Designing spaces for care in the time of Covid

Colour and light have an actual physical effect. Variety of form and brilliancy of colour in the objects presented to patients are actual means of recovery. (Florence Nightingale 1850)

There has always been a strong association between health and wellbeing, place and space. If we did not have enough evidence presented by researchers such as Ulrich, COVID-19 provided the opportunity for us to experience this first hand. It is not surprising that as the pandemic subsides, place and space are themes which run throughout the papers in this issue of the journal.

Papers on different ways of thinking, engaging and designing spaces explore the tensions that come with increased public involvement and the difficulties in hearing the authentic voice of the ‘end user’. Even though she based it on an apparently humane and thoughtful set of principles, Nightingale’s own devastating experience of seeing her work in the Crimea rubbished by empirical data of her patients’ survival, reminds us of the importance and strength of linking research practice to design practice.

The modern hospice movement from 1967 onwards, favoured building new facilities and was most prolific as commissioner of real estate by the 1980s. Along with the convention of naming the institutions after a Christian saint, came a consensus that the buildings should not have the look of a hospital. Hospice trustees, with a few early exceptions, commissioned domestic-style bedrooms or hotel-style rooms more than clinical spaces. Architects with a track record of previous hospice builds were often hired and as the sector grew, diversity of the palliative care estate expanded in the absence of academic curiosity about how these architects and their clients made their decisions. Papers in this issue open up our understanding of the issues that give us the spaces where we give and receive care at the end.

Personal experience of designing facilities for palliative care within the NHS taught this editor (BN) the extraordinary conflicts that follow from the client/architect relationship when the client is not the user of the facility. Debates around vinyl versus carpet, communal space versus budget and privacy versus safety are etched in the memory. Important general themes are elucidated in McLaughlan and Richards‘s paper Realising Homeliness in Palliative Care: Inpatient and Family Perspectives on Designing the Built Environment. They report a valuable study that elucidates the priorities of families receiving palliative care in a new facility. Architects’ ideas about the needs of the dying and the families are not often tested during the design and build, so the literature on service user views of the built environment is particularly valuable. There is a consensus around privacy, homeliness, and nature as the tenets of good design for palliative care. However, concerns of infection control, ingrained procurement processes, standardized cleaning protocols, and expectations of uniform design standards between hospital sites hamper best practice.

Beuls et al.’s Architectural-rich service users’ experiences within palliative environments: a designerly scoping review extends the scoping review form to include more emphasis on service user experiences. Traditional review elements are completed (inclusion criteria, search strategy, paper screening, selection process, charting data and results) but according to the authors ‘the difference is mainly reflected in the fact that a scoping review will formulate the accumulated knowledge from a higher level of abstraction whereas a “designerly scoping review” will seek to capture the validated data underlying that knowledge to make academic knowledge more tangible for designers or architects’. This is achieved by inclusion of studies that involve personal experiences. The authors argue that a palliative environment design has done a good job if it lifts all service users’ spirits and helps them cope with difficulties by providing them with an atmosphere of proximity, a supportive atmosphere, an engaging atmosphere, and a comfortable atmosphere. In addition, this paper indicates that knowledge of service-users’ experiences of palliative environments can be found in the existing literature. However, this knowledge is not always considered ‘architectural-rich’ as it is often too abstract for architectural practitioners, so future academic research in the interdisciplinary fields of palliative care and architecture should consider collecting and presenting more actual user experiences from diverse perspectives.

One area that hospices led was their gardens and the designs that connected nature to clinical spaces. Harries et al.’s ‘Designing a Wellbeing Garden’ A Systematic Review of Design Recommendations does a thorough job of reviewing the area and defining characteristics of wellbeing gardens. This paper highlights that whilst there is strong evidence to show the positive impact that outdoor spaces and particularly gardens can have on wellbeing there are no evidence-based guidelines or recommendations available for designers to support such endeavours. The authors undertook a systematic review of garden design literature and identified the defining characteristics of wellbeing gardens centre around the following design aspects: accessibility, wayfinding, fostering serenity, multisensory planting, spatial organization, and cultural artefacts. From these, recommendations were developed for garden designers to create wellbeing gardens.

It’s not only hospices that are made by individuals that are not the users of the facilities. Any environment designed to account for the need for care shares the problem. Marney Walker has reviewed Inside Retirement Housing by Sam Clark. This interrogation from the author’s primary research, conducted between 2014 and 2018, describes the nature of retirement housing using narrative, personas, and visual analysis. The book sheds light on the motivations and priorities of architects and developers and their impact on occupants of the buildings.

Other barriers to real coproduction include racism and Mashford-Pringle et al.’s Creating an online indigenous cultural safety micro-credential for public health professionals in Ontario, Canada is based on the premise that systemic racism exists in public health systems throughout Canada as a consequence of lack of understanding of indigenous culture. The authors collaborated closely with elders, knowledge keepers and indigenous community members to design an online training intervention to educate public health staff in indigenous protocols and cultural safety protocols. An Indigenous online cultural safety micro-credential provided knowledge of Indigenous worldviews, socio-political history and contemporary issues while engaging the learner in self-reflection of their 3Ps: power, privilege, and positionality. They conclude that development of an online Indigenous cultural safety micro-credential for a small public health unit in Ontario provided basic knowledge for collaborating with Indigenous Peoples in a culturally respectful way to move towards increased awareness of including Indigenous Peoples in planning, developing and providing public health programs, services and policies. The novelty lies in the involvement of the community in its development and of the making of a safe cultural space. One of the most striking paragraphs in the paper begins:

‘Failure to meaningfully incorporate indigenous worldviews, frameworks and perspectives in public health programs and services lead to the incorporation of ‘feathers and beads’ whereby some cultural symbolism is introduced in fragments and often in a pan-indigenous approach. Pan-Indigeneity amalgamates all Indigenous Peoples and promotes that there is one homogenous group … [It] is a manner of tokenistic inclusion which further entrenches western societal values … and discourages Indigenous People from (re)learning their own traditional and nation-specific ways’. There is a growing literature regarding indigenous cultural safety and health professionals which can be graphed on a continuum of learning. The continuum of learning moves from cultural awareness to cultural sensitivity to cultural competency and finally to cultural safety. This is not a linear pathway that moves directly from one to the next; moving requires continuing self-reflection, active listening, increasing knowledge, interactions with first nations while using power, privilege and positionality to assist made-vulnerable people to move towards equity.

We include two papers which illustrate user-centred design; Kempske et al.’s Identifying requirements of an IMU based gait assessment interface for incomplete spinal cord injury through user centred design approach focuses on identifying the requirements of an IMU-based gait assessment interface for use in a clinical setting by rehabilitation physicians and physiotherapists. Their objectives were to identify the requirements of an IMU-based mobile gait assessment user interface, intended to be used by rehabilitation physicians and physiotherapists in a clinical setting, and also to conceptualize and propose an initial interface design. User-centred design was utilized in every stage of the design process to better understand and assess user needs and to adapt the design to these needs. Through involving users throughout the whole design process, this approach allowed for a more usable and accessible product to be designed. Mary Butler et al.’s From Prototype to Practice: Developing a Comprehensive Toolkit for Vision Awareness in Schools describes the development of a toolkit aimed to raise awareness of vision in schools. A team of allied health, education and design professionals worked with a group of 11-year-old children and their teachers to design and develop a novel authentic learning experience about vision, including an experiential activity whereby children could test vision with each other. Prototypes of a vision screening flipchart and recording system were co-designed with one classroom. This was embedded in an education module and then evaluated with 288 children across 7 classrooms, which resulted in the development of the final toolkit. The results indicate that teachers appreciate the opportunity to engage with health promotion when it is ‘added-into’ rather than ‘added-onto’ the curriculum. The evaluation suggested that it is feasible to carry out vision screening process in the classroom context and that it results in higher levels of awareness about vision, since children went on to get spectacles when they needed them, while others started to wear their spectacles in class.

While the pandemic seemed to shut down many opportunities for meaningful collaboration with service users, there were apparent anomalies. A report on Third-space Participatory Research Experiences during the Pandemic: Challenges, Adaptations, and Lessons Learned in Design Research by Chua et al. reports a PhD project to explore how augmented reality technologies together with environmental graphic design might improve the workplace experience and overall wellbeing of healthcare staff. The initial findings suggest there may be potential to improve employee wellbeing by combining Augmented Reality (AR) and Environmental Graphic Design (EGD) in office environments. COVID led to a ban on researchers entering hospital facilities and as a consequence the PhD was modified to become an experimental case study that used a framework of participatory action research to create an alternative environment to bring together a variety of stakeholders. Challenges posed by the pandemic limited opportunities for sharing spaces, but there was a deeper exploration of the types of augmented reality experience that might be possible. They concluded, ‘By creating a simulated healthcare work environment in the Open Lab space, people from a wide range of backgrounds were able to explore and give feedback on the design interventions’. Arnold Mages et al.’s Resurrecting carvings in stone: deploying design research methods for public health investigations in the age of COVID-19 describes how a transdisciplinary team overcame the complex challenges of the pandemic by translating in-person workshops into at-home design probes exploring connections between university students’ climate change attitudes and their health. Their methods changed during the pandemic and in doing so generated richer data in many ways.

We began this editorial with the assertion that there has always been a strong association between place and space in the context of health and wellbeing. The papers in this issue continue this conversation, highlighting that as our understanding of health evolves and as world events unfold, our methods and practices as researchers across design and health also need to constantly develop. In 1991 Roger Ulrich famously said that 'scientific research and design are complementary activities from the standpoint of the common goal of creating healthcare facilities that promote wellness’

This issue is a testament to Ulrich and the ongoing value of the academic space that is design for health.

Disclosure statement

No potential conflict of interest was reported by the author(s).