Applied Ergonomics 40 (2009) 608–616

Contents lists available at ScienceDirect

Applied Ergonomics
journal homepage: www.elsevier.com/locate/apergo

An investigation of the use of health building notes by UK healthcare

building designers
Sue Hignett a, *, Jun Lu b,1
a
Healthcare Ergonomics and Patient Safety Research Unit (HEPSU), Department of Human Sciences, Loughborough University, Loughborough,
Leicestershire LE11 3TU, UK
b
Department of Civil and Building Engineering, Loughborough University, Loughborough, Leicestershire LE11 3TU, UK

a r t i c l e i n f o a b s t r a c t

Article history: Building design in the healthcare industry presents a complex architectural challenge. This paper reports
Received 4 May 2007 a qualitative study to investigate the use of building design guidance by healthcare architects and
Accepted 25 April 2008 planners in the United Kingdom. Sixteen architects, healthcare planners and facilities managers partic-
ipated in 11 group and individual interviews. The data were analysed using NVivo2, resulting in three
Keywords: main themes: changes in the design culture over 20 years for the context of guidance use; quality of the
Hospital design evidence base to support the guidance; and future guidance needs to include patient expectations, new
Architecture
building techniques and generic room templates. The use of guidance was variable, with some partici-
Design culture
User participation
pants seeing a clear role for new (more standardised) guidance in the future, whereas others were more
Evidence-based medicine concerned about loss of design freedom. Two clear roles for ergonomics were identified to: (1) facilitate
the participation of patients and clinicians in the design process; and (2) generate new research evidence
with respect to spatial requirements for clinical activities to support standardisation. These recom-
mendations pertain specifically to healthcare facility design for the National Health Service in the UK.
Ó 2008 Elsevier Ltd. All rights reserved.

1. Introduction
In the early 1980s the Department of Health and Social Security
(DHSS) developed an ergonomic database to act as guidance in the
design of new hospitals and the adaptation of old buildings. It has
been re-issued at regular intervals over the last 50 years as part of
Health Building Notes (HBNs) (Ministry of Health, 1961; NHS
Estates, 2005). The aim of the database was to produce a more
efficient planning of space by encouraging those involved in hos-
pital design to think in terms of the relationship between a user and
a particular component and other components located within a
room with respect to the critical minimum space required for
a wide variety of tasks in different working environments (De-
partment of Health and the Welsh Office, 1986). The DHSS hoped
that the use of data sheets would ensure good relatively stan-
dardized working conditions (Hilliar, 1981; Stanton, 1983).
The National Health Service (NHS) is the largest single health-
care provider in the world. It was established in 1948 and provides
comprehensive health care to the entire population such that ‘every
man, woman and child can rely on getting all the advice and treatment
and care they may need in matters of personal health; that what they
* Corresponding author. Tel.: þ44 1509 223003; fax: þ44 1509 223940.
E-mail addresses: S.M.Hignett@lboro.ac.uk (S. Hignett), J.Lu2@lboro.ac.uk (J. Lu).
1
Tel.: þ44 1509 223003; fax: þ44 1509 223940.
shall get shall be the best of medical and other facilities available; that
their getting these shall not depend on whether they can pay for them
or any other factor irrelevant to the real need’ (Webster, 2002). By
2005 there were over 600 NHS Trusts providing a range of primary
care, acute, mental health and ambulance services throughout the
UK (Davies, 2004). The complexity of the organisation and changes
in the capital funding, with private finance initiative schemes since
1997, add to the challenges for both the healthcare building de-
signers and the guidance writers.
For many years there have been criticisms of both the design of
hospitals ‘the mistakes at one hospital are repeated in others’ and the
construction process ‘taking years to build, costs escalating, leaking
roofs, cladding falling off’ (Smith, 1984). It has been said that ‘few, if
any other industries, have been subjected to so much piecemeal and
uncoordinated regulation. Hardly any aspect of hospital operation –
from the width of the corridor to the number of fire extinguishers to the
method of cost funding and accountancy and the overtime payment of
the orderly – escapes the scrutiny of some public official’ (Moran et al.,
1990). For example, the National Audit Office (2005) identified that
at least seven agencies were issuing guidance relating to patient
safety, including Medicines and Healthcare Products Regulatory
Agency, Health Protection Agency, NHS Litigation Agency, NHS Es-
tates, National Patient Safety Agency, Health and Safety Executive,
Healthcare Commission as well as individual hospital policy. The
level of guidance has produced duplication and redundancy with,

0003-6870/$ – see front matter Ó 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.apergo.2008.04.018
 S. Hignett, J. Lu / Applied Ergonomics 40 (2009) 608–616 609

for example, the HBNs offering over 1240 different room specifi-
cations, including 10 different pantry sizes and 6 different utility
room sizes, with 88% of rooms less than 40 m2 (LaFratta, 2006).
Scher (2006) commented that the ‘information for design in the NHS
is in a hopeless muddle’. A further layer is added by the multiple
bureaucracies to interpret the design guidance for example, fire
officer, building inspector and town planner (Lawson, 1997).
The principles and concepts behind healthcare building design
have changed over the last 50 years. Glanville (2006) suggested that
the focus of healthcare building has gone from design for designers
(1960s), to design for healthcare planners, and finally design for
service delivery. Francis (1998) identified a number of initiatives for
a standard design, the first being ‘Best Buy’, ‘a low, compact, eco-
nomic plan with highly serviced departments of diagnostic and
treatment in a central core separated by a ‘ring main’ corridor from the
wards’. The second initiative (Harness) had ‘all departments as-
sembled round a main corridor, known as the Harness zone, through
which people, supplies and energy pass’. It recommended standard
plans for most departments as a time saving measure for the
building programme and provided not only guidance and standard
plans but also a complete methodological approach from briefing to
evaluation. Many of the principles were derived from consider-
ations of multi-disciplinary teams. The Nucleus programme was the
third generation of guidance that took the notion of design stand-
ardisation a stage further. Cruciform templates delineated an out-
line plan for all departments for clinical care, diagnostic and
treatment. The neutralised design aesthetic was to create ‘a building
form flexible enough to blend into, not dominate, its environment
domestic in scale with overall geometry to give visual consistency to
a wide range of functions’.
The response by architects and stakeholders is reported in an
evaluation of Nucleus in 1987, where some ‘clients resolved the re-
strictions of nucleus by accepting the Nucleus model than then
(ab)using it to suit themselves’ (MARU, 1987). Architects and plan-
ners criticised Nucleus saying that ‘it was too prescriptive, tended to
stifle creativity and simply failed to address design issues such as lo-
cation, legibility and sense of place’ (Francis, 1998) and it eventually
became less used as the NHS was reorganised into independently
managed units (Trusts) in the 1990s with more autonomy over the
design process.
In 2001 another piece of design support/guidance was issued,
the Achieving Excellence Design Evaluation Toolkit (AEDET). This is
recommended for assessing new healthcare buildings with three
main headings, functionality (user, space, access), impact (character
and innovation) and build standard (performance, engineering,
construction). It is not promoted as a universally applicable tool,
but as a criterion which may be adapted and incorporated into
‘specifications of design vision, philosophy and quality’ (NHS Estates,
2001). The usability of AEDET has been questioned by Gesler et al.
(2004). They suggested that expecting participants (stakeholders)
to translate quite complex qualitative judgements about several
discrete questions into single scores in AEDET may, in practice, be
quite difficult to achieve.
More recently quality issues in the NHS have been included in
Clinical Governance. This is ‘a framework through which NHS orga-
nisations are accountable for continuously improving the quality of
their services and safeguarding high standards of care by creating an
environment in which excellence in clinical care will flourish’ (De-
partment of Health, 1998). As the effectiveness of healthcare de-
livery is determined, in part, by the design of the physical
environment and the spatial organisation of work (Reizenstein,
1982; Gadbois et al., 1992) it seems appropriate to apply this
framework to architectural design. A UK survey in 2004 found that
nurses based their decision to work at a hospital on a variety of
factors, including the workspace in wards (Harrison, 2004). In
particular the logical and rational organisation of space and
equipment was seen as highly important for staff retention, from
too little space to work in and doors too small to allow easy
movement of beds, to the location of equipment and insufficient
electrical points (CABE, 2004).
This qualitative study explored how hospital designers (archi-
tects and planners) have used guidance (HBNs) in the UK in the
past, and their expectations of future guidance.
2. Methods
A series of semi-structured interviews were held with archi-
tects, facilities managers and healthcare planners in the UK. An
interview schedule was developed from the literature and personal
experience, and piloted with minor changes to improve focus and
clarity (Fig. 1). The topic areas stayed the same through the data
collection with minor changes to the questions within the semi-
structured framework. The interviews were audio-taped and
transcribed verbatim in preparation for analysis. Contact summary
sheets were completed to capture immediate thoughts and sum-
marise the main points from each interview (Miles and Huberman,
1994). As the study progressed, and theoretical saturation was
approached, the new or target questions started to develop into
questions for the data analysis rather than the participants.
Data management was a three-stage cyclical process (Miles and
Huberman, 1994; Dey, 1993). Initially the data were organised and
reduced in NVivo2, a qualitative data management software

Topic area Questions

1. Use and impact of HBNs Please describe your experience of using HBNs in the design
of bed spaces (cubicles and rooms) and en-suite areas?

2. Space priority What do you think the HBNs bring to the design process?

3. Stakeholders Who do you think the stakeholders are for HBNs?

4. Staff working space In your experience how do the HBNs assist in ensuring good
working environments?

5. Changes How have the HBNs changed over the last 20 years?
How has the use of HBNs by Architects and Planners changed
over the last 20 years?

6. Future hospitals What will drive change in healthcare building design in the
next 20 years?

Fig. 1. Interview schedule.

610 S. Hignett, J. Lu / Applied Ergonomics 40 (2009) 608–616

package (Bazeley and Richards, 2000). Stage 1 started the analysis
by classifying the text into preliminary codes. Stage 2 involved re-
coding the interviews with the revised conceptual framework.
Stage 3 tested the interpretation against the literature and empir-
ical data.
Four sampling strategies were used (Patton, 1990; Hignett,
2005) to support iterative data collection/analysis (Fig. 2). Thirty
experts were contacted, of these 10 declined or failed to answer, 1
was unable to arrange a time for the interview and 19 participated
in individual and group interviews between September 2004 and
November 2005 (Table 1). Three architects withdrew from the
study, resulting in 11 interviews with 16 participants: 10 architects,
4 healthcare planners and 2 facilities managers.
The first sampling strategy was purposive sampling, where
a wide range of experts were approached to provide the greatest
opportunity to gather the most relevant data about the phenome-
non under study (interviews 1–4). The second sampling strategy
used both snowball sampling (where cases of interest were identi-
fied from people who knew people) and opportunistic sampling to
follow new leads during field work (interviews 5–7). The third
sampling strategy sought clarification on aspects of the in-
terpretation through focussing to seek out information-rich cases
(interviews 8 and 9) and finally analysis sampling (fourth) was used
to challenge the scope of the interpretation by seeking confirming
and disconfirming cases to elaborate and deepen the analysis, seek
exceptions, limit conclusions and look for variations (interviews 10–
12). The empirical transcripts were checked by the interviewer and
then returned to individual participants for confidentiality and ac-
curacy checking. The data from interview 6 (participants 8, 9 and 10)
were withdrawn at the request of the participants. On acceptance of
the transcripts, the data were entered into NVivo2 for analysis.
Ethical approval for the study was received from Loughborough
University Ethics Committee before data collection commenced.
3. Results
Stage 1 of data collection and analysis resulted in 45 preliminary
codes (Table 2).
At this stage a detailed secondary coding was conducted within
the codes to identify six higher-level themes (design climate; de-
sign culture; participatory design; evidence base/methods of de-
sign; future issues; guidance). The analysis of interviews 1–5 was
then checked and recoded with these higher-level themes. During
the coding of the interviews 7 and 8 minor changes were made to
clarify and expand the definitions of each theme. This included
moving design climate as a sub-code to the design culture code. The
analysis of interviews 9–12 developed the codes to more inclusive
descriptions and explanations resulting in three final themes:
1. Design culture (including design climate and participatory
design)
2. Evidence base (including design history, international research
and quality issues)
3. Future guidance needs (including concepts and patient
expectations).
All the data were then further reviewed and searched for the
final three themes (Table 3).
The research met the three criteria for general validity from
Dingwall (1997) by: (1) maintaining a clear distinction between the
data and analysis (NVivo2 datasets); (2) searching for the negative
cases in the data collection; and (3) dealing even-handedly with the
participants through the return of data for accuracy and confi-
dentiality checking. At an operational level internal validity was
established through the audit trail and the analytic induction pro-
cess of testing theory (Hignett, 2005). To enhance external validity
(generalisability and transferability) the findings from this project

Data collection and analysis/reduction (stage 1)

Sampling strategy 1: Spreading the net: Purposive sampling with advice from NHS Estates
for interviews 1- 4),
Sampling strategy 2: Following up leads: Snowball (suggested contacts) and Opportunistic
(at meetings/conferences) for interviews 5-7
Transcription and participant checks. Preliminary coding using conceptual framework from
literature and personal experience = 45 codes
Analysis of codes resulted in 6 themes: design climate; participatory design; design culture;
evidence base (methods of design and evaluation); future; guidance.

Data collection and analysis/reduction (stage 2)

Sampling strategy 3: Focusing: Intensity sampling (information-rich) for interviews 8-9
Sampling strategy 4: Analysis sampling: Confirming/Disconfirming to seek more information
for interviews 10-12
Transcription, Participant checks
Secondary coding using revised conceptual framework (6 themes)
(N.B. data from interview 6 withdrawn)

Data Display & Conclusion drawing (stage 3)

Interviews 1-5, 7-12 recoded and searched to test final 3 themes
Literature dataset coded in NVivo2 using final codes to search for explanation and explore
alternative theories. Alternative theories then tested against data.

Fig. 2. Method flowchart.

 S. Hignett, J. Lu / Applied Ergonomics 40 (2009) 608–616 611

Table 1
Participants.

Participant Profession Experience Individual/group Interview

1 Healthcare planner >20 years Individual 1
2 Healthcare planner >20 years Group 2
3 Architect >20 years Group 2
4 Architect >20 years Individual 3
5 Architect >20 years Group 4
6 Architect 10–20 years Group 4
7 Healthcare planner 10–20 years Individual 5
8a Architect >20 years Group 6
9a Architect >20 years Group 6
10a Architect 10–20 years Group 6
11 Facilities manager 10–20 years Individual 7
12 Facilities manager >20 years Group 8
13 Architect >20 years Group 8
14 Architect 10–20 years Group 9
15 Architect 10–20 years Group 9
16 Architect 10–20 years Group 10
17 Architect >10 years Group 10
18 Architect 10–20 years Individual 11
19 Healthcare planner >20 years Individual 12
a
Data withdrawn.

Table 2
Preliminary codes.

NVivo2 codes First level Second level Third level

(1 1) Stakeholders Nurses
(1 2) Stakeholders Doctors
(1 5) Stakeholders Patients
(2 1) Healthcare area Mental health
(2 2) Healthcare area Primary care
(2 3) Healthcare area Infection control
(2 4) Healthcare area Manual handling
(2 5) Healthcare area Disability access
(2 6) Healthcare area Resuscitation
(2 7) Healthcare area Bariatric
(3 1) Architects’ issues Recommendation compromise
(3 2) Architects’ issues Experience
(3 3) Architects’ issues Design concepts
(3 4) Architects’ issues Professionalism
(4 1) Room types Waiting areas
(4 2) Room types Office
(4 4) Room types Circulation spaces
(4 5) Room types Ward
(4 5 1) Room types Ward Storage
(4 5 7) Room types Ward Nursing ward station
(4 5 11) Room types Ward Single room
(4 7) Room types Speciality
(4 7 2) Room types Speciality A&E
(4 7 3) Room types Speciality Critical care
(4 7 6) Room types Speciality OPD
(4 7 10) Room types Speciality Surgery
(4 9) Room types Room design
(4 9 1) Room types Room design Flexible acuity
(4 9 2) Room types Room design Layout
(4 9 5) Room types Room design Generic–standardised
(5) Planners’ issues
(6 1) Schemes PFI
(6 2) Schemes LIFT
(8 1) HBNs History
(8 2) HBNs Purpose
(8 3) HBNs Participation
(8 4) HBNs Future
(8 5) HBNs Use
(8 6) HBNs Adjacencies
(8 7) HBNs Legal
(8 8) HBNs Nucleus
(8 9) HBNs Research
(9) Construction
(9 1) Construction Compromise
(10) Technology
612 S. Hignett, J. Lu / Applied Ergonomics 40 (2009) 608–616

Table 3
Final themes.

Code Includes
(1) Design culture [ideas and concepts Conflict between consumerism (patient) and efficiency (staff)
driving design] Timid. Innovation stifled
Who are the buildings being designed for?
Criteria; customer; speed of healing; outcomes; recruitment; retention
External constraints, e.g. Design Review Panels, H&S law, Building Regulations, Prince’s Trust
Loss of architectural and planning expertise due to lack of hospital building during 80s and 90s
Use of HBNs in design process
Sub-code: design climate [day-to-day Changing face of hospital design: includes issues about
interactions]
 PFI structure and process:
B Sub-contracting relationships and discontinuity
B Position on the feeding chain (architects, healthcare planners)

Sub-code: participatory design  Stakeholders (staff and patients)

BHistorical patterns
 Need to be involved to give any validity
 Theory – levels
 Value of input (superficial art projects)
 Which aspects of design?
 End stage at commissioning to get ‘buy-in’

(2) Evidence base [methods of design Experiential

and evaluation] Historical, nucleus, loss of confidence in guidance without evidence (rationale),
e.g. infection control
International – different cultural and economic drivers (USA, France)
Whom does it convince, e.g. academics, clinicians, healthcare managers, CHAD
(Design Review Panels), architects?
(3) Future needs of healthcare in-patient Standardise at ward level, generic rooms (5/6, 10, 12/15) with 7–8 activities
accommodation in each room
Flexibility
Ageing workers and increasing use of technology.
Demographic preferences for accommodation and treatment
Shorter stays and increased community treatment and care
Guidance still needed but different and evidence-based
Sub-code: patient experience Room occupancy preferences
Sub-code: guidance [what is wanted in Generic, web-based, modular (multi-functional rooms)
terms of guidance?] Protocol-based compared with competencies
Level of interpretation (mandatory or guidance)
Cost – some government guidance is free
Task analysis – not clinical practice (as it changes)
Designer tool
Interface with other professional codes (construction input)
How little is actually needed in terms of HBNs?

have been reviewed by a research panel (Hignett et al., in press) and
in a professional forum (Hignett and Lu, 2008).
4. Discussion
4.1. Design culture
The culture of design in this context relates to the use of guid-
ance in healthcare building design. There was felt to be a conflict
between consumerism (design for the patient) and efficiency (de-
sign for the service provider) reflecting the complex social power
relations (Gesler et al., 2004). The consumerism aspect was de-
scribed as a shift towards a blame culture, termed ‘defensive brief-
ing’ by participants 2 and 17, with the effect of limiting creativity. As
the consumer, the patient is the focus for both service provision and
design, this may be unrepresentative in terms of building use,
where staff are in the hospital environment for longer periods.
It was suggested that elements of building design impact on
patient recovery. The design principles at the micro level (patient-
centred) were felt to drive compromises such as space for equip-
ment, visibility, dignity, privacy and infection control (participant
19). Two examples of compromises were the use of glass walls
(visibility versus privacy) and location of the en-suite, inboard to
give the patient a larger window or outboard to give more visibility
into the room (participants 3 and 4).
In the UK there is a monitoring system through Design Review
Panels (2001) but some participants felt that this could stifle the
design process resulting in much more timid designs as the ‘NHS
[is] populated with dogmatic individuals with respect to building
design’ (participant 13) with the effect that ‘sometimes you try and
do something a bit different, they’re [Review Panel] down on you like
a ton of bricks and just make life enormously difficult for you in ap-
proval terms’ (participant 7). It was felt that the architect could start
with a good design which was changed through the planning and
tendering process (participant 17) and although ‘you’re [architect]
 S. Hignett, J. Lu / Applied Ergonomics 40 (2009) 608–616
desperate to give ideal. the funding[s] is not there for innovation’
(participant 16).
The use of HBNs in this culture was perceived as a constraint
where non-compliance could have a significant impact on tender-
ing process (participants 13, 15, 16 and 17). Changes to the
healthcare building process were perceived to have progressively
changed the design culture. In 1997 the first Private Finance Ini-
tiative (PFI) schemes were funded. The ‘1st wave of PFI allowed in-
novation’ (participant 15) but now PFI consortia embed the
guidance in contracts (participants 3 and 5) which can lead to a lack
of trust between the architect and the contractor (participant 17).
For example, there was a feeling that schedules of accommodation,
usually drawn up by the Trust in conjunction with a Healthcare
Planner, were ‘over-egged, there’s far too much space in them and
they’re defensive briefing’ because the Trusts ‘don’t trust the consor-
tium to come back with a decent space’ (participant 2). This is per-
haps a response to the cost pressures on PFI, leading to a reduction
in facilities (including fewer beds). Webster (2002) suggested that
‘the PFI scheme looks at its best at the beginning, when gleaming new
high technology facilities spring out of their green field sites’ but went
on to say that the ‘gilt has soon worn off’ and that the first completed
scheme (Cumberland Infirmary) was a ‘veritable museum of design
and building failures’.
The perspective of the service provider was exemplified by the
interactions during the design process. The architects felt that they
had expertise from professional experience whereas most of the
clinicians were working on a building project for the first (and
possibly only) time in their professional career. This could be as
simple as challenging clinical practice in terms of ‘right handed v left
handed approach’ (participant 13) or individual practice (participant
19), however the architects and planners felt that they lacked the
‘clinical knowledge to challenge clinicians’ (participant 17), and
wanted evidence to challenge clinical practice (participants 16 and
17). With the change to Foundation hospitals (NHS Foundation
Trusts, 2004) and more autonomous management there was con-
cern expressed that the design process might get ‘even looser.do
what they pleased in designing hospitals’ (participant 1). This could
contribute to already identified problems of ‘every Trust wants to do
it in a different way’ (participant 16) and some ‘hospitals giving ar-
chitects carte blanche’ (participant 11).
Organisational issues about service provision also impacted on
design with respect to the size of the building and future flexibility
(participant 2), with influences noted from the USA for ‘deep
planning everything’ (participant 5). The differences in cultural
and economic drivers in the USA were identified in terms of
healthcare provision (private versus public, participant 11), geog-
raphy (participant 13, earthquake zones), social expectations
(family attendance in hospital, participant 13) and clinical practice
(participant 14).
4.2. Design climate: professional status and interactions
The climate of design represents the day-to-day interactions
between the architects, clinicians, hospital managers and PFI con-
tractors and sub-contractors. The relationships within the PFI
consortium were felt to produce an adversarial climate between
contractors and clients (participant 7). The PFI managers were
perceived to exert control over the sub-contractors (architects) by
managing the climate of interactions so that architects were not
‘allowed’ to be confrontational (challenge practice) with the end
user (clinician) because that could impact on the client or con-
tractor having problems (participant 6). This resulted in the archi-
tects being answerable to the contractors (PFI consortia) not to the
health client (participant 3), resulting in a ‘discontinuity of [the]
design [process]’ (participants 4 and 17) between the architect and
building users.
613
There was a general feeling that the design climate was influ-
enced by the location of the designer on the ‘food chain’ with
a feeling that architects and healthcare planners had moved down
the ‘food chain’ and that architects had been ‘emasculated’ (partic-
ipants 5 and 19). This was exemplified by the perception that a lot
of money from the PFI process would go into procurement and
‘absolutely zero going into planning and a bit more, but not much
more, going into design’ (participant 4). The tender process was seen
as a very ‘negative experience’ (participant 13), with ‘no learning in
the process’ contributing to a culture of a ‘lack of sharing between
designers’ (participant 16).
4.3. Participatory design
The inputs by various stakeholders were described as ‘meddling
in an area they know absolutely nothing about’ (participant 2), only
having limited experience and skewing the agenda by getting on
a ‘hobby horse’ (participant 3). One participant suggested that the
‘user group system enabled architects to become lazy, where you could
have every nurse in the hospital telling you what to do’ (participant 5).
Some questioned the importance of input (participant 11) and even
suggested that there was no need for participation (participants 7,
16, 17 and 19), for example ‘most of the nursing staff will work in
whatever they’re given and do it very well’ (participant 16). Others
felt that stakeholder participation was important so that ‘every
person working in hospital should feel part’ to avoid the feeling of
‘imposition if lack of participation’ (participant 13). The iterative
review process used in the NHS was contrasted with a less partic-
ipatory approach used in the independent sector (participant 7).
Other countries report a more participatory role with ergonomic
involvement, for example in the Netherlands (Remijn, 2006), Can-
ada (Villeneuve, 2006) and Brazil (Cardoso et al., 2006). Contrasts
were also drawn with France (participant 12) commenting on the
relative lack of interaction with stakeholders. Mazuch (2006)
agrees with this cultural difference, saying that in France ‘the brief
arrives and there’s very little dialogue with clinicians’.
There were practical difficulties in participating with respect to
reading drawings (participants 13, 16 and 19), thinking in 3D
(participant 19), getting information out of clinicians (participants
2, 12, 16, 17 and 19) and getting staff to think in terms of future
service provision. It was suggested that staff tend to focus on their
current practice whereas ‘the walls around the rooms are 20 year
decisions, what goes on in those rooms are not 20 year decisions’
(participant 5). Lawson (1997) suggested that the image of the
designer–user relationship was misleading. For large organisations
in particular, the architect may be buffered from the actual users by
client committees, estates departments, in-house project man-
agers, etc.
There is a statute of responsibility to involve patients in change
(NHS Estates, 1994; participants 4 and 7) but few of the participants
described a structured participation at any level. It was felt that
patient involvement tended to come from ‘management’s favourite
departments’ and that patient participants would be the ‘pro-
fessional public’ (participants 5 and 6). There was concern that in-
volving patients could just provide a forum for the ‘articulation of
frustrations’ from ‘less informed and less professional people’ (par-
ticipants 4, 17 and 19). Others felt that it was important to get pa-
tient engagement (participants 4 and 13) and that the patients’ role
should be increased (participants 2 and 12). Input has previously
tended to be only for aesthetic decisions rather than functional
design (participants 16 and 18) but this was perceived to be
changing, the ‘public voice wasn’t given much credibility but now
much changed and much stronger’ (participant 4). Lincourt (2002)
felt that patients and families were not consulted on hospital de-
sign, and suggested that this could be addressed with increased
empathy from managers and architects. None of the architects and
614 S. Hignett, J. Lu / Applied Ergonomics 40 (2009) 608–616
healthcare planners mentioned the role of a patient expert as a paid
member of the design team. There seemed to be a reliance on pa-
tient representation as a voluntary role.
4.4. Evidence base (methods of design and evaluation)
Architects have a number of resources that can be used to
support the design process in addition to the guidance, including
professional expertise and research, but have been repeatedly
criticised for not using all the resources (Smith, 1984; Moran et al.,
1990; Lawson, 1997; Hamilton, 2003).
There were a range of comments describing the methods of
design from assessing the space needed for clinical activities
(participant 2) to using best experience and creating rooms in
line with the equippers (participants 5 and 6). The use of HBNs
ranged along a continuum from being taken literally through to
using them as a reference and ignoring the detail (participants 5
and 6). This fits with a view from the 1980s, where Smith (1984)
suggested that ‘one reason why a standard hospital design will
never be adopted fully or go unmodified is because of the challenge
it presents to those who think they can do better’. It was felt that
the research from 50s, 60s and 70s was world-leading (partici-
pants 7 and 18) and that evidence-based design might lead to
the merger of architecture with clinical delivery (participant 14).
However, there were questions about the quality of the available
evidence (participants 17 and 18). The need for more evidence
was expressed as ‘understanding not only that’s a good layout, but
why is that a good layout’ (participant 3). One participant felt
that they would like ‘somebody to design a standard en-suite and
we can confidently understand why the dimensions are recom-
mended and what is its functionality’ (participant 17).
It was suggested that in the past the ‘design of hospital is more
common sense than science’ (participant 15) and that ‘a lot of hospitals
were designed on a wing and a prayer really’ (participant 12). The
difficulty of addressing apparently disparate goals of standardisation
and improving standards could result in the ‘architects’ budget [being]
hostage to 14 people’ (participant 5). Participant 6 described their
experience of having been involved in 15 different hospitals and
seeing clinical layout for the same functional area in 15 different
ways. It was suggested that there was a lot of repetition ‘due to lack of
standardisation’ (participant 18) and lack of evidence (participant 16).
Many of the participants expressed concern about the time
taken for research to be available and incorporated into practice
(participants 15, 16, 17 and 19) which could lead to conflict about
using research evidence ‘incorporating evidence versus winning
a tender’ (participant 12). There was a lack of knowledge about
research processes, ‘what proof will you have that some particular
layout [works], how can you test that without actually building it?’
(participant 1). When asked about their understanding of research
the participants tended to refer to professional experience as an
evidence base ‘I can only work on the basis that we know it works
because we’ve done it before’ (participant 17) and practical research
‘as part of scheme walk-around visit to the department to get the feel
of where people are coming from’ (participant 19). One participant
commented that conferences in healthcare design tended to be
‘people telling about their research projects and how they did them,
but not a lot of physical outputs’ (participant 16). This concurs with
a view of the design process (using professional experience rather
than research/guidance) from Lincourt (2002), saying that ‘armed
with the notion of what the building is supposed to do, architects start
out with some expectations about how human beings who will use the
building, rooms lobby etc. are going to behave’.
Hamilton (2003) set out his view of EBD in four levels for ar-
chitects. The first level describes the practitioner as a user of re-
search, making thoughtful interpretations of design implications
from research. Levels 2–4 plot the transition of the practitioner
from a user of research to a generator of research by defining
measures to evaluate outcomes of design interventions, publishing
the results and writing in peer-reviewed academic journals. Ham-
ilton (2005) suggests that most practitioners (designers/architects)
will remain at level 1 and would need to acquire specific skills to
ensure that any research is valid, reliable and of high quality. In
order to communicate effectively with and challenge clinical
practice, designers will have to learn to discuss research (and re-
search quality) with clinicians.
4.5. Future needs
Many participants felt that the role of guidance was perhaps
even more important now due to a loss of experience in healthcare
design in the UK during the 80s and 90s (participants 2, 3, 6, 11, 16
and 19). Several of the participants felt that the guidance could be
based around a set of generic rooms (participants 2, 3, 11 and 17),
with possible benefits including modular construction (partici-
pants 3 and 17) with the possibility of off-site fabrication (partici-
pant 13). The proposed number of generic rooms varied, ranging
from 4–5 (participant 16), 5–6 (participant 2), 7–10 (participant 7),
12–14 (participant 6) through to 40–50 generic rooms covering 60–
70% of the hospital (participant 17).
Some felt standardisation was useful (participants 2, 7 and 11)
but others felt that it could lead to third-rate consultation (partic-
ipant 15). One participant expressed the opinion that ‘people do like
to have a prescription’ (participant 1) but others felt that pre-
scriptive design didn’t‘ fit with the culture of what we’re trying to do’
(participant 4). When asked about standardisation some partici-
pants reflected on the nucleus hospital design (Francis, 1998) but
felt that it ‘went too far into design solutions’ (participant 19) and
over-standardisation (participants 14 and 16) and due to the
amount of guidance it had limited innovation (participant 14)
resulting in ‘clinical functional factories’ (participant 19). It was felt
that future hospitals would need more ‘flexibility across specialities’
and ‘smaller units, more flexible, more generic’ (participant 2). This
model would also support the idea of very small unit supported by
expert systems and interpretation at a central point (participants 4
and 16).
The guidance needed to be designed as ‘something that people
can use’ (participant 3). A number of participants suggested that the
guidance could be simpler (participants 4, 11, 12 and 16) with
perhaps more diagrams (participant 16) in the form of generic
guidance (participant 12) or base line guidance only (participant
13). As a response it was felt that the internet could be used to
provide more frequent updates (participant 16) and improve
availability/accessibility (participant 11). The goal should be to
bring together the language from the clinicians and the design team
(participant 3).
There was a feeling that there would still be a need for some
kind of guidance (participant 1) but that it could be more modular
and/or generic to identify perhaps a range of ‘activities that could fit
into a room of a certain size’ (participant 2). This would have benefits
for standardisation (participant 12) and even making tendering
fairer by supporting the requirement to design to the same
standard (participant 12). Scher (2006) suggested that the design
information needed should be ‘simple, unambiguous and non-
repetitive.with a clear definition of what is mandatory [or not]’.
Designers are relying on the academics to present the research
information in a way that will transfer into practice without having
to read detailed pages about NHS policy, research studies, etc.
4.6. Patient expectations
Participants identified a range of possible patient expectations
from their professional and personal experience; including privacy
 S. Hignett, J. Lu / Applied Ergonomics 40 (2009) 608–616
and dignity (participants 3, 4, 7, 11, 12 and 14), choice (participant
11), age preference (participants 7, 12 and 13), different cultural
preference based on geographic location (participant 12) and the
role of the family as caregivers (participant 13). The role of the single
room was discussed with a strong emphasis placed on the increasing
importance for the future demographic with bigger (obese) patients
(participants 13 and 16), decreased mobility (participant 4) and
infection control as the driver for design (participants 13 and 17).
The increasing use of technology to monitor patients could offer
different future design options (participants 4 and 17). It was sug-
gested that future hospitals would have more of an intensive care
function with higher levels of acuity (participants 2, 15 and 16) and
that there would be shorter stays (participants 7 and 18). At
a societal level the role of community hospitals versus large acute
hospitals was discussed and it was felt that the decentralisation
model might be winning (participant 4). This has been confirmed
by the Minister for Health (Hewitt, 2006), saying that a new
generation of community hospitals would be developed over the
next 5 years.
5. Conclusion
Design in the healthcare industry presents a complex challenge
due to the large amount of uncoordinated regulation and guidance.
The findings from this study suggested that the context for using
guidance within the NHS has changed over the last 20 years. The
participants identified a conflict between consumerism (patient-
focussed) and efficiency (service provider), with an associated shift
towards a blame culture. There was perceived to be a stifling effect
on design due to changes in the building process, with increased
monitoring, and defensive briefing (linked to the use of guidance)
reflecting a perceived lack of trust between parties (clinical, de-
signers, PFI Consortia).
This was also reflected in the design climate in day-to-day de-
sign interactions and an uncoupling of the design–stakeholder
relationship. These may contribute to the perceived mismatch in
research communication between clinicians and designers.
The participation of stakeholders was mostly unstructured and
involved a lot of iteration due to differences in conceptual frame-
works between designers and clinicians. There was a perception
that any input from patients and clinicians might have limited
benefit due to a lack of knowledge about the design process. This
offers a clear role for ergonomists in facilitating the involvement of
clinicians and patients to engage with future designs of healthcare
environments.
Participants reported a lack of confidence in the quality of the
available evidence base, but this may also be related to the level of
knowledge about the research process. Some participants reported
using guidance literally, and others just as a reference (ignoring the
detail); both result in a lot of repetition across building projects due
to the lack of standardisation. This offers a second clear role for
Ergonomics in producing evidence to support safer working prac-
tices relating to spatial requirements. It was suggested that stand-
ardisation might be achieved using a set of generic room sizes in
future guidance, ranging from 4 to 50 room templates, with some
participants suggesting that this type of guidance might free up
design creativity.
In conclusion, the use of guidance in this design culture was
varied, with some participants seeing a clear role for new (more
standardised) guidance in the future, whereas others were more
concerned about loss of design freedom. Two clear roles for ergo-
nomics were identified to: (1) facilitate the participation of patients
and clinicians in the design process; and (2) generate new research
evidence with respect to spatial requirements for clinical activities
to support standardisation.
615
Acknowledgements
This research was supported by Grant No: B(02)13/HUJBA from
the Department of Health’s Estates and Facilities Research Pro-
gramme (UK). This article presents independent research com-
missioned by the National Institute for Health Research (NIHR). The
views expressed are those of the authors and not necessarily those
of the NHS, NIHR or the Department of Health. The NIHR NHS
Physical Environment Research Programme is funded by the De-
partment of Health.
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