
3.4 The design studio
41
3.5 “Maggie” in the design process
42
3.6 Discussion
48
3.7 Conclusion
49
2.4.1 2.4.2 3.5.1 3.5.2 3.5.3 Information in the design process
Introducing and using experiential user data
Interaction with real-life people
Maggie
The architectural brief
22
23
27
29
42
43
44
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4. BEING WHEELED THROUGH THE HOSPITAL: HOW CAN DESIGN BE INFORMED ABOUT HOSPITAL PATIENTS’ SPATIAL EXPERIENCE IN MOTION?
53
4.1 Introduction
55
4.2 Introducing patients’ experience in motion in the design process
55
4.3 Approach of the workshop “Moving designs for moving real people” 4.3.1 4.3.2 Procedure
Analysis
59
4.4 Findings
60
4.5 Discussion: Motion in design (process)
69
4.6 Conclusion
70
5. DISCUSSION AND CONCLUSION: INFORMING HOSPITAL DESIGN ON PATIENTS’ SPATIAL EXPERIENCE IN MOTION
75
5.1 Gaining insight into the use of experiential user information in architectural practice 78
5.2 Evaluating the applicability of experiential user information in architectural practice 79
5.3 Towards an information format to inform hospital design on patients’ spatial experience in motion
81
5.4 Conclusion
85
4.4.1 4.4.2 4.4.3 4.5.1 4.5.2 From the brainstorm
From the design session
From the Discussion
People in motion
The environment is mobile
59
60
60
61
64
69
69
How can insights into patients’ spatial experience be translated in a format that is applicable
in architectural practice? In this volume I address this research question in four steps, each
corresponding to one chapter. First I explore the effect of using experiential user information
during design on the resulting building to identify its added value and limitations.
Subsequently I look into how architects currently design care buildings and the role of
information therein. Then I assess the impact of using different kinds of information on
patients’ spatial experience in design. Finally I unite the collected insights in an information
format to inform architectural practice on patients’ spatial experience in motion.
To explore the impact of using experiential user information on actual buildings, I looked
for well-documented projects where user experience stood central during the design
process. The Maggie’s Cancer Caring Centres met these criteria. The architectural brief
which forms the basis of the centres’ design focuses primarily on experiential matters rather
than traditional square meters and functions, and Maggie’s personal experience is key in
the communication between client and architect. Although the centres considerably differ
from a hospital building in terms of scale and complexity, they are designed for and used by
people in a similar situation as many participating patients. Therefore the way these people
are represented in the information provided to the centres’ architects may be transferrable
to the hospital context. To take the acid test I interviewed the architect and a group of users
of Maggie’s London respectively about how the design was approached and the building
intended, and about how it is experienced.
How do architects currently use information in designing hospitals, and to what extent could
experiential user information change their thinking about their projects and current way
of working? To address these questions I conducted two focusgroup interviews: one, with
architects having various roles within the same firm, identified differences in information
use across design and building phases; the other one, with architects having similar roles,
addressed the diversity in information use across different firms. In both interviews, I
started by probing participants’ information use during design in general, and subsequently
presented specific examples of research data to question their usability and attractiveness
for architects.
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Asking architects to reflect on their design processes is rather non-committal. Taking part in a
design studio in which fourth year architecture students designed a Maggie’s Cancer Caring
Centre, offered me an opportunity to study how engaging with users inspires and directs
(student) architects effectively. Students received the documents the Maggie’s Trust offers
architects working for them, and were introduced to cancer patients and care professionals.
Students’ designs were analysed to identify how and to what extent users were represented.
The insights gained in volume 2 address not just patients’ spatial experience but patients’
spatial experience in motion. Therefore I organised a workshop in which designers and
non-designers were teamed up to design a hospital lift. The provided information enabled
workshop participants to empathise with patients and to identify what spatial experience
in motion comprises. The choice for a lift as design task was informed by insights gained in
volume 2, As participating patients frequently mentioned the lift as largely determining their
experience during transport: it is a small, closed of space, with a distinct atmosphere and clear
boundaries; it interrupts the route - entering and leaving are remarkable haptic experiences.
it unites many aspects of active and passive movement and shifting mobile objects - once
inside the bed seems to stand still, yet, the space moves. A complementary reason for the
choice of the design task is that the workshop aimed at architects, product designers, and
adjacent professions, and a lift seemed a good option to address these profiles’ interests and
design expertise.
Together the insights from each of the studies reported on in this volume laid a solid foundation
for an information format to inform architectural practice on patients’ spatial experience in
motion. In the final step of this volume I presented a proposal of such an information format
to an expert panel at osar architects to assess its applicability and usability in architects’
design process.
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1. What makes an environment
healing? Users and designer
about the Maggie’s Cancer
Caring Centre London
An earlier version of this chapter has been published as a conference paper.
Annemans, M., Van Audenhove, C., Vermolen, H., Heylighen, A., 2012. What makes an environment healing? Users and designer about the Maggie’s Cancer Caring Centre London. In Out of
Control. Proceedings of the 8th International Design and Emotion Conference by Brassett, J., McDonnell, J., Malpass, M. (Eds.), Design and Emotion, London, pp. 1-8.
Keywords
architecture
building
healing environment
Maggie’s centre
user experience
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Abstract
When being admitted to a hospital, you largely loose
control over your life. Others decide your time schedule,
where you go and stay, and what the environment looks
like. Ongoing research about healing environments hardly
seems to affect the design of current hospital buildings. An
exception are the Maggie’s Cancer Caring Centres, designed
specifically to offer a healing environment.
In our research we explore architecture’s impact on patients’
well-being. Through interviews with both the designer
and users of Maggie’s Centre London, we confronted the
architect’s vision with the daily experience and the actual
building. This analysis enables us to start uncovering the
meaning of a healing environment. At Maggie’s London
the combination of a well-thought-out architectural brief,
an engaged architect, and ‘suiting’ client seem to form the
basis for a successful building that is not only designed as
healing but is also experienced as such by its users.
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1.1 INTRODUCTION
“There is an intimate relationship between our emotions and the things
around us,”
Swiss architect, Peter Zumthor (2010) writes. Whether an environment works healing
or not is often closely related to the emotional experience it triggers. Which elements
or aspects are involved in this is investigated based on the case of the Maggie’s
Cancer Caring Centre in London. The insight, as expressed by Zumthor, is rather
recently acknowledged. Whereas early research about the relationship between the
built environment and its effect on health focuses largely on medical outcomes (Rubin
and Center for Health Design 1998, Ulrich et al. 2004), more recently influence on the
mental welfare is being recognized. As the World Health Organization (2006) states:
“Health is a state of optimal physical, mental and social well-being, and not merely the
absence of disease and infirmity.” Based on this definition we want to gain insight into the
spatial experience of patients and provide architects with sufficient information to design
wholesome hospital environments.
As the starting point for the Maggie’s Centres is to design a healing environment,
analysing them gives us insight into those elements that add to the experience of a
building as wholesome. Whereas we are looking for those aspects that affect patients
in particular and users in general, in the case of the Maggie’s Centres the architects start
from a description of what forms the basis for a healing environment and have to translate
these into a material form. The document they are provided with to start from (Keswick
and Jencks 1995) emphasizes the emotional state a cancer patient is in when receiving
the diagnosis and fighting the disease. A first step is taken to translate a patient’s needs
into more spatially oriented requirements (s.n. 2011), however it is mainly the experience
of the user that forms the basis for the architect to start designing. A good architect
will design a building that optimally supports these needs. To gain insight into why the
building is actually considered healing we set out to investigate how the building provides
this support. Based on the analyses of a group discussion with users of the Maggie’s
Centre in London and an interview with the architect, we found that the emotional impact
of the building is situated at three levels: the aspects related to the material realization of
the building; the feeling of identification the building generates among its users; and last,
but not least, the way in which the centre and its architecture support social interaction
between its users and people around them. Designing a building that reaches all these
goals is a major challenge. A lived through brief, elaborated by a skilled architect and
organized by a supportive client lays the foundation to reach this goal. At Maggie’s
London all these factors come together and indeed, seem to result in a building where
the user considers the same elements as healing as those advanced in Maggie’s brief.
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1.2 HEALING THROUGH THE ENVIRONMENT?
When Roger Ulrich published the outcomes of his 1984 study on how the view from
the hospital room influences the use of pain medication (Ulrich 1984b), he set the tone
for a growing field of research about the impact of the environment on patients’ actual
healing. From that moment on various studies were conducted where clinical evidence
was sought for the effects of architectural decisions in (healthcare) buildings. The insights
from these studies are collected under the common denominator of Evidence Based
Design (EBD) (Ulrich et al. 2004). This notion found its origin in the analogy with other
evidence based approaches to research and practice. When it comes to buildings for
healthcare especially Evidence Based Medicine was a source of inspiration, here too the
effectiveness of medication is proven by clinical measurements. These studies mostly
investigate the direct link between a single aspect of the building and its clinical outcome.
Many of them cannot provide sufficient clinical evidence (Rubin and Center for Health
Design 1998). Reports that try to collect results from different studies to obtain insight
into how the various aspects relate to each other, all have to conclude that the collected
evidence is not (yet) ready to be used in design practice (Rubin and Center for Health
Design 1998, Berg 2005, College bouw zorginstellingen 2008). However, both medical
professionals and architects believe that the built environment can have a beneficial
effect on its users. Whether this is directly measurable is another question. Based on these
insights, we argue that a wholesome environment involves more than the measurable
aspects that withstand the evaluation of EBD studies (Annemans et al. 2012). For this
reason we also opt to use the term ‘wholesome’ rather than ‘healing’ in our research.
Charles Jencks himself, co-founder of the Maggie’s Centres, is the first one to contradict
the strictly clinical effect of architecture (Jencks 2006). Still, he argues, the centres can
definitely make a difference, for five reasons (Jencks and Heathcote 2010). Several
of these reasons involve social support. Cancer caring centres can alleviate the death
sentence, by negating the negative effect of receiving one. Training patients in stress
management reduces the impact of stress on the immune system. Positive feelings,
enhanced by the building and complementary therapies, may contribute to longevity.
And, an extended shared knowledge about possible new treatments or therapies can
provide users of the Maggie’s Centres with informed opinions, which may make a
difference over time. Finally the centres can also work like a placebo, they work because
they operate on patients’ beliefs. Within this context Jencks defines three possible sorts
of effect. The Style Effect indicates the impact of image building. Like a placebo injection
works better than a pill and a placebo from a brand has a better effect than a generic one,
the fact that a building has a specific design may have an influence as well. The Cultural
Effect refers to the fact that it is not just an individual’s psychology that matters, also
cultural aspects count. The third, and probably most important, is the Caregiver’s Effect.
If a doctor or, in the case of the Maggie’s Centres, a caregiver is convinced that it will
work, chances are higher that it will.
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All three effects mentioned above relate to the experience of the building by its users.
Indeed, what we see, hear, smell or touch determines our state of mind (Sternberg 2009).
The impressions we receive from our environment influences how we feel. Architecture
is experienced through the senses (Rasmussen 1964, Pallasmaa 2005) and the senses are
part of human life through one’s involvement in the world (Ingold 2000). They are a key
factor in the experience of our surroundings. To come to a profound understanding of the
meaning users ascribe to the Maggie’s Centres, we need to dig into their experience and
emotional affiliation with the building. By comparing this information with the vision of
the designer based on the provided architectural brief (s.n. 2011) and inspiring testimonial
of Maggie Keswick (Keswick and Jencks 1995), we can form an image of why exactly a
building designed as healing could actually be experienced as wholesome.
1.3 MAGGIE’S
1.3.1 MAGGIE’S CANCER CARING CENTRES
When Maggie Keswick and Charles Jencks founded the Maggie’s Cancer Caring
Centres in 1995, they outlined the guidelines along which all future centres should be
designed. The purpose of the centres is to offer a new approach to cancer support. To
reach this goal, both the buildings and the architects should meet certain requirements.
Leading international architects and landscape designers are asked to design centres that
are characterized by a distinctive and highly individual design, giving support to anyone
affected by cancer.
As a basis for the design the Maggie’s Centres provide different kinds of documents.
There is “A View from the Frontline”, a leaflet written by Maggie herself in which she
describes her battle with cancer and sets out how the centres should be approached
and organized (Keswick and Jencks 1995). This document is complemented by a more
recent publication “Maggie’s Architectural Brief” (s.n. 2011) which informs architects
about the requirements for the design of the Maggie’s Centres.
The architectural requirements contain a list of spaces that should be provided such
as an entrance, sufficient office space, a kitchen, and lavatories. Each of these spaces
is described in such a way that the obtained atmosphere is clear but no fixed solution
is given. The entrance should be obvious, welcoming, and not intimidating. The layout
should be clear and the building as light as possible. The lavatories should not be all in a
row with gaps under the doors; they should be private enough to cry in. Apart from these
contextual descriptions for specific spaces, there are also pointers for the architecture in
general. The Maggie’s Centres and the way they are designed should raise your spirits, be
safe and welcoming, but not too cosy and increase the sense of connectedness between
people (s.n. 2011).
To meet these requirements, architects are chosen of which the organization thinks that
they will rise to the challenge of making spaces that help the people using the buildings to
cope. To do so, the architects should go beyond preconceived ideas. They are expected
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to step off the beaten track and open our eyes. Although the quality of the created
buildings is believed to be crucial, the choice of the designer involves more. It capitalizes
on the Style Effect. Special architects make special buildings, which is a key element in
the feeling of ownership the community has of the building. They feel proud of their
Maggie’s. The created image assures the people of the attention that is given to them,
that they are appreciated and cared for.
1.3.2
MAGGIE’S LONDON
The Maggie’s Centre in London was designed by Richard Rogers of Rogers Stirk Harbour
+ Partners (fig. 1-1). It is located at a busy junction in Hammersmith, next to Charing Cross
Hospital. To contrast the main hospital, the centre is designed as a ‘non-institutional’
building (Rogers Stirk Harbour + Partners 2011). In line with the requirements mentioned
above the building unites a welcoming open image with a shelter from the urban noise. A
bright red wall wraps around the four sides closing it off from the city, whereas a floating
roof above forms a uniting element for the spaces below (fig. 1-2). The entrance can
be approached by a walkway, which meanders from within the main hospital ground to
the centre (McDonald 2011). The heart of the building is the centrally located double
high kitchen (fig. 1-5) around which the other facilities are located. Light comes into the
building through the glazed walls of the first floor and openings in the roof, providing the
downstairs area with a good combination of crucially located sights and privacy.
--------fig. 1-1
Floor- and site plan of Maggie’s Cancer Caring Centre, London
(source: http://www.rsh-p.com/assets/ib/2015/04/28/3610_
Maggies_JS_en.pdf)
--------fig. 1-2
Outside image of Maggie’s Cancer Caring Centre, London
(© Richard Bryant/arcaidimages.com source: http://www.
rshp.com/render.aspx?siteID=1&navIDs=1,4,25,566,1510&showImages=detail&imageID=2925)
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1.4 RESEARCH APPROACH
Since we want to explore as many aspects and nuances of a wholesome environment
as possible, we opted for a qualitative research approach (Creswell 2003). To be able to
confront the requirements from the client, the point of departure of the architect, and the
users’ experience of the building, we conducted a group discussion with four users of the
centre - three cancer patients and one whose husband died of cancer - and interviewed
the associate at Rogers Stirk Harbour + Partners who lead the design and building of
Maggie’s in London. Both the group discussion and the interview were audio-recorded,
transcribed and coded using qualitative data analysing software (ATLAS.ti). As we
wanted to start our analysis from the user perspective, first the group discussion was
processed using open codes. Three major topics were identified: how building aspects
impact users emotionally, how users identify with the building and how the building
supports social interaction at different levels. With the results of this first analysis in mind,
the interview with the architect was coded according to these categories. This approach
allows balancing the intentions of the architect against the actual user experience.
--------fig. 1-3: Entrance to the building
--------fig. 1-4
Entrance area without reception desk
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--------fig. 1-5
Kitchen area and view on the hospital at Maggie’s
London
(source: http://www.maggiescentres.org/newspublications/prarchive/maggies_london_first_birthday.html)
--------fig. 1-6
Seating area with sliding door (on the right)
1.5 THE USERS AND THE ARCHITECT
1.5.1 THE BUILDING
Architecture can definitely influence people’s state of mind (De Botton 2006). This
conviction is shared among architects (e.g. Zumthor 2010). Also the architect of Maggie’s
London mentions in the interview:
“You generally have a feeling about what spaces can do and what architecture can do. You can depress people, you can expand people, you can make
people tall, you can make people small. You can bring a lot of light in, you
can make space devoid of light, dark. And I think all those have an effect
on how somebody experiences that space. And I think we know that as
architects, that is what we do. And that is how and why we design it. There is
not necessarily a scientific nature to it.”
Indeed, it is clear that the building does not leave its users unaffected. Even without
being asked questions the participating ladies start by emphasizing the merits of “their”
building. The architecture is most definitely appreciated,
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“… this charity is very special because I’ve been to other charities in London
and this is by far the most beautiful, we are so lucky that this is, yeah Richard
Rogers and open space and. For example there is a very good one at [X],
you can get all these free massage and I don’t know all these other things
but the building is absolutely horrible and when you come there once you
finish your treatment you don’t want to stay there because it depresses you
so much.”
During the discussion the participants refer frequently to the feeling they have when
they enter the building. One lady literally cites the feeling when she comes into the
door as “Ooh my god this is gorgeous feeling, relaxing.” Someone else adds to this: “Yes,
the energy.” Not only primary users experience the environment like this. A participant
explains how she brought her parish priest and family to the centre to illustrate what an
impact it has. She says:
“When [the priest] came in here, he had lost his wife 17 years ago with
cancer, […] he couldn’t believe how lovely it was. He went back and told
everybody about it. And my brothers came in with me, and my sisters in law
all came in with me and they couldn’t come back home to tell everybody
what the building did for them. It was the building that did it for them. When
you push that door open, you are at ease.”
Also for themselves they describe the building as an important factor in how they feel
during or after a visit. Quotes such as:
“[…] this place gives us optimism”
“[it] gives us a bit of confidence”
are uttered or approved by all four participants.
In “Maggie’s Architectural Brief” (s.n. 2011) specific attention is paid to certain spaces that
should be available at each Maggie’s Centre. A central kitchen (fig. 1-5), a welcoming
entrance (fig. 1-3&4) and a loo with enough space to retreat and cry are mentioned as
key elements. Both the architect and the participants address the central kitchen as the
heart of the building. The kitchen table definitely is the number one place to meet. As
they describe it:
“Ooh that is our table. That is our family table.”
“That is our anchor that is the family anchor.”
However, it is the entrance, or the moment of entering, that plays the most significant role
on different levels. On the architectural level, the absence of a clear reception desk has
a major impact. As demanded in the brief, Maggie’s London does not have a reception
desk, the architect states:
“There is no reception desk which is vital. You know, the fact of having a
reception desk empowers somebody behind, automatically gives the wrong
feeling.”
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Indeed designing a building without reception has a sincere influence on the social
interaction. Obviously the principle of approachability should be supported by the design
of the entire building. At Maggie’s London the creation of an open structure with many
visual connections throughout the building enables the people working in the centre to
easily see who is entering, wherever they are in the building. This conceptual choice has
a major influence on the image of the centre and its social impact.
Finally, the architectural brief for the Maggie’s Centres (s.n. 2011) includes some spatial
aspects that are frequently mentioned in EBD studies such as the presence of light and
green (Ulrich 1984a, Ulrich 1984b, Ulrich et al. 2004, Van den Berg 2005). The same
spatial aspects are also brought up in the group discussion. One of the participants
literally says:
“a big space, the open area, all the plants, yeah, that is healing environment.”
1.5.2 IMAGE BUILDING
In Western culture cancer and people affected by cancer are often hidden. In the case
of the Maggie’s however, the centre’s architecture acknowledges their plight and affirms
their worth, which for cancer patients is a rare recognition (Jencks and Heathcote 2010).
Indeed, even if it was only for its bright orange-red colour, the building of Maggie’s
London stands out. The colour also affirms the centre as the antitheses of the nearby
hospital. The juxtaposition of the classic, grey mega-hospital and the bright orange,
intimate centre could not be any bigger (Jencks and Heathcote 2010). Since it is so
bright there is no way you could think the building is trying to hide. Indeed, this is what
the architect expresses in the interview:
“[…] the orange building in the corner, if you cannot see that you probably
have a few more problems. It is about not being shy about it.”
It makes a very clear statement, something even the users have to get used to. As a
participant puts it:
“It is red! […] I have never seen in the grounds of a hospital a red building.
This is where the standard of this is. A red building in the hospital ground! It
should be either white or grey […] or red brick but not red.”
Although not a spatial aspect, the name given to the centres and how they are advertised
add to the image. Only “Maggie’s” is printed on the front door, no reference to cancer
or whatsoever. It is also this name that is used by the users, resulting in funny situations
and a source of laughter. One of the participants tells us that she said to someone “I am
going to Maggie’s,” which made the other one ask: “What is it? A nightclub?” No negative
connotation is associated. The participants do not see Maggie’s as a charity. It is more
than that. Like they say:
“[…] this is not a charity. This is life. Not a charity.”
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As illustrated, both the outside appearance of the building and the image created by the
name giving result in a strong identification of the users with “their” building.
1.5.3 SOCIAL NETWORK BUILDING
An important purpose of the Maggie’s Centres is to support social interaction between
the users. Although the remarkable architecture is clearly appreciated, it is the people,
staff and visitors,who make the place into what it is today, according to the participants.
To start with, there is the interaction between people affected by cancer, such as the
group of participants. Not being on your own at home, worrying, having someone to
talk to, and feeling “normal” all add to the feeling of well-being the centre provides. This
conversation says it all:
“You feel normal here.”
“You ARE normal.”
“… because at home I feel pfff”
“Yeah, but don’t forget at home you are alone.”
“When you are diagnosed, at home [you] always prepare for the last day.”
The difference with a traditional hospital ward in the support of social interaction is
striking. According to one of the participants being among others in a different but
similar situation is essential in this respect. One states:
“We have a lot of people coming from the wards as well and sitting in here
and having a chat and getting to know rather than sitting in four walls,
looking at nothing, nobody to talk to. Plus the fact they all have something
different and none doesn’t want to talk about it and when you come in here
nobody talks about their illness. “
It is precisely to facilitate this kind of interaction that the architectural brief asks for the
building to provide a large central kitchen where people can meet, but just as well small,
intimate rooms where a face-to-face chat can take place. A good architect interprets
these expectations about intimacy and adds some additional value. In the case of
Maggie’s London, the architect explains why they opted to use only sliding doors:
“We have sliding doors as well on all the rooms, so when [the rooms] are in
use, [the doors] are closed, when they are not in use they are open. Sounds
obvious but it means that you don’t have the sort as with a normal door, if
slaps, and then you do not quite know whether you are meant to knock or
you are not. There is an apprehension, a door; you shouldn’t go in there. By
having them open there is a very clear indicator whether someone is in there
or not.”
Initiating such a subtle deviation from the standard solution, steered and facilitated
human interaction.
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As mentioned, the absence of a reception desk avoids that the person behind it is being
empowered. This simple intervention has a major influence on the kind of relationship
between those affected by cancer and the caregivers. The lack of a front desk results
in people entering the building being personally welcomed and staff not hiding behind
their computer. Both are highly appreciated. The architect explains how a first contact is
guided by the building:
“[…] not having a reception desk means that […] you can see somebody, that
you already have a personal relationship ready. Somebody comes up to you
to see how you do and you can make a cup of tea and you can already start
interacting. […] If you come in the front door […] then you have the main
table where people sit around the corners and you can have a conversation.”
The availability of the caregivers is pointed out as an element that distinguishes Maggie’s
from any other charity. As a participant explains:
“one of the main differences between this charity and other charities in
London is that here there are three people looking after us and in all the
other charities they are behind a computer doing their own thing and they
don’t talk to you and you just go for your yoga class or whatever and then
you finish and you just go out again.”
By creating a comforting environment, people feel welcome to stay and take part in the
ongoing action.
Finally, the existence of the centre can help to establish an improved, renewed relationship
between cancer patients and their family. Logically friends and relatives are worried
about the ill, when they know he or she is at Maggie’s and they have seen the centre, this
is often a relief for them, which in its turn is comforting for the patient (as testified in the
discussion).
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1.6CONCLUSION
From the moment you receive the diagnosis of cancer, the control over, at
least part of, your life is taken away from you. At this point, all possible support
is welcome. Our study of the Maggie’s Centres shows that architecture can
have an empowering effect. Despite the possible placebo effect, upon
which we are unable to pronounce, it may not actually be healing but it
definitely is strengthening people. Anticipating the Style and Cultural Effect,
architecture can support social interaction and create a positive image.
Whether a good building has a healing effect because of its architecture
alone remains unclear. Obviously, this study was rather limited, more
profound (ethnographic) research about the use of the centres is needed
before we can draw conclusions on this point.
Designing a wholesome, or even healing, environment appears to be largely
about spatial experience and (its) emotional impact. As such, the study of
the Maggie’s Centres forms an important illustration of the relevance of
research about the spatial qualities that add to the wholesome character of
the built environment. Further insight into this topic is expected to have a
profound impact on future design for healthcare.
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Conclusion
Judging from the discussion with its users, Maggie’s London can be named a
success. In this case the combination of a good architect and the opportunity
to start from clearly formulated and well understood user requirements, results
in a building that lives up to its ambition of offering a healing environment.
However, this would be impossible without a client who is actually strong
enough to stand up to get the project realized the way it is designed. In the
case of the centres the common goal of all parties involved is a key factor
in the performance of the buildings. To obtain buildings and spaces that
achieve a positive emotional effect, the approach of the Maggie’s Centres
may provide a source of inspiration for everyone involved in the design of or
research about healing or wholesome environments.
ACKNOWLEDGEMENTS
collaboration with the industry, in this case osar architects nv provided this opportunity.
Ann Heylighen received support from the European Research Council under the
European Community’s Seventh Framework Program (FP7/2007-2013)/ERC grant
agreement n° 201673.
The authors thank the participating users of Maggie’s London and the architect, Will
Wimshurst of Roger Stirk Harbour + Partners, for sharing their time and insights. We would
also like to address as special thanks to Bernie Byrne for her support in the organisation
of the interview and group discussion and for the warm welcome at Maggie’s London.
References
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from A Lying Perspective: Exploring a Sensory Research Approach. In: Langdon P., Clarkson
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London, pp. 3-12.
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De Botton, A., 2006. The architecture of happiness, Hamish Hamilton, London.
College bouw zorginstellingen., 2008. Kwaliteit van de fysieke zorgomgeving : stand van zaken omgevingsvariabelen en de effecten op de (zieke) mens, College bouw zorginstellingen,
Utrecht.
Creswell, J., 2003. Research design : qualitative, quantitative, and mixed method approaches,
Ingold, T., 2000. The perception of the environment : essays on livelihood, dwelling and skill,
Routledge, London.
Jencks, C., 2006. Maggie Centers and the Architectural Placebo. In The architecture of hospitals. NAi publ., Rotterdam, pp. 449–459.
Jencks, C. and Heathcote, E., 2010. The architecture of hope : Maggie’s Cancer Caring Centres, Frances Lincoln, London.
Keswick, M. and Jencks, C., 1995. A View from the Frontline.
McDonald, M., 2011. Gardens of Hope? The Restorative Paradigm and the Maggie’s Centre
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Multi-dimensions of Well-being. Birmingham,8 p.
Pallasmaa, J., 2005. The eyes of the skin : architecture and the senses, Wiley-Academy, Chichester.
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Rasmussen, S., 1964. Experiencing architecture , M.I.T. Press, Cambridge Mass..
Rogers Stirk Harbour + Partners, 2011. Maggie’s Centre. Available at: http://www.rsh-p.com/
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Rubin, H. and Center for Health Design., 1998. An investigation to determine whether the
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s.n., 2011. Maggie’s Architectural Brief. Available at: http://www.maggiescentres.org/about/
our_publications.html.
Sternberg, E., 2009. Healing spaces : the science of place and well-being, Belknap Press of
Harvard University Press, Cambridge Mass.
Ulrich, R., 1984a. The psychological benefits of plants. Garden, 8(6), pp.16–21.
Ulrich, R. Zimring, C., Quan, X., Joseph, A., Choudhary, R., 2004. The role of the physical
environment in the hospital of the 21st century: a once-in-a-lifetime opportunity, The Center
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Zumthor, P., 2010. Thinking architecture, Birkhauser, Basel.
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2. How to introduce experiential
user data: The use of information
in architects’ design process
An earlier version of this chapter has been published as a conference paper.
Annemans, M., Van Audenhove, C., Vermolen, H., Heylighen, A., 2014. How to Introduce Experiential User Data: The Use of Information in Architects’ Design Process. Design’s Big Debates.
The Design Research Society’s 2014 conference. Design Research Society and Umea Institute of
Design. Umea, pp. 1626-1637.
Keywords
architecture
design process
evidence
focusgroup interviews
information use
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Abstract
As architecture influences people’s daily life
considerably, architects need in-depth insights into people’s
spatial experience, needs, and desires. To be able to provide
them with sufficient and suitable information on these
matters we aim to investigate how architects currently
use information in design, and how experiential user
data could change their thinking about their projects and
way of working. We conducted two focusgroup interviews
with architects (designing healthcare buildings), each
covering two parts. First, we discussed information use
and knowledge generation during design. This resulted in
a better understanding of a design process’ iterative nature
with shifts in information content, type, and use. Several
nuances were identified, e.g. between using general legal
information and information focused on the building’s actual
situation, and between obligatory and inspiring sources.
Second, we presented different forms of research data, and
probed participants’ interest in and possible use of these.
This provided insights into what information qualities
architects look for while designing, identifying strengths
and weaknesses. Also ideas for disseminating research
results amongst architects were collected. We conclude by
pointing out opportunities of using experiential user data to
initiate and support changes in design practice that benefit
users’ well-being, especially in healthcare buildings.
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2.1 INTRODUCTION
Swiss architect Peter Zumthor (2010, p. 12) describes architecture as “the background
for life.” What architects design influences people’s daily experience considerably.
Therefore, architects need sufficient information on people’s spatial experience, needs,
and desires. Since “information” is a very broad term, questions arise as to which (type
of) information is needed in different phases of the design process and how this is used.
Designers cannot collect all the needed information by themselves. However, when
researchers provide data, designers’ expectations regarding these data and how they can
be effectively communicated should also be explored. Therefore we addressed a twofold
research question: how do architects currently use information in design, and how could
experiential user data change their thinking about their projects and current way of
working? In two focusgroup interviews with architects we sounded out how information
content, type, and use differs in different design phases, and based on these insights
we tried to identify opportunities to introduce such information more appropriately into
architectural design practice. This double aim was reflected in the organisation of the
interviews: a first part addressed the use of information during the design process in
general, in a second part specific examples of research data were presented followed by
questions on their usability and attractiveness for architects. The interviews were analysed
based on themes found in literature, after which the generated findings were discussed
against these same themes. This provided us with a more nuanced understanding of
what information is desired in what phase and how architects would like to gain access to
it. These insights could inform research projects, to better match the content and type of
research data with architects’ needs during design and thus bring research and practice
closer to each other.
2.2 (USER) INFORMED DESIGN IN LITERATURE
Since design tasks are ill-defined or wicked in nature (Rittel & Webber, 1973), the
information necessary to solve them cannot be readily available (Cross, 1982). As the
information needed to understand the problem depends upon the designer’s idea for
solving it, collecting information and designing is a continuous iterative process. Donald
Schön (1983) argues that even if designers have a virtuous ability to string out webs of
design decisions of great complexity, they still cannot handle an indefinitely expanding
web. At some point during the process, they have to come to an intermediate decision
which can then become the basis for further exploration, new problem statements and
new (partial) solutions. Designers continually reflect-in-action (Schön, 1983). This design
is described as ‘knowledge-rich’, meaning that the design requires designers to have a
considerable amount of knowledge beyond what is provided in the problem description
(Lawson, 1994). Designers have to derive knowledge from the available information the
design process needs to be fed with continually. Since each phase in the design process
has a different purpose and focus (Cuff, 1989), the question arises whether and how the
content, type, and use of information needed in different phases differs too.
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Each designer brings his/her own concerns into the process (Lawson, 1994). Sometimes
these are clearly articulated; sometimes they are based on tacit knowledge designers
gained through personal or professional experience. Due to some great architects’
fame, we sometimes mistakenly assume their work to be entirely personal (Lawson,
1994). In reality the coming-into-being of a building is teamwork, among architects from
one or more firms, between architects and other building professionals, and between
architects and clients. Bryan Lawson (1994, p.5) also points out: “It is quite likely today
that those who commission buildings are not actually going to use the buildings themselves.
Architects therefore must try to consider the feelings of their ‘users’ as opposed to their
‘clients’.” Especially in the healthcare context, it is important that buildings meet the social,
psychological, and developmental needs of those using them. Since the gap between
decision makers and users is often too wide to be overcome by designers using only a
personal perspective (Zeisel, 2006), experiential user data collected by researchers can
play an important role when incorporated into the design process. Which data meet
designers’ requirements, and how they can be communicated effectively are interesting
research questions (McGinley & Dong, 2011).
Compared to other professionals, designers are quite specific in terms of their approach
to information. They are very much attracted to information presented with maximum
use of graphics and limited text. If text is presented it should be short and easily digestible
(Lofthouse, 2006). Moreover, designers often feel mistrust towards data that have already
been through a process of interpretation (Restrepo, 2004). This may explain why they
prefer raw data in a format that is condensed to be design-relevant, allowing them to
quickly pick up both overarching themes and discover depth relevant to a specific project
(McGinley & Dong, 2009). Therefore, it should not come as a surprise that, to inspire
designers, images made by users (i.e., photographs, drawings, or handwriting) are more
effective than words (Lee, Harada, & Stappers, 2000). There is indeed a need to bring
information on real human experiences to life based on actual situations, not through dry
representations, but through presenting experiential user data as fuller stories (McGinley
& Dong, 2011). However, apart from visual sources (whether or not directly derived from
users), it would be interesting to explore more narrative techniques to surpass designers’
visual focus.
2.3 RESEARCHING
METHODS
2.3.1 ARCHITECTS’
INFORMATION
USE:
FOCUSGROUP INTERVIEWS: AIM AND SET-UP
Since design is both a personal and collective process, we looked for a technique that
addressed participants’ own experience but also left room for interaction. As focusgroup
interviews are well suited to diagnose problems and to gain insights into people’s way of
looking at a certain theme (Stewart, 2007), we opted for this technique. To improve the
chances of success we wanted the respondents to be able to communicate on the same
level and being comfortable with each other (Mortelmans, 2007). Therefore we chose
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to organise two focusgroup interviews with a slightly different accent. The first group
featured seven architects, each fulfilling a different role within the same architecture
firm (Table 2-1). Since the members of this group knew each other in advance and had
sometimes even been working on the same project, they shed a more nuanced light on
interaction between (people working on) the different phases of the design process. The
second group consisted of five architects from different firms (Table 2-2). Within each
firm, we invited those architects who were most involved in care building projects and
in collecting information for the design. This group could provide us with a broad range
of approaches towards information. Each firm indeed takes a different stance as to the
importance they attach to external information and how it is collected. Both groups of
architects were working in the (health)care sector. This selection was made based on the
focus of our own research in this field (Annemans et al., 2012a).
Profile
Gender
Years of experience
Trainee 1
M
<5
Trainee 2
F
<5
Responsible concept phase
F
5-10
Responsible building phase
M
10-20
Hospital architect
F
10-20
Care architect
M
5-10
Partner at the firm
M
10-20
Table 2-1: Participants of the focusgroup interview at one firm
Profile
Gender
Years of experience
Company V
M
10-20
Company W
M
> 20
Company X
F
10-20
Company Y
M
10-20
Company Z
M
5-10
Table 2-2: Participants of the focusgroup interview with architects from different firms
2.3.2 DATA COLLECTION AND ANALYSIS
Both interviews covered a general part and one specifically focussing on experiential user
data, collected in the context of a study on hospital patients’ spatial experience. Although
the interviews’ main outline remained the same, some shifts in emphasis occurred
between both. The interview with architects of one firm started by inventorying the
different phases in the design process and what information was used in each phase. Only
after a consensus was reached, more general questions were asked on which information
was missing, and the reliability and management of the collected information. The group
involving architects from different firms was asked to describe the importance and use of
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evidence in their firm. While preparing this interview with architects from different firms,
we decided to use the term evidence rather than information, staying closer to the, for
architects, maybe more familiar concept of Evidence Based Design (EBD)1. However,
the connotation associated with this term did not improve the communication. Therefore
we gave some additional explanation and soon shifted towards the term information.
After a short break, both focusgroups were presented various kinds of data on patients’
spatial experience collected through ethnographic research (Annemans et al., 2012a).
We were mainly interested in the importance architects attached to each information
type and which strengths and weaknesses they identified. These data were diverse in
nature: photographs and drawings made by patients, and video-recordings of hospital
trajectories, capturing the experience of movement were shown and accompanied of
some explanation.
All of these were presented as raw data (videos shown without any post processing)
and accompanied by quotes from participating patients. To extend the possible ways
of informing the design process, we added a biographical text from a cancer patient,
Maggie Keswick and the translation of this text into a rather atypical architectural brief
(written for architects designing a Maggie’s Cancer Caring Centre) (see Annemans et al.,
2012b). Subsequently participants were asked to comment on the different information
types, what they found interesting, whether and how it could inspire them, and what they
thought was missing in or could be complementing the presented data.
The audio-recordings of both interviews were transcribed verbatim. The transcripts were
analysed through coding. To establish a list of representative codes, we started by open
coding followed by axial coding (Mortelmans, 2007). Throughout this process previously
established topics grounded in literature (Creswell, 2003) were kept in mind. As the
focusgroup interviews were mainly explorative in nature, the results will be used as a
basis to set up further ethnographic research in hospitals (aiming to collect the type of
data architects are longing for) and to be able to come to selective coding of follow-up
interviews with architects on the use and communication of information in the design
process.
In what follows, the material shown to the architects, combined with other material
regarding spatial experience in care settings, will be referred to as (research) data. These
can become part of the large amount of sources architects consult while designing, all
of which we address as information. Finally, just collecting this information will not be
enough for architects to actually work with it. It will need to infiltrate their daily practice to
a point that it forms part of both their tacit and explicit knowledge.
1 Using information, or evidence, to inform the design process, is often referred to as Evidence Based Design (EBD). This concept found its
origin in the analogy with other evidence based approaches to research and practice. Parallel with Evidence Based Medicine, EBD studies want to
provide evidence for the healing outcome of building aspects (Ulrich et al., 2004). Architects frequently misunderstand the term. Many fear EBD
to be overly prescriptive rather than informative, moreover they do not fully grasp how to assess its strength or weakness, and in what context it
could be valid (Brandt et al., 2010). However, as clients increasingly expect architects to base design decisions on an explicit chain of knowledge
that can be directly linked to facts, research data, or own field observations and also share this information with them (Hamilton, 2009), architects
cannot stay behind.
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--------fig. 2-1
Maggie’s Architectural Brief (source: s.n, 2011)
--------fig. 2-2
Narrative of photographs and drawing made by a patient (V1 §2.4.3)
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00:02
00:07
00:22
00:27
--------fig. 2-3
Video-recording of hospital trajectory shown during
focusgroup interview (original recording 16.07.2012)
00:32
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2.4 ARCHITECTS ON EXPERIENTIAL USER DATA: FINDINGS
2.4.1 INFORMATION IN THE DESIGN PROCESS
When asked which information they use, architects from both groups mentioned the site,
design brief, cooperation with engineers or other support services, client, architectural
examples (mostly called “references”) and feedback from former projects. However,
the group with architects from one firm paid considerably more attention to how client
and user could differ and how they could find entries into users’ experience, e.g., by
participation in daily activities taking place in an existing building with a similar program as
the one considered, testimonies in online movies or texts, workshops, or exhibitions. Still,
although sporadically these efforts were already made, the partner at the firm mentioned
that real user involvement was still lacking in the workshops they organise:
“[the people who take part are not people from our field] a psychiatrist, or
a doctor, or a geriatric, a user we should involve more, but well, maybe not
someone with dementia, but maybe relatives of someone with dementia.”
Additionally, the focus on separate phases seemed to generate a shift in importance
towards more practically oriented sources of information like constructors, building
material producers or quality labels and certificate providers.
In the second interview, the presence of different firms coloured the discussion. One
participant explained:
“What do we look at as evidence? We have an internal library with reference
projects, both our own and star projects. Sometimes we also organize visits
to other projects with the client and things like that. […] We also have a database with evaluations of our clients, but also inside the firm, square meters,
prices, ratios between programs.”
This firm clearly invests in post-occupancy evaluations of their projects, focussing on
both quantitative and qualitatively aspects, thus working on a feedback loop and lifting
those projects to the level of reference for future design projects.
Despite a different view on which information to use during design and how to collect
it, both groups pointed at how collecting, processing, and evaluating information is an
iterative process. This does not mean that the same information is used during each cycle,
however. While refining a design from concept to actual building, architects oscillate
between information content. On one hand this occurs between generally available
information and information on the same topic specifically focused on the building’s
actual situation at its construction site, taking into account all other preconditions.
General legal information such as building regulations or information on subsidies is
often readily available on the internet, yet once you have an outline of an actual design, it
is highly recommendable to engage in a dialogue with the particular (local) government
to discuss the specific project. An example of a combination of clear rules and local
decisions is fire regulation, as an architect explains:
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“For example the law on fire regulation is a document that you find on the
internet, that you almost have on your desktop.”
Another one continues:
“the law is one side, but you also have to talk with the government. It’s not
one against the other […] you will always have to visit your fire department
so they can give advice. Therefore a conversation with the local department
is very useful, whether or not they dare to divert from the norm.”
In the other interview, the risk of simply following regulations was addressed too. As
someone put it:
“Actually it’s funny that we build norms, we build norms in stone.”
On the other hand nuances are found between obligatory and inspiring information.
One architect working on a large hospital project mentioned that a part of the building
that is now used as a geriatric ward, was originally intended as a day ward and designed
according to the corresponding building regulation. Due to the original requirements
the space is now way too big for the six patients residing there, therefore extra furniture
was ordered and installed to fill up the space and create a more intimate atmosphere as
intended in the concept for such a program. Still, this may not strictly be according to
the regulations.
The participating architects almost unanimously pointed out that much information
derived from research is far too abstract to be used while designing:
“It’s mostly at the beginning that we, at our firm look for information that
other architects might not look for. What we’re missing is a link between
architecture and […] how the building really operates.”
Later on in the interview this quote was further exemplified:
“[…] it’s about how design decisions […] have an influence on the maintenance, exploitation cost, and the operating cost. And the latter is very
difficult to find, exploitation is easier.”
One of the architects gives another example:
“Running lines are very important in the healthcare sector because the cost
of staff is one of the biggest for the client. But those models that are the best
concerning running lines, to find those in structured way to work with [is very
difficult]. Of course, there are some logical starting points that everyone
knows, a simple layout, but basic models to work with that I didn’t find yet.”
As illustrated, the mutual influence of user experience, organisational structure, and
cost implications is not easy to find in information for architects. This lack of explicitness
combined with the nuances mentioned above, creates a considerable burden to find the
desired information. Evidence from real, realized buildings could fill this gap. However,
due to the time lapse between the design and use of many healthcare buildings, feedback
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loops risk to lack accuracy. Although most participants are convinced that research results
on specific topics or programs could be highly interesting during the design process,
both groups pointed out that an important reason to make the effort of searching for
it is to convince the client. It almost sounded as if the architects need the results only
to convince others what they already know. Quotes like “that’s also what you want to
legitimate your choice with respect to the client” were very common.
Finding the right information at the right time seems a challenge. The participants use
the sources that are most ready-to-hand, like the internet or magazines. However, the
choice of where to find information may also be generational:
“The way you find your information, I think, is also very generational. […] The
three of us, we belong to … For us it may be a book or something like that,
whereas with those youngsters, they find everything on the internet. They
are faster, much faster, that’s a real difference. And that’s also why it’s a good
thing to be able to use different sources.”
The reliability of these sources is not always easy to trace. Generally speaking, participants
seem to find it hard to evaluate what makes a source reliable or not. As mentioned:
“I find it hard to judge on the internet […] whether it’s really someone’s experience or just an opinion. That’s also hard to derive from literature; you always
have to interpret it. The best is to meet someone, who can say these are the
advantages, these are the disadvantages.”
This someone then should have enough experience and authority, yet who is valued as an
authority is not always clear. One participant stated:
“When you dub it [a video] with a voice from a documentary, it seems to
increase the scientific value.”
Sometimes surprising elements seem to provide an architect with a (false) feeling of
reliability.
2.4.2 INTRODUCING AND USING EXPERIENTIAL USER DATA
After various data on patients’ spatial experience were presented, strengths and
weaknesses were brought forward by the participants. For both a distinction can be
made between those relating to the data’s content, type and use. Content wise the
main advantage is found in the information’s layered structure. An image that, at first
sight, may just seem to show what a patient sees, can tell the viewer something about a
different sensory experience or point at a relational malfunctioning when the underlying
story is added (Annemans et al., 2012a). One trainee formulated it as follows:
“Yes, I see the pictures and I especially hear the stories. Then actually how
the subjective way of how the user sees it makes it interesting.”
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A more experienced architect on the other hand states:
“The information of the story of that person is always at least as interesting
as the conclusion connected to it.”
How the information was communicated to the architects was largely appreciated.
Directly communicating with raw data, avoiding (too much) analysis by researchers,
allows architects to pick up aspects that are relevant to their specific design or situation.
For some, additional structuring would be welcome. The trainee continued:
“… maybe you can come to a matrix, that offers a structure to all the material, for example when you have a picture, objective [physical parameters],
subjective, what the user says what’s positive and negative.”
The additional video material reflected more closely the visual information architects
would consult spontaneously. An architect said:
“If tomorrow there was a website with forty videos at different locations of
someone who’s wheeled through the hospital, I’d definitely click on ten of
them, and then maybe also the next ten, that would depend. But a way of
documenting it in an a-typical way, that seems very interesting to me.”
According to the architects information in the design process in general, and experiential
user data specifically, could mainly be useful to convince clients. The participants claimed
they currently have hard times convincing clients of the importance of experience related
design decisions. Interventions aiming at an improved well-being of users in general, and
patients in particular, now often have to lay thumbs against aspects that are easier to
“prove” or easier to calculate. A partner at an architecture firm literally said:
“The biggest disadvantage of this kind of information is that it’s very hard to
calculate.”
They hope that the presented data could possibly provide a counter argument.
The above-cited strengths relate directly to the mentioned weaknesses. Some form
their counterpart. A major threat to the layered structure of the data is the possible
loss of part of the richness. Although some participants call the data subjective or too
anecdotal, others consider the enormous number of diverse testimonies as ideal to
increase sensitivity without standardising or steering too much. Indeed, the architect who
sincerely appreciated the videos later continued:
“[…] if we got something too concrete, we curse it.”
However, when not communicated well, e.g., showing only images without the
accompanying narratives, much information gets lost, and misinterpretation lies in wait.
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2.5 DISCUSSION AND CRITICAL REMARKS
The presented study was motivated by two research questions: how do architects
currently use information in design, and how could experiential user data change their
thinking about their projects and current way of working? In response to these questions,
we aimed to identify whether and how the content, type, and use of information
needed in different phases differs and which (kind of) research results meet architects’
requirements. The results of the focusgroup interviews suggest that each phase has its
own specificities and corresponding information needs. Therefore, architects consult
in each phase external advisors, besides those taking part in the entire design process.
Although designing is an iterative process wherein questions concerning the same, more
or less specific topics are addressed each round, the content, type, and use of the required
information shifts. Whereas for some, often more technical topics, designers base their
decisions in the first phases on generally available information and later enter into a
dialogue with those doing calculations or formulating legal advice, for more experienceor user-related topics, the nuanced and particular is highly appreciated as an inspirational
source from the start. In a very early phase participants mention engaging in real-life
settings, reading blogs or watching movies with testimonies as a basis for their design.
In later phases, this experiential user information becomes a frame of reference to check
more punctual decisions. For example, the desire to design a homelike environment can
serve as a framework to assess the choice of materials at a later moment.
Additionally, we examined to what extent and why the presented data match
architects’ informational requirements. As Chris McGinley and Hua Dong (2011, p.193)
point out, “There is a need to move away from the dry representations […] and to bring
human information to life through presenting user insights as fuller stories, conveying
liveliness through visual material, and giving scope for the design audience to complete
the interpretations, allowing a level of co-ownership.” The insights from the focusgroup
interviews seem to confirm this. As architects often feel mistrust towards data that
already underwent a process of interpretation (Restrepo, 2004), our research provides
the opportunity to pass data directly from patients to architects (Annemans et al., 2012a),
offering the analysis as an addition rather than a result. Architects already working with
experiential user information are looking for the stories underlying people’s experience.
By engaging, or reading or watching testimonies, they try to relate directly to particular
users’ personal stories. Although some criticize this approach as subjective and overly
anecdotal, others value its richness. As the complementarity of the layers was highly
appreciated by the participating architects, a major part of the challenge will lay in finding
a way of accessibly communicating the data without losing the layered content. A simple
and reliable structure with an original viewpoint, presented through a channel architects
are familiar with, like the internet, would be ideal.
Finally, we would like to make some critical remarks. As Nigel Cross (1982) points out,
scientist almost unanimously conclude their analysis by stating that further research
is needed. This is exactly what architects do not want to hear. They need hands-on
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information they can start working with. Endless refinements do not help to come to
a physical result. As designers work in a solution-oriented way (Cross, 1982; Rittel &
Webber, 1973), they make a decision based on the best possible information available
at a certain point. If that information is later refined or even contradicted, the proposed
solution can be adapted depending on the phase or, if this is not possible anymore, the
knowledge gained could be transposed to a future project. Although one participant
argued that the long time laps between projects makes learning from one for another
hard, others indicated to still consider what they learn in one project valuable for the next.
A gap seems to exist between what architects expect from research and what research can
provide. The participating architects want research data that provide them with concrete
experiential user information, but also with a measurable outcome of implementing
these data. However, as each design problem is “essentially unique”, despite a long list of
similarities with a previous problem, there might always be an additional distinguishing
property that is of overriding importance (Rittel & Webber, 1973). Therefore, no research
can ever provide architects with exact numbers on the outcome of a design solution and
as such redeem the expectations.
While all participating architects expressed a need for (experiential user) information
when designing, a significant difference was found between both focusgroups. In the
interview conducted at one firm, a general agreement seemed to exist on the need for
architects to support their clients with as much information as possible, even to the extent
of taking over the entire reasoning underlying organisational decisions to support a client
unable to take care of it him/herself. The other focusgroup raised the question how much
information should come from architects. Several architects in the latter group seemed
to consider a fruitful design one where the client takes the responsibility to provide
information on the healthcare organisation and approach, whereas they as architects add
spatial and technical knowledge to the process. Each party could then profile itself as an
outsider in the knowledge field of the other and, from this position, question the other’s
assumptions in an unprejudiced way. A permanent dialogue between both parties then
shapes the design process.
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2.6 CONCLUSION
Although architects may not appreciate the statement, more research is
needed to gain profound insight in the use of these experiential data. In
the presented study we were gauging for designers’ interest in this kind of
information and their preferences concerning type and accessibility. An
interesting next step would be to observe whether and how the presented
data are used in an actual design process. Do the participating architects
practice what they preach? Only by following the coming into being
of a building, starting from the conceptual phase and ending with a post
occupancy evaluation, can we trace when and why which information is
introduced, used, worked with, and finally also recognized or appreciated for
its added value by the final user. Despite practical and time related burdens,
such study would be worth investing in. Only by consciously collecting and
structuring precise insights on the impact of experiential user information,
will we, in the end, be able to shift architects’ but also clients’ focus to people’s
spatial experience.
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Conclusion
Both focusgroup interviews aimed to find out how architects currently use
information in design, and how experiential user data could change their
thinking about their projects and current way of working. Especially in the
specific context of healthcare projects, which we focus on in our research,
we noticed that architects are already aware of the importance of people’s
experience of the built environment. As people are often confronted with
these buildings at a very vulnerable moment in their life, the societal relevance
is never far away. A general consensus exists that these buildings’ design can
add to an evolution in the connotation that is assigned to them by the general
public. Some architects believe their design can be a trigger to change entire
organisations; others only aim at improving patients’ experience through
punctual interventions or making their direct environment more convenient.
Although the degree to which they consider their responsibility stretching
seems to differ across the participating architects, all feel, somehow,
responsible for the outcome of their design. Despite different approaches
to the design process, all seemed to value the presented data highly, as an
introduction to an unknown experiential world, as a way to expand their
horizon, or as means to convince their clients of the critical importance of
aspects that are often difficult to prove.
ACKNOWLEDGEMENTS
(FP7/2007-2013)/ERC grant agreements n° 201673 and n°335002. The authors thank
the participating architects, for sharing their time and insights. Also thanks to our AIDA
colleagues for their comments on an earlier version of this paper.
References
Annemans M., Van Audenhove, C., Vermolen, H., and Heylighen, A., 2011. Lying architecture. Proceedings of Well-being 2011: The First International Conference Exploring the Multi-dimensions of Well-being. Birmingham City University and the RIBA, Birmingham, 10p.
Annemans, M., Van Audenhove, C., Vermolen, H., and Heylighen, A., 2012a. Hospital Reality
from A Lying Perspective: Exploring a Sensory Research Approach. In Designing Inclusive
Systems: Designing Inclusion for Real-world Applications. Cambridge: University of Cambridge, pp. 3-12.
Annemans, M., Van Audenhove, C., Vermolen, H., and Heylighen, A., 2012b. What Makes
an Environment Healing? Users and Designers about the Maggie’s Cancer Caring Centre
London. In Proceedings of 8th International Design and Emotion Conference. London, pp. 1-8.
Brandt, R. M., Chong, G. H., Martin, W. M., and American Institute of Architects., 2010. Design informed driving innovation with evidence-based design. John Wiley and Sons, Hoboken,
N.J.
Creswell, J., 2003. Research design : qualitative, quantitative, and mixed method approaches.
Cross, N., 1982. Designerly ways of knowing. Design Studies, 3, pp. 221–227.
Cuff, D., 1989. The social art of design at the office and the academy. The Journal of Architectural and Planning Research, 6(3), pp. 186–203.
Hamilton, D. K., 2009. Evidence-based design for multiple building types. John Wiley and Sons,
Hoboken, N.J.
Lawson, B., 1994. Design in mind. Butterworth Architecture, Oxford.
McGinley, C., and Dong, H., 2009. Accessing User Information for Use in Design. In Universal Access in HCI (Vol. Part I). Springer-Verlag, Berlin, pp. 116–125.
McGinley, C., and Dong, H. (2011). Designing with Information and Empathy: Delivering
Human Information to Designers. The Design Journal, 4(2), pp. 187–206.
Mortelmans, D., 2007. Handboek kwalitatieve onderzoeksmethoden. Acco, Leuven.
Restrepo, J. 2004. Information Processing in Design. Delft University Press, Delft.
Rittel, H. W. J., and Webber, M. M., 1973. Dilemmas in a General Theory of Planning. Policy
Sciences, 4(2), pp. 155–169.
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Lee S. H., Harada, A., and Stappers, P. J., 2000. Pleasure with Products: Design Based on
Kansei. In Proceedings of the Pleasure-Based Human Factors Seminar. Copenhagen, 10p.
Schön, D. A., 1983. The Reflective Practitioner. Basic Books, New York.
Stewart, D. W., 2007. Focusgroups: theory and practice. SAGE Publications, Thousand Oaks.
s.n., 2011. Maggie’s Architectural Brief. Available at: http://www.maggiescentres.org/about/
our_publications.html.
Ulrich, R., Zimring, C., Quan, X., Joseph, A., and Choudhary, R., 2004. The role of the physical environment in the hospital of the 21st century: a once-in-a-lifetime opportunity. The
Center for Health Design, Martinez.
Zeisel, J., 2006. Inquiry by design: environment/behavior/neuroscience in architecture, interiors,
landscape, and planning. W.W. Norton and Company, New York.
Zumthor, P., 2010. Thinking architecture. Birkhäuser, Basel.
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3. From designing for the patient
to designing for a person
An earlier version of this chapter has been published as a book chapter2.
Annemans, M., Karanastasi, E., Heylighen, A., 2014. From Designing for the Patient to Designing
for a Person. In: Inclusive Designing: Joining Usability, Accessibility, and Inclusion by Langdon P.,
Lazar J., Heylighen A., Dong H. (Eds.), Springer-Verlag, London, pp. 189-200.
Keywords
architecture
design studio
education
Maggie’s centre
user experience
2 A follow-up study of the study reported in this chapter has been published as a conference paper.
Annemans, M., Van der Linden, V., Karanastasi, E., Heylighen, A., 2015. Learning to Shape Places of Care by Empathizing with Patients and
Caregivers. Engineering 4 Society. Leuven, 9p.
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Abstract
Research on inclusive design stresses the value of user experience
as a resource to design with respect for the diversity in human abilities
and conditions. So far, however, relatively little research has been
conducted on how exactly user experience benefits design processes and
their outcome. How is it introduced into the design process, what kind
of knowledge do designers get from it, and how does it inform and direct
their design process? The study reported addresses these questions
in the context of a design studio in which student architects designed
a Maggie’s Cancer Caring Centre. After briefly discussing the role of
(user) experience in design processes, we sketch the context of the
Maggie’s Centres and introduce the assignment and procedure of the
design studio. In order to analyse how different sources of information
about user experience feature in students design process and outcome,
we rely on documents students handed in, notes taken and audiorecordings made during conversations with patients and care givers,
and students’ presentations. Four sources of information about user
experience were addressed explicitly or implicitly by various students:
direct communication with cancer patients and with people working at
a day centre; the person of Maggie Keswick; the architectural brief; and
exemplary projects of user-sensitive buildings. Despite its limitations,
participation in this studio clearly increased students’ knowledge on
specific users. Many students mentioned the fact that a Maggie’s Centre
should not be designed for the patient but for a person. If only this
insight remains, it will already contribute to them becoming architects
who design with more than just functionality in mind. Additionally
the existing Maggie’s Centres provided students with examples of
exceptional architecture. The studio assignment thus drew their
attention to the possibility to create extraordinary buildings, appealing
to users and specialists alike, designed for the well-being of everyone
involved with them. By doing so it opened students’ eyes to designers’
ability to really transform the daily lives of the people engaging with the
spaces they conceive.
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3.1 INTRODUCTION
Research on inclusive design stresses the value of user experience as a resource to design
products and environments that respect the diversity of human abilities and conditions.
Elaine Ostroff (1997) therefore introduced the term user/expert, denoting “anyone who
has developed natural experience in dealing with the challenges of our built environment”.
Since user experience may offer designers unique insights (e.g. Pullin, 2009), several
methods for involving it in design are developed, extending traditional focusgroup
interviews into more embodied approaches (e.g. Annemans et al., 2012a; Heylighen,
2012), critical user forums (Dong et al., 2005; Cassim, 2007) and co-design (e.g. Tsianakas
et al., 2012). So far, however, relatively little research has been conducted on how exactly
the user experience brought in through these methods benefits the design process and
its outcome. How is it introduced, what kind of knowledge do designers get from it, and
how does it inform and direct their design process?
This chapter addresses these questions in the context of a design studio where student
architects designed a Maggie’s Cancer Caring Centre. These centres, of which 14 are
operational so far, are meant to improve the well-being of people affected by cancer.
Based on the belief that high-quality architecture may support people’s well-being, the
Maggie Keswick Jencks Cancer Caring Centres Trust puts users’ (spatial) experience
at the centre of the design process. For cancer patients, stress and anxiety are frequent
but have highly context and person specific causes; designing for them thus requires
that designers consider their particular concerns, wishes and experiences (Mullaney et
al., 2012). In designing a Maggie’s Centre, world famous architects like Zaha Hadid or
Richard Rogers were challenged to work with and for specific users. By studying how
various information sources on user experience impact student architects’ design of
a Maggie’s Centre, we aim to gain insight into what knowledge of people and users
(student) architects use in their design and how it informs and directs their design process.
After briefly discussing the role of (user) experience in design processes, we sketch
the context of the Maggie’s Centres and introduce the design studio’s assignment
and procedure, and analyse how different sources about user experience feature in
students’ design process and outcome. Finally, we confront our findings with literature
on experience in design processes, and formulate lessons learned to deepen (student)
designers’ understanding of real persons engaging with their design.
3.2 (USER) EXPERIENCE IN DESIGN
In traditional societies, where human-made objects were conceived, made, and used
by the same person (Jones, 1970), the experience of using the object could be fed
back directly in the design and making of its material, physical features. The industrial
revolution introduced a separation between the designer (who conceives an object),
maker (who produces it), and user (who experiences it). As a result, the direct feedback
loop got interrupted. Today, designers typically conceive products and environments
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with an eye to offering users a certain experience, without having direct access to their
motivation, values, and prior experiences. How users eventually experience the result
may correspond to what the designers intended but might also differ from it in various
ways (Crilly et al., 2008). Inclusive design’s emphasis on involving user experience in the
design process can be understood as an attempt to bridge this gap.
Research on inclusive design advocates involving user experience in the design process,
in line with user-centred design (Dong et al., 2003). Adopting a design approach in
which the actual people being designed for and their real-life experiences are present,
is considered crucial if the resulting design is to benefit people of different ages and
abilities. The idea is to involve real people who actually take part in designing, contributing
to the design process from their own personal experience (Dong et al., 2005; Cassim,
2007; Pickles et al., 2008; Mullaney et al., 2012), giving input and reflecting on solutions
proposed by the designers (Tsianakas et al., 2012), or even proposing ideas themselves
(Luck, 2012).
In practice, however, involving users during design is considered time consuming and
thus expensive (Dong et al., 2003). Designers therefore rely mainly on other forms of
experience, offering ersatz feedback on how future users will experience the product or
space being designed. Architects, for instance, rely heavily on their personal experiences
of places they have visited (Downing, 2000), on exemplary buildings designed by others
in books or magazines, and on projects they have designed themselves (Heylighen
& Neuckermans, 2002). Throughout their career they collect an extensive record of
precedents, serving as a source of knowledge during design. Moreover, through engaging
in various social situations and interactions, (student) designers acquire a ‘culture
medium’, which embraces various substances, phenomena and traces, from both within
and outside design, all of which can function as raw material for design (Strickfaden et al.,
2006). As will become clear in the next section, designing a Maggie’s Centre potentially
combines these different forms of ‘experience’ in architects’ design processes.
3.3 MAGGIE’S WORLD
Maggie Keswick was a landscape designer. The importance of a supportive environment
for her emotional well-being became particularly clear to her when she was told that the
cancer she had been battling before had returned and she had only a few months left to
live. She remembered the announcement as follows:
“How long have we got? The average is three to four months (‘and I’m
so sorry, dear, but could we move you to the corridor? We have so many
patients waiting...’)” (Keswick and Jencks, 1995).
The corridor she was moved to can be imagined by everyone who ever visited a hospital.
Corridors, toilets and waiting areas are the main hospital spaces for which Maggie
advocated the provision of alternatives:
“waiting areas could finish you off, they do not support you as a patient but
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rather tell you: ‘How you feel is unimportant. You are not of value. Fit in with
us, not us with you’”.”
She was convinced that with little effort the opposite could be achieved (Keswick and
Jencks, 1995).
Based on Maggie’s experiences and initiated by her and her husband Charles Jencks, the
Maggie’s Centres aim at creating supportive environments that add to their users’ wellbeing. Starting from A view from the frontline (Keswick & Jencks, 1995), a booklet about
Maggie’s personality and how the disease affected her entire being, the Trust governing
the centres wrote an architectural brief for their design. Unlike most briefs, it focuses
on the creation of spaces for different moods and uses rather than on square meters or
number of rooms (s.n., 2011). Architects are expected not so much to translate rules into
spaces, but rather to think along and come up with a truly inspirational building that suits
the needs of patients, relatives and staff:
“So we want the architects to think about the person who walks in the door.
We also want the buildings to be interesting enough that they are a good
reason to come in rather than just ‘I’m not coping’” (s.n., 2011).
For certain spaces, the brief lists more specific requirements. A Maggie’s Centre should
be approximately 280 m2, the only numerical value in the brief, and contain an entrance,
sufficient office space, a kitchen, and lavatories. For each space the atmosphere aspired
to is described without prescribing a fixed solution. The entrance should be welcoming,
not intimidating. Unlike what is often the case in a hospital, the layout should be clear and
the building as light as possible. The lavatories should be not all in a row with gaps under
the doors, but private enough to cry in. Apart from descriptions of specific spaces, there
are also pointers regarding the overall architecture. The Maggie’s Centres and the way
they are designed should raise your spirits, be safe and welcoming but not too cosy, and
increase people’s sense of connectedness (s.n., 2011).
3.4 THE DESIGN STUDIO
Maggie’s story combined with the specific brief and examples of existing centres, inspired
us to set up a design studio for student architects. The 34 master students attending the
studio (15 female, 19 male) were asked to design a Maggie’s Centre for Leuven. The
studio was led by two professional architects (including the second author). Students
received the brief formulated by the Trust and a plan of an area near
the university hospital, where they could choose their own spot to situate their project.
The area has an advantageous slope and alternating areas of dense thicket and
deforested spots.
Students also received various other sources: the first author guest lectured about how
users experience Maggie’s London, pointing out multiple levels of emotional impact
of the built environment (Annemans et al., 2012b); other guest lectures addressed the
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subjectivity of spatial experience, or post-traumatic stress in patients diagnosed with
cancer and intervention techniques related to space; students participated in a workshop
with three (ex-)cancer patients testifying about the importance and character of healing
environments, based on their subjective experience; they visited a day centre for patients
with life threatening diseases; and they analysed in groups an existing Maggie’s Centre.
Finally, every student presented his/her project for a jury of two studio teachers and
two guest lecturers (including the first author). Seven projects were presented to two
of the three (ex-)patients and an oncologist working in the university hospital. This was
expected to sensitise students to differences between architects and lay persons in
reacting to or dealing with the presentation of design ideas.
3.5 “MAGGIE” IN THE DESIGN PROCESS
The design studio aimed to raise students’ awareness of the diversity in people’s (c.q.
cancer patients’) experiences and sensitivities. Yet, how present were these people in the
design (process)? And how did students refer to the people using a Maggie’s Centre?
We analysed documents students handed in (drawings, ‘storyline panels’, inspiration
sources), notes taken by the authors during the presentations, and audio-recordings of
the final presentations and conversation with patients and care givers. We also looked at
how these people were (re)present(ed) during the design process.
Four sources about user experience were addressed explicitly or implicitly by various
students when (re-)presenting their design. The first and most straightforward information
came from the direct communication with cancer patients, and people working in the
day centre. Testimonies by patients triggered students’ awareness of the specificity of
the group they were designing for, but also of the diversity within this group which they
otherwise might have considered as “patients”. Second, the person of Maggie Keswick
was very present during students’ design process. Although she spoke to them through
a written source only, her message came through quite strongly. Maggie took the role
of representing all unknown users, still being a real person, in a real situation, with strong
ideas on her medical treatment, space, personal empowerment and even nutrition.
Third, there is the architectural brief, underlying the assignment, but also translating user
needs into a more architectural language. Finally, as world famous architecture forms
an inspiration source for many (student) architects, user-sensitive examples of other
Maggie’s Centres or examples of architects designing sensory-rich spaces, seemed to
add to the user-related qualities of students’ designs.
3.5.1 INTERACTION WITH REAL-LIFE PEOPLE
Many students explicitly mentioned the dialogue with (ex-)cancer patients as an
important source of inspiration and information at different stages in the design process.
During the site visit, they explored the given building site with this dialogue in mind. One
student chose his centre’s location away from the hospital, at the most quiet place, based
on what the patients had said:
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“From the talk with the user/expert, I derived that they expect from a
Maggie’s Centre that it creates a whole new living atmosphere, not closed
off, but visually separated from the hospital. Therefore, I chose this spot in
the woods, away from the hospital, with a buffer formed by the relief and the
vegetation, accessible from the other street.”
Also while designing, the patients’ personalities were never far away. A student cited in
his presentation a specific quote from a patient. She had said:
“During my treatment, it was very hard for me to concentrate. Reading a
book was not possible.”
Obviously reading books is not a patient thing, but an aspect of this woman’s personal
life. In his design this student provided a quiet room, not just for isolation but specifically
designed to be able to listen to music, or as he explicated “an audio book, since it is hard
for them to read ” (fig. 3-1)
Not all students directly linked their design decisions to a specific element or quote.
Some spoke in more general terms about the users’ influence, like:
“The workshop with user/experts made us feel the difficulty and the nuance
which we’d have to use in the assignment.”
While it is hard to pinpoint exactly which design aspects stemmed from this understanding,
the project testified to the students’ sensitivity about patients’ well-being. Interpreting
the client’s wishes and desires is a task of an architect; here too, someone translated the
patients’ need to be able to retreat into the central concept of her design. A structuring
object such as an equipped wall became a meaningful element to enable users to
“disappear into the closet” when needing time for themselves.
3.5.2 MAGGIE
Like any other architect asked to design a Maggie’s Centre, students were provided
with the booklet A view from the frontline (Keswick and Jencks, 1995), in which Maggie
tells her story of being diagnosed with cancer and how she, a landscape designer and
mother interested in Eastern medicine and meditation, experienced her environment
throughout this process. It provides user information in a passive, uni-directional way,
but many students found it inspiring. As mentioned Maggie addressed waiting rooms,
corridors and toilets as most depressing spaces in the hospital. During the presentations,
a student literally told how, at the beginning of her design process, she worked in a very
functionalist way: only when she went back to Maggie’s story (and the movies on the
Trust’s website), did she realise she should take a different approach, so she redesigned
her centre into a building without corridors, where dynamic spaces followed one another.
Even more explicit was someone who showed a painting by Claude Monet of a woman
walking in a field, saying that she was how he imagined Maggie. While presenting for the
patients and oncologist the same student called the people who would use his building
“his Maggies”.
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For some students Maggie’s personal spirit of enjoying life to the fullest was even a
starting point. One student showed as first slide of her ‘storyline panel’ an image with the
saying “Today is a good day.” Also the message that the building should be anything but a
hospital came across. Some based their design on the archetypical terrace house, others
came up with a resort-like typology. Either way, not having waiting areas and corridors
was a central theme for many. The retreat of the toilet was given alternatives or was
upgraded with daylight and some more space to move.
3.5.3 THE ARCHITECTURAL BRIEF
The brief of the Maggie’s Centres is somewhat different from the usual case, focussing
more on atmosphere than on square meters. Still it remains close to what (student)
architects are used to starting their design from. Most of the designs feature elements
mentioned in the brief, e.g. flexibly usable spaces, a central kitchen island and table, therapy
and lecture rooms, spaces to retreat, and collective areas. Given Maggie’s fascination
with nature, the presence of green was an essential element in the centre’s quality. Also
the number of natural elements on the given location became an important constituent
of many projects. Some chose to make their building disappear in the wood, or reflect
it so as to become as transparent as possible; others really worked with it, designing the
green just as they designed the building (fig. 3-2).
Despite requiring these clearly listed elements to be present in each centre, the brief also
challenges architects to not follow it blindly, but make spaces that help the transition from
being patients, or even cancer victims, to becoming individuals again. It even challenges
designers to come up with maybe contradictory things (s.n., 2011). Whereas none of the
students did refer to this requirement explicitly, several seem to have taken up the challenge.
By designing a longitudinal building, some questioned the notion of centrality of the kitchen
for example. How do you make a central kitchen and avoid corridors when all spaces are
--------fig. 3-1
Quiet rooms, specifically designed to listen to e.g. an audio book (© Pieter-Jan Debuyst)
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located in a row? This may not be easy but choosing this spatial configuration brings
all the rooms closer to nature, thus contributing to users’ well-being. One student also
explored the meaning of “domestic space” (fig. 3-5). Do users experience the archetype
of a house as domestic, despite a rather abstract material choice?
3.5.4 MAGGIE’S CENTRES AND OTHER BUILT EXAMPLES
Consciously or not, both professional architects and students build on their knowledge
of exemplary architectural projects (Heylighen and Neuckermans, 2002). Given the list
of famous international architects who preceded the students in designing a Maggie’s
Centre, it is likely that they drew inspiration from them. Images from other centres were
explicitly displayed on students’ panels. Amongst others, the differentiated light levels
in OMA’s centre for Gartnavel formed a popular reference (fig. 3-3&4). By referring to
this example, students almost automatically addressed two requirements formulated in
the brief, namely the presence of light and providing intimacy when needed. However,
students did not limit themselves to Maggie’s Centres to find inspiration on user sensitive
architecture. The work of Swiss architect Peter Zumthor was frequently cited as an
example of architecture relating to nature without neglecting the atmosphere inside (fig.
3-6). Only one student specifically looked for examples of care buildings focussing on
user experience. He stated that the Ronald McDonald family room, a facility for families
of hospitalised children in the Netherlands, showed him how to deal with well-being in
relation to the built environment.
While the actual design outcome may differ considerably, there are only so many
typological ways of dealing with inside-outside relationships combined with the required
programme. No wonder some student projects reflected existing Maggie’s Cancer
Caring Centres, maybe even unintentionally. This could be observed even on a more
general level. Typologies such as a beam-like building or archetypical houses in a uniform
material can also be considered basic architectural references.
--------fig. 3-2
Natural (left) and designed (right) green environment
(© Laura Van Bel; Pieter-Jan Debuyst)
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--------fig 3-3: Outside view of Maggie’s Cancer Caring Centre,
Gartnavel by OMA used as reference (© osar architects)
--------fig. 3-5
Design based on the archetype of a house (© Matthias Salaets)
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--------fig. 3-4
Inside view of Maggie’s Cancer Caring Centre, Gartnavel by OMA used as reference (© osar architects)
--------fig. 3-6
Building by Peter Zumthor, reference for fig. 3-1
(source: https://aumuangudom.files.wordpress.com/2012/05/pz-serpentine-pavilion-14-press-page.jpg)
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3.6 DISCUSSION
If we confront the sources about user experience documented above with the
interpretations of ‘experience’ in the design process described in literature, some
additional sources can be identified. Indeed, (student) architects rely on their own bodily
experience of places they have visited when designing. The central kitchen table is
referred to by different students as a table at the popular bread and breakfast location
Le Pain Quotidien, not designed by world famous architects, but definitely creating
common ground with the (ex-)cancer patients attending the final presentation. When
asked what they liked most about students’ projects, this was the example patients cited.
The importance of buildings or spaces designed by others, which students know from
literature or courses, or are advised to look at by studio teachers, is illustrated above. We
could not clearly identify references to other buildings students designed themselves.
Yet, one teacher referred to an assignment the year before whereby students designed
an apartment building. That some students extruded a plan to a height of 3 m instead of
designing in 3D, he ascribed to this assignment, which would have raised their interest in
piling up identical floor plans.
In reality, the different sources of user experience involved in design (processes) are
not as clearly distinguishable as presented here. Besides the real-life people invited for
the students to talk with and the person of Maggie, a variety of in-betweens may have
informed the design as well. The Trust’s website contains movies showing testimonies by
the centres’ users. Here too, people somehow affected by cancer, give a personal, often
touching, view of how the organisation and building add to their personal well-being.
Before the studio started students received a list of movies they could watch to become
familiar with the life-world of the people they would design for. The design teachers
mentioned both testimonies and movies as important references for students. One
student even incorporated testimonies from the website in his final presentation, making
it seem as if the people visiting the centre commented on his design.
While introducing users in a design process is not new, confronting students with real
people is not a common practice in our programme. Instead teachers or students
“invent” their buildings’ users, adapting them to their design instead of vice versa. In this
design studio people representative of these users were involved, but they did not wield
much power, as is often the case (Cuff, 1989). The (ex-)patients and oncologist who
participated were invited at the start of the studio and at the final presentations of some
projects, selected by the teachers. Yet giving feedback along the way and grading the
projects was done by the teachers, trained in architecture and design.
For the coming year, we have slightly altered the approach. Small groups of 2-3 students
are motivated to engage with “their” user/expert and discuss their design with them along
the way, while sharing their findings with the other groups so as to get access to a more
diverse set of perspectives on cancer care in the broadest sense.
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3.7 CONCLUSION
If designers are to design for inclusion, informing them about people’s
experiences is a key concern. By analysing the use of different sources on
user experience in a design studio, we gained a better understanding of what
kind of knowledge, students refer to in their design and how it informs and
directs their design process. For many students these sources functioned
as something to fall back on when they were stuck while designing. The
presence of real persons, representing possible users of the centre, at both
the beginning and the end of the design process, challenged students not to
forget about them, not while designing, not when presenting. Still, with the
real users being an audience rather than a source of feedback, nuances, like
the shades between patient and person were not always taken into account.
With the altered approach of this year’s studio we hope to improve students’
sensitivity towards the future users of the buildings they design.
Despite the limitations discussed above, the assignment offered a unique
opportunity to study how users and user experience can enter the design
process through different means. As studying and passing on experience
is not easy, it is important to start growing awareness of the subject during
education, especially when aiming to design for well-being. Participation in
this design studio clearly increased students’ knowledge about specific users.
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Conclusion
Since in the studio reported on the people representing ‘the users’ were not
present in person during the entire period, the different sources about their
experience should be compatible, at least to some extent. In spite of small
nuances, we indeed found many similarities in the topics addressed by the
patients, the oncologist, Maggie’s booklet, the brief, and the built examples.
For example, the presence of nature, pointed out by Maggie as a crucial
element, and thus included in the brief, was also appreciated by the patients
and oncologist during the final presentations. Whether this nature should
be “wild” or “designed” depends on personal opinions. The same is true
for the small isolation spaces. Although the oncologist thought they would
hardly be used, the patients could imagine retreating in there, alone or with
a companion. This kind of small inconsistencies, or nuanced interpretations
of elements mentioned in the brief, challenged students to question the
assignment and the actual meaning of well-being for different persons.
Conclusion
Many students mentioned the fact that a Maggie’s Centre should not be
designed for ‘the patient’ but for a person. If only this insight remains for
their future careers, it will already add to them becoming architects who
design with more than just functionality in mind. Additionally the existing
Maggie’s Centres offered students examples of exceptional architecture.
The assignment thus drew their attention to the possibility of creating
extraordinary buildings, appealing to users and professionals alike, designed
for the well-being of everyone involved with them. By doing so it opened
students’ eyes to designers’ ability to really transform the daily lives of the
people engaging with the spaces they conceive.
ACKNOWLEDGEMENTS
This study received support from the Agency for Innovation by Science and Technology
in Flanders (IWT-Vlaanderen) through a PhD grant of the Baekeland program, osar
architects nv, and the European Research Council under the EU’s Seventh Framework
Program (FP7/2007-2013)/ERC grant agreement n° 201673. Thanks go to all involved
in the studio, including Mauro Poponcini, Hans Verplancke, the guest lecturers, TOPAZ,
Stichting tegen Kanker, the user/experts and the oncologist.
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References
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Designing inclusive systems, Springer-Verlag, London, pp. 3-12.
Annemans M, Van Audenhove C, Vermolen H, Heylighen A, 2012b. What makes an environment healing? In: Proceedings of 8th International Design and Emotion Conference, London, pp. 1-8.
Cassim J, 2007. It’s not what you do, it’s the way that you do it. In: Stephanidis C (ed.) Universal access in HCI, Part I, HCII 2007, LNCS 4554, p. 36-45.
Cuff D, 1989. The social art of design at the office and the academy. JAPR, 6(3): pp. 186-203.
Dong H, Keates S, Clarkson PJ, Cassim J., 2003. Implementing inclusive design. In: Carbonell
N, Stephanidis C (eds.) User interfaces for all, LNCS 2615, p. 106-117.
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Heylighen A., 2012. Inclusive built heritage as a matter of concern. In: Langdon PM, Clarkson PJ, Robinson P, Lazar J, Heylighen A (eds.) Designing inclusive systems, Springer-Verlag,
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Heylighen A, Neuckermans H., 2002. Are architects natural case-based designers? The Design Journal, 5(2): pp. 8-22.
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Tsianakas V, Robert G, Maben J, Richardson A, Dale C et al., 2012. Implementing patient-centred cancer care. Supportive Care in Cancer, 20(11), pp. 2639-2647.
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4. Being wheeled through the
hospital: How can design be
informed about hospital patients’
spatial experience in motion?
This chapter has been submitted as a book chapter.
Keywords
design process
motion
user experience
workshop
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Abstract
Hospital buildings are experienced from a, for most
architects, a-typical perspective. Once you are admitted
to the hospital, you are assigned a bed and from that
moment on, this is your sole truly personal space, which
travels with you through the building. Insight into patients’
spatial experience in motion is thus of crucial importance
for architects and hospital boards who aim to put patients’
experience centre stage in a hospital design.
To gain a nuanced and in-depth understanding of how this
insight can be introduced in design processes, we organised
a workshop in which participants were asked to design a
lift based on research data about hospital patients’ spatial
experience in motion. The aim of the workshop was to test
and evaluate design input based on different information
formats to provide designers with an extended background
on real people’s experience of moving through a hospital
environment. We analysed the workshop in terms of the
design outcome and the design process, paying specific
attention to the affordances of the information formats.
We conclude that moving space can hold different
meanings. The diverse design solutions offer insight into the
relationship between space and motion. They illustrate that
the hospital environment is not a priori static, and suggest
that the information format plays a significant role in the
design outcome.
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4.1 INTRODUCTION
How we move or are moved shapes our experience of the built environment. Therefore,
architects and other designers who design spaces where many people move through
are confronted with a major challenge to take into account people’s spatial experience
in motion. Locations, such as hospitals, where patients spend a considerable amount of
time moving or being moved, could benefit even more from a better understanding
of people’s spatial experiences in motion. Our research aims to provide architects with
adequate information to design healthcare buildings that anticipate the needs of patients
and other users. On the one hand, we explore the spatial aspects that influence patients’
experience during their hospital stay. The main goal here is an improved understanding
of spatial experience from a lying perspective both static and while being moved through
the building. Returning themes are material aspects, social issues, and time perception
(Annemans, et al., 2014a). On the other hand, we look for ways to introduce these
insights regarding spatial experience in motion in architects’ design process. We set up
a research approach that provides us with both visual and narrative data which hold the
potential to be passed on to designers with only limited post-processing (Annemans
et al., 2012). In doing so we aim to collect research data on patients’ spatial hospital
experience in motion that are more easily transferable to designers. This should inspire
and trigger them to start working with these insights, as such creating buildings based on
an improved understanding of the mobile subject.
By exploring how design can be informed about patients’ spatial experience in motion,
we aim to evaluate design input based on different information formats that can provide
designers with background on real people’s experience of moving through a hospital
environment. To this end, we organised a workshop in which participants designed a lift
and were presented with research data on hospital patients’ spatial experience in motion.
Real human experiences were thus introduced in the design process in various formats.
We analysed the workshop in terms of the design outcome and the design process,
paying specific attention to the affordances of the information formats. This analysis
resulted in a profound understanding of the issues at stake in being wheeled through
the hospital from a patient perspective and raises interest in other actors involved in
the mobile experience. The resulting designs offer insight into the relationship between
space and motion.
4.2 INTRODUCING PATIENTS’ EXPERIENCE IN MOTION IN THE
DESIGN PROCESS
To be able to design for patients’ well-being it is important to have an in-depth
understanding of their experience. Creating empathy with users in the design process
can be done in various ways (Kouprie & Visser, 2009). Ideally the information needed for
the design is obtained through interaction with real target users, c.q. patients, allowing
the designer to develop a more thorough understanding and empathy with these people
(Kouprie & Visser, 2009; McGinley & Dong, 2011). However, since time and money
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restrictions in a typical design process result in a minimal user engagement (Cassim,
2010), designers are often unable to obtain this direct input from users and become
dependent upon indirect sources of human information (McGinley & Dong, 2011). As
most architects rarely consult scientific articles (Annemans et al., 2014b), researchers
need to use special communication tools to convey the users’ stories (Kouprie &
Visser, 2009). Apparently, designers are rather motivated by visual communication and
like information to be graphically presented (Lofthouse, 2006). Moreover, they often
feel mistrust towards data that have already been through a process of interpretation
(Restrepo, 2004) and seem to have a desire for raw data in a format that is condensed
down to be design-relevant (McGinley & Dong, 2011).
Various techniques have been developed to bring designers closer to the users’
experience (Kouprie & Visser, 2009; McGinley & Dong, 2011; van Rijn et al., 2011). Most
of these techniques aim to foster designers’ empathy with the persons they are designing
for. The specific situation in which these users find themselves affects the degree to
which actual interaction can be achieved. In the case of patients being moved through
a hospital, practical and ethical restrictions make it hard for designers to actually engage
with the users during the activity under study. Therefore, we set out to explore which
formats could be suitable to inform design about hospital patients’ spatial experience
in motion. We aim to find a format that meets the above-mentioned requirements and
supports communicating data about motion.
Tim Ingold (2011) draws a parallel between the development of a story and the trajectory
along which it develops. In the design briefing this parallel is often not so clear. Traditional
design briefs tend to focus on functional and organisational matters. Including user
information is often limited to attention for the values of the (care) organisation (Bogers,
van Meel, & van der Voordt, 2008; Elf & Malmqvist, 2009; Elf et al., 2012). Research
suggests that an alternative approach to the design brief with a focus on experiential
information (Van der Linden et al., 2016) improves designers’ ability to relate to users’
experience. Introducing real users’ experiences in the design process clearly works inspiring
and increases designers’ ability to relate to people’s specific situation (Annemans et al.,
2014b; van Rijn et al., 2011). In product design co-creation and other forms of designeruser interaction are fairly common (Howard & Somerville, 2014). Bringing this humancentred approach to architecture and planning is apparently “a big nut to crack” (Sanders,
2009). Given designers preference for graphical and visual information, complemented
with the difficulty to grasp experience in motion in words, visual communication tools
seem promising in transferring patients’ impressions while moving to architects. While
static images can trigger reflection on motion (Annemans et al., 2012), video seems even
better given its mobile character. Introducing video in the design process can be done
under various forms (Ylirisku, 2007). Data can be collected by designers themselves or by
an intermediate researcher, processing of the collected data ranges from an ethnographic
approach to design documentaries (e.g. Raijmakers et al., 2006).
Shifting attention to “the user” in the design process changed design from a study
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of things to a study of people. This change introduces user concepts from the social
sciences like affordance, use, and meaning in design studies (Almquist & Lupton, 2010).
The relation of these concepts with the built environment has been elaborately studied
elsewhere (Clapham, 2011). The concepts can be applied to the subject or object under
study – patient, bed and building – and to the design formats we are seeking.
MOVING DESIGNS FOR MOVING REAL PEOPLE:
DESIGNING AN ELEVATOR AND THE ACCORDING EXPERIENCE
REQUIREMENTS FOR THE ELEVATOR
Hospitals are locations in which a supportive environment is most
desired. As a patient you tend to experience these buildings from a
rather atypical perspective: lying in a hospital bed. Apart from being
atypical, the perspective is also multi-layered.
The elevator should be:
- a place of transition between the spaces before and after
The bed as a material object, with its specific accessories,
-
interacts with the built environment around it. Its dimensions and
practicalities influence how it is used and experienced by patients.
- spacious enough, so it doesn’t feel like a cage
- made of a warm material, not something that seems to close down
on you
- However, the bed also has a significant influence on the social
interactions you, as a patient, experience while being in the hospital.
Unknown people intruding your personal space and relatives and
friends keeping a distance are commonplace.
- pleasant in temperature, so it won’t be associated with an oven
- easy to operate, without unnecessary wringing of personnel to get
to the buttons
- Moreover, both physical and social interactions are not limited to
one location or situation. A hospital bed travels with you through
the entire building, as such adding a motional aspect to the hospital
experience.
- supportive in manoeuvring the bed
- able to make people feel at ease
In the elevator all of these and even more elements of the spatial
experience of hospital patients are condensed. Therefore, this
specific space forms an ultimate challenge to start designing from
patients’ perspective.
PRACTICALITIES
The elevator should be suited to be loaded with
- a stretcher
- a hospital bed (for which you need reinforced doorsteps, both at the
platform and the cage + a reinforced floor)
PURPOSE OF THE DESIGN
Obviously an elevator is meant to move people and things up and
down in a building. For patients, on the route from a ward to the OR,
a hospital elevator is also a transition zone where many actors come
together.
- An elevator for bed transport is approximately 1,4 x 2,8 x 2,3 m (W
x D x H).
- The elevator should be able to stop at each floor (6).
Due to the limited size of the space, the built environment comes
oppressively close to the bed and the person in the bed.
- Users should be able to get in and out of the elevator at two
opposite sites in the longitudinal direction.
As a patient, you are never on your own. A nurse accompanying you
pushes your bed in the elevator, and it is him/her that pushes the
buttons. To do so (s)he may have to lean over the bed reducing your
private space even more. Complete strangers can try to squeeze in
or leave the elevator when the patient enters.
- The operation panel and badge reader should be easily reachable.
- Each platform should be equipped with operation buttons and a
badge reader.
- Sliding doors are required.
Patients are wheeled in and out of the small cage of the elevator,
but also when the bed stays static, they still move closer to their
destination.
OVERALL
An elevator, and its influence on the according experience, is thus
an example of how a thoughtful design could result in a supportive
environment.
The elevator should make people feel better rather than worse.
Some things are obvious:
- pleasant lighting
---------
- optimal privacy without patients feeling to be neglected
fig. 4-1
- suiting patients’ state of mind
Experiential design brief
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Charles: “I noticed that saying [on the left on the wall], silence or
Researcher:
something like that. It went fast. It went to fast to read it.”
It feels like sitting in the bus when you go over a ramp
Nurse: “when the lift door opens you will immediately feel that for
Researcher:
a moment there is this fresh air”
I feel a draught on my feet.
Charles: “This arrows, ups and downs, that’s symbolic”
William: “Happy to be out of that lift!”
--------fig. 4-2
Original videomaterial complemented with participants’ quotes and observations of the researcher while being
wheeled in a bed (original recording 16.07.2012 adapted October 2014 based on V2 chapter 3)
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4.3 APPROACH OF THE WORKSHOP “MOVING DESIGNS FOR
MOVING REAL PEOPLE”
4.3.1 PROCEDURE
To gain a nuanced understanding of how one could design for a mobile subject we
organised a workshop, named “Moving designs for moving real people,” in which
participants were provided with different formats addressing information on spatial
experience in motion. The workshop’s aim was to test and evaluate various sorts of design
input that provided the participants with background on real people’s experience while
moving through a hospital environment. Based on this input participants were asked to
design a lift on the route from the ward to the operation room (OR). This task combined
designing a moving building element (a lift) for a mobile subject (the patient), supported
by a mobile object (the bed).
The group consisted of six participants, three trained architects currently working in
research and/or practice and three people with a different profile, a geographer, an
anthropologist, and a psychologist-pedagogue. Each architect was paired up with a nonarchitect.
The workshop started with a brainstorm session in which the participants were asked
to write down on post-its what it meant to be a patient and to be wheeled through the
hospital. Different aspects were addressed. Participants were asked to focus on the
patient in the bed, the building and the transport.
Subsequently, the actual design task was given. Real patients’ experiences were
introduced to the participants in various formats. The experiential information provided
in the formats formed the basis for the participants’ design processes, which took place
in two phases. In a first phase each of the three teams received one of the information
formats. Team A, was given a written design brief (fig. 4-1), slightly differing from a
traditional brief due to its focus on experiential information. Team B was provided with
a video of the route patients took from the ward to the OR (fig. 4-2). The video - made
by a researcher lying in bed – was subtitled with the researcher’s reflections on embodied
perceptions along the route. During the video quotes from real patients appeared when
relevant to what was shown. Team C had the opportunity to talk to a former patient with
a background in architecture. At the start each team was allowed to consult only their
assigned information format. After an hour and a half, each team was asked to present
the results of this first phase, including their design process. Subsequently, all teams were
allowed to consult all sources of information and adapt their design according to new
insights gained from them. Each team gave a final presentation focussing on how and
why they had adapted their design.
We concluded with a discussion on the design process: where, how, and why did
adaptations (not) take place and what role did the provided information play in this
process? Finally we identified how the use of the different information formats influenced
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participants’ sense of patients’ experience and how this was translated into the design.
4.3.2 ANALYSIS
A content log was made of the brainstorm session. The presentations of the designs and
the final discussion were transcribed verbatim. All material was reread multiple times.
The synopsis of the designs was made based on these transcripts combined with the
visual and textual material participants provided. Transcripts were coded to establish
common themes. All material was then cross-analysed according to these themes. The
findings were organized according to the structure of the workshop and substantiated
with original quotes from the interviews.
4.4 FINDINGS
4.4.1 FROM THE BRAINSTORM
During the initial brainstorm session we aimed to achieve a common basis as to whom
the different teams would be designing for. Three questions were asked: what does
it mean to be a patient (in bed)? What does a hospital mean to you? What does it
mean to be transported through a hospital? Participants mentioned aspects like sensory
perceptions, social interactions, and duration of the stay that were similar to themes
identified in previous research (Annemans et al., 2011). Most participants had at least
some personal experience of being a patient and reflected on these questions from their
own perspective.
According to the participants, being a patient in bed means in the first place being under
the control of and dependent on a stranger. Due to the changed perspective as a patient,
the participating anthropologist mentioned, the visual perception is largely reduced, on
which an architect commented that indeed mainly the ceiling is then visible. Smells and
sounds become more important. Especially the soundscape is altered.
One participant told about her experience in an MRI machine that, since patients are
unable to see who is present, their experience of others’ presence relies more on sound.
Someone else gave the example of a nurse breathing above a patient’s head.
Participants described the bed as patients’ only home in the hospital. They live in it, they
sleep in it, they are transported in it, and it is used to transport their personal belongings.
As one participant explained from her own experience:
“When staff came and changed the blankets, that didn’t feel nice, because
they made it all new, and I lost my home.”
Someone else mentioned that the bedcovers in a hospital are really thin, and always leave
patients feeling cold. The conversation then shifted to how patients experience the bed
and the hospital with their whole body: lying in bed, feeling their own things close to them
and the given hospital sheets around them.
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Participants reflected on how patient and bed become one, and how patients thus
experience the built environment through the bed. A hospital building is for most people
a strange place, disconnected from everything they know or are familiar with. Typical
sounds emerge from the building, like the plong-sounds of the lift. Often the built
environment does not seem suitable for the activities that take place. Patients are parked
in the corridor to wait. Moreover, many hospitals are said to be ugly, worn down and in
desperate need of maintenance. A participant questioned:
“if the building is in such a bad shape, then what will they do to me?”
The group came to the conclusion that patient, bed, and building are connected through
the transport. Although the hospital bed ties patients to themselves, they are mobile as
long a someone is moving them. Being wheeled around compromises patients’ sense of
orientation, it is hard for them to know where they are or where they are taken, building
up a mental map seems almost impossible. Moreover, as patients are often not told were
they are taken, being transported makes them feel like an object being processed rather
than a person being taken care of. Movement sometimes happens very sudden, which
can be disturbing. On the other hand, a participant recalled that when she was in the
hospital for a long time, being taken out of her room and wheeled around through the
building was also a positive experience.
4.4.2 FROM THE DESIGN SESSION
The designs
Based on the dimensions mentioned in the experiential design brief, team A (fig. 4-3)
started by making a small 3D model of the space they were asked to design, a “type of
tunnel shaped elevator” as they called it. From there on they made adaptations based
on the experiential information mentioned in the brief and the ideation during the
brainstorm. The first aim of their design was to create a protective corner so people
stepping into the lift would not directly bump into the bed. Therefore, one wall of the
lift would be curved. They positioned the lifts at an outside wall of the building, making
the curved wall in glass, so patients would be able to look outside, having a broader
perspective and not feeling oppressed. Staff were invited to stand in the additional space
generated by the curved surface so they could easily reach the panel to operate the lift.
As the architect in the team put it: “through the shape we want to give directions on how
to use this space.”
Also the bed was taken into consideration. In the adapted design, beds were equipped
with a cover, like a baby pram, with LEDs inside to create a personal ambient. This would
give patients the possibility to withdraw, “like raising the sheet over you head.” Team A
also listed technical details that would facilitate the interaction between patient, bed,
and building. They mentioned a map of the hospital at the wall so patients would know
where they were, a moving platform to smoothen entering the lift from the corridor, and
an indication of the floors high enough on the wall so a patient could see it from the bed.
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Consulting the patient and watching the video made team A list four adjustments to
their design. Changing the window to a screen, showing a landscape could create a
better ambient in the lift. It was also a practical decision since this allowed situating the lift
at any place in the building, not just at an outside wall. Additional ideas were to provide
information technology on the ceiling, or create daylight ambient. Installing a mirror
above the bed so the patient in the bed would be able to observe what was happening
when the doors behind the bed opened, was abandoned in dialogue with the patient who
thought seeing yourself as a patient could be frustrating. Finally also the area in front of
the lift was taken into consideration to make it more pleasant.
Team B (fig. 4-4) did not have an elaborated design when presenting after the first round.
As most important aspect of the patient’s story they identified the route, starting in the
room all the way through to the OR and back: “like a loop she did in the hospital.” This
loop asked for some personalisation, which they wanted to achieve by creating a cover
for the bed (just like team A), however they abandoned the idea right away because the
patient “was not that into it.”
The design idea they proposed was a personalised path that would be unrolled for the
patient through media architecture. Ideally
“the bed would be recognized as your home, and the building would recognize where it would go.”
The ceiling and walls would then be used to display something visually interesting but not
entertainment. The patient had mentioned several times that
“reading the magazine she was given or watching TV is frustrating because
it ‘s so stressful, the situation is so stressful that this kind of normal entertainment is apparently a little bit banal in that situation.”
Making use of media architecture would provide patients with something to focus on,
changing the uniform white spaces without interfering with the medical procedure.
Consulting the video especially opened participants’ eyes for the awkwardness of the
built environment, and the ugliness of some places. This insight made them look for a
way to improve the interior into something more appealing. It made them think more
about the actual materiality, which should be a plain white wallpaper of paint that could
be turned into a patient’s colour of choice. They further elaborated the ideas of the media
architecture, offering patients the opportunity to choose their own theme or colour that
would travel with them along the corridors, into the lift, and in each room they stayed. In a
space like the lift where the bed stood still additional information, like the estimated time
of surgery, could be given to the patient. The essence lay in the bed communicating with
the building when moving through it, so there would be no need for manoeuvring around
to call or start the lift. The caregiver could concentrate entirely on the patient.
Starting from the video team C (fig. 4-5) started thinking about the lift but “a little bit
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broader than the lift, the lift as a system that connects the floors.” As they put it:
“[now] the experience of the space is a little box with a very hard threshold to
the surroundings. What if we can see it like a space that ‘s just a continuation
of space?”
Team B thus proposed a “paternoster lift”, an existing concept but adapted to the hospital
context. Patients would be picked up at the ward and then reside in the lift until they were
dropped off at the OR, being wheeled along the corridor would as such be reduced to a
minimum. The disadvantages of the concept could be turned in advantages:
“For example it ‘s too slow, but it also holds some good insights, it can be a
combination of rooms, so you don’t feel oppressed. You just enter and you
have a continuous going and maybe the time that you spend, the surplus
time that you spend in this loop, is maybe more pleasant than when you
have to wait.”
Specific attention was given to entering the lift. The corridor was designed in such a way
that the entrance would be smoothed, reducing unnecessary manoeuvring with the bed
and bumps at the ridge of the lift door. A connection between the patient, the caregiver
and the building was stimulated through the use of mirrors so a patient would have a
broader perspective than usual when lying down.
In the second round of the design process, team C continued to work on their “slow lift.”
They aimed to create a place where you want to be and relax, a continuation of broad
spaces rather than an interruption on your route to the OR. This concept was further
elaborated in the interior design of the lift. A bench would afford the accompanying
caregiver to spontaneously sit down on eyelevel with the patient lying in the bed. A
screen showing images of nature would provide something to focus on.
The design process
The design process of the three teams diverted considerably. Team A started from the
most traditional information format, an (experiential) design brief. This resulted in a
design that kept close to the assignment. The architect in the team found the brief easy
to work with, although he mentioned that he might be biased because it is the kind of
information he is used to. However, both team members explained that all the functional
and experiential requirements listed supported them by providing a framework to keep
focused, although some, like the dimensions also restricted them to a rectangular shape.
By taking a step back and shifting their focus to the patient they felt empathy for through
the brainstorm, they were able to come loose from this limiting information. Watching
the video and talking to the patient made them look at their own design decisions from a
different angle, abandoning previous options:
“when we saw the video we started to downsize our ideas. Just because we
were confronted with the harsh reality of entering the lift. [before, based on
the brief] we had to create it in our visionary perception.”
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Team B indicated how different their design process was from the one explained by team
A. Instead of the spatial focus common in design, the dialogue with the patient drew
their attention to her story, which took time, also because they reworded her story several
times focussing on different details, resulting in a much more temporal and experiential
focus of the design process than a spatial one. As one of them explained:
“Her experiences happened on a timeline, so we kind of went through this
path, […] to me it unfolded as a path, a spatial path but […] even though I
saw it as a spatial path the process was definitely more verbal. Definitely a lot
more verbal than usually, definitely more to do with senses and feelings […]
We didn’t get down to the solutions.”
Given the importance of the path, or route, it was very hard for them to focus only
on the lift. Emphasizing the patient’s perspective also made them wonder about the
experiences of different actors, like the caregiver. Taking into account all these different
perspectives was felt to be limiting the design possibilities. Following this kind of process
was considered rewarding and eye opening, but very time consuming. Looking at the
video drew their attention to the actual material, spatial reality, they said.
Team C’s design process was shaped by the combination of a “fresh visual experience”,
the video with patients’ testimonies, and the brainstorm session. Seeing the movement
of the lift, reading quotes of different patients, and being able to situate these in a real
environment gave them a broad basis to start designing. Several times they addressed
sensory perceptions as a motivation for a design decision, for example:
“you could see the ceiling and it made you very sick to see the lines there,
so it enhanced the perceptual feeling, so that was one detail that you had to
choose the ceiling materials and forms carefully.”
Even in the second round of the design, when they were able to, they said to have
consulted the design brief not at all, and the patient only very briefly, because there were
too many items on their to-do list. As one of them explains:
“we didn’t exactly come to a design, more to design typologies or things we
want to implement. […] We used this as a communication tool in combination with the video. So it was also time consuming to come to an actual
design.”
4.4.3 FROM THE DISCUSSION
The design processes were shaped by the information formats consulted initially, but
regardless of the order they were consulted in, each had its own merit. As one participant
who started from the conversation with the patient explained:
“the story was a lot more compelling than the main exercise but during the
first exercise I thought well, if I ‘d have to start designing right now, maybe
I ‘d lie down on one of the desks here. But then I watched the video and I
thought - what struck me most was the flow of spaces […] entering the lift
was dreadful, but in the whole video it was about really being able to move
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through spaces. I got that from the video, so I got different things from each
thing. Her story obviously didn’t have the [dimensions] the brief had. So if I’d
really have to do some work, design work, I’d need that.”
The value the different teams assigned to the brainstorm session varied. The team who
started from the brief highly valued it:
“We had the traditional, even mechanical brief from the client, but this
session before, that affected a lot of things.”
They considered the brainstorm in which they became aware of their own experience,
as they described it, as a primary layer, not directly related to the design assignment, but
essential for their design. As they said:
“We started the process like, let’s imagine we were lying down, the perspective you pointed at and how it would feel. We didn’t start from the brief.”
For the other teams the brainstorm session was guiding the final result to a lesser extent.
Despite its experiential character, the brief could not compete with a real testimony:
“When I started reading the brief, the first sentences were about [the experience of] lying down and being in a weird position. But it was striking, after
listening to her [the patient] for 45 minutes, [the text of the design brief] felt
really flat, obviously.”
However, the same person referred to the dimensions in the brief as essential for an
actual design. Whereas the brief still had to be analysed and confronted with the ideation
from the brainstorm, the video clearly identified the problems of being wheeled in a bed,
as such easily allowing team C to start thinking of solutions:
“I had the feeling that we could step over some phases to come to a design. I
‘m not sure, but we went straight to- […] nobody had to tell us anymore what
the problem was.”
As mentioned above, it showed the flow of spaces, something that the other sources did
not seem to do.
“The video really feels like you ‘re walking in someone’s shoes,” (participant
from team A)
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--------fig. 4-3
Design team A (images made by participants)
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--------fig. 4-4
Design team B (images made by participants)
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--------fig. 4-5
Design team C (images made by participants)
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4.5 DISCUSSION: MOTION IN DESIGN (PROCESS)
Having analysed the workshop’s process and outcome, let us have a closer look at how
motion appears in the designs and design processes.
4.5.1 PEOPLE IN MOTION
To be able to truly design for patients in motion, designers need a profound understanding
of the issues at stake in being wheeled through the hospital. To obtain this insight empathy
with the mobile subject and understanding of the specific situation one is designing for is
indispensable. As illustrated, the information formats designers received influenced their
understanding of the specific situation a patient is in. The ideation during the brainstorm
made them reflect on personal experiences (if any) in the given situation. Although the
session sensitized those who did not have personal hospital experience, their insight
could not go further than imagining.
Providing information on patients’ spatial experience in motion opened designers’ eyes
for the importance of a mobile perspective. They strongly believed that adding others’,
like caregivers’ perspective to the patients’ would enrich and bring nuance to the design.
In case of hospital transport the mobile subject indeed cannot be reduced to the patient
alone. Patient, caregiver, and bed are moving together. When architects design for the
mobile patient, paying specific attention to the design of the object in which patients are
moved could thus provide an additional value. A good example of how person and object
are entangled was the design of the cover for the bed, to give a patient the opportunity
to “hide under the sheets” while being wheeled through the corridor, even though it was
not applauded by the patient involved.
4.5.2 THE ENVIRONMENT IS MOBILE
Experiencing space while moving is not a linear process. While different spaces are moved
through sequentially in time, various impressions are perceived in parallel. Purely textual
communication is intrinsically sequential and thus does not seem suited to capture spatial
experience in motion to the fullest. Although talking to a patient provided designers with
a rich, profound insight into her experiences, as they indicated they gained insight mainly
from a time related perspective, grasping moments, not spaces. Despite the valuable
input from the patient and the video, a member of team A reflecting on both said to the
patient:
“Again, it would be different if we could be in the room with you, if we could
go through the route, we could sense the environment ourselves. I don’t
know how to translate it to the design, but still it would be very different […]
even watching it from the video, you don’t get all the senses.”
For a nuanced and rich design result, the architects need to feel the environment, not
from one person’s perspective but from several perspectives, including their own.
The hospital environment is known for its uniformity. Most wards and corridors look
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identical: walls plain white, grey, or beige and suspended ceilings. Many aspects seem to
be determined by unspoken hospital procedures. A traditional hospital brief apparently
does not challenge designers to think beyond what is known. The workshop’s results
suggest, however, that providing designers with different information formats makes
them question the environment as a static given. The flow of spaces shown in the video
resulted in a lift that was more than vertical transport equipment: it became a real room,
accommodating patients during their trip through the building. The patient’s story left
the basic organisation and appearance of the hospital unchanged, yet brought forward
the idea of patients’ personal space travelling with them, making the environment mobile
not only in space but also in time.
Conclusion
4.6 CONCLUSION
By organising the workshop we aimed to gain better insight into which
information formats could be valuable for designers to design hospital
environments that adequately address the diverse needs of patients
experiencing space in motion. Spatial experience in motion is a complex
phenomenon. Sensory perception provides a first layer of impressions of the
built environment. Although frequently addressed during the brainstorm,
insights regarding this layer were applied in the designs only marginally.
When this duality was pointed out, the designers argued that implementing
aspects addressing sensory perception would come in a later phase when
they started thinking about the materials. Some ideas were mooted rather
as a suggestion than an actual solution. A second layer concerns the social
character of moving in a hospital bed. The perspective from which patients
observe their environment while lying in a hospital bed largely determines
their interaction with others. They look up to everyone around them. Others
look down on them. Various design solutions, like the benches in the lift
or the cover for the bed, addressed this specific situation. A third layer is
time related. As one of the participants concluded: “moving in the hospital is
about waiting.” Although the largest part of the hospital environment is now
designed for those moments when every minute counts, focussing on easily
manoeuvring beds and working time efficiently, many patient transports are
just a concatenation of moments of waiting. We saw that all teams addressed
the spending of unoccupied time to their ability, based on the information
they received: with information screens, by making a lift as a residential room
instead of transport equipment, or through virtual personal space.
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The designers’ personal background and experiences likely influenced the
meaning they assigned to the different concepts they worked with, and thus
steered the outcome of the design processes. However, the nature of the
designs was so different and so closely related to the nature of the provided
information that it seems plausible to conclude that the information format is
a steering factor in the attention given to mobile aspects in design. Whereas
the video material showed the flow of spaces and thus drew designers’
attention to space in motion, the patient’s story was obviously personal,
inspiring a personal space that moved with the patient. The design solutions
point at two distinctly different interpretations of mobile space: an actually
moving space in which a patient can reside, or a virtual space, moving along
with a patient. The meaning addressed through language, as in dialogue
with the patient, differs significantly from the meaning conveyed through
embodied use as presented in the video (Clapham, 2011).
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Conclusion
Communicating motion through language, written or spoken, alone seems
hard. Despite its experiential character the design brief fell short of addressing
the nuances and details of a real person’s experience. Talking with a real
patient in this case worked as an eye opener for the designers. However, the
selected patient was trained as an architect, thus we can assume that she had
a significant advantage in communicating her spatial experience. We cannot
expect all patients to be able to do so as eloquently. Although consulting real
patients is advisable, in a real design assignment this might not be feasible,
nor as easy as held out in literature (Sanders, 2009). Combining words and
images or even better moving images, seems promising but obviously lacks
the interactive element of a conversation. Combining our findings with
insights from literature (McGinley & Dong, 2011), we can conclude that the
challenge to introduce insights regarding spatial experience in motion in
architects’ design process concerns both the content and the format of the
information. The communicated content should be as close as possible to
raw data, reflecting patients’ own testimonies. The information format should
be able to convey a nuanced image of the research findings and preferably
facilitate interaction. Passing on video material supported by an extended
narrative, with the opportunity to consult more information than what is
initially provided in the flow of images, seems promising in supporting design
for mobility in the hospital context. Further research is needed to develop a
format that can actually support this aim.
ACKNOWLEDGEMENTS
(FP7/2007-2013)/ERC grant agreements n° 201673 and n°335002. The authors thank
the organisation of the 6th Annual Symposium of Architectural Research 2014 for the
organisation of the workshop and the participants for sharing their time and insights.
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5. Discussion and conclusion:
Informing hospital design on
patients’ spatial experience in
motion
Volume 3 aimed to inform hospital design on patients’ spatial experience in motion.
To optimally introduce insight into this experience in architectural practice, they
should be offered to architects in a format that resonates with their way of working.
Therefore I posed the research question: how can insight into patients’ spatial experience
be translated in a format that is applicable for architectural practice? In response to this
question, I iteratively built up insights into architects’ design process and tested sources
of information stemming from them. Below I will discuss the insights gained, first, by
conducting focusgroup interviews with architects and, second, by studying (student)
architects’ designs, which brought me to the requirements for a format applicable in
architectural practice. As the proof of the pudding is in the eating, I choose to implement
what I learned in a proof-of-concept format to inform architects on patients’ spatial
experience in motion. This proof-of-concept was discussed with an expert panel of
eight architects with different profiles at osar architects. The architects’ opinions, gained
through the discussion, are used to reflect on the insights which formed the basis for the
developed format.
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hospital from a patient perspective
CONCLUSION
COMMUNICATION
MOTION
ASPECTS
PATIENTS
MATERIAL
SOCIAL
TIME
“What also impresses me is, like here when
you enter, see what a number of doors! How
many doors would there be in the hospital?
That’s a huge number, I think. […] That are
a lot, and behind every door there’s a little
bit of misery.”
audio with quote of patient on the numerous doors cf. V2 §1.4.1
read more - CONCLUSION - ASPECTS MATERIAL
CONCLUSION
“Olorecesti sequia nobite litia nest, inciisquis nam fuga. Catur aut quas aute optiur magnatquam
alit aut enihitae. Untia pra quiae et que mi, simi, se moluptatur aliquias ut facepud ipsapererum
voloresse adis experio quossimaios sus etur as molestis sinventium quas eaque consecu ptasperum fugit doluptati od magnam faccae nonse sit que quae.
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voloresse adis experio quossimaios sus etur as molestis sinventium quas eaque consecu ptasperum fugit doluptati od magnam faccae nonse sit que quae. Andia sitemquo.”Lent aut ex everum,
as magnis endus explitat laudanima quuntus ent utemquae. Nem libustiusa num experum
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The waiting area I find gushy. That’s something I expect in a hotel at the Mediterranean
Sea, not here.”
audio with quote of patient on the numerous doors cf. V2 §1.4.1
read more - CONCLUSION - ASPECTS SOCIAL
ASPECTS SOCIAL : CONNOTATIONS
A building can create a very specific image, which influences people’s - in this case, patients’ self-esteem (Annemans et al., 2012b). At the traditional centre patients mostly appreciate the
hospital environment for being a hospital, using quotes like “it’s not a hotel”; at the out-patient
centre many patients make the same comparison with a different incentive. ...
full article V2 chapter 4
audio with quote of patient on
the reference to patients by colour
(instead of by bednumber) cf. V2
fig. 3-5
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5.1 GAINING INSIGHT INTO THE USE OF EXPERIENTIAL USER
INFORMATION IN ARCHITECTURAL PRACTICE
A first impression of how user experience could be translated to architectural practice
was gained by confronting the vision of the architect who designed the Maggie’s Centre
in London with how users experience the building. The requirements for the design of
the centre, and by extension all Maggie’s Centres, were communicated to the architects
under various forms. Architects receive two leaflets: 1) A view from the frontline (Keswick
& Jencks, 1995), Maggie’s personal testimony of how it feels to be living with and dying
from cancer, addressed amongst other topics how space can be an uplift or a downfall
under the given circumstances; and 2) the architectural brief (s.n., 2011), which summarizes
Maggie’s aspirations regarding space and spatial experience. Unlike a traditional design
brief, the text describes the desired atmosphere, rather than proposing solutions. Besides
these written sources the client played a crucial role in case of Maggie’s London. Head
architect Richard Rogers had known Maggie personally. Yet, also the staff of the Maggie’s
trust can be considered a reliable source to communicate Maggie’s needs and desires
(Van der Linden et al., 2016). As the design appeared to be successful in creating the
aspired user experience, I conclude that this experiential way of briefing is rewarding.
As the Maggie’s trust’s way of briefing is rather exceptional, it aroused my interest in
the use of information in architectural practice. Moreover, it incited me to ascertain
architects’ view on the use of experiential user information in their design process.
Architects apparently may feel that the use of information stemming from scientific
research could erode the intuitive and artistic side of the profession (McCuskey Shepley,
2006). Therefore, I presented different types of user information during focusgroup
interviews to obtain a sense of the participating architects’ feelings towards the character
of the information. I used a combination of a drawings and photos from the pilot study
(V3 §2.3), Maggie’s architectural design brief, and a video-recording made from the
perspective of a patient being wheeled around in a hospital bed.
In the first chapter of the introductory volume, I already identified initial requirements
for a possible format to inform architects, based on Bryan Lawson’s (2010) analysis of
the combination of artistic and scientific ways of knowing. The format in which insights
are presented should be solution-oriented, be able to contain episodic knowledge, and
communicate layered information. The need for solution-oriented information was
confirmed in the focusgroup interviews (V3 §2.4.). The insights gained into patients’
spatial experience (in motion) are nuanced and layered (chapter 2.5). Offering a
single solution ready to be applied in architectural practice, as may be desired by some
architects (V3 §2.4), will thus not be achievable. However, linking experiential user data
to more abstract conclusions could be a first step in this direction. The character of
the information architects collect tends to oscillate between general and site specific,
and between regulating and inspiring. The insights into patients’ spatial experience (in
motion) can be considered rather general, inspiring information (V3 §2.4.1). According to
the focusgroup interview participants, other interesting information would be references
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(to own or others’ projects), and sporadically testimonies heard during visits to similar
buildings or in (online) movies and own experiences. As could be expected based on
insights from literature (McGinley & Dong, 2011; Restrepo, 2004), the visual presentation
of information close to the original data was valued by the interviewees as being
inspiring and supporting creativity. Yet, to grasp the complexity of the research findings
to the fullest, images do not suffice; they need to be accompanied by patients’ stories.
Testimonies directly relating to particular users’ personal stories may provide architects
the missing information. By connecting these testimonies to conclusions an additional
type of information applicable in architectural practice could be provided.
Although the experiential user information presented to the focusgroup was valued by
the participating architects for being inspiring and supporting creativity, they thought it
to be most useful to convince a client of the importance of space in patients’ experience.
Addressing clients was not the first intent of this PhD. Yet as the Maggie’s centres illustrate,
the combination of a ‘suiting’ client, an engaged architect, and an inspiring architectural
brief, seems to play an important role in realizing a truly user-centred building (V3 §1.6).
Existing tools aiming to support clients in evaluating a design or building, like AEDET
and OAZIS (Department of Health, 2015; TNO, 2015) thus address an important target
group. The way the tools present information - as a checklist - and the scored output
are not what would be expected from an information format that translates experiential
user information and triggers designers’ creativity. Platforms like IDEAs (Lawson, 2010)
and InformeDesign (Informedesign LLC, 2003) are more in line with this aim. Despite
these platforms being much appreciated by designers (Restrepo, 2004), none of these
works with original data on users’ experience as a source of information for architectural
practice.
An additional advantage of the existing tools and platforms is that they can be consulted
online. According to the architects participating in the focusgroup interviews, architects
look up any type of information mostly online. Books are also appreciated, but are more
consulted by an older generation. When developing an information format to inform
hospital design on patients’ spatial experience (in motion), significant attention should
be paid to its appearance. Architects can be provided with a (false) feeling of reliability
through the way information is presented. Information in a documentary format for
example, with the typical spoken voice, is considered by some as trustworthy.
5.2 EVALUATING THE APPLICABILITY OF EXPERIENTIAL USER
INFORMATION IN ARCHITECTURAL PRACTICE
To evaluate the applicability of experiential user information in architectural practice, two
design assignments were set up in which this type of information was provided. The
approach of these design assignments sprung from the insights collected through the
fieldwork at Maggie’s London and the focusgroup interviews with architects. Below I
focus on how this evaluation confirmed or contradicted the insights gained.
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First I studied a design studio in which fourth year architecture students were asked to
design a Maggie’s Centre near the University Hospital in Leuven. They were provided
with the documents from the Maggie’s trust: A view from the frontline (Keswick & Jencks,
1995) and the architectural brief. A group discussion was organised with patients and
caregivers, and (academic) lectures were given on the philosophy and approach of the
centres and multisensory architecture. The studio teachers and I functioned as “the
client” to whom the designs were presented and by whom they were commented on.
By following this approach, cancer patients, and to a lesser extent other users, were
particularly present in the design proposals. This pointed at the role played by the type of
briefing in the relationship architects establish with people they are designing for. Various
students explicitly mentioned quotes from patients as a motivation for a design decision,
as such revealing the value they assigned to this unprocessed information (Restrepo,
2004). Yet, also references to existing Maggie’s centres or other sensory rich buildings
were common. Both episodic knowledge from actual buildings (Lawson, 2010) and
information given in an academic lecture can thus function as a source of experiential
user information.
The second assignment, given to a voluntary group of architects and people from related
professions, built on the insights gained through the focusgroup interviews combined
with the analysis of the design studio. As I aimed to inform architectural design practice
on patients’ spatial experience in motion, only focussing on communicating patients’
(spatial) experience, as was done in the case of the design for the Maggie’s centres,
did not seem sufficient. Providing textual or narrative information and static images are
certainly valuable but do not address the continuous flow of space that characterizes
patients’ spatial experience in motion. Both the assignment and the information provided
emphasized this impact. Three types of information that previously proved to be
successful were offered:
-- Given the expected profit of interaction between architects and patients (V3 §3.5.1),
a real patient was asked to talk with the designers about her spatial experience while
being wheeled through the hospital.
-- The video-recording of the route through the hospital was shown, complemented
with my comments on what I perceived while being wheeled along the same route as
the patients and quotes from patients.
-- Based on the information provided in the video an experiential architectural brief
emphasizing experience in motion was written in line with the brief of the Maggie’s
centres.
Asking three teams of designers to work with these types of information showed the
strengths and weaknesses of the various formats with regard to the communication of
experience in motion. Although all three types of information were considered useful at
some point in the design process, it was mainly the video that drew designers’ attention to
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the flow of spaces. The accompanying quotes and comments on embodied experiences
were a cautious attempt to provide testimonies on (patients’) spatial experience as
additional layers of information. However they seemed to miss the level of engagement
designers could build up through personal interaction with patients, as was shown in the
design for the Maggie’s centres.
5.3 TOWARDS AN INFORMATION FORMAT TO INFORM
HOSPITAL DESIGN ON PATIENTS’ SPATIAL EXPERIENCE IN
MOTION
Triggered by Lawson’s (2010) notion of the layered composition of architecture, I plea
for offering architects layered information. As concluded before: “a major part of the
challenge will lay in finding a way of accessibly communicating the data without losing
the layered content. A simple and reliable structure with an original viewpoint, presented
through a channel architects are familiar with, like the internet, would be ideal” (V3 §2.5,
p. 33). These requirements still count, but should be complemented with the additional
needs that stem from aiming to communicate spatial experience in motion. Presenting
moving images in a way that strikes a balance between informing architects based on
scientific results and inspiring them through presenting raw data constitutes an additional
challenge.
The information layers should be able to communicate the insights gained into
patients’ spatial experience in motion as discussed in volume 2. This means that they
should cover:
-- the different components of experience: perception, meaning making, and
affordance;
-- the aspects that have been identified as impacting on patients’ spatial experience (in
motion): material, social, and time-related;
-- the conclusions drawn from the fieldwork at the different research settings (V2 §5.3).
Based on the forms in which I collected and presented my research, five possible layers
of information can be identified:
-- As many designers including architects are in the first place visually oriented
(McGinley & Dong, 2011) a first layer contains the images, both drawings and
pictures, made by me as part of the research protocol, or by the participating patients.
Some of these show visual elements in the hospital environment directly addressing
visual perception.
-- To be able to communicate the impact of motion, video was added as a second layer.
-- As third layer narratives of various origin like comments from the researcher or
testimonies from participating patients, are added. These complement the visual
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information with sensory perceptions besides the visual, with meaning, and with
affordance.
-- Text explicating one of the aspects can be considered a fourth layer.
-- The full articles reporting on patients’ spatial experience in various hospital settings
and the conclusions derived from them (volume 2) would be the fifth.
By way of a proof-of-concept of an information format based on these layers, I created
a mock-up of an online platform with interactive video. The aim of the format is to
inform architects on patients’ spatial experience in motion. Based on the insights that
designers do not like extensive text (Lofthouse, 2006), appreciate raw, unprocessed data
(Restrepo, 2004), and are visually oriented (McGinley & Dong, 2011), we presented the
collected video material as the starting point. However, the platform also provided the
opportunity to start from the conclusions or the aspects. Since the outcome of the design
studio (V3 §3.5) and workshop (V3 §4.4) pointed at the importance of personal contact
with patients, whether or not in combination with video, the videos were augmented
with audio from interviews with patients conducted during the fieldwork in the hospital
(volume 2). Following one’s own route through the information, creating one’s own
narrative, as is an important added value of hypermedia (Pink, 2007, p. 197). To support
viewers in doing so, the video includes hyperlinks leading to either related conclusions or
aspects, which are then further elaborated. From these conclusions or aspects one could
jump to other videos or images. When viewers would like more information on a certain
aspect or location the full articles as presented in volume 2 could be consulted.
The expert panel’s comments addressed different aspects of the mock-up, the most
important of which were the added value for architectural practice, the character of the
content, the structure, the information layers, and the attractiveness and accessibility.
The information format’s added value for architectural practice is considered by the
expert panel as twofold. On the one hand, insights into patients’ spatial experience is
supposed to be basic knowledge for architects designing hospital buildings. They should
have this knowledge in the back of their minds when talking to hospital boards or other
stakeholders to be able to speak for those who are often not heard in the design process.
On the other hand, the information can also be used to substantiate design decisions. If
the client does not pay attention to patients’ experience, it is the architect’s duty to put
it on the agenda. Results from scientific research can then offer a persuasive argument.
The architects in the expert panel appreciated the character of the content. They would
even like to see it extended with more and a different kind of content than what lies within
the scope of my research. Similar routes in different hospitals would be appreciated, but
also the same route followed by different patients. As I opted to follow real patients in
real-life situations, each of the patient groups started from a different location and had
a different destination. Making a one-on-one comparison of their spatial experiences
is thus not an option. Like the participants in the focusgroup interviews on the use of
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experiential user information (V3 §2.4), the architects of the expert panel wanted to
obtain very concrete information of a kind that research can impossibly offer based on
generalised results. To make an online platform offering this kind of information truly
interesting, the expert panel thought it should contain a high number of testimonies. This
discrepancy between what is expected from research and what is considered trustworthy
as results remains an issue. Yet, the content is valued for being real images and real
testimonies of real patients, which contrasts with the nice images usually presented on
webpages targeting architects.
Presenting all the above-mentioned information - the components of experience, the
aspects impacting patients’ spatial experience, and the conclusions - in a comprehensive
way requires setting up a suitable structure. In the information format presented to
the expert panel the emphasis lay on providing viewers the opportunity to decide ad
hoc which path through the information they took depending on their preferences and
interest. The panel members felt they could not control whether or not they had viewed
all the available information, therefore an appreciated addition to the format would be
to suggest a route through the information while offering the opportunity to divert from
it when preferred. What should serve as an entrance point was a point of discussion.
Some architects of the panel would prefer to start from the conclusions. Others doubted
the relevance of offering conclusions in general. Given the experiential character of the
information offered the majority agreed on entering the information from an experiential
angle, as was foreseen in the mock-up.
The intertwining of different layers of information was subject to discussion within the
expert panel. Unlike what I derived from the design workshop, the panel members did
not like the audio testimonies running parallel with the video. They would have preferred
to watch the video without any comments and later be able to read and maybe in second
order listen to the testimonies. As mentioned, the need to be able to consult conclusions
drawn by the researcher was contradicted by those convinced that they could draw their
own conclusions just from watching the video. Conclusions would be read to check
whether nothing was missed. The added value of the audio testimonies was contested.
Some thought they would be good to check their own ideas against. Others truly
valued them as a source of additional information. Apart from the presented layers, two
interesting additional ones were proposed. Some participants would appreciate plans of
the hospital building to analyse and to locate and judge the character of the place the
videos and testimonies related to. At least one participant would also like links to articles
or texts from other authors on related topics. Most of the others doubted that they would
read these, as they would probably not even read the full articles either.
Finally also the attractiveness and accessibility of the information format will likely add
to its use. According to the architects in the expert panel, the layout of a possible online
platform should be simple and sober. Frequent updates would attract viewers to come
back to the site. Videos should load fast and play smoothly. Sharing the material through
an existing platform like Vimeo, where it shows up with similar topics seems an interesting
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way to catch people’s attention.
To summarize volume 3, the discussion with the expert panel resulted in the following
requirements for an adequate information format:
-- communicating motion from a patients’ perspective is interesting and supported well
by the video, however, a larger number of videos is needed for viewers to draw their
own conclusions;
-- the content should be easy to consult:
-- viewers need to be able to access the information through different entrance
points;
-- a preferred, structured path through the information should be provided and be
easy to follow;
-- the presented information should leave the choice to the viewers whether they want
to view the videos, listen to the testimonies, or read the conclusions.
-- the format should be expandable, with more research results, but also with additional
layers, like exemplary projects represented through plans or images, or (links to)
scientific articles. This latter information layer should not disturb the main route
through the experiential information
-- when text is presented it should not be too long (Lofthouse, 2006), ideally
accompanied by images and visually well structured;
-- the format should be easily findable and accessible. Being suitable to be consulted
online seems the most valid option.
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5.4 CONCLUSION
The aim of my PhD pursued in this volume was to inform architectural practice
on patients’ spatial experience (in motion). As indicated by the reactions
in the focusgroup interviews (V3 §2.4), the workshop (V3 §4.4), and the
expert panel (V3 §5.3), architects recognize the relevance of this information
for architectural practice. Moreover, they would value it to become tacit
knowledge applicable throughout the design process, especially:
-- when talking to hospital boards or other stakeholders to allow them to
speak for those who are often not heard in the design process.
-- to substantiate design decisions. If a client does not pay attention to
patients’ experience, architects can thus put it on the agenda. Results from
scientific research can then offer a persuasive argument.
Some of the new insights gained by presenting the proof-of-concept to the
expert panel contrasted with what I derived as requirement from the results
of the focusgroup interviews and design outcomes. I aimed to present the
information as closely as possible to a conversation with a real user, however,
the patients’ testimonies were rather considered as an addition to the video
and images than as an intrinsic part the information. This confirms architects’
visual preference and raises questions on how patients’ testimonies can be
given a more central role in architectural practice.
The presented requirements give a good indication of the direction to follow.
Further research should show whether they are satisfactory yet to transfer
the type of information that apparently helps architects to design truly
user-centred buildings as is illustrated by the Maggie’s centres (V3 §1.6).
Whether the proof-of-concept focused architects’ attention on the moving
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Conclusion
The content was valued for its authenticity and could even be extended with
better comparable, not necessarily real, information. By presenting the proofof-concept of the information format to the expert panel I gained some
additional, sometimes contradictory insights. More explanation regarding
the why and how of the information was demanded, but text should be
avoided as much as possible. Conclusions were superfluous for some, but
proposed as a main entrance to the information by others. To meet these
contradictory wishes, flexibility of the format is a key concern.
Conclusion
aspect could not be clearly derived from the discussion with the expert panel.
More research is needed to align insights into patients’ spatial experience in
motion with an information format applicable in architectural practice. Some
hints are given that clients could take up an important role in this. However,
investigating their role in the design process is a topic for future work.
Providing architects and other viewers different layers of information without
forcing them to consult what they may not be interested in, asks for a format
that supports multi-linear exploration of the content. The format should also
be easily accessible and consultable. By making use of hypermedia both
requirements could be met. Moreover, as designers appreciate to make their
own interpretations of raw data (Restrepo, 2004), which was confirmed in the
expert panel, empowering them to create their own narrative (Pink, 2007)
seemed an additional benefit. However most architects in the expert panel
did not recognize this benefit. The presented information format without
much guidance on the optimal route to take through the information offered
received mixed comments.
Simply presenting the insights gained in volume 2 will likely not suffice to
foster architects’ tacit knowledge on patients’ spatial experience in motion.
Truly informing architects asks for a way of briefing that is attuned to the
character of the information, thus taking into account experience and motion.
The final form of the information format should thus communicate patients’
testimonies, allowing architects to relate to their lived experiences in all their
richness, and provide a profound insight into the issues at stake while moving
through a hospital building, addressing not just visual elements but also other
sensory aspects, meanings and affordances of the built environment.
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References
Department of Health, 2015. Achieving Excellence Design Evaluation Toolkit (AEDET Evolution) http://webarchive.nationalarchives.gov.uk/20130107105354/http:/www.dh.gov.uk/en/
Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_082089
Informedesign LLC, 2003. InformeDesign: Where Research Informs Design http://www.informedesign.org/ (accessed 4.19.15).
Keswick, M., Jencks, C., 1995. A View from the Frontline.
Lofthouse, V., 2006. Ecodesign tools for designers: defining the requirements. J. Clean. Prod.
14, pp. 1386–1395. doi:10.1016/j.jelepro.2005.11.013
McCuskey Shepley, M., 2006. Evidence Based Design and Architecture, in: Wagenaar, C.
(Ed.), The Architecture of Hospitals. NAi publ., Rotterdam, pp. 267–270.
Pink, S., 2007. Doing visual ethnography : images, media, and representation in research. Sage
Publications, London.
s.n., 2011. Maggie’s Architectural Brief.
TNO, 2015. Healing Environment meten met behulp van OAZIS https://www.tno.nl/nl/aandachtsgebieden/leefomgeving/buildings-infrastructures/innovatiecentrum-bouw-icb/healing-environment-meten-met-behulp-van-oazis/
environment in designing a Maggie’s Cancer Caring Centre. Des. J. (forthcoming).
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Margo Annemans
Supervisor:
Prof. Ann Heylighen
Co-supervisors:
Faculty of Engineering Science
Department of Architecture - Architecture & Design - Kasteelpark Arenberg 1 - 3001 Leuven - Belgium
tel. +32 16 32 34 52 - [email protected]
rxd.asro.kuleuven.be

Informing the design of hospital architecture on patients

Transcription

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