Transforming the NICU Environment for Parent and Staff Wellbeing: A Holistic and Transdisciplinary Supportive Design Approach

Abstract

This chapter describes an interior and spatial design challenge at the Neonatal Intensive Care Unit (NICU) at the Royal Brisbane and Women’s Hospital that occurred over the Summer of 2022–23. The QUT Design Lab team worked closely with nurse champions from the NICU to help re-vision how their space could be used more effectively to increase feelings of comfort and belonging, particularly for parents of children in the ward. From a long list of potential design solutions to the many issues faced, a short list of six were developed in detail so that the hospital’s facilities team could implement the proposed solutions to the most pressing concerns.

The importance of creating a supportive and positive environment in neonatal intensive care units (NICUs) has gained increasing attention over the past few decades. This paper explores the transformative impact of a holistic and transdisciplinary supportive design approach to the refurbishment of non-clinical spaces of a NICU environment on the wellbeing of parents and staff. Drawing upon the ongoing research on environmental design in healthcare, in this project the design team focus on strategies to promote positive experiences, rather than merely addressing the discomfort caused by negative aspects of the environment [5]. We also apply a holistic and transdisciplinary approach by considering the visual, spatial, and service experience aspects of design, and bring together individuals from diverse backgrounds, including parents, clinical staff, and a core design team with expertise across interior architecture, visual communication design, service design, and design psychology, to work collaboratively towards a common goal. While neonatal intensive care units draw upon medical expertise to prioritise the care of sick infants, this project applies design expertise to cater to a broader perspective which also encompasses family-centred care, and recognises the significance of supporting the wellbeing of all stakeholders involved in NICU care. In particular, this project acknowledges the importance of caring for the carers, namely staff and parents, and, while it was not a focus of this study, we also recognise that design transformations may result in secondary benefits for infant patients in the NICU, such as improved caregiver morale and attentiveness, which can positively impact the quality of care provided to the infants.

The following sections of the chapter offer a brief overview of the project aimed at transforming an urban Neonatal Intensive Care Unit through a holistic and transdisciplinary supportive design approach. It also outlines the strategy for engaging with staff and parents, and discusses the Theory of Supportive Design and its application for the design approach. Finally, six supportive design concepts are presented for transforming the Case Study site, along with a reflection on the challenges and limitations of a holistic and transdisciplinary supportive design approach for creating change within a NICU environment.

1 Engaging Differently

One of the first considerations for involving staff and families of a NICU environment in the design process is their capacity to be involved and designing bespoke engagement strategies which meet the unique needs of both user groups. In this project the design team drew upon our experience on a similar project in a Paediatric Intensive Care Unit—see Chaps. 3, 17, and 20 [1,2,3], where we discovered the challenges of designing engagement methods for unpredictable settings. In intensive care settings like PICUs and NICUs, each day is different, as a patient’s health can change suddenly, causing staff and parents to move into action—responding to the ever-present patient monitoring alarms.

While workshops are a common tool for co-design, they are not something that staff can necessarily commit to, and do not account for how parents or other family members might be feeling on a particular day.

Therefore, in this project, we built upon the strategy used in the PICU project chapter “‘It Takes a Village’: The Power of Conceptual Framing in the Participatory Redesign of Family-Centred Care in a Paediatric Intensive Care Unit” [2] involving a bespoke ‘marketplace’ engagement strategy, which involves setting up mostly self-guided activities in a visible, yet unobtrusive area of the ward to encourage engagement from staff and families, with the design-research team being available to speak to those who wish to engage and giving space to those who do not (see Fig. 1).

Fig. 1

Tree installation (top), photo-talk (middle), and unstructured interviews & walk-shops (bottom)

The engagement activities comprised three parts:

• 1. The first part was Static Interaction Displays, located in the staff tearoom for staff and in the marketplace for parents. These displays took the form of a Dot Plot, where participants placed a dot on the item that they feel could improve the NICU spatial experience the most.

• 2. The second part consisted of Guided Activities, including a Tree Installation (Fig. 1—top) where participants responded to six different questions. Additionally, there was a Photo-Talk activity (Fig. 1—middle) where participants wrote their perspectives and ideas on printed photos of the current space.

• 3. The third and final part is described as Designer Interaction, which involved inviting staff and families to have an Unstructured Interview (Fig. 1—bottom) with a member of the design team or go on a 1:1 Walk-shop. During the walk-shop, a member of the design team took a participant to designated areas throughout the unit to gather feedback based on an embodied response to the environment.

2 A Holistic & Transdisciplinary Approach

While the origin of the term ‘holistic design’ is unclear, especially given its use across various fields and disciplines over time, its use in the context of healthcare design has increased significantly in recent years, where it refers to a comprehensive and integrated approach that takes into account physical, psychological, and social factors to promote healing and wellbeing [4]. In this project, we interpret a holistic approach to transforming the NICU environment as considering the complex interplay between spatial, visual, and service experience factors in the redesign of various spaces within the unit, and understanding how they may impact one another.

The approach taken in this project was informed by a variety of theories and approaches which focus on the connection between environmental design and wellbeing within healthcare settings, including: Environmental Psychology [5, 6]—a field of study which is broadly focused on the relationship between people and their physical environment; Ulrich’s Theory of Supportive Design [7]—a specific theory within environmental psychology which proposes that the design of healthcare environments can have a significant impact on the wellbeing of patients, staff, and family; Biophilic Design [8]—an approach which incorporates natural elements such as green walls to impact on wellbeing; Salutogenesis [9]—a theory focused on the promotion of health and wellbeing rather than merely treating illness; and Evidence-Based Design (EBD) [10]—an approach which seek to create environments based on the practical application of theories and research data.

We describe the design approach and outcomes taken in this project, as an ‘Evidence-Based Holistic & Transdisciplinary Design Approach’ informed by Supportive Design principles. While many studies on this topic focus on patient outcomes, this project takes a different approach, by focusing primarily on improving the experience of staff and parents. While there are aspects of the existing NICU environment at the Case Study site which could be addressed to improve patient wellbeing and healing outcomes (such as redesigning patient bathing procedures), the complexity of responding to these meant that it fell outside the scope of this project. In narrowing our focus to the wellbeing of staff and parents, we were able to shift away from the design of ‘health’-care for the treatment of illness, and instead focus on factors which provide support, ‘humanise’ the environment, and foster ‘Care’ ¹ in accordance with a Salutogenic approach.

In practice, in addition to the clinical perspectives of staff, and the lived experience of past and present parents, this approach is applied through three main design approaches including Spatial Design, Visual Design, and Service Design:

2.1 Spatial Design

In this project we applied our skills in Interior Architecture to redesign specific spaces to enhance its functionality, usability, and aesthetics, while also being tailored to the specific needs and goals of the users, whether that be parents or staff. In this project, the design of interior spaces involved the redesign of existing spaces including planning, arranging, and reorganising of zones and elements of the space, designing new joinery, and the selection of materials, finishes, and furnishings.

2.2 Visual Communication Design

This field of design incorporates a broad array of approaches which are used to convey ideas and information. In this project we draw upon our skills in graphic design, branding, image making, and information design through the use of colour and artworks to enhance functional aspects such as wayfinding and creation of an aesthetically cohesive environment.

2.3 Service Design

While service design is typically concerned with the end-to-end ‘customer’ journey experience, in this project we draw upon service design approaches to narrow in on specific opportunities to improve upon or create better touchpoints to meet the needs and expectations of parents.

3 Developing Solutions with Cross-Benefits for Parents and Staff

One of the ways in which this project responds to a holistic approach is through the development of design solutions which have cross-benefits for both staff and parents. The aim of this project was to design a family-friendly environment that supports family-centred care with an awareness of the impact that such changes would also have on the wellbeing of staff. While we were motivated to find solutions that were specifically aimed at improving the experience of staff, the findings from our engagement indicated that staff were mostly invested in solutions that would improve the wellbeing of parents. This could be attributed to a felt sense of responsibility from staff to provide an environment which reflects the high level of care that they deliver. This is reflected in research that explores the influence that the physical space has on the perceived level of care being delivered, a phenomenon that can felt by both parents and staff. While hospital staff have limited control over the physical environment of hospital spaces, there have been various studies [11,12,13] which reveal that, regardless of how much control staff actually had over the physical environment, patients believed staff to be at least partially responsible or to have the ability to take some actions to improve the environment. The overall importance of the appearance of hospital spaces was evidenced in a study by Arneill and Devlin [12], who discovered that perceptions of care were greater in attractive spaces than in those which were cold and outdated. During our stakeholder engagement process with staff and parents, we discovered evidence of this phenomena from healthcare staff, rather than parents, and their concern over how they might be perceived by parents for their felt sense of responsibility over factors which they shouldn’t necessarily be responsible for.

A felt sense of responsibility can become an emotional, financial, and time burden for healthcare staff. During our experience at the Case Study site, we could sense how this perceived feeling of responsibility contributed to feelings of shame, guilt, and anxiety amongst staff. This was evidenced in a conversation about the existing kitchen, when one of the staff stated, “it’s not a space we’re proud of”. We also observed where staff were using their own money to purchase artworks, decorations, and even sculptural trees to create seasonal activations and ‘brighten the space up’. Finally, we witnessed the burden of time where staff took on additional workload, researching options to upgrade the space and applying for funding—on top of their existing work commitments. We realised that offering design concepts and details to revamp the unit, even if it is solely for family areas, not only reduces the workload on staff but also has the potential to improve their wellbeing. Other studies have discovered that improving the physical environment in healthcare facilities like NICUs, beyond providing a more familiar and inviting atmosphere for families, can impact both the behaviour and mood of healthcare staff, potentially influencing patient outcomes [11]. Therefore, the project aimed to improve the provision of support services in the ancillary spaces of the existing unit most utilised by parents and families, including the main entrance corridor, parent kitchen, lounge, and craft areas, as well as the conference and x-ray room.

4 Supportive Design Theory for Neonatal Environments

The design team’s response to designing a supportive environment in the Case Study site—an urban NICU, was identified, defined, and justified in alignment with the feedback gathered by our own engagement with staff and families, in addition to the Recommended Standards for NICU Design [14], and Supportive Design Theory.

In his Theory of Supportive Design [15], Roger Ulrich—a leading expert in evidence-based healthcare design, cites three factors for designing environments which provide support coping with stress and promoting wellness: (1) Perceived Sense of Control, (2) Positive Distraction, and (3) Social Support Opportunities. A description of these and their application in this project is explained further below.

4.1 Application of Theory: Perceived Sense of Control

According to Ulrich, “humans have a strong need for control and the related need of self-efficacy with respect to environments and situations” [7, p. 100]. However, studies suggest that parents of infants in NICU often feel a lack of control and independence, which can lead to feelings of helplessness [16]. The NICU environment, with its unfamiliar rules and regulations (e.g., scheduled visiting hours), can contribute to these negative emotions, as parents may feel restricted in their ability to care for their child and be in their primary caregiver role. The hospital environment can often exacerbate these feelings, as parents may struggle with wayfinding, resulting in feelings of agitation, disorientation, and a loss of control [17, 18]. Carter explains that finding solutions to mitigate these negative emotions and create a sense of control for parents, “without actually allowing complete authority, is critical” [19, p. 19].

In order to minimise feelings of helplessness and dependence, and promote feelings of control and independence, Carter recommends applying environmental elements that provide users with ‘autonomy, a sense of routine, self-efficacy, and choice’ [19, p. 18]. In addition to a clearly articulated wayfinding design, enabling the regulation of room temperature, lighting, and amenities such as television and acoustic systems are common recommendations for cultivating an increased sense of control. Unfortunately, in this project, the building design limited our ability to enable occupants to control temperature, lighting, and sound. Instead, we explored opportunities to enhance their sense of control by humanising the environment, an approach with clear psychological benefits for parents in the care-giving process. While a ‘cold and hostile’ environment may potentially increase psychological discomfort for parents, a ‘warmer and human-friendly’ environment could reduce environmental stressors and facilitate emotions that support the healing process [16].

There are obvious limitations on how the nursery spaces within the NICU can be humanised. While parents may personalise small pockets of space with photographs, artwork, and mobiles above the open cribs, these spaces are inherently clinical environments with restrictions in relation to the furnishings and finishes which are allowed to be used. However, there are opportunities to humanise non-clinical parent spaces. Oftentimes, parents may need to step away—take a break or have something to eat, and may not necessarily want to go all the way home. Having a space within the hospital is important, but it does not mean that it should look and feel like a hospital. Family spaces in the Case Study site, including the parent kitchen and lounge, and the parent craft rooms, are an opportunity to create a retreat from the rest of the hospital–somewhere that feels more like home, where parents can feel a sense of ownership over the space and create familiar routines e.g., make a coffee, heat up a meal, or even take a nap.

4.2 Application of Theory: Positive Distraction

While parents’ attention in NICU settings will undoubtedly be focused on their child, creating opportunities for parents to have mental breaks, zoom-out, and nurture self is important. There are two main concepts within environmental psychology to describe this, one is ‘cognitive refocusing’ a coping strategy or technique which directs attention away from negative thoughts to positive or neutral ones, the other is the ‘distraction effect’, specifically one that is positive [16]. According to Shepley [5]—a leading expert in evidence-based design for healthcare, ‘positive distraction’ strategies present an opportunity for NICU settings to enable parents to temporarily redirect their attention from negative healthcare surroundings to more restorative non-medical features such as artworks or views of nature.

There are a number of ways to support positive distraction in the NICU environment, including both mental and physical escapes through going for a walk, taking time to eat and sleep, maintaining relationships with friends or co-workers, and even doing daily tasks such as preparing food or doing the laundry [19]. In this study, we looked for opportunities to design for positive distraction, particularly using colour and artworks of nature.

Colour can be a useful tool to not only provide visual interest and distraction, but also to aid in wayfinding [17, p. 50]. According to a review of literature conducted by the Research Centre for Primary Health Care and Equity in NSW, “building cues and architectural features provide significant prompts, and are more powerful than signage for wayfinding” [17, p. 51]. This is useful in the context of this study, where signage is controlled by the broader hospital, relying on us as a design team to find alternative methods to enhance wayfinding. The research literature also states that “colour should be used as a cue in wayfinding for simple zoning of no more than four main areas of a building” and that “the colours should be easily recognised by their descriptive words (for example blue, red, yellow)” [17, p. 51].

In addition to colour, the provision of art and views of nature are also commonly cited in literature as sources for positive distraction in healthcare environments. Unfortunately, the existing unit was in short supply of views out of the unit, yet alone art, presenting a need to fill this gap, ideally through artworks of nature. Fortunately, there are a large number of studies which support the benefits of pictures, photographs, and videos of nature, and confirm that such images are associated with positive health outcomes, in addition to having benefits for staff [17, p. 42]. The use of images of nature for positive distraction, creating a restorative experience, and humanising the healthcare environment is also referred to as ‘pictorial humanisation’ [16]. This was the focus of a study in Italy in 2014 which sought to understand the impact of pictorial humanisation for reducing the sense of unfamiliarity by infants’ parents, and improving the level of parental distress and affective perception of the NICU environment [16]. Despite showing no differences on parental distress, the parents in the study reported an improved perception of the NICU environment as more ‘pleasant’, demonstrating the usefulness of images for positive distraction and creating a welcoming environment for both parents and staff.

4.3 Application of Theory: Social Support Opportunities

Being a parent in NICU can be both an isolating and unfamiliar experience. While this is the case for most hospital environments, the NICU unit is a particularly foreign experience, which most parents are introduced to suddenly during the often emotional, stressful, and in some cases traumatic period following the birth of their child.

Research indicates that during the perinatal period, parents (particularly mothers) are at significant risk of developing perinatal generalised anxiety disorder [19], post-traumatic stress disorder [20], and post-partum depression [21], that could persist for a long time after discharge [16, p. 2]. As so pertinently described by Carter, while a mothers’ continual presence in the NICU is seen as crucial to patient development, it “may comprise her own wellbeing” [19, p. 13]. The evolving knowledge on the important role of mothers for patient care has been recognised in the ninth edition to The Recommended Standards for NICU Design [22] which suggests a range of recommendations to further integrate mothers within the NICU care delivery model.

Early in the project we identified the potential to use design strategies to influence the recovery and wellbeing of parents so that they don’t go home ‘broken’, as a clinician told us they often do. Drawing on Ulrich’s Theory of Supportive Design, Carter explains that designers can “influence recovery by creating spaces that promote wellness and are ‘psychologically supportive’” [19, p. 18], indicating the potential for the redesign or repurposing of hospital spaces to enable parents to begin the process of emotional recovery during their time in hospital, while they are surrounded by healthcare professionals and other parents going through a similar experience.

In this study, we approached this by designing ‘experiential’ service design solutions through identifying opportunities to improve upon the utilisation or function of existing spaces to facilitate social support activities. The major challenge of this project was the limited available space, which required that existing spaces become more flexible to facilitate multiple purposes. Two such spaces were identified: the X-ray Room and the Conference Room.

5 Transforming the Neonatal Unit: An Overview of Six Supportive Design Concepts

After conducting research and engagement, a long list of possible design concepts was created. However, due to limitations such as budget, timeline, and feasibility, not all concepts could be pursued. A negotiation process was undertaken to determine which concepts were achievable and most critical. From this process, six design concepts were chosen and narrowed down for further development. Table 1 below outlines the selected design concepts and demonstrates how each concept aligns with the three factors of Supportive Design Theory.

Table 1 Application of supportive design theory to the six design concepts

5.1 A Place for Parents: Re-Designing the Parent Hub for Dining, Working, and Resting

This initiative focused on a redesign of the parent hub spaces, comprising both the parent kitchen and parent lounge, to create a distinct place for parents to dine, work, and rest. Both spaces required updates, particularly the kitchen, to ensure that they are not only functional, but also welcoming and comforting. This ward is home to the families for the duration of their baby’s care. For some that is a week or two, but for many it can go on for months—long days that need to be supported with warm, comforting facilities that make the families feel valued, cared for, and nurtured.

The existing parent kitchen (Fig. 2) has a worn, tired aesthetic, and though improving wayfinding will help parents find this space, when they do, they may feel underwhelmed. The lighting and colours in this space make it look and feel like an extension of the hospital. It is not a space that staff feel proud of show to new parents on ward tours, in fact many told us they feel embarrassed. The colours and cool lighting are uninviting, there is underused storage, closed cupboards used to store outdated documents and other resources with no apparent home, flaking chipboard on the inside of cupboards, and there is often also broken furniture and equipment lurking in this space. For the kitchen, we proposed a full refurbishment with a reconfigured parent kitchen, new joinery, a new café-style dining space to seat more people, a work pod, and a warmer colour palette.

Fig. 2

Existing kitchen (top), proposed kitchen mood board (middle), and proposed kitchen design (bottom)

Unlike the kitchen, the parent lounge (Fig. 3) had recently had a refurbishment, with new timber-look flooring, artworks, fresh paint, and new lounge seating, all done in memory of a colleague. While these changes were an improvement, the lighting and furnishings still made the space feel like an extension of the hospital. There was nothing in the space for siblings, and when we spoke to families, we found that not many use it regularly. Therefore, in the proposed parent lounge (Fig. 3—bottom) we proposed some aesthetic upgrades to make the space feel much warmer and more welcoming, including a lounge in an earthy orange colour where parents can rest or nap, a work pod to enable parents to work or access the internet, or even for siblings to do their homework (which we heard some do). For the siblings, we also propose some floor pads in the centre of the space that can be stacked away or left out, a mural or sensory wall, and a shelf for books, toys, and plants. In addition to the earthy colours, we also proposed timber veneer ceiling tiles and warm lighting to soften the space and distinguish it from the rest of the hospital.

Sense of control	• Comfortable and moveable seating in the dining area. • The new design of both spaces creates a distinct family zone to use how they please.
Positive distraction	• In the lounge there are artworks and a library. • In both the kitchen and lounge there are work pods.
Social support	• The proposal for the lounge area fosters more social support with a large corner lounge and floor pads for play. • The new café-style dining space in the kitchen can host more people.

Fig. 3

Existing parent lounge (top), and proposed lounge design for parents and siblings (bottom)

5.2 From Parent Craft to Parent Retreat: Transforming the Parent Craft into a ‘home away from home’

The Parent Craft was another space that needed to be transformed to create a ‘home away from home’ for parents at what is hopefully, the last stage in their journey before taking their baby home. The NICU Standards suggest that ‘Family Transition’ room(s) be provided which enables families and infants some time together to prepare for the transition from hospital to home prior to discharge, with access to sleeping facilities for both parents and bathroom facilities [22]. In the urban NICU Case Study, these spaces are referred to as ‘Parent Craft’ rooms and include two separate rooms, each accessed from the parent kitchen space, with a shared ensuite bathroom. While these spaces are a fantastic facility, the existing spaces are worn, tired, clinical, and underwhelming, and in much need of aesthetic upgrades to make the space more homely, and a retreat from the rest of the hospital. Though the doors to these spaces are often closed, the experiences of neonatal families as they leave the ward need also to be nurturing and comfortable. Our intention with this space was to create a homely hotel suite, replacing hospital furnishings with furniture that wouldn’t be out of place in any home, replacing aluminium blinds with new block-out roller blinds, and all new joinery—relocated to the entry—just as you would have in a hotel, enabling the seating area to be positioned by the window and natural light (Fig. 4).

Sense of control	• This is a private space for parents to spend time with their baby to become familiar with breastfeeding and feeding cues, away from the other areas of the unit.
Positive distraction
Social support	• While these rooms are private, as they are located within the hospital, they enable parents to have access to the support and guidance of staff when needed.

Fig. 4

Existing parent craft (top), and proposed design for parent craft rooms (bottom)

5.3 Placemaking and Creative Wayfinding: Creating Zones and a Sense of Identity for the Neonatal Unit

This initiative is focused on placemaking and creative wayfinding solutions using colour to create zones and a sense of identity across the neonatal unit. According to the International Standards for the design of neonatal units, the design of the entry and reception areas should “contribute to positive first impressions for families and foster the concept that families are important members of their infant’s health care team, not visitors”, and highlights the importance of signage and art for achieving this [22, p. 14–15]. Overall, the unit has no sense of visual identity. From the moment you walk through the front sliding door, there is an overwhelming sense of sameness, with no visible change in the appearance of the space from the outside to the inside of the unit. The space has been described by both staff and parents as clinical, cold, boring, and dull.

In addition to lack of identity, there is also limited signage, and there is no evidence of wayfinding cues to indicate the location or direction of spaces such as the parent kitchen, or aid people in intuitively directing themselves through the unit, especially for someone who has not been there before. We were shocked, yet unsurprised, to discover that one parent had been there for 6 weeks before they knew there was a kitchen for parents. This is a very stressful time in a parent’s life, and, as someone shared with us during our engagement, the current space is not helping. This would also help to support parents for whom written English is an obstacle.

In this case, signage was the responsibility of the hospital, and while we requested a sign for the parent hub, this largely fell outside the scope of this project. Therefore, we recommended the use of colour to create zones through the space to enable parents to have some orientation within the space without the explicit need or reliance upon signage.

As a change from the cool white walls, we proposed warm colours informed by an Indigenous artwork which was scheduled to be installed in the outside corridor leading to the entrance to the unit. In this scheme colour could be used to identify or ‘zone’ the family spaces throughout the unit such as the Expressing Room, the entrance to the family hub from the entrance corridor, and the Xray room. Ideally, this would enable staff to tell parents “look for the orange walls” or “follow the corridor until you reach the orange wall”. While the mock-up images don’t show the full concept, the proposal for updating these spaces and transforming the identity of the unit also includes new carpet and ceiling tiles, and new artwork throughout.

Sense of control	• Wayfinding tools enable parents to have an enhanced spatial awareness and enhanced their ability to navigate the space and minimise the need to ask for assistance.
Positive distraction	• The use of colour provides a distraction by distinguishing it from other spaces.
Social support

5.4 Bringing the Outside-in: Fostering Connection to Nature through Photographic Artworks of Australian Native Flora

As previously stated, the corridors of the unit, particularly throughout the main entrance are bland and clinical, as can be seen in Fig. 5 (top images). In this project, we recommend the use of photographic floral art to bring the outside in. The unit has only one window with a decent view out of hospital, and although many people visit this window, beyond that, there is very little opportunity for positive distraction. In terms of artwork, in the corridors of the clinical spaces (Fig. 5—bottom), staff have supplied artwork to help brighten the place up, but the styles are inconsistent, from a moody photograph of koalas to a bright illustration of cacti, most of which are mostly camouflaged by other visual paraphernalia. In contrast, the corridor of the main entrance has walls entirely blank, and, as a parent described it to us, it does not celebrate life.

Fig. 5

Existing walls of the entrance corridor (top), and existing walls of the clinical corridors (bottom)

Our solution was to display nature-themed artworks, particularly photographic artworks which respond to both the need for view of nature, in addition to artworks for ‘positive distraction’. In addition to bringing nature into the unit, the artworks also celebrate life and diversity. We are inspired by the lyric ‘from little things, big things grow’ which reflects the hope that parents have for their infants, and the way that could be represented through art in the form of seedpods and flower buds. In reference to the medical setting, we also recommend selecting photographs which use a style emblematic of Xrays and other medical imaging techniques.

Sense of control	• The use of artworks helps to humanise the hospital environment and contribute to making the spaces feel less clinical and more familiar to parents to enable them to feel more comfortable within the space.
Positive distraction	• The artworks contribute to positive distraction through ‘pictorial humanisation’ and provide additional access to views of nature through art.
Social support

5.5 Creating a Comforting Place for Private Conversations: Re-Imagining the Xray Room

Standard 16 of the NICU Design Standards responds to the ‘extensive’ emotional and psychological challenges experienced by families and staff in NICU settings [22]. It recommends the provision of a dedicated support space with comfortable furnishings for counselling services, grieving, and other private conversations, to be accessed by family and staff [22, p. 26]. Unfortunately, the existing unit did not have a designated space for these activities. Furthermore, we discovered from our research that parents are often having ‘private’ consultations with staff in the hallway in earshot of other parents, and staff we spoke to were concerned that overhearing bad news might be distressing for other parents. We also discovered that there was no dedicated space within the unit to grieve or process heavy emotions. In our design proposal, we identified the ‘Xray Room’ as a space which could service this gap. The existing space (Fig. 6—top) is a small, internal, non-parent, hospital-controlled space which is used for hosting morning meetings, clinical discussions (over Xrays and other results), and some parent consultations. However, the existing conditions of this room are not great. We identified an opportunity to turn this into a quiet space that can hold parents in these extra difficult times and allow them to feel safe and secure.

Fig. 6

Existing Xray room (top), and proposal for re-imagined Xray Room (bottom)

Our design solution is two-fold: (1) rebranding of the room, and (2) aesthetic upgrades. Firstly, being known as the ‘Xray Room’ does not reflect the types of discussions that could be held in this space, and therefore we recommended that the room be renamed to something such as the ‘Dadirri’ Room—named after an Indigenous word from the language of the Ngangikurungkurr people, which describes the Aboriginal practice and philosophy of ‘deep listening’ based on respect, inner quiet, still awareness, and waiting [23]. As part of this rebranding, we recommended that this room become more accessible for families and staff when they need a short break from the intensity of the ward, and for facilitating private conversations (e.g., counselling sessions) with speech privacy. ² Secondly, we proposed a reconfiguration of this room, with new furnishings that reduce the cluttered feel, and promote a softer, more nurturing environment (Fig. 6—bottom).

Sense of control	• The reimagining of this room as the Dadirri room provides parents with a sense of control by providing a place of their own that they can retreat to if and when they need.
Positive distraction
Social support	• This room enables parents to get support from staff or spend time with extended family in a private space away from other parents.

5.6 Creating a Place for Connection: Re-Imagining the Conference Room

Providing resources to support parent wellbeing is extremely important. According to Standard 18 of the Recommended Design Standards for Newborn ICU Design [22], a unit should provide a dedicated family education area so that families can learn about health conditions, child development, and parenting issues, in addition to providing parent-to-parent support, and the resources to learn about—and practice—caregiving techniques. However, in the existing unit, there are limited spatial opportunities for facilitating wellbeing or educational sessions for parents.

While the neonatal unit display an abundance of resources and information to support parental wellbeing on various information boards, we discovered that parents don’t look at these, and prefer to seek out information from other families—whether that be from other families in the unit, or in online forums. Families shared that hearing stories of other families makes the feel less alone. We also discovered that once a week a volunteer of Life’s Little Treasures Foundation was running ‘NICU Connections’ sessions for parents in the kitchen space, and experiencing the challenges of hosting a morning tea at a small table in the corner which can only fit 2–3 people at a time. The ability to host social activities in this space is further complicated by its location outside of the parent craft rooms where people are expected to keep noise to a minimum.

The NICU standards state that “in order to be present and functional, parents need (at a minimum), rest, good nutrition, psychosocial and educational support, access to social networks, and a way to address everyday needs efficiently” [22, p. 13]. In this project, we envision a space which can host a broad range of information to support parent wellbeing including existing programs such as NICU Connections and new programs focused on nutrition, Baby First Aid training, mental health sessions with visiting psychologists, sessions for dads, and massages for parents and staff.

The conference room of the Case Study site is primarily used by staff for meetings and training sessions. However, during our engagement we discovered that the space was also being used to run lactation information sessions with parents. We identified an opportunity to use this space for other parent and wellbeing-focused sessions. While the existing space is functional, it is clinical like the rest of the unit and not a space where parents would feel comfortable, as evidenced in the images on the left of Fig. 7. Therefore, in this project, we proposed that the existing staff training and conference room be reinterpreted in a similar way to the Xray Room proposal, with a vision to at-minimum broaden the utilisation of the space, and at-best make cosmetic changes to improve the feel of the space (Fig. 7—Mood Board and Finishes).

Sense of control	• Educational programs for parents such as baby first aid training, and information sessions on sleep and nutrition will foster a sense of control over their own health and equip them with information to help them care for their baby once they take them home.
Positive distraction	• Other programs and services such as craft activities, massages, and social activities can provide parents with a momentary break to focus on their own needs.
Social support	• Providing a larger space for programs such as NICU connections will enable more of the parents to get to know one another, in addition to getting additional support from visiting healthcare professionals and service providers.

Fig. 7

Design proposal of Case Study Conference Room

6 The Challenges and Limitations of a Holistic & Transdisciplinary Supportive Design Approach for Creating Change within a NICU Environment

In this project, we recognise the challenges and limitations of trying to create change and address complex design problems in environments such as healthcare, which often require input from multiple fields, beyond that of clinicians and consumers. However, we also recognise that a collaborative approach is necessary, and that non-design experts can contribute unique perspectives and knowledge to the design process, leading to more holistic and effective design solutions that address the needs and concerns of all parties involved. Collaboration also fosters innovation and creativity, as individuals can learn from each other and generate new ideas that may not have been possible working in isolation.

This project posed a number of challenges that extended beyond navigating a complex landscape of stakeholders and departments. In particular, changes in staff roles and the presence of multiple project champions operating in silos created additional complexities that required careful management. Specifically, we encountered a change in staffing when the service improvement manager’s contract came to an end and was replaced by a clinician who volunteered as a liaison between the hospital and the design-research team. This shift in roles required us to establish new lines of communication and adapt our approach to accommodate the strengths and limitations of our new key stakeholder.

Moreover, we identified multiple project champions who were pursuing their own initiatives in isolation. For example, we discovered that one champion was pursuing a project involving digital signage and ceiling tiles, while another had already ordered new beds for the parent craft rooms without consulting with the design-research team. These siloed efforts created redundancies and inefficiencies in the project, and required us to engage with the champions to better understand their goals and ensure that their efforts were aligned with the broader project objectives. While having enthusiastic healthcare partners who are eager for change is a positive, the presence of multiple project champions and changes in staff roles underscores the challenges of managing stakeholder engagement in a hospital environment. It also highlights the importance of clear communication, collaboration, and coordination in order to achieve meaningful and sustainable service improvements.

Given the limited budgets of healthcare organisations, the cost considerations also presented a significant challenge in this project, particularly when determining the proposals’ scope and the ability to prioritise certain projects. A holistic approach that balanced the value of tangible (comprising spatial and aesthetic design solutions) and non-tangible service design solutions was necessary to deliver maximum value for the available resources and achieve sustainable service improvements. The provision of six supportive design concepts (Fig. 8) aimed to offer the hospital a range of both tangible and non-tangible solutions that varied in cost, including low, medium, and high-cost options. This enabled the hospital to select design solutions that aligned with their available resources while still achieving meaningful and sustainable service improvements.

Fig. 8

Six concepts ranging from low cost to high cost