Thinking about the Human Side of Care, More than Ever

Before COVID-19 spread, the issues surrounding mental health and resiliency for healthcare staff were widely discussed. Rates of nurses feeling burned out or unengaged reached nearly 50 percent in some studies, while physicians have some of the highest suicide rates of any profession with between 300 and 400 annually.

Then the pandemic hit, stressing an already fragile health network and pushing care staff to the point of mental and physical exhaustion. A Medscape report on nursing during the pandemic found nearly 20% of nurses feeling burned out, about a fourfold increase in some nursing specialties. Another Medscape study found close to 45% of physicians feeling burned out.

“COVID isn’t making this a new issue, it’s just really brought to our attention that it’s time to start thinking more broadly and, really, more about the overall human experience in healthcare, prioritizing those unique experiences not only for patients but for families, for visitors and for the staff, those that are providing the care,” said Danielle Ostertag, a senior interior designer at BWBR who works in healthcare. “We’re already designing elements into patient spaces that contribute to healing, but it’s time to translate those to staff spaces, as well.”

Ostertag addressed the issue of staff resiliency in the latest episode of Side of Design. Joining her in the discussion was Devan Swiontkowski, Assoc. AIA, EDAC, a medical planner who studied the architecture of health and wellness during graduate school.

Arguing for a greater focus on serving the health and wellness needs of staff to increase their physical and mental resiliency, Swiontkowski said a slight shift in thinking, especially to advocate for the staff who, themselves, advocate for others, could make an impact on how the environment serves their needs as well as patients.

“It’s just thinking harder about what exactly [care staff] job entails, not only from a physical standpoint and trying to make it as efficient as possible, but, really, the emotional taxing part that happens to them on a day-to-day basis.”

Danielle Ostertag, senior interior designer

“When you’re meeting with these staff that are boots-on-the-ground, they’re so dedicated to their job and helping people that they, themselves, won’t advocate for these spaces. They’re like, ‘If you can just make the bathroom really nice, or the stairway have a window, I’ll be happy,’” she said. “I think that shift to [resilient thinking], they also need a place to be human, because they’re really entrenched in some pretty terrible things sometimes, and they just need to reset and focus on themselves for a second.”

“Happy staff means happy patients,” Ostertag said. “And you can just imagine, when we all go into work every day, you’ve got good and bad days. Multiply that by people who are dealing with human lives, these people are caring for people that are in desperate need. So it’s really just thinking harder about what exactly their job entails, not only from a physical standpoint and trying to make it as efficient as possible, but, really, the emotional taxing part that happens to them on a day-to-day basis.”

In shifting the focus to accommodate staff emotional wellbeing and support, Ostertag highlighted the WELL Building Standards that can provide a blueprint to wellbeing strategies. In addition, lean design processes open the door for care staff to participate in the discussions about how the space can support their needs.

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“In the lean processes, what they do really well is engaging those staff members that are doing the day-to-day work in how their space is getting built,” Swiontkowski said. “I think we’re at that point where we can take that one step further and, you know, include those staff spaces, especially where it’s the best location for those staff spaces. We can figure out where’s the best place for you to take your breaks, you can take that break, but get right back to what you want to be doing or need to be doing and be most efficient with that break time that you have.“

“WELL really starts to accommodate mind, body, and spiritual health, like how can the design of a space really foster all of those different parts of being human,” Ostertag said. “A lot of those healing elements that we look at in patient care and patient spaces, [WELL] talks about clean air, access to water, bottle fillers, things like that. In our experience, the staff are grateful for the things that they’re given, but we can be giving them so much more in a not overly difficult way.”

The two healthcare designers said many of the strategies come down to providing control for people who may be caught in what feels like an uncontrollable situation. Designing in strategies to control lighting or sound or ways to make a space more personal are simple ways to helping staff regain control. Such strategies in areas where staff are already taking breaks don’t have to add square feet to a building program.

“The sensory rooms that we’ve designed for behavioral health units can apply to anybody…because we’re all faced with really emotional challenges throughout our day. It’s okay to take those mental breaks.”

Devan Swiontkowski, EDAC, medical planner

Other strategies could include small areas for staff to access telehealth services for counseling or to telephone family or friends during long and stressful shifts. When the program allows, sensory rooms proven effective for patients in mental health environments could also provide an area for staff to find respite and recharge.

“The sensory rooms that we’ve designed for behavioral health units can apply to anybody,” Swiontkowski said. “We all have moments where we just need to block ourselves off from everything that is going on. So, choosing a serene graphic that we put on the wall, and lights that can change colors and help your mood, and a sound machine. Everybody would find those things calming and relaxing, and they should be available to anybody in a workplace, because we’re all faced with really emotional challenges throughout our day. It’s okay to take those mental breaks.”

“It’s just thinking harder about what exactly their job entails, not only from a physical standpoint and trying to make it as efficient as possible, but, really, the emotional taxing part that happens to them on a day-to-day basis,” Ostertag said.

As COVID-19 has challenged the best of organizations and their staff, it’s also created opportunities to rethink how the spaces support the myriad of emotions staff experience throughout their shift, experiences that go beyond the pandemic.

“I don’t think we do a good job of designing for grief, especially in hospitals. I think we are starting to think about that, especially in those departments where it seems like it should be happy but bad moments can happen. Since we know we can’t have the happy room and the sad room, we need a room to function as everything, with those simple aspects of the lighting and the sound and the kind of separation from space, if need be,” Swiontkowski said.

“It goes back to maybe to just asking the questions of staff, from their perspective, what types of spaces they need,” Ostertag added. “Some people like to grieve through connecting with others and talking about it and being around other people. Others, you know, would prefer to be on their own and just have a small room that they can go cry their eyes out, and then come back when they’re okay.”

“COVID has really made us think about the human side of care more than ever, and just really thinking about how it’s impacting everyone so differently,” she said. “This has brought out feelings that maybe some of us have never felt before. And it’s this huge, huge growth opportunity just to take that new spin on things and just kind of take a step back and remember why we’re doing this and what impact healthcare design truly can have.”

Is It Time to Make Work More than a Destination?

The debate is not new. However, the past year changed the narrative around where people can be most productive, at home or in the office.

The remote work environment that the pandemic forced on organizations and their staff over the past year showed that people can be productive in this work arrangement, in some cases, even more productive than when in the office. Yet, at the same time, the struggles have been real, ranging from the forced shared work arrangements with partners and roommates to the assistance required in the learn-from-home environment to the challenges of inadequate internet access or workspaces.

Then there are the constant video conference meetings and, despite facetime, a feeling of isolation without the social connections that offices facilitated.

As children go back to in-person learning and vaccination rates rise, the expectation grows that people will return to their offices in the near future. What those offices will look like, and why we would even return to the office, was the topic of discussion in the latest episode of Side of Design.

“A lot us aren’t getting very much social interaction outside of our normal day,” said Jennifer Stukenberg, NCIDQ, LEED AP, WELL AP, a principal and workplace strategist at BWBR, citing one of the more prominent challenges of working from home. “I used to get a lot at work. I’d get a lot after work with friends and extended family. When we go back to a time when we can have more social interactions, will it be enough to get us through the working-from-home scenario, or will we need to also continue to supplement that with the social aspect at work?”

“That person-to-person connection has definitely been highlighted that we’re just not getting right now,” said Tina Fisher, CID, LEED AP, a senior interior designer with extensive experience in workplace design. “As much as we can always use our video when we have our calls, video is different than that face-to-face, personal interaction. This distant environment has highlighted the importance of those connections, even in the work world.”

“What we’re missing most are those casual collisions, those non-purposeful connections that you just can’t simulate, or are difficult to simulate, virtually,” Stukenberg said.

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Yet, even if missing many of those serendipitous encounters in the work café or casually at a coworker’s desk, employee surveys across organizations indicate when facilities reopen for in-person work, there’s a desire to continue offering options and flexibility to work from home. Fisher said for companies examining both their policies and spaces to accommodate this new work preference, the question will be how to accommodate this new work style.

As much as anything, organizations will need to look at the reasons people are coming back to the office, and then shape the environment to make it most effective to accommodate those needs.

“The approach coming forward is this hybrid work model, where you can get the best of both worlds. You can capitalize on what people are gaining from being at home, but then allow those areas for people to come together to collaborate in those shared spaces, to team in a much more interactive way, but then also allowing them to have focus spaces,” Fisher said.

“We’ve seen a little bit of experimenting with some early design concepts that include more team rooms,” Stukenberg said. “You may be working at home in a very focused manner, but then you come in on a weekly basis for these short sprints, like Agile, for periods of time when you come together and collaborate really intensely, Then you go back and do some of your focus work. It’s not just kind of the co-working option that has been popular in the last 10 years.”

Beyond the collaboration and teamwork, Fisher and Stukenberg said companies need to understand their space as a tool for building culture and promoting equity in the work environment, especially for new employees onboarding who have not built their internal network and trusting relationships yet.  

“The onboarding process and being able to mentor, being able to train and teach, it is a little more challenging in the virtual environment. You don’t have that person sitting right next to you who you can just turn and ask a question,” Fisher said. “Face-to-face interactions, those impromptu conversations, those are something that the office environment provides.”

We’ve become really great at being more equitable about hearing all the voices, but the flip side is not everyone has great internet, or a great place to work, or has three roommates and not a good desk…[W]e need the office for many of those workers who may not have the opportunity to have a good remote work setup.

Jennifer Stukenberg, workplace strategist

“Many of us went into this pandemic with what we call social capital. We all knew each other. I kind of get you. I know how you communicate, and when you make a comment, I know you’re joking,” Stukenberg said. “During this pandemic, we’ve all been spending that capital, slowly, bit by bit by bit. If you’re a new person, you haven’t built up that trust and all that social capital.”

Even as Zoom and Teams have made conferencing easier and given an equal voice to participants, the actual work environment at people’s personal spaces can prove to be more challenging for some, making the office a more equitable environment to do work.

“This pandemic has really, in some ways, just leveled the playing field. We have three branches, and now all the people in the smaller branches are kind of saying ‘This is how we all feel being the little, little face on the screen when we’re not in the room,’” Stukenberg said. “We’ve become really great at being more equitable about hearing all the voices, but the flip side is not everyone has great internet, or a great place to work, or has three roommates and not a good desk. What has really hit home with me is that we need the office for many of those workers who may not have the opportunity to have a good remote work setup.”

Recognizing that Zoom calls are here to stay, and the option to work from home is likely here to stay, the two designers describe an environment that will be different from the environment that people left more than a year ago with more technology, rooms outfitted to seamlessly facilitate in-person and teleconferencing, and an atmosphere that may be flipped from what we experienced previously.

“Our focus spaces are going to become a lot more private, versus what we’ve seen with open benching in previous years. Those spaces are going to be more private, and then our collaborative spaces are going to be more open. That really puts this workplace on its head,” Stukenberg said. “We’re going to have more private spaces. I think we’re going to see a lot more teaming areas. And social spaces are going to be a lot more important. That’s where we build our social skills that we need to work together and practice those skills.”

“Creating that level of energy, buzz, and excitement will be key in bringing people back to the office environment in the future,” Fisher said.

BWBR Joins Other AEC Leaders Calling for Presidential Action on Green Building

President Joe Biden made a commitment to “Build Back Better” in the wake of COVID-19, the economic crisis, social upheaval, and regulatory rollbacks by the former administration. A growing group of architecture, engineering, and construction (AEC) firms is calling on his administration to also build back greener. He can do this, they say, by adding sustainable building strategies to his climate agenda and environmental justice plans.

“The gaps that have exacerbated many of our problems the past year existed before the pandemic exposed them,” said Pete Smith, FAIA, presidents and CEO of BWBR. “We have a great opportunity to fill those gaps with more and effective sustainable strategies, and it needs support throughout business and government to do it.”

The president has already signed multiple orders and memoranda relating to climate and environmental justice, but only a few have directly addressed the building sector. Actions so far have focused on fair and affordable housing. What remains, according to the Sustainable AEC Leaders making their appeal to the administration, is a panoply of executive actions that are designed to address the building sector’s outsized impacts on greenhouse gas emissions and social equity—and its vulnerability to climate change.

The letter recommends actions in six categories:

  • Enhance federal building standards—Includes a return to Obama-era requirements for high performance along with new initiatives aimed at decarbonizing the federal building stock, like a base building code for all federal buildings, which are not subject to local codes.
  • Stimulate building reuse and upgrades—Calls for tax code reforms and other means of promoting reuse and retrofits.
  • Promote healthy housing and resilient communities—Suggests national guidelines for healthy housing, along with better resilience tools like higher-quality flood maps.
  • Electrify to achieve a carbonfree grid—Highlights opportunities like model net-carbon building codes and model electricity rates that incentivize grid harmonization.
  • Promote material health and product transparency—Addresses toxic cleaning products and building materials, along with embodied carbon.
  • Promote healthy schools for all—Includes the idea of an Office of Healthy, High Performance and Resilient Facilities within the Department of Education.

By speaking as an industry sector rather than an advocacy group, the Sustainable AEC Leaders hope to gain more traction within the Biden administration. Companies can review the AEC letter here and sign on to be included in that campaign by filling out this Google form by March 10.

About BuildingGreen

BuildingGreen, Inc. is a consultancy and information company trusted by thousands of AEC professionals for insight and guidance on sustainable design, resilience, and health in buildings and communities. BuildingGreen also supports and facilitates peer networks for sustainability leaders interested in learning from each other and advocating for positive change, with initiatives including this letter to the Biden Administration.

Human-Centered Safety®: Seeing Mental Health through a Different Lens

As Scott Holmes recounts his evolving interest in the design of mental health spaces, it was the story of a young man Holmes met who described his experience being led to an inpatient unit that had a profound impact on Holmes’ commitment to changing the image of mental health treatment.

“The behavioral health units were in the oldest part of the building. It was in a bed tower,” Holmes recalled. “There was not a great way to get from the emergency department on one side of the campus to the inpatient unit. There was really two choices: you either take that patient through a kind of main circulation spine on the main level, or take them through the lower level, which, I think, the facility thought was a better option.

“Unfortunately, it took him through service corridors where the corridors had plywood on the walls, exposed ceilings, just lots of clutter. The young man made the comment about how humiliating and how much shame that he felt through that, and used the term, ‘walk of shame.’ I think that fundamentally has changed our approach. We need to think about what that first impression is, and, instead of thinking about the walk of shame, how can we create the walk of hope?”

Stories like that one from patients, family members, and staff led to a new approach to the design for mental health care at BWBR, one called Human-Centered Safety®. Holmes, RA, ACHA, LEED AP, and Melanie Baumhover, AIA, LEED AP, talked about the development and application of that approach on the Side of Design podcast as a prelude to their upcoming webinar presentation on March 18 with the Center for Health Design.

The approach of Human-Centered Safety® is different because it looks at promoting safety through design elements that go beyond anti-ligature and restrictive measures. Focused around six tenets (access, connections between spaces, technology, calm, integrated safety, and culture), the human-centered approach places dignity and an environment of hope at the center of the strategies, promoting safety through the environment of care.

“Anyone who’s worked in the environment of mental and behavioral health know that it is important for accredited agencies that you have a safe space, and in mental and behavioral health that’s often from self-harm, most frequently ligature points,” Baumhover said. “Sometimes it can be, quote, easy to only focus on ligature resistance and that self-harm and stop there. Our Human-Centered Safety® approach with the six tenets really tries to focus on the whole person, and not just looking at them as a sick person.”

In this approach, the strategy focuses on both what the space is communicating to the patient as well as how the space accommodates a patient’s movement. Where therapy and treatment occur outside of the patient room, the focus turns to creating open environments with sight lines that build trust between patient and staff, reducing corridors and pinch points that could agitate patients sensitive to their personal space, and leveraging the appropriate colors and materials to build a sense of hope and confidence that patients can heal.

Pine Rest Christian Mental Health Services Van Andel Center Expansion

“These are humans who can read, and you are not being treated as human,” Baumhover said, referencing previous strategies that would communicate safety and harm reduction first with authoritarian messages and heavy, institutional elements. “You were being talked about as an object, as a thing that needs to be managed, too.

“So [we’re] paying attention to those messages that patients are getting, and how the environment is speaking to them, literally through signage, but also through the very elements of the space and what it tells them about their condition, what they can feel, or trust about their condition, and how they might move into that space.”

“It’s not just the patient,” Holmes said. “It’s family members: to imagine yourself as a parent, bringing your child, knowing that your child needs help, but then showing up at a place like that and thinking, ‘Oh my gosh, what am I doing to my child?’ So I think it’s for everybody. Unfortunately, mental health has taken the backseat for a number of reasons, and it’s really time for us to bring that…parity of experience for patients and family members and for staff.”

Holmes said that improved experience of care can have a dramatic impact on staff injuries, which can have a correlating improvement in staff satisfaction and recruitment.

“The other aspect of these concepts of Human-Centered Safety® is really about trying to reduce those things, environmental triggers, or other things that agitate a patient and cause aggression, which often results in violence and staff injuries and other things,” he said. “So, really smart design, the best practice is to create space that’s not only safe for patients but are safer for staff, and when staff feel that they’re going to be safer there, they feel empowered.”

Knowing that [patients] can do things that impact how [they] feel and impact the world can be really empowering, and sometimes demonstrating that to patients can help them feel more in control.

Melanie Baumhover, AIA, LEED AP, behavioral designer

A significant contributor to the positive outcomes of the human-centered approach is giving patients a sense of control at a time in their life when the world can feel out of proportion. Color-changing LED lighting in sensory rooms or even the patient room, music station choices in bedrooms, and seating options may seem like little gestures, but they can be significant for the patient.

Sensory room with blue lighting.

“Our post-occupancy evaluations of our projects, as well as environmental psychology studies that we have read, show that giving people choice and control can help them see that they can impact the world. They don’t just have to take it as it washes over them,” Baumhover said. “Knowing that [patients] can do things that impact how [they] feel and impact the world can be really empowering, and sometimes demonstrating that to patients can help them feel more in control. And when they feel more in control, they have fewer out-of-control moments, which sometimes manifests in attacking or lashing out at other patients or staff members.”

The biggest challenge, both said, is the diversity of needs that each patient brings to their treatment, including those needs defined by region or age, especially between children and adolescents who may react to spaces that either speak down to them or aren’t playful enough.

“Trauma-informed design can’t predict every trigger for every individual,” Baumhover said. “So, you look at the population that’s there. You work with the staff to try to understand what they’ve found historically. But there is no one-size-fits-all color. There is no one-size-fits-all layout. So, really, it’s a matter of working with the staff and clinicians within that unit to talk about what kind of patients do they get. What are their concerns? Who do we want to design this around?”

With a focus on the high points of a patient’s stay and where they could go after treatment, she said it’s makes the work rewarding.

“One of the most rewarding stories is when we designed a new facility and, at the open house, somebody who had been a past patient realized that we were the design team and said, ‘You know,’ tears in his eyes, ‘Thank you. This is the most beautiful space I’ve ever been in. And I really appreciate that you designed this for me, for us.’” Holmes said. ”That’s what makes it rewarding. It’s seeing the impact that it has.”

Does Space Matter in Mental Health Treatment?

Treating children and adolescents with mental and behavioral health issues is challenging. For those seeking treatment, care must be of the highest quality. Research suggests therapeutic environments can positively influence the patient experience. Treatment, culture, and care models that place emphasis on enhancing the relationship between patients and staff rather than on controlling patients are a growing standard of care and have greater effectiveness when supported by a therapeutic environment.

The groundbreaking University of Minnesota Masonic Children’s Hospital Mental Health Unit renovation used evidence-based design strategies to enhance the organization’s care model, uncovering a better understanding of the link between the physical environment and the healing process for children and adolescents facing mental health challenges. After completing the inpatient renovation, the University of Minnesota Masonic Children’s Hospital and BWBR partnered to conduct a post-occupancy study focused on how the design elements and spaces influenced calm feelings for patients.