Indigenous Preferences for Inpatient Rooms in Australian Hospitals: A Mixed-Methods Study in Cross-Cultural Design

Abstract

Aim:

This mixed-method study aimed to establish preliminary evidence for spatial and design features that can improve the experience and participation of Indigenous inpatients in healthcare.

Background:

Disadvantaged across a range of health measures, a disproportionately high number of Indigenous people leave hospital without receiving appropriate medical care. Australian government policies to improve cultural safety of Indigenous patients have largely ignored physical settings and their potential to improve health outcomes. Despite increasing evidence on the potential of design to reduce patient stress, there is minimal research on cross-cultural design in health facilities, including for Indigenous Australians.

Methods:

A cross-sectional, area-based survey elicited design preferences of four healthcare settings from Indigenous participants (n = 602). On the screen-based survey, participants selected from paired images that indicated their preferences for room layout and features of inpatient rooms. Semistructured in-depth interviews (n = 55) explored meanings behind preferences.

Results:

Participants showed majority preferences for the two-bed patient room, for a balcony rather than a window only, Indigenous art, and view of a park over an urban environment. Analysis of qualitative data shifted the focus from Ulrich’s three supportive design components to cultural recognition, the desire for company of family members, and connection to life outdoors.

Conclusions:

Social and cultural factors were highly significant to patients for sense of control, family support, and positive distraction. In response, inpatient room size and type, views, access to outdoors and Indigenous art need to be considered in hospital design for Indigenous patients and families.

Keywords

patient rooms cross-cultural design Indigenous health theory of supportive design mixed-methods

In Australia, the burden of disease experienced by the Aboriginal and Torres Strait Islander (hereafter Indigenous) population compared to the non-Indigenous population has heightened the need for specific policies and services that improve the health of Indigenous people. Since 2008, research on the culturally appropriate delivery of health services has been increasingly codified in government policies, with coordinated state and federal policy frameworks aimed at closing this “health gap” (Australian Institute of Health and Welfare, 2018). By contrast, how physical environments might affect Indigenous patients’ use of healthcare facilities remains underexplored. This article examines Indigenous people’s preferences and experiences as inpatients in public hospitals, and the design implications of this research. It is based on a broader study of Indigenous people and healthcare settings in two regional areas of northern Australia (Haynes et al., 2019).

We begin by placing our investigations in the context of the literature on evidence-based design (EBD) in healthcare facilities that aim to reduce patient stress and improve recovery. A wide range of research on design features of inpatient rooms is discussed as well as cross-cultural design studies. Following a brief introduction to the study, the quantitative survey and the qualitative interview methods are presented separately. Results from the analysis of the different data sets are compared to Ulrich’s (1991) theory of supportive design (SDT) and the three concepts around patient needs: a sense of control of environment, social support, and positive distraction.

EBD and the Inpatient Room

Since 2006 in the United States, single patient rooms (SPRs) have become the industry standard replacing multibed wards (Facility Guidelines Institute, 2014) with this trend reflected internationally (Verderber & Todd, 2012). This benchmark was based on evidence for better infection control and for the therapeutic benefits to patients from increased privacy and sense of control (Chaudhury et al., 2005). Similarly, hospital design in Australia has moved toward a patient-centered care model (Australian Commission on Safety and Quality in Health Care, 2011) with a corresponding increase in SPRs in public hospitals. The Australasian Health Facility Guidelines (AusHFG, 2015/2018, p. 12), used widely as a standard, recommended SPRs because of the evidence on “patient safety, infection control, patient privacy and dignity, plus staff comfort.” Although SPRs can offer patients improved privacy and sense of control, this architectural choice may affect the level and frequency of care (Taylor et al., 2018). Decreased visibility of patients and reduced staff interaction are both relevant to quality of patient care and staff satisfaction (Ampt et al., 2008).

Several systematic reviews of the literature have a specific focus on patients, their families, and inpatient rooms, including Ampt et al. (2008), Devlin and Arneill (2003), Cifter and Cifter (2017), Dijkstra et al. (2006), Harrison et al. (2015), Laursen et al. (2014), MacAllister et al. (2016), Taylor et al. (2018), Timmerman and Uhrenfeldt (2014), Ulrich et al. (2008), and Voigt et al. (2018). SPRs have supported user needs for privacy and better infection control, as well as improved access to windows, views, and gardens that were significant for reducing patient stress (Andrade et al., 2017; Huisman et al., 2012; Laursen et al., 2014; Timmermann & Uhrenfeldt, 2014; Ulrich, 1986, 1991).

The effects of the ambient environment in the inpatient room, such as noise, smell, temperature, lighting, and soundscape have varied according to the setting and the users. Patients have felt stress when unable to achieve thermal, visual, and auditory comfort (Cunha & Silva, 2015; Mackrill et al., 2013; Ulrich, 1991). Music and art could be soothing, although the vulnerability of patients or families was considered to be important in the choice of artwork and music (Iyendo et al., 2016; Laursen et al., 2014; Ulrich, 1986; 1991).

The connection between the physical and social environment of hospitals has been significant for reducing patient stress (Devlin & Arneill, 2003; Ulrich et al., 2008). Although SPRs have become widespread, hospital policies encouraged family involvement as part of patient-centered models of care. Whether in the patient room or nearby, flexible spaces for family members offer settings that may contribute to stress reduction for the patient and visitor (Huisman et al., 2012). Although design and other features of inpatient rooms have been viewed as potential solutions to patient stress, less focus has been given to different cultural needs.

Cross-Cultural Studies

The expanding field of EBD research has contributed limited studies on cultural difference. In each of the three studies cited below, attention to cultural context brought added opportunities to improve hospital design for a particular patient group. A comparison of patient responses in Portuguese and U.S. hospitals suggested that more comments about light and sun from Portuguese patients compared to U.S. patients reflected preferences for the Mediterranean climate and renowned quality of light in Lisbon (Devlin et al., 2016). In the United States, Bell (2018) studied refugee and migrant populations in Maine and showed that architectural features along with mixed ethnic histories and social networks of patients can influence patient responses to hospitals. A study in China looked at the relative importance of patient room design in two Chinese hospitals (Zhao & Mourshed, 2012). Findings indicated that the overall high expectation of cleanliness compared to the relatively low importance of “pleasant exterior view,” for example, may be linked to “the culture and aspiration of the Chinese for better air quality in indoor and outdoor environments” (Zhao & Mourshed, 2012, p. 212). In Australia, cross-cultural studies are also limited, including on Indigenous patient experiences (Harrison et al., 2015). A number of surveys around health service delivery however indicate design as a factor in improving experiences and participation, although the diversity of Indigenous people in Australia limits generalized solutions (Willis et al., 2011; Wotherspoon & Williams, 2018).

Indigenous Cultural Recognition and Healthcare Facilities

For several decades in Australia, advocacy for culturally appropriate health services has been steadily growing across the health sector confirming the relevance of Indigenous cultural values to health behaviors (National Aboriginal Community Controlled Health Organisation, 2019). Cultural safety in service delivery recognizes the link between the social determinants of health for Indigenous people including the ongoing effects of colonization, such as loss of land and language, forced removal of children, and racism (Dudgeon et al., 2010). As a consequence, Indigenous people can experience lack of recognition in the form of social and political invisibility (Taylor, 1994) and their health needs can be overlooked (Schultz & Cairney, 2017). On the other hand, positive contributions to health and well-being may derive from Indigenous cultural domains, including connection to country (traditional homelands), language, kinship, cultural expression, and self-determination (Salmon et al., 2018).

Indigenous people in hospitals are frequently visited by large extended family groups, including to celebrate a birth or mourn a death (McGrath et al., 2006). Without familiar visitors, an Indigenous patient may feel threatened about their status as a family member (Dussart, 2010). Differences in Indigenous people’s expectations and their responses to healthcare settings influenced the design of this study.

Research Question

We hypothesized that the cultural background and social practices of Indigenous people affect their perceptions of patient rooms and the physical environment in hospitals. It follows that inpatient rooms and facilities can be designed to better support Indigenous inpatients and their visitors during care. If the physical environments in hospitals contribute to anxiety and stress for Indigenous patients, what are the design changes that will mitigate stress and support recovery?

Research Methods

This research used both quantitative and qualitative methods including a screen-based survey (n = 602) of an adult Indigenous population followed by semistructured interviews (n = 55) to collect data on Indigenous perceptions of physical healthcare settings. Ethics approval for this research was granted by the University of Queensland Human Research Ethics Committee (approval numbers 2016001618, 2017000329).

The study locations were chosen for the need to compare the perceptions of healthcare facilities between a remote and an urban Indigenous population. Townsville (pop. 186,757) is a regional city on the northeastern coast of Australia with 7% Indigenous population, Mount Isa is a small northern inland city (pop. 18,342) with 16.6% Indigenous population, and Dajarra (pop. 191) with 61% Indigenous population (Australian Bureau of Statistics, 2016). Responses for Dajarra were included in the Mount Isa region analysis, partly because of the low sample in Dajarra, the proximity of the two locations, and their social and cultural similarity. The locations and associated regions have relatively high percentages of Indigenous people who represented 2.8% of the total Australian population (Australian Bureau of Statistics, 2016). Indigenous people represent a much higher proportion of public hospital patients in the two regions (Duckett & Griffiths, 2016).

The Survey Design

The quantitative study was a cross-sectional area-based survey using a representative sample of Indigenous adults in the three study locations. To ensure that the achieved responses were as representative as possible of the adult Indigenous population in the selected locations, sampling used targeted quotas for age and gender. The survey instrument contained two main components: (1) closed and open-ended questions and (2) digital images displaying variations of a hospital setting for pairwise comparison and ranking. First, questions were included on demographic characteristics, culture, well-being, healthcare behavior and attitudes, health conditions, doctor consultations, and hospital visits. In two specific questions, participants were asked about failure to attend medical appointments and to rate their own health and need for health services. Second, the survey included digital images that displayed varied design attributes of hospital settings in pairwise comparisons. The inpatient room was one of four settings tested in the survey, which also included waiting rooms, a public entry, and an outdoor courtyard.

To limit cultural bias, a repertory grid technique (after Kelly, 1955) was used to elicit constructs about design attributes from a sample of 28 Indigenous people. An Aboriginal cultural advisor on the survey design recruited the participants for the repertory grid interviews held in Brisbane. The images were developed using graphic design software (Revit 2015 and Photoshop CC 2017), which allowed greater control of the design attributes compared to photographs. Digital images of the inpatient room referenced standard single- (15 m²) and twin-bed rooms (27 m²) in the AusHFG (2015/2018), as well as desktop survey of images of recent hospitals. The construct elicitation technique used 11 images with varied attributes including room size, bed number, window size, view type, wall finish, and artwork. In the presence of an interviewer and a scribe, participants compared sets of three images, with the discussion of preferences used to elicit constructs and counterpoles during a 40 to 60-min interview (paid AUD 40 on completion). Frequency determined the ranking of the most relevant themes and constructs identified in the interview data.

Constructs suited to inpatient rooms informed the design of the final images used in pairs in the screen-based survey delivered on tablet computers. The pairwise comparison included single versus shared room (Figure 1), balcony (Figure 2), headboard material finish, view type (Figure 3), daybed option, and window size. Additional constructs, such as the presence of Indigenous art, were compared across the three other settings. The duration of the survey, designed to be completed in about 20 min, restricted the number of inpatient room images used. The survey was piloted with a diverse group of Indigenous participants (n = 29) recruited in Brisbane (outside of the study area). Minor amendments were made to the digital formatting and wording of questions as a result of the pilot study.

Figure 1.

The first paired image in the tablet survey compared a single-bed and two-bed patient room, both modeled on dimensions given in the Australasian Healthcare Facility Guidelines.

Figure 2.

The second paired image in the tablet survey offered the choice of a balcony. Balconies or verandahs were common to hospitals in the early and mid-20th century.

Figure 3.

Preference for type of view contrasted park-like scenery with an urban building in this paired image.

Survey Recruitment

A total of 602 valid survey questionnaires were completed by Aboriginal and Torres Strait Islander adults in Townsville (n = 398), Mount Isa (n = 175), and Dajarra (n = 29), from June to September 2017. Local Indigenous research assistants were employed in each location and were integral to a culturally appropriate recruitment strategy. Survey participants were recruited through Indigenous organizations, local research assistant networks, and “cold” approaches in public places frequented by the Indigenous community. Participants were paid AUD 20 on completion of the survey. Sampling quotas were applied to ensure that the age and sex distribution of the sample reflected the distribution of the Indigenous population in each location (Table 1).

Table 1.

Sample for Quantitative Screen-Based Survey. Survey responses from Mt Isa and Dajarra are combined in the analysis of the data.

	Sampling Location
	Townsville		Mt Isa		Dajarra
	n	%	n	%	n	%
Sample	398	66	175	29	29	5	602
Gender
Women	201	51	93	53	13	55	307
Men	197	49	82	47	16	45	295
Age
18–24	121	30	38	22	5	17	164
25–49	195	49	94	54	13	45	302
50+	82	21	43	25	11	38	136
Highest education level
University	59	15	15	9	1	3	75
Year 12 (high school)	153	38	31	18	6	21	190
Year 10	116	29	85	49	6	21	207
Did not complete Year 10	36	9	33	19	14	48	83
Missing	34	9	11	6	2	7	47

Bivariate analyses were used to test for associations between preference for an inpatient room design attribute and gender, age, and education. Multiple logistic regression models were used to estimate odds ratios for preference of a healthcare setting with or without a specific design feature controlling for age, gender, highest level of education, and existence of a long-term health problem. These analyses were performed separately for the survey locations.

Semistructured Interviews

The results from the survey raised questions and identified significant themes that were further explored through semistructured interviews (n = 55). The interviews were conducted during three 1-week field periods during 2018 in the two study locations. Interviewees were drawn from the portion of the survey cohort who had consented to a further interview, with additional participants identified through Indigenous partner organizational networks. Of the total 55 interviews (men = 31 and women = 24), 68% of men and 62.5% of women were 35–54 years in age. The interviews took place in a variety of locations including the Indigenous organizations, public places, and a few in private homes. Each interview lasted about 1 hr and the participant received a payment of AUD 30.

The semistructured interview protocol opened with biographical questions followed by 60 items (short-answer and open-ended questions) about hospital attendance (purpose, rates, and evasion), visitor experience, primary care facilities (Aboriginal Medical Service or other), inpatient rooms, outdoor areas in healthcare, nonclinical settings, services, mode of travel, and traditional beliefs. Ten questions focused on the inpatient setting, exploring length of stay, type of services; likes and dislikes of room sharing, control of auditory and sensory environment (noise, smell, lights, TV, cooling/heating), and interest/boredom and mobility. The interviewees were asked about preferences for design features that were welcoming and could make a better experience, prompted by images from the survey of inpatient room layout, number of beds, type and amount of seating, window size, balcony, and preference for urban or park view.

For this article, the semistructured interviews provided responses to questions and discussion around the experiences and perceptions of patients and family associated with inpatient rooms. These responses were coded manually, and themes were derived from the data using an inductive approach. Several readings of the interview responses produced a list of repeated keywords and phrases, with similar topics grouped into themes. The two field interviewers conferred on the final overarching themes, assisted by discussions with the research team, both during and at the completion of data gathering in the two field regions.

Survey Results

In a set of paired images of an inpatient room, showing either one or two patient beds, 54% of participants preferred the two-bed room. This differed significantly by location with 66% of participants from Mount Isa preferring the two-bed room and 49% from Townsville. This preference did not differ significantly by age-group or gender in bivariate analyses. A logistic regression model for the preference of a two-bed compared to a single-bed room was fitted to the survey responses with independent variables included for gender, age-group, and long-term health problem, separately for participants from Townsville and Mount Isa, respectively.

For Townsville participants, odds of preference for an inpatient room with a two-bed versus single-bed design were greater for participants who had completed Year 10 (last year of junior high school) only (OR = 3.8, p < .001), followed by those who had completed Year 12, the final year of high school (OR = 2.7, p =.005), relative to individuals with a university degree or postgraduate qualification. For Mount Isa, the odds for the preference for a two-bed room was 2.8 times higher for people who did not have a long-term health problem relative to those with a long-term health problem (OR = 2.8, p =.003). However, highest education level did not have an additional impact on odds of preference for a two-bed inpatient room for participants in Mount Isa. This may not be surprising as a much higher proportion of participants (74%) completed Year 10 only or lower in Mount Isa compared to those in Townsville (48%). In a single-bed room, 90% of participants preferred to have a balcony rather than a window only. Of those who chose the window only, 57% preferred the “warm” wood interior finish to the plain white. Of those who chose the balcony, 95% preferred the wood finish.

Of all participants, 68% preferred the park view from the window, while 32% preferred the urban view. This pattern was similar across the two study sites; however, the youngest age-group was significantly more likely to prefer the urban view. Of all participants, 89% preferred additional furniture in the room, including a daybed and comfortable chair in addition to the bed, with this response consistent across locations.

There was a significant association between preference for two-bed room and for preferred choice of health service, including an Indigenous controlled clinic. Just 35% of those who preferred a non-Indigenous clinic selected the two-bed room, while 60% of those who preferred Indigenous clinics or hospitals selected two-bed room rather than the single patient room. From the surveys, it was not always clear how choice of images might relate to the experiences and background of the viewer as an Indigenous person. In the next stage, semistructured interviews explored people’s experiences and investigated the potential motivations for survey image preferences.

Semistructured Interview Results

The themes that emerged in the analysis aligned broadly with the three main components of Ulrich’s SDT (perceived control, social support, and positive distraction), although a revision of these categories better accounts for consistent influence of social and cultural factors in the interview data. Findings from the interviews are summarized under the following categories: recognition, family presence, and connection to life outside. Each of Tables 1, 2, and 3 outlines one of these three categories subdivided into social, cultural, and spatial themes and illustrated by participant comments. Categories and themes were not mutually exclusive.

Table 2.

Recognition: Social, Cultural, and Spatial Themes and Participant Responses.

Recognition	Participant Responses
Social need for family privacy desire company from family, not strangers	Have a room to yourself, not share with other patients so have some privacy. Probably get more family in there visiting [in single room] (T38) Certainly [I prefer] the room with a single bed because of privacy and because we had a swag of kids that make a ton of noise and it’s good to be able to shut the door. (T28) You can hear everybody’s business when you share. The staff seemed to disapprove of large families visiting…It was mixed gender in the same room—I didn’t like that (I15)
Cultural fear of exclusion different beliefs family size racism	I was in a room at the end of a long hallway. I felt a bit isolated. Don’t know why they put me in a single room. Why? Was it because I was Black? We think those things. Or am I sicker then they’re making out? I don’t like to be on my own. (T31) Need space for visitors too—hospitals don’t understand that we have to be there for when they cross over to the spiritual world. (T22) Murri [Queensland Aboriginal people] and non-Indigenous are from a different culture, e.g., White family probably isn’t as big. Murri families are bigger and kids are noisy. Murris worry that White people might think that Black people are going to steal from them. (T1)
Spatial inadequate space/seating color preference against White	Spacious rooms make you feel welcome…My mother has 13 brothers and sisters so there were 20 people—let in by elders [for] each part of the family (T24) Need more chairs and couches. Most Aboriginal people have big families. (12) Need lots of color, calming blues, not reds. White walls make you not want to touch anything. (T4)

Table 3.

Family Presence: Social, Cultural, and Spatial Themes and Participant Responses.

Family Presence	Participant Responses
Social longing for home and/or extended family Against fear, loneliness	When you go away to hospital you do need family. You can’t have home in hospital but you can have family…(I15) I don’t want to sit in a room by myself because I start thinking about a lot of stuff…If I am in hospital I like to have a family member to sit and talk…quiet place makes me think too much. (T3) You’ve got to look at size, about the number of people visiting Some people get frightened when they are in a room on their own. When people visit it’s like a yarning session because everyone knows everyone else. (T32)
Cultural for safety for grief support for solidarity	She did not want to be left without family. Need people with strong heart to talk for person. If left alone they, people can do black magic on her. You can’t trust people—there’s stories of man that looks to kill and take blood from people. (T26) When someone is sick, like when my grandmother was passing…She lived with us and they didn’t come around and then when she was dying, they’re all around! The sick person is going through a lot…need common room ready to chat, debrief, support each other. Family feels uncomfortable—not used to it. It’s a dying place. On the other hand, other non-Indigenous people might equally be frightened if a lot of Indigenous people were meeting—it’s the visibility factor. (T5)
Spatial physical separation for families social/cultural group separation	Need more chairs and couches. Most Aboriginal people have big families. (I12) More privacy would be good, particularly from men in ward. (T4)

Recognition

Perception of difference and the need for recognition was inherently social and related to the individual’s sense of identity and Indigeneity (Table 2). Many respondents indicated that they felt different as Indigenous people. They preferred to be separated from unknown others including staff, patients, and their visitors whose acceptance of an Indigenous person could not be taken for granted. Perceptions of difference centered on their typically large Indigenous families, noisy children, and different cultural beliefs and practices around sickness and death. Because of these differences, they often preferred privacy and presumed that non-Indigenous patients/friends wanted this too. While many preferred company of another patient rather than being alone, the preference was for another Indigenous patient of same gender.

Perception of difference and the need for recognition was inherently social and related to the individual’s sense of identity and Indigeneity

Although participants commented on the room’s spatial or physical features, including the position of bed/s, chairs, lighting, window shades, and bed curtains, most did not see the room features or thermal comfort as significant compared to lack of recognition and social inclusion. For example, in two specific questions about thermal comfort, less than half (20 of 55) replied they had been “cold” typically from air-conditioning, whereas most people spoke about being racially different and being judged negatively.

Family Presence

Most interviewees commented on the need for family visitors in hospital (Table 3). Those who had spent much time alone reported homesickness and worry about their absent family members. The majority preference for a two-bed room in the survey was qualified by comments from the qualitative interviews about the extra space that a two-bed room offered, for visitors to rest or stay over. Additionally, participants desired a space outside or nearby the inpatient room for family to gather. These comments reinforced the view that the need for family is highly significant and that without family, a patient can become lonely or succumb to harmful spiritual forces. Being alone exacerbated any perceptions about lack of autonomy. As often mentioned, “yarning” or chatting informally with other Indigenous people was both affirming and relaxing. In certain settings, yarning can define an open, safe, and purposeful environment for the exchange of views, but typically yarning is a convivial pastime.

…participants desired a space outside or nearby the inpatient room for family to gather .

The quantitative and qualitative findings suggest that SPRs can exacerbate the sense of social isolation for Indigenous patients. The majority preference for two-bed rooms in the survey reinforces the need to question the SPR as the increasing dominant type in public hospitals. Design that reflected such preferences could be beneficial where a hospital is serving high numbers of Indigenous patients. Nevertheless, the qualitative interviews indicated that these room preferences depended on multiple factors.

Connection to Life Outside

Understandably, and as anticipated from the literature and the survey results, the view from the window in the patient’s room was a primary source of their interest (Table 4). By comparison, the standard features and furnishings of the rooms were of secondary consideration. The survey results showed that age and gender influenced the preferred view type with preference for a view of nature more likely for older age groups. Most respondents in the interviews however made positive comments about views of nature and gardens, irrespective of age or gender. Notably, most people associated a view not only with their preferences for seeing and being outside for physical and psychological reasons but also with their social and cultural preferences for sitting in the sun and for yarning with others. Being outside facilitated interaction with others who might be looking for the same experience; and for some local traditional land owners, the direct environmental contact also satisfied deep cultural needs for connection to their lands.

Table 4.

Connection of Life Outside: Social, Cultural, and Spatial Themes and Participant Responses.

Connection to Life Outside	Participant Responses
Social desire for social interaction (yarning)	Everything was perfect. I could see who was coming in from the outside. Bed was near the door and I could see out. If you see others coming to see family you can call them over—Hey, sit down and have a yarn! (I8) Sitting for the atmosphere and for smoking. In winter, we feel that bit of sunshine—and see another face perhaps someone you know and have a yarn. (T35) Too many people. It was like musical chairs. But it was good to get outside and have a yarn. Inside people don’t feel comfortable to do that. I reckon it’s Indigenous but lot of people Indigenous and non-Indigenous both want time-out. (I4) As inpatient—I like a good view—green I like. A single room is good. View of buildings is good too because I can see people walking around and what’s going on in the streets—see the family walking around. (I10)
Cultural connection to place/people and nature sense of belonging to Indigenous family/community	I like the views to the outside. And drawings make you feel like you’re part of an area where you belong. (T21) The trees are mentally and culturally relaxing. We can go back to the land. We know what part of the country they come from and seeing them takes us back there. (I6) Yes, with the trees and the playground area was more inviting. And I walked around to the big tree [know as the “Family Tree”]. I liked being social, seeing passers-by and seeing people visiting hospital—lots of family members. (I3) I didn’t like being indoors too much. I like the fresh air and the bench chairs were good. I sat by myself but if I see family I talked to them—whoever happened to be in hospital at the same time. And yes, I go out for the sun. (I12)
Spatial need to see/feel/be outside	Open spaces. Views and big windows…views not of a/c or building walls next door—that makes you feel “off.” (T2) Rural people are different from city people but if we could have a hospital with a courtyard, a beautiful garden with access to every room—so single storey.…A beautiful garden because it’s good for your mental wellbeing. And to be able to smell the outside…you’ve got all the smell of disinfectants inside—blood in renal…. then smelling outside smells is beautiful. Then you realize what you’re missing. (I15) An outside window would be great. You’ve got hope—you can see birds flying around and trees blowing. It’s going to give you hope to live. You don’t want to live if you’re just staring at four walls. It sends you off a bit—cabin fever. (T9) Room with the daybed. I need to be able to get out of bed and see the outdoors. To be positive about own health I like to lie down in day bed to give a different mindset. I believe the body can heal itself and you need to try and keep positive to get better and get out quicker. It reduces stress even though you are in hospital. (T8)

Discussion

In Australian healthcare institutions, policy makers, management, and staff have looked primarily at service solutions to overcome barriers against optimal care outcomes for Indigenous patients (Taylor & Guerin, 2013). The aim of this article, however, was to present Indigenous people’s perceptions of inpatient rooms and explore cultural preferences and the motivations behind them that have implications for design. Significantly, the quantitative survey results and the semistructured interview findings were broadly complementary in expressing how Indigenous people perceive the physical settings and experience problems related to design.

The survey findings about inpatient rooms demonstrated a strong preference for large windows with views of nature; this was most prominent in the older age groups. It was significant that preferences for images of two-bed rooms did not align with the increasing emphasis on SPRs. While some of the identified concerns can be easily solved, other issues, particularly, the need for privacy and for family presence are more complex and will be more challenging for health planners and designers. This article identifies and raises awareness of questions that have long been ignored in healthcare design. The potential design implications from this research clarify the types of questions that designers and health planners should ask in early stages of projects that serve significant Indigenous populations (Table 5).

…preferences for images of two-bed rooms did not align with the increasing emphasis on SPRs .

Table 5.

Indigenous Components of Supportive Design With Implications for Practice.

Theory of Supportive Design Components	Indigenous Components of Supportive Design	Patients and Visitor Preferences and Needs	Implications for Practice
Sense of control with respect to physical–social surroundings	Recognition and perception of difference	Ameliorate perceptions of racism	What are the features of inclusive spaces? Private visitor spaces in wards Indigenous art and signage
Access to social support	Need for family presence	Assist family interaction and preferred cultural behaviors in healthcare settings	How can large families be accommodated as visitors? Increased room area from 15 m² Daybed for overnight stays
Access to positive distractions	Connection to social and physical life outside hospital	Promote outdoor connection to people and nature	What kind of spaces promote connection to outdoors? Large windows with views of nature Balconies and verandahs Ward proximity to outdoor spaces

Our analysis of the interviews demonstrated how the SDT concepts (sense of control, social support, and positive distraction) are relevant but required some adjustment and clarification in reference to Indigenous patients. The Indigenous respondents underplayed their need to control temperature and light in the inpatient room compared to the need for recognition in the social environment. Comments about social interactions (visitor numbers, family size) and spatial dynamics demonstrated that considerable discomfort can result when a patient is unable to accommodate family visitors in a culturally appropriate and welcoming way, for example, because of insufficient seating to meet with family. Many considered the problems in terms of their Indigeneity and lack of recognition by non-Indigenous hospital users. Unfortunately, many had experienced racism in hospitals and the healthcare system that has been associated with poor health outcomes for Indigenous Australians (Bastos et al., 2018).

The need for social support was significant but this component of SDT has a different and specific sense for the Indigenous participants. Longing for the presence of family members while in hospital was a major theme for respondents. This incorporated their concern for the needs of family visitors as well as their own need for family support. Maintenance of social relationships and family practices reinforces cultural identity and requires frequent and regular social interaction often involving extended family (Browne-Yung et al., 2013; Peterson, 2015). If appropriate interaction is lacking while in hospital, a heightened sense of longing for family may be associated with stress, as reported by many respondents. In maternity and palliative care wards, the associated social and cultural practices require space beyond the usual ward and inpatient room. At these times, the ability of family members to provide support can be compromised by inadequate design, while increased visitor numbers can place an additional burden on staff.

The need for social support was significant but this component of SDT has a different and specific sense for the Indigenous participants .

Design preferences elicited in the study accord with a need for positive distraction (Ulrich, 1991), but analysis of the results revealed a more specific social and cultural emphasis. A desire for connection to life outside through interaction with the physical and social environment was common to our quantitative and qualitative findings on preferences for inpatient rooms. The benefits to patients of both viewing nature and using landscaped settings are widely accepted (Cooper Marcus & Sachs, 2014; Ulrich et al., 2008); however, Aboriginal people have a spiritual connection to country and kin that is more than a therapeutic distraction. A view to the outside can deepen this sense of connection.

Our analysis of the quantitative and qualitative results was broadly consistent with the theory of supportive design, but this study of Indigenous hospital users adds particular cultural dimension to each of the three components of SDT (see Table 5). While the preference by the majority for two-bed rooms suggested that respondents were amenable to sharing a room, further investigation is needed to fully explain their choices. Interviews suggested that preferences for shared rooms might vary with the patient’s medical condition.

Limitations

Although the public survey achieved a statistically representative sample for the two locations in different regions, caution is required in a generalizing from the results and their design implications. While there may well be similarities between the study groups and other Indigenous people in Australia, the history and circumstances of health service delivery varies significantly by location. The survey measured health status; however, more data are needed regarding actual experience, medical condition, and other influences on choice.

Our results and discussion have pointed to possible reasons for Indigenous preferences around inpatient rooms and the healing environment. Other cultural groups for example may share these preferences. Given the survey design and project funding, a representative statistical comparison between an Indigenous and non-Indigenous population would require sampling of such a large scale to be prohibitive. These questions would benefit from further research but were beyond the scope of our study of Indigenous groups.

Conclusion

The influences of cultural background on responses to healthcare settings are significant but remain underresearched. As a first step in an Australian context, this study identified consistent cultural and social influences on Indigenous people’s perceptions and experiences of inpatient rooms. The results raise questions about current procurement policies and the design of public hospitals. Consultative briefing processes can, at least, frame questions about cross-cultural design for Indigenous user groups based on these results and their implications, which remain to be validated in different Indigenous cultural regions of Australia.

Implications for Practice

Increased patient room size with inbuilt daybeds and the inclusion of private family rooms in wards would support Indigenous visitors and patients.

Many Indigenous people prefer large windows with views of natural environments, in contrast to urban environments for the increased opportunity to connect to nature while confined indoors.

Direct access to outdoor courtyards or balconies from patient rooms is recommended, and, where sites or climate limit this option, close proximity of rooms to outdoor areas benefits Indigenous patients and visitors.

Integrated Indigenous signage, graphics, and art offer a sense of inclusion for First Nations people using hospitals.

Options for shared rooms could be considered where a large proportion of the inpatients are Indigenous and in medical units that have lower risks of nosocomial infection.

Footnotes

Authors’ Note

The views expressed herein are those of the authors and are not necessarily those of the Australian Government or Australian Research Council.

Acknowledgments

The authors acknowledge the contributions of Dr Bernard Baffour (CI 4) and others in the research team who participated in the development and delivery of the survey, including Sue York, Carys Chainey, Georgia Betros, Kali Marnane and Indigenous cultural advisor Alex Bond. The authors gratefully acknowledge the Aboriginal and Torres Strait Islander community and the assistance of Indigenous and other organizations: Townsville Aboriginal and Islander Health Service, Palm Island Community Company, Yumba Meta Housing, James Cook University, ABIS Community Cooperative, Australian Red Cross Townsville, Community Gro Townsville, Rainbow Gateway/Max Employment Mt Isa, Jimaylya Topsy Harry Centre, Queensland Department of Communities, Ngurri Ngurri Young Women’s Refuge, and Mt Isa Family Support Service & Neighbourhood Centre.

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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was fully supported by the Australian Government through the Australian Research Council’s Discovery Projects funding scheme (project DP 160100494).

ORCID iD

Timothy O’Rourke, BArch(hons), PhD, FAIA

References

Ampt

Harris

Maxwell

(2008). The health impacts of the design of hospital facilities on patient recovery and wellbeing, and staff wellbeing: A review of the literature. http://hiaconnect.edu.au/old/files/Hospital_Design_Review.pdf

Andrade

Devlin

Pereira

C. R.

Lima

(2017). Do the hospital rooms make a difference for patients’ stress? A multilevel analysis of the role of perceived control, positive distraction, and social support. Journal of Environmental Psychology, 53, 63–72. https://doi.org/10.1016/j.jenvp.2017.06.008

Australasian Health Facility Guidelines. (2018) Australasian Health Facility Guidelines. Part B health facility briefing and planning: 0340 Inpatient accommodation unit. Australasian Health Infrastructure Alliance. https://aushfg-prod-com-au.s3.amazonaws.com/HPU_B.0340_6_IPU_0.pdf (Original work published 2015)

Australian Bureau of Statistics. (2016). 2016 Census Quickstats, Census of population and housing 2016. https://quickstats.censusdata.abs.gov.au

Australian Commission on Safety and Quality in Health Care. (2011, September). National safety and quality health service standards. https://www.safetyandquality.gov.au/sites/default/files/migrated/NSQHS-Standards-Sept2011.pdf

Australian Institute of Health and Welfare. (2018). Australia’s health 2018. Australia’s health series no. 16. AUS 221. https://www.aihw.gov.au/getmedia/7c42913d-295f-4bc9-9c24-4e44eff4a04a/aihw-aus-221.pdf

Bastos

J. L.

Harnois

C. E.

Paradies

Y. C.

(2018). Health care barriers, racism, and intersectionality in Australia. Social Science & Medicine, 199, 209–218. https://doi.org/10.1016/j.socscimed.2017.05.010

Bell

S. E.

(2018). Placing care: Embodying architecture in hospital clinics for immigrant and refugee patients. Sociology of Health & Illness, 40, 314–326. https://doi.org/10.1111/1467-9566.12604

Browne-Yung

Ziersch

Baum

Gallaher

(2013). Aboriginal Australians’ experience of social capital and its relevance to health and wellbeing in urban settings. Social Science & Medicine, 97, 20–28. https://doi.org/10.1016/j.socscimed.2013.08.002

10.

Chaudhury

Mahmood

Valente

(2005). Advantages and disadvantages of single-versus multiple-occupancy rooms in acute care environments: A review and analysis of the literature. Environment and Behavior, 37(6), 760.

11.

Cifter

A. S.

Cifter

(2017). A review on future directions in hospital spatial designs with a focus on patient experience. The Design Journal, 20(Suppl.), 1998–2009. https://doi.org/10.1080/14606925.2017.1352719

12.

Cooper Marcus

Sachs

(2014). Therapeutic landscapes: An evidence-based approach to designing healing gardens and restorative outdoor spaces. John Wiley

13.

Cunha

Silva

(2015). Hospital noise and patients’ wellbeing. Procedia—Social and Behavioral Sciences, 171, 246–251. https://doi.org/10.1016/j.sbspro.2015.01.117

14.

Devlin

A. S.

Andrade

C. C.

Carvalho

(2016). Qualities of inpatient hospital rooms: Patients’ perspectives. Health Environments Research & Design Journal, 9(3), 190–211. https://doi.org/10.1177/1937586715607052

15.

Devlin

A. S.

Arneill

A. B.

(2003). Health care environments and patient outcomes: A review of the literature. Environment and Behavior, 35(5), 665–694. https://doi.org/10.1177/0013916503255102

16.

Dijkstra

Pieterse

Pruyn

(2006). Physical environmental stimuli that turn healthcare facilities into healing environments through psychologically mediated effects: Systematic review. Journal of Advanced Nursing, 56(2), 166–181. https://doi.org/10.1111/j.1365-2648.2006.03990.x

17.

Duckett

Griffiths

(2016). Perils of place: Identifying hotspots of health inequalities. https://grattan.edu.au/report/perils-of-place-identifying-hotspots-of-health-inequality/

18.

Dudgeon

Wright

Paradies

Garvey

Walker

(2010). The social, cultural and historical context of Aboriginal and Torres Strait Islander Australians. In Purdie

Dudgeon

Walker

(Eds.), Working together: Aboriginal and Torres Strait Islander mental health and wellbeing principles and practice (pp. 25–42). Australian Government, Department of Health and Ageing.

19.

Dussart

(2010). “It is hard to be sick now”: Diabetes and the construction of indigenous sociality. Anthropologica, 52, 77–87.

20.

Facility Guidelines Institute. (2014). Guidelines for design and construction of hospitals and outpatient facilities. American Society for Healthcare Engineering.

21.

Harrison

Walton

Manias

(2015). Patients’ experiences in Australian hospitals: An evidence check rapid review brokered by the Sax Institute (www.saxinstitute.org.au) for the Australian Commission on Safety and Quality in Health Care, 2015. www.saxinstitute.org.au

22.

Haynes

O’Rourke

Nash

Baffour

York

Chainey

Betros

Memmott

(2019). Aboriginal and Torres Strait Islander preferences for healthcare settings: effective use of design images in survey research. Australian Health Review, 44(2), 222–227. https://doi.org/10.1071/AH18196

23.

Huisman

E. R. C. M.

Morales

van Hoof

Kort

H. S. M.

(2012). Healing environment: A review of the impact of physical environmental factors on users. Building and Environment, 58, 70–80.

24.

Iyendo

T. O.

Uwajeh

P. C.

Ikenna

E. S.

(2016). The therapeutic impacts of environmental design interventions on wellness in clinical settings: A narrative review. Complementary Therapies in Clinical Practice, 24, 174–188. https://doi.org/10.1016/j.ctcp.2016.06.008

25.

Kelly

(1955). The psychology of personal constructs. Norton.

26.

Laursen

Danielsen

Rosenberg

(2014). Effects of environmental design on patient outcome: A systematic review. Health Environments Research & Design Journal, 7(4), 108–119. https://doi.org/10.1177/193758671400700410

27.

MacAllister

Zimring

Ryherd

(2016). Environmental variables that influence patient satisfaction: A review of the literature. Health Environments Research & Design Journal, 10(1), 155–169. https://doi.org/10.1177/1937586716660825

28.

Mackrill

Cain

Jennings

(2013). Experiencing the hospital ward soundscape: Towards a model. Journal of Environmental Psychology, 36, 1–8. https://doi.org/10.1016/j.jenvp.2013.06.004

29.

McGrath

Anne Patton

Holewa

Rayne

(2006). The importance of the ‘family meeting’ in health care communication with indigenous people: Findings from an Australian study. Australian Journal of Primary Health, 12(1), 56–64.

30.

National Aboriginal Community Controlled Health Organisation. (2019). National Aboriginal Community Controlled Health Organisation annual report 2018–2019 . https://www.naccho.org.au/wp-content/uploads/NACHHO0043-Annual-Report-18-19-web-version.pdf

31.

Peterson

(2015). Place, personhood and marginalization: Ontology and community in remote desert Australia. Anthropologica, 57, 491–500.

32.

Salmon

M. K.

Doery

Dance

Chapman

Gilbert

Williams

Lovett

(2018). Defining the indefinable: Descriptors of Aboriginal and Torres Strait Islander peoples’ cultures and their links to health and wellbeing. Aboriginal and Torres Strait Islander health team, research school of population health, Australian National University. https://openresearch-repository.anu.edu.au/handle/1885/148406

33.

Schultz

Cairney

(2017). Caring for country and the health of Aboriginal and Torres Strait Islander Australians. Medical Journal of Australia, 207(1), 8–10. https://doi.org/10.5694/mja16.00687

34.

Taylor

(1994). The politics of recognition. In Gutman

(Ed.), Multiculturalism: Examining the politics of recognition (pp. 25–73). Princeton University Press.

35.

Taylor

Card

A. J.

Piatkowski

(2018). Single-occupancy patient rooms: A systematic review of the literature since 2006. Health Environments Research & Design Journal, 11(1), 85–100. https://doi.org/10.1177/1937586718755110

36.

Taylor

Guerin

(2013). Health care and Indigenous Australians: Cultural safety in practice. Palgrave Macmillan.

37.

Timmermann

Uhrenfeldt

(2014). Patients' experiences of wellbeing in the physical hospital environment: A systematic review of qualitative evidence protocol. JBI Database of Systematic Reviews and Implementation Reports, 12(12), 67–78. https://doi.org/10.11124/jbisrir-2014-1537

38.

Ulrich

R. S.

(1986). Human responses to vegetation and landscapes. Landscape and Urban Planning, 13, 29–44. https://doi.org/10.1016/0169-2046(86)90005-8

39.

Ulrich

R. S.

(1991). Effects of interior design on wellness: Theory and recent scientific research. Journal of Health Care Interior Design: Proceedings from the Symposium on Health Care Interior Design, 3, 97–109.

40.

Ulrich

R. S.

Zimring

Zhu

DuBose

Seo

Choi

Y. S.

Quan

Joseph

. (2008). A review of the research literature on evidence-based healthcare design. Health Environments Research & Design Journal, 1(3), 61–125.

41.

Verderber

Todd

L. G.

(2012). Reconsidering the semiprivate inpatient room in U.S. hospitals. Health Environments Research & Design Journal, 5(2), 7–23. https://doi.org/10.1177/193758671200500202

42.

Voigt

Mosier

Darouiche

(2018). Private rooms in low acuity settings: A systematic review of the literature. Health Environments Research & Design Journal, 11(1), 57–74. https://doi.org/10.1177/1937586717702597

43.

Willis

E. M.

Dwyer

Owada

Couzner

King

Wainer

(2011). Indigenous women’s expectations of clinical care during treatment for a gynaecological cancer: Rural and remote differences in expectations. Australian Health Review, 35, 99–103.

44.

Wotherspoon

Williams

C. M.

(2018). Exploring the experiences of Aboriginal and Torres Strait Islander patients admitted to a metropolitan health service. Australian Health Review, 43(2), 217–223. https://doi.org/10.1071/AH17096

45.

Zhao

Mourshed

(2012). Design indicators for better accommodation environments in hospitals: Inpatients’ perceptions. Intelligent Buildings International, 4(4), 199–215. https://doi.org/10.1080/17508975.2012.701186