Exploring Innovative Solutions for Quality of Life and Care of Bed-Ridden Nursing Home Residents through Codesign Sessions.

Bed-ridden nursing home residents are in need of environments which are homelike and facilitate the provision of care. Design guidance for this group of older people is limited. This study concerned the exploration and generation of innovative environmental enrichment scenarios for bed-ridden residents. This exploration was conducted through a combination of participatory action research with user-centred design involving 56 professional stakeholders in interactive work sessions. This study identified numerous design solutions, both concepts and products that are available on the marketplace and that on a higher level relate to improvements in resident autonomy and the supply of technological items and architectural features. The methodology chosen can be used to explore the creative potential of stakeholders from the domain of healthcare in product innovation.

1. Introduction

There are approximately 165,000 persons residing in Dutch long-term care institutions [1]. This is equivalent to around 6% of the Dutch population aged over 65. Nursing homes are often the final place of residence for the occupants. It is, therefore, important that the nursing home is not only a place where care is delivered, but also a place where one lives and feels truly at home making use of a wide array of architectural and technological solutions [1, 2]. This also applies to nursing home residents who are bed-ridden due to their declining health and physical fitness. Bed-ridden residents are confined to bed because of illness or infirmity, especially for a long or indefinite period. This group faces many difficulties in terms of activities of daily living and mobility. The percentage of nursing home residents who are permanently or sometimes bed-ridden was estimated by the Netherlands Institute for Social Research to be about 25%, with the highest percentages found in psychogeriatric wards [3].

To date, not much research has been done on people who are bed-ridden or staying in bed for prolonged periods of time, both in long-term care and hospitals, and how they perceive the space around them. Annemans et al. [4] cited the work by van der Geest and Mommersteeg [5], who concluded that the role of the bed in the general hospital experience is largely under researched: van der Geest and Mommersteeg [5, pages 11-12], “[t]he importance of the bed for health is obvious [, and] beds in hospitals and other medical settings have a special relation to health. They are tools to organise and realise health recovery. [… Hospital] beds are not meant to provide privacy but rather to allow for optimal access to the patient by clinical staff. Hospital beds are surrounded by medical care providers and medical equipment, facilitating permanent surveillance and the possibility of intervention.” In addition, Annemans et al. [4] showed that persons who are bed-ridden, including patients in hospitals, have a different experience and perception of the space around them. For instance, while being transported through the hospital, the bed is an important mediator between the patient and his or her environment. Annemans et al. [4] concluded that most research on beds and transport seems often restricted to functional matters such as organisation and ergonomics.

The situation in well-facilitated nursing homes, in terms of design and technology, is assumed to be similar to that of hospitals. There are, however, significant differences. As mentioned before, a nursing home is a place of residence, and many residents deal with the consequences of dementia syndrome affecting one's perception and abilities, resulting in further limitations to one's resilience and autonomy [6]. Given the transitions in Dutch long-term care, it is expected that the number of bed-ridden nursing home residents, both with a somatic and a psychogeriatric background will increase. This is a direct consequence of the increased threshold for admission, which is related to one's health status and the ability to carry out activities of daily living independently or with the help of home care services [1]. The way long-term care settings are designed for bed-ridden nursing home residents is different from that for residents who have a degree of mobility. This is because the space bed-ridden residents are able to access and use independently is so limited. This should have implications to the character and appearance of buildings. Apart from guidance concerning fire safety that exists on a national level [7], there is practically no design guidance for this group of residents.

The design and construction of nursing homes are a complex and dynamic process, as the very design of these buildings forces us to consider the technology-human interface directly in terms of living-space, ethics, and social priorities [8]. Moreover, the design process includes a large variety of stakeholders, who further add to the complexity. Technology and architectural solutions can support the well-being, activities of daily living, and quality of life of older residents and support and optimize the work processes of healthcare professionals and professionals in the domain of maintenance [9-11]. In order to meet the needs of future nursing home residents, in particular those who are bed-ridden, new creative and inclusive approaches are needed to come up with new and innovative design solutions. In addition, Annemans et al. [4] mentioned that spatial aspects, for instance, that of the direct environment of a bed-ridden resident, cannot be studied isolated from the activities going on in the spaces considered. Depending on what is happening and who is involved, each experience is shaped differently.

The aim of this study was to explore and generate design concepts for the direct environment of bed-ridden residents of nursing homes through interdisciplinary participatory design sessions. These design concepts should consist of innovative environmental enrichment scenarios, which, in this study, concern the enhancement of a person's physical or social environment.

2. Methodology

2.1. Type of Research Methodology: Participatory Action Research and User-Centred Design

Delhoofen [12] stated that, in the concept phase of a design process, also called the creative phase, creativity is allowed. Creativity, on the one hand, is an important source of inspiration for any dynamic organization, and, on the other hand, it is a capricious and uncontrollable phenomenon which defies any formalization and set of rules. Creativity is hard to manage, even though this is often necessary to find new solutions for complex problems. According to Delhoofen [12], creativity is the ability to ignore restrictive frameworks of thinking and to find original solutions for both everyday and new problems. Creativity is not the same as innovation, but creativity is necessary to come to new innovations. We define innovation as the creation of new products and the improvement and differentiation of products.

A qualitative methodology called participatory action research was used for this study and it provides a tool to deal with the complexity of the design challenge and stakeholder-related needs [13-18]. According to Madden et al. [15], participative frameworks have been shown to be useful in design of environments, and participatory action research has a long history of use with disadvantaged groups in order to assist them to improve their living conditions, with researchers and the research subjects working collaboratively to develop solutions for community issues. Moreover, participatory action research “involves practitioners as both subjects and co-researchers” [13, page 613]. According to Howard and Somerville [17], participatory action research is a common methodology among designers but is not often framed as a codesign practice. In this study, participatory action research is integrated with activities of making [19], such as scenario writing and storyboarding, performance ethnography, and collaborative design and prototyping [20-22]. According to Sanders and Stappers [19], “making” is an important activity for designers, as one can bring insights to the surface. Prototypes can play a number of roles, such as evoking a focused discussion in a team, the testing of a hypothesis, and confronting others as the theory is not hidden in abstraction. Other types of visualisation such as scenarios and storyboards can be made to allow designers to experience, test, transform, develop, and complete early ideas [19]. Sanders and Stappers [19, page 6] stated that “in the very earliest phase of the design process, the focus is on using making activities for making sense of the future. Here, making activities are used as vehicles for collectively (e.g. designers and codesigners together) exploring, expressing and testing hypotheses about future ways of living.” This is why the current study focuses on scenarios and prototyping as a way to think about the future of nursing home care for bed-ridden residents. According to the map of design research by Sanders and Stappers [19, 23], the current research can be classified as user-centred design, more than participatory design research, as end users (bed-ridden nursing home residents) are not included in the study but seen as the subject. At the same time, care professionals, who are end-users of the solutions identified in this study, are also stakeholders who benefit from these solutions. Therefore, we do qualify this study as participatory design research.

2.2. Location, Researchers, and Participants

Work sessions were held in the evening of 18 June 2013 at the educational hospital wards of the Fontys School of People and Health Studies, Eindhoven, the Netherlands (Figure 1). The large nursing rooms (containing 4 beds) were about 50 m2 and the small rooms (containing 1 bed) 16 m2 in size. Each session lasted for 120–150 minutes. A total of 12 scenarios were made by 56 participants (Table 1, Figure 2) during the design improvisation sessions that were guided by creative facilitators (10 professional group facilitators and 9 assistant with a background in industrial design and creative techniques). All session facilitators and assistants had been briefed about the procedures and were provided with a manual and an instruction guide prior to the start of the sessions. The role for the session facilitator was to stimulate creativity, supporting the creative process, and to obtain a maximum of variety in responses and input. In the group rooms, session facilitators and assistants supported the various groups of participants. Apart from these facilitators and assistants, JVH, RO, and AD managed the overall processes of the sessions, supported the supply of materials, and collected written documentation. The participants of this study had a mixed background in healthcare, design, housing, and technology (Table 1).

Figure 1

Layout of the rooms at the Fontys School of People and Health Studies, Eindhoven, in which the sessions took place.

Table 1

List of sessions and the characteristics of the participants.

Group/scenario	Group facilitators and assistants	Room	Characteristics of participants	Background
1	CVL	3.416 (single-resident room)	n = 4 (1 female, 3 males)	Healthcare real estate, construction and architecture, and environmental health
2	SA, TW	3.417 (single-resident room)	n = 4 (3 females, 1 male)	Healthcare, interior design/architecture, and medical beds
3	LZV, LV	3.418 (single-resident room)	n = 5 (2 females, 3 males)	Interior design, healthcare, mobility aids, and electrical engineering
4	PG, CH	3.419 (single-resident room)	n = 5 (2 females, 3 male)	Healthcare technology, electrical engineering, ICT, and interactive technology
5	EW, JW	3.406 (group room)	n = 6 (4 females, 2 males)	Architecture, building physics, healthcare, and medical devices
6	MM, BP	3.406 (group room)	n = 6 (3 females, 3 males)	Healthcare, electrical engineering, healthcare technologies, and construction
7			n = 4 (1 female, 3 males)	Healthcare, electrical engineering
8	MN, NP, LOW, and CDH	3.403 (group room)	n = 5 (1 female, 4 males)	ICT, real estate, healthcare, and electrical engineering
9			n = 4 (1 female, 3 males)	Acoustics, assistive technologies, and healthcare
10			n = 4 (3 females, 1 male)	ICT, cleaning, healthcare, and municipality
11	CV, AE, TR, and MW	3.408 (group room)	n = 4 (2 females, 2 males)	Social innovation, assistive technologies, and technology innovation services
12			n = 5 (3 females, 2 males)	Building services, healthcare, electrical engineering, and acoustics
	Total: 10 facilitators, 9 assistants		n = 56 (26 females, 30 males)

Figure 2

Working together to generate ideas, followed by the enactment and filming of the scenarios.

2.3. Procedure and Assignment

At the start of each collaborative design session, a session facilitator welcomed the participants and explained the procedure. Informed consent, covering the permission to use of all written, videographic, and photographic materials, was obtained from the participants at the start of the session. The participants were invited to consider the beds in the rooms as actual nursing home beds and to enhance the environment with materials presented to them in a shared “material library,” including paper and card board, sticky tape and ropes, balloons, plastic covers, and various other do-it-yourself materials. These materials allowed the participants with a high degree of freedom to shape the modifications to the bed and use their imagination. The participants were told that the new scenarios and concepts mattered, not the level of perfection of the results or the execution of the modifications. The 12 scenarios that the participants developed were based on a persona (a fictional character) of a nursing home resident [21, 22, 24, 25]. Triantafyllakos et al. [21] stated that fictional characters have been used as user representatives, either substituting actual users or supporting idea generation. Their foremost objective is to facilitate the identification of user needs and goals and to support the development of detailed and comprehensive scenarios [21]. The interdisciplinary approach to the sessions was used to minimize stereotypical thinking [26]. Context scenarios were defined as a short story, which represented the use of the bed environment by the resident. The scenarios were represented by making actual changes and adaptations to the beds and the direct surroundings using a wide range of materials, which symbolized actual environmental modifications (Figure 2). At the end of the session, the personas were enacted by participants from each group who served as proxy residents (Figure 2). As creativity cannot be forced upon participants, it was important to create optimal conditions in which new ideas can come to the fore. For creativity to thrive, participants had to be comfortable, motivated, and stimulated through challenging goals [12]. Triantafyllakos et al. [21] found that design alter egos technique liberated the majority of participants from the fear of straightforwardly exposing themselves, supported and enhanced their introspection, stimulated their creativity, and helped to establish an informal and constructive atmosphere throughout the design sessions.

2.4. Data Analysis

The scenarios of the sessions were each documented on paper by the participants and filmed by a professional camera crew for further analysis. This is in line with the narrative videotaping approach to “storytelling laboratory” described by Bate and Robert [22]. The results of all 12 scenarios and the rationale behind each one of them (combination of a context scenario and requirements analysis) are presented as case studies containing potential design innovations that can be thought-through and developed in more detail for implementation in the nursing home setting. The transcripts of the scenarios were analysed in conjunction with the videos, in order to also include visual data. The data were analysed based on the six phases by Braun and Clarke [27] and in conjunction with the steps of content analysis by Krippendorff [28].

First, the transcripts were each read in their entirety. Then, they were read a second time to develop open codes identifying design solutions. Open coding concerns the process of unravelling all of the collected data into fragments or codes. Thereafter, codes were added to the transcripts. Similar codes and quotes were clustered and labelled, and themes emerged from this process. Together, the research team organised the codes and clustered them into smaller thematic groups. The final themes were grouped in amalgamation with graphical material from the films that reflected aspects of these themes, which is a form of axial coding. Thereafter, these themes were reviewed and then defined and named. These themes are made up of design concepts and solutions, which in turn could also be clustered in major themes, that is, to which level of human functioning they relate. Researcher triangulation was applied during the entire process; for example, separate analyses of the scenarios were conducted by two of the authors (J. van Hoof, A. M. C. Dooremalen). This guarantees that the data are interpreted independently and from different perspectives. A method triangulation was applied due to the use of both written scenarios and video images.

3. Results

The 12 scenarios contained suggestions that can be used for improving the living situation of bed-ridden nursing home residents or for changing product design and are given in the Appendix. Figure 3 shows a composition of the enactments of each of these scenarios. The main themes which emerged from the analysis of the written and video materials are shown in Table 2. A high degree of convergence and data saturation has been found. The interdisciplinary character of the groups (and the interaction between participants) and the mixed location in both single-person and group rooms contributed to the richness of the scenarios and the data. Some of the themes found in this study are overarching (such as the use of tablet computers), whereas smaller themes are an elaboration of the functionalities one should use the tablet computer for (for instance, opening curtains).

Figure 3

A composition of the twelve scenarios written and enacted by the participants.

Table 2

Themes or design concepts emerging from the scenarios.

Themes	Scenario
Touchscreens, control panels, and tablet computers	1, 2, 5, 6, 8, 11, and 12
Transformer beds (into chairs and baths)	1, 3, 4, 6, 8, 9, and 12
Sensors in bed for measuring vital functions and analysis	1, 2, 3, 7, and 9
Massage mattress of modified mattress (decubitus)	1, 2, 3, 5, and 9
Arm rests	1
Virtual, interactive walls (displaying pictures, films), and picture frames	1, 2, 3, 4, 5, 6, 7, 8, 9, 11, and 12
Home wall with personal belongings	1
Low sill window	1
Sensors responding to movement of arms and legs for control	1, 6
Odour box	1, 7
Mobile furniture for relatives	1, 2, and 12
Workplace for relatives with ICT and Wi-Fi	1, 2
Moveable walls (privacy)	2
Flowers and plants	2, 3, and 5
Food and drinks services (for relatives)	2, 4, 5, 6, 8, 10, and 11
Devices and screens for online contacts (voice calls), chatting	2, 5, 6, 8, 9, 10, 11, and 12
Own choice for interior design	2
Wake-up call and good morning service	2, 4, 6
Atmosphere and homelikeness	2, 5, 7, 8, and 12
Moving experience ceiling	3
Lights, luminaires, sounds, and music	3, 4, 7, 8, 9, 11, and 12
Control buddy	3, 9
Mobile shower	3
Two-person bed	3, 5
Medical equipment unobtrusive	3
Robotics	4, 10, and 11
Smart window	4
Operable curtains	5, 6
Smart wardrobe	5
Doorbells, entrance control, and do-not-disturb button	5, 6, and 8
Mobile washbasin	5
Skylight	5
Mattress with temperature control/HVAC	5, 12
Bionic arms	6
Self-repetitive videos for restlessness	7
Wind machine	7
3D projector	7
Technology for sexual support	9
Planning assistant	10, 11
Control of technology based on eye movement	10
Need for face-to-face contact	11
Freedom to live where you want/mobile environment	12
Information glasses	12
Smart hat: control device for brain activity to steer locomotion	12

The most frequently mentioned theme (11 out of 12) is the use of virtual and interactive walls for displaying pictures, television programs, videos, and materials from the past. This theme is followed by the possibility to have online contacts and to chat with relatives, friends, and fellow residents (8 out of 12). Seven out of twelve scenarios deal with the use of touch screens and tablet computers for the control of the space around them or to place orders for meals and plan the care tasks throughout the day and to control the environment such as curtains. Lights and luminaires, sounds, and music are mentioned (7 out of 12) as important areas for development when designing nursing home environments, for creating a proper atmosphere, for functionality, in order to stimulate day and night rhythms, and in order to make people feel more at ease through music and sounds of nature. The so-called transformer beds, beds that can change their shape into a chair, wheelchair, or bathtub are mentioned by 7 out of 12 scenarios and reflect new products on the market place: beds which can bend and turn and become like real chairs in which residents/patients can sit upright. These developments go together with the desire for smart mattress and smart beds measuring vital signs (6 out of 12) and special mattresses that improve comfort and prevent decubitus (6 out of 12). Seven out of twelve scenarios give attention to the free choice of food and drinks and the need for minibars and coffee corners where visitors can get something to drink. This should contribute to a sense of home and coziness.

Autonomy is an overarching or major theme, which encompasses the freedom and being in control of residents, which is reflected in the choice for meals, planning care activities, being in control of people entering the room, and so on. The smaller themes constituting this overarching theme are numerous. Robotics is a theme mentioned by 3 out of 12 scenarios, mainly in relation to transfers and delivering meals. Homelikeness and atmosphere are another overarching theme, of which smaller themes as flowers, furniture for relatives, and picture frames could be an elaboration.

4. Discussion and Conclusions

4.1. Reflection on Identified Design Solutions

The twelve scenarios resulting from this study contained numerous design ideas and solutions that can be used for improving the quality of life for bed-ridden nursing home residents. In this round of workshops, there was a lot of focus on technologies improving the autonomy of residents and for improving communication capabilities. Overall, the minor and major themes can be on different levels. For instance, tablet computers are things or items and are named as design solutions, whereas the autonomy relates to a personal experience or a human state. The computer tablets, however, can be used for achieving autonomy. The definition of environmental enrichment used in this study, which is the enhancement of a person's physical or social environment, allows for themes that relate to different levels. Various technological solutions were identified, which, apart from the aforementioned tablet computers and touchscreens, include assistive and medical technology such as special beds containing sensors, architectural modifications as windows, and building services solutions including heating, ventilation, and air-conditioning systems and smart home technologies. Although some of the design solutions proposed are futuristic, the vast majority is already available on the marketplace. These innovations are not yet implemented on a large scale in practice, and, therefore, they are still innovative.

Concept generation was at the centre of the study. The goal was to come up with innovative and conceptual design concepts which can be developed into implementable solutions. This study welcomed five types of innovation as distinguished by Delhoofen [12], namely, new products, product improvements, product differentiation, service innovations, and process innovations. The most important aspects of improvement to be achieved with innovations are savings, improvements of functionalities, and extensions of functionalities [12]. Whether the identified solutions can in fact contribute to improvements to healthcare is beyond the scope of the current work.

4.2. Applicability of the Methodology

The chosen approach to this study, participatory action research, has been used within the domain of public health care before. Its combination with user-centred design approaches, however, is relatively new within the domain of healthcare. A small number of scientific publications applying these methodologies within the domain of healthcare and technology are being published (for instance, [29, 30]). The current method had been shown successful in identifying aspects of healthcare facilities which are necessary for the quality of care and life of bed-ridden nursing home residents and for obtaining convergence in design solutions. The creative methodology is very suitable for bringing together people with different backgrounds and quality of knowledge. Cooperation in healthcare innovation is not uncommon in practice. Participatory action research aims to obtain “knowledge and action directly useful to people, and also to empower people through the process of constructing and using their own knowledge” [31, p. 225]. The methodology could, therefore, also be applied within healthcare settings in order to think about improving products, environments, and services and, most of all, to involve nondesigning professionals in a design process. In this methodology, all participants have a role to play, whether it is a designer or engineer or a healthcare specialist. It is, therefore, a truly inclusive design process, but inclusive design in this sense does not pertain to inclusive design or design-for-all. In addition, the participants working in commerce can use the methodology to improve products being designed and produced within their own enterprises. The methodology can also be used for educational practices, for instance, in multi- or interdisciplinary classes [32, 33], for a large spectrum of design challenges, as is currently being done.

4.3. Reflection on the Methodology of the Study

In this study, older persons, nursing home residents, and actual bed-ridden persons were not included in the creative sessions. This means that any solution that comes to the fore does not necessarily reflect the actual needs of older, bed-ridden people. At the same time, the participating healthcare professionals could provide a foundation for the design solutions based on their practical knowledge. In future sessions, one could think of including informal or family carers or professional actors trained in playing nursing home residents, in order to obtain more accurate scenarios. The current cohort of participants, as was discussed in the methodology section, could have based their scenarios on stereotypes of bed-ridden residents or could have portrayed them as somewhat active and independently functioning older people, which does not match with the actual health status and abilities of bed-ridden nursing home residents. Moreover, the methodology chosen may lead to scenarios that are enacted in too playful a manner.

Another potential weakness of the study is that participants are not aware of all innovations in the field, of those that appear on the market or are being researched in research and development (R&D) facilities. This may give a skewed perspective on the scenarios, which are either too optimistic or somewhat out-of-date. In the current study, scenarios are enacted using simple, low fidelity prototypes. This also means that concepts are not being developed into real innovative products, which can, in turn, be tested in the nursing home. This means that no field-evidence is being gathered, although the scenarios themselves are based on practice-based evidence. The evidence-based and performance-based designs (van Hoof et al. [34]) are becoming important tools in optimizing the spatial layout and interior design of healthcare facilities. Marquardt and Motzek [35, page 116] stated that “because architects and designers are often not trained in research methods, they may feel somewhat overwhelmed by the terms used in the description of the methodology of scientific papers. Therefore, when designing healthcare facilities, they may not feel confident discussing the evidence available from research studies with members of the medical professions, who often display a profound knowledge of research methods.” When evidence of certain measures is absent, or when new innovations need to be designed, a qualitative approach based on performance ethnography and collaborative design may be a good step in exchanging ideas and come up with new innovative design solutions. The duration of an optimal session should be researched. In the current study, the 2–2.5-hour period was considered to be sufficient for writing the scenario, building the scene, and enacting the scenario.

4.4. Conclusive Remarks

In conclusion, the chosen methodology may help practitioners identify potential solutions that exist to support the challenges in nursing home care. Moreover, the results of this study can be used to adequately design the private rooms and bed environments of nursing home residents in accordance with personal preferences and needs and to stimulate innovations in product design which may become available on the marketplace in the future.