universal design in healthcare servicescapes: … · customer's perspective, atmospherics...
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UNIVERSAL DESIGN IN HEALTHCARE SERVICESCAPES:
UNCOVERING MULTISENSORY CUSTOMER EXPERIENCES
AMONG VISUALLY IMPAIRED PATIENTS TO ENHANCE SERVICE
CONVENIENCE AND CUSTOMER INTIMACY.
Carmen Martens
Cécile Delcourt
Jasmien Herssens
University of Hasselt (Architecture ) & HEC Liège (Management)
Abstract: Healthcare services are subject to huge challenges such as improving user experience
while being (economically) sustainable. However, little attention has been dedicated on how to
create adequate healthcare servicescapes through an optimal architectural design to enhance
service convenience and customer intimacy. Hospitals often lack awareness for architectural
experiences and can even create disabling situations: this is especially true for visually impaired
patients as servicescapes heavily rely on visual components while those may not be
(sufficiently) perceptible to visually impaired patients. After an extended customer journey
throughout four hospitals, in-depth interviews with visually impaired patients are conducted to
uncover obstacles met by the patients and to identify multisensory qualities that patients would
value to enhance the service convenience and customer intimacy. This multidisciplinary
research will provide both managers and architects of healthcare facilities with insights on how
to best define architectural design methods to improve both service convenience and customer
intimacy.
Keywords: Multisensory experiences; Service convenience; Customer intimacy; Healthcare
servicescapes; Universal Design
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UNIVERSAL DESIGN IN HEALTHCARE SERVICESCAPES:
UNCOVERING MULTISENSORY CUSTOMER EXPERIENCES
AMONG VISUALLY IMPAIRED PATIENTS TO ENHANCE SERVICE
CONVENIENCE AND CUSTOMER INTIMACY.
Introduction
Although several studies indicate that healthcare services have a pervasive impact on users’
well-being, life, and economies (Anderson et al., 2013; Berry and Bendapudi, 2007), tangible
architectural environments that facilitate these services (Bitner 1990, 1992) often lack
multisensory customer experiences, service convenience and customer intimacy. Moreover,
sometimes these environments paradoxically contribute to the creation of disabling situations
in terms of physical, cognitive, cultural or social inclusion (e.g., unwelcoming environments,
disorientating corridors, bad acoustics, bad access for disabled people, bad smell, unpractical
sanitary environments, …) (Herssens, 2017a, b).
In the context of intimacy, paradoxically privacy policies (HIPAA, 2002; FOD 2002) protect
patients’ privacy and staff is not allowed to speak with/about patients in elevators (FOD, 2002;
Khullar, 2017). However, when entering a room with more than one patient, acoustics does not
always guarantee privacy or intimacy. Moreover, lack of acoustics makes many patients suffer
from insomnia (Ulrich et al., 2008; Khullar, 2017). Studies even prove that both staff and
patients withhold parts of the story or refuse extra exams in a double room (Mlinek & Pierce,
1997; Barlas et al., 2001).
To quote Dr. Khullar: “Hospitals are among the most expensive facilities to build, with complex
infrastructures, technologies, regulations and safety codes. But evidence suggests we’ve been
building them all wrong — and that the deficiencies aren’t simply unaesthetic or inconvenient.
All those design flaws may be killing us.” (Khullar, 2017). But what is missing? Herssens (2016,
2017b) states that insights in design methods that link customer experiences with design
principles is lacking. This is most visible in extreme contexts like hospitals in which “the
utilitarian building types have generally led to the main attempts at system building” (Lawson,
2006, p.102). Most hospitals are designed by means of using a rational problem-solving focus
on typologies, they meet technical needs for medical operations, but still lack a holistic
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multisensory and care-oriented approach. It is this focus on rational use, modularity and
standardization that has led to the lack of customer experiences. Places that lack physical,
mental or socio-cultural inclusion are considered as ‘architecturally disabled’ (Goldsmith,
1997) or ‘distorted spaces’ (Brosnan, 2003). It is important to leave the full creativity to the
well-informed designer. However, to some extent it might be interesting to have more insight
in bridging the gap between customer experiences and the necessary design principles.
Theoretical framework
Transformative Service Research (TSR)
As a research paradigm, Transformative Service Research (TSR) aims to create uplifting
improvements and changes in the well-being of individuals, families, social networks,
communities, cities, nations, collectives, and ecosystems (Anderson et al., 2011).
TSR in healthcare invites researchers to focus on reducing consumer vulnerability and
enhancing consumer agency because many consumers find themselves in a position of lesser
knowledge during a service encounter (Adkins and Corus 2009; Anderson et al. 2011).
Therefore, marginalized groups and disparities in the quality of services provided to various
groups are especially emphasized. Various studies show the discrepancies between healthcare
access, knowledge, experiences, and outcomes of privileged versus disadvantaged customers.
Also of interest are the contexts and service environments that promote physical health and
emotional and mental well-being (Jamner and Stokols 2001; Rosenbaum et al. 2007).
Steering toward highly inclusive and equitable healthcare services ask for a system which is
flexible and responsive to the needs of diverse users of healthcare services (Rendtorff, 2009).
Gallen and Black argue that patients play an important role in co-creating value in healthcare
services. Therefore, poor service quality within a healthcare system may derive not only from
service providers but also from patients, who may for example withhold important information.
Thus, Rosenbaum (2015) concludes, a service system and the patient must work together to co-
create value.
In sum, TSR is a call for service research that encourages improvement of personal and
collective well-being of not only individuals and citizens, but the entire global ecosystem. The
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paradigm stimulates researchers to create novel theories and to borrow theories from other
disciplines, to try to understand how service systems, providers, and other customers in service
settings can improve the consumer well-being. (Rosenbaum, 2015)
Universal Design (UD)
In the same vein, Universal Design calls for a shift in mentality and a different attitude among
designers (Herssens, 2011). ‘Universal Design’, firstly coined by Mace (1985) is an ability-
based design strategy that results into a design whereby users do not have to adapt but are
invited and supported in their actions and experiences in a positive and elegant way (Herssens,
2011, 2014, 2017). The strategy considers an inadequate environment as creating impairments
for its users which can cause disabling situations. As a result, a disability is now seen as related
to the environment (and not to the user), as a phenomenon that manifests itself in social,
physical and virtual environments.
Traditional design adds accessibility to inaccessible buildings/products. The underlying
principle of accessible design is the fact that there are two contrasting populations: the ‘normal
people’ and the ‘people with disabilities’, which results in isolation and stigmatization. In
contrast, UD considers only one population, formed by individuals with different characteristics
and abilities.
Although the domain of UD has clearly defined the theoretical eight user goals (i.e. Body fit,
Comfort, Awareness, Understanding, Wellness, Social integration, Personalization and Cultural
appropriateness (Steinfeld and Maisel 2012: 90)) and seven design principles (i.e. Equitable
use, Flexibility in use, Simple and Intuitive use, Perceptible Information, Tolerance for Error,
Low Physical Effort and Size, and Space for Approach and Use (Folette Story 2001:10.5)), the
domain lacks design methods to link these user goals with the design principles (Herssens,
2017a,b).
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Conceptual framework
Figure 1: conceptual framework
Healthcare Servicescapes
Health is a vital personal and social resource, as well as an economic one, and therefore a
valuable ambition for every society. Studies show that the physical environment can be
therapeutic if it removes environmental stressors, joins patients to nature, offers possibilities to
enhance feelings of being in control, and provides opportunities for social support and
relaxation (Malkin 2003).
The impact of natural environments is already known since ancient times. Locations of the
Asclepieia (i.e. the healing centers of ancient Greece) were carefully selected, using thermal
springs, designed on spectacular views, and creating buildings for leisure activities, closely
located to the medical buildings (Christopoulou-Aletra et al. 2010). Alvar Aalto and Richard
Neutra, leading architects from the modern period, also stress the advantages of well-planned
architecture, and the influence of nature for healing in their architecture (Sternberg 2009).
Contemporary science points out to the strong relationship between emotions and health and
has found evidences that confirm those connections, providing scientific explanations through
transdisciplinary researches. The built environment is strongly linked to the emotional health,
and at the same time, it is a widely accepted opinion that emotions directly affect the overall
health (Sternberg 2001). The relationship between human and environment is also discussed in
the management literature, where Bitner (1992) coined the term 'servicescape' referencing to
the built environment, which affects both consumers and employees in service organizations.
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This study focuses on health care environments as they represent a challenging service context.
Hospitals are places where comfort, care and intimacy are top priorities. Those are meeting
places for a diversity of users, in terms of actual use (e.g., patients, staff, visitors, …), socio-
demographic profiles (e.g. class, gender, ethnicity, ...), patient abilities (e.g., vulnerable,
disabled, top-athletes, …) and emotions (e.g., happiness, death, hope, fear, …).
Multisensory Experiences
Kotler (1973) introduced the term "atmospherics", indicating how the physical elements of an
environment affect a buyer's "purchasing propensity." Other research also denoted the
relationship between atmospherics and customer satisfaction, patronage, and advertising via
word-of-mouth (Bitner, 1990, 1992; Grossbart, et al., 1990; McElroy, et al., 1990). From a
customer's perspective, atmospherics involves not only the design of the physical environment,
but at the same time, incorporate the cognitive, emotional, and physiological influences on
customers (Hutton & Richardson, 1995).
Atmosphere is apprehended through the senses. Kotler states that the main sensory channels for
atmosphere are sight, sound, scent, and touch (Kotler, 1973). Although he considers taste as
unimportant in relation to atmospherics, the impact of the fifth sense is highlighted by the
instinctive reaction it can evoke in customers. Taste aversion is one of the only examples of
what psychologists name one trial learning. One single negative experience to something eaten
leads to consistent long-term avoidance (Garcia, et al., 1955). On the other hand, one can also
recall highly positive experiences of food consumption perhaps even more intense than a single
auditory, visual, olfactory, or tactile experience. Thus, taste can evoke both very positive but
also negative experiences in customers and cannot be ignored in this research.
As the focus on customer experience has advanced, a better comprehension of the importance
but also the complexity of this experience has become clear. Sensory marketing approaches to
enhance the customer experience has occurred (Hulten, 2011; Hulten et al., 2009; Krishna,
2013; Spence, 2002), and settings are increasingly being designed to appeal on both rational
and emotional levels, as well as across multiple senses (Spinney, 2013). This approach has been
further strengthened by findings arising from the field of cognitive neuroscience (Yoon et al.,
2012). However, most of the research on atmospherics focuses on a single sense in relation to
the environment while environments, and our perception of them are by nature, multisensory.
Herssens (2011) stresses that multisensory experiences are an indispensable key in the design
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of multisensory human-centred servicescapes, as customers perceive servicescapes holistically
(Bitner, 1990; Mattila & Wirtz, 2001). If an environment offers a range of sensory triggers,
people with different sensory capacities are able to navigate and enjoy that environment. Still,
most architects overlook haptic, olfactory, gustatory and auditory senses. As all sensory
sensations contribute to human behaviour, it is important not to limit the architectural
experience to that which is visual but to expand the knowledge and study every type of sensory
experience (Herssens, 2011).
Service Convenience
Service convenience, conceptualized by Berry et al. (2002) concerns users’ time and effort
perceptions related to buying a product or using a service. Healthcare environments create
customer value largely through services, and as service convenience is an essential
consideration for most customers (Berry et al., 2002), it becomes a critical concept in this
research. In many service exchanges, especially those requiring customers’ participation such
as healthcare services, physical, emotional, and cognitive effort are likely to be relevant (Berry
et al., 2002). The greater the effort users spent, the stronger their commitment to the service
outcome and the higher is his or her potential frustration (Hui et al., 1998). Inconveniences and
disabling situations can impede a favorable customer experience while key in the creation of
customers’ perceptions (e.g., service quality), customers’ attitudes (satisfaction) and customers’
behaviors (e.g., positive word-of-mouth) (Delcourt et al. 2016, 2017).
Users of healthcare services often pursue enduring relationships. They value communication,
the ability to build a relationship of trust, understanding, and empathy with the patient
(Blumenthal, 1996) and expect humanism, sensitivity and responsiveness (Carmel & Glick,
1996). Therefore, they allot time and effort in finding services in which they can be confident,
as healthcare services can be consequential, involving, complex, and recurring (Berry et al.,
2002). Other factors like the service facility location, parking availability, customers’
experience or familiarity with the environment (Brucks 1985; Rao & Monroe 1988; Sujan 1985)
affect the service convenience
In sum, users’ convenience perceptions will have a positive influence on their service
satisfaction, assessments of service quality, and perceptions of fairness (i.e. the balance of input
and output among exchange partners (Berry et al., 2002). We believe that healthcare
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servicescapes plays a vital role in service convenience as it is the physical environment that
represents and encompasses the provided healthcare service.
Customer Intimacy
The term intimacy has its roots in the Latin words “intimatus” (i.e. closely acquainted, very
familiar) and “intimus” (i.e. “inmost” or close friend). Since the 1970s the interpersonal
relations literature has conceptualized, and measured intimacy from a non-economic
perspective (e.g. Orlofsky et al., 1973; Repinski & Zook, 2005; Sternberg, 1997). Intimacy in
this literature stream is understand as closeness in personal relationships (e.g. Repinski & Zook,
2005; Sternberg, 1997). The focus on relational rather than transactional economic exchanges
in marketing arose in the 1980s (Berry, 1983). Although different research refers to customer
intimacy as an important concept to create and maintain fruitful customer relationships (e.g.,
Aaker et al., 2004; Johnson et al., 2006; Rust et al., 2000, p. 60; Yim et al., 2008) the concept
customer intimacy stayed quite unspecified.
Customer intimacy is categorized by Treacy & Wiersema (1993) as one of three value
disciplines on which leadership companies should focus to deliver superior customer value.
Kai-Uwe Brock & Yu Zhou (2012) came up with a working definition of customer intimacy
and express the concept as a customer’s perception of having a very close and valuable
relationship with a supplier, characterized by high levels of mutual understanding. They show
that customer intimacy is reflected by the three formative dimensions of mutual understanding,
closeness, and value perception.
As users of healthcare services often pursue enduring relationships, they value communication,
the ability to build a relationship of trust, understanding and empathy with the patient
(Blumenthal, 1996). We believe this concept of intimacy may indeed be achieved by the
relationship between customer and in this context, the medical staff. But we also believe that
the servicescape may influence customer intimacy, especially in healthcare facilities, where
privacy and intimacy are top priorities and customers may stay for a longer time (e.g. data
provided by Eurostat (2017) show that in 2015, the average length of a hospital stay for in-
patients ranged from 5.3 days in Bulgaria to 10.5 days in Finland. The average length of a
hospital stay for in-patients in Belgium was 6.5 days).
Patients, a good example of passive users, are less empowered and have low knowledge about
healthcare services. Therefore, they are often expected to cooperate and deliberately disclose
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very personal information/intimate parts of their body as it is about their own health (Berry &
Bendapudi, 2007). These patients may feel highly vulnerable (Anderson et al., 2013) and when
they perceive the environment as inadequate, they may feel uncomfortable and, accordingly,
may not self-disclose personal information while this information might be key in the healing
process. In the same vein, the high pressure and stress experienced by the staff can be reinforced
by poorly designed servicescapes. Research has shown that healthcare servicescapes possess
motivational potential for the achievement of goals through increased work engagement and
improved performance (Khasmisa, et al., 2016). Also, staff may need to reveal very personal
and negative information to patients, which is a delicate task that must be carried out in a
suitable intimate environment.
Accordingly, creating adequate environments, where staff can successfully perform their jobs,
and patients can receive and reflect on obtained information, may result in healthcare
servicescapes that foster intimacy for the well-being of all users.
Exploratory Research Design
Considering the exploratory nature of the study, we will start this qualitative research with a
(visual) ethnographic customer journey throughout four selected university hospitals in
Belgium (two located in Wallonia and two in Flanders). For analyzing the customer journey,
we should understand and map the journey from the patients’ perspective and, therefore, it
requires their input into the process. Together with the patients, multiple touch points are
evaluated that have a direct and more indirect effect on their customer experience. The whole
journey will be video recorded, using a Go Pro on the patients’ body to clearly observe and
identify the critical “moments of truth” throughout the customer journey that have significant
influence on key customer outcomes. Service blueprinting will provide a solid starting point for
this customer journey mapping (Lemon & Verhoef, 2016).
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Figure 2: service blueprint: considering all touchpoints met in the customer journey
Afterwards in-depth interviews are conducted to review the service convenience, to deeply
understand the obstacles met in the customer journey, and to identify olfactory, auditory, haptic
and gustatory experiences that these patients consider as facilitators of the customer experience.
Interview Guide
The interview guide provided open questions and consisted out of four parts. In the first part
the critical incident technique (CIT) (Flanagan 1954) will be used to collect detailed
descriptions of both the most convenient and inconvenient place the patients were confronted
with in the customer journey. The next part further explored the other touch points focusing on
the service convenience, multisensory experiences and important physical elements in the
health care servicecape. The third part mainly focused on customer intimacy. Participants were
asked to describe the concept of intimacy in a general way, and to define and grade the
importance of the concept in a healthcare setting, using word associations. The interview ended
again with the critical incident technique (CIT) to collect detailed descriptions of both the most
convenient and inconvenient place the patients were confronted with in any public environment.
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Sample and Data Collection
This research considers patients with visual impairments as experts for insights in multisensory
experiences (Herssens, 2011, 2017a). They are the ideal user-experts to create servicescapes
that are convenient to the greatest number of potential users. Although the experience of
visually impaired people has been under investigated, they have strong needs in terms of
servicescape design because they cannot rely on visual information whereas a servicescape is
often primarily visual (Warren, 1978; Herssens, 2011; Heylighen and Herssens, 2014).
Furthermore, previous research suggests that sensory-disabled populations – persons with
hearing and/or sight limitations – feel that mainstream service experiences could do more to
create value for this minority segment (Kaufman-Scarborough and Baker, 2005). Improving the
environment, focusing on other sensory experiences, will also enhance the overall customer
experience of all other users.
Two researchers will conduct the customer journeys and interviews in four selected university
hospitals in Belgium. Several patients are recruited among the network of acquaintances of the
researchers and they will serve to pretest the interview guide. In a later stage, doctors in
ophthalmology from the selected university hospitals in Belgium will be contacted and provided
with a call for participants. At least 30 visually-impaired patients from both the French and
Flemish speaking part of Belgium will be observed and in-depth interviewed.
The audio- and video-recorded data will be described, coded, and analyzed with NVivo.
Expected Research Findings and Contributions
This research aims at identifying inconveniences and disabling situations met by patients in the
customer journey throughout hospitals that strongly impact their customer experience.
We want to uncover and provide a definition for multisensory experiences and customer
intimacy in healthcare servicescapes. Working together with visually impaired people, will give
us more insight in multisensory experiences as both architecture and management are highly
focused on visuals. By focusing on those who have traditionally been overlooked, we believe
this research will help us to better understand the disadvantages these people encounter in
service contexts and offer recommendations to TSR researchers. In a later stage, we aim at
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bridging the gap between customer experiences and design principles by developing practical
UD design methods that can help architects to enhance multisensory and well-designed
servicescapes.
Research Limitations
Users of care environments are not restricted to patients alone: in addition of examining patient
needs in terms of design, the needs of other users like staff or visitors will need to be examined
as well. Mainly focusing on patients does not always lead to an ideal experience for all users as
Lawson states: “In a hospital, what is often convenient for the patients is inconvenient for the
staff” (Lawson, 2006, p.103).
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