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This is the submitted version of a paper published in Nursing Inquiry.
Citation for the original published paper (version of record): Andersson, M., Fridh, I., Lindahl, B. (2019)
Is it possible to feel at home in a patient room in an intensive care unit? Reflections on environmental aspects in technology dense environments: Is it possible to feel at home in a patient room in an intensive care unit?
Nursing Inquiry
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Abstract
This paper focuses on the patient’s perspective and the philosophical underpinnings that support what might be considered optimal for the future design of the Intensive Care Unit (ICU) patient room. It also addresses the question of whether the aspects that support at-homeness are applicable to ICU patient rooms. The concept of ‘at-homeness’ in ICUs is strongly related to privacy and control of space and territory. This study investigates whether the sense of at-homeness can be created in an ICU, when one or more patients share a room. From an interdisciplinary perspective, we critically reflect on various aspects associated with conflicts surrounding the use of ICU patient rooms. Thus, from an architectural and a caring perspective,
the significance of space and personal territory in ICU patient rooms is emphasized.
Recommendations for further research are suggested. In conclusion, privacy and control are deemed to be essential factors in the stimulation of recovery processes and the promotion of wellbeing in situations involving severe illness or life-threatening conditions.
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Introduction
The Intensive Care Unit (ICU) patient room is a highly specialized and technological environment that simultaneously functions as a temporary residential space for patients. It is well known within research on nursing that the ICU environment per se can cause illness to patients (Engwall, Fridh, Johansson, Bergbom & Lindahl, 2015; Olausson, Lindahl & Ekebergh, 2013; Page and Ely, 2011). Moreover, it is a workplace for the various disciplines of the ICU and a room for the patient’s next of kin. Key issues with regard to patient- and family-centred care (PFCC) within intensive care have been identified (Coombs et al., 2017), including the assertion that family members should be offered open and flexible visiting times within the ICU. Open visitation policies have been implemented in Scandinavian ICUs for several decades. However, practices differ globally. Another priority for PFCC is the physical environment. Private, individual rooms are recommended for ICU patients, in addition to designated space to facilitate family members’ rest (Coombs et al., 2017). However, none of these guidelines have explicitly discussed ICU patients’ bed space in relation to at-homeness.
This paper focuses primarily on the patients’ perspectives and on what can be considered optimal regarding ICU patient room design for the future. Additionally, we examine the issue from two other perspectives: that of the workplace, regarding the professional use of the patient room, and that of the visitor or next-of-kin. The conceptual framework is grounded in the caring sciences, architecture and philosophy. We discuss at-homeness and privacy in relation to space and place (i.e., a geographical perspective), and how at-homeness promotes agency and a sense of control. In a private residential context, the patient has the advantage of having control over the environment, as opposed to an ICU, where others have control. However, a systematic review (XXX & XXX, 2018) which examined the outcomes of the provision of ventilator treatment at home rather than in the ICU indicated that it was not home ventilatortreatment per
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se that presented challenges for participants, but rather the transformation of the perceived meaning of home caused by the presence of both technology and healthcare workers.
In European ICUs, patients often share rooms. “Control” in this context concerns whether the spatial territory can be individualized for or by the patient. The control of a space is also related to permanence and temporality; the longer one stays in a place, the greater the need for individualization and to exercise control, while the prerequisites for personal agency also increase (XXX, 2017). In this context, the nursing staff have a crucial role in promoting privacy and control (e.g., by opening or closing doors, controlling lighting, and avoiding sharp sounds), using the functions that are available in the physical environment in addition to other personalized interventions. Furthermore, patients’ physical and mental capabilities govern the degree of personal agency they are able to exercise and to what extent they are dependent on others. In the ICU’s increasingly complex environment, it is therefore crucial to understand which factors are prerequisites for human well-being (Taylor, 2017), and to make research findings in this area accessible and comprehensible for designers and planners (Quan & Joseph, 2017). In a study exploring the experiences of patients of staying in ICUs (Olausson, et al., 2013), patients reported on their experiences with life-threatening conditions and asserted that the seriousness of their illness affected their perceptions of the rooms they inhabited. Patients’ next of kin (Olausson, Ekebergh & Lindahl, et al., 2012) verified how fundamental the design, interiors and furnishing in the patient room were in shaping their experiences during visiting hours, and how these factors affected their own wellbeing. A Swedish observation study (Eriksson, Lindahl & Bergbom, 2010) concerning the interplay between patients and next of kin in the ICU setting found that, even where an open visitation policy was applied, the physical environment could become a hindrance, since it had been designed for medical and technical purposes and thus not necessarily conducive to human interaction.
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In current research, a growing number of studies in health care and nursing adopt a spatial orientation, that is, how place and space impact on the caring relationships, activities and institutional power that are at play in health care. Key research questions include the following: What meanings can be ascribed to place and space in high-tech environments, more precisely patients’ bed spaces in ICUs? Is it important or even possible to discuss the concept of home and its various meanings in relation to ICUs? Can philosophical ideas about meanings within the concept of home be transplanted to an ICU environment? And finally, is it possible to create an atmosphere in an ICU that promotes the sense of at-homeness? This paper discusses the concept of home, in terms of at-homeness, as it pertains to care transactions, and how the physical environment may promote or frustrate patients’ control and individualization. We argue that there are several critical issues regarding at-homeness in hospital environments that should be considered in future planning. Therefore, we aim to provide critical and novel reflections on the concept of at-homeness in the context of high-tech environments, such as ICUs. As a theoretical co-production between researchers within both the caring sciences and architectural design, this study contributes to the area of health geography.
Background
In recent years, residential care has come to encompass increasingly advanced care. This is epitomized in the concept of person-centred care (see, e.g., Lehuluante, Nilsson & Edvardsson, 2012), and includes the personal home environment of the patient. There has been a parallel development in hospital care, whereby single or double patient rooms have come to replace multiple rooms that accommodate up to eight or more patients (Persson, Anderberg & Kristensson Ekwall, 2015). We argue that it is certainly relevant to discuss at-homeness in relation to ICU patient rooms. Thus, as an opening to this paper, the concept of home is
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discussed from the perspectives of caring, architecture, and philosophy. The meaning inherent in the concept of home works as a guide both for research and for caring practices. The discussion begins with experiences accumulated through work with an intervention research project concerning ICU patient rooms (XXX, 2015). Our theoretical foundations are based on a caring science perspective, which holds that caring, both natural and professional, is the very essence of humanity and human existence (Martinsen, 2006). Moreover, we base our point of departure on the concepts of health geography (Andrews, 2003; Kearns & Moon, 2002), healing environments, and evidence-based design and architecture (Ulrich, 2006).
As part of an ongoing intervention programme (XXX, 2015) an ICU patient room was refurbished. Principles of evidence-based design (Ulrich, 2006) were applied, particularly with regard to the impact of active components, such as a cycled light system, sound absorbents, interior design, and views of nature. A plain interior design, including soft colours and ecological textiles, was adopted. An ordinary room with the original design was retained for comparison.
[Insert photos 1 and 2 here]
The programme’s planning followed a well-established framework for complex intervention research (Craig et al., 2008). Findings from studies evaluating the programme (Johansson, Bergbom & Lindahl, et al., 2012; Johansson, et al., 2017) have shown that previous sound levels in ICUs were too high, that daytime and night-time were inadequately distinguished, and that experiences of sound and noise were very subjective across individuals. Patient experience showed that, when receiving care in a room with cycled light, they were aware of the light despite their illness. In interviews (XXX et al., 2015), they described having experienced sleep
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disorders, nightmares and circadian rhythm disruptions. They felt at ease with the cycled lighting environment, as it supported their circadian rhythms, together with the natural daylight. At night, the lighting system helped them to orient themselves, and to connect with the staff. The ICU nurses that worked in the refurbished patient room reported being more alert and stated that the room promoted wellbeing to patients (Sundberg, Olausson, Fridh & Lindahl, 2017). Overall, spatial control and individualization are perceived differentially, depending on the patient’s degree of illness and cultural, experiential and ideological perspectives (XXX et al., 2013). In the text that follows we briefly explore and reflect the following topics; the concepts of home, privacy, control and the ICU patient room as bed space and workplace.
Philosophical and theoretical framework
We base our discussion paper on the assumption that philosophyhas the potential to incite a deeper understanding to health care professionals about human conditions in intensive care.
The concept of home is not only connected to space and territory but is also associated with multiple, ideal meanings, such as identity, safety, control and memory. We have adopted the metaphor of home in its positive aspects, despite the fact that home to some people represents oppression, hardship and assault.
Home: space and territory
Privacy and control are two of the main positive characteristics of a home (Hauge & Heggen, 2008). When people are dependent on professional care at home, the home is regarded as a place for “privacy” and “personal growth” (XXX et al., 2011, p. 456). Levinas (in Kemp, 1992) describes the home as a place of refuge where the inhabitant dwells and musters energy to deal with external occurrences. Svenaeus (2002) describes two aspects of home pertaining to health and argues that good health can be likened to a sense of “homelikeness”, whereas illness can
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evoke a sense “un-homelikeness” or even “homelessness” (p. 3). Home is also a space where people can socialize and extend hospitality to others. Home straddles the spatial boundaries between the private and public spheres, which are in a constant state of flux depending on the situation and inevitably affect the extent to which a sense of at-homeness is evoked. In intensive care, boundaries are constantly violated by medical procedures and technology; however, logistical aspects are of great significance in patients’ satisfaction and adaptation to the shifting prerequisites for privacy and at-homeness. From the patient’s perspective, the patient room in a hospital is a de facto temporary home (XXX, 2015). Temporality is one aspect that is related to the concepts of home and at-homeness, since the length of stay in the ICU affects the overall experience. Another aspect is spatiality and spatial control, which is affected by whether or not others have access to the space, but also by design aspects, such as materiality, scale and sensory impressions. Finally, a third aspect is concerned with the patient as an individual, and encompasses consciousness, diagnosis, expectations of recovery, agency, prior experiences and cultural identification.
Mayeroff (1990), with regard to space in relation to caring, observes that caring enables people to experience being “in place” in contrast to being “out of place” (p. 68). The latter implies a feeling of wanting to escape one’s place, or indifference or insensitivity to place. Lefebvre (1991) identifies three concepts of space: perceived, conceived, and lived. Perceived space denotes space as a prerequisite for use, conceived space is the image and conceptualization of space, and lived space is where interaction with people and artefacts occurs. A characteristic of lived space is that people do not often reflect on its meaning. The Norwegian architect Christian Norberg-Schulz (1971) describes architectural space as being transformed into an “existential space” (p. 15-17) through the user’s interaction with it.
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A “territory” is both a physical and an imagined space. Some researchers describe territory as an act rather than a space, and territoriality as spatio-temporal processes rather than spatial entities (Brighenti, 2010). Territoriality may, for the time being, encompass the concepts of home and at-homeness, which were among the goals of the ICU intervention room programme. Examples of measures taken to achieve this included the placement of a detachable photo frame on the patient’s bedside table, in which relatives could display personal photos of the home, pets and grandchildren, and a magnetic notice board for displaying drawings also placed within the patients’ view. Spatial territory is created continuously and “not defined by space, rather it defines spaces through patterns of relations” (Brighenti, 2010, p. 57). As early as the 1990s, Liaschenko (1994; 1997) described the dynamics in nursing in relation to spatiality. Her writings and, later, the work of Andrews (2003) form a scientific approach that focuses on place and space in relation to health care from a phenomenological and geographical perspective. However, place and home are also acknowledged as social constructions.
Access, control and agency
The degree of agency and control that an individual has governs their perception of existence and is closely related to temporal factors, such as duration and degree of permanency (Fig. 1). If we consider private and public, or common, aspects to be two opposite domains, they can be related to both a static physical environment and to the situational configurations of everyday life. To create a private life in a public environment, “spatial micro-conditions” (Nord, 2011, p. 55) of privacy may be established. In ICU care, this spatiality is often limited to the patient’s bed or even to their body. Technical equipment is mobile in an ICU and is brought to the patient’s bed according to medical requirements. This may result in a situation where the patient’s body and view are encumbered with machines, which may hinder human encounters and intimacy. If the body is invaded by intrusive treatments and monitoring, and the mind is
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affected by sedatives and analgesics, senses of control, of at-homeness and of privacy are likely to be difficult to evoke. Moreover, a common space, like a patient room in a hospital, does not belong to any particular person; it belongs to the public domain and is relational to both private and communal aspects (XXX, 2017). Research has shown that a sense of loss of control is associated with negative life events (Cairney & Krause, 2008), and a loss of psychological well-being (Morgan & Brazda, 2013; Quan & Joseph, 2017).
[Insert figure 1 here]
When people share their space with others, as happens in patient rooms, some of the interactions and activities are of a private nature, and would normally occur in a private home environment (Solove, 2002); The space here is staged for inescapable and inevitable social interaction within the confinement of the patient room (XXX, Ryd & Malmqvist, 2014).
Critical illness and ICU care
Foucault (1977) believed that the military camp was the ideal model for surveillance, executed through visibility by others with a superior hierarchical position. He claimed that this idea serves as an underlying principle for the construction of prisons, schools and hospitals.
Torkildsby (2014), from a design perspective, analysed places and spaces wherein people are locked in or confined to bed, including custodial spaces, psychiatric care clinics, and ICUs. In such places, she argues, there is an obvious risk of insult or assault to the lived body. It is, therefore, crucial to promote design processes that consider existential issues with the aim protecting people from activities that may be experienced as sinister and threatening.
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Patients with experience of receiving care in an ICU sometimes report fragmentary recollections of the environment as noisy, unfamiliar, frightening and out of control
(Baumgarten and Poulsen, 2015; XXX et al., 2012; XXX et al., 2013). Already in the nineteenth century Florence Nightingale (1969/1860) presented key aspects for a caring surrounding. These were ventilation, warmth, light, cleanliness, noise and distraction. The latter is often undervalued but it is well known that in cases of critical illness that require ICU care, patients’ orientation and sense of purpose in life easily can be lost. Critical illness implies confinement to the sickbed with little or no possibility of controlling or territorially possessing the sickroom and the space beyond the bed (XXX et al., 2012). The bed becomes both a temporary home and a prison, comparable with the patient room in psychiatric care (NN, et al., 2013): a home because the bed is the only space allocated to the patient, and a prison because it is a place that is impossible for the patient to leave voluntarily. This presents a dilemma. The need for private or personal space becomes intensified in contexts wherein the individual aspects are significantly diminished (Meriläinen, Kyngäs & Ala-Kokko, 2010; NN et al., 2013).
The intensive care scenario frequently entails the patient being tethered to a bed by tubes and lines, and becoming dependent on others, which can give rise to a strong desire to escape both the place and the situation (Baumgarten & Poulsen, 2015; Yang, 2016). Generally, people naturally strive to maintain an upright position that allows them an extended view. A change in this natural posture (e.g. into a lying position in a bed) reduces the visual field and what is possible for the individual to perceive. Patients in ICUs are often restricted to a position whereby their view is of the ceiling. Therefore, a smooth white ceiling was installed in the intervention room, since this is believed to have a soothing effect with regard to the triggering
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offers privacy for the occupant. This leads to feelings of being out-of-home or homelessness (NN et al., 2013). Here, the staff has the responsibility to create a homelike space and place through a caring relationship.
Workplace aspects of the ICU
The work environment in the ICU is governed by the regulations of the Swedish Work Environment Authority (AFS 2014). There is, however, a great need for improvements with regard to lighting, noise, safety and ergonomics both for patients and staff (Applebaum, Fowler, Fiedler, Osinubi & Robinsson, 2010; Barach, Forbes & Forbes, 2009; Pereira et al., 2011). There is also a great need for functional teams that can create a benign and caring environment (San Martín-Rodríguez et al., 2005) and an atmosphere that is conducive to emotional work (Hammonds and Cadge, 2014). Malone (2003) argued in a theoretical paper that nursing in such an environment carries the associate risk of making nurse-patient relationships distant and alienated. Tunlind, Granström and Engström (2015) found when interviewing ICU nurses that they viewed technology as an important tool but it could also sometimes be perceived as a barrier to patient-centred care. Technology is closely integrated with nurses’ work, and this integration is set to intensify in the future; while it does not need to be a barrier between patients and staff, nonetheless its power needs to be reflected (Barnard, 2016).
The pros and cons of single vs. multiple patient rooms have been widely discussed from the perspectives of patients, relatives and professionals (Chaudhury, Mahmood & Valente, 2006; Harris, Shepley, White, Kolberg, Harell, 2006). The possibility of family members’ presence in the patient room is strongly emphasized in the USA, in comparison to Europe; this possibility is certainly facilitated by single patient rooms (Chaudhury et al., 2006). Studies conducted in adults’ and children’s hospitals have shown that social support derived from the presence of
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family and friends alleviates the patient's stress and helps to reduce pain and improve other
outcomes (Koivula, Tarrka, M.T., Tarrka, M., Laippala, & Paunonen-Ilmonen, 2002). There
are several advantages to single patient rooms concerning infection risks and the possibility of isolating patients (Detsky & Etchells, 2008; Hamel, Zoutman & O’Callaghan, 2010). The considerable advantages to the creation of an environment that promotes privacy and satisfaction for patients and relatives, as has been observed for several decades, are also desirable outcomes for the professionals (Ulrich et al., 2008). Flexibility and adaptability are key factors in creating a work environment that promotes patient-centred care processes (Gallant & Lanning, 2001; McCormack & McCance, 2006). There are, of course, counterarguments to this: Two of these relate to the difficulties associated with control and observation and the fact that single patient rooms may require more space and work efforts (Apple, 2014). There are also economic aspects, including the higher costs involved in staffing, building and maintaining the ICU (Calkins & Casella, 2007; Maben et al., 2016).
The patient room and patients’ bed space in the ICU
Florence Nightingale may be regarded as the first designer of patients’ rooms in hospitals. She designed open and multi-patient rooms and, already in the 19th century, she recommended that patients with serious illnesses should be placed in special rooms close to the operating theatre. However, it was not until the end of the Second World War that dedicated units for trauma and postoperative care were established in the UK and the US, initiated by developments in anaesthesia and technology (in Fairman, 1992). In modern times, The American Society for Critical Care Medicine has, since 1993, awarded hospitals for their efforts in enhancing the design of the ICU environment (Rashid, 2014). Patient room size and design, support and service area layout and family space design are all various aspects that have been considered.
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Debate regarding the pros and cons of one-patient rooms has been ongoing over the past 20 years, emphasizing the social, logistic and economic benefits associated with multiple-patient rooms (Verderber & Todd, 2012). Disadvantages that have been documented in existing single-patient rooms include a lack of visibility (Rashid, 2006), and a sense of isolation experienced by staff (Apple, 2014). The hospital bed is not exclusively a physical object; it is both a spatial and a social product that is constantly created and re-created through activities, experience and interaction (Liaschenko, Peden-McAlpine & Andrews, 2011; Persson et al., 2015). The hospital bed has been described as both a socio-economic entity, and a place for individualization (Gibson & Sierra, 2006). There is evidence that patient satisfaction in a general ward is significantly higher in single-patient rooms than in rooms for more than one (Chaudhury, et al., 2006; Persson et al., 2015; Ulrich et al., 2008). Research has shown that patients in ICUs are disturbed by the presence of their fellow patients in shared rooms, since they are unable to control, hide or leave the place (NN et al., 2012; NN et al., 2015).
To share the ICU room with another person is to be aware of a roommate that you seldom see, never talk to, but who is nonetheless a person whose suffering and fate involuntarily worries and engages you, and contributes to your distress (Bergbom & Askwall, 2000; NN et al., 2013). There is evidence that single rooms can increase staff satisfaction and reduce stress, compared to rooms with open-plan designs (Ulrich et al., 2008). Other advantages to one-patient rooms are the significantly lower risks of contamination (Teltsch et al., 2011), and shorter stays (Harris, et al., 2006). A problem with shared rooms arises when people come to visit a patient in an ICU (Eriksson et al., 2010). There is a clear risk that visitors’ conversations about matters of a personal nature will provoke feelings of discomfort. In difficult situations, which constantly arise in ICU care, the need for privacy is obviously greater. Relatives and other visitors may get the impression that they are in the way and that there is no room for them (Ågård & Harder,
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2007). This is often the case when patients are terminally ill and in intensive care; in such cases, it can be very disturbing for relatives to have to cope with such a situation with another person in the room (NN et al., 2009). There is also the risk that patients might be disturbed and alarmed by sounds from other patients, and from medical equipment (Johansson et al., 2012). A study by NN et al. (2007) found that patients who died in shared rooms more often died without any of their next of kin at their bedsides at the moment of death.
Discussion
At-homeness is inescapably linked to the idea of a physical home. When asked what one thinks about on hearing the word “home”, certainly pictures will certainly spring to mind: pictures of one’s experiences of home, evoking notions of form, colour, light and other sensations. It is difficult to imagine home without it assuming a manifest form, an architectural form, perhaps. The construction of a home was the very first architectural task undertaken in human history. A home’s basic function is as a safe shelter for the body, a physical room. Merleau-Ponty (1962) asserted that humans understand and perceive a room only in relation to the body. As human beings, we must always relate to the physical room; both as experienced by our body and senses and as manifested in our mind. We strive to create a sense of being “in place” (Leith, 2006, p. 327) wherever we are; this is closely related to the conceptualization of home. Dekkers (2011) observes that “Being human is dwelling, that is, being at home” (p. 292). The nursing philosopher Kari Martinsen (2006) defines dwelling as having a secure foothold in life and a sense of belonging. She metaphorically describes (p. 26) a house as having many different tones and songs; idealistically, it sings songs of hope and joy. Contrarily, when one’s sense of belonging has been lost, the house can scream. Calkins and Marsden (2000) discuss the concept of home from the joint perspectives of architecture, psychology and the caring sciences. They divide it into three levels: a physical structure, a personal expression and a mental condition.
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The physical structures, or architecture, provide the spatial frames. Personal expression is related to the creation of territories within these physical structures, while the mental condition is concerned with control and safety, and the sense of “being at home”. Zannini, Ghitti, Martin, Palese, & Saiani, (2015) have phenomenologically described nursing at night in an ICU as being in the middle of a calm and intimate space that can suddenly erupt into chaos.
In this paper, we argue that it is indeed relevant to discuss the sense of at-homeness in relation to ICUs. Therefore, we return to the opening question of this paper: is it possible to build the feeling of at-homeness into the ICU patient room? Unequivocally, the answer is yes. The main argument for this position is based on the ongoing complex intervention research programme concerning the ICU room (NN, 2015). The findings from the evaluation process have so far been positive, and have shown that ICU patients are aware of their surrounding environment, and that staff require more theoretical knowledge about the effects of disturbing sounds (Johansson et al., 2016; Johansson et al. 2017). Furthermore, the patients’ circadian rhythms should be protected and a cyclic light system could be conducive to better health among both patients and staff (NN et al., 2015) and consequently should be used in the future design of ICU patients’ rooms. In conclusion, the results have been positive. This may be compared to the findings of Donetto, Penfold, Anderson, Robert and Maben (2017) in their study of the effects of the rebuilt hospital environment on staff. Single rooms were experienced by staff as hindering peripheral perception, compared to the earlier, open ward environment that had allowed them to access a rich range of contextual and preconscious information.
The smallest denominators of the concept of home are our bodies and our minds. Or, “home is where the heart is” as Calkins and Marsden remind us (2000, p. 8). If space is a physical dimension, then place is when and wherein meanings are contained for a particular individual
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or a group. A territory, on the other hand, can be described as a place, implicit or manifest, that the individual or group has, or aims to have, under their control. It has been shown that personal space and territory are crucial for patient satisfaction.
We believe that single rooms promote self-directedness, agency, patient safety and control, particularly in ICUs. Single rooms also come closer to the concept of home by offering more privacy; there is no intrusion from other patients, their care treatments or their visitors. Multiple-patient rooms are still common in older hospitals while, in current hospital construction projects in Sweden and elsewhere, two-patient rooms remain a regular option, both in ICUs and in other wards. We assert that the reason for this is not informed by the patients’ perspective, but rather by economic and organizational factors. Although patients in ICUs may have fragmented recollections of the environment for longer periods, several studies show that ICU patients register sounds, tactile impulses and also their physical surroundings (e.g. Uotinen, 2011; NN
et al., 2015). The paradigm shift in hospital design from “station-based” to “person-centred”
(McCormack & McCance, 2006, p. 473) care indicates positive organizational changes. However, we argue that there is a gap between organizational goals and the technical development and the traditional physical structure in the design of contemporary ICUs. There must be sufficient space, and unnecessary disturbance must be avoided by creating good physical and organizational prerequisites. Architects and designers face great challenges in devising ICUs in collaboration with the health care teams that create feelings of at-homeness, wellbeing and safety. They must maintain awareness of the importance of a good sound and light environment, interiors that support healing and a view of natural surroundings. They must also ensure the promotion of a caring atmosphere as well as making the ICUs attractive as workplaces.
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Conclusions
To understand the patient room as a tool for providing good care as well as a place that promotes recovery, space must also be understood from a functional perspective (Fig. 2). These different functions can be represented by static positions with varying proximity to the private domain, or to the home as a place associated with privacy and control (Hauge & Heggen, 2008). This model encompasses the idea that spaces have preconceived meanings, generally agreed upon by many people. The concept of space contains normative as well as relational aspects (NN, 2017). The idea of a specific space is manifested throughout the planning and construction stages of a building project. Regarding the normative aspects of architecture, it is manifested in the representations of architecture in the form of drawings. It is also manifested in the physical structure. Consequently, when a building is in use, the interaction between users and artefact is, contrarily, related to relational aspects of architecture, manifested in the ongoing relations between the users, in this case the ICU staff, the patients, their loved ones, and the built environment (NN, 2014).
[Insert figure 2 here]
By contrast, the contemporary architectural design of ICUs and other wards counteracts person-centredness in many cases by promoting double-patient rooms. Two counter-arguments from the organizational perspective are that control and observation are more difficult to achieve, and that single-patient rooms may require more space and work effort (Apple, 2014). The argument that single rooms are more expensive can be met by recent findings showing that ICU patients cared for in single rooms have a lower prevalence of delirium than do patients cared for in multi-bed rooms (Caruso, Guardian, Tiengo, Dos Santos & Junior, 2014). ICU delirium is a well-known complication in intensive care patients that increases length of stay, mortality
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and the risk of developing persistent cognitive dysfunction (Page and Ely, 2011; Kalabalik, Brunetti and el-Srougy, 2014). Generally, when single-patient rooms are designed, more space is allotted to the patient, in compared to double-patient rooms: approximately 27-25 square meters. Another argument is that ICU patients are mostly very ill and heavily sedated and, therefore, do not experience any intrusion. However, sedation regimens in intensive care are changing (Karlsson, Lindahl & Bergbom, 2012), rendering this argument obsolete. Moreover, in single-patient rooms, no other patients are disturbed by visitors. A light level of sedation is now recommended, since it shortens the patients’ time on mechanical ventilation, as well as their stay in the ICU (Egerod, Albarran, Ring & Blackwood, 2013).
Earlier, we described space as a physical dimension. A place is created when the space is imbued with meaning by the individual or group. Accordingly, a territory is a place wherein the individual or group exerts control. The degree of control is dependent on how the place is constituted, and on the actualsituation. How space is perceived, used and accessed is, of course, relative to the experiencing subject, in this case, the patient. It is also related to temporal aspects. In an ICU, as in a hotel room, occupants seldom stay for lengthy periods and the bed, the room and the garments have previously been used by others. The space is both for “anyone” and for “no one” (van Lennep, 1969, p. 212). The situational configuration of person and environment determines how space is experienced; this is the lived space, according to Lefebvre (1991). It is space becoming a place; or, it is place as an effect of space and meaning. It is the dimension of use, of space as an ongoing process.
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In this discussion paper, we have identified several highly relevant directions for further research concerning the ICU patient room, in the disciplines of the caring sciences and architecture. To promote at-homeness, agency and control in ICU patient rooms, more research is required with regard to physical spaces and human values. Many hospitals are under construction or being refurbished and the promotion of a healing environment that supports recovery becomes an added value. More research concerning how progress in medical treatment could be matched by progress in ICU design is called for. This concerns ICU environments, with regard to both the physical environment and care administration, to help patients maintain their personal territories and a sense of at-homeness. We also recommend longitudinal studies to track patients’ recovery processes after discharge from ICUs. We believe that our findings are transferable to other contexts, such as general hospital wards, home care and nursing homes
and vice versa. NN and Kirk (2018), describing the consequences of technology’s introduction into domestic space, reported that the feeling of at-homeness could be transmitted into feelings of loneliness and of being locked-in. In “good cases” however, the home was considered a place where new friendships could grow and where the presence of technology could cultivate creativity that supported socialising with others. The latter could also be created near the ICU
bed-space. There are significant benefits for ICU patients admitted to single rooms, with regard
to the prevention of sensory overload and the spread of contagion. However, single rooms place higher demands on staffing rates, since the goal is a one-to-one patient-nurse ratio. Therefore, more research concerning management and organisation in relation to architectural configuration, design and planning is needed.
Finally, we promote a discussion concerning the value of at-homeness, as the concept has been raised in various philosophical texts. We believe, in accordance with Danko, McCuskey and Shepley (2017), that these ideas are relevant to an ICU context, and to practices in architecture
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and caring. Our argumentation is based on the conviction that a deeper awareness of meanings within the body of philosophical literature will underpin research as well as encourage professionals to be sensitive to and follow a holistic and humanistic perspective.
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