The Salutogenic Perspective Applied To Hospital Staff (12th World Congress on Design and Health) by Wouter Pocornie

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The Salutogenic Perspective Applied To Hospital Staff 12th World Congress on Design and Health in Vienna, Austria

The Salutogenic Perspective Applied To Hospital Staff

fig. 1: Hospital staff Erasmus MC Rotterdam, The Netherlands

The Salutogenic Perspective Applied To Hospital Staff Liesbeth van Heel, MSc Willemineke Hammer, MSc Wouter Pocornie, MSc, EDAC

Introduction In all aspects of healthcare design, the patient should come first. This perspective is rightfully a commonality. However, what if the salutogenic perspective is applied to hospital staff? That would mean that the hospital aspires to continuously improve the environment of its base: the care professional, researchers and teachers of the new generation of hospital staff. What type of surroundings, physical and non-physical, supports the healthy lifestyle of staff and prevents setbacks such as stress, tension, injuries, or even illness? Here, the hospital and architect can join forces in proactively planning and envisioning, together with staff, in order to formulate an approach to salutogenic architecture. What would help the staff cope with a stressful job, stimulate health and happiness? In order to aspire to improve its staff’s health promotion and the quality of life at work, the hospital can benefit from exploring how a high-tech environment can also encompass ‘soft touch’ elements. This paper first explores salutogenesis and the perspective of hospital staff before zooming in on Erasmus University Medical Center (Erasmus MC) as a case study. In this hospital, staff perceptions on specific design elements were evaluated before and after departments moved into the new hospital. Building on these findings, this paper describes how the design of the clinical functions combines efficiency with health promoting elements for staff members. Finally, this paper explores the various scales that can be distinguished in a hospital complex, when designing with the salutogenic perspective of staff in focus.

Salutogenesis and the hospital staff: a perspective The hospital is often seen as a public symbol. The building serves society. EGM architects consider the needs of society at the heart of designing. Erasmus MC is committed to a healthy population and excellence in research and education. So a healthy community, outside and inside the hospital, is the joint focus in the collaboration between architect and hospital.

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The choice is to do nothing, to continue to work with bright ideas (which tend to merge with preventive medicine and, more often than not, focus on a particular risk factor and particular disease), or to structure a program which is based on the intellectually systematic organizing framework question: What can be done in this ‘community’ – [e.g.] chronic or even acute hospital population – to strengthen the sense of comprehensibility, manageability and meaningfulness of the persons who constitute it? A. Antonovsky

In any hospital design process, the design team aims to optimize processes that facilitate the needs of all endusers. It helps to distinguish three primary target groups in healthcare design: patient, staff/care professional, and family/support. However, at the core of it all, this paper positions the salutogenic perspective of the care professional as the focus through which eventually all end-users are reached. This is one of the main reasons why Erasmus MC took on a very inclusive approach to the objective to provide a healing environment. The context of Dutch healthcare infrastructure is rapidly changing. The growing shortages of hospital staff is one of the 21st century’s major challenges concerning healthcare infrastructure. This is a focus point in the planning of large university medical centres. The human capital it attracts and retains is still its largest asset. Erasmus MC employs 13,000 staff members, who need to be empowered in health promotion, both for their patients and for themselves. How do we attract, train and retain staff members and turn them into ambassadors for our organization in promoting health? In order to approach such ambitions, not as a means to avoid consequential problems emerging from the growing staff shortages, but rather as a way to attract and retain desired staff members, the theory of salutogenesis is a progressive model to work with. It considers potentials instead of just problems. Salutogenesis studies the origins of health. It could be seen in contrast to pathogenesis, which studies the origins of disease/illness, which traditionally dominates the healthcare sector. Salutogenesis is in essence proactive, aiming for a particular goal for which an approach has to be developed. However, this does not imply that salutogenesis is inherently idealistic or optimistic. Its realistic view of people’s nature is that humans are actually flawed in comparison to inherently healthy, which is the case with pathogenesis. In that sense, in order to fulfil aspirations for the wellbeing, happiness and health of hospital staff, progressive interventions have to be explored. The way hospital staff members view the world and their quality of life affects their ability to manage stress. The level of health depends on their SOC (Sense of Coherence), which can be understood in comprehension, manageability and meaningfulness. The SOC can predict health and is an applicable instrument for measuring health. The level of health also depends on GRR (Generalized Resistance Resources), which can be understood in material, ego identity, and social support.1 What efforts did we undertake to create an environment that is comprehensible and manageable for staff, and supporting the meaningfulness of their efforts towards patients? The salutogenic model contributes to the maintaining as well as development of health – and quality of life. It is important to note that many design aspects that are used to promote health and quality of life of hospital staff cannot rigorously be validated through evaluations or anecdotes. It depends on many changing variables, including the personal GRRs and whether different stages of health promotion are individually or group-based. However, the different stages, referring to the ‘Health in the River of Life’ analogue within salutogenic theory, can be translated into particular aspects of salutogenic architecture. The analogue proposes the following stages that comprise quality of life/ wellbeing and promote health: promotion, health education, preventive, protective, curative, and death/disease.2 Erasmus MC aims to deliver high-standard care, emphasize safety for all end-users (protective), use a proactive approach/process (preventive), involve staff in development process (education), and above all, promote a healthy working and living environment, which is safe, pleasant, and sustainable (promotion).

1 (Erikksson & Lindström, 2008, p.190-191) 2 (Erikksson & Lindström, 2008, p.194-196)

The Salutogenic Perspective Applied To Hospital Staff

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The very first requirement in a hospital is that it should do the sick no harm. F. Nightingale

How were staff involved in the design process? Staff were explicitly included in the definition and ambition of a healing environment - in addition to a safe environment (“do the sick no harm”)3 - to be achieved by building qualities such as accessibility/wayfinding, stress reduction, indoor climate, daylight, green, etc. These qualities were defined using expert groups, were prioritized and then brought together in the Technical Program of Requirements, which guided the design team and the review of these designs by hospital experts. By using decision matrices, care professionals and professional experts (e.g. infection prevention, various safety officers) were provided with the means to reflect on the design. How did salutogenic architecture help us in this respect? All of the arguments were assessed and considered to make design decisions. Research and exploration with a focus on salutogenic perspectives contributed to well-informed decision-making.

fig. 2: Inclusion of staff in the process of design development

Erasmus MC: a case study The pull of university medical centres goes beyond patient care. They emphasize research and education, and specialize in the more complicated treatments. All senior staff combine patient care with either education or clinical research. For example, half the staff at the Sophia Children’s’ Hospital (also situated on site as part of Erasmus MC) is in (advanced) training, be it in specialized paediatric nursing or medicine, or for paramedical qualifications. The new complex combines many different disciplines. The necessary comprehensible structure is designed to create a coherent building, where hospital staff benefit greatly from working in an environment with natural daylight, orientation and wayfinding, accessible green areas, etc. This continues to the smallest scale.

fig. 3: New work environment in AKC lab includes abundant daylight

3 (Nightingale, 1860)

The salutogenic perspective of Erasmus MC’s staff/care professional is at the heart of integral design aspects. As a case study, it demonstrates how salutogenic architecture can guide generic and specific aspects in healthcare design.

The transformation of Erasmus MC is a phased development. The project commenced in the late 1990s

with innovative ideas about providing tertiary healthcare in dedicated patient themes, i.e. centres of excellence. In 2007, the exterior design was finalized. In October 2009 the construction of the first phase started. In February 2013, the hospital started to use the first new parts with functions such as diagnostics and research laboratories, central sterilization, health sciences, and the outpatient clinic for rehabilitation medicine. In 2017, the remaining patient-centred functions such as (nursing) wards and all other outpatient clinics, diagnostic and treatment areas will be finished.4 The phased development is strategically planned in smaller parts in order to ensure that normal operations can continue while transforming from the old hospital complex to the new. During construction, public access had to be ensured at all times and this needed to be comprehensible for all end-users. Erasmus MC and EGM architects believe that communication translates into the commitment of all parties involved in such a major transformation challenge.

Pre and Post-Occupancy Evaluation In architectural practice, terms like ‘healing environment’ are becoming buzzwords. However, the terms stem from a scientific base. This research focuses on the causal factors of the built environment on health. Architects can do a lot based on intuition and best practices, but in essence that is not enough. Not anymore. Evidence can be gathered through EBD research and particularly by conducting pre- and post-occupancy evaluations: POEs. Abroad, forward-thinking jurisdictions are now mandating healthcare redevelopment projects include a POE.5 In the Dutch context, Erasmus MC in Rotterdam might be pioneering in a way of validating design that may become a demand in order to justify major investment in developing healthcare infrastructure.

To test the design, Erasmus MC and TNO (the Dutch Center of Health Assets, an independent body)

conducted a POE after the first phase being completed. The starting point was an interview with department heads, to explore where they expected, based on design intention, changes in staff appreciation to occur. These aspects ranged from the area for coffee and lunch breaks in labs (no food allowed in laboratories, coffee breaks, a moment for interaction between lab technicians and medical staff) to improved knowledge sharing (due to the central location of the coffee machine and informal meetings taking place). Based on the Technical Program of Requirements and earlier efforts to identify enablers in the design of a preventive, protective and healthpromoting environment, questionnaires were developed and validated as attributing to the hypotheses the research team defined.

Overall, regarding the indoor climate, perceived safety, well-being, work environment, sustainability,

facilities, and overall satisfaction, staff perception of the new buildings was significantly more positive compared to that of the old buildings. Regarding orientation, knowledge sharing, physical activity, work performance, working atmosphere and commitment to the employer, there were no effects found in the study.6

Particularly the elements of perceived safety and well-being are interesting from the point of view of this

paper. These findings could be illustrated with photos taken at various locations before and after the move. An example can be found in the transparency of the new lab building, which could be perceived as safer, as colleagues can monitor if someone is still inside the lab in the event of an emergency. In addition, departments themselves can now decide who gets direct and free access with a staff key card, and who has to announce themselves. Therefore, there are fewer strangers wandering through the department, because the elevator bank/stairwell acts as a natural barrier. Alternatively, sharing knowledge or consulting colleagues in the corridor still takes place, but lab coats are now hanging in the anteroom towards the various labs (and no longer in the corridor, where they could be switched), and an appropriate office area is now provided for this contact between staff.

From the research departments in Public Health it became apparent in this research that they really

appreciated the fact that they could open windows in the office area in the high-rise tower, even on the 29th floor. This ability reflects personal preference and autonomy. It is expected that patients will also appreciate having this choice when they are staying in a private room. 4 (Erasmus MC, 2016, p.16-23) 5 (Alvora, 2016 Apr 26) 6 (Schreuder et al., 2015, p.89)

The Salutogenic Perspective Applied To Hospital Staff

fig. 4: Safety in laboratory, before & after

fig. 5: Sharing knowledge/consulting colleagues in the corridor with lab coats hanging in the anteroom, before & after

fig. 6: Waiting area in Emergency Department, before & after

It is also good to note that this research took place in November of 2012 and 2013, just before and after

the move. Due to the phased construction, the public area, with shops and restaurants that also serve the staff involved in this POE, was not yet open in November 2013; staff walked through a corridor of containers towards the elevator bank. It seems understandable that their perception of orientation was hindered by this. This is one of the reasons for Erasmus MC to repeat the POE in November 2017, in order to see whether appreciation of the selected design elements has improved over time. In addition, both Erasmus MC, EGM architects and Royal Haskoning/DHV (the projectâ&#x20AC;&#x2122;s technical engineers) initiated additional evaluations after this study. In-depth interviews were conducted with department heads to review the layout and facilities and their use. These findings were shared with the design team in an effort to add to the knowledge base for this highly specialized building.

ÂŠ EGM architects - Erasmus MC

One department that was included in this evaluation, but had not been part of the POE research, was

the new Emergency Centre. The effectiveness of the design of this new Emergency Department has already been proven, as the number of incidents in the usually hectic centreâ&#x20AC;&#x2122;s waiting room has been significantly reduced. Where incidents were a fairly frequent occurrence, they are now rare and mostly limited to verbal abuse. The proximity of security personnel, situated near the walk-in entrance to the department, and with a view into the waiting area, has again contributed to a sense of safety among ED staff.

Focus on the care professional in designing clinical functions At Erasmus MC, multiple principles were formulated and emphasis was placed on the care professional. They personify the foundation of the institution, the environment within the continuum of care, and they are the executors of professional medical care. Once the foundation is in place, other concepts such as patient- and family-centred care can materialize. It does not mean it overrules or undermines the importance of such concepts, but it does structure an architectural approach to healthcare design with the focus on health promotion. For this paper, the salutogenic perspective of the staff is at its core. It is the main focus. What type of surroundings, physical and non-physical, support the healthy lifestyle of staff? Erasmus MC and EGM architects examined integral solutions to improve the efficiency of work and the wellbeing of nurses in the wards. A central point of discussion, at the scale of the patient/inpatient care unit and from the perspective of caregivers, is the choice of nursing station typologies. Often the choice is twofold: decentralized or centralized nursing stations. However, variations such as hybrid and multi-hub typologies exist.7

EBD research that focuses on nursing stations offers interesting insights. Various studies look to answer

which model is preferred, but the results and implications for practice often illustrate the integral and plural nature of architecture. In terms of efficiency, data can point out a favourite type, but from the point of view of salutogenesis/health promotion regarding care professionals, these models can severely hinder their wellbeing. To illustrate, efficiency could be improved but simultaneously privacy for caregivers could be compromised. From the point of view of the patient, the advantages of decentralized units outweigh the disadvantages. Nurses are able to spend more time in patient rooms and less time waiting in medication and supply rooms. From the point of view of the care professional, attention needs to be put on the level of privacy regarding professional and private communication, ergonomics, and focus on education and mentoring.8

In the new clinical wards of Erasmus MC, the nursing stations are spread out in the circulation area of

the wards. The integral design solution includes on-stage workstations in the wards and in the ICU, there are stations per two mirrored rooms. Off-stage areas are positioned nearby to enable formal (e.g. teaching) and informal communication between staff members, offer break opportunities, and respite. One of the references is the Norwegian Sengetun model: with a ratio of one station to eight beds.9 A mixture of different typologies was needed in order to stimulate a healthy work environment for staff. These typologies came about through intensive dialogue with staff. Their concerns regarding working in the middle of the circulation area were voiced during group sessions. However, parallel to those concerns, the value of separating workstations/areas was well understood. Just opposite the medication room and dirty utility, two decentralized workstations are clustered and comprise a square area. This is the centralized station at night, when fewer nurses are around and it is more important they can be easily found by colleagues. In short, the informal interaction between staff would not be compromised while the optimization of work performance near patients was established. The ambition was to optimize on the work performance as well as to limit walking distances for care professionals. To limit walking distances, a system of trolleys (supply cupboards on wheels) has been developed. Trolleys contain a 24-hour supply of either linen or care materials for eight patients, and are refilled from the central stores (shared by more units). A pneumatic tube system assists in priority transport of patient materials to labs or medication received from the central pharmacy. The Pharmafilter system supports the use of bioplastic (disposable) bedpans and urinals, reducing the number of trips nurses need to make to the dirty utility, but also disposing of potentially contaminated materials in a safer way (http://pharmafilter.nl/en/).10 7 (Pati et al., 2015) 8 (Gurascio-Howard & Malloch, 2007; Sadler et al., 2011, p.23) 9 (Solumsmo & Aslaksen, 2009; Aslaksen, n.d.) 10 (Pharmafilter, 2012; Pharmafilter, n.d.)

The Salutogenic Perspective Applied To Hospital Staff

fig. 7: Plan of a nursing ward

fig. 8: Impression of a PCU in nursing ward with nursing stations

fig. 9: Plan of a PCU in nursing ward with off-stage stations

ÂŠ EGM architects - Erasmus MC

Ceiling lifts are examples of elements that not only serve the patient but also should guarantee safe and healthy handling by care professionals. Internationally, these investments have proven to significantly reduce work injuries and increase staff availability.11

At Erasmus MC, the lifts are installed in every room to prevent overburdening an aging nursing staff and

they also improve the comfort level of the patient. At Erasmus MC, care professionals were included in developing the vision during the programming phase and during early design stages. The new ways of working are currently coordinated through a special programme: ONE (Our New Erasmus MC). This programme was established in 2014 to ensure a safe transition to the new hospital in 2018. Apart from the new building and new ways of working, a new electronic patient record is being implemented, and processes are supported with new IT and services.

This in itself is a major challenge, as has been established by Tucker et al.12 Here, methods included

training with scale models, a card game focusing on work processes, and excursions (live simulations) to already completed areas in the last part of the new hospital, such as staff areas, clinics and outpatient clinics. This programme will soon continue with the nursing wards.

Erasmus MC through the scales At the scale of urban planning: the campus as a complex In order to internationally compete on a high level, university medical centres are recruiting professors, researchers and students who deliver on the high aspirations of the healthcare institution. The hospital staff are a serious target group for university medical centres that look to profile themselves and secure a strong position in the Dutch healthcare infrastructure that is transitioning. How do we attract and retain staff members and make them ambassadors for the organization in promoting health?

Given its inner-city location and staff numbers, flows of staff to and within the complex have to be

designed for the highest level. For example, proper accessibility via public transport, access to green areas in the vicinity and the possibility to use them to rest during lunch breaks, easy-to-grasp wayfinding that follows the logical routing from entering via bicycle parking to staff areas, and provisions such as changing rooms with showers. In the case of Erasmus MC, the campus is housed in a building volume: it is considered a complex. It provides a healing environment in a highly urbanized area. Outdoor parks and adequate bicycle parking are some of the means in which a healthy lifestyle for hospital staff is promoted. Facilities that are conventionally found throughout the city or campus are situated inside the complex in the Passage, Square, Arcade and atria. This public domain houses a supermarket, bookstore, pharmacy, restaurants, and many different places for all endusers to occupy space, as they would do in the city. The building is structured in a way that these users, especially its permanent resident-users such as staff, have a positive distraction, a clear overview, and possibilities for leisure in rest areas.

At the scale of the building volume The Erasmus MC complex combines many components in one volume. The design team developed a structure that connects multiple disciplines and departments via a corridor: the â&#x20AC;&#x2DC;backboneâ&#x20AC;&#x2122;. Together with green atria that channel daylight, this structural network is essential for end-users to easily grasp wayfinding. At the scale of the building volume, these components for orientation and positioning add to the comprehensibility. The atria are situated on the periphery of the building in order to facilitate the transition of the inside-outside relationship, i.e. the direct visual connection to the city/vicinity from inside the building. Together with the landscape architect these are designed to be meaningful, especially for hospital staff. These meaningful places reoccur throughout the hospital because of Erasmus MC prioritizing the healing environment as a structuring concept; a conscious decision to create workplaces that motivate staff and help them cope with work-related stress by emphasizing qualities of natural elements.

11 (Sadler et al., 2011, p.21; DiNardo, 2013, Jul 1; Miller et al., 2006; Wolf, 2003; Li et al., 2004) 12 (Tucker et al., 2014)

The Salutogenic Perspective Applied To Hospital Staff

fig. 10: The â&#x20AC;&#x2DC;backboneâ&#x20AC;&#x2122; connects components inside and outside the corridor, it promotes easy to grasp wayfinding, and channels natural light

ÂŠ EGM architects - Erasmus MC

fig. 11: The Passage offers end-user the possibility to occupy space as they would do in the city: positive distraction, overview, and leisure in rest areas.

The outpatient clinic and nursing wards have a similar orientation and relation to natural daylight, and access to and visual connection with nature. In a highly urbanized context, the design integrates the natural landscape in order to promote meaningfulness. On top of that, the green roof gardens will demonstrate the new hospital as a very green building.

At the scale of the departments/units How did salutogenic architecture help in configuring the layout? At the scale of departments/units, Erasmus MC is designed to be manageable by use of front and back offices, a layout that welcomes natural daylight, short travelling distances in nursing wards, and clear orientation via the Passage. The (bed)accessible roof gardens, attractive staircases and Passage improve meaningfulness.

Meaningfulness is visualized through a perceived journey. The outpatient clinics are structured in a

uniform way with the emphasis on an unambiguous overview. Patients and visitors step out of the elevator and are directed towards a reception. Then they enter a waiting area, after which they can enter the (generic) clinical rooms, and finally reach the specials. This clear sequence still allows for a flexible use by caregiver professionals. Consultation can take place in multiple rooms, and even though the structure is unambiguous and based on a predicted patient journey, the flexible use of workspaces by care professionals provides much-needed variety.

At the scale of the room The patient room can be subdivided in patient zone, family zone, care professional zone, and an en suite bathroom (shower/toilet/sink). Even though most EBD research focuses on the (salutogenic) perspective of the patient, and in a supporting manner the family/visitor, there are many aspects to consider from the salutogenic perspective of the care professional. The work area(s) of the care professional gain a lot by being standardized, which is possible even in mirrored patient rooms.

The Salutogenic Perspective Applied To Hospital Staff

The care professional needs overview, predictability, and easy access to various points of focus. Concerning lines of sight, the care professional gains in efficiency and control by having continuous visual connection with the patient, whether he/she is in bed or in the bathroom.13 The mirrored patient rooms and inboard sanitary units are configured in a way that they are comprehensive and manageable for the care professional inside the patient room.

Patient rooms present the same paradox as hospitals. There is a need not only to concentrate care but

also to isolate patients. The single room offers privacy amongst other things but requires visual control from the perspective of staff. That is why the patient rooms are designed with flush or panelled doors in order to offer the patient the choice to direct sound and sight according to their desired level of privacy. In the patient rooms adapted for patients that need to be isolated due to their own low immune system or infectious threat to others, the doors are provided with a glass window to allow a view of the hall and a visual connection towards the circulation area/staff. Staff can therefore make visual contact with the patient without having to go through the process of protective ‘gowning’.

The salutogenic perspective of care professionals can adjust design aspects. An important method

in developing the standardized patient room is the mock-up. Mock-ups are a type of simulation.14 They offer opportunities to have a dialogue with care professionals about specific points of attention. They also offer possibilities to train and educate. It is essential that feedback and/or data be registered immediately.

At the scale of elements Perhaps most suited to health promotion is design from the scale of elements and then scaling up. The focus is on user experience and his/her specific needs. More than other scales, it allows holding the experience of different end-users as a narrative out of which design aspects emerge. Here, past experience in designing hospitals, interactive explorative methods, and international research resulted in detailed findings. The allocation of the sink in patient rooms illustrates this process. The configuration of the sanitary unit (bathroom: toilet, shower, sink) affects the patient as well as the caregiver in various ways. In the design of this particular space, it is important to consider the exact place of the main elements. To stimulate a safe and efficient use of the space for the patient, the designer has to consider the way/ direction and frequency of turns.15

In order to benefit the care professional, the design team has to consider standardization. Here two

main topics often emerge. Principally, it is important to consider sight, overview and orientation. In addition, it is beneficial to strategically place elements such as the sink in and outside the sanitary unit because it is imperative to stimulate hand-washing compliance. When aiming for health promotion in the patient room, the accessibility to the sink can follow the standardized way staff enter the room and use their work areas. Potential problems are situations where the wet and dry working places are combined or in close proximity to each other. Separating wet and dry workstations is a design aspect that is promoted in initiatives such as the Adopt-a-Room prototype and the IPR project at Clemson University in the United States of America. In the US, handwashing compliance is generally speaking a focus point in health promotion.16 Designing with this in mind means to facilitate the (strict) protocols of antisepsis. In order to achieve the desired results, research has pointed out that technical and spatial solutions are preferred to non-physical programmes such as awareness and education. Education and feedback, including from the patient to hospital staff, is less efficient than solving the issues by making sanitation appliances more accessible. Placing those strategically in the line of sight and upon entry from the door, the care professionals washed their hands with a higher frequency.17

At Erasmus MC, the design team also applied height differentials and minimalized the amount of

turns the care professional has to make in order to wash his/her hands. The preventive measures are designed to not be intrusive or cause avoidable social tension. It illustrates a particular detail in which the journey of the care professional determines room configuration while also keeping the focus on the patient’s wellbeing. This way, the care professional’s situation is understood, adding to the comprehensibility, and facilitated particularly by enabling the right spatial tools, which in turn adds to the manageability. The sink illustrates that health promotion can take place at the scale of an element.

13 (Pati et al., 2009, p.104-106) 14 (Peavey et al., 2012) 15 (Pati et al., 2009, p.92) 16 (Bischoff et al., 2000; Pittet, 2000; D. Pittet et al., 2000) 17 (Bischoff et al., 2000)

Conclusion The salutogenic perspective is applicable to hospital staff with respect to other principles. A hospital can aspire to continuously improve the environment through its base: its staff. By doing so, the care professional focus is the departure point for salutogenic architecture. The SOC model is applicable and can validate integral design solutions at an early stage of development. In addition, it requires participation from the staff, which in turn can result in the much-desired commitment. The type of surroundings, physical and non-physical, that support the healthy lifestyle of staff and prevents setbacks such as stress, tension, injuries, or even illness, is achievable with design principles. This aim to establish a safe, pleasant and sustainable environment can be successful and can be established using a pre- and post-occupancy evaluation. In essence, hospital and architect require a proactive approach in planning and envisioning. Together with the staff, this defines the SOC-inspired models that comprise salutogenic architecture. Here, methods interpret ‘disease and curative’, ‘preventive’, ‘education’, and ‘promotion’ and formulate the potential of creating a healing environment. The project is validated when staff are enabled to cope with a stressful job and stimulate health and happiness. The different levels of wellbeing and quality of work and life can reach towards their highest form: health promotion. Erasmus MC is a case study that shows that a healing environment in a highly urbanized area, focusing on the hospital staff, can use an approach based on salutogenesis. All end-users will ultimately benefit from the salutogenic perspective that focuses on hospital staff.

Authors Liesbeth van Heel, MSc

Willemineke Hammer, MSc

Wouter Pocornie, MSc, EDAC

Program Secretary ONE

Partner/Architect

R&D/Architect

Our New Erasmus MC

EGM architects

Senior Policy Advisor Program Integrated Buildings

Biography of the authors: Liesbeth van Heel (1964) was trained in Facility Management and Business Economics before joining Erasmus MC as a management trainee. Since the late ’90, she has been involved in the Erasmus MC redevelopment project as project secretary, and manager within the directorate of Corporate Real Estate. She has gained expert knowledge on the cutting edge of developing a good new university hospital and an innovative, sound and robust new building. Recently she focusses on a safe transition to the new facility, but is still involved in national and international orientation and knowledge sharing. She is also responsible for PR on the Erasmus MC project. Since joining EGM architects in 1998, Willemineke Hammer MSc (1971) has been involved in the development of large academic institutions, general hospitals, residential care projects and initiatives in which living as normally as possible and welfare are central themes. In the overall spectrum of Cure & Care she searches, in dialogue with clients and (end)users, the appropriate connection between people, processes and physical environment. Willemineke is also responsible for scientific architectural research, which is considered part of EGM’s core activities. Before joining EGM architects, she worked on retail, private housing and small business buildings. Willemineke Hammer studied Architecture at Delft University of Technology and Art History at Leiden University. Wouter Pocornie (1986) studied Architecture at Delft University of Technology and graduated in the directions Architecture as well as Urbanism. In 2014 he joined EGM architects to help set up the R&D department, which was officially launched within a year. He explores new approaches to healthcare design, ways of contextualizing themes and innovations, and integrating multiple perspectives in a narrative of healthcare design. Adjacent he holds a strategic position at two platforms in Amsterdam and works on various business initiatives between The Netherlands and Suriname. During his studies, he worked on multiple research projects abroad. Here, he explored urbanization processes in Haiti, China, Nigeria, and El Salvador.

The Salutogenic Perspective Applied To Hospital Staff

References Antonovsky, A. (1996). The salutogenic model as a theory to guide health promotion. Health Promotion International, 1996, Vol. 11, No. 1, p.11-18. Retrieved on June 28, from http://heapro.oxfordjournals.org. Alvaro, C. (2016, Apr 26). POE: finding answers to billion dollar questions. SALUS. Aslaksen, R. (n.d.). From visions to plans and physical environments; designing hospitals from a patient perspective. Retrieved on March 16, 2017, from: www.designandhealth.com. Bischoff, W.E., Reynolds, T.M., Sessler, C.N., Edmond, M.B., Wenzel, & R.P. (2000). Handwashing compliance by health care workers: The impact of introducing an accessible, alcohol-based hand antiseptic, Archives of Internal Medicine, 160, no. 7, p.1017-1021. DiNardo, A. (2013, Jul 1). Room for all: Trends in bariatric healthcare design. Retrieved on October 6, 2016, from Healthcare Design Magazine website: http://www.healthcaredesignmagazine.com. Erasmus MC (2016). Our New Erasmus MC: Future-proof buildings. Retrieved on March 30, 2017, from Erasmus MC website: http://www.erasmusmc.nl. Eriksson, M. & Lindstrรถm, B. (2008). A salutogenic interpretation of the Ottawa Charter. Health Promotion International, Vol.23, No.2, p.190-199. Gurascio-Howard, L. & Malloch, K. (2007). Centralized and decentralized nurse station design: An examination of caregiver communication, work activities, and technology. HERD Health Environments Research & Design Journal, October 2007, Vol. 1, No. 1, 44-57. Retrieved on November 2, 2015, from http://her.sagepub.com. Li, J., Wolf, L., & Evanoff, B. (2004). Use of mechanical patient lifts decreased musculoskeletal symptoms and injuries among health care workers. Injury Prevention 10, no. 4, p.212-216. Miller, A., Engsta, C., Tatea, R.B., & Annalee Yassia, A. (2006). Evaluation of the effectiveness of portable ceiling lifts in a new long-term care facility. Applied Ergonomics, 37, no.3, p.377-385. Nightingale, F. (1858). Notes on nursing: What it is, and what it is not. New York: D. Appleton and Company. Retrieved on February 13, 2015, from http://digital.library.upenn.edu/. Pati, D., Harvey Jr., T.E., Redden, P., Summers, B., & Pati, S. (2015). An empirical examination of the impacts of decentralized nursing unit design. HERD Health Environments Research & Design Journal, January 2015, Vol. 8, No. 2, p.56-70. Retrieved on October 27, 2015, from http://her.sagepub.com. Pati, D., Harvey Jr., T.E., Reyers, E., Evans, J., Waggener, L., Serrano, M., Saucier, R. & Nagle, T. (2009). A multidimensional framework for assessing patient room configurations. HERD Health Environments Research & Design Journal, January 2009, Vol. 2, No. 2, p.88-111. Retrieved on February 16, 2016, from http://her.sagepub.com. Peavey, E.K., Zoss, J. & Watkins, N. (2012). Simulation and mock-up research methods to enhance design decision making. HERD Health Environments Research & Design Journal, January 2012, Vol. 5, No. 3, p.133-144. Retrieved on February 4, 2016, from http://her.sagepub.com. Pharmafilter (2012). Pharmafilter: Resultaten demonstratieproject in het Reinier de Graaf Gasthuis Delft (April 2012). Nieuwkoop: Ecodrukkers Nieuwkoop. Retrieved on December 14, 2015 from Renier de Graaf website: https://reinierdegraaf.nl. 20.

ÂŠ EGM architects - Erasmus MC

Pharmafilter (n.d.). Information. Retrieved on March 30, 2017 from Pharmafilter website: http://pharmafilter.nl/ en/processen/pharmafilter-installation/. Pittet, D. (2000). Improving compliance with hand hygiene in hospitals. Infection Control and Hospital Epidemiology 21, no. 6, p.381-86. Pittet D., Hugonnet, S., Harbarth, S., Mourouga, P., Sauvan, V., Touveneau, S., & Perneger, T.V. (2000). Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet 356, 2000, p.13071312. Sadler, B.L., Berry, L.L., Guenther, R., Hamilton, D.K., Hessler, F.A., Merritt, C., & Parker, D. (2011). Fable hospital 2.0: The business case for building better health care facilities. Hastings Center Report 41, no. 1, p.13-23. Schreuder, E., van Heel, L., Goedhart, R., Dusseldorp, E., Schraagen, J.M., & Burdorf, A. (2015). Effects of newly designed hospital buildings on staff perceptions: A pre-post study to validate design decisions. HERD Health Environments Research & Design Journal, 2015, Vol. 8, 4, p.77-97. Retrieved on March 15, 2017, from http://journals. sagepub.com. Solumsmo, A.-O. & Aslaksen, R. (2009). Chapter 11 St Olavâ&#x20AC;&#x2122;s Hospital, Trondheim, Norway. In Rechel, B., Erskine, J., Dowdeswell, B., Wright, S., McKee, M. (Eds.), Capital investment for health: Case studies Europe (Observatory Studies Series No. 18) (p.168-170). Retrieved on March 28, 2017, from World Health Organization (WHO) website: http://www.euro.who.int. Tucker, D.A., Hendy, J., & Barlow, J.G. (2014). When infrastructure transition and work practice redesign collide. Journal of Organizational Change Management, Vol. 27, 6, p.955-972. Wolf, E.J. (2003). Promoting patient safety through facility design. Health Care Executive, 18, no. 4, p.16-20.