HEALING DESIGN: A HOLISTIC APPROACH TO SOCIAL INTERACTION IN PEDIATRIC INTENSIVE … ·...

ABSTRACT

This paper explores the relationship between healing and its embodiment opportunities inarchitectural design. It puts forward a method for identifying some key architectural vari-ables which may be measured for their sensitivity toward healing design. Specifically, itexamines the impact of the pediatric intensive care unit (PICU) setting in the healingexperience of children, as well as families and caregivers. Data is collected through aqualitative methodology including participant observations, behavioral maps, and in-depth interviews. The meaning and value ascribed to the PICU setting in the observedTurkish and the U.S. facilities present different care practices and philosophies. Howev-er, field studies identify social interaction as a universal healing function transcending thephysical setting. Crowding, parental absence, and over-stimulation in a single multi-bedunit play against healing in the Turkish model. However, staff collaboration and sense ofdedication support healing. In the U.S. model social support, family-centered-care, andfocus on patient experience are acknowledged as central concepts to healing. This studyidentifies six design indicators for healing social interaction.

Keywords: Pediatric Intensive Care Unit (PICU), Social Support, Social Interaction,Common Gathering Areas (CGAs), Healing

INTRODUCTION

This study is based on the comparison of the existing spatial organization anddesign trends in two pediatric intensive care units (PICU) to emphasize their sim-ilarities and differences, and explore how their physical environment influenceshuman behavior. The study calls for a holistic approach to identify the potentialfor cultural healing in health facility design and promote cross-cultural under-standing for a global context that can generate better hospitals and health caredelivery models. With this objective, the PICUs of two children’s hospitals were

243

HEALING DESIGN: A HOLISTIC APPROACH TO SOCIALINTERACTION IN PEDIATRIC INTENSIVE CARE UNITS INTHE UNITED STATES AND TURKEY

Hilal ÖzcanWHR Architects, Inc., Houston, Texas, [email protected]

compared. The observed Turkish hospital (HCHA) is an academic non-profit350-bed hospital established in 1958. The PICU consists of a 9-bed single roomunit and one isolation room. While their acuity is high with various disease enti-ties, they specialize in trauma and cardiac care. No data is available for length-of-stay (LOS) and mortality rates. The U.S. hospital (CMCD) is a private, non-profit 406-bed institution established in 1948. (CMCD had 348 beds during thecase study period in 2002, which paralleled the bed number of the observed Turk-ish hospital.) Caregiving is provided for patients suffering from medical, surgi-cal, neurosurgical, traumatic and cardiac diseases. It contains four specializedPICUs, which foster family centered care. With a total of 63 beds scheduled, ithas the largest PICU in the U.S. The average LOS in the PICU is 4.7 days, andPICU mortality rates rank among the lowest in the U.S.

RESEARCH STRATEGY

In contrast to curing, healing is a psychological and spiritual concept of health. Itmay not be effectively understood with quantitative and statistical studies, whichfragment analyzed concepts to single measurable criteria. To inform healingdesign indicators, a qualitative methodology seemed more beneficial in thisstudy. The use of a holistic approach called for the provision of practical, physi-cal and psychological needs through 1) stress reduction and relaxation, 2) socialsupport and positive social interaction (touch, talk, meaningful communication).The study identified six design indicators, which are provisional, scale, location-al, functional, symbolic, and ambient interventions for healing.

LITERATURE REVIEW

The benefits of social support and social interaction are well-established in healthdesign literature. However, there is only a moderate amount of research concern-ing how facility design can facilitate or hinder access to social support and inter-action. The six design interventions which emerged in this study support the lit-erature regarding the healing benefits of social interaction.

Hilal Özcan

244

Figure 1. Observed Turkish Hospital HCHA (left) and U.S. Hospital CMCD (right)(Image credit: Hilal Ozcan)

Social Support

Social support is the emotional support, caring and tangible assistance that a per-son receives from others (Ulrich, 2000). Research in healthcare and workplacesituations found that individuals who receive higher social support experienceless stress and greater health. Socially isolated people, on the contrary, experiencehigher rates of illness and less favorable recovery indicators. For example, car-diac patients receiving higher levels of social support recover more quickly fromheart attacks and have more favorable long-term survival rates. Social supportimproves recovery outcomes in myocardial infarction patients, and survivallength in patients with metastatic cancer (Spiegel et al, 1989).

The evidence showing benefits of social support across health-relevant contextssuggests that design promoting social support will reduce stress and improve out-comes (Ulrich, 1991). Provisional design interventions for fostering social sup-port include comfortable, pleasant waiting areas; convenient access to food, tele-phones, and restrooms; convenient overnight accommodations; and accessiblegardens with sitting areas that encourage socialization.

Social Interaction

Staying connected with others has important healing benefits. Social and parentalsupport plays an important role in helping patients recover from illness. Evidenceindicates that social interaction levels can be increased by providing lounges andwaiting rooms with comfortable movable furniture arranged in small flexiblegroups (Ulrich & Zimring, 2004). Studies in psychiatric wards and nursing homeshave found that appropriate arrangement of movable seating in dining areasenhances social interaction and improves eating behaviors (Melin & Gotestam,1981; Peterson et. al., 1977). Research on day rooms and waiting areas has shownthat arranging seating side-by-side along room walls inhibits social interaction(Holahan, 1972; Sommer & Ross, 1958).

Social interaction in an ICU may be influenced by: 1) floor and room layouts, 2)physical, visual relations and spatial ordering systems between CGAs, 3) furni-ture placement and settings, 4) interior order and transparency. For instance,“heavy or unmovable furniture inhibits social interaction, while comfortable andmovable furniture arranged in small, flexible groups can facilitate it” (Levin,2003). Locating support areas closer to patients may improve social support andcollaboration. Since CGAs were not present in the Turkish unit, the CMCDmodel indicated the social benefits of these rooms, which facilitate interaction.

MATERIALS AND METHODS

A qualitative methodology is used to emphasize the relationship between theknowledge sought and the methods used to reveal that knowledge. Naturalistic

1st International CIB Endorsed METU Postgraduate Conference Built Environment & Information Technologies, Ankara, 2006

245

inquiry, which originated in the work of Lincoln and Guba (1985), became themethodology of choice. Six data gathering methods were used: 1) participantobservations, 2) behavioral maps, 3) in-depth interviews, 4) measurements of thephysical environment, 5) analysis of medical records, and 6) floor plan analysis.Both the Turkish and U.S. model were observed for six weeks each.

Participant Observations

Participant observations involved intense social interaction with people in theirown setting. Continuous-interval recording every quarter of an hour recorded avariety of caregiver and patient behaviors and background variables from differ-ent locations. Observation notes standardized behavioral (patient’s state, comfort,well-being; caregiver attention, proximity to patient, tactile, visual, vocal stimu-lation of the patient; family state, comfort, well-being, caregiver function) andenvironmental categories (room layout, flexibility, patient monitoring, equipmentattached to patient, general appearance, temperature, sounds, smells, lighting).Daily observations lasted for 4-6 hours. The researcher also spent nighttime hoursto test the validity of the generalizations emerging from daytime observations.

Behavioral Mapping

Behavior is mapped to space to determine how humans interact with space andorganize place activities. Behavioral maps were recorded from different stationsto compare the two units, which differed in size and spatial configuration (openversus bay design), and to determine what individuals do in different areas of theunit. The data was collected by identifying subjects and recording their activity,path, and interactions as well as the movement of equipment and furniture everyquarter of an hour for 65 hours, which resulted in 263 data entries.

Individual in-depth Interviews

Interviews were conducted individually, audio-taped in full, and content ana-lyzed. Fifteen interviews were conducted in Turkey, and fifteen in the U.S., whichidentified needs assessment by staff members. Six categories guided the inter-view protocol: 1) personal questions, 2) practical and psychological needs ofpatients, families and staff, 3) evaluation of social practice, 4) evaluation of thebuilt environment and how it responds to perceived social and psychologicalneeds, 5) social and professional relationships, and 6) cultural diversity.

Measurements of The Physical Environment

Quantitative measurements of daylight levels and walking distances were record-ed in all four units at CMCD. The impact of daylight and walking distances onstaff behavior was observed qualitatively.

Hilal Özcan

246

Analysis of Medical Records

Medical records were gathered from CMCD for the study period to identifybehavioral outcomes of patients, families, and caregivers, and relate them to envi-ronmental variables. Medical records included patient demographics, length-of-stay (LOS) days, and mortality rates. Information about families’ needs wasobtained from 2000-Strategic-Plan and the final report of Patient Family FocusGroup Interviews. Staff performance data included nurse quitting rates and nurs-ing errors. Unlike the U.S. hospital, where patient admission, family evaluation,and staff performance data was available, there was only a handful of patientadmission data, no family evaluation data and no staff performance data in theTurkish model.

Floor Plan Analysis

This included a quantitative evaluation of plans that measured and comparedquantitative facts such as room dimensions and walking distances between them,and a social evaluation assessing the links among the different areas of the facil-ity. Floor plan analysis revealed six themes, emphasizing CGAs: 1) Unit spatialconfiguration, 2) location and adjacency of spaces, 3) acoustic/physical separa-tion, 4) visual control, 5) spatial organization, location of equipment and furni-ture, 6) the numbers and size of spaces, walking distances, and proximitiesbetween.


247

Figure 2. ICU Floor Plan, Turkish and U.S. PICU (Image credit: HCHA, CMCD)

RESULTS

Provisional Intervention

Provisional intervention defines the minimum program requirements for greatersocial interaction, social support and collaboration among patients, families, andcaregivers. Provisional objectives relate to the quantifiable aspects of space andbasic programming issues, such as the quantity, size, and type of spaces. Findingsrevealed that the core values of family-centered-care model relate to the provi-sion of CGAs, particularly patient room, waiting room, staff lounge, counselingroom, consultation room, as well as the provision of family space in the patientroom.

Single Patient Rooms (SPRs)

At CMCD, the oldest ICU is a single open bay environment, which is used as astep down unit. The general, cardiac, and trauma units contain SPRs, which haveincreased steadily in both room and unit size. The Turkish ICU is an open multi-bed unit, diminishing environmental control, privacy, and family presence atpatient’s bedside. It also increases overstimulation, noise, exposure to resuscita-tion and death. If the provision of single rooms is not feasible, double-occupan-cy rooms or shared clusters for 3-4 patients would be more progressive than theopen bay. Providing resource centers for staff and families in close proximity topatient areas would support healing.

It was observed that the provision of SPRs increased the opportunities for inter-action between caregivers and families. While working in individual roomsreduced simultaneous staff interactions, the staff station may have been perceivedto be less threatening (Figure 4). In the open bay environment, the staff stationinhibited privacy of conversations. For instance, when a nurse needed supportfrom colleagues, she feared to seem incompetent. In the U.S. model with singlerooms, feeling less threatened to be overheard nurses frequently invited the care-givers at the staff station for input. In the Turkish model, double, triple or evenquadrant-occupancy rooms or clusters may increase privacy and improve staffcollaboration.

Staff Resource Center (SRC)

The provision of generous space for staff rejuvenation function impacts staff sat-isfaction and performance, while increasing staff interaction. Turkish caregiversreported that they had a high degree of staff interaction and collaboration whenthere was a small room and kitchen in the unit, where they prepared their meals,celebrated birthdays, and interviewed families. This room was demolished duringthe 1998 ICU renovation. Four years later, nurses expressed their need for a stafflounge and staff refrigerator proximate to the PICU, which will enable them to

Hilal Özcan

248

have a proper lunch break. The provision of a small break room for 8-9 caregiversequipped with a kitchenette, refrigerator, dining table, and comfortable sofa tomeet their practical needs will increase staff performance and dedication.

Family Waiting Room (FWR)

Since the waiting room function is not present at HCHA PICU, families wait in apublic hallway, from where they can view the unit through transparent glazing.Many of them often sabotage ICU access rules, thereby increasing cross-infectionrisks. In this spatial organization, caregivers are often distracted trying to keepfamilies out of the unit. Alternate operational solutions were considered such asorganizing scheduled family-physician meetings and encouraging them to wait intheir homes for information so they can banish family presence in the hallway.

Family Resource Center (FRC)

A centrally located room equipped with research facilities, Internet accessibility,business center services (fax, copier, printer), a library of medical information,


249

Figure 3. Patient Zone, Turkish and U.S.PICU (Image credit: Hilal Ozcan)

Figure 4. Staff Station, Turkish and U.S. PICU (Image credit: Hilal Ozcan)

meeting rooms for small and large groups, and adequate facilities (washer/dryer,refrigerator, food service, a kitchen to prepare meals, sleeping arrangements) willimprove family well-being, thereby impacting patients’ medical outcomes.

Scale Intervention

Scale indicates a relative system of measure, which can range from intimate spa-tial order to gigantic and monumental. In the history of architecture, human scalehas been a reliable source of measure, and various trends emerged to the humanscaling of a building such as anthropomorphism, which addressed the relation-ship between architecture, human body and human sensory experience. Howev-er, the role of the human body in informing the size and scale of the ICU has beenlimited. In this study, size and scale emerged to be the most important design indi-cators influencing the perception of an ICU and informing higher level designinterventions for healing.

Programming for the most beneficial size of CGAs may impact the curing aspectsof care through reduced LOS days. This is often linked with cultural factors andspatial comfort that is also culturally influenced. Scale influences spatial percep-tion through comfort and image. Particularly, a generous patient room size mayindicate the focus on healing design. However, due to the diversity in the percep-tion of scale, 1) spatial comfort and image are by and large culturally influenced,and 2) different cultures utilize and experience the same space in different ways.

The Turkish unit’s CGAs and department size per patient are approximately five-fold smaller. However, whatever was perceived to be an appropriate size in theU.S. model, Turkish caregivers found out of scale and to have lost its connectionto the people experiencing it. Neither can they imagine the size requirementsneeded for the single patient room functioning efficiently with their currentresources. On the contrary, most felt comfortable with the open bay, where theycould see all patients at once.

Increased unit size increases walking distances, and reduces the chances forsocial interactions. The relationship between scale, geometry and spatial organi-zation has long interested health care architects regarding how to size each ICUspace, and configure the spatial combination most effectively. Ozcan and Caden-head (in review) compared ten exemplary U.S. units awarded by the Society ofCritical Care Medicine since 1992. Indicating that the ICU and patient room sizeincreased steadily since 1960s, they claimed the design trends to increase thepatient room size will diminish in coming years, while new growth will occur innursing unit support (NUS) and common gathering areas.

Locational Intervention and Spatial Ordering Systems

Locational intervention relates to planning for the most beneficial locations andproximities between spaces for promoting social interaction as well as function-

Hilal Özcan

250

ality, visibility and privacy. Reducing walking distances between inpatient areasand support spaces will enable nurses to spend more time with their patients.

In the Turkish ICU: 1) NUS areas outside the unit caused nurses to continuallymove back and forth, causing fatigue, exposing them to families waiting outside,thereby distracting them and reducing their performance. 2) Delayed specimentransportation to laboratories required staff to draw more blood, causing morepain. While the compact unit geometry saved time, it did not translate into staff-family interaction but only staff interaction time. The circulation pattern betweeninpatient areas and staff lounge indicated the more distant the lounge the lesscaregivers will rejuvenate intermittently. Turkish administrators worry if thelounge is too close, staff would use it excessively.

In the U.S. ICU, which is less compact and flexible, increased walking distancesand charting time reduced staff time spent with patients. Since increasing the unitsize increases walking distances and reduces social interactions, the U.S. modelrecognized the value of locating related common gathering functions most bene-ficially, particularly in relation to the SPR. Additionally, there is increased aware-ness to increase human contact through informal chance meetings by offeringcareful consideration of furniture and equipment.

Location of Staff Station and SPRs

The observations and interviews identified staff perception of the visual relation-ship between staff stations and SPR. Both the central staff station and decentral-ized stations should offer visual access to each patient, and provide direct pathsbetween rooms to enable caregivers to immediately react to emergencies. Partic-ularly respiratory care practitioners, who care for patients in different rooms, willbenefit from clustering SPRs in a more compact and flexible arrangement.


251

Figure 5. ICU Patient Room with Family Space, Clarian Methodist, Indianapolis; Lega-cy Good Samaritan, Portland, Oregon. (Image credit: WHR Architects, Inc.)

Location of SRC

Proximate location of SRC to the unit may increase staff collaboration and per-formance through increased opportunities for staff interaction. In the Turkishmodel, beneficial staff functions are either missing or located outside the hospi-tal (e.g., medical library). At CMCD, staff lounges have varying proximities tothe inpatient unit, which can be measured and correlated with the utilization ofeach staff lounge, staff interaction levels, and resulting health outcomes.

Location of Waiting Room and FRC

In the Turkish unit, families can wait in other departments with the waiting roomfunction, yet they prefer waiting in front of the PICU to stay close. At CMCD,waiting room proximities vary from the inpatient unit: three out of four are out-side the unit and several floors away, therefore families in more distant roomsvisit their children less frequently. CMCD patient family focus group study con-cluded (Strategic Research, 2000) if the FRC is too far from the child’s room,many parents will not visit the FRC.

Functional and Technological Intervention

A functional, flexible and accessible environment is a major aspect of the criticalcare setting. Functionality involves meeting complex technological innovationsand practical everyday needs, while improving the physical and technical workenvironment through maximum building performance.

Hilal Özcan

252

Table 1. Programmatic Intervention

Functionality and Instrumentality

Functional intervention is linked with providing important resources to supportthe practical functions of staff, patients, and families, which may increase thechances for social interaction. Some practical functions are the need for rest,relaxation, and nourishment, having access to drinks, snacks and small meals,having a shared space equipped with an oven, a few tables, a comfortable chair,quiet areas for parents to relax away from their child’s bedside, overnight sleep-ing, separate phone, laptop computer connectivity, comfortable seating, and quietareas for staff with a comfortable couch, recliners, or a nap room. For developinghealth care delivery models, simple interventions are most effective, and caninfluence staff performance tremendously. Table 2 indicates a Likert-scale meas-ure to evaluate unit response to functionality from simple to highly complicated.

Technology and Social Interaction

Functionality in design is ultimately linked with the meaning of technology andsocial interaction. Providing maximum building performance within a context ofsocial interaction may define functionality. Particularly ICU design must honorhuman dignity by focusing on social interaction.

Functionality in the ICU relates to the utilitarian tendency of everyday humanactivities, which informs a praxis approach, and a technological understanding ofthe world. Martin Heidegger argued that our fundamental relationship to oureveryday world is primarily practical, and therefore that scientific knowledge is


253

Table 2. Functional Intervention

to be derived from practice (Ihde, 1979; Little, 1999). While the things that areused for practical ends (i.e., equipment) embody highest significance in our abil-ity to know theoretically (Walters, 1995), the embodiment of common practicesof everyday life results in a quality of being taken for granted, which Heideggercalls ready-to-hand (Little, 1999). In the ICU setting, caregivers may view tech-nology as a conspicuous instrument, which Heidegger views as present-to-handsince it is decontextualized. Therefore, caregivers need to transform the ICUatmosphere driven by technology from present-to-hand to ready-to-hand througha conscious act of familiarization and social interaction.

Symbolic Intervention

Healing could be influenced by the symbolic and communicative function ofarchitecture. Through symbols, a building may represent a real idea, or content.Meaningful messages sent from the environment may impact users’ behavior,particularly socialization. The geometry, shape, color, texture, tectonic quality,size, scale, volume, order, and regularity of an ICU setting can support healing bycontributing to a distinctive form and meaning.

Materiality

Symbolism is linked with the choice of materials, colors, textures, furniture, andfinishes, which inform communicative value. Materiality relates to the celebra-tion of the experiential and sensual dimensions of architecture through exteriorand interior building materials and systems. Sometimes, it can be used to domi-nate, and impose the sterile, institutional, authoritative character of a facility. Orit can reflect humanistic design intentions, influencing social interaction. Harris(2000) found that family and friends stayed longer during visits to rehabilitationpatients when patient rooms were carpeted rather than covered with vinyl floor-ing.

Transparency

Transparency in architecture refers to dematerialization of form, which isexpressed in degrees from translucent to opaque. Transparency symbolizes theability to distinguish between the hidden and visible content to transmit inten-tions, ideas, meaning and even the capacity for Truth. This interplay betweenemergence and hiddenness may be associated with the idea of healing. Yet it isquestionable if transparency is desirable or achievable in an environmentdesigned for healing.

Transparency in an ICU may signify healing by involving the family in carerather than being invisible, inaccessible, and mysterious. Social transparencyindicators include giving families access to information, disclosure about thediagnosis, treatment options, prognosis and control over their child’s care. Archi-

Hilal Özcan

254

tecturally, this translates into the way the unit reveals itself, its activities, its per-ceivable scale, the relationships between its spaces, the use of translucent mate-rials, and the exposition of its structural and mechanical systems.

Transparency can be played out by making shared spaces more visible and acces-sible, which will lead to more eye contact and interaction, thereby encouragingpeople to readily support one another more frequently. From an ontological viewof person, the subject in the ICU needs an environment, where comfort and well-being do not result from incorporating the latest and greatest equipment and tech-nology, but from an ideal of transparency, where the desire of relating meaning-fully to others is revealed and fulfilled.

Geometry

The geometry, shape, and regularity of an ICU setting can support healing bycontributing to a distinctive form and meaning. Throughout history, many peoplewere fascinated to work with geometries because a geometry can be isolated fromreality as a coherent organized whole, and can make one feel the perfection ofGod.

Opposites in form language can symbolize the distinction between sacred andmundane. Sacred activities involve with knowledge and meaning while mundanefunctions involve lower needs, such as eating, resting, and sleeping. Through theinterplay between sacred and mundane functions, the form and geometry of anICU can symbolize social interaction.


255

Table 3. Symbolic Intervention

Ambient Intervention

Ambient intervention deals with creating a home-like, familiar and comfortableenvironment, which is sensitive to the needs of the participants particularly insocial interaction spaces of the ICU through access to nature, extant natural lightopportunities, shapes of spaces, color, high degree of enclosure and privacy.

Comfort and Familiarity

A comfortable and familiar environment may contribute to healing through thecelebration of social interaction made possible within shared common spaces. Asense of comfort or dwelling can enhance the full capacity of social interactionand healing. Lawlor suggests, “like […] people coming together to celebrate thehuman spirit, deepening into architectural dwelling is an everyday practice.”

Comfort in the U.S. ICU is expressed through the selection of furniture, seatingarrangements, residential-like design, comfort of family space, use of healing col-ors and home-like materials, attention to detail to project an image of individual-ity, exhibition of family photographs, and the general atmosphere of commonspaces. In the Turkish model, many argued expressing high levels of comfort andpersonalization can destroy the institutional image of the facility.

Image and Character

Interiority refers to the interior quality or character, inner life or substance of aplace. Within the context of the ICU, image and character are more influential insocial and cultural activity settings rather than universal caregiving functions,

Hilal Özcan

256

Table 4. Ambient Intervention

because the place tends to become more personally expressive, unique, full ofcharacter, and comfortable within the former. Common gathering spaces may beexpressed with the choice of colors, materials, and furniture.

Access to Nature

Nature and daylight are effective for fostering social support, social interaction,and healing. At CMCD cardiac and trauma units, windows are maximized inpatient rooms to increase views to the outside and daylight. Access-to-natureresearch focuses on human response to exposure to indoor and outdoor plants andgardens, views of nature and daylight, indicating reduced LOS days. There is lim-ited evidence that gardens in healthcare facilities can be especially effective forincreasing staff access to social support from other staff (Ulrich, 1999).

Resulting Social Design Intervention

Social design is linked with providing the social systems and requirements thatmake the place work, and create an atmosphere supporting the facility. Theseinclude 24-hour food service, sleeping arrangements for families, planned activ-ities for siblings, private meetings with doctors away from the child’s bedside,support group and educational meetings for parents, religious and spiritual serv-ices, and the social aspects of common gathering spaces: CMCD patient familyfocus groups concluded that the FRC must be accessible 24/7, as parents feelmost comfortable visiting it late at night, while their child is asleep.


257

Table 5. Social Design Intervention

The lack of family space and disabling policies minimize the chances for socialsupport between the patient and family in the Turkish model. Particularly, fami-lies’ low education level constitutes a barrier in adopting a family-centered caremodel. Providing meeting rooms for support group and educational meetingswould increase their understanding of their child’s care: particularly chronic dis-eases such as cancer, asthma, and metabolic disorders require knowledge tounderstand the disease and adopt an appropriate lifestyle.

MEASUREMENT INSTRUMENT

This paper puts forward a method for identifying key architectural determinantswhich may contribute to and be measured for their sensitivity toward healingdesign. To measure the contribution of patient rooms and other common gather-ing areas to healing design, a 5-point likert-type scale measurement instrument isproposed, which ranges from very low through moderate to very high.

DISCUSSION

This paper explored the relationship between the healing aspects of socialinteraction and its embodiment opportunities in architectural design. The studyexamined how the spatial organization of the PICU affects face-to-face interac-tions and collaborative relationships among patients, families and caregivers. Forinstance, the more staff members collaborate, the better care they will deliver.The qualitative exploration has uncovered problematic areas in the PICU envi-ronment through analysis of social interaction function within common spaces.

Using qualitative tools for measuring characteristics of the observed PICUs, thisstudy demonstrated that PICUs characterized by increased provision and scale ofCGAs, where social interactions occur naturally, their increased configurationaland relational accessibility and functionality (e.g., physical and visual proximi-ties, interrelationships, accessibility and flexibility among related spaces), provi-sion of shorter walking distances, and higher visibility and transparency of CGAswill exhibit higher rates of unprogrammed, unscheduled, and supportive socialinteractions and collaborations. This, in turn, will increase staff performance,relaxation, and general well-being in the unit, thereby influencing healing.

Limitations

This study was based on qualitative narratives of in-depth interviews and obser-vations. Future studies may triangulate research findings with quantitative data toindicate the healing benefits of positive social interaction. Fewer LOS days andbetter recovery indicators may provide more convincing evidence for healing.Average LOS days for specific units may be correlated with healing design indi-

Hilal Özcan

258

cators. This study claimed that increased staff interaction would increase staffperformance and collaboration, improving medical outcomes. Future studies maycollect quantitative records of staff performance (e.g., nursing errors, nurse quit-ting rates, attrition, morale, efficiency).

Implications

An ICU navigation model may analyze social interaction function by changing:1) walking distances, 2) scale, 3) configurational and relational accessibilities,and 4) visibility and transparency ranges between CGAs. Analytic and statisticaltools can measure characteristics and interrelationships between shared spaces.Simulation and visualization of research findings may demonstrate the impact ofunit configuration on face-to-face interactions, thereby improving healing. Avideo clip may highlight how reduced staff walking distances as they movearound would affect the chances for interacting with patients, families and othercaregivers.

CONCLUSION

Findings indicated that design interventions that increase the rate of unscheduledsocial interactions may also improve healing in an ICU, particularly through theprovision of practical everyday needs: the placement of the tea kettle, refrigera-tor, copier, printer, fax machine, shared workstations and the staff station maygather people in a small unit. More social encounters will create more support-ive interactions, improving well-being and recovery.

The importance of touch, talk, and love in caregiving is well acknowledged, yetthese insights may not translate into physical design: a staff lounge may be sev-eral floors away, which is less effective for staff interaction than having all sharedactivities and the unit intermingled in a compact, flexible arrangement. This studysuggests healing results from social interaction, which is influenced by walkingdistances and spatial, visual and intellectual proximities between spaces. That is,the closer it is between different functional units the more people will encounterwith one another as they share a common space, and engage in a supportive,meaningful conversation. Having these conversations enables a more therapeuticcaring environment, which translates into healing.

The study found clustering shared activities in a more compact and flexiblearrangement may increase socialization. Turkish caregivers recalled the benefitsof their lounge space, which enabled them to interact positively in a small space,and involve families in care. Although compact spaces may not support genericICU functions, the beneficial size and location of common areas may impacthealing through meaningful social interaction.


259

In summary, healing design is about the creative, festive discovery of the possi-bilities of social support and social interaction, which can simply project fromproviding lower level practical needs such as beverages. This study emphasizedthe potential of common spaces in the ICU, which gather patients, families andcaregivers and stimulate meaningful interaction, care-in-situation, communica-tion, collaboration, and love. Shared hospital spaces, where emotional care andconcern are exchanged unconditionally, may encourage a new social life resistingagainst the destiny of the West, which reduces the human capacity for establish-ing natural and unscheduled social interactions in favor of a more technological,mechanistic lifestyle.

REFERENCES

HARRIS, D. (2000), Environmental Quality and Healing Environments: A Study of FlooringMaterials in a Healthcare Telemetry Unit, Texas A&M University, College Station, (unpub-lished PhD thesis), Texas, USA.

HOLAHAN, C.J. (1972), Seating Patterns and Patient Behavior in an Experimental Dayroom,Journal of Abnormal Psychology, (vol. 80, no. 2) pp. 115-124.

IHDE, D. (1979), Technics and Praxis: A Philosophy of Technology, D. Reidel, Dordrecht, TheNetherlands.

LITTLE, C.V. (1999), The Meaning of Learning in Critical Care Nursing: A HermeneuticStudy, Journal of Advanced Nursing, (vol. 30, no. 3) pp. 697-703.

MELIN, L. and GOTESTAM, K.G. (1981), The Effects of Rearranging Ward Routines onCommunication and Eating Behaviors of Psychogeriatric Patients, Journal of Applied Behav-ior Analysis, (vol. 14, no. 1) pp. 47-51.

OZCAN, H., CADENHEAD, C. (paper in review), Designing a Critical Care Unit: SquareFootage Allocations in ICUs.

PETERSON, R. et al, (1977), The Effects of Furniture Arrangement on the Behavior of Geri-atric Patients, Behavior Therapy, (vol. 8) pp. 464—467.

SOMMER, R. and ROSS, H. (1958), Social Interaction on A Geriatrics Ward, InternationalJournal of Social Psychiatry, (vol. 4, no. 2) pp. 128-133.

SPIEGEL, D. et al, (1989), Effect of Psychosocial Treatment on Survival of Patients withMetastatic Breast Cancer, Lancet, (vol. 2, no. 8668) pp. 888-891.

ULRICH, R.S. (1991), Effects of Interior Design on Wellness: Theory and Recent ScientificResearch, Journal of Health Care Interior Design, (vol. 3, no. 1) pp. 97-109.

ULRICH, R.S. (1999), Effects of Gardens on Health Outcomes: Theory and Research in Heal-ing Gardens, Cooper Marcus, C., Barnes. M, (eds.), Wiley, New York, USA, pp. 27-86.

ULRICH, R., ZIMRING, C. (2004), The Role of the Physical Environment in the Hospital ofthe 21st Century: A Once-in-a-Lifetime Opportunity, Funded by the Robert Wood JohnsonFoundation.

WALTERS, A.J. (1995), A Heideggerian Hermeneutic Study of the Practice of Critical CareNurses, Journal of Advanced Nursing, (vol. 21) pp. 492-497.

Hilal Özcan

260

HEALING DESIGN: A HOLISTIC APPROACH TO SOCIAL INTERACTION IN PEDIATRIC INTENSIVE … ·...

Documents

Transcript of HEALING DESIGN: A HOLISTIC APPROACH TO SOCIAL INTERACTION IN PEDIATRIC INTENSIVE … ·...