Month: April 2021

By Swati Goel

Approximately 187,000 students enroll in a Ph.D. program each year in the United States. My journey is specific to Clemson University’s Planning Design and Built Environment cohort of 2023, with a concentration in Architecture + health during COVID-19 times. I would say that makes it quite unique.

I am an international student from India. I am trained as an architect. My research interest brought me to the United States in 2017 to get a master’s degree in design and health from the University of Michigan. I started my Ph.D. program at Clemson in the fall of 2020 after working as an architect for two years (to ensure I was making the correct decision for my career). I am passionate about architecture and mental health and was looking to combine design and research. That is when I stumbled upon Clemson’s Architecture + Health program.

COVID-19 hit the United States hard a year ago in March of 2020 and slowly took away all sense of community and peer support. Initially, I thought it would allow me to focus better. Still, as time went by, physical distancing began to feel exhausting, and there was no one to share the good and the bad. I had moved to South Carolina from Indiana after quitting my job as an architect and leaving behind all my friends and support system. COVID-19 made it hard to establish new connections at the onset, a crucial ingredient of graduate school.

The first semester at Clemson University was a significant change and called for adjustment. I had moved multiple times before, but this time was different with no previous acquaintances. Besides, shifting my mindset from an Architectural Designer to a full-time researcher was exceptionally challenging. It required a complete rehauling of my approach towards work. While designing, architects constantly improvise a set of drawings or writing guidelines, which can be reused and do not need a systematic process. However, research is very organized and novel. The process is unique and requires constant reading and insight. The first two months went into decorating my new apartment, but once that was done, all I had left was my studies and an endless series of ZOOM calls. Three months into it, I realized there was a term for it- ZOOM fatigue! (Fauville et al., 2021)

All the classes were online, research assistantship work was online, and all my friends and family were online. I could not meet people and make many new friends in Clemson. A few months into the program, my advisor suggested that the research assistants work in the Ph.D. student offices while practicing social distancing. It was nice to leave my house and be around my research team once or twice a week. I was beginning to see the importance of peer support while pursuing a Ph.D. We could talk through ways of doing research activities and brainstorm ideas. It is tempting to stay home and sit in front of the computer and plan and read. However, once I started going to school, I realized the importance of in-person interaction, taking breaks, and investing in myself; instead of just being a Ph.D. student. In a study assessing the effects of the COVID-19 pandemic on college students’ mental health conducted at a large university in Texas, 86% (n=195) of the participants reported decreased social interactions due to physical distancing, while 89% reported difficulty in concentrating (Son et al., 2020).

I grew more and more grateful for the support system I found in the other Ph.D. students who I had the opportunity to meet and work with in person. Earlier I used to think that a Ph.D. is a feat to be accomplished alone, but it is the opposite. The more we alienate ourselves, the harder it gets. It needs to be shared and celebrated, at least the first two years! That’s how we grow as individuals and researchers. It gets better. In the Fall of 2020, the Center for Health and Facilities Design Testing (CHFDT) team organized multiple (physically distant) events such as pumpkin carving on Halloween and hikes in nature to enforce peer connection. Clemson University held socially distant football games at the memorial stadium with reduced seating. And finally, in my winter break, I celebrated Christmas with my fabulous new friends in Clemson and later saw my friends in Indiana. These activities reinforced the importance of combining work and play and the power of community and peer support.

I am in my second (spring) semester right now. The expectations are higher, but I feel more at home with myself. I have a nice routine. I am more organized. I am more in sync with my role as a researcher. I have a great support system within my research community and outside. I reach out to my friends and mentors whenever I need them. I am more productive and yet carve time to be myself.

All research papers end with a conclusion! A year later, and COVID-19 hasn’t left our lives; in fact, it has been a unique experience for everyone. Students and professionals are suffering due to more than usual hours spent at home. Clemson’s dining halls are open this spring, and I think the line between sweatpants and jeans is blurred. Screen time has increased, and exposure to sunlight and physical activities plummeted, leading to a rise in mental health issues. In the research at a Texas University, only 76% (105/136) of students utilized any coping mechanisms to handle the stress due to the outbreak (Son et al., 2020). Out of these 105 students, only 30% of students mentioned using physical exercise to manage stress. Another 21% used streaming and social media as a means of self-management. 44% of the students experienced some depressive thoughts due to loneliness and uncertainty. These outcomes worry me, and I wonder how an architect + researcher would respond to that? I do not have a perfect answer, but I am looking.

Personally, COVID-19 taught me to be grateful for my peers and colleagues. I am thankful for a supportive and encouraging team at the Center for Health and Facilities Design Testing. I am thankful to my advisor for thinking ahead of time and encouraging us to return to our offices while being safe. These experiences made me humble and appreciative of little things that I would not have if I were not forced to spend so much time alone. Maybe there is a lesson for all of us here!

Sources:

1.  https://www.statista.com/statistics/185167/number-of-doctoral-degrees-by-gender-since-1950/
2. https://news.stanford.edu/2021/02/23/four-causes-zoom-fatigue-solutions/
3. https://cookchildrens.org/coronavirus/action/Pages/Safe-Reopening.aspx
4. Son, C., Hegde, S., Smith, A., Wang, X., & Sasangohar, F. (2020). Effects of COVID-19 on College Students’ Mental Health in the United States: Interview Survey Study. Journal of Medical Internet Research, 22(9). https://doi.org/10.2196/21279
5. Fauville, G., Luo, M., Muller Queiroz, A. C., Bailenson, J. N., & Hancock, J. (2021). Nonverbal Mechanisms Predict Zoom Fatigue and Explain Why Women Experience Higher Levels than Men (SSRN Scholarly Paper ID 3820035). Social Science Research Network. https://doi.org/10.2139/ssrn.3820035

by Anjali Joseph

I started my work in healthcare design research more than 16 years ago as a doctoral student at Georgia Tech working with Dr. Craig Zimring on synthesizing the literature on evidence-based healthcare design. This literature review and its follow up study published in 2008 clearly showed that the built environment of healthcare settings mattered in terms of improving patient safety, healthcare quality and patient experience. However, it also highlighted the complexity involved in studying healthcare environments and the difficulty in isolating the impacts of single built environment features from other factors such as patient characteristics, staffing and organizational factors. Over the years, I have come to realize that while it is important to conduct research focused around single built environment variables (e.g. light levels, door width) and healthcare outcomes (e.g. patient falls), it is perhaps even more critical to study and design healthcare physical environments as part of a larger work system. This is particularly true in high-risk patient care environments such as patient rooms, operating rooms and exam rooms that involve complex interactions between individuals, teams, tools and technology and the space where care is provided.

Existing frameworks in the health systems and human factors world recognize the physical environment as one of the components of the healthcare work system that impact healthcare processes and outcomes. These models such as the Swiss Cheese Model and the Systems Engineering Initiative for Patient Safety (SEIPS) framework suggest that the onus for providing safe patient care does not solely rest with the clinicians that interact with the patient. Rather, well-designed work systems are critical for achieving safe patient care. The work system as described by the SEIPS framework and others includes the physical environment, the people (patient, staff, families), the tasks performed, the tools and technology used as well as the organizational policies, that dynamically interact with each other over time to shape care delivery and healthcare outcomes.

While these models recognize the built environment as a system component, the physical environment is usually considered a given, hard to change, even while recognized as a significant barrier to care. Human factors researchers often focus on studying individual and team level interventions such as tools to support communication, or device and interface design to support physical and cognitive ergonomics, improve usability and reduce error. This body of research and practice recognizes the role of the physical environment in supporting healthcare work, but the interactions between the physical environment and other elements such as technology are understudied. For example, for one of our projects at the Center for Health Facilities Design and Testing focusing on integrating computer workstations in preoperative exam rooms, we found that while there were studies and tools around the physical ergonomics of the workstation itself and computer interface design, there was a lack of information about how these workstations should be integrated into the physical space of the exam room to support workflows and communication between clinicians, patients and families. This led us to develop an ergonomic assessment tool that focused on the integration of the workstation within the physical space. Similarly, several studies have identified clutter, crowding and noise as significant environmental challenges in operating rooms. However, we found that information on how the operating room physical environment layout and design supported the work of nurses, surgeons and anesthesia teams in ORs was lacking. This led to a multi-year collaboration as part of an Agency for Healthcare Research and Quality (AHRQ) funded patient safety learning lab on safe OR design resulting in a deep understanding of the OR work system, design of a new OR prototype and Safe OR design tool and implementation of our work in two ambulatory surgery centers.

It is challenging for healthcare architects and researchers to study complex healthcare work systems – they are difficult to access and observe, with a steep learning curve involved in understanding and interpreting what is observed. In this context, simulation-based evaluation of physical mock-ups are extremely helpful in obtaining input on work system performance. These evaluations engage frontline clinicians by asking them to simulate clinical tasks in typical and high-risk patient care scenarios using different equipment and technology. This allows staff to experience proposed designs within the context of their everyday work and identify physical environment features that pose challenges. For example, as part of the design process for a new 400-bed children’s hospital, the team at Children’s Healthcare of Atlanta built out a large warehouse with physical mock-ups for 11 clinical areas and conducted three rounds of simulation-based evaluations with more than 154 clinical staff. These evaluations focused on understanding the performance of the work system, resulted in significant design changes to address the 190 workflow and patient safety challenges identified. This project also highlights the importance of collaborating with clinicians, human factors and simulation experts in healthcare facilities to study and design these complex work systems.

A poorly designed healthcare work environment will create barriers to safe care every single day, while a well-designed and flexible physical environment can support the inherent variability of healthcare work. The healthcare facility design process for new buildings or renovations can be viewed as the design of multiple interconnected work systems at different spatial scales. These work systems will shape healthcare work and patient safety for years to come. It is important that healthcare design teams approach facility design projects from a health systems perspective, actively incorporating feedback from front-line staff using approaches such as simulation-based evaluation of physical or virtual mock-ups that allow the interactions between physical space, people, tasks and technology to be understood. Similarly, it is critical that healthcare organizations commit to incorporating questions and approaches related to the physical environment into all of their patient safety initiatives. The physical environment is a critical tool in the quality improvement and patient safety toolbox that is yet to be utilized to its full potential.