Well-being through design: transferability of design concepts for healthcare environments to ordinary community settings

Authors: Will Boex, Sam Boex, of Boex, design consultants

………………….. Abstract

Purpose The paper explores current interest in the concept of well-being, and traces, with examples, the growing use of design ideas in healthcare settings to reduce stress and maximise efficiency. Finally, we look at the relevance or transferability of such design principles and approaches to opportunities to enhance well-being through design in community settings.

Design/methodology The potential in this approach is illustrated with some examples of design approaches applied in healthcare, teasing out the wider implications with ways to explore and arrange the patient journey, for example, or the “care pathway” for a vulnerable adult into a care or support service for maximum benefit.

Findings Thinking on enhancing well-being by design has been further advanced in applications in the health service, but a number of design concepts and approaches seem to promise similar benefits in community settings where issues in managing the health and well-being of vulnerable individuals are equally relevant.

Value Design principles may be especially useful in current efforts towards creating dementia-friendly homes and communities, or “psychologically informed environments” in services for marginalized and excluded individuals.

Paper type: General review

Keywords: stress; patient journey; touch points; designer task; generalisability; dementia-proofing; psychologically-informed environment …………………..

Well-being through design

The concept of well-being is now well established, both in our ordinary language and more recently, in government policy. With increasing frequency economic think tanks and political philosophers are suggesting that the goals of public policy must extend beyond simple measures such as Gross Domestic Product, to consider broader measures, such as the happiness of the population. The UK Coalition government has stated that it will regard enhanced well-being as a measure of the success of its policies, in addition to more traditional measures such as economic performance. How this may be achieved in practice – especially in a climate of financial austerity – is less clear. There are certainly significant influences on well-being which are beyond our control– for most of us, at least - such as climate change and the state of the economy. But there are features over which we do exercise some control, such as lifestyle, and the things we spend money on, including the things that the state spends our money on, on our behalf. Over this spending we can exercise control, if at all, via the ballot box and other forms of representation. Perhaps for this reason it is in this last sphere of effects and influence that there is currently most concern to develop the evidence base for the effectiveness of the money spent, in enhancing well-being.

Measuring and defining wellbeing

We must begin with some definitions of well-being; and how to measure well-being, and the improvements that we can aim to bring, in design. So, we might start with a dictionary definition, such as:  “the state of being comfortable, health or happy” (Oxford dictionary); or  “a state of complete physical mental and social wellbeing, not merely the absence of disease or infirmity” (the World Health Organisation’s definition). These definitions are still a little fuzzy, even ambiguous – though they at least give us some context, in the way the word is used. Perhaps this is inevitable and even right, for a conception of an issue that has such a pervasive, and also personal, impact on our lives.

Nevertheless, if it is hard to define and measure well-being per se, we can more confidently measure features at the opposite end of the spectrum - non-well-being. We can conceive of this generally in terms of stress, this being both an emotional and a biological state or experience. There have also been attempts recently to identify significant symptoms or markers of stress in the population as a whole, such as rates of depression, substance abuse, suicide, and other related indicators which are more or less measureable (Wilkinson & Picket, 2009: Marmot, 2009; Young Foundation, 2009).

There is now a growing trend in research looking at the effects of environment design on wellbeing, building upon Ulrich (1984) whose pioneering work established the link between reduced recovery times in patients who had views from a window. For example, as part of a research programme on healthcare environment design, researchers at the University of Warwick are working to better understand the links between stress, wellbeing and environment design (Cain et al 2011a). In one project focussing on the Emergency Department – a highly stressful environment, staff identify the stressors within the environment along with how they cognitively and emotionally restore from these stressful interactions. A variety of techniques e.g. walk and talk interviews, comments cards and postboxes located around the department are used, along with measures of staff stress.

A co-design process with staff and the research team is seeking to design solutions to these experiences, and over time to measure the effects of stress-reducing design interventions (Cain et al 2011b, Payne et al 2011, 2012). Another project has considered the affect of the sound environment (the ‘soundscape’) on staff and patients within a hospital ward, as noise is often considered as a negative and unwelcome aspect of hospital environments and can contribute to stress. Interviews were conducted with staff and patients, along with lab-based listening evaluations with simulated ward soundscapes to create a better understanding of which aspects of the ward soundscape and which design interventions could contribute to a more positive perception of the ward experience (Mackrill et al 2011a, b).

For a further example, in an era when waiting lists and waiting times has become a hot political issue, there has been some interesting work comparing patients’ perceptions with the reality of waiting times. The difference in perception may reflect the fact that the anxious person has worries looming large and is in a state of heightened arousal of the senses. With no distractions, he or she may feel every moment drag.

But in healthcare settings, where there is great attention paid to the costs of services, and consequently a huge amount of relevant data to draw upon, we can also add other specific ‘measurables’ such as recovery times, incidences of aggression to staff; and also perhaps subtler questions, such as replacement costs. So we can now refer to studies, with fully quantified effects, which indicate that patients suffering with depression who are admitted to the sunny side of a mental health ward will be discharged sooner; and that moving a reception area in an A&E department can reduce assaults on staff (Design Council 2011).

Similarly in housing, it has been suggested that such measurables as repairs, arrears, tenancies abandoned and high turnover, are useful objective indicators of stressful environments and non-wellbeing for tenants. Since crime, and fear of crime, is a major stress, there have been attempts to consider how to ‘design out’ crime in the layout of buildings, transit and communal areas, defensible space, etc

In more specialist housing such as sheltered accommodation or residential care for more vulnerable people, there are studies that suggest that, for example, a pleasant view onto greenery seems to delay the progress of dementia (references yet to add) – possibly because it will provide a focal point for attention and so stimulate the individuals orientation in the external world. Equally significant here, though, will be the studies that have demonstrated that allowing elderly residents a measure of choice and control over their environment – timing of meals, choice of furnishings – will actually prolong life (Langer & Rodin, 1976).

Meanwhile, there are many studies on the link between stress and health (Foresight, 2008) Finally, laboratory research on rats, finding that living in a more stimulating environment can improve recovery from traumatic brain injury (Hamm et al: 1996); will show more growth in neural synapses (Schwartz, 2003), and will even ward off the effects of genetic debilitating illness (Döbrössy& Dunnett, 2008), all suggest that these effects of the environment are not merely symbolic and subjective, but lie very deep in our basic biological nature (Folensbee, 2007: Cozolino, 2002) .

Feel-good design

One useful place to start, in looking for the potential healthcare gain from good design, may be to look at examples of the “feel good” factor in design in other fields. Many services put well-being (or, as it tends to be described in commercial terms, “customer service”) at the heart of their offer to their clients. Some of the best examples here would be hotels and spas. These are businesses that set out to create places that make the customer feel good, relaxed, wanting to be there, even believing, in the case of spas, that it is doing them some good. We can also learn from retail settings, where we also want customers to feel welcome, and to feel good about the choices (in this case, purchases) they can now go on to make.

In healthcare, certainly, there are different priorities. Apart from the essential tasks of helping people get better with technical assessments and clinical interventions, there are issues of infection control; and, granted the need for intimate personal details, confidentiality. For both cost and safety considerations, there is a very great stress on efficiency. There are often huge numbers of people in flows through the service and the space – some fast flows, some very slow, or repeated – with many of these people in discomfort, with pain or disability. There are, however, other, arguably subtler, considerations in managing the emotions of vulnerability, anxiety and dependence; and of confidence and trust.

Mapping the patient journey and “touch points”

We have found it useful to identify and map out the “patient journey” in terms of “touch points” – the times and place where the individual interacts with the physical and social environment of the building. This gives us a useful framework through which to explore the use of space, and we will use this to consider the patient’s encounters with and experience of the physical and emotional presence of the service they have come for. But we can in fact take the same approach back even long before, and consider for example the styling, and the image of the treatment environment, which is given in appointment letters, or any web presence for the service.

Notorious in healthcare for example is the management of car parks. But this is not simply a question of parking charges. The health service often re-uses premises designed originally for other needs, and other technology – perhaps many years old. Buildings are adapted and departments moved. This creates problems of signage, and access to any particular unit is often less than ideal. Yet the Eden project, in Cornwall, provides a good example of a re-used and re-imagined space with access points crafted to create a positive atmosphere, in which the – inevitably – long journey from multiple car parks to the site is made a pleasant experience in its own right…….

The next key touch point is the entrance itself. We suggest that the entrance signage needs to convey first of all re-assurance – this is the right place. Then the entrance itself – the doorways and “street furniture” – can help to build confident expectations of what to find beyond the entrance. In healthcare settings, there is a tendency to rely heavily on giving detailed but often conflicting information. In our work, we aim to make entrance ways not just less intimidating, but also more intuitive, so that there is less reliance on information and instructions. It should feel right. At each stage, the design team will be asking: What information is given off? Is it what you want? Information giving is not just factual; it is a gesture of reaching out – a social act. Equally important is the patient/customer/user’s immediate orientation, once inside. In the retail trade, much thought has gone into the entry spaces, and what are known as decompression areas, where the customer will be initially familiarising themselves with the contents, hinting at future decisions and sequences of action. Does this place feel right for me? To enter is to take on membership of a community of users, and involves rites of passage. The physical and information design then needs to give confidence as to routes and implied permissions, the behaviour that is expected of you here. Healthcare design here must also recognise the need for safety and security for staff and patient alike, and increasingly we recognise the vulnerability of both.

Creating spaces for stress reduction

Once through the doors and engaged, we can go on to look at some examples of design to reduce tension. One key area – found in almost all buildings – is corridors. These are typically places of noise, action; and corridor noise increases agitation. Corridors also embody un-spoken power relations; doors can exclude and bar, as well as providing entrance. They are used to negotiate physically the person’s progression in and through some process, their membership. Here, the use of graphics, lighting and colour, texture can “say” things that then do not then need official notices and instructions. Thus they can provide landmarks that reduce anxiety and so treat and improve well-being and a sense of belonging

Once inside, we are in the work area, the inner sanctum. Here too there will typically still be a mixture of waiting and purposive activity, and here we may begin by mapping movements, of staff and patients (and family); routes and flows of people through the area, identifying busily used areas and available space for the comfort of those waiting without compromising efficiency. From this we can identify the key tasks being performed; and the space which is needed and that which is not in use for those tasks ( see Fig 1) . This can then be used to create spaces for greater comfort for those waiting – usually service users, patients or family - without compromising efficiency.

The design challenge here is to create spaces where patients/people will feel ok to be, maybe even want to be. People will naturally gravitate towards spaces where they are comfortable, whilst also allowing staff movement without hindrance or creating inconvenience to users; or use of extra effort or authority to establish behaviour. Even quite trivial interactions can have a striking cumulative effect, in making a person feel welcome or uncomfortable, there by right or there on sufferage, and so defensive.

The design challenge here is to creates spaces where patients/people will feel ok to be, maybe even want to be, to make the experience comfortable, even soothing. Here we can look to use lighting to enhance a welcoming feel. We can give clear permissions via lighting, and materials. For example, it is generally best to avoid sharp edges, and hard materials, which inhibit both comfort and fluid movement. People give them a wide berth, so they take more space, and can create obstructions and awkwardness.

Otherwise, lighting and décor (or planting, a sculpture) can “say something” in otherwise un-used spaces. Colour and texture of furnishings can also make statements that give clear permissions to “users” to use the space comfortably, as if they had a right to be there. We need to consider the use of colour –for example, green is often seen to be calming, blue is cool, white is efficient/clinical and red is speedy (which why it is often used in the packaging for fast food). But psychology of colour psychology of colour research is a contested field, and the impact is probably not universal but varies in each environment.

For example, in the vestibule area of a counselling service for young people, we may want to reduce their anxiety, and the threatening force of their need to face up to the challenging content of their experiences. This might be eased through a décor with an external focus on visually striking objects, such as sculpture, posters. Even the conventional waiting room furnishings of glossy magazines may have a place – though the current vogue in teenage sub-cultures is often hard to second guess..

One question is how far to allow or even encourage patients/users to adapt their environment – choosing or switching seats, moving chairs, to suit their own comfort or their family configuration. Agitated people- for example, patients on a dementia unit - may move furniture around; and others – especially children, whether as patients, or as visiting family - may need some distraction

How much to allow or encourage this? This may be a matter of how many regularly share this space and may need to feel “at home” here? But particular zones where those sitting and waiting can do things for themselves can create a sense of belonging and ease tensions. A play space for children, or a web-enable terminal for older children, can attract an agitated youngster to an area where they will not be in the way, and can do no harm, so that worried parents can relax.

The designer’s task

Such issues need teasing out in discussion with those who commission, and especially with all those who will use, the space. It is important for the designer team to get the essential commissioning brief very clear (or other unstated priorities can over-ride). Especially perhaps in healthcare and hospital settings, implicit hierarchies can suddenly intrude on more collective and consensual attempts to find new ways of working. But if we may want to have a real impact, we may want to innovate; and that means to take risks.

Design is then a collaborative activity, and the role of the designer team is to lead the collaboration and tease out the implications of users’ thinking on requirements and use of space. We have found great value in using workshops with all the participants in a service, to explore and un-pick the issues. Although there is now some very sophisticated software that designers can use to visualise uses of space with flexibility and precision, we will avoid using computer-assisted design in these settings, as this creates a distance between the designer/expert and the user.

Instead, we use quite simple, low tech techniques, such as flying in cardboard sheets, to represent how walls and room dividers create a space; using paints and plastics for colour, and working with hand-crafted models, that other participants can also use and ‘play’ with. Colleagues of ours, for example, when working on a community project involving local children, used cake to model walls and furniture; at the close of the session, the children got to eat the cake that they had worked with (see Fig.2) .

We would however particularly stress the importance of getting involvement and feedback from all stakeholders – including consulting with the admin staff, cooks and cleaning staff. If this last may seem to be taking the political correctness of consultation to extremes of piety, we would point out that cleaners have insights on the use of a building that others simply do not see. Meanwhile, if the over-riding concern is for costs, we can point to the savings of longevity - another good reason to talk to cleaning staff. Furniture and rooms that are harder to clean, or constantly moved around, will incur more wear and tear …

Generalisability of design principles to community settings

Health funding for health buildings comes within a healthcare research culture which, over many years, has demanded a clear rationale and good evidence of benefit, as well as persuasive logic, in efficiency and/or other reduced costs; and in recent years, there has been considerable work to identify the healthcare gain from good design – work which is on-going.

The question we wish to address finally is the issue of generalisability. Care, both health care and social care, especially for long-term conditions and disability, is now often provided in people’s own homes, or in residential care, or in similar settings. In such community environments, too, therefore, we will now need to explore the ways that more conscious design of the built environment can similarly support design of the social and emotional environment (CABE, 2008).

How far can we say that the design principles for healthcare gain in healthcare establishments may apply outside, to healthcare in community settings? We would suggest that design thinking may often offer fresh perspectives leading then to new insights into the potential to produce the desired atmosphere, and to re-design spaces to reduce potential stresses and the additional problems that stress brings.

Concepts such as touch points to imagine the user’s (and carer’s) experience of entry and passage through the available space can be applied more widely. The careful use of colour, texture and lighting, rather than reliance on verbal instructions to imply boundaries and permissions, may well be relevant for services for all those client groups that may have problems with comprehension, literacy or authority figures.

Especially in waiting areas or similar spaces, there may often be the option to offer activities, or other ways to engage, that the user can modify to suit themselves or their family or other social grouping. Some thought can be given to the “sonic environment” in corridors and in other areas where sound creates atmosphere. Just as in health settings, in many others where users typically have heightened vulnerability and may be expected to be more sensitive to stress, it will be all the more significant to consult with all stakeholders, as we need to understand the needs and perceptions of users most thoroughly Just as in healthcare, design in many care settings needs to recognise and address broader issues than simple “bottom line” calculations of productivity or sales - issues such as a concern for staff safety as well as customer security, and the need to work towards the relative compatibility of the space needs of multiple communities, of staff, users, carers and others, to minimise potential conflict.

We are seeing currently efforts to identify approaches to dementia-proofing of care homes and of ordinary domestic residences (Chapin, 2011), and also outside the home. A recent Housing LIN Viewpoint paper (Mitchell: 2012) has pointed out that, over the past 20-30 years, we have seen a transformation of many areas of outside space, to become wheelchair friendly and ensure disability access. With dementia rapidly rising as an issue for the population as a whole, we may now need to devote similar attention to ways to make our neighbourhoods more accessible, with more attention to signage and other design features.

We have also seen calls for more “psychologically informed environments” (CLG&NMHDU, 2010; Johnson & Haigh, 2010) – for example in homelessness shelters and resettlement services, refuges and foyers – and Cockersell for example has argued (2011) that working with the environment as a whole, and not solely with individual interventions, may also hold the promise of greater efficiency and hence savings, in a cost-conscious era.

It is worth noting finally that the recent operational guidance on development of ‘psychologically informed environments’ (Keats et al 2012) included comments on the need for physical design and layout of the environment to support the engagement and resettlement task, and also calls for “evidence generating practice”. There is clearly a need for more research on effective design in community settings, comparable to the efforts that have recently gone into design in healthcare settings, to bring together researchers and practitioners both in care and support and in design, to identify first examples of successful innovation, and to gather appropriate data by which to measure success.

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