etd-tamu-2004C-2-ARCH-Ozcan

363 Pages·2004·8.76 MB·English

HEALING DESIGN:
A PHENOMENOLOGICAL APPROACH TO THE RELATION OF THE
PHYSICAL SETTING TO POSITIVE SOCIAL INTERACTION IN PEDIATRIC
INTENSIVE CARE UNITS IN THE UNITED STATES AND TURKEY

A Dissertation
by
HILAL OZCAN

Submitted to the Office of Graduate Studies of
Texas A&M University
in partial fulfillment of the requirements for the degree of

DOCTOR OF PHILOSOPHY

December 2004

Major Subject: Architecture
HEALING DESIGN:
A PHENOMENOLOGICAL APPROACH TO THE RELATION OF THE
PHYSICAL SETTING TO POSITIVE SOCIAL INTERACTION IN PEDIATRIC
INTENSIVE CARE UNITS IN THE UNITED STATES AND TURKEY

A Dissertation

by

HILAL OZCAN

Submitted to the Office of Graduate Studies of
Texas A&M University
in partial fulfillment of the requirements for the degree of

DOCTOR OF PHILOSOPHY

Approved as to style and content by:

___________________________ ___________________________
Mardelle M. Shepley Malcolm Quantrill
(Chair of Committee) (Member)

___________________________ ___________________________
Donald A. Sweeney Stephen Daniel
(Member) (Member)

___________________________
Phillip J. Tabb
(Head of Department)

December 2004

Major Subject: Architecture
ii i
1. ABSTRACT

Healing Design: A Phenomenological Approach to the Relation of the Physical Setting to Positive Social
Interaction in Pediatric Intensive Care Units in the United States and Turkey.
(December 2004)
Hilal Ozcan, B.Arch., Middle East Technical University, Ankara, Turkey;
M.S., Middle East Technical University, Ankara, Turkey
Chair of Advisory Committee: Dr. Mardelle M. Shepley

This study examines the impact of the physical setting in the care and healing process of
hospitalized children, their families, and the caregivers in two selected pediatric intensive care units
(PICUs) in the U.S. and Turkey. A holistic, cross-cultural, comparative, and naturalistic approach
emphasized the importance of the total (i.e., physical, social, cultural, spiritual, organizational, political)
environment and quality of life to health and healing. Information was gathered through qualitative
methods such as participant observations, behavioral maps, in-depth interviews, and floor plan analysis.
Despite some universal features of the PICU atmosphere, the value and place ascribed to pediatric critical
care in Turkey and the U.S. present different worldviews. Field studies revealed social interaction as a
universal healing function despite its cultural specificity stemming from socio-cultural, ethnic, economic,
and religious differences between different groups.
Crowding, parental absence, and over-stimulation, which stem from the lack of individual patient
rooms, and organizational problems related with human resources and staffing shortage play against the
critically ill child’s deep need to heal in the Turkish PICU. Despite spatial limitations, informal social
interactions and cooperative relationships among caregivers, their devotion, and their ability to adapt to the
existing physical and social environment enable care delivery. While staffing shortage continues to be a
crucial problem in the U.S. model, specialization of labor and the systemic organization in general support
care delivery, reducing the importance of informal social interactions and cooperation among caregivers.
However, emphasizing the role of the family in the child’s care, social interaction is also identified as a
healing function in this setting. Therefore, despite the significant role the physical setting may play in
healing, social interaction is found to be more important for improving patient outcomes and the well-being
of families and caregivers. The study focuses on six healing design interventions to increase the chances
for positive social interaction and collaboration. These are programmatic (provisional, scale, locational),
functional, ambient, symbolic, social and psychological interventions.
2.
iv

This work is dedicated to:

Huriye and Ali,
for the 31 years of caring, love,
hard work and dedication they provided.

Bulent,
for the meaning
he brought into my life.

And Zuhal,
for her sweet care
in the most critical moments.
v
ACKNOWLEDGMENTS

I would like to express my sincerest appreciation to:
Dr. Mardelle Shepley, the chair of my committee, for her knowledge, inspiration, mentorship,
friendship and her generous support and assistance during my Ph.D. journey;
Dr. Donald Sweeney, for his support as a member of my committee, our meetings and the many
insights he gave me whenever we met and his general support and respect of developing countries;
Dr. Malcolm Quantrill, for the knowledge, encouragement, care and support he gave me during
the production of this dissertation and before;
Dr. Phillip Tabb, for challenging me, sharing his knowledge with me, and urging me “to be the
person I am waiting for,”
Dr. Stephen Daniel, for his passion, talent and dedication in teaching philosophy, the creative
ideas he shared with me, our meetings, and constantly encouraging me to explore home;
Dr. Elizabeth Maret, for the love, respect and friendship she offered and her concern for world;
All care providers for choosing their career, especially Turkish nurses and physicians, whose spirit
overcomes practical constraints in the delivery of critical care. I also want to express my gratitude to Dr.
Tezer Kutluk for allowing me to use their facility, and to Benan and Tolga, for their friendship, hard work
and dedication, and for inspring me to do the same;
The U.S. children’s hospital observed, for offering state-of-the-art services for children, and
allowing my presence at their facility. Special thanks to Deborah for helping me gather my data for this
study, and Diane for sharing her knowledge generously with me;
The Turkish High Education Council and Izmir Institute of Technology, for realizing my dream
for receiving graduate education in the U.S., and supporting me generously with their scholarship;
The College of Architecture, Texas A&M University, for their financial support. Special thanks to
the 1999-2000 Caudill Fellowship Committee, for increasing my dedication to this work;
The American Institute of Architects and the American Hospital Association, for encouraging me
to pursue a career in the practice of healthcare architecture, and special thanks to Mr. James Easter, AIA,
for his support and mentorship;
The 2004-2005 Tradewell Fellowship Committee, particularly Mr. Kirk Hamilton, AIA, for giving
me the possibility to carry the conclusions of this work to practice;
Pinar, Gwendoline, and Jennie, for their friendships, and for opening their homes to me, which
contributed to the cross-cultural insights of this study; and
Last but not least, Sugar, for providing me with constant joy and happiness through my journey in
a foreign country.
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TABLE OF CONTENTS

Page

ABSTRACT..................................................................................................................................................iii

DEDICATION...............................................................................................................................................iv

ACKNOWLEDGMENTS...............................................................................................................................v

LIST OF TABLES..........................................................................................................................................x

LIST OF FIGURES......................................................................................................................................xii

CHAPTER

I INTRODUCTION AND REVIEW OF LITERATURE.................................................................1

1.1 A HOLISTIC APPROACH TO HEALING ENVIRONMENTS..............................................2
1.1.1 Modern Cartesian Medicine and the Shift from
Techno-Scientific Domination to Holistic Health................................................4
1.1.2 The Need for a Holistic and Post-Cartesian Medicine..........................................6
1.2 CURRENT LITERATURE ON PEDIATRIC INTENSIVE CARE UNITS.............................9
1.2.1 History of Pediatric Intensive Care Units and Children’s Hospitals.....................9
1.2.2 The Psychology of Pediatric Intensive Care Unit...............................................17
1.2.3 Contribution of Phenomenology to the Care of Critically Ill Children..............21
1.2.4 The Role of the Physical Environment in Healing.............................................23
1.2.5 Cross-cultural Literature.....................................................................................34
1.3 CONCLUSION........................................................................................................................41

II CONCEPTUAL FRAMEWORK OF RESEARCH AND INTRODUCTION OF
CASE STUDIES.............................................................................................................................43

2.1 NATURE OF METHODOLOGY AND RESEARCH PARADIGM......................................43
2.1.1 Theoretical Stance Beyond Qualitative Paradigm..............................................43
2.2 STATEMENT OF THE PROBLEM AND RESEARCH OBJECTIVES..............................46
2.2.1 Problem Statement..............................................................................................46
2.2.2 Research Objectives...........................................................................................47
2.3 DESCRIPTION OF SELECTED PROCEDURES..................................................................49
2.3.1 Data Collection Procedures: Naturalistic Inquiry...............................................49
2.3.2 Data Analysis Procedures: Grounded Theory.....................................................56
2.4 BACKGROUND INFORMATION ON CASE STUDIES.....................................................58
2.4.1 Turkey and Turkish Healthcare System..............................................................59
2.4.2 Development of Pediatric Intensive Care Units in Turkey.................................62
2.4.3 The Turkish Children’s Hospital........................................................................62
2.4.4 U.S. Healthcare System......................................................................................63
2.4.5 The U.S. Children’s Hospital..............................................................................64
2.4.6 Preliminary Pilot Studies and Hospital Tours.....................................................66
2.4.7 Comparison of Selected Sites and Their Health Care Systems...........................68
2.5 CONCLUSION........................................................................................................................71
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CHAPTER Page

III ANALYSIS OF THE INTERVIEWS WITH THE U.S. CAREGIVERS.......................................72

3.1 THE INTERVIEW METHOD.................................................................................................73
3.1.1 Interview Settings...............................................................................................73
3.1.2 Interview Participants.........................................................................................73
3.1.3 Why They Chose Their Jobs and Best Features of Their Jobs...........................74
3.1.4 The Meaning of Leadership and Management...................................................75
3.1.5 Interview Questions............................................................................................76
3.2 EVALUATION OF THE MEANING OF TECHNOLOGY IN THE PICU...........................77
3.2.1 Passion with Technology....................................................................................78
3.3 EVALUATION OF THE CARING AND HEALING ENVIRONMENT..............................80
3.3.1 The Relationship between Technology and Caregiving.....................................81
3.3.2 The Need to Refocus on Caring..........................................................................83
3.3.3 Care Models and Philosophies............................................................................83
3.3.4 The Meaning in Death and Dying.......................................................................85
3.3.5 The Role of the Physical Environment in Healing.............................................87
3.4 EVALUATION OF THE NEEDS...........................................................................................88
3.4.1 The Needs of Patients.........................................................................................89
3.4.2 The Needs of Families........................................................................................93
3.4.3 The Needs of the Caregivers...............................................................................97
3.5 EVALUATION OF DESIGN................................................................................................107
3.5.1 Evaluation of the Current Physical Environment of the PICU.........................107
3.5.2 Evaluation of the Design Process.....................................................................113
3.5.3 Evaluation of Design Issues and Design Modifications for the Future.............115
3.5.4 Master Planning Issues.....................................................................................118
3.5.5 Continued Hospital Expansion After the Case Study Period............................123
3.6 CONCLUSION......................................................................................................................126

IV ANALYSIS OF PARTICIPANT OBSERVATIONS AND BEHAVIORAL MAPS
CONDUCTED AT THE U.S. HOSPITAL...................................................................................128

4.1 THE OBSERVATION METHOD.........................................................................................128
4.1.1 Observation Strategies......................................................................................129
4.1.2 Analysis of Observations, Field Notes and Behavioral Maps...........................137
4.2 RESULTS OF OBSERVATIONS AND BEHAVIORAL MAPS.........................................138
4.2.1 Step down ICU.................................................................................................138
4.2.2 Second Floor Main PICU: Zone 1 (Staff Station 1).........................................139
4.2.3 Second Floor Main PICU: Zone 2 (Staff Station 2).........................................148
4.2.4 Second Floor Main PICU: Zone 3 (Staff Station 3).........................................151
4.2.5 Second Floor Cardiac ICU: Zone 4 and 5 (Staff Station 4 and 5)....................155
4.2.6 Fifth Floor Trauma ICU: Zone 6 (Staff Station 6)............................................159
4.3 CONCLUSION......................................................................................................................166

V ANALYSIS OF THE INTERVIEWS WITH TURKISH CAREGIVERS...................................167

5.1 THE INTERVIEW METHOD...............................................................................................167
5.1.1 Interview Settings.............................................................................................168
5.1.2 Interview Participants.......................................................................................168
5.1.3 A Typical Day of Caregivers and How They Seek Happiness.........................170
5.1.4 Why They Chose Their Occupations................................................................170
5.1.5 The Best and Worst Liked Features of Their Occupations...............................171
5.1.6 Cultural Characteristics of Management and Leadership.................................171
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CHAPTER Page

5.2 EVALUATION OF THE PHYSICAL ENVIRONMENT....................................................173
5.2.1 Overall Evaluation of the Children’s Hospital..................................................173
5.2.2 Evaluation of the Pediatric Intensive Care Unit...............................................175
5.2.3 Problems with the Current Physical Environment and Proposed Solutions.....176
5.2.4 Comparison of the Renovated ICU Space to Original Design..........................188
5.2.5 The Future of the Hospital................................................................................191
5.3 EVALUATION OF PSYCHOLOGICAL ENVIRONMENT AND “NEEDS”....................198
5.3.1 Psychology of Patient Family and their Need to Stay at the Unit.....................198
5.3.2 The Needs of the Caregivers.............................................................................201
5.4 EVALUATION OF CARING AND TECHNOLOGY..........................................................205
5.4.1 The Role of Technology and its Relation to Caring.........................................205
5.4.2 Care Models and Philosophies..........................................................................207
5.4.3 The Psychology of Death and Dying: A Meaning-Giving Experience.............209
5.5 CONCLUSION......................................................................................................................210

VI ANALYSIS OF PARTICIPANT OBSERVATIONS AND BEHAVIORAL MAPS
CONDUCTED AT THE TURKISH HOSPITAL.........................................................................213

6.1 THE OBSERVATION METHOD.........................................................................................213
6.1.1 Observation Strategies......................................................................................214
6.1.2 Analysis of Observations, Field Notes and Behavioral Maps...........................217
6.2 RESULTS OF OBSERVATIONS AND BEHAVIORAL MAPS.........................................219
6.2.1 Description of the General Physical Environment, Décor, and Atmosphere....219
6.2.2 Place Functions, Activities and Design Considerations....................................222
6.2.3 Floor Plan Evaluation and Design Recommendations......................................229
6.2.4 Quantitative Analysis of Participant Observations and Behavioral Maps........236
6.3 CONCLUSION......................................................................................................................238

VII CROSS-CULTURAL AND SOCIOLOGICAL COMPARISON OF CASE STUDIES.............240

7.1 THE NORTH AMERICAN MODEL.............................................................................241
7.1.1 Social and Professional Relationships in the North American PICU...............242
7.1.2 The Social Practice of Caring and Institutional Culture...................................243
7.1.3 Comparison to other PICUs and Children’s Hospitals.....................................244
7.1.4 Strengths and Weaknesses of the American Model..........................................246
7.1.5 Conclusion........................................................................................................249
7.2 THE TURKISH MODEL...............................................................................................249
7.2.1 Social and Professional Relationships in the Turkish PICU.............................250
7.2.2 The Social Practice of Caring and Institutional Culture...................................252
7.2.3 Comparison to other ICUs and Children’s Hospitals.......................................255
7.2.4 Strengths and Weaknesses of the Turkish Model.............................................258
7.2.5 Conclusion........................................................................................................265
7.3 COMPARISON OF TURKISH AND NORTH AMERICAN MODELS......................265
7.3.1 Similarities or Universals.................................................................................266
7.3.2 Differences or Particulars.................................................................................267
7.4 CONCLUSION...............................................................................................................273
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CHAPTER Page

VIII CONCLUSION.............................................................................................................................278

8.1 SUMMARY OF RESEARCH...............................................................................................278
8.2 SUMMARY OF FINDINGS.................................................................................................279
8.2.1 Findings Associated with Provisional Intervention..........................................279
8.2.2 Findings Associated with Functional Intervention...........................................288
8.2.3 Findings Associated with Symbolic Intervention.............................................291
8.2.4 Findings Associated with Ambient Intervention..............................................295
8.2.5 Findings Associated with Social Intervention..................................................297
8.2.6 Findings Associated with Psychological Intervention......................................301
8.3 THE MEANING OF THE PHENOMENOLOGICAL STRATEGY.....................................303
8.4 LIMITATIONS AND IMPLICATIONS................................................................................308
8.4.1 Limitations of the Study...................................................................................308
8.4.2 Implications for Future Research......................................................................309
8.5 CONCLUSION......................................................................................................................310

REFERENCES............................................................................................................................................314

APPENDIX A GLOSSARY OF TERMS..........................................................................................328

APPENDIX B HOLISTIC MODELS OF PEDIATRIC CRITICAL CARE......................................332

APPENDIX C HISTORY OF CHILDREN’S HOSPITALS IN TURKEY.......................................340

APPENDIX D IMPLICATIONS OF THE STUDY FOR FUTURE TURKISH PICUS...................347

VITA...........................................................................................................................................................350
x
3.
4. LIST OF TABLES
TABLE Page
2.1 Turkish Population Statistics by Age Group...................................................................................61
2.2 Infant and Child Birth and Death Rates in Turkey..........................................................................61
2.3 Shortcomings in PICUs in Turkey...................................................................................................61
2.4 U.S. Population Statistics by Age Group in 2004 (Source: CIA World Fact Book)........................64
2.5 Birth and Death Rates for 2001 in the U.S. (Source: National Center for Health Statistics &
the Centers for Disease Control and Prevention, 2001)...................................................................64
3.1 Protocol of Questions......................................................................................................................76
3.2 Summary of the Needs of Caregivers............................................................................................106
3.3 Multidisciplinary Design and Planning Issues at Children’s.........................................................127
4.1 Distribution of Observation Sessions............................................................................................131
4.2 The Total U.S. Observed Experience............................................................................................132
4.3 Behavioral Coding Chart...............................................................................................................135
5.1 Infection Control Function – Problems and Solutions...................................................................179
5.2 Storage Space and Ordering Systems – Problems and Solutions..................................................180
5.3 Social Support, Social Interaction and Relaxation Functions – Problems
and Solutions.................................................................................................................................181
5.4 Ambient Interventions – Problems and Solutions.........................................................................182
5.5 Functional Interventions – Problems and Solutions......................................................................183
5.6 Safety and Privacy Function – Problems and Solutions................................................................184
5.7 Noise Control Function – Problems and Solutions.......................................................................185
5.8 Needed PICU Facilities – Minimum Guidelines and Services......................................................186
5.9 The Hierarchy of Needs and Corresponding Healing Functions for the Pediatric ICU
Environment..................................................................................................................................211
5.10 Expected Occupant and Organizational Outcomes of the Proposed Functions in the
Turkish PICU.................................................................................................................................212
6.1 The Observed Turkish Experience................................................................................................216
6.2 Relationship Between Social Interaction Types and Design Considerations................................223
7.1 Author’s Observations – Contrasting Turkish and North American Values.................................268
7.2 Similarities Between the Turkish and U.S. Pediatric Healthcare Models.....................................269
7.3 Differences Between the Turkish and U.S. Pediatric Healthcare Models.....................................270
7.4 Proposed Architectural Solutions Based on Cross-cultural Comparison......................................274