Transcript
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Case Study

Designing With Empathy:Humanizing Narrativesfor Inspired HealthcareExperiences

Candy Carmel-Gilfilen, MArch1, and Margaret Portillo, PhD1

AbstractObjective: Designers can and should play a critical role in shaping a holistic healthcare experience bycreating empathetic design solutions that foster a culture of care for patients, families, and staff. Usingnarrative inquiry as a design tool, this case study shares strategies for promoting empathy. Back-ground: Designing for patient-centered care infuses empathy into the creative process. Narrativeinquiry offers a methodology to think about and create empathetic design that enhances awareness,responsiveness, and accountability. Methods: This article shares discoveries from a studio onempathetic design within an outpatient cancer care center. The studio engaged students in narrativetechniques throughout the design process by incorporating aural, visual, and written storytelling.Benchmarking, observations, and interviews were merged with data drawn from scholarly evidence-based design literature reviews. Results: Using an empathy-focused design process not only moti-vated students to be more engaged in the project but facilitated the generation of fresh and originalideas. Design solutions were innovative and impactful in supporting the whole person. Similarities aswell as differences defined empathetic cancer care across projects and embodied concepts of designempowerment, design for the whole person, and design for healing. Conclusions: By becoming moreconscious of empathy, those who create healthcare environments can better connect holistically tothe user to take an experiential approach to design. Explicitly developing a mind-set that raisesempathy to the forefront of the design process offers a breakthrough in design thinking that bridges thegap between what might be defined as ‘‘good design’’ and patient-centered care.

Keywordsacademic research, case study, ambulatory care center, cancer center, evidence-based design, interiordesign, patient-centered care, qualitative research, design methodology

Purpose

Empathetic design, by definition, is life affirming.

By centering on patients, engaged family mem-

bers, and caregivers, empathetic design contributes

to a holistic culture of care. We argue that narrative

inquiry—giving insight into the thoughts, feelings,

and experiences of others—can and should inform

1 University of Florida, Gainesville, FL, USA

Corresponding Author:

Candy Carmel-Gilfilen, MArch, University of Florida, 334

Architecture Building, Gainesville, FL 32611, USA.

Email: [email protected]

Health Environments Research& Design Journal

2016, Vol. 9(2) 130-146ª The Author(s) 2015

Reprints and permission:sagepub.com/journalsPermissions.nav

DOI: 10.1177/1937586715592633herd.sagepub.com

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the design process and brings design solutions into

close alignment with the physical, emotional,

spiritual, and interpersonal needs of patients and

caregivers. Design, guided by personal narratives,

offers a myriad of opportunities to inspire the

healthcare experience.

We argue that narrative inquiry—giving

insight into the thoughts, feelings, and

experiences of others—can and should

inform the design process and brings

design solutions into close alignment with

the physical, emotional, spiritual, and

interpersonal needs of patients and

caregivers.

This article shares a new way of designing

empathetically for the whole person using narra-

tive inquiry. This approach offers a unique vehi-

cle to heighten compassion for people that can

be grounded in evidence-based design (EBD)

principles, thus linking the subjective personal

experience with objective ways of knowing. This

case study focuses on designing an outpatient

cancer care center using a narrative methodology

within a senior-level design studio. Within this

context, narrative inquiry became a vehicle for

students to explore multiple dimensions of empa-

thetic design from patient, family, and staff per-

spectives. This process involved exploring end

user experiences through three modes of story-

telling (i.e., verbal, written, and visual) to inspire

design thinking. Original narratives, told in first

person, situated the members of the design jury

within the ambulatory cancer care experience.

The award-winning results of this experience,

we argue, invite a new design process, one that

integrates narrative inquiry with EBD.

Background and Context

Cleveland Clinic’s1 YouTube 4.32-min video

Empathy: Exploring Human Connection has gen-

erated wide attention beyond the healthcare indus-

try since its release on February 27, 2013, and has

been viewed over 2 million times. A montage fea-

turing over two dozen fleeting profiles captures a

range of hospital experiences through deeply per-

sonal and impactful vignettes. An accident victim

in a body cast wills himself to be at his daughter’s

wedding scheduled a few days later. A man spends

3 hr in a waiting room. A new mother in a neonatal

intensive care unit wonders when she will be able

to take her daughter home. A doctor reflects on

being cancer free for 7 years. The viewing audi-

ence of Empathy sees the thoughts and feelings

of patients, family members, and caregivers.

Patients become more than ‘‘end users.’’ They are

mothers, fathers, sons, husbands, or wives. They

are single, married, or divorced. Their stories

involve receiving life-altering diagnosis, tolerating

the prosaic frustrations of testing and receiving

treatment, and experiencing a moment of happi-

ness or feelings of relief.

As the inner worlds of the patients, family

members, and caregivers build to a crescendo,

empathy ends with a single question, ‘‘If you

could stand in someone else’s shoes . . . Hear

what they hear. See what they see. Feel what they

feel. Would you treat them differently?’’

Clearly the answer is yes and ‘‘empathy takes

on a new dimension in a hospital, where there is

the push and pull of health and sickness, and

where giving and receiving care happens every

day’’ (Cleveland Clinic, 2014). Designers and

design educators play a critical role in creating

empathetic healthcare environments. Empathy:

Exploring Human Connection inspired us and

reinforced the power of narratives to capture

human experience in ways that could be particu-

larly useful for designing interior spaces (Dohr &

Portillo, 2011; Portillo, 2000).

The project profiled in this article began with a

design charrette2 where students viewed Empa-

thy: Exploring Human Connection and then were

asked to consider the following questions: ‘‘If you

could know what patients and staff were seeing,

thinking, and feeling, would you design their

spaces differently?’’ Students had a 48-hr period

to explore responses to these questions by reflect-

ing on ways healthcare influences specific patient

or caregiver needs. Students were asked to pres-

ent their ideas through the words and images of

a story. Ideas from the charrette, shared with

healthcare and design specialists, showed imagi-

nation. Far from seeming forced, the students’

first attempt at design storytelling seemed ener-

gizing. The narrative structure not only allowed

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students to enter into the world of patients, family

members, and caregivers but also helped them

conceptualize the experience of moving through

space, paralleling the narrative unfolding of a

story’s beginning, middle, and end point. This

temporal focus encouraged the active consider-

ation of movement through space in ways that

seemed to support patient-centered design.

The narrative structure not only

allowed students to enter into the world

of patients, family members, and

caregivers but also helped them

conceptualize the experience of moving

through space, paralleling the narrative

unfolding of a story’s beginning, middle,

and end point. This temporal focus

encouraged the active consideration of

movement through space in ways that

seemed to support patient-centered

design.

The creation of reality-based narratives

necessitated secondary research and information

gathering throughout the course of the project. To

collect story content, students talked with former

cancer survivors, family members, and caregivers

and engaged with cancer patients and other mem-

bers of the community in a local arts-in-medicine

program. Visiting cancer care centers and other

related healthcare facilities led to a better aware-

ness of precedents and generated fresh insights.

Another indispensable source of material (and

potential for story content) came from students

gaining a working knowledge of related scholarly

literature. Experiential learning coupled with

empirical knowledge informed the ensuing narra-

tives and the design process.

Over the course of 3 months, students read and

discussed stories from Rachel Naomi Remen’s

Kitchen Table Wisdom (2006) and crafted their

own narratives. These stories captured the varied

perspectives of those seeking treatment and offer-

ing care in their designed spaces. Individual

responses and perceptions were also anchored in

empirical findings. EBD became more compel-

ling to students when coupled with the more sub-

jective narratives of patient and caregiver

experiences. Not only did narrative inquiry offer

a tool for inspiring creative ideas during the

design process, but during the midpoint and final

project reviews each team shared their designs

using first-person voice-overs narrating the

experiences with the space as corresponding

images of the design appeared to the design jury.

Narratives offered a new way to communicate

design ideas. Design storytelling engaged the out-

side specialists who responded to the student

work. The end goal of the narrative was not to

write publishable but rather authentic stories rein-

forced by EBD literature. Again the ‘‘first-per-

son’’ narrative humanized the design and

seemed to motivate the student teams and

heighten empathy in ways that led to sensitively

designed, patient-centered spaces.

Empathetic Design

Empathy is well established as a critical charac-

teristic for healthcare providers (Holloway &

Freshwater, 2007) but is a habit of mind that also

should be established as a critical trait for the

designer. Tim Brown, affiliated with IDEO,3

defines design thinking as involving empathy,

integrative thinking, optimism, experimentalism,

and collaboration. According to Brown (2008),

‘‘By taking a ‘people first’ approach, design thin-

kers can imagine solutions that are inherently

desirable and meet explicit or latent needs. Great

design thinkers observe the world in minute

detail. They notice things that others do not and

use their insights to inspire innovation’’ (p. 3).

This detailed attention to the human experience

supports good design across market sectors but

is particularly essential in the context of health-

care design. Skills in listening and observation

encourage empathy and human-centered design,

‘‘By empathic design, designers attempt to get

closer to the lives and experience of (putative,

potential or future) users, in order to increase the

likelihood that the product or service designed

meets the user’s needs’’ (Kouprie & Sleewijk,

2009, pp. 437–438). However, it may be impor-

tant to reconsider the use of the term end user that

implicitly implies a generic quality stemming

from the language of technology and a postposi-

tivistic worldview (Beecher, 2015). Nevertheless,

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the idea of end users does acknowledge a human-

design connection (Rubin, 1984; Sanders, 2002).

User-centered design optimizes products, for

example, around human wants and needs, rather

than forcing people to accommodate or ‘‘work-

around’’ the product’s design. Shifting one’s per-

spective to consider other viewpoints often

involves an iterative cycle of creating, testing, and

evolving design concepts. Leonard and Rayport

(1997) discussed the five steps to empathetic design

as observation, capture data, reflection and analy-

sis, brainstorming for solutions, and developing

prototypes. This process positions designers to cre-

ate intuitive, sustainable, and creative outcomes.

Empathetic design has been studied primarily in the

areas of product design (Koskinen & Battarbee,

2003), web design (Garrett, 2010), and human

factors and engineering (Kouprie & Sleewijk,

2009); however, we see great untapped potential

in the design of healthcare environments.

Empathy in Healthcare

Empathy in the larger healthcare context influ-

ences the quality of care, showing improved

patient satisfaction (Kim, Kaplowitz, & Johnston,

2004), clinical outcomes (Nightingale, Yarnold,

& Greenberg, 1991) as well as reduced malpractice

suits (Virshup, Oppenberg, & Coleman, 1999) and

medical errors (Haslam, 2007). According to the

Institute for Patient- and Family-Centered Care

(n.d.):

There is an increasing body of evidence that the

experience of care is important, that it matters how

healthcare practitioners communicate with patient

and families, and that the active participation of

patients and family members in clinical care and

policy and program development will enhance

outcomes.

Health professionals including physicians, nurses,

technicians, therapists, social workers, and others

have the opportunity to be empathetic during each

clinical encounter. Caregivers can express empathy

by listening attentively or talking honestly with com-

passion to their patients. Empathy not only makes

staff more effective but enables patients to gain con-

fidence and often become more proactive concerning

their own health trajectory. In fact, the Association of

American Medical Colleges cites physicians’ under-

standing of a patient’s perspective and ability to

express caring, concern, and empathy as educational

objectives (Hojat et al., 2002). Informed dialogue

among leaders in design practice, education, and

industry on the qualities needed by the next gen-

eration of interior designers acknowledges the

importance of empathy (Council for Interior

Design Accreditation, 2010). Further human-

centered design is positioned prominently for

inclusion in the 2017 Council of Interior Design

Accreditation standards.

Today reality is that design reinforces connec-

tivity and collaboration. Interestingly, empathy is

antithetical to separateness and isolation (Bolog-

nini, 1997). This is illustrated in the healthcare

context, ‘‘Emotionally engaged physicians com-

municate more effectively, decreasing patient

anxiety and improving patients’ coping, leading

to better outcomes’’ (Halpern, 2007, p. 696) and

ultimately engagement supports the continuum

of care (Press Ganey, 2007). Scholarly literature

including personality theory, social psychology,

psychotherapy, psychoanalysis, and practitioner–

patient communication all acknowledge the im-

portance of empathetic processes (Squier, 1990).

Research also maintains that physicians are more

effective healers and experience increased levels of

personal satisfaction when they are empathetic to

their patients (Larson, 2005). Hojat, Louis, Maio,

and Gonnella (2013) underscore empathy as a core

competency for physicians and Larson (2005)

describes how empathy creates a cycle of healing.

Empathy makes patients more forthcoming about

their symptoms and concerns, thus, facilitating

medical information gathering, which, in turn,

yields more accurate diagnosis and better care,

helps patients regain autonomy and participate in

their therapy by increasing self-efficacy, and leads

to therapeutic interactions that directly affect

patient recovery. (Larson, 2005, p. 1110)

Based on three decades of applied research,

Planetree4 has identified four types of care that opti-

mize the healthcare experience: care that is rooted

in kindness, compassion, and dignity; care that

recognizes the role of the patient’s family; care

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that understands the influence of the physical

environment in healing; and care that responds

to the patient’s psychological, emotional, spiri-

tual, and social needs (Frampton, Charmel, &

Guastello, 2013). This philosophy becomes a

reality in many ways. Patient-centered care ele-

vates personal interaction; supports patient edu-

cation, choice, and responsibility; engages

family involvement; includes a holistic approach

to healing and the impact of food, nutrition, and

the dining environment; and considers the overall

community (Planetree, 2014). The Planetree des-

ignation, found in healthcare organizations

worldwide, explicitly recognizes best practices

in patient-centered care. Empathy is at the core

of Planetree and arguably should be at the heart

of design education and practice.

Narrative Inquiry

Design Thinking for Interiors (Dohr & Portillo,

2011) presents real-life narratives that not only

reveal diverse reactions to designed environments

but show the power of interior spaces in the lives

of individuals:

Studying memorable design carefully leads to a

fuller appreciation of interior environments. People,

as individuals, as groups, as societies, or across cul-

tures, exhibit behaviors and values that connect to

spaces and objects within them. When we study

these connections with care, a fuller appreciation

of designing interiors emerges and society benefits.

(Dohr & Portillo, 2011, p. 22)

The rationale for using narrative inquiry as a

method for revealing insights into human–envi-

ronment transactions is further supported by evi-

dence on student learning outcomes relating to

engagement of narratives in the design process

in ways that heighten self-reflection, acknowl-

edge diverse perspectives, and encourage design

for the whole person (Danko, Meneely, & Por-

tillo, 2006).

Further narrative inquiry integrates subjective

with objective, recognizing individual percep-

tions, feelings, and facts defining a context.

‘‘Stories are never just representations of experi-

ence, they are also interpretations’’ (Holloway &

Freshwater, 2007, p. 82). And as such the type of

stories, crafted in our healthcare studio, infused

factual information with human emotions.

Tension points occur internally and between

characters. Further in the healthcare context, con-

flict and complex trade-offs can be acknowledged

and considered throughout the research and writ-

ing of narratives. According to Jerome Brunner

(2003), narrative inquiry is an instrument not so

much for solving problems but for finding prob-

lems. Stories celebrate detail and nuance. Stu-

dents and practitioners can turn to well-crafted

narratives—shared orally, visually, and through

writing—to communicate the power of interior

design (Dohr & Portillo, 2011; Ganoe, 1999;

Portillo, 2000) and encourage the development

of whole-person environments supported by the

unifying language of stories (Danko et al., 2006).

An example of empathy in healthcare design is

found in the book The Power of Pro Bono that

features high-impact projects serving the public

good (Cary, 2010). The ‘‘Adopt A Room’’ proj-

ect, connected Perkins þ Will, The University

of Minnesota Children’s Hospital, and a client

who personally experienced the impact of cancer.

The client, Brian Schepperle, shared his rationale

for spearheading this project, ‘‘My family spent

ten years in and out of hospitals caring for my

daughter who suffered from acute lymphoblastic

leukemia. During our treatment in Southern Cali-

fornia, the Midwest, and on the East Coast, we

found the same thing: rooms that were small and

not set up for long-term stays . . . Fighting a dis-

ease is about more than the quality of care; it’s

also about environment.’’ He founded the founda-

tion on the belief that ‘‘While we can’t control the

illness, we can control the environment’’ (p. 176).

Ironically, David Millington, a member of the

Perkins þWill team, also had lost a child to can-

cer. Together the designer and client focused on

designing a hospital room to support pediatric

patients, reinforcing the primacy of empathetic

design. This prototype has inspired countless

designers and clients.

Narrative inquiry allows entree into thoughts,

feelings, inner motivations, conflicts, and chal-

lenges. Stories revealed the challenges faced by

patients, their families, and caregivers. Processes

for incorporating design thinking into studio

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learning can offer models that can be replicated

and expanded in other healthcare design applica-

tions. Stories, such as Adopt A Room, we believe

become even more compelling when grounded in

empirically based principles and practices.

Narrative inquiry allows entree into

thoughts, feelings, inner motivations,

conflicts, and challenges.

Processes for incorporating design

thinking into studio learning can offer

models that can be replicated and

expanded in other healthcare design

applications.

Method: Narrative in Design

To explore empathy in the healthcare context, this

case study involved designing prototypes for an

outpatient cancer care facility using a process of

narrative inquiry. Further, EBD principles and

empathy for patients, family members, and staff

informed the design solutions. A unique aspect

of the project was the support provided by Her-

man Miller, Inc., an industry leader in healthcare

design. This support gave the studio access to

design and healthcare specialists to engage with

the students. This sponsorship facilitated behind

the scenes tours in their manufacturing facility,

and also provided the studio with an opportunity

to learn from their product prototyping process,

Table 1. Project Engagement and Development.

Engaged Experts

Member Title/CompanyDoug Bauzin, EDAC Healthcare Research Lead, Herman MillerKristen Bennett, LEED AP, EDAC Designer-Environments, Herman MillerAnthony Rotman Manager, Design Exploration, Herman MillerJanet Zeigler, RN, MN, MBA, EDAC Director of Healthcare Consulting, Herman Miller

Review Process

Review Design JuryCharrette Review (3) Project TeamMid-Point Review (5) Project Team

Sales and Marketing ManagerFinal Review (12) Project Team

Sales and Marketing ManagerHealthcare Sales LeadApplication StrategistChief Design OfficerHealthcare Designer, NCIDQDirector, Arts in MedicineHealthcare Facility PlannerDesign Researcher

Site Visits

Facility LocationUniversity of Florida Health: Cancer Hospital Gainesville, FLCancer Specialists of North Florida: Baptist Downtownand St. Vincent’s

Jacksonville, FL

Gresham, Smith and Partners Jacksonville, FLUniversity of Chicago: Center for Care and Discovery Chicago, ILHerman Miller Headquarters Holland, MIHerman Miller Showroom: Merchandise Mart Chicago, IL

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offering compelling insights on the role of

research in design (refer to Table 1).

The project involved designing a two-story

prototype facility of approximately 46,000 square

feet and focused on designing public areas includ-

ing the lobby, public restrooms, a resource center,

and pharmacy; clinical areas for radiation and

infusion along with their support spaces; and staff

areas including offices, conferencing spaces, and

break areas. In addition, the program specifically

required empathetic design be considered but did

not explicitly prescribe how that would be accom-

plished. Empathy was interpreted differently by

each team and offered amenities such as a cafe,

healing gardens, spaces for alternative medicine,

and those that supported spirituality as well as

wellness and advocacy.

The project was completed as part of an interior

design studio course at University of Florida.5

Eighteen students participated in the 12-week

project during the fall semester of 2013. The

majority of participants in the studio were seniors

in the interior design program, but two students

were in the Master of Interior Design program and

two others were exchange students also in the final

year of their respective degree program.6 This

group had a similar level of design experience and

had either completed an internship and/or design-

related study abroad experience before enrolling

in the studio. We created small teams of four or

five students to facilitate collaboration and com-

pletion of the project. The studio focus on ambula-

tory cancer care reflected the wide segment of the

population that is impacted by cancer; over 90% of

cancer treatments has moved to outpatient set-

tings. Increasingly cancer care facilities have

become more patient centered and open to less tra-

ditional spaces.

The studio project involved iterative phases dedi-

cated to research, narrative inquiry, and collabora-

tion. First, student teams focused their efforts on

the extant literature and gathered over 75 peer-

reviewed articles from scholarly journals, including

Health Environments Research and Design Jour-

nal, Journal of Interior Design, Environment and

Behavior, and Journal of Nursing Administration.

The literature addressed issues relating to empathy,

cancer care, the patient experience, caregiver needs,

and design factors. Next, students engaged in

benchmarking, observations, and interviews gather-

ing firsthand experiences from cancer patients and

survivors. Teams also had at least one interview

with a nurse, resident, or physician who specialized

in cancer care and were willing to share their profes-

sional experiences with patients in general.

In addition, the students benchmarked health-

care facilities locally and had the opportunity to

spend time in a nationally recognized facility. They

also toured Herman Miller’s headquarters, manu-

facturing site, and regional healthcare showroom

where they experienced, tested, and evaluated a

nursing station prototype and healthcare furniture

designed for a range of patients. Together, these

experiences informed the narrative created by the

student and their solutions. Further, feedback from

specialists in design research, practice, and medi-

cine promoted the intellectual and emotional

growth, necessary for the cultivation of empathy.

Coupled with EBD research and application,

narrative techniques were incorporated into the

design process. Students were required to read

first-person patient stories and experiment with

crafting narrative dialogue to capture emotions

and life circumstances. This not only facilitated

whole-person design but also enhanced the teams’

ability to communicate their design intent. Narra-

tive inquiry forced the students to design beyond

visual or purely aesthetic dimensions of space to

consider the smells, sounds, and movements

defining the healthcare experience. As mentioned

earlier, a project charrette immediately immersed

the student teams into crafting stories about the

cancer experience from the vantage points of

patients, family members, and caregivers within

a healthcare environment. Later in the project,

we offered an intensive narrative workshop with

preparation and follow-up assignments allowing

time to read, reflect on, analyze, and experiment

with narrative techniques to develop the art and

craft of storytelling. These experiences helped

hone skills to develop story lines, visually, orally,

and in writing. Students also turned to storytelling

when sharing their design solutions (at midpoint

and final reviews). This was accomplished

through taped voice-overs representing first per-

son accounts of patients, family members, and

staff describing their feelings and sensorial experi-

ences within the proposed cancer care center.

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The storytelling continued through the devel-

opment of ibooks7 documenting process and by

offering a vehicle to engage with the jury. The

storytelling continued through the development

of ibooks documenting the process and offering

a vehicle to engage with the jury: a flexible tool

for focusing in on aspects of the process or prod-

uct. Bringing to life cancer experiences, narrative

inquiry surfaced patient, family, and caregiver

stresses, demands, and sources of fatigue and led

to ideas to offer support for these issues through

the interior spaces. Reflecting on the process, one

student described her experience with narratives:

Bringing to life cancer experiences,

narrative inquiry surfaced patient,

family, and caregiver stresses, demands,

and sources of fatigue and led to ideas to

offer support for these issues through the

interior spaces.

Without delving into the concept of empathy and

really getting into the mind-set of users through var-

ious methods including narrative we would not have

come out with the same outcomes. Every group

thought from the user’s point of view and by inte-

grating empathy we created innovative spaces.

Results

An empathy-focused design process not only moti-

vated students to become enthused about the pos-

sibilities and potential in the healthcare design

arena but inspired fresh and original ideas for out-

patient cancer care. Design solutions were recog-

nized by the studio’s juries as innovative and

impactful and most importantly as supporting the

whole person. Recognizing that people with lives

full of challenges and demands used the spaces,

illustrated a commitment to EBD, and incorpo-

rated narrative inquiry and storytelling as part of

the design process communication strategy. The

studio outcomes support an empathetic model that

is increasingly appreciated by a widening circle of

healthcare leaders. The award-winning results8 of

this project inspired imaginative solutions. So

what was unique about this approach?

First of all, the design process was distinctive

in that it involved both EBD and narrative

inquiry. When students began to put themselves

in the position of the patients, staff, and family

members, truly understanding what they thought,

felt, and saw, they were able to connect on a deep

level. Designs framed in the context of empirical

research provided the opportunity to buttress nar-

ratives of compelling individual experience with

EBD principles. Situating narratives in research

fully supported patient-centered care.

. . . the design process was distinctive in

that it involved both EBD and narrative

inquiry.

A close examination of design solutions also

revealed explicit people-and-place-based empathy

dimensions in the design prototypes. The qualities

of these spaces relied upon knowing and feeling the

physical, psychological, spiritual, and social needs

of people. Specific zones supported engagement

with others by containing opportunities for commu-

nity outreach, allowing stress release and creative

self-expression through arts-based immersion, and

creating an environment embodying a holistic

approach to care. Opportunities for rethinking the

patient and staff experiences surfaced via education

and engagement spaces, waiting areas, art therapy

spaces, and advocacy rooms. Healing zones gave

patients opportunities for choice and control during

infusion treatments. Other areas offered respite, and

some projects also incorporated opportunities for

alternative medicine. Specialized features included

healing gardens, spiritual and meditation spaces,

and diverse treatment areas.

Similarities as well as unique approaches to

empathy will be compared in three team solu-

tions: empathy is defined as (1) patient empower-

ment; (2) whole person; and (3) healing, respite,

and restoration. However, each team employed

narratives as a tool to find and develop their

respective themes. Stories of personal empower-

ment, whole-person design, and restoration pro-

cesses also connected to EBD findings and

information gathered through benchmarking,

observations, and interviews.

Design Empowerment

This team focused on designing a cancer care

facility where empowering the patient was a

Carmel-Gilfilen and Portillo 137

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paramount concern. The question became how do

we support the inner motivation and strength of the

patient population? The look and feel of the space

immediately runs counter to typical treatment cen-

ters. There are no waiting areas. Instead, patients,

friends, and family are welcomed into empower-

ment zones designed to channel energy from

supporting communities or engage the inner resour-

cefulness and resiliency of patients and other stake-

holders. For example, the public empowerment

space illustrated in Figure 1 welcomes current

patients, survivors, and advocates into an open

environment with a central hub with resources and

activities centered on cancer advocacy and educa-

tion. These areas exude with positive sensory sti-

muli (e.g., fresh baked cookies at the reception

desk or large-scale, interactive touch screens to

locate 5K runs for cancer research). As visitors

move vertically in the facility toward the treatment

areas, they enter into the private empowerment

zone illustrated in Figure 2. This space offers pri-

vate areas for prayer, personal reflection, or media-

tion and also includes more intimate opportunities

for small group socialization. Opportunities abound

for thinking, relaxing, reading, or enjoying nature.

Patients can be less inhibited in these spaces. For

example, this represents a safe haven space for a

female patient, who has lost her hair during chemo-

therapy, to remove her headscarf and still feel com-

fortable. Empowerment acknowledges that cancer

patients are people who live a full life outside of

their treatment experience. These design moves

align with research recommendations for alleviat-

ing illness-related stress and depression by offering

social support opportunities for patients and their

family members and friends (Ulrich et al., 2008).

Over the course of design development, this par-

ticular team struggled to develop the ideas of

empowerment spaces while meeting specified

design criteria including square footage, functional

requirements as well as codes and guidelines

requirements. At the midpoint review, several jur-

ors wanted to see stronger development of the path-

ways from the more public empowerment zones to

the clinical treatment areas, ‘‘The message behind

empowerment is clear . . . however too much space

is accounted for [in the educational and resource

areas], the spaces seem segregated from one

another, and there is no link between the public and

private empowerment spaces’’ (Juror, personal

communication, October 23, 2013). This insight

prompted a complete rethinking of the navigation

Figure 1. Public empowerment zone.

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throughout the facility, including shifting specific

programmatic elements to different floors to

strengthen the concept of empowerment through a

more equitable allocation of space and better devel-

opment of transitional areas. In addition, the team

focused the narrative to better reflect the infusion

of empowerment throughout the prototype that ele-

vated the patient experience.

The first time my wife and I walked into this

lobby she gasped. It was the sound of relief.

There are no corridors of white walls, scuffed

flooring or people scurrying frantically in scrubs

to be found here. . . . The receptionist is always

welcoming with a smile on her face and a fresh

batch of cookies on her desk. (See Figure 1.)

I survived another treatment and my beautiful wife is

waiting for me in the living room ready with my

favorite snacks from the complementary snack bar.

I always feel like it is my goody bag after another

successful treatment. This place is bustling with

doctors, patients, and their families. (See Figure 2.)

This design solution created advocacy spaces for

engaging current patients and cancer survivors,

staff, as well as family, and community members

through access to cutting-edge cancer research and

treatment options and opportunities for outreach

(shown in Figure 3). The technology-infused spaces

also encouraged patients and their families to inter-

act virtually with the global cancer community,

offering another opportunity for empowerment.

I don’t want to play victim to my cancer, I want to beat

it. I proudly go into the advocacy center. I am over-

whelmed with how many organizations and events

are dedicated to the same thing. My sister joins in the

rally against breast cancer and signs up for a breast

cancer awareness walk on the spot. (See Figure 3.)

A final example of empowerment is illustrated in

the story wall shown in Figure 4, offering five mes-

sages of peace and hope captured by the voices of

cancer patients and survivors. Located adjacent to

the radiation treatment area, this wall provides a

focal point with an emotional impact designed to

inspire patients and staff with stories of unique

human experiences. Stories told through poignant

images and words to engage and hopefully

empower those who pass through this corridor.

I walk down the hall to my radiation treatment. I

have never liked the enclosure of hospital hallways.

Figure 2. Private empowerment zone.

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However, this one uplifts my spirits with real-life

survival stories. For the few minutes I am in that

awful machine, I will focus on thoughts on what

my survival story could be like. (See Figure 4.)

The space was designed to energize and inspire:

Empowering patients with information shifts the

traditional dynamic of the health care relationship

wherein professionals are the active providers of

information and care, and patients are consigned

to the role of passive recipient. Activated patients

take the reins of their health care and wellness,

asserting their fitting place as a central member of

the care team. (Frampton et al., 2013, p. 109)

Research illustrates that this type of patient appears

more likely to report higher satisfaction with their

healthcare experience (Mosen et al., 2007). Oppor-

tunities for choice and control also offer strategies

for high-quality, high-value care that promotes con-

tinuity of care (Frampton et al., 2013). These spe-

cial spaces supported learning about cutting-edge

trends in cancer care as well as opportunities to

Figure 3. Advocacy center.

Figure 4. Story wall.

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connect with the larger cancer network. Education

offered power as did community-building sup-

ported by spaces replete with electronic resources

(e.g., online forums) and reference materials. Myr-

iad opportunities allowed patients to take control of

their illness. Designed spaces implicitly sanctioned

patients and family members to actively learn about

and manage their cancer journey. At the heart of this

design was knowledge and advocacy. Learning

spaces also became social spaces where groups of

patients and caregivers could explore cutting-edge

treatment protocols, learn from webinars, or find

the right type of support group to better navigate the

treatment and recovery process. For this team,

empowered patients and families could partner

more effectively with caregivers ‘‘to beat cancer’’

as a united team.

Design for Healing

This team focused on telling the story of healing,

a concept that is universally recognized. Princi-

ples of biophilia inspired the spaces to reflect

qualities of solace and draw energy from the well-

spring of nature, which differed from the source

of inspiration from the last team. The design is

soft, embracing, and offers opportunities for quiet

reflection. The team’s overarching design goal

was to be able to see a healing garden from every

vantage point within the facility. As illustrated in

Figure 5, healing gardens were designed as three-

dimensional pockets within the building.

These gardens formed an intimate connection

with nature and represented water as a healing

element (active, still, and dripping) to meet phys-

ical, emotional, and spiritual needs. Offering

respite these gardens are visible from the main

lobby and public spaces; infusion and radiation

treatment spaces; and staff, patient, and family

respite areas. Additionally, the common path

linking these gardens was further reinforced and

articulated by changes in the flooring and ceiling

treatment, optimizing wayfinding throughout the

facility. This investment acknowledged the body

of research that has linked exposure to nature to

reduced stress and increased restoration among

other positive health outcomes (Ulrich, 1991,

1999, 2008).

Throughout the development of the project,

this team emphasized not only the patient experi-

ence but other stakeholders who needed consider-

ation. At the midpoint review, jurors encouraged

this group to continue exploring staff and family

perspectives (in addition to patient needs) and

more fully develop these supporting narratives

vis-a-vis the healing gardens. The response of the

team centered on creating an additional healing

garden designed to support a wider net of social

needs, including a community cafe for staff, visi-

tors, and patients that offered a fresh menu in a set-

ting welcoming conversation and socialization.

Further, the spaces designed specifically for staff

respite were relocated to be adjacent to the healing

gardens. This offered another way of supporting

the well-being of caregivers. The team’s narrative

was also broadened to include these additional user

groups, strengthening the story of healing.

The healing gardens also represented a valu-

able nexus to beauty and restoration (Frampton

et al., 2013). Again research indicates that design

directly impacts the patient and family healthcare

experience by influencing communication, satis-

faction, and the overall continuum of care (Press

Ganey, 2007). ‘‘There is strong evidence that

design changes that make the environment more

comfortable, aesthetically pleasing and informa-

tive relieve stress among patients and increases

satisfaction with the quality of care provided’’

(Ulrich, Zimring, Quan, Joseph, & Choudhary,

2004, p. 25).

Figure 5. Healing gardens.

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My physical, emotional, and spiritual needs fluctu-

ate greatly and often cause frustration for myself,

my friends and family, and my caregivers. . . . See-

ing the large garden when I enter makes me think

back to when I received my terrifying diagnosis and

how when I entered here for the first time it made

my fears diminish. It embraces me with a welcom-

ing feeling. (See Figure 5.)

The team also created art therapy spaces offering

opportunities for self-expression and the ability to

experience creative flow of the patients and fam-

ily members (see Figure 6). These open flexible

spaces encouraged socialization and created a

sense of community. In addition, this type of

space is supported by research that relates posi-

tive distraction with decreased patient stress

(Ulrich & Gilpin, 2003).

This concept was inspired by student engage-

ment with the local cancer center’s arts in medicine

program where patients and others created together

across media and forms of expression from art mak-

ing to yoga. This experience powerfully connected

students to a community of current and former can-

cer patients, family members, staff, and others from

the university and local community. This team was

particularly influenced by their experience and a

defining space within their ambulatory facility sup-

ported healing through creative engagement.

As my sister leaves for her treatment, I take a seat in

the art class to join in. It keeps me entertained; the

sounds of laughter lift my spirits and give me a

sense of community and belonging. I notice the

flexibility of the space allows me to decide where

I want to sit depending on whether I feel like socia-

lizing or feel the need to be alone. (See Figure 6.)

Extending beyond function and aesthetics, the

spaces embodied a holistic approach to healing.

Design decisions were supported by interviews

with staff members who expressed the need for

respite and recovery spaces that looked and felt

differently from the typical break room. Staff

wanted areas to decompress and mentally disen-

gage briefly from the day’s activities. They

needed spaces offering privacy and solace for the

losses and patient setbacks that are the reality of

cancer care. The healing gardens were designed

as an oasis for caregivers and clearly would

become a gathering place for patients and fami-

lies. Further, the distinct plant materials defining

each garden were designed as visual landmarks to

support navigation throughout facility.

Whole-Person Design

This team’s solution relates to the last example yet

brings in unique design attributes. The team was

inspired by the journey of each cancer patient. The

patient journey necessarily included supporting

caregivers and often included family members and

friends who provided different sources of energy

at various points of the treatment and healing pro-

cess. This design driver focused on the connection

with caregivers and support providers. For exam-

ple, the team designed the treatment zones by cre-

ating flexible private, semiprivate, and public

experiences that were tailored to the patient’s

needs, mood, and preferences.

The private treatment option, illustrated in

Figure 7, allowed for privacy and personalization

while minimizing stress, enhancing comfort, and

maintaining dignity. Full height partitions with

physical and acoustical separation between patients

also provide ample space for an accompanying

friend or several family members. In addition, a

porch area with a view to nature was open and

invited socialization, if desired. Semiprivate treat-

ment options, illustrated in Figure 8, provided some

privacy coupled with group support spaces. This

treatment option allowed for the continuation of

daily life beyond cancer care by providing work

Figure 6. Art therapy space.

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surfaces for writing or doing other kinds of work.

This was a request voiced in one of the family mem-

ber interviews. Finally, opportunities in the space

could be found for providing outdoor treatment

options, under permissible weather conditions.

At the midpoint review, this team was chal-

lenged to reconsider the pathways throughout the

space for patients, staff, families, information,

medication, supplies, and equipment. The jury

posed a series of questions to the team: How do

staff navigate in this environment? How do sup-

plies get to their proper destination? How will

patients and any accompanying family or friends

move throughout the facility?

The group responded by creating a diagram

tracking these pathways and functions, which in

turn, impacted the layout of spaces. In addition, they

were challenged to facilitate staff functioning within

the treatment zones to better serve patients by

removing the ‘‘work-arounds’’ that would inadver-

tently cause caregiver frustration. The circulation

in final prototype substantially improved as did the

functionality of the spaces supporting each stake-

holder group. The story was also refined to reflect

these changes and provided an opportunity to con-

nect with the designed spaces on a deeper level.

My treatment space has its own room with an

indoor family porch where I can sit closer to the

windows with my sister or even another patient.

There is also space to put my belongings and plug

in my ipad. (See Figure 7.)

Sweetie, they even have a place over here for you to

do your work. Through these long hours I hardly

notice I am going through my treatment with this

wonderful view and comfortable chair. It just feels

so warm and inviting here. (See Figure 8.)

Treatment spaces illustrate opportunities for the

design of the physical space to go beyond treating

the symptoms to encompass a holistic model of

care, one that offers choice and control. The design

also recognizes the need to emphasize partnerships

between patients, family members, and staff.

Health care that establishes a partnership among

practitioners, patient and their families (when

appropriate) to ensure that decisions respect

patients’ wants, needs, and preferences and that

patients have the education and support they require

to make decisions and participate in their own care.

(Institute of Medicine, 2001a, p. 127)

Embracing active involvement of family members

can aid in optimizing the health and well-being as

well as promote continuity of care (Frampton

et al., 2013). Research has also underscored that

family member presence has minimized patient

anxiety and stress (Ulrich, Zimring, Quan, &

Joseph, 2006) and increased patient comfort and

satisfaction (Choi & Bosch, 2013).

Conclusion

In this article, we advocate for using narratives

to achieve inspired experiences within

Figure 7. Private infusion treatment.

Figure 8. Semiprivate infusion treatment.

Carmel-Gilfilen and Portillo 143

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healthcare environments. Narratives enable

design students to gain insight about the people

for whom they design. Storytelling offers one

way to cultivate empathy in designers and helps

develop a mind-set for elevating the level of

patient-centered care. The challenge for all who

contribute to the healthcare experience is to

become more ‘‘respectful of and responsive to

individual patient preferences, needs and values,

and ensures that patient values guide all clinical

decisions’’ (Institute of Medicine, 2001b, p. 40).

Gensler’s Design Forecast 2015 reinforces the

paradigm shift in the areas of healthcare, ‘‘From

providers to consumers, from organizations to

individuals, healthcare is in the midst of massive

change . . . personalized medicine integrates

clinical innovations with tailored care delivery.

The rise of specialty care facilities reflects this

development’’ (p. 48). The narratives of patients,

families, and staff focus on the individual and

expand to lessons for the greater good. Well-

crafted stories offered the possibility of connect-

ing students more deeply to the inner lives of

patients, families, and caregivers.

Narrative inquiry has the potential to heighten

empathy within the design process and finalized

product unlocking human-centered design. One

student noted the power of a narrative approach

in healthcare design:

Writing a narrative along with the design process

really helped me go back and identify empathy for

the patient or staff member. Sometimes you can get

so caught up in a design that it doesn’t become

about the user anymore. Writing a narrative forces

you to be that user and speak about your experience.

It brings the design full circle.

Implications for Practice

� Designers can and should play a critical role

in shaping a holistic healthcare experience

by creating empathetic design solutions that

foster a culture of care for patients, their fam-

ilies, and staff.

� Narrative inquiry can encourage design crea-

tivity and innovation in considering the end

users of the spaces—patients, caregivers, and

families—from a whole-person perspective.

� Narrative inquiry offers an effective means

to surface misconceptions about end users

and tensions between stakeholders that can

be reconsidered in the design to create more

satisfactory outcome.

� Narrative inquiry can be learned as a design

tool and can be integrated into predesign

research, schematic design, and in final solu-

tions to reinforce empathetic solutions show-

ing strong alignment between individuals and

environments.

Acknowledgments

This authors would like to thank Herman Miller,

Inc. for their generous support. Herman Miller,

Inc. greatly contributed to the project and helped

shape this study. The project team of Doug Bau-

zin, Kristen Bennett, Anthony Rotman, and Janet

Zeigler are recognized for their contributions to

this study. The authors also wish to recognize all

students who were part of this studio as well as

graduate research assistant Jill DeMarotta for her

work on the project. Finally, we would like to

acknowledge the following students for image

contributions—Figures 1–4: Dianne Austria,

Kayla Johnson, Kristin Kaiser, and Jordan Mer-

ricks; Figures 5 and 6: Mariel Beesting, Santanna

Cowan, Meike Humpert, Leah Leto, and Lauren

Mahrer; and Figures 7 and 8: Daniel Fragata,

Theresa Kellner, Sabryna Lyn, Rachel Mathis,

and Brianne Shane.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of

interest with respect to the research, authorship,

and/or publication of this article.

Funding

The author(s) disclosed receipt of the following

financial support for the research, authorship,

and/or publication of this article: This work was

supported by Herman Miller, Inc. [grant number:

00110075].

Notes

1. Cleveland Clinic is a nonprofit medical center

committed to integrating clinical and hospital

care with research and education.

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2. The term ‘‘charrette’’ describes an intense,

concentrated period of design and/or planning

activity to develop a creative design solution

(McLaughlin, 2013).

3. IDEO is an award-winning global design firm

that takes a human-centered, design approach

to helping organizations in the public and pri-

vate sectors innovate and grow (IDEO, 2015).

4. Founded in 1978, Planetree (2014) is a nonpro-

fit organization of healthcare organizations

committed to patient-centered care.

5. The Department of Interior Design at Univer-

sity of Florida is part of the College of Design,

Construction and Planning that includes under-

graduate majors in interior design, architecture,

construction management, landscape architec-

ture, and sustainability in the built environment.

The interior design program is accredited by the

Council for Interior Design Accreditation.

6. Students were enrolled at the Hochschule

Ostwestfalen-Lippe, University of Applied

Sciences, School of Architecture and Interior

Architecture in Detmold, Germany.

7. iBooks were created using ibooks author, an

app that allows individuals to create books

viewable on the ipad or other digital devices.

These books were used as a multimedia tool

to reveal the unique process including its

impact on the final design solutions.

8. A refereed paper on the design process and

product outcomes was presented by the coau-

thors at the Interior Design Educators Council

Annual International Conference in New

Orleans, LA, and received the 2014 IDEC

Award of Excellence, Best Presentation Scho-

larship of Teaching and Learning. The student

project Holistic Healing Outpatient Cancer

Care Center by Santanna Cowan, Leah Leto,

Mariel Beesting, Meike Humpert, and Lauren

Mahrer earned 2013 Healthcare Environment

Awards, Student Honorable Mention.

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