HOW CAN HEALTHCARE DESIGN SUPPORT INDIVIDUAL WELLNESS?
A Roundtable Discussion with a Caregiver, a Patient
and a Designer
The dialogue with (from left) Kenny Chen (the author), Linda
Lee (an architect from SAA), Yong Jieyu (a multi-disciplinary
designer) and Tan Sok Leng (a full-time mother of a special
needs child) at Professor Brawn Café at Enabling Village.
Abstract: A mother of a special needs child, a patient who went through months of physical
rehabilitation and an architectural designer sit down to discuss how Singapore’s healthcare design
is evolving to enhance wellness and meet the needs of various users. While all acknowledged that there
has been a greater shift towards people-centred design in clinical settings and more focus on
factors that promote healing and recovery, much needs to be improved. For Tan Sok Leng, she has
found that greenery helps patients and parents feel calmer in waiting areas. For Linda Lee, an
architect who spent months in rehabilitation, she discovered that having privacy and access to a window
gave her a sense of hope for recovery. For Yong Jieyu, a multi-disciplinary
designer, designing healthcare spaces requires one to listen and understand user needs first before
engaging in design. This level of empathy means ultimately embracing sensitive questions about
death and bereavement in order to deliver the best design to promote healing.
Tan Sok Leng
Architect-turned-full-time mother
Architect-turned-full-time mother
Sok Leng has three children, with the eldest being a special needs child with severe and multiple disabilities. She is familiar with the hospital setting and often finds herself having to make difficult decisions in a clinical environment
Tan Sok Leng
Architect-turned-full-time mother
Architect-turned-full-time mother
Sok Leng has three children, with the eldest being a special needs child with severe and multiple disabilities. She is familiar with the hospital setting and often finds herself having to make difficult decisions in a clinical environment
Due to a sporting accident in 2021, Linda underwent a few months of surgical and post-surgical rehabilitative care and convalescence for back and leg surgery. She stayed variously in a high dependency ward, inpatient ward and rehabilitation ward. This has impacted her understanding of how the healthcare environment affects the recovery process.
Linda Lee Wen-Xin
Architect at SAA Architects Received some months of surgical and post-surgical rehabilitative care and convalescence
Architect at SAA Architects Received some months of surgical and post-surgical rehabilitative care and convalescence
Due to a sporting accident in 2021, Linda underwent a few months of surgical and post-surgical rehabilitative care and convalescence for back and leg surgery. She stayed variously in a high dependency ward, inpatient ward and rehabilitation ward. This has impacted her understanding of how the healthcare environment affects the recovery process.
Linda Lee Wen-Xin
Architect at SAA Architects
Received some months of surgical and post-surgical rehabilitative care and convalescence
Yong Jieyu
Co-founder of STUCK, a design and innovation consultancy
Co-founder of STUCK, a design and innovation consultancy
Yong Jieyu is a multi-disciplinary designer and co-founder of STUCK. His recent works investigate the use of design thinking in the design of future spaces. His projects include nursing homes, assisted living facilities, hospitals and healthcare programmes.
Yong Jieyu
Co-founder of STUCK, a design and innovation
consultancy
Yong Jieyu is a multi-disciplinary designer and co-founder of STUCK. His recent works investigate the use of design thinking in the design of future spaces. His projects include nursing homes, assisted living facilities, hospitals and healthcare programmes.
“How can HEALTHCARE designERS give paediatric patients more emotional support?”
- Caregivers need spaces that give them emotional support as they process critical conversations with doctors and nurses.
- Paediatric patients need to be protected from the tense and hectic environments of ERs and ICUs.
- Spatial designs that offer a sense of “uplift” provide a sense of hope.
- Offering choice, even in the final months, give patients and caregivers a sense of independence and dignity.
Tan Sok Leng
Architect-turned-full-time mother of a special needs child
When working as an architect years ago, Sok Leng used to think that architects are more concerned
with macro issues of space planning, layouts, façade design, materials and so forth.
But due to her experience of frequent visits to hospitals, therapy offices and clinics with her firstborn, a
child with severe disabilities, for many years, Sok Leng is more concerned with how to stay sane for
her child’s sake – and protect the young girl from the tense and anxious environment. She firmly
believes that there is so much more design needed on a micro and even emotional level.
Being overwhelmed in a hectic healthcare setting
Her firstborn is easily overwhelmed by the environment and the stress in turn poses internal physiological challenges for the child. This can be challenging for her. Hence wherever possible, Sok Leng tries to identify a quieter spot for a long wait at a clinic or a hospital.
Often, outpatient waiting spaces at clinics are quite stressful for the family. Sok Leng shares: “Although we do get to have a space in the Nurses’ Room if we request for it, it also feels like a leftover space as nurses will be walking in and out doing their work or making phone calls.”
As an inpatient, the lack of personal space within wards can be another challenging experience. Doctors may make their rounds with an entourage of consultants and medical staff which makes it hard for both the parent and child to rest. Also, nurses tend to discuss notes right next to the patient’s bedside. This is not helpful for the patient and the family during their ward stay.
Also lacking in privacy, Sok Leng adds, are the waiting areas outside the Intensive Care Units (ICUs). These are often defined by vending machines and toilets with no natural light or ventilation. A U-shaped seat formation meant that strangers can easily overhear one’s conversations. She shares: “It is rather surprising and contradicting to see many happenings taking place within an ICU waiting area, where patients and their families experience higher levels of anxiety”
It is rather surprising and contradicting to see many happenings taking place within an ICU waiting area, where patients and their families experience higher levels of anxiety.
These personal experiences and interaction with healthcare facilities has made Sok Leng more sensitive to users’ needs, emotions and empathy beyond spatial circulation planning, lighting, ventilation and functional aspects. She feels there is an urgent need for more thought on micro space planning in terms of interior finishing and furnishing as these are what users would come into contact with.
Some existing healthcare facilities are trying to adopt similar strategies through the refurbishment of their spaces. For Sok Leng, an example is how is how the outpatient clinics within KK Women’s and Children’s Hospital (KKH) have been refurbished. “Much thought has been given to the user process – from registration to diverse options of waiting areas and spaces and even ease of payment options available at the end of the clinic session.”
The refurbished wards at KKH seek to improve the user experience from its design of the registration and waiting spaces (Photos: Tan Sok Leng)
Another good example is the Early Intervention Centre (EIC) at Rainbow Centre Margaret Drive Campus.
Another good example is the Early Intervention Centre (EIC) at Rainbow Centre Margaret Drive Campus.
The refurbished wards at KKH seeks to improve the user experience from its design of the registration and waiting spaces (Photos: Tan Sok Leng)
Another good example is the Early Intervention Centre (EIC) at Rainbow Centre Margaret Drive Campus.
Sok Leng visited Rainbow Centre’s Early Intervention Centre (EIC) on the recommendation of an architecture friend. On her first visit to the new extension, she noticed “interesting light shafts” coming into the main lobby space, which functioned as an internal play area and an out-of-classroom rehabilitative therapy area. Within the interiors, they had intentionally done away with the traditional classroom model so that these children have more interaction. These zones of spaces were all facing a large green open space at the back, separated by full height glass doors that opened into a nice verandah area for water play for the children. The sun shading façade of the verandah also brought in a delightful play of light and shadow for the children.
(Above) The main lobby space, which also doubles up as an internal play area. (Photo: Rainbow Centre Margaret Drive Campus)
The external play area facing an open green space at Rainbow Centre’s Early Intervention Centre at Margaret Drive in Singapore.(Photos: Rainbow Centre Margaret Drive Campus)
The external play area is outside the classroom area. (Photos: Rainbow Centre Margaret Drive Campus)
(Left) The external play area facing an open green space at Rainbow Centre’s Early Intervention Centre at Margaret Drive in Singapore. The external play area is outside the classroom area (right). (Photos: Rainbow Centre Margaret Drive Campus)
“I was quite surprised then how just a set of full height glass door opening into a verandah and green space felt so much more uplifting for myself and I could also see the potential impact it had on the kids and their caregivers. The unusual design gave me a sense of ‘uplift’ – a rare feeling as a full-time caregiver of a special-needs child.”
Can healthcare learn from deathcare?
Sok Leng feels that designing for death is an inevitable part of healthcare design in its pursuit for better design in healthcare.
“Healthcare can take an investigative, objectifying feel to the whole experience. From identifying and diagnosing the problem to the process of seeking treatment or even just managing presented symptoms, things can become overwhelmingly stressful when conditions become critical,” she shares.
“On the other hand, deathcare seems more empathetic with prioritised emphasis on comfort and emotional wellbeing of the patient and family. Even the conversational tone of the doctors would often be softer and warmer.”
“And through my experience as a parent to my child with severe disabilities, I have learned that there are options and systems in place such as the Advance Care Plan that allow us to indicate specifics of how we would like the plan to be executed should things take a critical turn. It is such conversations that offer options that should be encouraged in healthcare design,” she stresses.
“The basics of human needs – be it physical, emotional, mental, spiritual and even practical – in both healthcare and deathcare have to be considered. Such conversations must take place before things reach a critical stage so that caregivers still have the mental clarity to make informed decisions,” she says. “Being able to advocate the care we wish for our loved ones, including the process leading to death, is one way to bridge the divide between life and death.”
Being able to advocate the care we wish for our loved ones, including the process leading to death is one way to bridge the divide between life and death.
Offering choices to individuals regardless of their stage of life serves as a form of respect. This is why Sok Leng is inspired by Oasis@Outram by HCA Hospice and Lien Foundation. It offers hospice day care with end-of-life caregiving.
(Above) The conservatory at
Oasis@Outram where patients enjoy horticulture
classes. (Photo: HCA Hospice and Lien
Foundation)
(Above) Wheelchair-bound clients can enjoy the swing at Oasis@Outram. (Photo:
HCA Hospice and Lien Foundation)
(Above) The paediatric room at
Oasis@Outram (Photo: HCA Hospice and Lien
Foundation)
Clients enjoying a round of mahjong at Oasis@Outram (Photo: HCA Hospice and
Lien Foundation)
“From having a bar to secret mahjong rooms and movie theatres, the whole experience is certainly uplifting.
There is even an area for pediatric patients like my daughter, and we were invited to visit the day care anytime. It was heartening for me to know that such services are provided free for the patients which definitely helps lighten the load for families who are preoccupied with long-term caregiving for their loved ones.”
LINDA LEE
Architect, SAA Architects
Architect, SAA Architects
“How can WE create spaces for people to recover from severe injuries and protect their SHATTERED self-ESTEEM?”
- Universal Design helps patients who are suddenly incapacitated to learn to use mobility aids to regain their sense of self.
- Patients need valuable space in hospitals to learn how to use wheelchairs and other tools to help them with daily activities in their own homes.
- Access to windows, natural light and greenery helps patients to recover.
- Designing spaces for a transition to deathcare can give dying patients a sense of dignity and closure.
Design is a cumulative exercise where requirements are predicated on needs, functionality, and user-friendliness and appropriateness. The real difficulty to achieving good design is often focused on how to address these potentially wide-ranging needs.
Having experienced life as an in-patient and outpatient wheelchair user, Linda believes that designing “in general” is not applicable in healthcare design as the needs are rather specific. One must experience it physically to appreciate the detailing and considerations, she says.
“My stay in the inpatient and rehabilitation ward has allowed me to experience first-hand the importance of Universal Design. I was both bed-and-wheelchair-bound for two months in the hospital after my accident and had to rely completely on the healthcare professionals and hospital facilities for all my basic daily activities. Activities of daily living (ADL) namely washing, toileting, dressing, feeding, mobility and transferring were suddenly difficult for me. The most basic activities became challenging or even impossible without assistance for me. Each of my recovery phase required varied levels of assistance, be it in terms of impaired physical capabilities or psychological wellbeing.”
Using Universal Design for every stage of recovery
Toilet Grab Bars
“Functionally, a simple circular grab bar of a comfortable size with good grip texture has enabled me to maintain my self-esteem which was very important when I lost my sense of independence.”
Wide Corridors
“I needed to be constantly active to prevent muscle atrophy. One of the first activities I had to master was the use of a wheelchair which was rather overwhelming for a first-timer. Wide corridors allowed me to practise moving around without affecting the operation of the staff and other patients.”
Doors
“The size, weight and swing of a door affected how I could open doors independently. Manoeuvring through door openings while on a wheelchair requires a specific sequence of steps and sufficient space in the right configuration. It made me appreciate all the prescribed codes and dimensional clearances we have been using in our design work for the physically impaired.”
Railings
“The railings along the corridor helped me to practise simple actions like standing up from the wheelchair.”
Using Universal Design for every stage of recovery
Toilet Grab Bars
“Functionally, a simple circular grab bar of a comfortable size with good grip texture has enabled me to maintain my self-esteem which was very important when one loses their independence.”
Wide Corridors
“I needed to be constantly active to prevent muscle atrophy. One of the first activities I had to master was the use of a wheelchair which was rather overwhelming for a first-timer. Wide corridors allowed me to practise moving around without affecting the operation of the staff and other patients.”
Doors
“The size, weight and swing of a door affected how I could open doors independently. Manoeuvring through door openings while on a wheelchair requires a specific sequence of steps and sufficient space in the right configuration. It made me appreciate all the prescribed codes and dimensional clearances we have been using in our design work for the physically impaired.”
Railings
“The railings along the corridor helped me to practise simple actions like standing up from the wheelchair.”
“I deeply appreciated very basic universal design features which were functionally designed and
appropriately incorporated,” she shares. “Designers sometimes tend to be minimalistic or fanciful but when installations become non-functional, it is not fit-for-purpose.”
Another key feature she was grateful for were fall prevention features within the hospital wards. These help to
minimise accidents for people who have suddenly become incapacitated in one way or another.
“Good design encourages and motivates a person in the journey to recovery both mentally and physically. The emotional boost with greater mobility and the desire to uphold our sense of self-independence and self-esteem cannot be underestimated,” says Linda.
The emotional boost with greater mobility and the desire to uphold our sense of self-independence and self-esteem cannot be underestimated.
Close interaction with patients to help them regain independence
Linda believes that the Singapore healthcare fraternity has been making greater efforts with a
salutogenic approach to wellness rather than merely approaching it from a pathogenic viewpoint.
For example, the medical staff conducted daily reviews on her injury and she was closely briefed on
her condition. Regular conversations on her mental and physical state also served as great
encouragement to her.
The physiotherapist or occupational therapist prescribed exercises and training sessions to strengthen
her muscles so that she could use various mobility aids. “They adapted to different stages of my
recovery and even simulated my home condition in the ward where I was coached me to adapt to the
conditions which could be expected when I return home,” she shares.
They discussed in detail how she would enter her bathroom at home and how she would transfer to the shower chair and the wheelchair. These simulations were very important and helped to
reduce the anxiety of returning home from a high care environment and improved her mental
preparedness. “They even simulated the ramp length and height and planned for how I would enter the
house,” she recalls. “There needs to be sufficient space in the rehabilitation ward to allow these simulations to be carried out to boost the confidence of the patient.”
There needs to be sufficient space in the rehabilitation ward to allow these simulations to be carried out to boost the confidence of the patient.
The importance of windows and light
Nonetheless, the road towards recovery is not without challenges. The most significant, as Linda shares, are the physical pain, discomfort and an almost complete loss of mobility and independence in the early stages.
“Being monitored with tubes and needles inserted to my arms, I felt helpless. I was only able to comprehend the environment immediate to me and what relationship that had to the avoidance of the constant pain and discomfort. Nothing else mattered; my world became quite small.”
“In the early stages, the most important things to me were the adjustable hospital bed and the overbed table. As I was not able to move about, I could only reach for things within my arm’s reach. Even with this reduced universe, managing my immediate environment was a still a challenge.”
“Privacy in the open ward was also non-existent. There were screaming patients in high-anxiety mode or in a somewhat confused state, wailing, wanting to go home or continuously asking for a drink. I was in a constant state of anxiety myself in a six-bedder ward.”
“When I was subsequently moved to a single ward where the level of care was higher and with the much-needed privacy, I was able to get better rest. My psychological state started to improve almost immediately.”
“Being in a bed adjacent to the window was a significant improvement. Lying down and not being able to move much instils a degree of fear and loneliness,” she shares. “Being close to a window allowed me to look at the sky outside and gave me a sense of connection to the outside world. I could think of resuming a normal life.”
Linda felt connected to the outside world through the ward windows
Linda feels that access to a window offers her much-needed privacy and
personal space in a single ward
Throughout the sense of constant pain and transfers, paradoxically, Linda found the consistency
of the white ceiling grid pattern comforting as it was predictable and familiar.
Linda was also grateful for a small potted plant which was a get-well gift from a friend. The simple act of
watering the plant gave her a sense of meaning and purpose amidst all the pain she endured. “It
comforted me,” she recalls.
Potted plants given to Linda during her hospital stay
Potted plants given to Linda during her hospital stay
“At the rehabilitation ward, the corridor is lined with framed photos of people flying kites and blue sky with trees and flowers. Having such pictures to look at provides a visual connection to happier times and hope for a return to such a life. Every morning, the nursing assistants draw the curtains to allow sunlight to fill the room. I lose track of time while lying in bed all the time. The sunlight calms me and the transition between day and night also allows my body to acknowledge the time of the day. When my world shrinks, I need to maintain the connection to the world outside and experience its normality in order to recover well.”
Transition to deathcare: addressing the specific needs of users
Linda’s first-hand experience through this incident has made her far more sensitive to user needs as a designer. The term “user” goes beyond just the patient’s needs but also covers the many caregivers and even visitors who themselves are in a state of transition while their loved ones are hospitalised.
The term “user” goes beyond just patient’s needs but also the many caregivers and even visitors who themselves are in a state of transition while their loved ones are hospitalised.
In the face of death, no amount of fancy design can ease the fear. Linda shared how an old lady passed
away alone in a Class C bed next to hers.
“She had been suffering from pneumonia before she passed away. Two days before her passing, her daughter
sat next to her and started to chat with me about her mom’s condition and she was waiting for her time
to pass. Unfortunately, due to Covid-19 restrictions, the old lady took her last breath alone in the middle
of the night. The doctors tried to resuscitate her but her heart had already stopped.”
Linda still finds herself asking: “Could there be a space to bridge the waiting for death and what would this space be like? If we cannot plan for an unexpected and sudden death as designers, can we plan for
the transition phase for end-of-life patients whose demise is expected, so to speak? Like how we enter
this world as babies who are celebrated and loved, can the transition be observed as a part of life’s journey
and not as dreaded event?”
She believes that as healthcare facilities are designed to be more welcoming along with a focus on
wellbeing and healing, the day may come when design also caters for transition to deathcare.”
Her experience as a patient had led to her realisation that between deathcare and healthcare, it is futile to
prioritise one over the other. “Death is never an easy topic to broach but we can find ways to give the
journey the dignity it deserves,” she says.
“We need a mindset shift to Design for ageing and dignity in death”
- The process requires designers to listen first before creating
- Challenges such as nimbyism and a bureaucratic mindset to building facilities need to be overcomed
As a multi-disciplinary designer, Jieyu has worked on projects investigating the use of design thinking for the design of future spaces with notable projects in healthcare, namely nursing homes, assisted living, hospitals and healthcare programmes.
He is particularly passionate about designing for
ageing in place and for raising the quality of life
among seniors. Jieyu says, “I believe that when
design thinking is paired with a genuine desire to
listen and debate about the kind of life one hopes to live
and how the living environments should be designed
and built, we embark on a process for human-centric
thinking which brings together business, aesthetic,
and regulatory considerations in architecture.”
Yong Jieyu
Co-founder of STUCK, a design and innovation consultancy
Yong Jieyu is a multi-disciplinary designer and co-founder of STUCK. His recent works investigate the use of design thinking in the design of future spaces with notable projects in healthcare: nursing homes, assisted living, hospitals and healthcare programmes.
Co-founder of STUCK, a design and innovation consultancy
Yong Jieyu is a multi-disciplinary designer and co-founder of STUCK. His recent works investigate the use of design thinking in the design of future spaces with notable projects in healthcare: nursing homes, assisted living, hospitals and healthcare programmes.
Designing for good means listening first
For him, “good” design means that the solution really benefits the end user who is using it.
This means that the role and perspective of a designer must shifts from “pure artistic and technical creation” towards a “listener first, creator next” process. “Care needs are so diverse,” he says, “It is impossible for the design team to have fully experienced or understood the needs of the healthcare system users. Only with listening and understanding, would the designer be able to move into the creative process to translate all the needs and aspirations of the people he is serving into a relevant and beneficial design.”
It is impossible for the design team to have fully experienced or understood the needs of the healthcare system users.
Balancing a person-centred model with operational efficiency
He believes healthcare in Singapore is moving towards a more person-centred model of care as
shown by two recent projects which he worked on: a nursing home and hospital reimagining project.
Jieyu shares: “Both briefs focused heavily on uncovering person-centred needs and then designing for
them. You can tell that the operators and agencies are beginning to shift away from
over-institutionalised designs into providing more options and choices to cater for different needs of the
people. It is not easy especially with operational efficiency in consideration as any cost increment
from implementation will inevitably create a more expensive healthcare model. The delicate balance is
hard to achieve.”
There are often two main challenges.
The first is to ensure that the design propositions fit into a reasonable operational cost structure as this is
a perennial problem where manpower demand, cost of materials and services will always be rising. The
other challenge lies with the procurement, design process and change management of large projects,
he cautions.
(Above) A conversation tool used at Oasis@Outram. The model of care at Oasis@Outram focuses on the personal growth of patients on the last leg of
their life journey and aims to help reframe the thinking on dying. Oasis@Outram’s caregiving framework is anchored by the three ‘D’s – Dignity, Diversity,
and Development. It facilitates the development and growth of patients, encouraging them to reflect and find meaning despite facing the end of life.
(Photo: HCA Hospice and Lien Foundation.)
Innovative ideas would typically require changes in mindsets among stakeholders in the built environment and tweaks to healthcare operations.
What this means is that the researcher
uncovering human insights needs to work
closely with the designer or architect and
eventually with medical planners, as well as
the operators. It is vital to have a change
champion in each organisation especially
among the medical planners and operators.
So being able to get everyone onboard and ensuring that human insights get translated into spaces
the way they are imagined requires a project process that includes everybody right from the
start. The project should also stretch into prototyping and testing phases to make sure that whatever
was proposed on the drawing board is iterated with real-life testing and experiences. Having the time
and resources for testing, however, can be a luxury, he observes.
Mindset shifts for managing deathcare
One challenge Jieyu has experienced in his nursing home project is that nursing homes were not
popular in a neighbourhood as residents typically believe it is undesirable to have nursing home close
to residential areas. “We as a society need to understand it is normal to age, and that perhaps, talking about ageing and dying is beneficial to the individual and the family.”
“I think healthcare operators cannot run away from the scenario of managing death within its facilities.
That would mean managing the grief of losing a loved one; allowing the space and the right
sensitivities towards such a situation, and consider what services and how to deliver the human touch
for handling such emotionally significant moments. It might mean doing more, starting by rethinking the
bureaucratic approach of simply providing space and services.
“Ultimately”, he concludes, “the first thing to change is how we view death, as our perspectives about
death shape how we design and deal with death not just in healthcare, but in the whole of society.”
“We as a society need to understand it is normal to age, and that perhaps, talking about ageing and dying is beneficial to the individual and the family.”
The SEEDS Journal, started by the architectural teams across the Surbana Jurong Group in Feb 2021, is a platform
for sharing their perspectives on all things architectural. SEEDS epitomises the desire of the Surbana Jurong Group
to Enrich, Engage, Discover and Share ideas among the Group’s architects in 40 countries, covering North Asia, ASEAN,
Middle East, Australia and New Zealand, the Pacific region, the United States and Canada.
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