Supportive healing environment. La dimensione utente nel progetto delle strutture sanitarie

In the most advanced vision of health services, the patient assumes the role of an active subject in the action of care. Moreover, the effect of the physical healthcare environment on the user well-being is recognized, as the importance of the patient’s perspective for the designing of care services. Starting with the early research in Environmental Psychology, numerous studies analyze the impact of the healthcare environment’s components (spaces, finishing, furniture) on patients, with a growing number of studies focused on the effects as health outcomes and proposing a design based on evidence of outcomes. If important dynamics of interaction are established between "place" and "subject" of care, understanding and optimizing them becomes a key element in the design of therapeutic spaces. However, it is still far from systematic inclusion of the user dimension in the design of care places. The transfer of the research knowledge to the planning and design of healthcare facilities is not immediate. The information, produced in heterogeneous fields, is not yet sufficiently translated in a design language. Furthermore, most of the innovative contributions come from international studies and they have not yet been analyzed in order to assess their applicability to our national context. In addition to these elements, there is the difficulty to include moments of interdisciplinary exchange (architecture, medicine, psychology, etc..) in the design process, which are essential for the understanding of the interaction between environment and users and the definition of criteria focused on patient’s needs. The purpose of this research is to promote the inclusion of the user dimension in the design and assessment of care places. To respond to the highlighted critical issues, the work aims to develop a tool to facilitate the decision-making process to design “supportive healing environments”, which provides: an interpretation of the scientific background, an information base where the knowledge is elaborated and expressed so as to be easily usable to drive the design choices, the indication of a methodological support to facilitate the introduction of the user dimension in the different phases of the design process, a section of analysis and experimentation as thematic deepening and possible operating reference. The activity was carried out by operating simultaneously on two levels – a theoretical one (design patient-centered) and one applied to a specific user/environment system (psychiatric residential facilities). The theoretical study on patient-centered design was developed through a review of the scientific literature. Information in this area is characterized by a large production of first-level literature (articles in scientific journals, conference proceedings), mainly from international sources, especially from the northern European and U.S. area, together with information from heterogeneous sources (articles and technical reports by organizations and magazines). There is a relative lack of systematic treatises and manuals. Then the study focused on the identification of a method to support the design process. The theoretical investigation was supported by the experience gained during the field investigation, carried out in parallel. The study on the psychiatric residential facilities was inspired by the centrality of the patient and modulated according to the guidelines of the identified method. The work started by analyzing documents provided directly by some patients of a therapeutic community in Milan. Then, a small multidisciplinary team was created to carry out a direct analysis of the three residential facilities of the community and to define patient-centered principles. The field analysis was carried out through informal tours, analysis of the sites, interviews evaluating patient’s expectations, direct observation of the environments in use. The study was then extended to acute psychiatric facilities. The results relate to two main areas (patient centered design; psychiatric residential facilities), in relation to the operational levels of the research. The developed tool, to facilitate the decision-making process of “supportive healing environment” design, has been formalized by aggregating the results according to the four areas indicated in the objectives: Context, Information, Methods, Applications. CONTEXT - The evolution of the patient-centered design is traced, finding its essential lines within its development over time (holistic vision of care, perception of the patient as a person and not just for his illness, awareness of the relationship between physical environment and well-being) and the main scientific domains of relevance to the topic (i.e. environmental psychology, ergonomics). The actual lines of research are then identified, pointing out any critical points for further development. INFORMATION – An information base is provided to support the decision-making process, with data such as: aspects of the physical environment and their impacts on the patient and the care process, requirements and criteria to address a patient-centered design. One section contains a description of some of the main channels for research, disseminate and sharing of information (research centers, scientific journals, conferences) in the area of patient-centered design. METHOD – Evidence Based Design (EBD) is the methodological support that has been identified, analyzed and proposed to facilitate the introduction of the "user dimension" in the different phases of the design process. It is an iterative decision-making process that begins with an analysis of the best "evidence" and goes searching for project’s "key". The EBD is currently one of the main references in the international arena for the design of supportive healing environments but it is still not widespread in the Italian context. A critical analysis of the EBD method is also provided, with particular reference to the use of evidences in the design process and the measurement of the outcomes aimed at the construction of evidence themselves. APPLICATION – The application section shows the final results together with the detailed description of the study carried out on psychiatric residential facilities. In this way it aims to provide specific criteria for mental care spaces as well as a working reference for the adoption of the evidence-based approach. Initially an overview of the current supply of psychiatric facilities is provided, highlighting the remaining difficulties in the process of overcoming the old model of asylum. Then, the goals and the different activities of the study are shown. Finally, the study’s results are shown, with principles and criteria for the design of patient-centered residential psychiatric facilities. Among the most significant findings there is the need for environments that support a dynamic view of the process of psychiatric care, as opposed to the static view of the old asylum’s model. Among the issues raised, it should be noted the difficulty of defining criteria that meet the needs of patients (i.e. home-like environments, not institutional, adaptable to the various needs of patients) along with the key needs expressed by some caregivers and institutions (i.e. safety, hygiene). The study confirms that the built space strongly influences the well-being of patient and participates in building, as well as contain, the process of care. The achieved results can help to facilitate the inclusion of the "user dimension" in the design of care places by providing both a knowledge base for further development of research, both an operational support to the healthcare environments’ planning, design and assessment. For psychiatric facilities, the study provides specific principles and design indications and highlights the role of the patient along with the multidisciplinary team in planning patient-centered care places.

La visione più avanzata del sistema sanità è quella di un servizio in cui il paziente assume il ruolo di soggetto attivo nell’azione di cura. Allo stesso tempo è ormai riconosciuto il peso che l’ambiente costruito delle strutture sanitarie esercita sul benessere psico-sociale, oltre che fisico, del paziente e di tutti gli utenti coinvolti. Numerosi sono gli studi che, a partire dalle prime ricerche di Psicologia Ambientale fino agli ultimi contributi dell’Evidence Based Design, ne evidenziano l’influenza sia in termini di stress ambientale che di supporto al processo terapeutico. Se quindi tra il “luogo”, il “soggetto” ed il “processo” di cura si instaurano importanti dinamiche di interazione, la comprensione e ottimizzazione delle stesse diventano un elemento chiave ed un possibile fattore di innovazione nel progetto dello spazio terapeutico. Ad oggi però si è ancora lontani da un’inclusione sistematica della “dimensione utente” nella progettazione dei luoghi di cura. Il trasferimento di conoscenza dal mondo della ricerca a quello applicativo non è immediato: l’informazione, prodotta in campi eterogenei, non è ancora sufficientemente tradotta in termini progettuali. Inoltre, per quanto concerne la realtà italiana, si agiunge il fatto che molti dei contributi innovativi provengono da studi internazionali non ancora analizzati al fine di valutarne l’applicabilità al nostro contesto nazionale. A questi fattori si associa la difficoltà di inserire nel processo progettuale dei momenti di confronto interdisciplinare (progettazione, medicina, psicologia, etc.) indispensabili per la comprensione dell’interazione tra ambiente e utente e la definizione di criteri centrati sul paziente. Scopo della presente ricerca è promuovere l’inserimento sistematico della dimensione utente nell’iter progettuale e valutativo dei luoghi di cura attraverso la predisposizione di uno strumento di supporto al processo decisionale che fornisca: una lettura del contesto scientifico, una base di dati e indicazioni progettuali, l’identificazione e proposizione di un efficace supporto metodologico, una sezione applicativa di approfondimento tematico e di sperimentazione dell’approccio metodologico individuato. La ricerca è stata svolta operando su due livelli: uno teorico, di indirizzo (progettazione patient centered), ed uno applicativo, declinato su di uno specifico sistema utente/ambiente (residenzialità psichiatrica). A livello di indirizzo, l’attività si è sviluppata attraverso una revisione della letteratura scientifica di riferimento, caratterizzata da un’ampia produzione di primo livello (articoli su riviste scientifiche, atti di convegni), da fonti prevalentemente internazionali, in particolare di area nord europea e statunitense, e da una relativa scarsità di trattazioni sistematiche e manualistica. L’informazione è stata elaborata individuando percorso evolutivo, linee attuali di ricerca, elementi informativi essenziali (dati, criteri, fonti). Un particolare approfondimento è stato riservato al tema dell’Evidence Based Design, scelto come riferimento metodologico a supporto del progetto di ambienti supportivi rispetto al processo di cura. In riferimento al tema specifico della residenzialità psichiatrica, la ricerca si è sviluppata alternando fasi di indagine sul campo (comunità protette, reparto psichiatrico) con il coinvolgimento diretto dell’utenza (colloqui, interviste, osservazione diretta, etc.), a fasi di analisi degli aspetti affrontati dalla letteratura scientifica di riferimento, arrivando infine a produrre una sintesi dell’informazione ottenuta in termini di principi e criteri di indirizzo progettuale. La sezione applicativa, oltre ad essere uno spazio di approfondimento tematico, è stata terreno per una sperimentazione dell’approccio metodologico individuato (EBD). I risultati raggiunti attengono a due macro aree, in linea con i livelli operativi descritti. Per quanto riguarda la progettazione centrata sul paziente, la ricerca ha prodotto: un quadro del contesto scientifico di riferimento, internazionale e nazionale, con percorso evolutivo, linee attuali di ricerca, punti critici/di forza per un possibile sviluppo della progettazione patient centered (Contesto); una base informativa con dati (aspetti e impatti, criteri di indirizzo) e canali di ricerca, diffusione e condivisione dell’informazione, a supporto del progetto patient centered (Base Informativa); la proposta di un metodo, l’Evidence Based Design, attualmente uno dei principali riferimenti in ambito internazionale per interventi patient/care-responsive (Metodo). Per quanto riguarda la sezione applicativa sulla residenzialità psichiatrica, la ricerca ha prodotto: una descrizione dello stato dell’arte sulla progettazione centrata sul paziente dei luoghi per la cura del disagio psichico; un set di principi e criteri patient centered per la progettazione delle strutture psichiatriche residenziali (comunità e reparti psichiatrici); una descrizione puntuale del metodo adottato e delle attività svolte, come possibile riferimento operativo per interventi patient centered (Applicazione).