Interdisciplinary User Groups and the Design of Healthcare Facilities

Abstract

Aim:

This Australian research explores how “user group” participants from diverse professional discipline backgrounds understand, define, perform their roles, and assess the outcomes of the healthcare design process.

Background:

Part of the design process in Australia and New Zealand, the purpose of interdisciplinary user group consultation is to design the best healthcare facilities possible within the parameters set by project clients and funding bodies.

Method:

An online survey was used to explore how user group participants viewed the process, including how well informed they felt they were about their role/s in it, its success in achieving specific outcomes for their project, and how they felt their project client, owner, or funding body assessed these same issues. It included both closed and open-ended questions, and data were then analyzed using an interpretative methodology by an architect researcher based in practice.

Results:

Emergent issues identified include governance of the process, knowledge asymmetries between participants, missed opportunities for innovation, composition and workloads of user groups, and the quality of resources available to guide the process.

Conclusions:

The interdisciplinary user group process could be improved, and future research will look at how drawing on participatory design methods used in sectors such as urban planning may support the development of new techniques for conducting user groups.

Keywords

interdisciplinary design participatory design academic research design methodology hospital survey

The Australian healthcare system is a large and expensive part of the Australian economy with approximately 3.6% of Gross Domestic Product (GDP) spent on the hospital system per annum (Australian Institute of Health and Welfare, 2014a). In 2013–2014, estimated capital expenditure on hospitals was AUD$9.1 billion in total, including $4.8 billion spent by state, territory, and local governments (Australian Institute of Health and Welfare, 2014b). Hospital buildings are significant public buildings, often large, complex, with increasingly high levels of sophisticated and high-priced technology, and expensive to operate due to large numbers of staff. They cost more to construct than other major public buildings including airports (Turner & Townsend, 2013). Australian, New Zealand, and other healthcare clients in countries such as the United Kingdom and Canada usually require, as part of the design process for a health facility, consultation with “user groups” whose members include clinicians, managers, and other hospital employees and, where possible, patients, their families, and members drawn from the broader community.

Significance

Effective interdisciplinary collaboration entails understanding the differing skills, decision-making, and design-related priorities of all design team members, and especially how the expectations of project clients and funding bodies affect achieving, managing, and applying “user” input to their projects.

Aims

Part of the requirements for a doctorate in creative industries at the Queensland University of Technology (QUT), Australia, this research explores the contributions of user group participants from diverse professional discipline backgrounds to the design of healthcare facilities, including how they understand, define, and perform their roles and assess the outcomes of the process. The research questions asked, “What is the role of interdisciplinary project ‘user groups’ and how do they affect the design of a healthcare facility?” To investigate this, an online survey was used with closed- and open-ended questions that probed how user group participants viewed the user group process, including how well informed they felt, whether it was successful in achieving specific outcomes for their healthcare design project, and how they believed their project client or funding body assessed these same issues.

Literature Review

Introduction

The changing nature of architectural design practice, including the rise of the specialist “health architect,” has influenced contemporary healthcare facility design. In Australia and New Zealand, interaction of the design team with an interdisciplinary user group is almost always required. Resulting considerations include participants’ differing attitudes toward health design research and how this affects the decision-making process and negotiation of the different professional cultures and skill asymmetries of managerial, clinical, and design team project members. In particular, the impact of professional culture on user group participants’ attitudes must be acknowledged and addressed to ensure the effective pursuit of common goals and objectives. Further, the channeling of users’ diverse skills and knowledge into the design process for a healthcare facility is required to ensure best-practice and innovative healthcare delivery.

Rise of the Health Architect as a Specialist Designer

Verderber and Fine (2000) described the rise of the health architect as a specialist designer during the 1960s, but it was well into the 1990s before the mainstream architectural profession became convinced of the value of interdisciplinary education in health architecture. Yet Australia and New Zealand still lag behind in this type of educational initiative despite the optimism of Lyon (2013). It is also rare for clinicians to be formally educated in the design or management of capital projects unless they enroll in a health administration course or degree (Forbes, 2013). Yet as “users,” they are increasingly expected to participate in the design and briefing (programming) of health facilities, so designers including architects must initiate them into this process. Architects have traditionally worked with users (Lawson, 2006), and Miller and Swensson (2002) emphasize for health projects, the importance of “socially responsible design” noting that

[d]uring the design process itself, the participation of the users of the facility needs to be sought. This will help to clarify the design objectives and to ensure that the objectives of the primary project planners, the architects, and the users mesh. (Miller & Swensson, 2002, p. 56)

However, as there is often an asymmetry of skills or knowledge, the relationship between the design team and the clinical users working in a collaborative setting requires highly nuanced communication (Kim & Shepley, 2008). As clinicians know much about their practice but significantly less about design, they are often more interested in functionality and less concerned about how a building will look or feel, whereas an experienced health architect, trained to appreciate aesthetics, may know much about clinical practice from previous projects but is rarely also a clinician. Further, attitudes toward research and training differ between the world of science-focused clinicians and designers such as architects.

Users’ Professional Discipline Backgrounds and Decision-Making

Kim and Shepley (2008) observe that architectural design decisions can appear to lack credibility in the eyes of healthcare clients and users, so, to ensure effective collaboration, user group participants must not only jointly agree on the project requirements, they must also accommodate differing perspectives regarding research and “evidence” when making decisions in a user group setting in order to successfully practice evidence-based design. This type of decision-making requires a collaborative learning environment that explores the needs of end users and the available evidence base that will guide design decisions—a “method…in sharp contrast to construction meetings that focus primarily on room size and building location” (Elf, Frost, Lindahl, & Wijk, 2015, p. 3).

The differing professional discipline backgrounds of user group participants may also result in different professional cultures affecting decision-making in collaborative work settings. Interdisciplinary clinical teams work together differently than those comprised of clinicians solely from one background such as only doctors or only nurses (Bloor & Dawson, 1994; Hall, 2005; McNeil, Mitchell, & Parker, 2013; Mitchell, Parker, & Giles, 2011; Sommerfeldt, 2013). Bloor and Dawson used a case study to demonstrate “medical dominance” as the prevailing theme when team members drawn from different medical subcultures work together, and Hall (2005) discusses the development of professional identity, the different cultures of each healthcare profession, and how these result from history, “social class and gender” factors. Education and socialization that occur during training reinforce “common values, problem-solving approaches and language/jargon of each profession” and “cognitive learning theory suggests that each profession may attract a predominance of individuals with a particular set of cognitive learning skills and styles” (Hall, 2005, p. 190). McNeil, Mitchell, and Parker (2013) further contend that “the differing processes of professional socialisation within the healthcare occupations mean that there are divergent values…[and] varying opinions as to the nature of the roles within the team is a potential source of conflict” (p. 298).

Education of Designers, Pierre Bourdieu, and “Habitus” Theory

In terms of the socialization and professionalization of designers, various authors discuss how architects are educated and how they view their role both within the construction industry and in relationship to their clients. Cuff (1991) and Stevens (1998) refer to the philosophy of Bourdieu (1990), in particular the theory of “habitus” that explains how the worldview of different professionals determines what each regard as important and perhaps more significantly how “common sense,” the “thinkable,” or the “unthinkable” are defined for each particular habitus. Socialized through education, architecture graduates are then inducted by architectural practice into the ways of the profession, including assisting novice architects to develop and identify with the social, cultural, and economic capital of the architect persona that ensures the survival and promotion of the profession when interfacing with other professionals and the wider community.

Creation of Successful and Productive Working Relationships

However, architecture is also a practice that requires business and management skills and acknowledgment of its responsibilities in creating a built environment for the wider community, as discussed by Cohen, Wilkinson, Arnold, and Finn (2005). Developing this theme, Oak (2009) explores the roles or social categories of “architect” and “client” and how these manifest, with Sang, Ison, Dainty, and Powell (2009) confirming that “the anticipatory socialisation process of architects…appears to have fostered a belief that the core value of the architectural profession is creativity, despite this accounting for little of a practicing architect’s work load” (p. 318). Cuff (1991) and Stevens (1998) support this and propose an inevitably steep learning curve for any client working with an architect for the first time. Siva and London (2012) also noted this in explaining the development of the relationship between an architect and a client during a housing project as a form of learning that includes at least partial adoption by the client of the architectural habitus and believe this to be almost inevitable if the project is to be regarded as successful, particularly by the client. Similarly, although often relatively inexperienced in the design of a healthcare building, clinicians must also learn quickly about the architectural habitus in order to add maximum value to the user group process. Chandra and Loosemore (2010) describe how project participants, particularly clinicians, learn during the interdisciplinary process of briefing a health facility and found that the clinicians’ learning accelerated as the project progressed, and they were then able to offer a much more nuanced appraisal of its outcomes than any of the clinicians who were not involved. Thus, clinicians and other user group members possessing their own distinct habitus and seeing the world from that position must learn about the habitus of other group members and, in doing so, adopt some of their skills, traits, and points of view in order to form the most successful and productive working relationships (Siva & London, 2009).

Henri Tajfel and Group Behavior

Tajfel (1974, 1981), in discussing how the behavior of groups may be biased, outlines the concept of “in-groups” and “out-groups” as a fundamental organizing principle of human society. This offers an individual a “continuing process of self-definition” (Tajfel, 1974, p. 67) and “social identity [as] that part of an individual’s self-concept which derives from his knowledge of his membership of a social group (or groups) together with the emotional significance attached to that membership” (1974, p. 69). An in-group usually displays favoritism to its members including preferring their attitudes and opinions, yet will also see and allow for greater differences within that group than they would ascribe to any out-group members. This favoritism determines those who can be trusted or assumed to understand what is required from the design process, and therefore an out-group will not be trusted, will be regarded with suspicion, and, on occasion, treated with outright hostility (Brown, 2000).

“Profession-Centrism” and Communication Within User Groups

In these circumstances, an in-group may be “profession-centric,” for example, with membership restricted to say clinicians or designers, and this will affect communication within the user group setting. Described by Pecukonis (2014) as “similar to ethnocentrism, profession-centrism (professional centric thinking) is a constructed and preferred view of the world held by a particular professional group developed and reinforced through their training, educational, and work experiences” (p. 62), and results in “the creation of stereotypes that can be limited, involve bias judgment and action, and must be managed” (p. 63). So, clinical and other users must overcome “profession-centrism,” in order to guide cohesively the work of the design team that may otherwise be regarded as an out-group not to be trusted or respected (Khalili, Orchard, Laschinger, & Farah, 2013). Sometimes, even the project client or funding body, the patients, and the wider community may be regarded (perhaps unconsciously) as out-groups with negative consequences for project outcomes. Although there is little in the literature regarding the manner in which architects and other designers form in-groups and out-groups, it is reasonable to assume that this does occur. The formation of these groups is again centered on a similarly “constructed and preferred view of the world” derived and reinforced by professional training as described by Pecukonis (2014, p. 63), so must be managed in a user group setting. Strategies suggested by Pecukonis, Doyle, and Bliss (2008) to improve the functioning of interprofessional teams include the creation of a “superordinate” identity for all team members that will more closely identify with the strategic goals of the healthcare project. The focus of the project should also be broadened to include the needs of patients and the wider community rather than largely concentrating on clinical workplace needs. Similarly, a skillful leader or user group facilitator should address power imbalances (e.g., doctors vs. nurses), organizational political hierarchies (clinicians vs. managers vs. funding bodies), and differing professional cultures and roles (clinicians vs. designers vs. managers). Creating positive team interactions may reduce the incidence of profession-centrism impacting negatively on user group outcomes.

Leadership of the User Group Process

However, the most suitable discipline to lead the user group process can be contentious. Stichler, a nurse, contends that nurses are very capable of providing leadership to the healthcare design process using their clinical knowledge to guide facility outcomes (Stichler, 2007, 2009, 2014, 2016; Stichler & Gregory, 2012; Stichler & Okland, 2015). Others also look at how nurses can add value to the process as leaders and advisors (Lamb, 2016; Lamb, Connor, & Ossmann, 2007) and how nurses can work with architectural educators to develop core competencies in students of healthcare design (Lamb, Zimring, Chuzi, & Dutcher, 2010). Hamilton (2010a, 2010b, 2011, 2014), an architect, discusses the issue from a different perspective and calls for greater recognition of the skills of all participants in the process, whether clinician, manager, or designer. Various authors note the need for effective “interprofessional” collaboration; yet this is a term used far more frequently in the literature by healthcare professionals, in particular nurses, than by designers.

Design Decision-Making and Participatory Design

Becker and Carthey (2007) discuss how decisions are made in interprofessional health design settings, noting that the process is nonlinear, iterative, reflective, and involves many players, with outcomes passing through a series of filters or frames to a final solution. Lawson (2010) outlined a decision support tool called ASPECT—“A Staff and Patient Environment Calibration Tool” believing that the “process of briefing [programming] is itself interactive…and current thinking suggests that problem and solution emerge together in a good design process rather than one totally preceding the other” (Lawson, 2010, p. 104). Zerjav, Hartmann, and Achammer (2013) reviewing a complex railway station project proposed that reflective practice assists in making decisions in an interdisciplinary design team setting, especially where many complex issues require resolution, with issues “framed” consecutively as manageable pieces of work that move a project forward. It seems likely that the user group process supports similar framing of the major issues that drive a healthcare project toward a design solution.

Finally, Potter-Forbes and Barach (2012) recommended making the user group process more transparent to participants, especially in terms of purpose and required outcomes following their review of several mental health building projects in New South Wales, Australia. This is consistent with the findings of Arnstein (1969) who, in discussing urban planning in the United States, provocatively suggested that a participatory design process requires those promoting it to explain and agree on the level of input required from users and the extent of their influence on the potential outcomes. Commenting that “[t]here is a critical difference between going through the empty ritual of participation and having the real power to affect the outcome of the process,” Arnstein (1969, pp. 216–217) proposed a typology of eight levels of participation in a ladder pattern ranging from “manipulation” and “therapy” as types of nonparticipation at the bottom of through to “citizen control” at the top, intending to encourage debate about this type of activity.

Research Methodology

An online survey was used to examine how Australian and New Zealand user group participants rate the user group design process including its outcomes, and this approach was chosen in accordance with the observations of Groat and Wang (2002) that this is a suitable method for gathering data quickly and broadly and also to triangulate research data that will be gathered using interviews in the next stage of the research. Questions were developed in the software program Key Survey. Ethics approval was granted by Queensland Institute of Technology (QUT) no.1700000155, and prior to distribution, the questions were trialed with the input of several selected respondents from design, management, and clinical backgrounds. To ensure a spread of respondents from different professional disciplines, the survey was distributed anonymously to a range of user group participants by Australian and New Zealand health authorities including Health Infrastructure NSW, the Victorian Department of Health and Human Services, Queensland Health, Canterbury and Southern District Health Boards; professional organizations such as the Australian Institute of Architects, Australasian College of Health Service Management, and Australian and New Zealand Health Design Councils; plus by several large architectural and project management consultancy firms.

Questions were both closed- and open-ended, with further comments invited in response to each section of the survey. Respondents provided informed consent by proceeding past the information page and completing the first question. To ensure a suitable spread of respondents, the first part of the survey gathered demographic information regarding respondents’ geographic location, professional background, project role, and healthcare design experience. To continue to the next part of the survey, respondents were required to have participated in a user group process for a healthcare facility within the last 5 years.

Findings

The survey was open for a period of 14 weeks, started by 107 people and fully completed by 68. The completion rate was 64%, although another 39 participants (36%) answered at least one question. Ninety-five respondents (89%) confirmed that they had participated in user group consultation within the last 5 years and were qualified to proceed with the survey. However, 28 (30%) then dropped out progressively giving a completion rate of 72% for all qualified respondents. These respondents may have found it impossible to complete the survey at one sitting and may have intended to return to complete it at a later date but never did so. Main workplaces were Australia (66, 64%), or New Zealand (34, 33%), with the remainder Singapore (2, 2%), or another country. Australian respondents came from Queensland (29, 44%), New South Wales (23, 35%), Victoria (9, 14%), and Western Australia (5, 7%). The current professional disciplines/occupations of 95 respondents were aggregated, ranked by major occupational group, and are shown in Table 1, with the top three being (1) designers (26, 27.4%), (2) project manager/project director (20, 21.1%), and (3) clinician (18, 18.9%).

Table 1.

Responses by Current Discipline Aggregated and Ranked in Terms of Occupational Group.

Rank	Current Discipline/Occupational Group	Number	Respondents (%)
1	Designer—any type	26	27.4
2	Project manager/project director	20	21.1
3	Clinician—any type	18	18.9
4	Management	15	15.8
5	Service planner/health planner	5	5.3
6	Facility manager	4	4.2
7	Building contractor	1	1.1
8	Other—including equipment (FF&E) specialist, ICT program manager, wayfinding consultant, design and fabricate artwork, consultant—user group facilitation, clinician-nurse/design-interiors/health planner	6	6.2
	Total who answered this question	95	100

Note. FF&E = Furniture, Fittings & Equipment, ICT = Information & Communications Technology.

More than half (53, 52%) of the 102 respondents who answered this question had 11 years’ experience or more on healthcare design projects, 15 (15%) had 6–10 years’ experience, 68 (67%) had more than 6 years’ experience overall, and 34 (33%) had 1–5 years’ experience or less. Most experienced disciplines (11 years or more) on healthcare design projects were designers (25, 49%), then project managers/project directors (9, 17%), followed by managers and service planner/health planners, both (4, 8%), and clinicians (4, 8%). By contrast, designers were (1, 2%) of those with less than 10 years’ experience compared to clinicians as (14, 32%) of this group, followed by project managers/directors and managers, both (11, 25%). Overall, clinicians had the least experience on healthcare design projects with 13 (73%) with 5 years or less experience, compared to no designers in this category.

Respondents were next asked how well informed they felt prior to commencing their most recent project regarding the objectives of their project client or funding body for “user group” consultation on projects within their jurisdiction. Ninety-two respondents answered this question, with the majority (81, 88%) at least adequately informed—very well informed (36, 39%), moderately well informed (29, 32%), and adequately informed (16, 17%)—while 11 (12%) felt poorly or very poorly informed—see Figure 1.

Figure 1.

How well informed were respondents regarding the objectives of their project client or funding body?

Broken down by discipline/occupational group, those who felt poorly or very poorly informed were clinicians (4, 24%), service planner/health planners (1, 20%), project managers/project directors (3, 16%), designers (2, 8%), and no managers or facility managers. Designers, plus the small number of facility managers and building contractors, felt the best informed, while clinicians did not feel as well informed as other disciplines, with 13 (76%) responding that they felt at least adequately informed (or better), compared with 24 (92%) of designers. When asked to indicate how well informed respondents felt regarding the purpose, process, and outcomes required from the user group process for their specific project, results were similar, with 83 (90%) responding that they felt adequately informed (or better)—see Figure 2.

Figure 2.

How well informed were respondents regarding the outcomes required for their specific project?

The breakdown by discipline/occupation and comparison of answers to these questions are shown in Figure 3.

Figure 3.

How well informed did respondents feel regarding B2—the objectives of their client/funding body for projects in their jurisdiction; B3—the purpose, process, and outcomes required for their specific project?

Respondents were asked the extent to which they believe that the “user group” consultation process achieves the results required by project clients or funding bodies for projects in their jurisdiction. A majority of respondents (76, 85%) believed that it does so at least adequately—adequately (34, 38%), well (36, 40%), or very well (6, 7%)—see Figure 4.

Figure 4.

How well does the process achieve the outcomes required by project clients and funding bodies?

However, in terms of the respondents who believed that it did so poorly (13, 15%), clinicians were overrepresented; although only 17 (19%) of all who answered this question, 7 (42%) gave this response. In particular, half the nurses (5, 50%) felt the process achieved poor outcomes for clients or funding bodies compared with no managers and few designers (3, 12%) or project managers/project directors (2, 10.5%). Respondents were then asked how well the user group consultation process achieved the outcomes required for their specific project. The majority of respondents (80, 90%) felt that it did so at least adequately, scoring it adequately (40, 45%), well (32, 36%), and very well (8, 9%), with several believing that it did so poorly (7, 8%) or very poorly (1, 1%) or didn’t know (1, 1%) as illustrated by Figure 5.

Figure 5.

How well does the process achieve project-specific outcomes?

Several clinicians (7, 42%) and one designer (1, 5%) assessed the outcomes as poor or very poor, with clinicians again overrepresented as they were 17 (19%) of all who answered this question. The breakdown by discipline or occupation and comparison of answers to these two questions are shown in Figure 6.

Figure 6.

How well did respondents feel the process achieved its outcomes in terms of B4—the objectives of their client/funding body for projects in their jurisdiction; B5—the purpose, process, and outcomes required for their specific project?

Although the quantitative results suggest that the user group process achieves an adequate outcome for most participants, the qualitative results from the open-ended commentary suggest more nuanced conclusions. As shown in Table 2, open-ended commentary was analyzed—using nVivo (version 11) in terms of emergent themes and key words, with additional coding in Excel. The main themes identified were (1) how the user group process is run including defining and managing the objectives and expectations of users (governance); (2) the demonstration of integrity by project clients (governance); (3) how the success of the process varies, depending on the knowledge of users and whether they had “buy-in” to the project (knowledge asymmetries); (4) the outcomes of the process including missed opportunities for innovation (process); (5) the ideal composition of user groups and recognition of their workload (process); and (6) the quality of resources available to user groups, for example, the Australasian Health Facility Guidelines (AHFG; resources).

Table 2.

Qualitative Commentary—Emergent Themes and Examples.

Emergent Theme/Subtheme	Examples of Commentary
GovernanceSubtheme: How the user group process is run including defining and managing the objectives and expectations of users	Designer: “Clients believe very strongly they need user group input but do not have a clear idea of exactly what they want user group input to achieve and how that might be distinct from expert advice.”Clinician: Existence of “conflicting agendas/function vs form.”Service planner/health planner: “Roles of participants and their expectations could be more clearly articulated.”Clinician: “Depends on the facilitator of the user group. Outcomes are dependent on what management and CAPEX can provide. Often there is a lack of feedback to the user group once a decision has been made that the user group schedule of accommodation has been reduced.”Clinician: “You are constrained by $$ and building footprint & key principles.”Clinician: “Requested changes not always implemented.”Clinicians—several: [User] input was often disregarded and not translated to the final design outcomes.Designers, managers, and project managers/project directors: Called for strong leadership of the user group process and the need for skilled facilitation to reconcile the needs of users with the demands of the project especially where meeting budget and other nonnegotiable requirements.
GovernanceSubtheme: Demonstration of integrity by project clients	Clinician: Concerned with “lack of integrity within [the] process displayed by project clients and funding bodies.”Clinician: Felt “powerless as decisions made were over-ridden by groups higher up the chain.”Clinician: “Issues with the concept design were raised multiple times and resulted in papers being written informing the Executive Team that compromises in design are at high risk of affecting patient safety and experience. Whether there is an outcome from this remains to be seen.”Clinician: “The buck often stops due to financial constraints and acts as a major roadblock to the user group needs.”Clinician: “[I] felt that the opinions and ideas of the user group were well regarded within the group and in immediate managers above, but once it went higher into management other requirements (budget, management agendas) began to take priority.”Clinician: “I feel that the user group process was used by both the project and health department to tick a box stating they had ‘consulted’ users during the process.”
Knowledge asymmetriesSuccess of the process varies depending on the knowledge of users and whether they had “buy-in” to the project	Designer: The success of the process “varies according to the knowledge base of the users.”Designer: “Changes in stakeholders leading to changes in requirements, despite signoff.”Manager: Achieving the outcomes of clients “depends on the project and user buy in to process.”Manager: “I feel end users can lack understanding of plans/FF&E and the ramifications of their decision making.”Clinician: “Some ideas from other hospitals may have helped rather than being given a totally empty sheet.”Project manager/project director: Users’ lack of ability to read plans “we still had changes when built.”Project manager/project director: The process could increase “ownership” of the outcomes by the users.Clinician: “Architects took note and ideas but clearly had their own agenda and imposed designs that were not best practice. A lot of useless space with inefficient design which looked impressive was the outcome.”
	Architect: Knowledge of users varied widely, and that the input of “strong” characters could sway the process to produce poorer outcomes for all those involved.Architect: Need better education of the users regarding how designers work, how project decisions are made, and also how things are done differently in other locations and countries.Project managers/project director: Is the time and cost of the user group process worthwhile in terms of the design outcomes it achieves (“time and costs vs benefits unproven”)?Project manager/project director: “Typically its more about bringing people on the journey and initiating the change process than providing any major benefit to the designed outcome.”
ProcessSubtheme: Outcomes of the process including missed opportunities for innovation	Designer: “It seems to produce the lowest common denominator.”Designer: It introduces inconsistencies in outcomes by “sometimes contradict[ing] agreed policies and minimum standards.”Designer: Ongoing user group involvement can delay project progress.Project manager/project director: Need for change management to improve outcomes.Project manager/project director: “The input is valuable in terms of sharing experience and understanding” but “there is also the risk that ‘users’ struggle to transition their thoughts from the now resulting in missed opportunities.”
ProcessSubtheme: Composition of user groups, and recognition of their workload	Manager: “The full extent of consultation is not achieved” due to lack of consultation with Engineering and Maintenance staff, and administrators, compared to the greater representation of clinical people in the process.Designer: Size of groups is important (with smaller groups preferable).Designer: Membership should be consistent as commonly the changing of members “caused backtracking and re-assessing of things previously agreed.”Clinicians—several: Time pressures are an added burden to their everyday work.Designer: Time pressures due to inadequate time allowed, and inexperienced users.
ResourcesQuality of resources available to user groups, e.g., the Australasian Health Facility Guidelines (AHFG or AusHFG)	Designers and service planners/health planners—several: Need greater recognition of standardization and the need to ensure consistency and minimum standards across projects as embodied in the Australasian Health Facility Guidelines (AHFG).Designer: Draft status of the AHFG renders them less robust as a design reference and hence more easily disregarded by clinician users.Service planner/health planner: “User groups are often not even aware of the existence of the AusHFG’s and this should be part of the introduction to their role as a ‘user.’”

Conclusions

User group consultation is required for the design of healthcare facilities in Australia and New Zealand (and some other countries), yet given the time and money spent on user group consultation, less than 50% of all respondents assessed as “well” or “very well” the extent to which the user group process achieved the goals either for their specific project or for their project client. Users from different professional backgrounds had very different levels of healthcare design experience, especially managers (project, facility, and general) and clinicians who perhaps not surprisingly, generally had much less experience with healthcare design projects than any other discipline group. Quantitative data analysis shows that the majority of respondents considered the user group consultation process and its outcomes to be at least adequate. Yet when analyzed in terms of respondents’ professional discipline backgrounds, there was much greater variability, with clinicians in particular feeling less informed and less confident that the process achieves the required outcomes for either their project clients or their specific projects. This suggests that with less healthcare design-related experience, clinicians may have initially higher expectations of the process and its outcomes and consequently find the process and its outcomes to be less successful than those with more experience, especially the designers.

The open-ended commentary of clinicians, project managers, and designers also suggests that the user group process is not as effective as it could be, with governance of the process being the most commonly expressed reason for dissatisfaction. Drawing on Arnstein’s (1969) findings and referring to the conclusions of Potter-Forbes and Barach (2012), the objectives and expectations of users should be better defined and managed, making it clear whether users are the decision makers or whether their role is that of expert advisors and as such, one part only of the input to the decision-making process by clients and funding bodies. Sources of expertise are available from other fields such as urban planning including methodologies promoted by the IAP2 Spectrum of Public Participation (Federation of International Association of Public Participation, 2014) that discuss differing types of design participation (inform, consult, involve, collaborate, or empower), goals for each, and promises that can be made to participants regarding process and outcomes.

Many clinician users do not understand the overall user group process and exactly what it is expected to achieve, although designers offer clinicians and others who participate in user groups interactive presentations explaining the stages in the process and what to expect from designers and employ technologies such as virtual reality modeling to explain the design as it proceeds. Instead, several clinicians made negative comments regarding the motives of project clients and designers, and although designers understand the process better, rating it and the results more highly, they feel it could be improved, especially in terms of promoting more innovative healthcare delivery. One designer stated that the success of the process “varies according to the knowledge base of the users,” and another felt that it “seems to produce the lowest common denominator.” Consistent membership, composition and user group workloads should also be addressed, and as suggested by several designers and health/service planners, the design process could be improved if the AHFG (Australian Health Infrastructure Alliance, 2016) were more widely recognized by users, made more robust as a design reference, and applied more consistently across projects.

No patients answered the survey, and their needs were not explicitly considered by respondents who were primarily concerned with the design of a clinical workplace. As noted previously, strategies to address profession-centrism include the creation of a super-ordinate identity for the project user group, expanding it to include patients and the wider community to ensure their issues receive as much attention as other project priorities. This is an implication for practice as an improved user group process may improve the design quality of healthcare facilities for all those who pay for, work in, visit, or are treated there.

Limitations and Future Research

Limitations of this study include (1) the lack of specific input from project clients, owners, or funding bodies and (2) no input from patients, families, or members of the wider community affected by the design of a healthcare facility.

Future research will look at how the user group process may be improved, commencing by inviting input from project clients, owners, and funding bodies. Drawing on participatory design principles in fields such as urban planning and planning methodologies for other types of major public projects, it may also be possible to offer new or refined techniques to user group design forums in sectors in addition to healthcare. In the healthcare sector, these techniques may also be useful for health service planning, development of healthcare delivery models, and for more effectively including patients, their families, and the wider community in the healthcare facility design process in Australia, New Zealand, and other countries.

Implications for Practice

The information in the article can be used to enhance health facility design by improving utilization of the skills and knowledge of all “user group” members—clinicians, managers, and designers.

Understanding and addressing project client expectations will assist in achieving, managing, and applying user input to projects efficiently and effectively.

Governance of the user group process may be improved by better definition of the roles of user group participants—for example, determining whether they are “expert advisors,” “decision makers,” or “reviewers.”

Recognizing and addressing knowledge and experience asymmetries, especially between clinicians and designers, may support project facilitators in determining the most appropriate composition and size of user groups.

Supporting review and improvement of resources, such as health facility design guidelines and other required standards available to user groups, may improve the evidence available for decision-making and so support the greater use of evidence-based design on health facility projects.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Jane Carthey, BArch, MPM

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