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A Psychosocial Approach to A Psychosocial Approach to Architectural DesignArchitectural Design

Enhancing well-being in health care facilities by architectural design?

Géza Fischlfige@ltu.se

Department of Human Work SciencesDivision of Engineering Psychology

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ContentsContents

1. Perspectives on stress and therapeutic environment

• Model of environmental perception• Environmental stress perspectives• Psychosocially supportive environments• The therapeutic environment

2. Environmental assessment techniques• Assessment tools and perceived environmental

quality, emotions, and aesthetic preference• Assessment tools and health care users/clients

3. Research based design process

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ContentsContents

4. Aim and research question5. Summary of papers Paper I. Fischl, G. & Gärling, A. (2003). Triple-E: A Tool to

Improve Design in the Health Care Facilities? (Submitted for publication). An earlier version was presented at Design and Health, 3rd World Congress and Exhibition, Montreal, Canada. June 2003.

Paper II. Fischl, G. & Gärling, A. (2004). Patients’ and architects’ perspective of psychosocial supportiveness in a health care facility. (Submitted for publication). An earlier version was presented at the Annual Meeting for Environmental Psychology Group, Gävle, Sweden. October, 2003.

6. Discussion and Conclusion7. Further direction: Restorative environment,

ART

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1.1 Model of environmental perception1.1 Model of environmental perception

Brunswik’s model on environmental perception & understanding of individual learning differences (Brunswik, 1956; Gifford, Hine, Muller-Clemm, Reynolds, & Shaw, 2000)

LENS

Perceptual process

Environmental stimuli

Relevant cues ecological validity (objective usefulness)Emotional impressions

Evaluations of the built environment

Past experiences, personality or other

differences

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1.2 Environmental stress perspectives1.2 Environmental stress perspectives

Stress Gatchel, Baum, & Krantz (1989): a centrally important

concept in understanding person-environment interactionsGiles & Neistadt (1994): a collection of physical and

psychological changes that occur in response to a perceived challenge or threat: the outcome of the interaction between the person and the environment

Selye (1956): proposed the physiological component of stress

Lazarus (1966, 1998): suggested the behavioral and emotional components of stress

Kagan & Levi (1971): constructed a theoretical model to describe psychological factors in the mediation of physical disease: hypothesized that psychosocial stimuli cause physical disorder

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1.2 Environmental stress perspectives 1.2 Environmental stress perspectives (Cont.)(Cont.)

Cox (1978): suggested a transactional model of Person-Environment (PE) stress• a part of the complex and dynamic system

of transactions between an individual and his/her environment

• an individual perceptual phenomenon embedded in psychological processes

• an intervening variable, which reflects transaction between the person and his/her environment

: draws attention to the feedback components of the system, which makes it cyclical rather than linear : offers the benefits of Kagan and Levi’s model (1971) as a dynamic cybernetic system

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1.2 Environmental stress perspectives 1.2 Environmental stress perspectives (Cont.)(Cont.)

Karasek & Theorell (1990): stated that the individual’s background and capability should be matched with the demands of the environment

Lazarus (1976): introduced the concept of demand as a requirement for mental/physical action, and implied some perceived time constraint

8Transactional model of stress (Cox, 1978)Transactional model of stress (Cox, 1978)

Actual capability

Actual demand

Perceived capability

Perceived demand

Cognitive appraisal

Imbalance =Stress

Emotional experience

Stress response

Psychological response

Physiologicalresponse

Cognitivedefence

Behavioral response

Feedback

Feedback

Feedback

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1.2 Environmental stress perspectives (Cont.)1.2 Environmental stress perspectives (Cont.)

Bell et al. (2001): introduced the eclectic model of Environment-Behavior (EB) relationships: states that the objective environmental conditions, such as physical cues and building design characteristics, exist independently from the individual, although the individual can act to change them. These physical cues represent the actual demand on the individual and become a perceived demand throughout the observation or interaction. : involves individual differences, such as:

: refers to social support as the feeling that one is cared about and valued by others as well as the feeling that one belongs to a group

place attachment competence to deal with

the environment social support like or dislike towards

others in the situation

adaptation level length of exposure in the

environment perceived control over the

situation personality privacy preference

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Objective

Physical Conditio

n

Perception of

environment as within optimal range of

stimulation

Homeostatis

Adaptation

and/orAdjustme

nt

Possible aftereffects

and/orCumulative effects

(e.g. higher self-esteem, skill development,

fatigue, reduced frustration tolerance)

Individual differences

(e.g. adaptation level)Situational factor(e.g. time in setting,

control)Social condition

(e.g. affection, social support)

Cultural factors(e.g. housing design)

Perception of environment as outside optimal

range of stimulation

(e.g. overstimulating, understimulating and/or behavior

constraining)

Arousaland/orStressand/or

Overload

and/orReactan

ce

Continued arousaland/or

Stress;Possible

intensified stress due to

inability to cope

Possible aftereffects

and/orCumulative

effects(e.g.

mentaldisorders, learned

helplessness, performance

deficits)

Coping

Perception of

environment

If coping successful

If coping unsuccessful

The eclectic Environment-Behavior model by Bell et al. (2001).

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1.3 Psychosocially supportive environments1.3 Psychosocially supportive environments

Dilani (2001) & Ulrich (1999): stated that the perceived built environment should be psychologically and psychosocially supportive to people

Oxford English Dictionary (2003): defines

psychosocial as the interrelation of behavioral and social factors and its influence on an individual’s mind or behavior

Seymour (1998): stated that psychological and

psychosocial skills give people the ability to interact in society and process emotion

Ulrich (2001) described the term ‘supportive’ as “an environmental characteristic that support or facilitate coping and restoration with respect to stress that accompanies illness and hospitalization” (p. 53)

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1.3 Psychosocially supportive environments (Cont.)1.3 Psychosocially supportive environments (Cont.)

Psychological skills

Social skills Self-management

ValueInterest

Self-concept

Role performance

Social-conductInterpersonal

skillSelf-expression

Coping skillsTime

managementSelf-controlPsychosocial supportiveness can refer to the

quality of the (built) environment, which strengthens or sustains the ability of an individual to perform his/her role, conduct him-/herself in society, and communicate or interact with others in accordance to his/her values, interest, and self-concept.

Uniform terminology for occupational therapy (AOTA, 1994):

the classification of psychosocial components

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1.4 The therapeutic environment1.4 The therapeutic environment

Ulrich’s theory (1991) affirmed that therapeutic environments improved medical outcomes of patients by reducing stress. Stress alleviation occurred with the increased perception of control and privacy, enhanced social support, and by offering positive distractions, such as art, music, and access to nature.

Congruent research findings show that therapeutic environments for patients allow recovery from stress through access to nature, exercise and physical movement, and enhanced social activities.

Rubin (1997): Recent studies have shown an association between patients’ medical outcomes and the quality of health care facilities

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Problem identificationProblem identification

Despite the growing number of scientific studies on the effect of healthcare environments on medical outcomes, there is a clear need for research to identify environmental characteristics that are perceived as stressors, as well as, what end-use consumers really need and want in health care environments.

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2. Environmental assessment 2. Environmental assessment techniquestechniques

Craik & Feimer (1987): Environmental assessment is a general conceptual and methodological framework for describing and predicting how attributes of places relate to a wide range of cognitive, affective and behavioral responses.

Environmental assessments can be classified into three categories; evaluative, descriptive, and predictive.

1960’s when POE emerged: flexible framework Can include surveys and interviews, behavioral, cognitive

and annotated mapping exercises; observational methods:• facility walk-through using checklists and rating

methods;• participant workshops; • filmed visual representations.

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2.1 Assessment tools and perceived 2.1 Assessment tools and perceived environmental quality, emotions, and aesthetic environmental quality, emotions, and aesthetic

preferencepreference

Osgood, Succi, & Tannenbaum (1957): The use of semantic differential as a measure of perceived environmental quality

Bechtel (1976): pointed out that when such an instrument is used, the perceiver measures connotative rather than denotative meaning.

Allport (1955): connotative meaning refers to the quality of associations with an object while denotative meaning refers to everything else that cannot be pointed out as associations to quality (e.g. color, texture, and hardness)

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2.1 Assessment tools and perceived 2.1 Assessment tools and perceived environmental quality, emotions, and aesthetic environmental quality, emotions, and aesthetic

preference (Cont.)preference (Cont.)

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Neuropsychological mechanism (Küller, 1991)Neuropsychological mechanism (Küller, 1991)

1. Arousal /Activation2. Attention /

Orientation3. Reward / Aversion4. Coping / Control

The basic emotional process implies that every impulse, causes a brief temporary arousal reaction.

Depending on the nature of the impulse it may also give raise to an orientation reaction accompanied by a certain degree of reward or aversion.

As a result of repeated impulses, the long-term arousal level maybe altered upward to an even higher level.

This change in the emotional state of the organism results in a growing preparedness to react to the upcoming situation.

Once control is established, the basic emotional process may be said to be concluded.

The process will be repeated over and over again.

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2.2 Assessment tools and health care 2.2 Assessment tools and health care users/clientsusers/clients

Stern et al. (2003): A qualitative research technique, known as a focus-group methodology, serves as the primary method of obtaining health care staff’s, patients’ and visitors’ (consumers’) responses

It is important to note that focus groups are not appropriate for problem solving, decision-making, or reaching consensus. Data generated from these discussions are neither representative nor generalizable.

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2.2 Assessment tools and health care 2.2 Assessment tools and health care users/clients (Cont.)users/clients (Cont.)

Instead:Multi-stage process, beginning with the use of qualitative

research, including focus groups, cognitive interviews, and analysis of staff critical-incident reports to elicit issues of importance to patients and consumers.

It also entails the development of survey instruments that incorporate identified dimensions of importance and testing surveys in the field to assess patients’ experiences of care within and across institutions, or geographic areas. The quantitative data on patients’ experiences that the surveys yield are used, in turn, to inform consumers and to foster quality improvement. (Cleary, 1999)

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Problems with environmental Problems with environmental assessment techniquesassessment techniques

• Semantic scaling became a standardized method in the 1970’s, but the socio-cultural context has changed.

• How semantic environmental assessment techniques can be used by designers in the planning phase has long been an issue.

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3. Research based design 3. Research based design processprocess

When a therapeutic environment is about to be designed, design practitioners are able to create such an environment, but only a few cases can fully reflect the understanding of and knowledge about the task.

By using the appropriate data at the right time in the process, unnecessary conflicts may be avoided. Therefore, results of environmental quality assessments should be part of the process before self anchored concepts are in place.

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4. Aim and research question4. Aim and research question

The main aim of the thesis is to develop a method or a tool, which collects both quantitative and qualitative data on the well-being supportiveness of environmental attributes useful for designers.

What are the psychosocially supportive components of the built environment?

Is the suggested multi-methodological approach an appropriate tool for evaluating those components?

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ObjectivesObjectives

The specific objectives are:

1. To investigate the relevance of psychosocial components in the suggested multi-methodological tool.

2. To analyze the data gathered by the suggested tool in terms of well-being supportiveness in a real environment setting.

3. To provide guidelines for designers about psychosocial supportive environmental components integrated in the design process.

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Objectives Objectives (cont.)(cont.)

4. To evaluate the proposed design by comparing it to the existing environment and

5. To compare design professionals and laypersons perspective with regards to perceived psychosocial supportiveness.

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5. Summary of Papers5. Summary of Papers

The aim of the first paper was to find a method or a tool, for collecting data on psychosocial supportiveness in the built environment for redesign purposes.

The paper consists of four studies, which includes:

1. Development of the assessment method called Triple-E (Empowering Environment Evaluation);

2. Case studies at two locations in the northern part of Sweden, Piteå Älvdals Hospital, Piteå and Örnäset health care facility, Luleå;

3. Redesign procedures regarding two public areas in each case study; and

4. Assessment of the redesigned environments.

5.1 Summary of Paper I.5.1 Summary of Paper I.

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Paper I : Study 1Paper I : Study 1

Study 1. Investigated the possible assessment techniques in relation to psychosocial approach. A three-stage approach was designed.

Triple-E tool: a brainstorming technique (Jungk & Müllert, 1987), a semantic differential questionnaire (Küller, 1972; 1991) and an architectural detail questionnaire.

The Triple-E tool went through a relevance analysis for psychosocial components.

• In the empowerment session, the relevance analysis revealed that the subjects mostly related their negative experiences to physical environmental components (77%) while aesthetical based complaints (23%) were less relevant.

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Paper I : Study 1 Paper I : Study 1 (cont.)(cont.)

• In the environment description session the adjectives might create denotative meanings in 17% of the cases while connotative meanings might be as high as 83%.

• In the architectural detail questionnaire the results demonstrate possible associations to psychosocial categories, but failed to show any connection with the Self concept component.

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Paper I : Study 2Paper I : Study 2

Study 2. Patients and staff members participated in the trial of the Triple-E tool.

In the empowerment session provided a large variety of general comments.

• The given ideas basically built on each others, which assumes more elaborative types of groups.

• The originality of ideas concerning the theme was rarely found.

• Observation of the participants revealed that a psychosocial related theme might cause production blocking and task-irrelevant behavior as well as unnecessary cognitive loading on the subjects, which generates ideas outside the field of interest.

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Paper I : Study 2 Paper I : Study 2 (Cont.)(Cont.)

In the environment description session, • The differential scales in this study were, for

design purposes, separated from the more general factor concepts in order to gather in depth information about each location.

• Usability analysis of this session revealed that less demanding numbers of scales, or factors, should be administered to facilitate the supportive design process.

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Paper I : Study 2 Paper I : Study 2 (Cont.)(Cont.)

In the evaluation of architectural details session,

• it was found that systematic evaluation of an environment might cause problem for subjects in terms of separating their personal preference in each environmental component.

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Paper I : Study 3Paper I : Study 3

Research

Acquisition and

assessment of

knowledge to produce

general rules

Design

Problem is broken

down into discrete elements

Application

Analytic activity

Information is assessed,

analyzed and applied

to the appropriate elements of the design

Synthesis

Design elements

are synthesized

into a coherent

whole

Evaluation

Results are evaluated and stored for future

use

The relationship between research and design as identified by the analysis-synthesis model (Milburn & Brown, 2003).

Design Problem

Emp.

Env.

Evaluation

Info

Info

Info

Schematic diagram of the analysis-synthesis model enhanced with the Triple-E tool (Based on Millburn and Brown, 2003).

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Picture taken in the corridor. The proposed design of the corridor.

Paper I : Study 3 Paper I : Study 3 (Cont.)(Cont.)

Piteå Älvdal HospitalPiteå Älvdal Hospital

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Paper I : Study 3 Paper I : Study 3 (Cont.)(Cont.)

Piteå Älvdal HospitalPiteå Älvdal Hospital

Panoramic picture taken in the dining room.

The proposed design of the dining room.

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Paper I : Study 3 Paper I : Study 3 (Cont.)(Cont.)

Panoramic picture taken in the reception.

The proposed design of the reception.

Örnäset Healthcare center Örnäset Healthcare center

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Paper I : Study 3 Paper I : Study 3 (Cont.)(Cont.)

Panoramic picture taken in

the waiting area.

The proposed

design of the waiting area.

Örnäset Healthcare center Örnäset Healthcare center

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Paper I : Study 4 Paper I : Study 4

Study 4. The proposed design at Piteå Älvdal Hospital was overall positively perceived.

• Staff members above the age of 50 years detected change in the corridor regarding the window sill height.

• In terms of gender differences, male subjects did perceive differences regarding furniture and chair location while female subjects did not.

• Only three out of nineteen modified variables (15%) were identified which might be explained by lack of experience in visual comparisons.

• The process of the post-test study raised questions regarding the perception of designers’ and staff members’ as well as patients’ perspectives on psychosocial supportiveness.

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Paper II.Paper II.

• The results show that between patients and architects, there are differences in terms of perceived factors contributing to psychosocial supportiveness.

• Furthermore, with years of experience in architectural design, differences were found in perception of environmental components such as windows, lights, chairs, and ceiling pattern.

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Paper II. Paper II. (Cont.)(Cont.)

• The ranking of the influential architectural details on perceived supportiveness for architect and the patient groups was in the following order: 1) window; 2) floor and wall; 3) ceiling and furniture; 4) handicraft, photograph, chair, and curtain; 5) noise level, safety, and space for moving.

• The significant architectural details may influence individual psychological skills, which in turn may affect individual social skills and self-management.

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6. Discussion and Conclusion6. Discussion and Conclusion

The studies showed that physical factors such as windows, floors, walls, ceilings, and furniture which location, material, pattern, color and area can affect psychological and social supportiveness.

As far as design is concerned, the Triple-E tool provided useful information for redesign purposes regarding psychosocial supportiveness and the visualized environment was perceived as overall more positive than the existing one.

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Further direction: Restorative Further direction: Restorative environmentsenvironments

Alternative to Stress Theory -

Attention Restoration Theory (ART)

The transformation of psychological measures to design considerations should be based on the ART.

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A transformation of psychological A transformation of psychological measures to design considerationsmeasures to design considerations

Restorative factors

(ART)

Psychological elements

Proposed design considerations

Being away

To escape from unwanted distraction

Geographical distancing

To distance oneself from one’s activity

Outdoor recreation facility

To suspend activity Place for relaxation

ExtentConnectedness

Clear master plan, central places for orientation

Scope Clear identification of the

surrounding

FascinationAesthetically

pleasing stimuliLively color, well lit rooms,

pleasing forms

Compatibility

Supporting behaviorRoom sizes, logical room

locations

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Need for identification of restorative Need for identification of restorative components in the built environmentcomponents in the built environment

Suggested steps:• Specifying what restorative built

environmental components can be: Interior/Exterior.

• Conceptualizing and visualizing of a optimal restorative built environment

• Evaluation of several built environments in terms of restauration potential

• Proposal for design guideline