«What would Florence Nightingale think?»

Doctors, architects and nursing staff can test what digital care models are capable of by accurately simulating them. The potential is as great as the challenges.

Fotos: Marco Frauchiger
In cooperation with the Swiss Center for Design and Health

Doctors, architects and nursing staff can test what digital care models are capable of by accurately simulating them. The potential is as great as the challenges.

An elderly man sits slumped in a cosily furnished living room. His chest rises and falls laboriously. He seems to be almost drifting away when he is aroused by a knock at the door. With considerable effort, he pulls himself out of his armchair and opens the door to a young woman. She is wearing a green scrub top and is carrying a bulging black case, which she places carefully on the wooden table. Straight away the man begins to talk, explaining that his heart is racing and he is worried about losing consciousness. Both are wearing felt slippers over their shoes and there are giant spotlights suspended high above their heads. The scene is part of the «Building trust: Designing for remote care» symposium run by the Swiss Center for Design and Health. A group of observers follow proceedings attentively, making notes and filming on their smartphones. Many of them are members of the SCDH team that has prepared four test scenarios for the two-day event. The simulations are intended to show how incorporating digital processes into healthcare delivery affects patients, nurses, doctors and family members. The case study is the story of a man with heart disease who has just been discharged from hospital and has been hospitalised at home. «Hospital at home» is an approach that delivers clinical care in people’s own homes.

Collecting users’ knowledge
The protagonists are nurses, doctors and staff members. There are actors too. Although they lack the patients’ experiences, their feelings during the roleplay exercise are important indicators. «Simulation is a very valuable technique in design research,» says Minou Afzali, Head of Research at the SCDH. «Experiencing these scenes first hand is a good starting point for a discussion.» And there is plenty of discussion. Each movement, each decision made by the participants is analysed in the debriefing session. «Wasn’t the process almost too perfect?» Deane Harder asks the participants. «Are people actually so patient in real life?» The professor from Bern University of Applied Sciences is one of the symposium organisers and a member of the SCDH’s Scientific Board.

Various members of the International Advisory Board, who have travelled in from the USA, Canada and Sweden, are also in attendance. There are people with backgrounds in public health, nursing, medical informatics, social anthropology, surgery, emergency medicine, design and architecture in the spacious building. The group assesses the use of digital communication tools with particular concentration. According to the script, the district nurse makes a video call to the patient’s cardiologist for a remote consultation, during which the cardiologist gives instructions and reassures the patient. The screen that she uses is built into the black case, which also contains medical accessories.

Although the professionals present see advantages in the two-stage treatment process they have just witnessed, they also spot critical issues. These relate primarily to the role played by the nurse, whose task load has increased as a result of the technological support. Digital care models are an issue that needs to be urgently addressed. Gaining experience with them is the only way of determining which tools are needed and how they should be handled. Nurses assume a central role as the interface between patients, their families and the hospital. It is important to share their knowledge with the technology developers. «They need to develop technologies that help us help patients,» says the medical informatics specialist and former nurse who played the role of the district nurse. It is clear that the black case with the built-in screen does not take account of nurses’ needs – it weighs in at twelve kilograms, hardly practical for people who spend their days criss-crossing towns and cities to visit patients.

Designing hybrid rooms
The simulation has raised a lot of technology-related questions. However, physical space is an important factor too. In many places it lags behind the pace of development. Hospitals are often very short of offices and there are rarely any for nursing staff. So where will the video calls that are an essential part of telemedicine take place? If they take place in an environment where there is a lot of noise and visual distractions, patients are unlikely to find the experience inspires trust. Yet trust is essential to successful treatment. Factors such as light, colours or materials and the effect they have on users’ experience can be tested in the «realistic testing spaces», as the mock-up flats are known within the SCDC.

More important though is the ability to put treatment procedures to the test in these facilities. Although patients do not physically enter an office or surgery during a remote consultation, the design of those spaces is nevertheless fundamentally important. The way they are fitted out needs to be carefully planned and attuned to a range of scenarios. If a therapist is conducting an online consultation from a sofa, the screen needs to be at eye level and the design of the furnishings has to be appropriate. After all, doctor and patient also look each other straight in the face during a physical consultation. «Therapy and technology should be thought of together because they form a system,» is how a psychoanalyst in attendance sums it up.

«The technology shouldn’t only be implemented afterwards». Hospitals are becoming increasingly hybrid places, built for both conventional and digital healthcare delivery. Just how complex planning them will be becomes apparent at the SCDH. You only need to imagine the user journey that goes with a digital consultation, starting with the wait in the practice’s digital waiting room, to get an idea of how much thought and care the team has put into preparing the script for the test scenarios. The focus is precisely defined. «In an operating theatre, for example, the risk of infection plays an important role, whereas in a care home residents’ safety tends to be the main consideration,» says Minou Afzali. «What would Florence Nightingale think about all this?» Nirit Pilosof, Head of Research at Sheba Medical Center in Israel, asks the group. She is another of the symposium organisers. «She’d certainly appreciate having technology that provides so much data to help design surroundings.» Florence Nightingale, a British nurse and statistician who died in 1910, is regarded as the founder of modern nursing. One of the things she worked on was how surroundings affect health.

Remote care
Being able to stay in the familiar surroundings of their own home has a positive impact on patients’ recovery. Studies show that people who receive «Hospital at Home» care spend less time in bed and return to health more quickly. The suitability of this treatment approach is determined by the nature of the patient’s disease and their home situation. While home care is widespread among senior citizens in Switzerland, it does not extend to acute care. Other countries, such as Norway, Israel or Japan, are at a more advanced stage here. Spurred on by the pandemic, Switzerland is now also keen to make progress. Technical progress means that some day, patients will only be hospitalised if they have no other option. Everyone else could be treated at home.

Patient well-being is not the sole consideration. The new model also promises to relieve pressure on hospitals and could potentially deliver cost savings. However, initial findings show that it is above all time-consuming and staff-intensive. A Zurich media outlet reported in May that an expert claimed this situation could improve with growing experience and efficiency. The same expert also praised the United Kingdom, where «four specially trained nurses can take care of up to 60 patients simultaneously using electronic monitoring.» While it is doubtful whether this is a desirable scenario, it does not alter the potential of remote care. No one at the SCDH doubts that the technologies in question will soon be in use. That’s why they want to make sure that they are implemented in a way that benefits users. And that planners, architects, designers and software developers learn to think from the perspective of care providers and patients.

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