SIGNAL´s core competency is to focus on the users of space and on the processes that create value for the end user of the space – to use space as a strategic tool in order to achieve new goals in organisations, to work with the link between management, space design, and relations between people.

The starting point of the hospice report

In 2006, SIGNAL completed a report on behalf of Realdania on the optimal hospice of the future – an outline of the hospice as part of the palliative care. The report was made in cooperation with a managing group based on project stakeholders.

The goal was to carry out a programme that could be used as inspiration for planning and establishing new hospices as well as improving existing ones. This article will outline the experiences from the work and shortly reflect upon what it means that physical space can actually play a significant role in creating, maintaining, and developing people´s well-being.

We all know how important it is to have a base; a safe place where we can plan our activities and develop our identities. This is a focus that is seen many places society; today many architects experience great interest from their clients who recognise the organisations´ physical space as a root to better well-being and higher efficiency. Among other things, the new set of rules in the knowledge society helps to recognise that innovation cannot be ordered but should rather be encouraged, and this is where the physical space of the product creating processes becomes an important factor in the value chain.

Hospice: quality of life for the dying

How is the quality of life connected to the development of the good hospice? Generally, a hospice is an institution that is part of our hospital service, but with a slightly different focus: it is about quality of life for the dying and their relatives.

Quality of life is often associated with the quality of the social factors in your life rather than with financial wealth and material goods. And as described above, the physical space is also slowly changing to include a great deal of the actual content of life rather than just focussing on the setting. As the frame that supports the quality of life and reflects the life that is being lived. Quality of life is perceived individually and is based on each individual´s personal needs. Equally, the purpose of a hospice is to create a personal space for death. Compared to either a hospital or a care home, a hospice is almost the closest you can get to dying in your own home. This personal ambition also means that devices and facilities such as pain relief and treatment in a hospice cannot dominate the space design, but that it is rather the link between the patient´s personal expression and the personnel´s professional expertise that should the basis for the architect´s design.

Therefore many of the above facts were the starting point when SIGNAL was first asked to make a programme for the good hospice. We wanted to take focus away from the traditional and often quite characterless architectural expression of the hospital service and instead focus on making the actual users – the patients and the relatives – the starting point of the physical space. Consequently, the purpose of the programme was to come up with concrete solutions to how physical space can encourage and promote presence and socialisation with the purpose of giving the patient the best possible quality of life at the last stage of life.

Focus of the problem solving: dialogue with the users

SIGNAL is a consulting firm that designs physical space for organisations and their activities in a design process where the end user is a very important contributor. The method is based on the link between the physical space and the organisational working processes. Through dialogue based involvement, the users play an important role in developing the spatial organisation and the interior design. The key issue is the ambition to use the conversation about space to actually understand more about working processes not to mention collaboration processes in organisations. Therefore we try to find out whether knowledge about design processes and spatial organisation can be used as a strategic tool in developing the organisation and thereby achieving new goals.

The programme for the good hospice as an example of how we develop tasks

At SIGNAL we work closely together with the future users as well as with various experts in order to keep the purpose of improved quality of life for the user, the patient, and the relatives. Through thorough research of tendencies and traditions and through a comprehensive dialogue with the users came the idea of making a number of design principles and recommendations on how the good hospice can be established and developed further concurrently with a changing target group. The results of the report consist of a factual part that make a status on what the hospice institution looks like today and points forward towards the second part about recommendations drawn up as input and ideas that will hopefully work as inspiration and concrete tools for decision makers, personnel, architects, and engineers who are working on establishing the hospice of the future. The report aims to indicate possible ways and relevant solutions, but it does not indicate a specific solution model. In the following we will briefly walk you through some of the main parts of the problem solving.

The reference group: users and experts as contributors

It was essential to us in the problem solving process to have a close collaboration between the two main groups: a formal management group consisting of central players and experts responsible for on-going evaluation of concept, ideas and results of the project. In addition to that group there was a very heterogenic reference group representing the citizens – some of them experienced within palliative care either as experts or users, but most of them were private members representing the future users. Through facilitated and dialogue based processes, several dilemmas and problems were discussed comprehensively. A few of the topics touched upon we were the role of a hospice in the local community, the spatial units of a modern hospice, the spatial characteristics of the units, the communication between the patients and the personnel, the process for the relatives and the procedure after a patient´s death. The topics were discussed in the beginning of the process in order to agree on the role a hospice should play; both from an individual perspective as well as a social perspective. It is our experience that these dialogues can help make death a natural and visible part of life, a part which is debated openly and prioritised highly. Apart from making death a more naturally part of life, the dialogue has been essential for those of us who work with different kinds of architecture and architectural design as it represent a key input to our work with the design.

An example of an interesting discussion in the reference group was the idea that future users will be more likely to compare a stay at a hospice with a stay at a hotel with a number of different offers to choose from and where the hope for recovery still plays a central role. This kind of stay should accommodate being together with relatives and offer the chance for the users to calmly say their goodbyes while at the same time it offers a treatment. This lead to a discussion about the target group and extent of the palliative care. In the report we suggest a somewhat larger view on the palliative care and it is also considered in the phase where the patient is given life-sustaining treatment. Furthermore, we believe that hospices can be an option for other patients than cancer patients in the future.

Another important issue is the fact that today´s society is a multicultural society: Patients with different ethnic backgrounds will have different needs, for example when it comes to performing religious rituals or the size of the ward. It is a known fact today that families with other ethnic backgrounds often have a larger number of relatives visiting at the same compared to Danish families. Furthermore, we see different and much more diverse family patterns and all these differences must be taken into consideration when planning and establishing new hospices. The report suggests the future hospices to accommodate social time spent between the patient and the relatives – adults as well as children – and to create a space as similar as possible to the everyday life they know.

Analysis on building physics and circulation of information diagrams

Althoug the report had its focus on the future hospices and how to establish them – please see page 30 for the design principles – the work also included a comprehensive research on building physics and the cultural and geographic conditions at a number of existing hospices representing a very large variety. The purpose of the research was to gain a better understanding and knowledge about how the different types of spaces and spatials at a hospice are divided and prioritised in the different cultural and geographic contexts they are part of. On the basis of this overview of space use compared to context, we began to look further into how communication and work processes function between the involved groups at the existing hospices: How does knowledge travel between patients, relatives, volunteers, and employees? It was not much of a surprise that a lot of the knowledge was exchanged between the involved groups at each ward (the care assistants, the charge nurse, and the relatives) or internally within the palliative team (nurses, doctors, and therapists). But it also turned out that a lot of knowledge travels across the established teams, and that this particular knowledge sharing should be supported, for example between the ward´s palliative team and the care assistants. When establishing the building physics, knowledge sharing and communication must be taken into consideration. And when planning the spatial organisation for future projects, experiences from the existing places should naturally be included. However, it is equally important to determine the ambitions for the knowledge sharing and the general communication for the future.

Evaluating atmosphere and expression of space

What expression and atmosphere is important to the patient? When carrying out the hospice programme, we have examined how the main spaces are perceived by the patient: The entry area, the ward, the common room, the reflection room, and the employee area. The data was assessed and processed by the reference group in order to clarify what is important in that particular situation that hospice users find themselves in. We have worked with the following contradistinctions: open vs. possessive, public vs. private, solitary vs. social, close vs. separated, impersonal vs. personal, order vs. mess, fast vs. flexible, light vs. dark, energetic vs. calm, formal vs. informal. The different term sets make up the external points of a scale that is used to describe each space (the entry area, the ward, the common room, the reflection room and the employee area). The placement on the scale for that particular space indicates the atmosphere that the space should encourage.

Collages: visualising visions

At SIGNAL we generally work a lot with collages as part of the user involvement in the design process. The purpose is to “visualise the vision”; to gather all the information we have about the project and create a kind of figurative language that is put together by different types of material. Making collages is a good way to create a broad understanding of the vision among the participants and thereby to ensure the involved stakeholders´ ownership of the project. In the previous illustration of the ward, we see how the different content items are being mixed: atmosphere, materials, surfaces, furniture, access to outdoor areas, lighting, bric-a-brac, space for relations and diversity.

Design principles: Focus and recommendations

The report resulted in a number of design principles which describe concrete focus areas that we believe identify the essential circumstances when it comes to establishing hospices in the future. The design principles have been made as pictographs indicating special points or issues to be aware of when planning and programming the overall building structure, the wards, the personnel areas, and the common areas.

The design principles (pictographs) lean on 8 focus areas. The most important points within those 8 areas will be outlined underneath:

Rethink and professionalise the establishment process. Involve all stakeholders early in the process, make important decisions as late as possible when the data is much stronger than in the beginning of the process, consider the entire process from idea to everyday use and work with a continuous revision.

Build a strong culture – the special hospice culture as platform for the palliative care can be created, maintained and developed through internal workshops and involvement of volunteers and representatives from the local community.

Improve and develop the collaboration across the organisation. By letting members of the palliative team circulate and experience all of the hospice´s functions, the patient and the relatives will to a larger extend feel continuity at the hospice and in its services.

Rethink the ward – higher demands of information and communication technology. The ward should support the differences of the patients. Make it easy for the patients to influence the surroundings (for example by changing the inflow of light, the view, the temperature, perceived size and the degree of privacy and publicness).

Use the hospice building to communicate – avoid direct associations to hospitals as a hospice is something else than a hospital. Use materials that of corporeity. Focus on details and choose high quality materials. Avoid big areas and seek to create a more intimate and personal atmosphere.

Use the physical space and surroundings to facilitate social relations – the informal social meetings are important to patients and relatives. The common areas should be upgraded and planned to be in open connection with the rest of the hospice and accessible for all the patients. Avoid too many and too large common areas as this will increase the risk that the social activities will be fragmented. Set up small and informal bays in the corridors that support spontaneous meeting.

Activate the volunteers who have an important social role at a hospice not to mention a practical help as well. Make sure to have one volunteer coordinator in the hospice management to ensure a closer integration of the volunteers.

The physical surroundings must be improved to facilitate knowledge intensive work processes. Knowledge sharing and cross-functional collaboration is a prerequisite for a good palliative care. Work with open, team based employee areas that include both the palliative team and the ward´s care assistants with the purpose of supporting knowledge sharing and cross-functional collaboration. Close down the individual offices that are often left empty anyway because the work for the most part takes place elsewhere. Devide the employee area into two parts: an open part where examination, consultation, and therapy will take place and a more private part where internal meeting, confidential phone calls, and concentrated work can take place.

We have tried to explore how user involvement can be a relevant input in the architectural design process, and there is every indication that this approach is being used more and more in the industry. In the future, it is important to look further into what it really means to both the architect and the architecture when the main purpose of the design process is to support the establishment of relations, collaboration, and identity.

Af Gitte Andersen.