/DR08-09_supportive_design

Current Research

A research and innovation project This research project is part of a larger innovation project which is carried out in cooperation with DTU (Technical University of Denmark), The Danish Design School, and the two textile manufacturers: Kvadrat and Trevira– Neckelmann. The project runs from April 2008 until April 2011 and receives funding from Danish Enterprise and Construction Authority’s programme for user–driven innovation.

The objective of the project is to create the foundation for a new innovation plat­ form for the Danish textile industry, its suppliers and customers, by developing a new understanding of how to utilise user– oriented knowledge in innovations and design processes. Consequently, the aim of the project is to generate knowledge and test methods which involve users in the development of new textile qualities and new product types.

The project consists of two separate innovation programmes which share common areas of interest and knowledge.

One programme has Kvadrat as its project partner; a company which manufactures interior textiles and has a large market within the hospital sector. In connection with the many new hospital develop­ ments and renovations planned for the coming years, the project investigates the presence and use of textiles within the hospital sector with a view to establishing innovation opportunities. The cases are based on selected Danish hospitals.

The other innovation programme has the fibre and yarn manufacturer Trevira– Neckelmann as its project partner. This programme investigates how globalisa­ tion and the international market have caused the splitting of innovation and production. This situation requires a new and improved communication e.g. regard­ ing textile qualities. The company forms the case for this investigation.

Kolding School of Design is actively involved in the innovation project within the hospital area. We focus primarily on interior textiles, but in mapping the overall conditions we also include tex­ tile categories such as linen, uniforms,

Lene Wul, Vibeke Riisberg, Caren Weisleder: User–driven innovation, ‘supportive design’, and the hospitals of the future — a new paradigm in the making?

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and patient clothing. Our objective is to uncover the systems which textiles enter into and create a common understanding among the market players of the possibili­ ties and obstacles of supporting a healing environment at the hospitals of the future.

The regions make up the key organisa­ tional and political framework for deter­ mining the future hospital developments, and the textile system will be investigated within that same framework. Kolding School of Design has chosen to focus on the Region of Southern Denmark. In its vision plans for the coming hospital devel­ opment, it is stated that: “The Region of Southern Denmark wishes to create a coherent, patient–oriented, up– to–date, quality–conscious, efficient, and competitive health service.”

(Report on hospitals in Southern Denmark 2009).

The term quality is applied in the vision plans, among other things, in relation to treatment and patient security, but also regarding the lay–out of private wards which is to support the quality of the treatment by ensuring the autonomy and integrity of the patients.

Quality is a word which must always be defined within a context. Thus, it is important to determine what the term entails and how it is applied in relation to the visions for achieving a healing envi­ ronment at the hospitals of the future.

As a consequence, the project deals with the development of an “extended quality term” which includes functional as well as emotional needs.

Furthermore, the purpose of the project is to spot innovation opportunities and in­ novation platforms for the textile industry within the hospital sector; consequently, we work on developing a theoretical frame which integrates product and service design with theories of ‘supportive design’.

in which the manufacturing of mate­ rial products plays a less significant role (Morelli, 2007). Within this paradigm, the objective is to create design solutions which include material (products) as well as immaterial elements (services). This solution is referred to as “Product Service Systems” (PSS), in which the design development and solution is character­ ised by the cooperation between different players, institutions, producers, service providers, and end–users in a co–produc­ tion process. (Morelli, 2007). It seems obvious to take a PSS view on the innova­ tion part of this project due to the fact that the hospital sector is a complex entity which interacts with many different play­ ers. However, the premise for a successful interaction of the system is that early on in the process, a mutual framework of un­ derstanding is established which supports co–creation and value creation.

Sanders and Simon identify three types of value creation within co–creation: economic value, user–experience value, and social value. The objective of the two latter value parameters is to improve qual­ ity of life for the users. (Sanders & Simon, 2009). Thus ‘the commodity’ is not only products that sell but the service entails elements such as ‘change’, ‘ownership’, ‘learning’, ‘behavioural change’, and ‘joy’.

Several of these terms are incorporated in the visions concerning the hospitals of the future.

The question is if theories exist within the health sector which can handle and comply with such visions.

The answer is far from obvious but as early as 1991, Roger S. Ulrich attempted to incorporate a number of mental needs in a theory regarding ‘supportive design’.

The theory rose from the basic premise that ‘supportive design’ by necessity must relate to the stress factor, and as a conse­ quence, Ulrich set up three basic elements for ‘supportive design’: — Sense of control and access to privacy — Social support — Access to nature and other positive distractions.

Ulrich argued that non–stressful or stress–reducing surroundings are neces­

The theoretical framework of the project: ‘product service systems’ and ‘supportive design’ Within strategic management there is talk of a paradigm shift to a business strategy 77

sary in order to stimulate a sense of well– being. To substantiate this assertion, he referred to a number of concrete studies which proved a connection between stress and the physical surroundings. The theory was intended as a guideline for architects and designers and was part of his efforts to develop ‘research–driven design’ as opposed to ‘intuition–driven design’. The reasoning behind his theory was and is that research–driven design has a greater impact on the decision–makers of the health sector. Ulrich pointed out the need for valid research and evidence to prove the connection between stress, physical surroundings, and well–being but it was not until 2003, when architect D. Kirk Hamilton introduced the term ‘evidence– based design’ that a new architectural and design paradigm really began to manifest itself.

“Evidence–Based Design is the process of basing decisions about the built environment on credible research to achieve the best possible outcomes.” (Center for Health Design, 2008).

In other words, ‘evidence–based design’ is a method for controlling, making, and motivating design choices.

Ulrich has continually contributed with more studies which have served to pro­ mote the breakthrough of the paradigm, including a comprehensive account of research literature which demonstrates evidence between the physical environ­ ment and its significance to and influence on patients and staff. (Ulrich et al, 2004, 2008).

However, the question remains if non– stressful surroundings alone are enough, or whether it is necessary to take it one step further and talk about health–stimulating surroundings which include ad­ ditional aspects in a more holistic view of human nature. Architect Alain Dilani, who has invented the term ‘psychosocially sup­ portive design’, takes exactly this view:1 “Psychosocially supportive design should challenge our mind in order to create pleasure, stimulation, creativity, satisfaction, enjoyment and admiration” (Dilani, 2005).

At present, however, the ‘evidence– based design’ paradigm is the more popular one among architects and deci­ sion–makers within the health sector; perhaps because it leans against, and obvious parallels can be drawn to, evi­ dence–based medicine. The result is a new and different focus on hospital construc­ tion, hospital surroundings, and hospital interior in which expressions such as ‘healing architecture’ and ‘hospital of the senses’ is used by an increasing amount of players. (Frandsen et al., 2009; Heslet & Dirckinck–Holmfeld, 2007).

You could say that, so far, what charac­ terises ‘evidence–based design’ research in Denmark and internationally is that its primary focus has been on WHERE studies have already been conducted which prove the influence of architecture, surround­ ings, and the interior on staff’s and pa­ tients’ well–being. (Frandsen et al., 2009; Ulrich et al., 2004, 2008).

On the other hand, it is indeed striking that, with a few exceptions, a large and unexplored area exists concerning the evidence of the aesthetic of everyday– life’s significance as psychosocially sup­ portive in hospital connections; (Fischl, 2006; Caspari et al., 2006), including the coupling of the functional, decorative, and emotional potential of textiles. In contrast, art and aesthetics have received quite a lot of attention; in Denmark es­ pecially via the book Sansernes Hospital (The Hospital of the Senses by Heslet & Dirckinck–Holmfeld, 2007).

Actual evidence–based research on the role of textiles as ‘supportive design’ is not possible within the framework of this project. However, via this project we try to direct attention to the innovation oppor­ tunities entailed in thinking and develop­ ing textile products and services within the theoretical framework of a ‘supportive design’ paradigm.

‘Supportive design’ thinks design solu­ tions (products, services, management, organisation types, etc.), which in actual fact are supportive as well as health–stim­ ulating in relation to existing and future needs. By its nature, ‘supportive design’ is invented and shaped first, while the 78

evidence is only there to be documented once the solution is implemented. This means that ‘evidence–based design’ has a hard time dealing with radical innovations and may give itself up to promoting only incremental innovations. By combining a ‘supportive design’ approach with tests of new products and services, you might be able to achieve evidence in some areas before building the hospitals, and thus be able to achieve a more health–stimulating environment and a higher degree of user– satisfaction. One way of ensuring this iterative process is by user–involvement from the very pre–design phase.

The representation thus displays a net­ work of players, their relations, and interactions. This provides a systemic view of processes, (service) systems, and their context. These maps give a clearer view of knowledge gaps and innovation opportunities, including the development of product service concepts.

The purpose is to show the connections and communication between players and the organisation of the system with a view to develop innovations that support user needs as well as the many complex func­ tional, logistic, and economic demands put forward by the hospital management within the hospital sector. The collected information has been validated and elaborated at two workshops attended by a number of different players.

The two workshops have produced experiences regarding user–involvement and the facilitation of design dialogue.

The first workshop was planned by our project partner DTU — we attended the workshop as observers. The other work­ shop was planned and hosted by Kolding School of Design. At both workshops spe­ cific games were used and developed for facilitating the dialogue among users and to create a common language (Sanders, 2000, 2008; Binder, 2008).

The first workshop at Kolding Hospital had the participation of nurses and pa­ tients. The focus of the workshop was to validate and elaborate on some of the in­ sights gained in connection with the field studies.

For the second workshop we gathered a number of key players who have either direct or indirect influence on decisions regarding the presence of textiles in the hospitals. Among others the partici­ pants included a buyer, a hygiene nurse, cleaning personnel, a laundry manager, a charge nurse, an architect, and repre­ sentatives of the Project organisation for hospital construction under the Region of Southern Denmark and project partners from Kvadrat.

The main purpose of the workshop was to get the participants to point out the needs and requirements concerning tex­ tile products in the hospital sector — and

A user–driven approach — methods and reflections This project is fundamentally user–driv­ en. This means that we continually and systematically work to involve different user–groups by using various well–known methods. For the first part of the project we conducted a number of anthropol­ ogically inspired field studies at selected hospitals. Here we applied participatory observation, semi–structured interviews, and visual anthropology to collect ex­ periences and needs among direct and indirect users / decision–makers, includ­ ing patients, staff, buyers, and service and logistics departments at hospitals, Laundries, curtain suppliers, furniture manufacturers, and architects.

These field studies have formed the basis for determining a number of textile categories which are primarily defined by their function and cycle of maintenance.

The categories are: Upholstery, curtains, linen, patient clothing, and uniforms.

In addition, the field study observa­ tions, the interviews with different play­ ers in and outside the hospital, along with the knowledge accumulated through liter­ ary studies have enabled the construction of a number of ‘actor–network maps’ of the systems, these maps are continually updated.

The purpose of an ‘actor–network–map’ is the establishment of a graphic repre­ sentation which visualises the system connected to the use of textiles, textile production and maintenance processes.

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to gain insight into how these needs are prioritised. At the workshop we attempted to create a common understanding of the context textiles enter into. A co–crea­ tion process made the groups specify and explain functional as well as emotional needs. This resulted in a common lan­ guage when speaking about textiles and textile categories.

The results of the workshop are cur­ rently being processed.

functional requirements and needs re­ garding textiles than the emotional needs.

Hardly any studies point to the possibility of textiles meeting functional as well as emotional needs. These findings are con­ firmed in the scholarly literature dealing with this field. (Iltanen, 2007; Caspari et al., 2006).

Throughout the field studies it has proven difficult to engage in any dialogue about how the users perceive textiles in the room — and the emotional needs at­ tached to this issue. What we can note is the fundamental paradox that the pres­ ence of textiles is taken so much for grant­ ed that they become difficult to see — and even more difficult to talk about. What we have learned from the field studies is that we need to apply other methods if we want the users to communicate their needs and experiences with textiles.

Funding from Danish Centre for Design Research has provided the means for a preliminary investigation of how a nar­ rative approach can develop improved theoretical and methodical tools for trans­ lating the accumulated knowledge on existing common usage and user–needs into user–driven design. The investigation will focus on design dialogue in a broad sense, in which the narrative element will be regarded as an aspect in several of the phases of the user–driven design process.

That is, the dialogue with users regarding common usage and ‘evaluation’ of possi­ ble design solutions.

The concern is not exclusively the need of the users but also the way in which these needs are communicated, interpret­ ed, and translated into health–stimulating design.

To sum up, the project work emphasises the need for more research. However, this research cannot be carried out within the specific framework and resources of this project.

Project status The project has presented us with a number of significant challenges which in various ways have affected the first half of the project work. One of the challenges was the creation of new regions; another has been trying to manage the complexity which characterises the hospital service, and a list of unavoidable requirements which cannot be ignored but have to be rendered visible in order to be part of the considerations regarding new innova­ tions. Similarly, the ethical aspect has played a role in relation to the possibili­ ties for active user–involvement — espe­ cially for patients and relatives — in the design and innovation processes. The formalities and logistics of being allowed access to the hospitals and its users has also been a long–running process.

It must be emphasised that despite the many laws, standards, and regula­ tions surrounding the hospital sector, these are interpreted differently within the individual regions. This means that generalisations across regions are not as obvious as we initially anticipated. This is especially the case concerning hospi­ tal extensions and developments. Here, it has also played a role that the regions are relatively recent, and that new play­ ers appear on the scene — as for instance innovation centres — who affect the construction process, the development of standards, the floor plan and lay–out of rooms in relation to the future hospital developments.

The main conclusion to be drawn from our field studies is that the hygiene re­ quirements constitute the premise, and that the players are far more aware of the

Lene Wul, Research Secretary, Research Assistant, Cross Faculty Department Vibeke Riisberg, Associate Professor, Department of Product Design Caren Weisleder, Research Assistant, Cross Faculty Department 80

1 Dilani adds to sociologist Aron Antonovsky’s theory about health and illness which

he referred to as Salutogenesis (salut — Latin for well–being).

Iltanen, S. & Topo, P. (2007). Ethical implications of design practices: The case of industrially manufactured patient clothing in Finland. In: Nordic Design Research Conference: Design Inquiries.

Stockholm, May 27–30.

References: Antonovsky, A. (1996). The salutogenic model as a theory to guide health promotion. Health Promotion International, 11(1), 11–18.

Morelli N. (2007). New Representation Techniques for designing in a Systemic Perspective. In: Nordic Design Research Conference: Design Inquiries.

Stockholm, May 27–30.

Binder, T. & Brandt, E. (2008).

The Design: Lab as platform in participatory design research CoDesign, 4(2), 115–129.

Sanders, L. & Simon, G. (2009).

A Social Vision for Value Co–creation in Design. Open Source Business Resource, December 2009; Value Co–Creation.

Localised March 4th 2010 at World Wide Web: http://www.maketools.com/pdfs/ Social_Vision_for_Value_CoCreation_in_ Design.pdf.

Caspari, S.; Erikson, K.; Nåden, D. (2006).

The aesthetic dimension in hospitals — An investigation into strategic plans.

International Journal of Nursing Studies, 43(7), 851–859.

Sanders, E. B. N. & Stappers P. J. (2000).

Generative tools for Co–Designing.

In: Scrivener, Ball and Woodcock (Eds.) Collaborative Design: Proceedings of CoDesigning 2000. London: Springer–Verlag.

Dilani A. (2005). Psychosocially Supportive Design — As a Theory and Model to Promote Health. Design & Health. International Academy for Design and Health, 2005, 13–22. Localised November 15th 2009 at World Wide Web: http://www.designandhealth.com/ uploaded/documents/Publications/ Papers/Alan–Dilani–WCDH–2005.pdf

Sanders E. B. N. & Stappers, P. J. (2008).

Co–creation and the new landscape of designCoDesign, 4(1), 5–18.

Fischl G. (2006). Psychosocially supportive design in the indoor environment. PhD. Thesis. Luleå: Division of Engineering Psychology, Department of Human Work Sciences Luleå University of Technology.

Ulrich R. S. (1991). Effects of Interior Design on Wellness: Theory and recent scientific research. Journal of Healthcare Interior Design, 3, 97–109.

Ulrich, R. S. et al. (2004). The Role of the Physical Environment in the Hospital of the 21st Century: A Once–in–a–Lifetime Opportunity. College of Architecture, Georgia Institute of Technology.

Frandsen, A. K. et al. (2009). Helende Arkitektur. Aalborg: Institut for Arkitektur og Design Skriftserie nr. 29.

Hamilton, K. (2003). The Four Levels of Evidence–Based Pratice. Healthcare Design, November, 3(4), 18–26.

Ulrich, R. S. et al. (2008). A Review of the Research Literature on Evidence– Based Healthcare Design. Health Environments Research and Design Journal, 1(3), 61–125.

Heslet L. & Dirckinck–Holmfeld K. (eds.).

(2007). Sansernes Hospital. København: Arkitektens Forlag.

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