Abstract: The design of healthcare buildings influences healthcare quality: hospital and ward design features can increase patient and staff satisfaction, improve treatment outcomes and reduce stress. However, due to societal changes, there is increasing attention to outpatient healthcare facilities close to the communities, such as healthcare centers (HCC). However, few studies concerned HCC. Nor has there been much attention to entrance areas of healthcare buildings. This study, therefore, investigates four health-related design features (i.e., privacy, nature, daylight, and wayfinding) in the entrance area of two award-winning Dutch HCC. Research question – How does the entrance design of HCC support views on nature, privacy, daylight, and wayfinding? This study compares two awarded HCCs based upon a selective thematic analysis focused on descriptions and observations of the four features in the HCC design. Data include descriptions by professionals, jury reports, floor plans and photos. The data show that views on nature are not mentioned in the data, privacy is mentioned and observed implicitly in both projects, and daylight and wayfinding are only observed in the floor plans and pictures. Most attention concerned daylight, wayfinding, and privacy in the waiting areas. However, while the importance of view of nature has been highlighted in many previous studies, these projects show little attention to view of nature and privacy for HCCs. The study revealed that the awarded healthcare buildings incorporate health-related design features, mostly implicit in the designs. However, in the descriptions by professionals and jury, they are not explicitly mentioned.Show Less
Peer-reviewed Conference Paper / Full Paper
Track title: Stream inclusive design/health promotion – communal design (4B)
Design features in the entrance area of Dutch healthcare centers
L.A.M. Willekens MD, MSc 1*, L. Krabshuis MSc2 and E. Miedema PhD3
1 Complex Projects, Faculty of Architecture and the Built Environment, Delft University of Technology, The Netherlands, email@example.com;0000-0001-6467-9399
2 Atelier LK, firstname.lastname@example.org, 0000-0001-9409-6557
3 Division Architectural Theory and Method, Department of Architecture and Civil Engineering, Chalmers
University of Technology, Gothenburg, Sweden; email@example.com; 0000-0002-8440-4859
* corresponding author.
(to be completed by the editors)
Names of the Topic editors:
Names of the reviewers:
Journal: The Evolving Scholar
Submitted: 14 Jul 2022
Citation: Willekens, L., Krabshuis, L. & Miedema, E. (2022). Design features in the entrance area of Dutch healthcare centers [preprint]. The Evolving Scholar | ARCH22.
This work is licensed under a Creative Commons Attribution BY license (CC BY).
© 2022 [Willekens, L., Krabshuis, L. & Miedema, E.] published by TU Delft OPEN on behalf of the authors.
Abstract: The design of healthcare buildings influences healthcare quality: hospital and ward design features can increase patient and staff satisfaction, improve treatment outcomes and reduce stress. However, due to societal changes, there is increasing attention to outpatient healthcare facilities close to the communities, such as healthcare centers (HCC). However, few studies concerned HCC. Nor has there been much attention to entrance areas of healthcare buildings. This study, therefore, investigates four health-related design features (i.e., privacy, nature, daylight, and wayfinding) in the entrance area of two award-winning Dutch HCC. Research question – How does the entrance design of HCC support views on nature, privacy, daylight, and wayfinding? This study compares two awarded HCCs based upon a selective thematic analysis focused on descriptions and observations of the four features in the HCC design. Data include descriptions by professionals, jury reports, floor plans and photos. The data show that views on nature are not mentioned in the data, privacy is mentioned and observed implicitly in both projects, and daylight and wayfinding are only observed in the floor plans and pictures. Most attention concerned daylight, wayfinding, and privacy in the waiting areas. However, while the importance of view of nature has been highlighted in many previous studies, these projects show little attention to view of nature and privacy for HCCs. The study revealed that the awarded healthcare buildings incorporate health-related design features, mostly implicit in the designs. However, in the descriptions by professionals and jury, they are not explicitly mentioned.
Keywords: the Netherlands, Healthcare centers, healing architecture/EBD, view of nature, daylight, privacy, wayfinding, person-centred care.
This paper studies the design of the entrance areas in two outpatient healthcare centers (HCCs) in the Netherlands in relation to views on nature, privacy, daylight, and wayfinding.
The design of healthcare buildings influences the health of its users, such as patients and staff (Morgan et al., 2021; Sundstrom et al., 2017; Malenbaum et al., 2008; Devlin, Arneill, 2003) and healthcare quality (J.Morgan et al., 2021). Consequently, designers of healthcare buildings should consider how their design supports health, care and wellbeing (Devlin & Arneill, 2003). The majority of research on healthcare buildings focused on inpatient healthcare (Devlin, Arneill, 2003). However, there are few studies focused on the design of outpatient care, such as primary care and HCC (Warin et al. , 2000). These studies highlight the need for careful design of interiors of HCCs with attention to feeling welcome (Morgan et.al., 2021, Sundstrom et al. 2017).
HCCs generally refer to a small outpatient care organization with several general practitioners in a common primary care practice, often combined with other outpatient services, such as physiotherapists, social workers, district nurses and a pharmacy. HCCs provide most everyday health issues and maintenance; it increasingly aims to stimulate people's health literacy and take control of their own health (Warin et.al.2000).
In the Netherlands, the HCCs are central in the distribution of healthcare as the general practitioner is often the first point of contact with healthcare providers for health complaints. The HCC buildings, therefore, are a representation of the system (Malenbaum et al., 2008) and should therefore be welcoming to patients (Warin et al., 2000).
This paper focuses on the entrance area of HCCs which includes the entrance door and surrounding area, the reception area, the waiting area, and the routes in between. The entrance area is important as it should be welcoming to all and easily recognized as healthcare facility (Little et.al., 2005). Some have argued that a recognizable entrance can improve the results of treatment (Dalke et. al. 2018). HCCs typically have situated their entrance area and in particular, the reception area and waiting area integrated with the routing through the building. However, this can lead to internal rooms with poor privacy and without access to direct daylight, poor wayfinding, or a lack of views on nature. Previous research on the design of the entrance area of healthcare facilities (in general) pays attention to the outdoor environment near the entrance (Morgan et al., 2021), accessibility of the entrance, the presence of a smoking area, signalling and direct contact with the environment (Leather et al., 2003). A renovated entrance hall with a service corner, light colours and new materials improves the results of treatment (Dalke et al. 2018).
The reception area is important as clients share their reasons for visiting the HCC, which will likely include private information about their health healthcare (Rachel, 2018; Van der Zwart, 2015). Lack of privacy in such conversations can affect clear communication and increase stress levels (Sundstrom et al., 2013). However, only a few studies focused on the design of the reception and the privacy it provides to clients (Morgan et al., 2021; Warin et al., 2000).
The design of the waiting area has also been researched (Margolies et al.,2015, Mclaughan et al., 2018; Dalke et al., 2018; Leather et al., 2003; Van der Zwart, van der Voort, 2015). As patients often stay longer in the waiting area of an HCC than in the consultation room, the waiting area can be considered as one of the most important areas for patients. In several studies, privacy, distancing, view of nature (even artificial) and sufficient distraction are considered important aspects of waiting areas (Abbas, 2000; Pati, Unas, 2011; Beukeboom, 2012). There are no studies that research the waiting area in primary care facilities.
2.1 Design features
Several design features of healthcare buildings have been researched on health-related outcomes (Ulrich et al., 2010). This paper focused on four design features: view of nature, privacy, daylight and wayfinding. These features appear to be the most important elements for users, clients as well as professionals, in their state of well-being and feeling ’at home’ in health centres (Ulrich et al., 2004; Morgan et al. 2021; Sundstrom et al., 2017; Warin et al., 2000)
2.1.1. View of nature
The research indicating the role of view of nature as part of healthcare design to improve human health in hospitals is rapidly growing (Ulrich et al., 1984; Malenbaum et al., 2008; Ulrich et al., 2004) Studies investigated health-related effects (e.g. pain reduction, stress reduction, shorter length of stay) on patients and staff by views on nature (Weerasuria et al., 2019) access to nature (Beukeboom et al., 2012), as well as nature-inspired art (Beukeboom et al., 2012). They mention that views on nature, even when artificial, give positive distraction for clients and thereby reduce the perceived waiting time (Beukeboom et al.,2012).
Privacy, both speech and visual, is also recognized as important for healthcare building design (Rachel, 2018). For instance, it is essential for good and thorough communication between patients and caretakers (Morgan et al. 2021). Patients tend to share more personal information when (speech) privacy is guaranteed (Morgan et al. 2021), and show higher levels of satisfaction when the design of patient rooms improves the feeling of (visual) privacy (Sundstrom et al., 2017; Margolies et al.,2015, ). Although there is a lot of research done on privacy in hospital environments, almost no research has been done on levels of privacy in HCC. Yet, one study focused on design and (lack of) privacy for staff communication including the design of the reception area; they found that the level of communication, as well as job satisfaction, is less with less privacy (Lim et al., 2020).
A lack of daylight disrupts our biological clock, and this leads to depressive feelings and fatigue (Moenssens, 2013). Instead, sufficient daylight can support orientation and performing tasks that require good visual feedback (Moenssens, 2013). Daylight in has also been linked to health-related outcomes for healthcare staff and clients, such as reducing medical errors, pain, depression, and length of stay (Malenbaum et al. 2008). Daylight can improve patient sleep, communication between patients and their relatives, as well as staff and patient satisfaction (Morgan et al.2021). In our study, we focus mainly on the reception area and waiting area, concerning daylight.
The effect of wayfinding on patients has been extensively researched in hospitals (Morag et al., 2016). Wayfinding refers to environments where people can orientate and navigate themselves well, which makes people feel more at ease and reduces stress and anxiety (Morag et al., 2016). Wayfinding could also improve good diagnosis and treatment (Morgan et al.2021). However, there is a lack of research on wayfinding in outpatient health centres, especially in the entrance area.
2.2 Problem Identification
To sum up, there is a lack of research on the design of HCCs, as well as entrance areas (Ulrich et.al., 2008). There is a lack of studies situated in the Netherlands (Beukeboom et. al., 2012), and only a few studies combine attention to views on nature, privacy, daylight and wayfinding (Ulrich et.al., 2008). In order to inform the design processes and design decision-making of HCCs generally, and particularly in the Dutch context, this study asks the question: To what extent do the projects, in their project descriptions, in the design solutions, pay attention to view on nature, privacy, daylight and wayfinding?
Research design is based upon a case study approach with two projects, using written, visual project documentation and on-site visit focused on attention to view of nature, privacy, daylight, and wayfinding.
The study is situated in two HCCs in the Netherlands which both have been awarded the LHV-award (see Table 1). The LHV-award is a bi-annual award organized by the Dutch general practitioner’s organization (Landelijke Huisartsen Vereniging e.g. LHV). LHV supports general practitioners in all aspects concerning management and household of their practices, including staff and employment, equipment and storage, patient documentation and archiving, as well as their building design (ref). The LHV-award is for healthcare practices that have recently (re)designed their practice with attention to the seven golden rules (see Table 2). The LHV golden rules do include wayfinding, privacy and daylight either as main ‘rule’ or subrule, yet views on nature are not addressed. The rules provide evaluation guidelines for the jury reports, who also visit the project sites and read through project descriptions submitted by the healthcare professionals. The jury consists of both professional, general practitioners, and designers. The project names, project descriptions, and jury reports can be found on the public website of the organization.
Table 1. Description of basic information about the two projects.
|Project||Gezondheidscentrum Haverstraat Oldenzaal||Huisartsenpraktijk Kapelle|
|M2||320 m2||430 m2|
|Amount of patients per year||5100||5800|
|Types of facilities||general practitioners physiotherapist, podotherapy, home care, psychologist||general practitioners, pharmacy|
Interior green dot design
Table 2. Overview of LHV ‘Golden rules’ translated and condensed from (LHV-bouwadviesgroep, 2016).
|Translated themes in LHV ‘gouden regels’||
Condensed summary of the themes as interpreted by the authors:
|optimal floor plan layout||
Assistant workspace central
|distinction between calm and lively areas||Public (lively) versus private (calm)|
|care about accessibility||
Accessibility for all: people with visual disabilities,
reading difficulties, sensory disabilities
|care about experience, atmosphere, and comfort||
colors, (day)light solutions, furniture, and finishing.
comfortable acoustic atmosphere
indoor climate (e.g. temperature, ventilation
|care about quality||LHV-norms, the building regulations, technical requirements|
|care for healthy building financing||
the facility costs should be in balance
with the organizational overall budget
The data were collected in 2019-2021 and included (1) written documentation (descriptions by professionals, jury reports, and design documentation) (2) visual documentation (plans and photos) and (3) Observations. The written and visual data was collected from the LHV website. The observations were done in 2020, 2021 by the main author .He visited both HCCs, examined the entrance reception area and waiting room and included notes taking focused on the four design features and a comparison of the written and visual data given on the website of the LHV. All data was stored in one digital folder accessible to the team.
The data were analyzed through several iterative steps, including selective text analysis (text of professionals as well as jury reports) and thematic observations (plans, photo material, observation notes). The question guiding the analysis states: To what extent do the projects, in their project descriptions, in the design solutions, pay attention to view on nature, privacy, daylight and wayfinding?
The selective text analysis is used for analyzing written documentation to describe and quantify content in relation to prior selected themes (Cavanagh, 1997). Each text section that concerned the four themes (e.g. original meaning unit) was extracted from the document into a digital spreadsheet. These (Dutch) meaning units were then translated and summarized (condensed meaning units). Those condensed meaning units were grouped relating to the four features.
The visual documentation was analyzed through plan analysis as inspired by Van der Zwart & Van der Voort (2015). This meant that the plans, drawings and photos were translated into a simple 3D sketch model (SketchUp) representing the layout (shape, sizes), openings (windows, doors), furniture and plants. While the document is mainly white, a few features were highlighted. For instance, the reception (orange), floor (yellow) and furniture waiting area (brown). The SketchUp models made several representations, including a plan, axonometry and perspectives of the entrance, reception and waiting area. These base drawings were used to develop diagrammatic interpretations.
The data shows the different projects and to what extent they address views on nature, privacy, daylight, and wayfinding as described in the written and visual documentation, and observed on site.
4.1 Gezondheidscentrum Oldenzaal
4.1.1. Views on nature
Views on nature are not mentioned in the jury reports or project descriptions.
The visual documentation shows that both the waiting areas and the back offices have windows to the outside (figure 1,3). The waiting patients look out over a parking lot. The staff overlooks the bike storage, a small garden and the neighbour's fencing. There is no visual connection to the outside from the reception areas, so there is no view of nature from this point.
Observations by the author are in line with the findings of the analysis of visual data: there is no view of nature to the outside but there is a great wallpaper drawing of flowers in the waiting area.
Figure 1. Picture of entrance area Oldenzaal outside
Figure 2. Reception area Oldenzaal
Privacy is not mentioned in the jury reports and descriptions.
Since there is no physical separation between the reception area and entrance, private conversation can easily be overheard by passers-by or waiting patients in the waiting area. This thus indicates low speech privacy.
In the waiting area (figure 3), patients can easily keep their distance from each other due to the space between the two sides of the area. The facing benches in the waiting area make patients face each other while waiting.
Observation shows that the entrance hall is small, closed with sliding doors. The sliding doors are on all sides of the reception area, transparent. So, if a client is in conversation with the assistant, on each side the next client can see this and wait to enter. So, privacy is well kept although the reception area is in the routing. In the waiting area there is a table with chairs around it in the middle of the area, privacy is not well kept, because there is one long bench on one of the wall sides
Figure 3. Part of the floor plan of Oldenzaal, the entrance area and waiting area.
There is no mention of daylight in the jury reports and descriptions.
The visual data show that daylight shines through the glass entrance doors into the entrance area (figure 3). The waiting area is also on this side of the building and receives light from the north. There is no daylight at the reception area. The back office receives daylight from the west through two windows.
Observations show the entrance area is indeed visible and recognizable from the streetside. Inside the building, the reception area receives little daylight. However, the waiting area is spacious and full of daylight.
There is no explicit mention of wayfinding in the jury reports and descriptions. However, they mention the functional set-up of the building.
The photos and floor plans show that the entrance to this HCC is surrounded by parked cars (figure 1), but still recognizable from the street. Once patients enter through the main door, there is a long corridor separated by a glass connecting door. After passing this second door, patients can directly walk towards the reception area, clearly located in the corridor.
The waiting area is located on the other side and is visible from the reception area (figure 3). The consulting areas can be reached via the waiting area and the corridor by passing another door. When patients go back after their consultation, they pass the waiting area and reception area. Before going out they can visit the pharmacy area on the right.
Observations by the autor according to wayfinding are completely in line with the findings and analysis of visual data.
4.2 Huisartsenpraktijk Kapelle
4.2.1.View of nature
In the jury report, there is no mention of views on nature.
The analysis of the visual data shows a view of nature from the entrance and the waiting area (fig4). From these windows a slow-traffic street, two-level buildings, plant borders and low trees are visible. In contrast, it is not possible to have a view of nature from the reception area.
Observations show there is almost no view of nature from the waiting area to the outside.
Figure 4. Entrance area Kapelle outside
The reception area is placed right behind the entrance (figure 5). It is a wide semi-circular space that is part of the walking route to the other areas of the building.
”the welcoming desk is left open, which fits the village-like character most…”.
Since there is no physical separation, privacy-sensitive conversations can be overheard by passers-by.
The waiting area (figure 5) is at a sufficient distance from the reception area and can be closed. The seats in the waiting area are sufficiently spaced so patients can easily keep their distance from each other.
However, When the area is full, patients are facing each other while waiting. Finally, the jury report mentions the usefulness of a separate back office for making privacy-sensitive telephone calls.
Observation showed the reception area is partly being used by the pharmacy. Benches in the waiting area are placed so that clients don’t have to face one another.
Figure 5. part of floorplan, reception area and waiting room
The visual data show windows in the waiting area and in the backoffices (figure5). However, there is no direct daylight into the reception area area, only indirectly through the back office.
The observations show daylight in the entrance area because of a rooflight at the reception area and big windows in the waiting area.
There is no explicit mention of wayfinding, while there is a mention of the well-functioning building layout and the accessibility of ambulances with stretchers in the professional description
Visual data show that the entrance is directly visible from the street. When entering, patients are guided to the semi-circular entrance hall and are directly welcomed by the reception area. After registering the visit, patients can reorientate themselves by turning around. They can then go in one line to the waiting area. This is directly visible from the area and has glass interior frames and a glass door.
The observations indicated that the turn to the waiting area was not obvious from the reception, yet a visual connection when turned helped find the waiting area.
This study examined the integration of health-related features in two Dutch HCCs including views of nature, privacy, daylight, and wayfinding. In general, we see in the results that there is implicit knowledge and use of these 4 elements in the designs of HCCs.
However, the features are almost not explicitly mentioned in descriptions and jury reports.
5.1 View on nature
The results show that view of nature is not addressed in any of the data. This is surprising as there is much research about the view of nature in hospitals (Ulrich et al., 2008. This can be explained by the lack of research on a view of nature in HCCs specifically, and probably because there is not very much exchange of knowledge about health care facility design professionals in hospitals and HCCs. Still, based upon previous research in both healthcare and workplaces it only seems logical that view and access to nature are also important to HCCs, in particular in the waiting area area, where clients stay longer time while often concerned about their health, and can use the positive distraction. We, therefore, advise that view of nature should be added to the golden rules of the LHV-advise group.
The analysis shows little mention of privacy, while floorplans indicate that privacy has been considered in the design, e.i. (sliding) doors between different sections, enough area for a good distance in waiting areas and entrance sections. As mentioned, previous studies already indicated the importance of visual and speech privacy in hospital wards, as well as privacy to accommodate sensitive staff conversations (Morgan et. al.,2020). This study indicates that some design solutions should be altered to improve privacy.
If clients and professionals would be earlier and better heard in the design process, this could help to improve privacy in especially the reception area and waiting area. However, it would have been expected that in award-winning projects like these, there would be even more privacy. This is even more surprising as privacy is widely described as being important in the golden rules.
The analysis showed one mention of (day)light, while the floor plans and pictures indicate attention to daylight in the design of working and waiting areas. Yet, the reception area, also a working area is without direct daylight in both projects. This is surprising as research highlights the need for daylight and the negative health-related outcomes of a lack of daylight, such as problems in orientation, performing tasks, causing medical errors, pain, sleeping problems, and decreasing staff and patient satisfaction (Ulrich et al., 2008).
The results showed that in both projects the walking route is easy to understand because it is visible from the entrance where to go next. Previous research emphasizes the importance of good wayfinding in stress reduction and improvement of wellbeing (Morag et. al., 2016).
5.4 Other reflections
The jury should, in their reporting, probably use the golden rules. And the rules should include a view of nature as an additional design feature.
There are some research limitations due to the number of data used for the two projects. Still, the triangulation of the data from different documentation types (e.g. jury reports, design guidelines, photo plans etc) allowed us to get an initial understanding of how the main design features are implemented and recognized in the design and design guidelines (e.g. golden rules) This thus provided input to revise the guidelines and may serve as a starting point for future discussion either to collect more data for these projects or to compare with other HCCs. Except for research done generally on health centres (Van der Zwart, 2016) there needs to be more research done.
This study investigated the incorporation of health-related features in two Dutch HCCs including privacy, daylight, wayfinding, and view of nature. The results indicate awareness and implicit knowledge of the importance of daylight, wayfinding, and privacy. However, while research on healthcare architecture often highlights the views on nature, it was not found in the projects. We recommend that the LHV-advise group incorporate views on nature and other components of EBD frameworks into their guidelines. Additionally, with this paper we hope to give a contribution to the discussion about wellbeing in the HCCs, to help broaden the awareness of features in healthcare design that improve the well-being of patients as well as professionals in primary healthcare, and to stimulate designers to incorporate the remarks of all users, professionals, and clients in their design.
Conceptualization: LW and EM
Methodology: EM and LW
Writing - Original Draft: LW, LK and EM
Writing –Editing: LK and EM
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