Abstract
This will be my last official editorial for Health Environments Research & Design Journal (HERD); the omega of a new era for me, since I am retiring from my role as founding co-editor in November 2019. Just saying this is bittersweet. I have loved the journey of 12 years watching growth in myself as an author and editor and the development of the science in healthcare design because of HERD and emphasis on evidence-based design (EBD) and design research. There have been many “alpha” experiences along the way, but I distinctly remember the true alpha (beginning) for HERD while sitting under a tree in an outdoor restaurant in San Diego at one of the Healthcare Design Conferences. At that very spot, Kirk Hamilton and I shared our similar visions for a journal focused on EBD and design research as contrasted to published project reports with glossy photos of completed projects. We had much to discuss—how to develop a proposal for a new journal, who would be the target audience, which publisher might be interested, and what resources (including ourselves) would be needed to start and sustain such an endeavor. That simple meeting with a shared vision and collaborating minds was the beginning of a fantastic partnership between us. Fortunately, there is no end in sight! HERD continues to improve and mature each year as evidenced by the escalating Impact Factor, which is important to our academic readers, authors, and colleagues in the industry. Two new co-editors have been added with Naomi Sachs bringing expertise in landscape architecture, research methods, EBD, and instrument development. Debbie Gregory will be replacing me and brings nursing/healthcare (replacing me), interior design, and information technology experience to the editorial team. Of course, I will always be involved with HERD as a founding co-editor emerita, as an Editorial Advisory Board member, and as a reviewer.
Patient-Centered Healthcare Design
Reflecting on my career as a nurse and the many roles I have filled over the years, I immediately remembered what I think was the alpha or beginning of patient-centered healthcare design. My clinical background has been maternal newborn and child nursing, and I was a part of the revolution that occurred in maternal-newborn care in the 1970s. It is said that change that is quick, controversial, and demanding is revolutionary, while evolutionary change is more methodical, strategic, and slow. What occurred in maternal-newborn care in the 70s was revolutionary, and the changes demanded by women and families not only affected maternity care, but also ultimately affected all hospitalized patients in other specialties as well. The 70s was a time of great discontent with national fatigue related to the war in Viet Nam, an antiestablishment/administration mentality, and a new spirit of standing up and speaking out for one’s beliefs and values. Childbearing women were fed up with hospital rules, regulations, and mandates about the birthing experience. Mothers who traditionally had little influence about labor and delivery in the hospital setting were now voicing their preferences. Restrictions on who could attend or participate in the birth or how the mother would manage the birthing process were challenged.
The book, Immaculate Deception, written by Suzanne Arms in 1975 illuminated the deception that birth was a painful and dangerous process, and only medical intervention with drugs, technology, and often surgical procedures (use of forceps, episiotomies, and cesarean section) would ensure a healthy outcome for mothers and babies. The architectural design of hospitals during this era supported the “deception.” Women labored in small, windowless, and cramped labor rooms or multibedded laboring wards, and when delivery was imminent, they were rushed off to a sterile delivery room, moved at the worst possible time from a stretcher to a delivery table, and placed in supine (flat on the back) position with legs in stirrups for the delivery. Often the father or other supporting persons where moved to a waiting room, while some hospitals allowed the father to attend the birth. After the delivery, the mother and baby were separated with the mother moved to a recovery room and the baby moved to a transitional nursery for a minimum of 4–6 hours.
Advocacy groups such as the International Childbirth Education Association, Lamaze, and other medical and nursing professional organizations provided evidence that birthing was a natural process. These organizations advocated that most mothers could progress through labor and delivery without medications and with those they loved in attendance. New research on mother–infant bonding supported the notion of keeping mothers and babies together after birth. Alternative Birthing Center (ABC) rooms were designed with labor rooms retrofitted to support patients with “alternative” thinking and birth plans outlining their wishes for the birthing process. Physicians and nurses sometimes labeled these patients as “alternate” as well.
Change Is Never Easy, and Revolutionary Change Is Definitely Not Easy
Women’s magazines, talk shows, childbirth education programs, and a few physicians and nurses began to empower women to take more control in the birthing process, and increased numbers of women and their partners demanded changes in the birthing process and the birthing environment. By the late 70s and early 80s, the architectural design of maternity units changed from one or two obligatory ABC rooms to an entire unit of labor–delivery–recovery (LDR) rooms. The LDR rooms were decorated with homelike furnishings, and waiting rooms began to look like home family rooms complete with fireplaces and comfortable chairs and sofas. One of the first of such designs was Cottonwood Women’s Center in Utah, but the idea caught on rapidly, and the LDR design was replicated across the country. Innovations in the birthing room design flourished with the inclusion of birthing tubs, whirlpool baths to ease the pain of labor and delivery, and even sleeping space for the father or family support person to stay with the mother and newborn. To prevent separation of mothers delivered by cesarean section from their babies, one hospital designed an admitting newborn nursery within the postanesthesia recovery room to keep mothers and babies together.
To prevent the separation of mothers, babies, and families after birth, some hospitals designed and built labor–delivery–recovery and postpartum rooms (LDRP) which were the beginning or early examples of the single-room design or acuity adaptable rooms.
Market-Driven Healthcare Design
Hospital administrators quickly recognized the market appeal of the LDR and LDRP rooms with their market share for maternity care rapidly escalating after building these new maternity units. Hospitals who would not or could not retrofit their traditionally designed maternity units lost market share. The 80s were the beginning of market-driven healthcare and ultimately market-driven architectural design. The healthcare design industry began to discuss person-centered design features that would support both patients and their families. Interior designs transformed the sterile hospital look to environments that were homelike and visually appealing including more natural light, indoor–outdoor relationships, and views or images of nature in patient areas. The Center for Health Design (CHD) was also launched in the 80s with leaders in interior and architectural design forming the initial board of directors for the CHD and with focus on improving the healthcare environment.
The notion of patient-centered design escalated in the 90s with beginning discussions of healing environments and using research to inform designs. Patient sensitive design was not only viewed as a marketing strategy, but also as a therapeutic intervention to reduce anxiety and facilitate healing for both patients and families. Hospitals that transformed their environments to include elements of healing environments were market leaders.
The new millennia brought even more innovative designs to promote patient-centered care and discussions of single room designs for all patients. During the first decade, the notion of acuity adaptable rooms or universal rooms was tested comparing the efficiency, efficacy, and cost outcomes of universal rooms to the more traditionally designed rooms for critical care and acute care units. Changes to the entire patient care unit design were discussed with more decentralized units designed and built with comparisons made to units with centralized nursing stations in terms of patient and provider outcomes.
HERD was launched in 2008 and immediately filled the need for actually comparing the efficiency, benefits, and outcomes of one design feature with another. HERD has moved the publication of architectural and interior design projects from “isn’t this pretty” articles to the “does this design really work” era. Both the healthcare industry and the design industry have recognized the intersection of their fields, and HERD has shaped the healthcare design industry with new knowledge, translation of research findings to practice, and the challenge to measure the effect of the design on patient, provider, and organizational outcomes. HERD has integrated and advocated for a multidisciplinary perspective in all phases of the design process as exemplified in HERD’s Advisory Board membership comprised of architects, interior designs, engineers, nurses, physicians, and healthcare leaders. HERD has challenged the status quo and encouraged measuring tough questions—are single room designs the best in all situations; how do decentralized nursing stations affect communication patterns among care providers, care delivery practices, or visualization of the patient; and how can facility design enhance patient safety or improve the work environment for providers?
The Omega—The End?
Fortunately, there is more to discuss about the alpha or the beginning and the continued transformation of healthcare environments over the past three to four decades than postulating about the future of healthcare design. Suffice it to say, I don’t see an end to the innovative designs that continually improve healthcare environments for those providing the care and for those receiving care. Patient-centered care has now morphed into person-centered care recognizing that the patient’s support persons’ needs must also be considered in design. Perhaps this new emphasis on including support persons as care partners will change designs in critical care environments to include bathrooms for every room regardless of the level of care or change emergency department designs to be more acuity adaptable as contrasted to compartmentalized by acuity level. We know advancements in technology will continue to influence facility design, care provision, and innovations in medical equipment (the smart bed) and furnishings (smart flooring or smart lighting). New knowledge about the microcidal properties of copper and copper alloys will likely transform the design of patient beds, overbed tables, chairs, bedside furniture, sinks and faucets, and even door handles to address risks of healthcare acquired infections.
We live in such an exciting time of rapidly accelerated change, instant dissemination of new knowledge through the Internet, resources to question and test innovative thoughts and ideas, and magic at the intersection of interprofessional education, knowledge, research, and service. There is no need to discuss the omega of it all because the rapid revolutionary changes in healthcare design are never-ending. There are simply too many questions to ask, too many ideas to test, too many changes to make, and too much to be accomplished to continually improve environments to receive care for patients and families and to give care for healthcare providers.
The alpha and the omega—the beginning and the never ending story of questioning, innovation, and transformation. I have been fortunate to be involved and engaged as a clinician, a healthcare executive, a consultant in design, a professor, a researcher, and editor. My career in healthcare design has been richly rewarding and fulfilling, and I look forward to new innovative thinking and continual improvements in the healthcare environment.