Designing a patient room: the process of stakeholders’ involvement

Type of the Paper: Peer-reviewed Conference Paper/ Short Paper

Track title: stream 3, visual tools as boundary objects, session number 3A

Designing a patient room: the process of stakeholders' involvement

Emma De Meester ^1*, Liesbet Delforge ^1, Simon Malfait ^1,2, Lynn Pieters ^1,3 & Veerle Duprez ¹

1. Nursing Department, Ghent University Hospital, Belgium

2. Strategic Policy Unit, Ghent University Hospital, Belgium

3. Infrastructural Team Ghent University Hospital, Belgium

* emma.demeester@uzgent.be; ORCID 0000-0002-3560-1100

Keywords: Hospital design; patient room; user preferences; stakeholder involvement

1. Introduction

The building of a new hospital is challenging. The design of hospital patient rooms should be in line with the demanding needs of its patients, visitors, and professionals (Patterson et al., 2017 & 2019). The majority of the literature explores hospital environment and well-being from a single perspective, eighter designers’ or patients’ perspectives (Huisman et al., 2012). Therefore, a process wherein all stakeholders are involved is advised throughout the different stages of the design of a patient room (Keys et al., 2016). This paper reports on the process of stakeholder involvement during the design of a new patient room at a large tertiary hospital in Flanders, Belgium.

Patient participation has gained increasing attention in the past decade and demonstrated benefits at all healthcare system levels (Castro et al., 2016). Including the patients' perspectives might increase patient satisfaction and comfort (Patterson et al., 2017). A recent study by van Oel and colleagues (2021) explored the relationship between patient preferences and patient room design. They asked patients themselves about their preferences for the physical environment, and the healthcare professionals what they thought patient preferences were. Their study revealed inconsistency between what patients actually preferred and what professionals thought the patients preferred (van Oel et al., 2021). These findings emphasize the importance of involving patients directly in the design process.

A hospital room is not only a residence for the patient. It's also a workplace for a wide range of health care providers (HCPs). A patient-centered room does not need to come at the cost of the professionals' own comfort. Nurses spend most of their time taking care of patients. Nurses' experience provides them with extensive practical knowledge (Stichler et al., 2007). Other stakeholder groups, like technicians and logistic staff who perform professional activities other than care, have different needs regarding the design of the room (Lavender et al., 2015). Although Keys and colleagues (2017) emphasized the importance of collaboration between designers and professionals, the needs of healthcare professionals are not always integrated into the room design (Keys et al., 2017). The professional's perspective can be valuable in the early stages of the design process, as it saves costs by reducing change orders (Lavender et al., 2016). Also, it enables the alignment of

Figure 1. Process of stakeholders' involvement

needs, value and cost at an early stage and, in the long run, it might facilitate a healthy work environment.

Various tools and guidelines are available to foster an evidence-based design and decision process to develop a new patient room (Quan et al., 2017; Lavender et al., 2020). These tools and guidelines assist designers in relaying user input in an evidence-based way. Additionally, national regulations need to be taken into account and often provide an obligatory outline for developing a patient room.

The design of a patient room should aim to combine the needs of all stakeholders in order to provide patient- and family-centered care. The first step is to involve all stakeholders throughout the process of designing a patient room. Stakeholders' involvement is beneficial (Malfait et al., 2018); however, evidence of stakeholders' involvement when designing a patient room is limited and focuses on the results rather than on the process of involvement (Lavender et al., 2020). Therefore, this paper aims to describe the stepped process of stakeholders' involvement when designing a patient room. By describing the process and providing a critical reflection on it, we aim to share experiences that might be helpful for healthcare institutions that want to involve their stakeholders in hospital room design.

2. Study description

A three-phased process was set up to develop the new patient room with (1) defining the evidence and regulation base, (2) large-scale exploration of stakeholder preferences, and (3) exploration of usability and functionality. Before recruitment, ethical approval was obtained from the ethics committee of the UZ Gent. An informed consent document had to be signed before the participants could access the survey (phase 2) or participate in the interviews (phase 3). An overview of the process of stakeholders’ involvement is given in Figure 1.

2.1. Phase one: defining evidence and regulation base

First, based on national regulation, designer experiences and in-house expertise, eight discrete choices (DC) were developed concerning the design of the patient room. The initial design was developed based on the designers' experiences and applicable national regulations, such as room or door size requirements. An in-house team of experts with various levels of accountability contributed to that design. The patient advisory board and various stakeholder groups examined the feasibility of the scenarios. If no consensus between them was reached, it was processed into a discrete choice between two or three options. A discrete choice experiment is often used to measure the eligibility of new interventions (de Bekker-Grob et al., 2012) or the preferences in the delivery of care (Ryan et al., 2001). Participants are offered a set of hypothetical scenarios where two or more options are presented, nevertheless in a hidden way. This method reveals the relative importance of the characteristics of the scenarios (Ryan et al., 2001). The options were represented by a colored 3D image, accompanied by the question "What do you prefer?". No additional information or explanation was given to avoid bias. An online video-animated survey representing the DC has been set up.

2.2. Phase two: a large-scale exploration of stakeholder preferences

Next, all users of the future patient room were included as participants and represented three stakeholder groups: patients, visitors and professionals. Participants needed to be eighteen or older. Within a timeframe of four weeks, a total sample approach was used. In total, 1561 participants indicated their preferences for the eight discrete choices. The average age was 43.3 years, with a range between 18 and 85 years. In total, 71% were female and 29% were male. An overview of the participants is presented in Table 1.

Table 1. Characteristics of the participants during the second phase (n = 1561)

Three recruitment strategies were used to accomplish this.

1. Direct recruitment of patients, visitors and professionals

For two days, a booth with posters was set up in a central place on the hospital campus and passersby were encouraged to participate. The researchers explained the purpose of the study. Several tablets were provided so the survey could be filled out immediately. Additionally, flyers, including a QR code, which gave access to the survey, were administered so potential participants could complete it at a more convenient moment. Within a timeframe of seven days (May 2021), the researchers visited patients and waiting rooms throughout the hospitals. Both hospitalization wards and outpatient clinics, with a variety of specializations, were visited by the researchers. Every attendant was invited to participate. If the candidate hesitated, a flyer was offered. Direct recruitment in the waiting rooms was the most successful way of obtaining study participation.

1. Indirect recruitment of patients and visitors

A flyer with an invitation to participate, including a QR code, was delivered with the patient meal tray on randomly selected days during May 2021. Non-hospitalized patients received an invitation added to their appointment reminder. The invitation contained a link to the survey.

2. Indirect recruitment of professionals

A two-fold strategy was used to recruit healthcare professionals. Every hospital professional was invited through the monthly newsletter of the new hospital project. This email contained information about the study and a link to the survey. On the other hand, professionals also received the same message with their monthly paper payslip. In addition, a website was developed to keep professionals informed about the new-build project.

We illustrate three discrete choices. The first example of the DC is illustrated in the two upper images in Figure 2. The DC shows two different designs of the hallway of a ward. The width of the hallway remains the same in both images. The first option (upper left image) shows a straight hallway without corners or niches. A flat wall with doors next to each other. The second image (upper right) contains a hallway with several niches. The second DC represents the door of two patient rooms. The first choice (middle left) has a window allowing you to look inside the room, while the second choice (middle right) represents a solid door. The last DC questioned the arrangement of the outlets. In the first option (lower left), the outlets are located horizontally above the patient's bed. A second option (lower right) shows the outlets placed vertically next to the bed.

Figure 2. Illustration of discrete choices

2.3. Phase three: the exploration of usability and functionality

Subsequently, in the third phase, two mock-up rooms were built to assess the usability of the patient room. Mock-ups are used to evaluate the usability and functionality of a care room before it is built (Durham & Kenyon, 2019). Participants can experience the room in a realistic size and try out different scenarios (Shultz & Jha, 2021). Professionals of different occupational groups were purposefully recruited to have a strategic representation of various stakeholders (Table 2).

Table 2. Description of the stakeholder groups during the third phase

Participants under ‘revalidation’ represent physical and occupational therapists. Whereas speech therapists, dieticians, mobile medical imaging nurses or nursing specialists are defined as bedside consultants. Among the patients, 50% were female and 50% were male. The average age was 59.6 years, with a range between 21 and 72 years. 45% of the HCP were female and 22,4% were male; the mean age was 40,8 years with a range between 23 and 61 years.

In total, 20 focus group interviews were conducted with 70 individuals from 10 occupational stakeholder groups. Focus group sessions were conducted with a monodisciplinary representation of stakeholders. The occupational groups were not mixed to prevent an imbalance of power, so all the participants could speak freely. During the interviews, the thinking aloud method was used. Expertise is based on experience is difficult to clarify to an outsider. The thinking aloud method encourages thinking aloud when evaluating or executing a task. Therefore, knowledge of which the participant was not aware can be accessed, and misinterpretations can be avoided (Sommeren et al., 1994). The presence of multiple participants per group led to interaction, discussion and a broad reflection on the usability and functionality of the mock-up rooms.

3. Discussion

Ideally, the design of a patient room should be in line with the demanding needs of its patients, visitors, professionals and current legislation. However, to date, no studies have integrated the multiple perspectives of a broad range of stakeholders. So, it remains unclear how these demanding needs can be brought together in a structured and meaningful way.

This paper attempts to bridge part of the gap and describes the stepped process of stakeholders' involvement when designing a patient room. The herein described participatory design has highlighted some strengths and pitfalls.

Shifting from a far away to a nearby event

The involvement of a wide range of stakeholders led to a sense of appreciation and meaningfulness among them. By giving them a voice, the participants became more committed to the upcoming event of building a new hospital. The positive effect of professional participation on organizational commitment is well studied, including within healthcare organizations (Lomo, 2017). Participation, as done in this study by knowledge and expertise sharing, had a strong positive effect on professionals' commitment towards the new-build project.

From assumed to realist perspectives

As seen in previous studies, if not directly involved, we may rather rely on the assumed instead of the real perspective (van Oel et al., 2021). From the professionals' perspective, elements of safety, ergonomics, and efficiency were brought into the discussion. From a patient standpoint, aspects of privacy, comfort, rooming-in, and accessibility were put forward. Merging a variety of perspectives delivers a holistic and realistic view. Nevertheless, it also brings in complexity and might lead to conflicting perspectives and principles, complicating the final decision-making process.

A valuable but time-consuming process

In total, this project took up to one year. Developing the DC, exploring the preferences, and evaluating mock-up rooms requires meticulous organization. Bringing various stakeholders together demands timely planning in between meetings and discussions. The advantages of this careful decision making process will only manifest later. As Durham (2009) pointed out, mock-ups are an opportunity to identify incoherences and resolve them before the actual building. It is also a cost-effective method for facilitating workflow and avoiding rework.

The possible rise of power imbalances

A broad range of stakeholders is crucial. Each stakeholder has different occupational needs regarding the room design (Lavender et al., 2015). But the use of monodisciplinary teams during the evaluation process is desirable. Given the historically based hierarchy between occupational groups, participants might not be comfortable speaking openly when this is needed.

For the acceptance of the final design in complex decision-making processes, commitment is important, and monodisciplinary teams have the advantage that people open up more easily but that it does not add to a mutual understanding of other stakeholders’ needs. In the next stage, the results of the DC and mock-up rooms will be analyzed by the research team, presented to, and discussed with a range of stakeholders.

4. Conclusion

An exploration throughout the literature concerning hospital environments reveals that current studies rely either on designers’ or patients’ perspectives. The interaction of the full range of stakeholders is unexplored. This study shares a process of stakeholder involvement in the field of hosptial room design. It is a time-consuming process, but it achieves a mutual understanding towards different needs and a higher level of commitment towards the project.

Data Availability Statement

Not applicable.

Contributor statement

All authors contributed to the conceptualization of this paper. The studies were developed by VD and SM and supervised by VD. All authors were involved in data collection, validation, and analysis. EDM and VD were responsible for the writing of the original draft. SM, LD, and LP critically reviewed and edited the paper.

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