designing with empathy: the author(s) 2015 humanizing...
TRANSCRIPT
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
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
Carmel-Gilfilen and Portillo 131
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,
132 Health Environments Research & Design Journal 9(2)
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
Carmel-Gilfilen and Portillo 133
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
134 Health Environments Research & Design Journal 9(2)
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
Carmel-Gilfilen and Portillo 135
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.
136 Health Environments Research & Design Journal 9(2)
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
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.
138 Health Environments Research & Design Journal 9(2)
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.
Carmel-Gilfilen and Portillo 139
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.
140 Health Environments Research & Design Journal 9(2)
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.
Carmel-Gilfilen and Portillo 141
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.
142 Health Environments Research & Design Journal 9(2)
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
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.
144 Health Environments Research & Design Journal 9(2)
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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