Evidence Based Design van Healing Environments: Wat is er precies bewezen? Ad Pruyn
Communicatie en Consumenten Psychologie in Twente
Communicatie in Service Omgevingen Beleving van wachttijden Optimalization of design of waiting rooms (v. Beuningen) Healing environments, the tangibles dimension of service quality (Dijkstra, Verhoeven, Pieterse, van Rompay); Design en Emotie Social justice in service exchanges (Galetzka) Consumer trust and ICT (de Vries)
Inrichting van dienstenomgevingen Is relevant in: Zorgomgevingen (Rubin et al. 98; Ulrich et al. 04; van den Berg 05)
Inrichting van dienstenomgevingen Is relevant in: Zorgomgevingen (Rubin et al. 98; Ulrich et al. 04; van den Berg 05) Bij de NS
Inrichting van dienstenomgevingen Is relevant in: Zorgomgevingen (Rubin et al. 98; Ulrich et al. 04; van den Berg 05) Bij de NS In leeromgevingen
Inrichting van dienstenomgevingen Is relevant in: Zorgomgevingen (Rubin et al. 98; Ulrich et al. 04; van den Berg 05) Bij de NS In leeromgevingen en sluit perfect aan op: Ontwikkelingen in de Beleveniseconomie (Pine & Gilmore, 98)
Inrichting van dienstenomgevingen Is relevant in: Zorgomgevingen (Rubin et al. 98; Ulrich et al. 04; van den Berg 05) Bij de NS In leeromgevingen en sluit perfect aan op: Ontwikkelingen in de Beleveniseconomie (Pine & Gilmore, 98) Marktwerking in de zorg
Wat is er nou precies bewezen? Healing environments Focus from functional delivery of care towards psychologically supportive environments The physical environment can encourage the healing process and patients feelings of well-being
Physical Environmental Stimuli that turn Healthcare Facilities into Healing Environments: A Systematic Review (Environment, Behaviour & Society, Sydney, 9-11 Febr 2006) Karin Dijkstra Marcel Pieterse Ad Pruyn
Physical environmental stimuli Three dimensions¹ Architectural features: relatively permanent aspects of the environment (e.g. spatial layout of the hospital, window placement) Interior design features: less permanent aspects of the environment (e.g. furnishings, colours, artwork) Ambient features: lighting, noise levels ¹ Harris et al. (2002)
Aim of this review Achieve a rigorous evidence base that may serve as a source: For evidence-based guidelines For future research Using the Cochrane Collaboration method
Inclusion and exclusion criteria (1) Interventions of physical environmental stimuli concerning: Effects on health and well-being of patients In healthcare environments Both clinical (e.g. length of stay) and psychological outcome measures (e.g. mood)
Inclusion and exclusion criteria (2) Clinical trials with at least an adequate control condition Published in peer-reviewed journals No confounding with non-environmental changes (e.g. changes in nursing care policy)
Search strategy Databases on medicine (MedLine, Cinahl, Embase), psychology (PsychInfo) and architecture (Iconda, Compendex) 17 environmental stimuli: furniture, art, colour, nature, plants, gardens, carpeting, room size, spatial layout, private rooms, noise, music, odour, television/video, light, windows, view from a window
Search results (1) 533 articles full-text screening Reason for exclusion n Non-empirical articles 290 Articles not studying effects of environmental stimuli 77 Articles not studying effects on patients 10 Articles not studying effects in a healthcare setting 7 Articles adopting study designs other than controlled trials 83 Articles lacking an adequate control condition 15 Articles confounding with non-environmental changes 10 Articles using the environmental stimulus as therapy 9 Articles studying the social environment 2 Total 503
Search results (2) Only 30 well-conducted clinical trials available No studies that exclusively studied effects of: colour, art, plants, gardens, carpeting, room size Randomised controlled trials: 2 Controlled clinical trials: 18 Natural experiments: 10 (7 retrospective)
Results multiple interventions (1) 11 studies manipulating several stimuli simultaneously (renovation/redecoration projects), showing effects on: Behaviour (e.g. social behaviour, hostility) of patients (inconsistent effects) Environmental appraisals (positive effects) Judgments regarding healthcare personnel (inconsistent effects)
Results multiple interventions (2) Physical healthcare environment affects patients, however: Effects on behavioural outcomes very inconsistent No effects on clinical outcome measures To what specific environmental stimuli can the effects be attributed?
Sunlight (4 trials) Ambient features Mainly positive effects on length of stay, mortality rate, perceived stress and pain Sound (4 trials) Mainly positive effects if intervention aimed to prevent negative effects of noise Inconsistent effects on adding positive sounds (e.g. music) to the environments
Architectural features Windows (3 trials) Presence of windows positive effects on length of stay, sleep, delirium Natural view from a window more positive (length of stay, medication intake) Spatial layout/private rooms (3 trials) Positive effects on privacy perceptions No effects on clinical outcomes
Interior design features Adding natural elements (2 trials) Marginal effects on pain control and heart rate, all other outcomes non-significant TV in a waiting room (1 trial) TV does not serve as a distractor (on short-term) Seating arrangements (1 trial) Affect social interactions
Conclusions (1) The general notion that the physical healthcare environment affects the wellbeing of patients is clearly supported When looking at effects of specific stimuli, conclusive evidence is still very limited and difficult to generalise
Conclusions (2) At this stage, formulating guidelines for evidence-based design seems premature The field appears in urgent need of wellconducted controlled clinical trials
Wat hebben we nodig? We weten (nagenoeg) niets over de preferenties (en prioriteiten) van gebruikers (patiënten, reizigers, etc.) (St.Thomas -London: kinderen-ontwerp)
Wat hebben we nodig? We weten (nagenoeg) niets over de preferenties (en prioriteiten) van gebruikers (patiënten, reizigers, etc.) (St.Thomas -London: kinderen-ontwerp) Er is (tot nu) selectief gekeken naar effecten (klinisch, psychologisch); geen aandacht voor (perceived) quality en loyaliteitseffecten. (Is er concurrentieel voordeel te behalen? Effecten op de samenwerking arts-patiënt?)
Hoe zijn omgevingseffecten te verklaren? Kleur well-being/ ligduur, etc.
Hoe zijn omgevingseffecten te verklaren? psychologische mediatie stress, anxiety Kleur well-being/ stemming ligduur, etc.
Hoe zijn omgevingseffecten te verklaren? psychologische mediatie stress, anxiety Kleur well-being/ stemming ligduur, etc. of: mediatie via kwaliteitsperceptie perceived quality = reliability (Zeithaml & Bitner) responsiveness assurance empathy tangibles
Hoe zijn omgevingseffecten te verklaren? psychologische mediatie stress, anxiety Kleur well-being/ stemming ligduur, etc. of: mediatie via kwaliteitsperceptie perceived quality = reliability responsiveness assurance empathy tangibles
Hoe zijn omgevingseffecten te verklaren? psychologische mediatie stress, anxiety Kleur well-being/ stemming ligduur, etc. of: mediatie via kwaliteitsperceptie perceived quality = reliability responsiveness assurance empathy tangibles
Wat hebben we (nog meer) nodig? We weten (NS herinrichting perrons) dat omgevingsingrepen elkaar kunnen versterken/verzwakken; hoe zit dat in zorgomgevingen? We weten nog betrekkelijk weinig over effecten op gedrag (relatief veel onderzoek in de psychiatrie/geriatrie)
Problemen Controlled clinical trials zijn duur Fine-tuning van meetinstrumenten vereist investeringen Het veld is versnipperd, en mist de middelen voor deze investeringen (onderzoek in medische omgevingen vergen een lange adem) Personeel
Wat gebeurt er in NL? SWIZ.nl kennisbank De laatste 3 jaar: veel (ad hoc) onderzoeksprojecten (afstudeerprojecten obv Gerjo Kok (Maastricht) Mieneke Weenig (Leiden) Yvonne Slangen (Eindhoven) Pruyn, v.rompay, Galetzka (Twente) Metha Fennis (Swiz-VU)