Podcast Transcripts

David Cummins: G'day and welcome to the AHDC podcast series, Health Design on the Go. I'm your host David Cummins, and today we're speaking to Dr Ruby Lipson Smith, who is a post-doctorate research fellow at the MARCS Institute of Brain Behaviour and Development at Western Sydney University.

Starting her career as a disability support worker. Ruby was driven by research early in her career, which led to health services research at Peter MacCallum Institute in Melbourne.

This helped make improvement to clinical care and experience of patients. Ruby is also affiliated with the Florey Institute of Neuroscience and Mental Health in Melbourne.

 With the background in psychology and neuroscience, Ruby has co-authored multiple research papers in the field of health services and healthcare design. Her PhD explored stroke rehabilitation environments and the interaction with care and the experience of stroke survivors. I'm excited to speak to Ruby today to find out more about her research in this field.

Hi Ruby. Thank you for your time to be here.

Dr Ruby Lipson Smith: Thanks, David. It's very nice to be here. Thanks for asking me.

David Cummins: I absolutely love your field of your PhD and your research. I find it so interesting and exciting. I found with some of your research, you've actually gone to a human connection which a lot of research doesn't always do.

What has driven you in your field of research?

Dr Ruby Lipson Smith: Yeah.

I think that your point about human connection is definitely a driver for my research because I was working in disability support. And then in a clinical setting at a cancer centre, I definitely experienced what it's like to work with people who have a different experience of the environment and how important the lived experience is for the clinical care and outcomes that people have in that setting as well.

So I think the human connection and the has really driven my research, but also I'm fascinated by how the environment we're in can impact on our brains and our behaviour and our mind and how we feel and how we behave.

I've always had a casual interest in architecture and design and thought it was fascinating. When I was a kid, I wanted to be an architect, and then I went to university and I was like, "oh, actually I really like psychology and neuroscience".

And then I found a way to bring them together. And so that's been the two sides of what my interest has driven my research.

David Cummins: I love the fact that you've got two passions and been able to combine them. I'm in a similar boat, but I just absolutely love when you can actually make your career your hobby and just enjoy things.

So, but keeping that in mind, how important is it for other people to be part of that journey, to actually work as a team towards better healthcare design and to better experiences with patients.

And for those using those environments, how do you take other people on that journey and other team members on that journey from a group perspective?

Dr Ruby Lipson Smith: Yeah that's critical.

I suppose because my research interest is very interdisciplinary, it crosses over between architecture and design and healthcare and health services, but also psychology and neuroscience.

My expertise is in environmental psychology. And my background was in psychology and neuroscience, so that's what my training is. I don't have the expertise to bring from architecture and design or from health services management, and I definitely don't have the expertise as a lived experience of person going through the healthcare system.

So it's integral to work with other people who have that expertise to really explore this subject and understand it. So explore it and understand it, but also to implement change in the system. So it's important to have that multi interdisciplinary group to your work, both to work out what kind of question you should ask and how you go about asking it in a research context, but then also to make sure that what you find through your research can then be applied in practice.

One of the projects that I've been working on at the Floory since finishing my PhD is called NOVELL, which is a Neuroscience Optimised Virtual Environment Living Lab. It's aim is really to optimise stroke rehabilitation services and environments.

But. A big part of doing that, how we're going about doing that is taking the living lab approach. What's really important in that kind of approach is to create really strong partnerships between all the stakeholders who are important for a stroke rehab context. So that's like government, obviously healthcare industry architects and designers, academia, but then people with the lived experience as well.

So stroke survivors and carers and clinicians and healthcare workers. And by working together we can co-design new solutions for stroke rehab services and environments and iteratively test them and refine them together.

And then we have people in that living lab who can help to apply our findings in practice.

David Cummins: Certainly stroke, rehabilitation, or neurological long-term stay rehabilitation traditionally was very clinical, very stale, very scary for a lot of people. Very, very clinical. So what is your research? What are some of those practical findings that are helping stroke survivors with lived experiences in that environment to help provide better clinical outcomes?

What are some of the practical and design principles that you discovered?

Dr Ruby Lipson Smith: Yeah. Well I'll start by saying that you are right.

Stroke, rehab or rehab facilities generally have definitely had more of an acute focus and there's research to back that up.

So I did a survey of all the rehab facilities in Victoria and I found that about 70% of them were not purpose-built for rehab. And that's an issue.

It's probably reflected across Australia, but it's an issue. The kinds of activities or the clinical priorities in rehab are so different from in acute care. People who have had a stroke or are having to undergo rehabilitation for some other reason, they really need to be active participants in their care.

They need to be doing the work. They're not having care put on them or, just given medication and off you go. They really need to do the practice and do the repetition as part of the rehabilitation.

And so it's not about lying in bed and having and receiving care. It's about being an active participant, and you're also in rehabilitation generally much longer than in an acute stay.

So obviously the kinds of environments that you're in are going to be different too. There was some key principles that came out of my PhD work about what should be carried through into a stroke rehab facility.

And what might make it different from acute care, and one is the important of variety and interests.

So ensuring that the environment outside the bedroom is as interesting as inside the bedroom or more interesting even to get people out and provide connections to the outside world and options as well. Because obviously every stroke and every person who had has a stroke is different.

So people have different kinds of preferences, different kinds of abilities about how they might want to spend their time. The second main principle is privacy without isolation.

In stroke rehab, it's really important to have any kind of activity. It helps to improve your recovery after stroke, and that includes incidental activity and social activity, cognitive physical activity.

So incidental social activity is a very useful way to just have more practice in your day which means a single patient room doesn't necessarily have the benefits that it might have in an acute setting, but obviously people need the privacy especially if they're in there for a long time.

So there's a kind of balance to be made there where you want to have the benefits of having a multi patient room and the benefits of having single patient room and find some way through clever design perhaps, to have both those things.

You also need to have a reliable means of contacting staff. People often have, physical impairments or cognitive impairments, which will make it hard to just call out. You can't necessarily call out or you can't get up and go over.

And then the third principle that that came out of my PhD was patient-centred design. So that's providing opportunity for informed and fair patient choice.

So that means that people need to have the information about the environment that they're in, in order to choose to go out of their bedroom or to choose where they might want to go, and it needs to be coherent and convenient for people to get there.

A small example of that is a power point being across the room versus just next to someone's bed. Or not knowing where the lounge is, and so people don't use the lounge. That happened quite a lot in my PhD research.

People don't know where it is and so they don't use it. And in terms of other practical changes, in the NOVELL project we are developing a few different design alternatives, so different designs for stroke, rehabilitation bedrooms and different designs for stroke, rehabilitation wards.

And they've been informed by a series of co-design workshops that we ran in 2020. They were all online and Dr Aaron Davis, who's part of the NOVELL project and works at the University of South Australia.

He was really key to facilitating those and he's very good at coming up with clever ways of co-designing in an online space or a hybrid space. And we came up with some key values and objectives to inform rehab design through doing that work.

And then Professor Marcus White, who's at Swim Burn University has led a design team along with some of our industry partners to use those values that came out of the co-design work to inform new and innovative design options for stroke rehab.

So there's a few different bedroom options and there's a few different ward options, and they all integrate those values to greater or lesser extents.

The next phase of the NOVELL project, which we're just entering into at the moment, is to compare those alternatives to each other, ask all of the interdisciplinary experts who are involved in the project and some who are new to the project as well to look at these alternatives in virtual reality and to compare them to each other to see which ones they think would best meet the needs for stroke rehab.

They are phenomenal outcomes and very practical that a lot of people can apply. Before you were talking about some of the methods that can be used for research and stroke rehabilitation.

David Cummins: How do you get around that methodology? What can we do to help with that?

Dr Ruby Lipson Smith: Well, not just for stroke rehab, but for thinking about how to do research, about the physical environment in general.

Because if you think about the kind of traditional way of doing medical or scientific researchers to try and isolate particular variables and change.

Just those variables in your experiment and to see what the outcome might be. When you're thinking about the physical environment, there are so many variables to consider. There's light, sound, colour, how big a room is, how far away the window is, all these different things, what the flooring is, all those different things, and they're all interacting.

So when you think about how a space makes you feel or how it makes you behave, it's usually not one of those variables that's making you feel or behave a certain way.

A loud noise in one context might not affect you the same as a loud noise in another context, if there's other things about the environment that are different.

So pulling out those single variables is a really tricky thing to do especially if you want to then apply that research in the real world.

It doesn't mean that it's not an important part of evidence-based design and healthcare design, because sometimes there are specific variables that you can pull out and that have a really big impact.

The kinds of methods that I use, try to accept and embrace that complexity and think about things as a whole space rather than as individual little bits.

The approach I took in my PhD is to have more of a mixed methods approach. You are including some quantitative measures, but also some more qualitative things too. And then you try and merge those two things at the end.

And having the user experience or the user voice, in that was really critical to understanding the complexities of the interactions of different aspects of the physical environment.

The approach we're taking in the NOVELL project, which I feel find really interesting is instead of thinking about the individual variables, we think about the types of values that might drive the design.

An analogy that I like to use when I'm talking about these two different research approaches is soup. So if we think about the variables in a research question or the features in a physical environment that you might want to study, they're the ingredients in our soup.

So in our messy physical environment, we've got carrots and onions and celery, and they're all in different ratios and different amounts in different soups or different physical environments. And the traditional clinical research methods that I spoke about would be to try and pull out one of those ingredients and see what happens to the soup when you change it.

But another approach, if you're wanting to compare between two soups is to work out first what it is you value in the soup. So what is important to you in soup? Is it how hot the soup is? Is it tasty? Is it that it's nutritious? And then you find a way to measure those values or those objectives.

So you might have a thermometer to measure how hot it is, and you might have some sort of self-reported. Deliciousness scale to measure how tasty it is. And you might have some sort of analysis of the micronutrients to look at how healthy it is. And so we're taking the same approach in NOVELL, but for physical environments.

So we are looking, we've defined these values that we think are important for stroke rehab, or actually not that we think are important, that all of the stroke survivors and stakeholders in our project think are important.

And that's things like having access to positive and stimulating environments, having access to outdoor and green spaces, and there's actually 18 of these.

And then we work out ways to measure those things and there might be multiple ways to measure each of them. So for example, for positive and stimulating environments or for access to green spaces is probably a better one.

We can ask people in VR how well they think each of the alternatives give you access to nature and green spaces. We can also use existing measurement tools for that.

I think there's some in the well criteria, there's some about access to nature and green spaces. So we could apply, ask people to apply them to our VR alternatives, and we can also use some sort of spatial analysis, spatial mapping techniques to look at the distance from bedrooms or other key spaces to the outdoor spaces.

And then we can rank the alternatives using each of these methods. And then there's a method called multiple criteria decision analysis, which has been really championed in the NOVELL project by Professor Leonid Churilov, who's a statistician at the University of Melbourne.

And this method allows you to get rankings from lots of different measurement approaches and combine those rankings, taking into account both how often each of the alternatives appears in each of the positions in the ranking scale, but also how often each of the alternatives appears above the other one.

And then you come up with an overall ranking at the end, which takes into account all of the measures that you did for all of the objectives that you know are important in stroke rehab. And then you can say, this design alternative is the optimal one out of our options for stroke rehab, and this is why.

David Cummins: Yeah, that's fascinating.

I think a lot of people wouldn't actually understand the level of detail of a recommendation for a positive clinical outcome, the level of detail required for that, which is fantastic.

Just before we go, what are some of the practical things that listeners can do try and action things now knowing that it does take generally a bit of time to go from research coming out to a practical approach.

What is something that we as people on the ground that build as the architects, even to help patient outcomes now?

Dr Ruby Lipson Smith: Well, I think yeah.

If the people on the ground who are listening are involved in research, then that's a really great first step because if you partner with a research organisation or if you have research happening within your organisation, then you get early access to this kind of information and you really have your finger on the pulse, so to speak.

And similarly, researchers who might be listening, the only way to keep your finger on the pulse is to partner with people who are actually doing the work. So I think that's really key, that kind of interdisciplinary approach.

The other really key thing is education and making sure that research is integrated in education for architecture, architecture and design.

Through the NOVELL project we've been lucky enough to have a stroke rehab topic given for international student design competition for the international union of architects and the deadline for that's just finished. Hopefully we'll have some really great design ideas coming out of that.

And through the process, the students will have found out a bit about what's important in stroke rehab environments and also some of the research that I did with Rebecca McLaughlin about how to conduct observation in healthcare design for research. That's been included as a continuing education unit by the American Institute of Architects.

So I think that having research integrated in that way means people get access to it at an early stage, which is really good. And then the third way I think, is to make sure that research is integrated in the guidelines and standards that architects and designers turn to.

So the Australian Health Facility guidelines, for example, the rehabilitation component of that as being updated this year. And that's a really great opportunity for the current research work and the current models of care to inform the design guidelines and yeah.

So I think that's a great pathway and that that's quicker than the standard 15 years of bench to bedside issue.

David Cummins: Absolutely. Love it.

Thank you so much for your time. I've tremendously enjoyed listening to you. I think your level of detail into this important topic is just, absolutely paramount, and certainly without people like you and your teams that you've talked about doing the research, we wouldn't be having clinical outcomes the way we are now.

So certainly the last 20 plus years, there's been a lot of research in this field and it's certainly part of what you have done. And I just think for those patients, especially having the clinical and the personal connection that you've been aiming for with your research has been paramount.

So thank you so much for your time and for all your research and your hard work.

Dr Ruby Lipson Smith: Thanks David. It's really great to talk to you.

David Cummins: You have been listening to the Australian Health Design Council podcast series, Health Design on the Go. To learn more about the AHDC, please connect with us on our LinkedIn or website.

Thank you for listening.

David Cummins: G'day and welcome to the AHDC podcast series Health Design, the Go.

I'm your host David Cummins, and today we are speaking to Dr Gabrielle Jenkin who has over 20 years experience of research into investigating critical social and public health issues. Dr Jenkin's research has focused predominantly on suicide, mental health and wellbeing research with over 20 published papers and 15 reports in the field, which many have been presented at international conferences.

We welcome Dr Jenkin today to our podcast series to discuss mental health, and also as part of our RUOK Day series.

Welcome Dr. Jenkins. Thank you for your time to be here.

Gabrielle Jenkin: Thanks so much David for the opportunity and good morning.

David Cummins: It's a very interesting focus of architecture, mental health.

It's obviously something that's become way more prevalent over the years and the one thing that I'm very aware of with mental health design and mental health facilities is that there doesn't seem to be enough beds. They're not designed properly, and we are just not getting it.

That's pretty much all I know about it in reference to design. Is that a pretty fair assumption or am I completely wrong?

Gabrielle Jenkin: We definitely don't have enough beds. I also think we don't have the right type of facilities. And we also don't have much in the way of step-down facilities, like places where people might go before they get to that acute crisis.

So what we've got is people getting really mentally unwell and ending up in those acute units, which are completely not ideal for recovery. So we need actually, I think a whole range of options, but my focus and my research was on the modern day acute mental health facility.

David Cummins: Yeah, so with with modern day acute facilities, you've obviously got you've got males, you've got females, you've got young people, you've got old people.

And the interesting thing about mental health is that they seem to all be put into the one facility, even though the array of mental health issues, anything from a psychosis or anything from

schizophrenia and all their depression, like all these huge array of mental health issues, but they seem to be all located or co-located in one facility.

Is that a pro or a con?

Gabrielle Jenkin: Well in a small country like New Zealand, it would be difficult to probably have bespoke facilities for different mental illnesses, which might actually be a bit more ideal. But yeah, so you would have generally presentations like schizophrenia, bipolar disorder, major depression.

Sometimes people just having an absolute life crisis, so they might not actually have a diagnosed mental illness, quite often suicidal people and people who've made a suicide attempt.

So the key is to get people stable and keep them safe from themselves and keep the community safe as well.

David Cummins: Yeah.

When people generally do research into facilities like rehabilitation, you might speak to a patient about how hard it is to move with a four wheel frame. How hard was it to investigate and research these facilities, noting in their acute mental status?

Gabrielle Jenkin: I think the hardest thing was, actually even when I was right back at the beginning designing this research project before it got funding, I'm a social scientist so, I don't have a clinical background.

I didn't have the networks to go in and go and be allowed into such facilities. There was a lot of gatekeeping going on because it's considered a very highly vulnerable population. I did have a family member in an acute facility (my brother) so I had been in and out of one in Christchurch.

So I knew what that was like. But even trying to design, how am I going to do this research, how would it work in reality was really difficult until I actually had psychiatrists come on board who actually worked in that sector and said, "I'll get you in there so you can have a lock so you can help design your research better".

 And when we did get the funding for it, finally, the ethics process was really complex and it was the highest level ethical approval because you are basically going into an acute mental health facility where people were acutely unwell. And the ethics committee concern is always that "are people competent to consent and would I be safe interviewing people"?

And there was a lot of stereotypes and misunderstanding I think, even on ethics committee members about what it was trying to do and that actually people are probably quite competent to consent to talk about their environment.

I wasn't asking them really about their mental illness, I didn't even ever ask them about their mental illness, it came up, but I was just really interested in what does it feel like to be there, how do they experience the environment and how does that impact them, is it therapeutic or just how they felt about where they were.

David Cummins: I know you touched base on the therapeutic benefit of mental health facilities these days, but certainly the old movies and the old, the old facilities, from the seventies and eighties, they, it seemed very, very different from today where basically an old mental health facility.

An institution where you are pretty much locked away in some facility, but it does seem to have been a big shift in the last few decades where it is about more therapeutic but more about open spaces, more about group work.

That shift changed a few decades ago. But it sounds like there is need for more change in certainly changes in models of care as well, correct?

Gabrielle Jenkin: Well, I think the other major driver, going from the old style asylum to the acute mental health facility was the pharmaceuticals that came available and that's really the key therapeutic agent in these places, that's good and bad.

In the old days, people lived in these institutions and they were out in the country. When people were going visit them, they were a bit more functional, a bit more like rest homes, you're there permanently there was no hope for recovery.

And so, now a modern acute mental health facility in New Zealand has about a 14-day Key Performance Indicator.

The ideal is that you are in there stabilised quite quickly. You are only in there for a couple of weeks. They're not designed to be people living in these spaces. So they function like a hospital.

 It's mental health ED I guess. And then the idea is you get them back out as soon as you can, as soon as people are stable, as soon as they have a plan, as soon as they've got medication and a proper diagnosis, and then real care happens back in the community.

Or that's the idea anyway.

David Cummins: Yeah, I understand what you're talking about with that.

You talked briefly about the importance of design. How hard is it as a designer? To design for all the needs of complex cases and the caseload that is ever changing, and they're only there for a few weeks.

So how hard is that to achieve that goal?

Gabrielle Jenkin: Well I think it should be a lot less hard than people imagine, but because we haven't really had the evidence base, I think it's really hard for people to understand and architects in particular, it's just people we're talking about people in various stages of unwellness.

They need the same as any other people who are in a space for a couple of weeks. They need access to outdoor space, ideally they need their own bedroom and bathroom. They need somewhere where they can have privacy, but they also need somewhere where they can connect with other people.

These facilities do have certain medical requirements but that's pretty standard. So there are other things that they need to design for now, I think is really the other therapeutic option so that people aren't just given medication as the only choice.

Most of these wards had a social worker, a psychiatrist and nursing staff, but there was no psychologist. So there's no talking therapy, there's no group therapy, there was no real organisation around introducing someone onto the ward, "This is what life is like. This is where you get this, this is how you do that".

From my point of view, it should operate a bit more like a guest house where people are treated with that real care. And people really just need respite and sleep and peace and care.

I don't think it's rocket science, but yes, you do have some people who might have psychosis and there are spatial things. I understand with schizophrenia that you need wider, more open spaces for people. Some people, at the moment, the model is that we have these seclusion units for people when they really are a danger to themselves, and you need good surveillance across the whole facility so that you can actually see what people are doing.

There are those requirements, but they're still quite institutional buildings, the courtyards are still full of concrete and either fake grass or no grass or no nature. There's just a lot of improvements that could occur, but what's really required is the resource to be put into it.

I mean, architects can design for that, but there's got to be the money too, and they have to have anti-ligature fittings and things like that in these places as well. So there is design for safety and security, but a lot of that can be through surveillance and through relationships between staff.

So if you've got a ward that's got a much more open environment where the staff and mulling around with the service users rather than hiding behind nurses station, there can be a lot more of that sort of therapeutic relationship and trust-building that can go on.

 One of the wards that I looked at had that very open design and it was completely different environment and feel to one where the staff are all hiding in this glass bubble, and service users are knocking on the door, can I get my phone charged, can I get this, can I get that?

And then feeling really completely ignored because the staff are really busy because they have to write and document everything that's going on all the time. Those things of design, opening Flexi-Wards and things like that is becoming much more important.

So you could actually say, if you could have a pod of three or four beds with their own courtyard in their own lounge and things like that is probably much more appropriate because then you can have people who you want to put together, and you might not know, it might not be by specific type of illness, but it might be by just their vulnerability.

They might be vulnerable, it might be transgender person, it might be a much older person, it could be quite a much younger person, it could be a really disinhibited person.

So I think if you've got flexibility and you can, instead of close off other books, these Flexi-Wards are really good because you can, they have their own staff and you're caring for people on small pockets of the building, I think that's the way that they're going to go and, the internal courtyards as well.

David Cummins: So, obviously some of the main principles you've talked about there is importance of nature, open spaces, group work, and some models of care for the relationship between staff and patients.

How important is it to get the detail right, the architectural detail, especially with ligature points in that design because, some architects say you can't it's impossible to design.

Some architects say, oh, it's possible, but there is some risk.

How important is it to get that balance of detail?

Gabrielle Jenkin: The layout is really important because the geography of space and the social relations that facilitates and the surveillance, that's really important I think in terms of the nature, it's not just views of nature people need, ideally they have views from their bedrooms, but it's not just views of nature that are important, it's actually interaction with.

 It's not so good to just be able to see something and not touch and feel. Some of the old wards had courtyards around the outside, which is not an ideal situation.

They were talking about contraband coming in through the the courtyard fences and stuff like that. And also then you've got a public view of people in an acute mental health facility which can be highly stigmatising when you actually look at the materials that they're using to make these external courtyards.

They're wire cages, and of course, when you are inside there and you talk to service users, they will tell you that they feel like a tiger in a cage. One of the facilities we studied, you could see those cages from the road. So they look very prison-like, they feel prison, like you don't want it to feel like that.

So they've gone more towards the, the internal courtyard model so that people can have their own privacy. But with that, there's the constraints of space on a hospital campus where you've got much smaller courtyards and then, they're not really nature based. They might have, well, I think I saw some spiky flaxes in the newest one.

It's not a feeling of nature, it's a institutional requirement to have access to sunshine and fresh air, and that's what it provides.

The details of surveillance are pretty important. The things about nature are pretty important. Allowing service users to have autonomy, so some things that they can do themselves.

So I think it's really important that service users can lock and unlock their own door. And a lot of facilities, they were too old and they couldn't do that. Those locks need to be overridden by staff on emergencies.

But to have some autonomy for service use is much more empowering to say, "well, you can bring in your own quilts, you can control the window, the light in your room, you can control your door, here's a locker to put your valuables in".

A lot of them don't have lockers for people to be able to lock your room when you walk out and know that your things are safe. I mean, these are basic simple things, but at the same time we have to provide for surveillance.

So they do have windows on the doors. They had special shower doors and the brand new facility, which actually just were velcroed on so that the staff could see what was going on but they were still afforded privacy. So you could see below the knee, and the height of a person and you could adjust them.

So designing for surveillance and privacy at the same time is a bit of an art and it required quite a lot of mockups. So they did mockups in the basement of what that would look like and how would you help someone in the shower and still give them privacy.

So it's all those things about keeping people's dignity, yet still being able to have your eye on everybody at the same time. And, things like a lot of the time, what service users go to the nurses station for, they end up congregating around this nurse station like it's a bar, really and that's where people hang out.

They go there because they don't have any way of charging their phone, they're not allowed razors or anything to have a shave. So being able to keep themselves clean and looking okay. I don't think they have hair dryers in the bedroom.

So there's lots of things that people are not allowed to have, but some of those things could have been really quite easily addressed by having sockets in the bedroom to charge your phone if you want to. You don't have to have cords, you know, there are some easy fixes for quite a lot of these things.

But they just need to be thought about. But the other complexity with those things is, because people are at varying stages of unwellness, it might be that, that person's care plan doesn't allow them to use a phone on the ward because they may be bullied on social media or there may be something going on there that's not helpful for their mental health at that point so, you've then got different care plans for different people.

And from a service user point of view, it has tended to look like some people were favoured over others and are allowed more opportunities and advantages than others. But it gets interpreted as a sense of injustice. So it's just understanding those human aspects of how can we talk.

You've got to talk to the people in the building, right? That use the building, the staff, the services, and the family who visit. So families need spaces now, especially in New Zealand, we're saying we want family involved in people's recovery. One of the wards that we looked at the room was so small, it was the size of an office, and that was for a 64-bed facility.

And so the family can't visit and there's lots of issues to consider. Do you want family members going on the ward or not on the ward? A lot of service users don't want other people coming on the ward because they're embarrassed of being in the facility. They don't want people to find out that they're there.

So that's another whole issue about should they be visible at the front of the hospital? Yes, I think so, but they also need the option of private entry and things like that because some people, quite rightly, want the privacy, but at the same time, family members want to go and visit their kids in these places, like teenagers in these places.

There's nowhere for family to sit and be normal and have a normal meal and environment. The newest one did design a Chi Room where family was supposed to be able to go and sit with service users but kitchens have a lot of things that are kind of not very safe, and so there's always concern there that knives aren't safe and other things aren't safe.

So that room never really got used for family members to go and eat with their loved ones but I don't see why you can't have a cafe public part of these places. In a lot of wards they're also separated by gender, so they have like a female corridor and a male corridor, and that's becoming a little bit outdated, but it's quite controversial.

Do you have males and females separated, because we know now we don't have two genders. There are multiple genders and this is what comes back to Flexi-Wards. It's much better to design them so you can modify them depending on the clients or the services you've got, the population you've got at the time.

Then they would say, "okay, so the men aren't allowed down the female corridors", well, that becomes a real problem if you're a father wanting to go and visit your daughter.

You can't, where are you going to go and visit? So they're going to have to go on the ward and sit on the bed in the bedroom and there's no comfortable chair, some of this is even about furniture.

But there's just no proper space. That, hasn't been thought about how do we care for family when they come in here and a lot of family members, I talk to.

To families, place is really difficult to find, so they're down the back rabbit warren of a hospital, you're going down corridors and you just keep on going and then you go drop down a floor and then you basically feel like you're going right down to the bottom of the basement.

And it's really, really stressful because you can imagine, if you're a parent with a suicidal young person that you've been caring for and you are distressed yourself and trying to go and connect with your family member, not even being able to find the front door of these places is really problematic.

Yeah, so a lot of what I did was try and get those kind of stories and just talking to people about, the issues that they faced. I'm not an architect, I'm a social scientist, so I have to work with the architects to then translate that into, okay, so what would be the design look like?

So we're still really working on that and we have some students at Vic Uni using VR and stuff like that to reimagine how it could be different. I think it's really hard for people who work in these systems to imagine what what it could look like. So they know what the problems are, but they don't seem to know so much what the solutions are.

And that's where I think architects are really good, they're very solution focused and they're like, well, how would you translate that into design, what would that look like? What does it look like to have a lounge, for example, where people can connect, but can also have privacy?

And how do you design that? You have half partitions and things like that, you can have hubs because you still need to be able to have surveillance over the whole lot.

So, I just think it just takes a lot of people's heads together to try and think how to make these places.

David Cummins: Yeah, it is a complicated beast, but through strong communication, it certainly can be achieved, and I certainly have seen some phenomenal mental health facilities in Australia.

One of the new models of care that's coming out here, I'm not too sure in New Zealand, is vertical mental health facilities where it's basically a building, obviously it's got a lot of advantages for space, but a lot of disadvantages for that connection to nature.

So I don't know if you've tackled that challenge over there where you've got more of a two or three floor mental health facility now which makes sense in the sense of space, but I just don't know how they connected nature as much as they need to.

Gabrielle Jenkin: Yeah, well I'd be interested to see how that works out. I know that they do overseas have them vertical.

My understanding when they were designing some of the new ones was the ideal was single floor. But I know of some that are like two floors and they have the staff area upstairs and then the service user area downstairs, I think it's quite good to have some separate space for the staff.

And having different floors is quite a good way of doing that. The connection with nature is really hard to design for if space is a premium, I don't know, they would still be doing internal courtyards. So I imagine an atrium switch, then again, you have to be a little bit concerned about the safety aspect of that.

David Cummins: Yeah, especially in the urbanisation of somewhere like Sydney or Melbourne where space is a premium. It is that challenge to try and get that model of care right but also the therapeutic benefits for patients.

But I just wanted to say thank you so much for your time today. It's been absolutely phenomenal.

It does sound like a lot of challenges there, a lot of opportunities, but certainly it's people with you in your research who are asking the tough questions, interviewing those people, doing the research.

That's certainly helping a lot of people with mental health conditions, but also people who are treating mental health facilities. So I think your research is paramount and certainly, I know it's gone around the world and I know a lot of people have appreciated the hard work you put into mental health and mental health facilities.

So thank you very much.

Gabrielle Jenkin: Thank you so much.

You have been listening to the Australian Health Design Council podcast series, Health Design on the Go.

If you'd like to learn more about the AHDC, please connect with us on our website or LinkedIn. Thank you for listening.

David Cummins: G'day and welcome to the AHDC podcast series, Health Design on the Go. I'm your host, David Cummins, and today we're speaking to Professor Claire Craig, who is a Professor of Design and Creative Practice in health. Professor Claire is a Senior Lecturer and Researcher at Sheffield Hallam University in the UK.

She has written several articles on the topic of dementia whilst was also managing to find time to co-write several books, one of which I found particularly interesting called 'Creativity and Communication in Persons With Dementia'. We welcome Professor Claire here today to our podcast as part of our Mental Health Week, and look forward to hearing all about dementia and what we can do in the world of health design.

Welcome, professor Claire. Thank you for your time to be here.

Claire Craig: David, thank you so much for inviting me. It's wonderful.

David Cummins: It's good to finally catch up with you and I have to really make sure that everyone does know you're not just a Professor, you're a Professor x4, which is basically that the head of the army of professorship in the world of dementia, I imagine it's a very, very impressive title.

Claire Craig: Wonderful, and as I don't often use it David.

David Cummins: It's very impressive because I've been reading your articles recently and certainly looked at that book and I really enjoyed it. because I used to work in aged care in a Dementia ward and some of the things that you're talking about is just so obvious, but also some of the things that talk about are so innovative.

What drew you to be such a passionate defender and pioneer in the world of dementia, especially in health care?

Claire Craig: It's really interesting, so I began my journey working alongside people living with dementia about 30 years ago. And I trained originally as an occupational therapist and the very first encounter that I had on my very first placement on day one of my course was on ward for people living with dementia.

And when I started, people lived in long-term care with very little stimulation and I arrived on the ward and at that time, there was a real negativity around what people understand about who people living with dementia were and what living with dementia meant.

And so it wasn't a place that very many people wanted to work. And I arrived on the ward and I had this incredibly amazing experience of meeting people who I felt were more in touch with their emotional dimension and more open than many people that I'd ever met in my life.

And I just felt immediately drawn, almost like a coming home feeling. And at that moment, all those years ago, I decided that this was a place that I really wanted to work.

And for the last 30 years, that's exactly what I've done and, people with dementia have really made me into who I am now. So it's been completely reciprocal and an absolutely extraordinary experience.

David Cummins: And what an amazing journey, especially in the last 30 years because education of dementia care, especially in the world of health design pretty much has only changed because of people like you, because the research I've done when I was at uni 20 years ago, it just didn't exist.

Claire Craig: Completely. The landscape has changed beyond recognition, and that when I started, there was such a prevailing negativity around what a diagnosis meant that people didn't really look.

And didn't really see or really think about who the individuals were that they're working alongside because there was so much stigma and real notions about what dementia was and who people with dementia were.

And that design has played really important part in demonstrating that actually, if people are given those opportunities and we create environments and spaces and places that promote stimulation, support people in their experiences of living with dementia that actually people can continue to achieve and to develop and to thrive in the midst of really significant disability.

So there has been a really significant shift. When I started on the notes, it would say, "not for rehabilitation" if you had dementia. And that I was really immediately shocked by that. And I remember the very first thing that I did, I noticed that people were spending about maybe 18, 19 hours on bedrest, which comprised of almost living in a white coffin.

So literally you had two white cot sides, either side, no stimulation. And then there was a real question about why people were responding in certain way as well. The first thing that I did was I hand sewed, basically covers for these cot sides as they were, and and created really stimulating images and pictures.

And suddenly staff noticed that people responding more and moving more and then that almost gave people hope that maybe there's something else that was happening. And then as a consequence of that, that then fed into people thinking and maybe doing things differently.

From that moment onwards, I just knew that design was integral, absolutely integral not only to the experiences of people having dementia, but enabling people not with dementia. People who are caring for people to have a very different perception about what could be achieved and who people were.

And that became really my life mission, just to challenge those preconceptions.

David Cummins: It's amazing because I was a physio in dementia care and certainly as a student (with no identifying hospital when I say this), the common treatment would be to put them in a seatbelt to make sure that they didn't move because there was a risk of a fracture, well there's plenty more risks associated with keeping someone in a seatbelt in a chair for 12, 14, 15 hours a day.

So luckily over time, as I continued as a physio, that was taken away, which is great because it was it was awful. But then a lot of people with dementia are just so happy to be walking and be out in nature. So even in that short period of time we did see improvements.

What would be some of the biggest challenges and opportunities and risks associated with your journey for the last 30 years?

Claire Craig: I guess that.. and again, it's really interesting that you're in Australia ...and again, the other really big shift that occurred was because people like Christine Bryden, 'the voice of people with dementia', that that has been real extraordinary.

And changing that mindset has been such a huge part of the challenge of what I've really tried to do and.. The difficulties.... I mean, I've spoken at conferences where people have basically said, "we don't believe that people with dementia can do that". Working with John Killick, looking at the role of creativity, poetry.

The profound statements that people living with dementia actually make when you hear, and it's really interesting. But that questioning from the medical profession at times of, "well, actually, does this person really have dementia"? So a big part of it has been the attitudinal shifts and changes and happily, we're in a completely different place now, certainly in the United Kingdom and I guess, hopefully in Australia.

I do think that that is a really significant barrier. Other challenges that we currently face, I mean, Covid was a really difficult time for individuals. Again, we know that people lose their skills incredibly quickly, and that notion of being really shut down during Covid not having stimulation, existing services not been available was a real challenge.

Again, we responded, we created a web platform called 'Connecting People, Connecting Support' that enabled people to continue to find ways and engage and we created structures for family members to really look at ways of bringing in, and using creative opportunities in the home during that time.

Again, we're going to be seeing quite a lot of the impact of that now for a few years to come. But then the opportunities are so big because actually over the last 30 years things have shifted in huge amounts and we are really recognising the richness of things that we can learn from people living with dementia.

About what people with dementia are really shaping maybe how we think about living in the moment, how we might need to redress maybe what some of our priorities are and how we think more closely in terms of places we live, the environments that we inhabit.

And from a design perspective, when we design with people with dementia and really draw on their expertise and their knowledge, not only does that make it better for people with dementia, but it makes it better for everybody.

The huge movement around dementia-friendly community makes it fantastic for anybody and I really think that, again people with dementia, have helped us to maybe rethink some really fundamental elements of the way that we design environments and everyday experiences.

David Cummins: Yeah, and that's good to hear. Keeping in mind the design element of your profession, how important is design, not only to the ward, but to the intrinsic detail of a room, and you talked about interior design before, and obviously you can go to the level of detail of the carpet and the pillows and cots and all that textile benefit and even a sensory room, how important is design to people with dementia and dementia wards?

Claire Craig: Yeah, it's absolutely huge and there's a massive body of literature, which demonstrates the importance of that.

The challenge that we have a lot, in the context, people living with dementia is, lots of those disabilities are hidden. And particularly around perception, the way that people are actually reading an environment, understanding an environment, navigating an environment, the place where they sit in space.

And as a consequence of that, we have to be really mindful when we create spaces is whether that's in a hospital, on a hospital ward, or whether it's in the home or in public spaces. Really thinking about the hidden challenges that people might have in terms of understanding the role of, like materials for example.

Reflective services are really difficult for people to navigate. We understand the challenges where the foreground is the same colour as the background. It's very difficult because of some of the changes that occur during dementia for people to be able to distinguish between those facets.

But the results, when you do make changes are amazing. I remember again, something as simple as having a different colour toilet seat, for a person with dementia walking into a white bathroom with a white toilet seat and a white basin and a white base, I mean, it might look the height of luxury, but let me tell you that for somebody with really significant perceptual problems, you can't see where the toilet is.

And yet something as simple as maybe changing the colour of the toilet seat, changing the colour of the basin, enabling those things to stand out makes somebody completely, far more independent.

And that restores a huge level of dignity and I think so few people know that. And I guess my question has been why is it that maybe a very small number of health professionals and designers, well, not even designers, but maybe health professionals know that.

But that knowledge isn't passed on necessarily to designers. It's not passed on to architects who are building and designing hospitals and spaces, and it's certainly not passed on to people living dementia and their families in terms of designing their own homes.

 Design has got a really important role, and we in health who are working in design, also have a massive role in communicating these really simple changes that we can make also to future proof our homes.

So that if people do experience, not just dementia but any form of cognitive challenges as consequence, for example, a stroke or head injury, that those facets are in place and ready for individuals. So that people can continue to live a good quality of life for as long as possible.

David Cummins: Yeah. I must admit, I didn't know that one and I thought I knew a lot... so even though I'm leaning something in this one, which is the whole point of the podcast, but why is it that some people don't know that. I know you've written a few articles about 'Policy for Change' and I know you do a lot of work with Scotland Government for Health and a lot of other governments.

So how important is it to make sure that government policy is part of that change. What are those principles to try and bring it forward?

Claire Craig: Government policy is really important. We've done a really big piece of work with Scottish Government and with the Alzheimer's Society in Scotland and with the lead for Allied Health, Elaine Hunter and that work... again, about 20 years ago, I've been doing this for a long time.

So about 20 years ago, I asked that question about why is it that, often we work with people at point of crisis when we know that people can get along really well, but then there are these key touch points and that point of crisis often ends up with people ending up in hospital and then ultimately in care.

And my question was, suppose we started working with people at a really beginning of their dementia journey, giving them design thinking skills, providing solutions, helping people to redesign their environment, thinking about ways that we could redesign communication, building creativity, and meaningfulness right from day one.

And then maybe as a person's progression through dementia develops that some of those skills are retained or that at least people can start to future plan. And that program was called 'Journey Through Dementia' and as I say, we started that research about 20 years ago. Brilliantly, it Was incredibly successful.

And as a consequence of that, and through the work that Elaine's doing, it then formed part of the dementia strategy and dementia policy, which then gave the green light to occupational therapists working in health services in Scotland, in the Health Boards to actually have that as part of their remit of opportunities that they could offer patients coming into their services.

So it's really important to operate at that level. And what was really lovely about that whole relationship is, it works really well because obviously.. I offered the research dimension, Elaine brings the policy perspective and she's a fantastic promoter, and working nationally with all of the allied health professionals across Scotland.

And then we have amazing service leaders at Kate Lawson who really pioneers that work and makes it work in practice. And then equally then we work with families, with people living with dementia who are advisors, and then spread the word that way.

So actually we're working at these four or five levels. So constantly it's feeding through and it becomes then part of a whole systems approach.

David Cummins: And you touched on it a few times there, but the importance of not only research, but the importance of sharing of research.

 Obviously we're in Australia, you're in the UK and I'm very familiar with your work here, but I don't know if your work does reach the likes of Southeast Asia or wherever.

Yeah. It may be Africa or even Canada, I'm not too sure, but it is important to be sharing this information and share research because dementia isn't something that just happens to people in the UK and Australia. So how important is it to get your research and to get your message out there?

Claire Craig: It's vital important and I think as well, what we focus on. Again, around dementia, there's so much element of cultural understanding. And dementia means things that are very different in different places.

And again, in some places there's no such word for dementia and in other places there's a very different understanding of what dementia is and what that means. And again we're massively always learning about that and that's the joy of doing what I do.

But for me, there's so many things that dementia still carries in terms of stigma, in terms of the unspokeness of it. And so it's enabling people to see that there is really positive research, that there are things that we can learn, but most importantly, that that knowledge is owned by everybody.

And actually, people with dementia need to own that knowledge, and health practitioners need to own that knowledge.

And so as a consequence of that, and again, I think that a real strength of design is the way that we can translate what can be really dry in terms of some of the academic papers that we might offer, to create opportunities like this, which is amazing, where we can reach a lot more people in ways that are far more accessible and that offer this opportunity to really spread the word and create positive and lasting change that is owned by the communities for whom our research is intended.

We do the work because we want to make a positive difference to quality of life and that's what makes me get out of bed every single morning, this drive to try and do something that makes a difference. And so finding ways to do that, it's absolute central.

But thinking about the medium through which we do that. Universities and research departments need to think far more creatively about the methods and methodologies that they use in communicating.

And we're definitely up for finding new ways. And hearing the voice of people living dementia who are telling us, when people need to hear it, how people need to hear it, and trying to create those opportunities to enable that to happen.

David Cummins: So if I'm a, student or if I'm a designer in the world of health design and I'm especially interested in rehabilitation or age care or even, dementia wards, what's a take home message that you would be saying, "Hey, you absolutely have to do this is something we always miss, it's basic principles and it will make a life-changing impact to people living with dimentia.

Claire Craig: So the first thing I would say is... every person that you meet living with dementia is different. And a person with dementia said to me "once you've met one person with dementia, you've met one person with dementia".

The importance is, we need to look at each person on an individual basis. What we need to do is we need to begin where the person is. Wherever you are and whatever you're doing with someone, take time to step back to pause for a second and to try and see the world through their eyes.

Try and think about the environment about where they're sitting, try and hear what they're telling you about what they're seeing and what they're experiencing, and then really pause for a moment, draw on all your amazing clinical knowledge and expertise and your design knowledge and expertise.

But most importantly, just stop and listen and pause and just be with somebody and move forwards then together. Because that the biggest challenge that we have is that often we come in with a preconception, with an idea about what we're going to do, how we're going to do it, and we forget actually that the expertise sits somewhere with that individual.

And that person is the beginning and the end, but they're incredibly the starting point. And what we're not very good in busy, busy, busy services is to give people time and space. Find an environment that's quiet, that's peaceful, where somebody can feel relaxed.

Because again, we know that stress causes people's memory and cognition to be compromised. Really think carefully about what those encounters are going to be and design each encounter to really maximise the opportunity to enable that person to get the most out of the encounter that you're going to have with them.

And remember that you are human too. And you'll bring a lot of things with you also. I always say to my students when I'm teaching design, " You bring yourself. You're not just going to bring this abstract knowledge, but you as a person are an incredibly valuable and important part of this equation. So bring yourself into that moment too".

David Cummins: Yeah. That's beautiful.

Beautiful words and good advice. I know we're going over time, but it's too interesting an interview to stop on time. I am a bit concerned about the next seven to 10 years where the aging population is basically going to double. And obviously with that brings a lot more incidence of dementia.

How concerned are you, and what can we do as designers to help prepare for that more noting that the incidence of dementia is most likely going to increase over time. And we are running outta spaces, running outta beds, and we are running outta staff.

And we're on a trajectory of disaster if we don't start putting some strong systems in place, whether that be government policies and so forth, or into Artificial Intelligence and digital control. What advice do you have for the designers designing for the future, which are pretty much in planning now, basically?

Claire Craig: It's a great question and it's a really important question to ask. I'm going to approach it very briefly in on two levels.

The first level is that's some really powerful and important research that might not serve the next 10 years, but will certainly serve the next 30, 40 years if you like.

So there's a lot of research at the moment around brain health that saying actually there are lots of things that we can do at a really early point throughout the life course that can really decrease the instance of dementia, right from childhood that we can massively take those opportunities and make change.

And that's really, really important and design's got a huge role to play in that in terms of communicating those messages, in terms of understanding those messages, in terms of thinking about broader environment. So I'd say that there's a body of work that's happening there, but for this current generation and certainly the next decade, and I might very well fall within that. So I'm making sure it's going to be good.

I would say, what I love about creativity and design is that often functions best at a point of crisis, where you really need creative, different thinking. And what I'd say is that the thinking that we've got at the moment, the way that we are thinking about dementia, thinking about where people with dementia are cared for, we are thinking about who people with dementia are absolutely needs to shift and change.

And that needs a radical rethink. And I know that you had your Royal Commission around Age of Care and I know that that has been a really significant part of what you are looking at. But we've got to really think carefully about..

Again, we are still putting people with dementia in boxes, we're still not enabling people to take simple steps to enable people to actually live really well. We're not thinking about the way that we empower people living with dementia or an early point in their dementia journey to actually do something to maximise function, to maximise the quality of life that people are experiencing.

And so what I would say is that we need to use design thinking, share these design thinking skills and really focus on communities and environments because that's where people are living. There's a massive movement around compassionate communities, which is saying, actually for a long time we've medicalised real significant issues.

And in some ways we've medicalised. We're saying that's the remit of the hospital or the care home. What compassionate communities and compassionate cities are saying is actually, let's look at the whole community. Let's look at the whole environment. Let's look at building these social networks that massively support the way that people function.

And it's through that, that we will maximise quality of life and cognitive functioning and Slow down those processes of crisis because people with dementia live well. It's just that these pinch points that people actually then have these crises.

If we can prepare people for that, then actually we can do something about it but we absolutely need to shift this really passive view and the way that we're thinking about dementia. And design can do that, and design can do that on scale.

David Cummins: Yeah, very good advice and it certainly inspired me. My brain's ticking with some of the stuff we can do on some of our hospitals because a lot of planning is happening now for the next seven to 10 years so it's a good challenge for us all to take up.

I just wanted to say thank you so much for your time. Your research is literally world famous. You are a multi-time Professor. Without people like you, we would still be probably 30 years behind in our knowledge and research with the world of dementia.

It's absolutely a pleasure to meet you and I've tremendously enjoyed our time. It's been well worth going over time because it's such an important topic and I have a strong feeling we'll be touching base again in the future as well. So thank you so much.

Claire Craig: I would love that. Thank you so much again for the opportunity.

Wonderful.

David Cummins: You have been listening to the Australian Health Design Council podcast series, Health Design on the Go. If you'd like to learn more about the AHDC, please connect with us on our website or LinkedIn.

Thank you for listening.

David Cummins: G'day and welcome to the AHDC podcast series Health Design on the Go. I'm your host, David Cummins, and today we are speaking to Nicole Eadie, an architect from Darwin, who has national experience of working in mental health projects across Australia, working at DWP Australia for over nine years, Nicole has designed some of the most innovative mental health standalone hospital projects up to 70 million across Australia.

I'm excited today to discuss mental health design with Nicole and understand more about the importance of design for people who require these facilities.

Welcome Nicole. Thank you for your time to be here.

Nicole Eadie: Thanks, David. I'm excited to join you.

David Cummins: Mental health facilities is such a huge array of patients, whether you are teenagers or kids, whether you are older women, acute rehabilitation, there's such a huge plethora of an array of people with needs. How does an architect hit that balance for such a different array of specialties within one facility?

Nicole Eadie: I think really it's about understanding what the demographic of the hospital will actually be. So what you'll find across Australia is that there's often specialist facilities.

So it's really unlikely that you would have a drug rehabilitation ward within the same area as you would, for instance, have a youth or teenager-specialised mental health facilities.

The needs are quite diverse, and so it's not really possible to make things multi-functional in that way. So what you end up finding is that a unit might have for instance, a non-acute level of care, which is people that are needing to go into an in-patient environment for three weeks voluntarily all the way through to your more acute levels that are usually tied to your public hospitals and to your emergency departments and admission systems.

So what we find is that, if you do need to provide multiple ward types, not dissimilar to a normal hospital environment, you would be designing them as particular areas and making sure you're providing dignity of privacy between a youth's area versus an adult mental health facility.

David Cummins: Yeah, that's really, really interesting point.

So, knowing that some people in mental health hospitals may be mentally unstable or may need some specialist equipment or specialist treatment, how do we find the balance of patient safety versus respect versus privacy versus compassion, empathy, but also making sure that they're able to function in such a space as well?

It's quite a task to get the balance between all those areas, is it not?

Nicole Eadie: Absolutely.

And the other part of it as well is that you've also got to tackle the problem of infection control as well, because fundamentally there's still a hospital and so they need to be licensed under the AusHFG (Australasian Health Facility Guidelines).

So when you throw that into the mix as well sometimes your infection control factors aren't really conducive to good design from a mental health perspective. I suppose to sort of circle back to your question in terms of how you balance the needs of safety versus all the other factors, safety is the number one in mental health in-patient ward.

So not necessarily talking about your community facilities, like intervention areas that you might be Victoria at the moment is setting up those community health hubs and regional centres, those sorts of areas, you can allow yourself to lower the risk parameters, but in an actual hospital environment, people are there because they've reached a point where they're not necessarily able to act in a way that is in their own best interest in terms of their physical safety.

So the way we tend to talk about it is in three spaces. So harm to self, harm to others, harm to your environment, or destructive behaviour is the other way that people often talk about a third one.

A harm to self is relatively obvious when you're talking about mental ill health, but you are trying to eliminate in design many of the things that make a space pleasant.

So you can't necessarily have things hanging on the walls, battening and things like that all needs to be flushed so you don't create ligature points because unfortunately people will look for ways to create hanging points within their environment to follow through on that self harm factor.

And I suppose harm to others is usually talking about your health staff. So we know that in normal health environments, there is unfortunately a lot of abuse that happens with your nurses and doctors that is compounded in a environment for patients that have mental ill health.

What we are trying to do is eliminate the ability for people to have projectiles, to be able to pick up chairs potentially and throw them around the room, and all of these factors in terms of your patient's risk profile versus what you actually intervene depends on the type of facility.

So in a non-acute environment, which is usually when maybe the patient has been having really bad depressive episodes and is self-admitted for three weeks, you can usually stand to pull back some of those interventions that you might do, and the tolerance from the hospital operations will be higher.

So maybe you don't necessarily have to have your full piano gear type hinges on doors and things like that in every single environment. They may only reserve that for the higher risk areas like laundries, bedrooms, ensuites.

Whereas if you're talking in a public setting, which has acute care, which is usually unfortunately when a person has presented to an emergency department, due to a act of self-harm, and that they've been transferred to a public facility, those types of environments, the tolerance for anything that constitutes a risk is very, very low.

So the way that we actually implement that in design is usually completely flush finishes to eliminate ligature hanging points. Usually anti tamper screws because patients will attempt to get in behind power points and access to electronics.

You can't ordinarily have any kind of acoustic tiles in your ceiling, and things like that, so you also get reverb problems within these types of spaces as well. So how you start to deal with that is quite specialised and highly specific to the patient demographic you're designing for, and the risk tolerance of the hospital operator.

Those two things do tie back into really understanding what your model of care is, and you should be gaining that understanding through really intensive user group sessions with the hospital that you're designing for.

David Cummins: I've noticed in a few new mental health facilities around Australia, the use of no doors in bathrooms or ensuites. Do you mind just talking about that from a privacy point of view versus safety point of view?

I suppose it goes back to your point of safety is a number one priority, but how does that sort of work and what does the research say about that?

Nicole Eadie: Yeah, absolutely.

So in a hospital that we've designed recently, it was discussed really early days about whether or not we are going to have doors within the ensuites. We have been able to remove them from our design.

Typically the no doors to ensuites is reserved for your higher levels of care. So those acute settings, like I discussed before, this hospital is actually a non-acute environment, so it's quite unusual to remove the doors because in those environments, we're trying to afford the patient a higher level of privacy.

And so what we needed to do is develop in conjunction with the health department and the hospital operator, how to actually overcome that so that we were creating and striking a balance between those two things.

So essentially what we ended up doing was arranging the on-suite design in a way that essentially you cannot actually see into the ensuite until you are fully within the room.

Now that does sound counterintuitive when you're talking about mental health in an acute setting because it's likely that you're going to be wanting to see into the ensuite, in case an incident has occurred there, but in a lower care setting, it is actually more important to afford the person privacy within that quite private environment.

So what we actually ended up doing was with the health department, we brought them into a 3D environment and did a walkthrough of all the typical bedrooms and non suite designs, and actually showed them how those site lines would work and how we were affording privacy.

It was very much a joint effort between us and the hospital. We presented how the physical implications were realised and then the hospital themselves talked through their different procedures that they were going to go through.

So they developed a particular doorknob policy, the way that we designed the doors had privacy vision panels that were operated from within the bedroom as opposed to outside of the corridor, which is typical, and those things all fit back into a design that felt a lot more like a hotel room, than a hospital environment.

And it also meant that we could afford, we could avoid some of the proprietary ensuite doors, which are often made out of foam and look very, very institutional and speak to the patient, that they're in an environment where you don't trust them.

And what we want to do is have safe interventions that are invisible. The problem that we have in mental health design so often is that we make a space safe, but it screams to that patient... "you can't be trusted, we think that you have no autonomy, no agency", and it really dumbs down and condescends the patient and makes them feel worse in some ways.

And what we're trying to do, through our design at least, is create environments that are empowering and not knocking somebody back. This intervention that we've done with the 'no doors' we got approval for that by agreeing to go through a really rigorous post-occupancy review 12 months after completion.

That hasn't happened yet, but the reviews from the patients at the moment is that they do feel like they have privacy and they do feel like they have dignity. And some of them have stayed in hospitals that have the other door types, which are not an ideal scenario and have commented that, yeah, they're really happy with the design outcome.

David Cummins: I know you talked about nurses and staff for that user group process, but was it hard to get consumers on that journey and investigate and discuss with consumers?

Because obviously people are at different mental states and different heightened awareness, so was there any real consumer feedback or just more based on research and nursing experience?

Nicole Eadie: I would say that from our perspective, I suppose there's lots of different ways that you can do that consumer engagement process, because it's quite a sensitive area.

Often the clinicians naturally are very protective of the people in their care and they don't necessarily want to expose them to architects who may say the wrong things that aren't necessarily as sensitive.

And so from my perspective, I've been thinking about this a lot recently, and actually I think it's more important that the clinicians have that back and forth with the patients and consumers then it's for us to have face-to-face time because so much of health design and mental health design specifically is about how the environment ties into your model of care or how the operations are actually managed.

And so they have the best understanding of that. The clinicians and nurses are the experts and where just stepping in to facilitate an environment that allows them to operate at the way that they need to.

Generally speaking, we do have opportunities to talk to consumers, but it's quite limited and I don't necessarily see an issue with that.

David Cummins: Yeah, that makes sense.

So we've talked about the importance of good design. Generally speaking, bad design can lead to bad operations in non-acute hospitals, but in this situation, bad design can actually lead to death.

So I'd say it's probably one of the main areas which can lead to a higher death rate than other departments. I think I'm comfortable to say that.

You talked about post-evaluation assessment on your projects, but you've built so many projects in the past. Is there examples that you are aware of, not necessarily on your projects where a death has occurred from bad design and what happens then?

Do we have to retrofit? Does the law have to be changed? Does BCA have to be shown to you? Report, like there must be examples in the past of things that haven't worked.

So what happens then?

Nicole Eadie: I've definitely been given examples from others in the industry of things happening. You know, There was a hospital I believe that was designed and then they went and put a bridge over a highway directly adjacent to it.

And, you know, things happen because of that co-location and there's not a lot that you can do about it when it comes to things like that because the boundary of your site is where you have the influence, if that makes sense.

And you can't actually stop people leaving that hospital environment. People do have agency and they are entitled to be able to leave depending on where they're at with their patient journey.

And that's quite confronting as well because the sighting is not necessarily up to us as architects often, that's decided by where a hospital for potentially physical health is best to be located, not necessarily one for mental health, because they're often located in similar areas.

I've also had, from a just personal experience, not related to mental health design, but when I was at university one of the students had a really bad exam result and died by suicide adjacent to one of the libraries and they did do a design intervention after that, quite similar to how we would design a courtyard for a mental health hospital.

Now they put up barriers that were three meters high and you kind of limited the use of that outdoor rooftop courtyard space, but it does become necessary in these public environments.

I think the question relates not only to mental health hospital design, but a broader context as well, in terms of how we actually help our community in those early intervention times.

 I do think I feel a lot of responsibility there. I had a moment last year where I was thinking about exiting the health sector completely because as we were going through the construction process, every time you had to have that argument, and our contractors were great, but you're still having these arguments about whether something's actually necessary.

"Are you sure? Nicole, are you sure that we actually need to put anti-tamper screws here? Are you sure that we need to silicone every single joint that exists in the hospital"? I am sure, but it is frustrating and, there are times when you think, oh, "maybe I am being unreasonable".... but then you think back to what the consequences are of designing something poorly.

And unfortunately, patients who are experiencing mental health, they're just looking for an opportunity for the environment that they're within, to be designed badly, to harm themselves. And that's a big responsibility and it's something we have to very much take seriously.

From my perspective, I have friends and family that have stayed in in-patient units before and I just think back to what I would want an architect to do for them. And I try to advocate as much as possible for a safe environment whilst balancing the aesthetic parts of it, which also play into the success of an in-patient unit.

David Cummins: It is a balancing act.

That seems to be a common theme throughout this conversation, I think if we come back to our number one priority of patient safety and care then that's a good guide for all of us.

I have . Spoken to a few mental health clinicians and one thing, especially with the older facilities, because you've been lucky enough to design a lot of new ones, with the older facilities where they are in literally in the basements with no windows with very small rooms, very, very 1960s, 1970's facilities.

They're listening to this going, "oh wow, you're so lucky you've been able to design something new". But for retrofitting, especially old departments, what are some tips that designers can do or hospitals, on a limited budget, try and enhance mental health patients in that environment, which is restricted by infrastructure and by money.

Nicole Eadie: I've been involved in one extension and one refurb and a retrofit I suppose, depends how you classify all of those. But I think what it's about is creating communal spaces potentially maybe the . Bedrooms themselves can't necessarily be resolved in a way that you would, in a newer facility that has less constraints, but you're often able to create environments that are a lot more conducive to best practice care.

So what you'll find in older facilities is that a dining room, for instance, may be in it's own little room or space, and so you are very much cutting off the access to natural light by having it in the older way, whereas there may be ways to take advantage of courtyards, because often even the older facilities tend to have really beautiful courtyards I've found.

Moreso I think than the newer ones, I think that now we tend to prioritise consult rooms and interview rooms a little bit more than maybe garden spaces, which again, balance act of can you provide your care in an indoor environment or in an outdoor environment.

But if you can take advantage of putting your communal spaces, like living rooms, et cetera, group rooms and things alongside those existing courtyards. I think that gives you a lot of opportunity to create a really pleasant environment.

David Cummins: Yeah, there's so much research to support biophilic benefits. We've got a podcast series about it coming up. I a hundred percent agree, do what you can and try and get as much connection to nature as possible where you can.

I think it's a great idea. Thank you so much for your time. I'm so glad you haven't given up on the profession. I'm a big, big fan of your designs. I think some of the facilities have made around Australia are absolutely phenomenal. So credit to you and to DWP.

It's very obvious that you put a lot of effort into your evidence-based research to support your findings and to support your thoughts so therefore, when some people are challenging it, you're actually supported by evidence, just not opinion.

 I think that's an absolute credit to you, to DWP and to your profession. So thank you so much for your time. I think you're phenomenal and look forward to seeing more designs with you in the future.

Nicole Eadie: Yeah. You're most welcome, David.

Thank you so much for having me on.

David Cummins: You have been listening to the Australian Health Design Council podcast series, Health Design on the Go. To learn more about the AHDC, please connect with us on LinkedIn or our website.

Thank you for listening.

David Cummins: G'day and welcome to the AHDC podcast series, Health Design on the Go. I'm your host, David Cummins, and today we are speaking to Garry Coff, who has been involved with health design for over 30 years.

Garry has helped improve the way health scientists are delivered to the community in Adelaide, around Australia and across the globe. Garry's experience covers all aspects of the healthcare system and ranges from design for remote Aboriginal communities to master planning for the Royal Brisbane and Women's Hospital covering emergency medicine, mental health, and age care facilities.

Today we welcome Garry to discuss the importance of design for mental health and how to improve patient care for mental health patients.

Welcome Garry. Thank you for your time.

Garry Coff: Thanks, David. Good to be here.

David Cummins: That is a very extensive CV of hospital projects around Australia and across the globe. I know you've specialised a lot in emergency medicine theaters, age care facilities. Why is mental health so unique in the world of health design, especially when you think about the patient cohort?

Why is, why is mental health something that people get wrong? And why is it so important to get right?

Garry Coff: Yes, good question. The main issues around mental health is to do with the, the cost of providing the services and the focus of dedicating the services to the right areas of where people have need.

Now we've been going through quite radical changes in the mental health system over the last 30 years. And I have to say one of my very first projects, I was involved with the devolution of the Hillcrest Hospital here in the northern suburbs of Adelaide.

And the planning for that was basically working around the principle that the sale of the land that would result from the freeing up of the facilities would generate. Sufficient resources to actually provide appropriate staffing for a community based service.

And therefore the reduction of in-patient facilities would be quite considerable. Now, as it turned out, that wasn't quite accurate in the context of the process. And of course the difficulty retraining people who were working within a mental health facility to be able to then provide a similar type of service out in the community was a hard lesson.

And it was difficult for the system to really respond quickly enough to manage the change in pace.

David Cummins: Just for context, you are referring from the seventies (1970's) when you were starting your career to today, where basically in the seventies mental health patients were pretty much locked away and put sometimes in a padded cell in a straight jacket.

Did that actually exist in Australia or that's more the American.

Garry Coff: Sadly, it was very much in Australia and really the padded cell is actually not quite correct. There weren't very many of those examples in Australia, but nevertheless they were very small cells and they were very robustly built with a lot of stone and cement to keep people from hurting themselves, was the principle, and to contain them.

Now that was a minority of the services, but the thing that was there in those early facilities, this would've been late mid eighties (1980's), I guess was the fact that there was asylum provided at those facilities.

There was a lot of space, there was outdoor areas where people could feel safe. They could generally interact with each other in a civilised way. Given that there was obviously medication being applied and people were able to modify their behaviours to become generally acceptable.

And given time they were going back into the community and generating quite a quality of life. So however, once the asylum factor disappeared there seemed to be a problem with the safety net factor of a place where you could keep people while they re-assimilated their medication profiles and while they went through the rehabilitation exercises.

Of course, the other part of that was there were always a number of people who were old psychogeriatric facilities. They were just a hardened nursing home effectively.

David Cummins: So when did that start to change that model of care from padded cells to isolation rooms to patients going out to the community and understanding as a community, they can offer a lot of benefits to community for many, many reasons. When did it start to change where going to a mental health hospital meant a lifetime of isolation to an a life of in community?

Garry Coff: Medication and treatments were very much the way of achieving that. And it was about modifying people's behaviours and generally reducing stress levels.

 And a lot of that is well truly practiced in our industry as well. I think just to keep everybody on in a balanced format. But that was about the late eighties. That really, there was a lot of change and a lot of differences. The community began to realise that this wasn't a humane solution to lock people away and it didn't actually solve anything.

 What was good about the devolution process was that a high proportion of people were able to function quite normally and be productive in their life. It did change things a lot in that direction, but the loss of asylum was a shame.

That was something that we still struggle with, not being able to quite provide. Modern facilities are much more live able. They're much more acceptable.

The finishes are all easily cleaned and the materials are robust, but not visibly constraining. Nobody gets chained to the wall anymore. Nobody gets tied to their chair even in a nursing home situation.

 There are limits that are very important for people to recognise that they are getting better and that they benefit from the treatment processes that they're in.

David Cummins: Yeah. It certainly has changed a lot. Even when I was a physiotherapist years ago, we did restrain elderly patients or elderly residents because it was deemed safe.

But when you think about it in hindsight, it's actually quite inhumane.

Garry Coff: Yes, I agree. It's a hard concept to grasp. And although at the time it was what was being done and there wasn't the same quantities or options with drug therapies and counselling and the other factors.

One of the big issues that I came across in another location. Was the secure units, medium and high secure units where people are actually in a prison sentence. Within a mental health facility. They have been convicted of a crime and sent to a place where they will get rehabilitation.

 The problem there is they have to actually serve a term of their sentence before they can actually see any likelihood of progressing a pathway out into the community again.

So that's one of the big difficulties that I see in the system is there are still a few of those which don't allow patients to actually re return to the community.

David Cummins: And is there any certain particular community groups in Australia that are more marginalised in reference to mental health and imprisonment? Or is it just generally the younger age group, more drug takers, the older age group? What groups are you generally thinking about or talking about?

Garry Coff: Well, the Aboriginal populations are one of the groupings where the numbers are disproportionate for the rest of the community. And a lot of those situations are difficult because there are several issues that become quite complicated. And for instance, the exercise of earning credibility within the community seems to be with young people that they have to go through a process of finding their way.

And in that process then can be accused of doing things that are antisocial and can be very difficult for them to get back into the community.

It's quite interesting that someone who has offended or created an offence perhaps in a remote community, for instance, for them to get released from a secure mental health institution, the community where the offence was occurred has to give approval for that person to go back to that community, and because of the family situations that occur, the separations between families and groups.

It can be very difficult to get approval to actually return to your country. And that makes it very hard because the pathways into a community where there is a strong, a large mental health facility that will generally be a small city or a metropolitan area.

To actually come from a remote area into the secure mental health unit and then be released into the suburban area is not necessarily gonna work anyway. It's not a good solution. It's not where he came from. It's not his lifestyle. The difficulties are that they'll re-offend and find themselves back in the situation.

So facilities are important in this because you really have to design a pathway from coming into the facility as a person who's done something wrong. You need to be educated to understand what it was that you did wrong in the first place. Then you have to be given a pathway to, and hopefully that pathway to release is something that gets you to appreciate your health and fitness.

It helps you to understand other people's feelings and rights and all of the things that they're associated with, with living in a free community. And of course that can mean flats and things in the community where they can still return to the facility for regular day activities and outpatient, if you like, sort of focuses.

Now that's difficult in a secure environment because there are issues about the fact that these facilities might be run by corrections rather than run by health practitioners. So corrections have a different view of their role than perhaps doctors and psychiatrists who really want people to get better.

David Cummins: It is interesting and if anyone's worked in the prison system or in mental health wards there's plenty of examples of not ideal pathways towards discharge, that's for sure.

Garry Coff: It's very easy to find the wrong direction to go, and it's quite complicated and difficult to find the right direction.

So you're absolutely right. And as much as we try, the full mental health package, it's a lifestyle. It's a life's work basically and special people are needed to be able to do that job. It's not everybody's skill set to be able to manage and gain the confidence of people who are frightened and who are unsettled in their environment.

David Cummins: Yeah. So how does health design. Change with mental health facilities. What are key things people need to be looking for? Understanding the sensitivity and the variance of patients who may be within a health, mental health facility.

Garry Coff: There's a big conflict in the process here, and that is that the facilities are designed, not to look secure, but to just be generally fairly stable and structurally sound.

And they cost money. And the big issue with mental health is, people need space and they need spaces where they can be on their own or they need spaces where they can do things quietly and separately and not be influenced by other people who may have a sense of aggression, or whose medication might not be working properly. There's a whole bunch of things that go on within the environment.

So ultimately the facility needs to offer some form of asylum, even if it's just a little courtyard here and there, or small nooks along the way where an individual can actually sit and read. There's a bunch of spaces that are not taken up with people who aren't feeling well or people who aren't happy.

 It's difficult because that is where the cost comes into providing sufficient areas where people can actually feel good, feel they're worth, feel value to their community.

David Cummins: I think extreme credit towards the mental health nurses because they deal with such variance of, of patients in and outside of the community.

And I do know that the design of the nurses station have changed dramatically over the years where it's now smaller. So the nurses have to spend more time with the patients where little things like the doors cannot be in line with each other. Because patients have more privacy because they're active than another person might be an award.

So I do think that design of mental health is extremely important. What do you think? Something that we keep on getting wrong with the design of mental health?

Garry Coff: Yeah. No, you're absolutely right. The things that appear in a mental health environment undoubtedly. It's not possible to hang yourself on them, for instance.

That's the sort of starting point that says, okay, no tapware that has a handle, or that you can strap something onto no door handle, or no coat hooks, no curtain tracks that you can take down and use as a weapon. All that sort of stuff takes away from the ability to look around and not see anything that's gonna be a problem and not do any harm to yourself because of it.

So that they become a practical factor. But they don't look as good or they don't have a, domestic feel about them. They don't make you feel that you are at home.

You're definitely somewhere different. Stainless toilet bowls and hand basins and stainless steel mirrors are just a horrible thing. But that's something that becomes a driver of the planning. And needs to be offset by a lot of other things, things that can provide some sort of comfort and things that bring fond memories back to people who are undergoing fairly strong medications.

 You need to really take all of those factors into account and the important factor of unobtrusive observation. You must allow that people are constantly observed, but you can't just stick cameras around the place and you can't have big glass sections around that don't provide them with any privacy or a quiet space for themselves is difficult.

So there's a lot of confliction information involved in how to do this, but daylight, greenery courtyard spaces, activity spaces within the courtyards that are safe but provide exercise, provide shading, generally, keep the environment friendly and warm.

So that people are actually feeling as though they are at home as well as that you can observe them.

Mental health nurses work really hard. It's a difficult job and the challenges are huge. They are the, the biggest ally that a designer in the mental health facility can have because they'll explain in real terms as to what it's about and why you shouldn't do something.

You've really gotta listen to that. That's where it becomes a real key issue to understand and be able to put yourself into their position and understand that they are at risk, so they need to be protected.

But the clients are at risk too, because they can hurt each other. They can be hurt by others as well. So yeah, there's a lot of factors in there that require more consideration. Not just a nice hospital bedroom.

It's got to be interesting and it's gotta be safe. And passive colors, things like that, they make a difference.

David Cummins: Yeah, certainly the user group what if questions are more predominant in mental health design than in normal hospital design, because there is so many what ifs for such a diverse range of patients at certain levels with their mental state.

So their body of questions are something that a designer has to listen to. Otherwise, it can have serious consequences.

Garry Coff: Absolutely. The things that can be used as weapons, incredibly surprising and challenging but yeah, you're absolutely right. It is all about safety, but then you have to try and make it look nice and feel good.

So yeah, life and space and plantings and things like that are important. Maintaining good sterile conditions can be a problem, can be a challenge. And as I was saying, the ab pollution areas are tricky because they're generally over designed for robustness and underdesigned for comfort.

 You can struggle a bit with that one but really the important thing is the staff and the way they interact with the clients and given the opportunity to provide encouragement and support that goes a long way. The overprotectiveness of staff can actually send all the wrong messages.

So you've gotta be pretty careful about that sort of thing. You have to be very careful about televisions and media factors in the environment. The wrong music can set people off in the wrong direction. And there's a lot of issues around the management of clothes and storage are clothes and things like that.

 That are not normal, but need to be taken into account because people can hurt themselves with the wrong sort of clothing and the wrong sort of materials at their fingertips, available to them, they can do bad things with them. So yes, it's a challenge.

 There are some good solutions out there and they often lie in having grounds around the space, around the buildings, so that you've got outdoor spaces that are visible from inside where the clients might be during most of the night and that sort of thing.

There are night spaces where they can go, where there's light. At night if they do need to get out and they do need to move around. And there are pathways again, it's all about providing something that leads people to somewhere better.

People will fall off those. Pathways will actually not always work, but if you've got them built into your thinking, they do actually provide a structure that eventually will get people through the process of rehabilitation and back into the community.

So that's really the best thing I can offer to it. We need to spend more obviously but we need to be cautious about how we do it too, and not just build prisons.

David Cummins: Yeah. I think there's some very, very good lessons for everyone there. And I think from your last 30 plus years of design in that space, you would've seen dramatic changes and have no doubt being part of that force to be a change for improving patient and client care in mental health.

So thank you for all your hard work with that.

Garry Coff: Oh, thanks David. I hope there's something in there for people to take with them, take a message from and yes, look forward to chatting later.

David Cummins: Thank you.

You have been listening to the Australian Health Design Council podcast series, Health Design on the go.

If you'd like to learn more about the AHDC, please with us on our website or LinkedIn. Thank you for listening.

David Cummins: G'day and welcome to the Australian Health Design Council podcast series, Health Design on the Go.

I'm your host David Cummins, and today we're speaking to Stanton Kroenert with a Masters' of Health Service Planning. Stanton has been planning, designing, researching, and building healthcare his whole career spanning over 27 years.

Stanton is a registered architect who lives for the world of health design. I'm excited to interview Stanton today to learn more about his view of mental health.

Welcome Stanton. Thank you for your time to be here.

Stanton Kroenert: Hi David. How are you going?

David Cummins: It's very interesting to say that you've spent your whole career working on healthcare.

I've interviewed a few people now and it's generally something people move towards and don't know about early on, or get sucked into later in their career and use basic health design or design principles to apply to health.

How did you get into the world of health design so early in your career?

Really easily, I was always hurting myself when I was younger and I'd just started my architecture degree and I was at uni and found myself in hospital which was very frequent. And I was lying there looking up at this dusty air conditioning grill above my head.

And I always thought, if I can ever have a say in how hospitals are designed, I'm never putting a dusty air conditioning grill above a patient's head ever again. So from that moment on, I decided I was designing hospitals. So that was how I got into it.

I love that.

But I would still argue, certainly in a lot of hospitals, I've been in the patient experience of going through a corridor where they still look at perforated ceiling tiles that have got water leaks and very, very dull design. I still don't think we've actually overcome that ceiling view for a patient lying in a bed have we?

Stanton Kroenert: And that's why I keep getting work, I think because I keep seeing it everywhere I go and it fascinates me. So yeah, it was that moment I decided, don't whinge about a problem, try and fix it.

So I've been trying to fix it ever since.

David Cummins: I love it. And the reason why I had to make sure I did say in your introduction is that you literally live for the world of health design, for those of you that don't know you, especially overseas, may I ask, how many times have you slept in your bed over the last 27 years based around your dedication to work.

Stanton Kroenert: Not a lot. I was homeless for quite a few years, just flying around doing projects. So yeah, it's been a fairly nomadic life, which I guess you can't really have a family when you live like this, but yeah, it's been very interesting and I think I've got about 15 years left, so I think it'll be an interesting 15 years.

David Cummins: I must admit, I did it for two years and became very, very single. But you do love the job and you love the projects and I think health is one of those things that, is so complex and so exciting that you can actually do so much and if we keep challenging each other and we keep identifying new problems, it's an an endless world of work that we can work with.

Stanton Kroenert: Yeah, and I think it's really sobering too, the thought that all of the most important things in your life happen to you typically in hospital. You're born in a hospital and most people die in hospitals. And the whole gamut of people... the first thing they see on this planet and the last thing they see on this planet are quite often something I designed well, that's really sobering and it does put into perspective what we do and how important it is.

David Cummins: I totally agree. So I remember very clearly a lot of people always say, oh, hospitals are a place that people die. My mum was quite sick at a younger age, and I always think hospitals are a place where people get better. So it's interesting to have that persona, but certainly when I was a kid, my mental health and my anxiety for being in a very strange, noisy clinical environment with a sick mom was quite scary.

So keeping in theme of mental health, how do you account for such an array of motions of excitement for a baby happiness, for someone getting better and people dying? How does one design for the mental health of not only the patient, the families, but the staff as well?

Stanton Kroenert: Yeah, so years ago I did a research project where I looked at the whole gamut of dying and being born and everything in between. And I was trying to work out what are the commonalities from a design perspective that you should look at in those kinds of thinking.

And what it came up with was, it needs to be familiar because one of the questions I asked patients who were literally within the last couple of days of their life and I got to interview 10 patients who were literally going to die within the next day or two.

And the question I asked them was (well, one of the questions was), "would you like to die here in this room you're in? And the rooms they were in were pretty average, but as a baseline point, it was a good point to start, or would you like to go home, and die at home?

And I thought everyone would say, I'd want to die at home. But I hadn't really thought that through because everyone answered "no" they wanted to die in hospital, but not one of them were happy with dying in the room they were in.

And the reason they didn't want to die at home was because they were scared, they might be in pain or there was also a stigma attached with "Auntie Jesse died in that room", therefore it becomes the dying room at home, there was some stigma attached.

So it was quite interesting that everyone that I spoke to preferred to die in hospital, but they didn't want to die in the room that they were in.

And so that got me thinking, and then the question I asked them was, what is it about your home that you like, that would maybe make it more comfortable if you had the other things that you got in hospital as well?

And the common thing was familiarity. So then I got thinking, the reason home feels familiar I think, is because you are used to it and you go there a lot and you're there for a period of time.

So I thought, well, why wouldn't you design a room that you could be born in and that you could go back to when you break your ankle for the first time, and then when you go to give birth, and you know when you are a parent, and then at the end stage of your life, to that same room.

Now, is there a way you could design a room that could do everything so that every time you go back to the room, at least the one thing that is common is it feels comfortable and you feel like you know what's going on?

And so that's where I got to, was trying to come up with a design for a room that would feel comfortable because you'd been there before and everything that you go to the hospital for makes it feel like it's familiar.

And we're not always talking about pictures of family or warm colours, how do you find that balance of respect and familiarity for someone in such a state?

Well, there's a few ways. Probably the best way is using technology.

So for example, you can have a room filled with screens now. Now there's nothing that stops you having the entire room filled with screens. You could put whatever you want on screens. So it could be pictures of family, it could be a live feed from your home, it could be a live feed from your dining table at home so you can have a meal with a family.

There's so much flexibility that using screens actually gives you in terms of how you can manipulate your own space or even a connection with the sky. So having a screen that's in the ceiling that potentially has a video camera on the roof of the hospital looking up at the sky, so you've got a connection with nature.

The use of technology in that respect can help but I also think that using AI will also help as well because as you become more incapacitated, AI could actually maybe predict what kind of images and what kind of feel will actually make you feel more comfortable in a particular physical state.

So I think that's where the future of that's going.

David Cummins: So just to clarify, you're talking about the technology just like the White Night or Vivid, where you can light up the Opera House or the Harbour Bridge where you can actually put those images throughout the room, correct?

Stanton Kroenert: No, I'm talking about physical, LED screens.

The cost of LED screens now is almost zero compared to what they were 20 years ago. And so filling a whole room with LED screens, and again, LED screens are pretty easy to clean as well, gives you the maximum flexibility in terms of the scenery that you are in, whether it be nature, whether it be your home, whether it be anything that makes you feel comfortable and familiar.

I think that would be a good use of technology.

David Cummins: It's a bit different from the small TV screens that hospitals are known for where traditionally, just like my mum, she just wanted to get out because she couldn't hear the TV and couldn't see the TV.

So that's taking it to next level isn't it, as a solution?

Stanton Kroenert: Yeah.

If you think about it in your last moments and you're lying in bed and you're looking up at this ceiling that hopefully doesn't have the dusty air conditioning grill, having a screen of some description where you could choose what you're looking at, I think is a nice way to, spend your last few moments.

I think that's really important.

David Cummins: How does one, again, related to mental health, help design for staff who are in a hospital for 12 plus hours a day or staff that sometimes don't have access to natural light, for families that are going through trauma and through joy, how does one create that safe, respectful environment with variants throughout the whole plethora of the hospital?

Stanton Kroenert: Yeah, with staff, you can look at retention rates as a pretty good measure of mental health in staff. So the places that have better retention rates typically have better staff facilities. So things like, places where they can go that are outside to be able to recharge, also not having stressed visitors and patients obviously helps staff be less stressed as well.

So anything that you can do, reduce stress, full stop will also help staff as well. The classic one is every time I go to a hospital I hear someone asking a staff member where they have to go to find something.

And to me that blows my mind in this day where everyone has a portable GPS, that we can't find our way around hospitals and we have to be constantly asking staff.

And it's just one of those things every time I see a staff member get asked by public... this is one thing they shouldn't have to do, but it's just part of being a staff member and every little thing like that adds stress, I'm sure.

Using technology, providing better staff facilities, they're obviously the things that are going to help staff mental health as well, especially reducing stress for visitors and patients will reduce stress on staff.

David Cummins: Yeah, I was going to say because it's already a stressful environment for people getting results or getting tests, so for them to get lost as well can add anxiety to people already in already a stressful environment.

What are some of the practical tips that we can use now? There's a lot of people listening who are designing, constructing patients who are entering these facilities and they've got certain pain points throughout the journey.

What is something that we can help do now for healthcare of the future? And what are some of the common themes that you've seen over your 30 odd years that we keep getting wrong?

Stanton Kroenert: As hospital architects, we're pretty good at designing spaces that work in terms of all the practical things.

I like the WHO's definition of health where they talk about "health isn't just the absence of disease, it's also physical, mental and social wellbeing". And I think that we have to focus not just on the physical wellbeing, but the mental and social wellbeing.

So at the moment, as I said, we're very good at designing spaces that are safe and you don't trip over things and you don't bash your head on things. So we're pretty good at that. But we haven't done very well at the other two sides, I don't think.

And when I look at the mental side of it and the social side of it, I also think of the spiritual side as well, because obviously, as I said, it's the place where you have your highest highs and your lowest lows.

And so I think looking at other sectors or other type of architecture that addresses those kinds of things is worth looking at. So things like churches, I think there are some lessons that you can take from churches. So for example when I grew up, and I got dragged along to church, and they had always a crying room.

Now crying room in a church was kind of a weird concept, but when you think about it was a room that the parents could take babies to, but they could still watch the service while it was going on. But it didn't disrupt everyone else because it was a soundproof room with a window that they could still watch what was going on.

But it was a really fascinating idea.

In hospitals, we don't have things like this because it's not seen with the same reverence. So I think there's other types of architectures we can take cues from to actually then, start treating rooms in the way that they should be.

David Cummins: Yeah, I totally agree and I do remember the crying room myself years and years ago.

Design innovation like that is fantastic and obviously served a purpose.

What are some design innovation techniques that architects can use today to help reduce anxiety for people entering facilities?

Stanton Kroenert: Wayfinding obviously is number one. That's not actually an architectural thing. Architects can show you the way, but I still think technology will be the thing that solves the problem.

As I said, everyone's got a GPS in their pocket and being able to get to wherever you need to in the hospital has to be as dumb as just following your phone. We've toyed with using, lights in ceilings or arrows in ceilings or things that light up to show you the way nothing works.

And I think using tech has to be the right way. Everyone carries a phone, so let's use that. So that's reducing stress in finding the way around hospitals. But my number one thing I think in patient bedrooms is make them quiet.

Now there's been this debate for years about, where you should place ensuites, whether they should be back to back or in board or whatever.

I can't even believe this is a debate anymore, but the number one thing is patients being able to sleep. And the number one way patients get their sleep interrupted is noise. So anything we can do to just make patient bedrooms quiet has the biggest impact on average length of stay.

So therefore putting ensuites in board to me makes perfect sense. That's one thing I would advocate for. But also, look back 30 or 20 years, and there was still a debate about single bedrooms, whether it's the right way to go. I think that's finished now.

Obviously, single bedrooms is the way to go for a whole variety of reasons. Using those principles just makes it a much nicer place.

David Cummins: And what about from a staff point of view, what are some of the design innovations we can do to improve their experience, to reduce their anxiety, to improve their work experience in the facility?

Stanton Kroenert: Being able to get outside to have your breaks tea rooms that aren't necessarily in a ward or a department so that when you take a break, you actually get out of the ward, and I know staff are very dedicated and they're reticent to actually leave a ward but you just have to, for your mental health, you have to get out, take a break, hopefully can get outside, but at least get away from the wards so you're not waiting for the bell to go ding.

I think that's gotta be number one.

David Cummins: And in reference to Healthcare of the Future, continuing with the conversation of AI, what do you think we need to start preparing for designing for, looking for, in this world of future health and the world of technology and AI?

Stanton Kroenert: So hospitals won't look anything like they do now. It's been interesting over the last really 70 or 80 years, hospitals haven't changed that much ever since the Nightingale Awards went away, still design them in a very similar way, but I think with AI and technology, they won't look anything like they do now.

For example, just a practical thing, I think medical wards will be a thing of the past. There's going to be a pill or an injection or something that's going to get rid of most diseases. And then I think there'll be much more focus on obviously emergency care, because that's worth humans.

We fall over and we break things. So you're still going to have a lot more emergency care, but I think that there's going to be a huge reduction in terms of in-patient type of medical patients. And so I think the focus should be on, not necessarily flexibility in design, because I don't think we can even design enough flexibility for this radical change that's coming.

But I think, thinking about what's coming and what's the best way to design it, because I don't think anyone knows yet and we better get pretty good at it pretty quick because otherwise all of us architects, we're going to lose our jobs to AI.

Some of the stuff I've been seeing recently that AI is doing, in terms of design is already got me scared, but fortunately hospitals are very complex, so I think we've got a while longer.

David Cummins: Yeah, I interviewed a futurist for our technology series and I questioned how scared should we be in the world of health. And as he said, "you'll always need someone to help you to go to the toilet, help you shower and things like that, and give you a hug". So it does have it's limit, especially the world of health.

Stanton Kroenert: I'm more thinking from a health architecture point of view. You'll always need nurses. Nurses are safe, us architects, maybe not so much.

David Cummins: Just before we go.

 You've had such an amazing career over the last 30 years predominantly in private health around Australia. Where do you think the next 15 to 20 years will be for yourself in the world of health design?

Stanton Kroenert: Actually, my background, before I started my own company was actually all public work. So I was actually doing big public hospitals.

And to be quite honest, I think that's where my future is because having an effect on large hospital projects, with all of the knowledge that I've dumped into my head, that's where I want to get back to and I think I've got something to contribute. So hopefully that happens.

David Cummins: Stanton, it's been absolutely pleasure to speak to you.

I have no doubt we'll be speaking a bit more in this world. Your company's 'SKAr' is absolutely phenomenal and well known around the world, especially with the world of health and private design.

Thank you so much for your dedication to this industry. To only sleep at your house a few nights a year is next level.

But certainly without people like you and your passion and design and desire to make sure that the patient experience is a better experience for all is a credit to you. So thank you so much for your dedication to this industry.

Stanton Kroenert: Thanks and good job on this podcast. It's pretty good. I like it. You have some really good stuff on here.

You have been listening to the Australian Health Design Council podcast series, Health Design on the Go. To learn more about the AHDC, please connect with us on our LinkedIn or website.

Thank you for listening.

David Cummins: G'day and welcome to the AHDC podcast series, Health Design on the Go. I'm your host David Cummins, and today we are speaking to Professor Leonie Callaway, who is a professor of medicine.

Leonie is also a general and obstetric physician at the rural Brisbane and Women's Hospital in Brisbane. Leonie is also the Executive Director of Women and Family Stream at Metro North, and we are very excited to speak today to Leoni as part of our Women's Health Series.

Welcome, Professor Leonie. Thank you for your time to be here.

Leonie Callaway: Thank you, David. Thank you very much for inviting me.

David Cummins: me I must admit, I've done a few interviews now and I've not met too many professors of medicine in the world and certainly none within the world of women's health.

How hard was that to become a professor of medicine and be such a, certainly local, but also national, dare I say, global phenomenon that you are with the world of women's health?

Leonie Callaway: Ah, well look, David, you do one thing at a time. You graduate from medicine, you become a doctor, you do some research and so forth.

It's just one step at a time. It's not different to your career running massive construction businesses, nothing special.

David Cummins: I feel that you are so humble just by even saying that in one sentence and comparing it to building a building, but I think it's extremely impressive. How important is it to ensure that we do get designed right in the world of women's health?

Because according to me, women's health is such a plethora of things. Not only women, but you've got babies, you've got families, you've got partners. It is such a plethora of complexity. How do we get that right?

Leonie Callaway: Well, David, it's just a delight to speak to you about this, and I hope that we inspire people to really think about good design for mothers, babies, and families.

I think we can all agree that the start of a new family is really one of the most important parts of human life, and we know that what happens for mothers and babies in early life really sets the trajectory of someone's health for the rest of their life so it's very important.

Obviously this is a highly emotionally charged space, and so care with the design and a pleasant working environment, a pleasant environment for women, families, partners, and babies at a very vulnerable point in their lives makes a big difference to the quality of the healthcare that we're able to provide.

David Cummins: It's a very interesting field of medicine, especially obstetrics where I would almost argue it's one of the only fields of medicine where people are planning to go into hospital, where generally speaking, most people do not plan to go into hospital. You know, a hip and a knees planned, but they don't necessarily want to go there.

But it's actually one of the destinations that people want to go to, to be planned as in nine months of planning. So in that sense, I would argue as well, birthing would be quite traumatic for some people, quite emotional, for some people, quite a joy for some people.

What are things that we need to focus on as designers and planners and builders in this world to make sure that that patient care is safe, not only for the patient, the families, but also the staff and the doctors.

Leonie Callaway: You're absolutely right. It's mostly a very exciting time, but it also can be a very dangerous time. I don't think that there's any more dangerous day in your life than the day you get born. I think it's the riskiest day that you ever have, of course, apart from the day that you die, which is definitely risky.

The considerations I think are really about making family friendly spaces. Birthing and having newborn babies is very noisy. And there's a lot of sleep deprivation involved for women and their babies after babies are born.

So making spaces that are welcoming to families that are large enough that take into account that it's not just the patient that the hospital's responsible for, but it's really a family event.

Women increasingly want to support people as well as the hospital staff that need to take care of them. So the spaces need to be large and spacious to take into account. The additional support people that. that are wanted around that episode of bringing a new baby into the world.

The importance of soundproofing in these spaces in birthing suites and soundproofing within maternity wards probably can't be underestimated because I don't think we've got any more noisy in-patients in an entire hospital than newborn babies.

And they're slightly older, toddler and child siblings that like to run around. That's another thing that's really an important consideration. Many women need to come to clinic and need to be in hospital with their other young children visiting, and we've never really thought about the needs of the young children that need to come with their mothers or visit their mothers on a regular basis.

So, you know some play spaces, some outdoor connection where children can run around, particularly if their moms are in hospital for a number of weeks.

David Cummins: I imagine the point about acoustic treatment for rooms is really important. I imagine also the opposite would also be true if a family has just gone through a bereavement during that process, they probably don't want to be hearing newborns next door.

And I imagine that would be quite triggering.

Leonie Callaway: Yes, bereavement spaces are a very important part of design for maternity care. Unfortunately, a number of babies die in utero, and that's obviously a very, very difficult point in a family's journey.

Like all other deaths, this one is profoundly grieved and it's grieved in a special way because people are both meeting their baby for the first time and also saying goodbye to their baby at the same time.

 The best bereavement spaces for families are once again large and really inspired by palliative care spaces with some extra beds for families to stay over.

Some self-contained facilities, coffee, tea, toast, making facilities, and obviously a private bathroom. In many situations, the families choose to keep their baby with them for a period of time, and we manage that with special little cots that are refrigerated that allow the, the family to be with their baby for as long as is required for them to undertake those tasks of bonding, grieving, and saying goodbye.

And obviously there's often a lot of aunts and uncles, grandparents, brothers and sisters and so forth that want to come and say both hello and goodbye to the baby at that time. So those particular bereavement spaces in maternity care are really important.

If they're very well designed, they're also valuable if you are looking after someone who's very unwell or had a tragic diagnosis. For example, sometimes in maternity care we unfortunately diagnose people with metastatic cancer severe end stage cardiac diseases.

They're probably the commonest things that come to mind. This can be just a completely devastating experience for both the patient and their family to be informed that at a time of life that should be happy and all about bringing a new life into the world.

That actually you're talking about tragic diagnoses and potentially very short periods of time to live.

And so those bereavement spaces that are well developed to look after families where they've had a little one who's died are also very valuable when we are taking care of women and their families where there's a terrible diagnosis.

So designing those beautiful, large, quiet, self-contained family spaces into maternity services is really important.

David Cummins: I must admit, I've never design a bereavement room, but do you need things like oxygen and special gases, or pretty much you just want to create a hotel style . Environment with windows and natural light and biophilic design or access to nature.

What is the ideal bereavement room look like?

Leonie Callaway: I suppose, David, if a bereavement room has got piped oxygen and all of the usual medical care, it does allow it to be more flexibly used. So for example, if we've got someone who's just been diagnosed with metastatic melanoma or metastatic breast cancer or a brain tumor, and we are wanting to provide a family with a place to grieve and to process that information and to take care of the patient in a private space.

Then obviously good monitoring facilities and oxygen and all of the usual medical inputs into that room are important. So I would say that it's worth including those things, just so that those spaces can be used in multiple different ways.

Obviously, if it's just a mother who's given birth to a baby, there may not be any reason for that. But for example, if the baby has died as a result of the mother being very sick with preeclampsia, for example, a condition of high blood pressure and many other complications, then you may have the situation where you've got a sick mother, a baby that's died, and where you're needing to take care of the family.

So I would say that having good medical support and facilities is useful but obviously also that space for families.

David Cummins: Yeah, so it'd be a good challenge for designers to find that balance between comfort compassion, warmth, but clinical as well so that's a good point to take.

Yeah.

Leonie Callaway: One of the other things that's really important, I suppose, in designing these spaces is appreciating something that we call trauma informed or trauma sensitive care.

You may not be aware that at least one in three women who are having a baby have experienced sexual trauma.

And actually recently the Australian Childhood Maltreatment study was just published in the Medical Journal of Australia and it demonstrated that about 39% of all Australians have got two or more forms of childhood maltreatment.

So when we are taking care of women, we do look after a lot of vulnerable women with a lot of a significant background of trauma.

And obviously if you're having a baby and you've had a history of sexual abuse, then there's a lot of considerations in taking care of someone and keeping them safe and not triggering off their post-traumatic stress disorder.

One of the things we've discovered in this is that very often having a support person be that person's partner, a doula, a close friend, a mum or an auntie being with that person throughout their hospital admission or as much as possible is very important.

So the other thing I would say in designing maternity spaces, is that there needs to be at least some rooms available where you can sleep the patient plus their support person. Because in these situations you often have people in hospital for a week or two needing a lot of intensive support with an extra person beside their bed.

Obviously enough space to house two people is important from a safety perspective. And also having comfortable sleeping arrangements so that that support person doesn't burn out and become diminished in their capacity to provide support is really important.

David Cummins: You talked earlier about some babies that get sick during this process.

 With NICU design (Neonatal Intensive Care Unit), I have worked on a NICU before, and I've also worked on a bad one before.

What's some good design principles for a good NICU for a staff member and a professor, and literally having access to the baby, noting that there are so many other moving parts and so many requirements for a baby in NICU.

Leonie Callaway: So David, I look after big people, not little people but, I can make a couple of comments about it. I would say that one of the main things we discovered during Covid in neonatal services across Australia was that actually they're so cramped that we weren't able to maintain social distancing.

And our focus on trying to make sure that there's much better bonding between families and their babies, there's just not enough space for both a mother and a father to be sitting at a baby's bed.

There's also not the recognition that actually the mother or father might want to stay with their baby.

There's no sleeping facilities, there's no facilities for that bond between the mother, father, or parents and the baby to be really promoted so those caregivers can increasingly take over skin to skin contact.

So the feedback that I get from my neonatal colleagues is that neonatal intensive care nurseries and special care nurseries need to be vastly more spacious and need to take into account the fact that parents want to be with their babies and in fact may want to sleep near their babies and be with them as much as possible.

David Cummins: Yeah, it's a really good point. It's probably something I hadn't considered the opportunity for someone to stay there in neonatal spaces so that's very interesting.

You've obviously worked in many, many hospitals no doubt around, not only Brisbane but around Australia.

What are some strong design principles that you would like listeners to take on board to try and help not only improve your workability with an interaction with patients would also have patient experience as well.

Leonie Callaway: There's one other thing just to flag. At the moment the leading cause of maternal death in Australia is maternal suicide, and we're really struggling with a high burden of peripartum mental health issues.

And so the design of our hospitals and birthing suites really needs to do what it can to diminish the risks of worsening mental health. And so some of the design principles that are very important, the postnatal ward include doing things that allow people to get some sleep.

Reducing all of the machines that go ping and making sure that there's dark spaces where people can sleep trying to get some noise control and not have lots of footsteps and other babies crying and so forth.

Minimising interruptions, allowing people as much privacy as is able to be obtained. And also trying to make sure that we get a good circadian rhythm with light exposure. So one of the difficulties with hospitals is you can have the problem of people really just living in a dim lit environment 24 hours a day.

And so as much as possible getting sunshine into rooms and making sure that at night it's truly dark and that you don't have all sorts of fire alarm lights and other lights shining. And also that during the day you've got as much natural light or you've got access to open spaces.

The other thing that's important is to make sure that you've got some of the beds very close to where your staff are sitting, particularly on the night shift so that sick patients can be carefully supervised.

And increasingly maternity patients are very unwell and got a lot of medical issues. And so I feel that it, an ideal design is to have an almost high dependency unit capacity for some of that space for intensive monitoring.

That's close to where the nurses are sitting overnight and then of course, the flow of staff, the total number of staff that are providing maternity care now has really increased in Australian hospitals.

Aboriginal and Torres Strait Islander health liaison people, social workers, psychologists, obstetric physicians, obstetricians midwives and so forth, pharmacists. So the total number of people that are working together to look after the increasingly complex nature of maternity care.

I think the way that we design the spaces for people to sit to conference about patients enough computers, thinking through the workflow of what it is staff need to do and being careful about where all of that noise that's related to staff gathering together and the impact that that potentially has, especially in the middle of the night, to try and think about where staff are working and how you try and keep that Quiet and away from where people are trying to sleep.

David Cummins: So, in these spaces, whilst a woman has given birth or just given birth, is there an actual risk of self-harm within these spaces itself that we have to consider? Something like a ligature point for these spaces?

Leonie Callaway: It's very rare for there to ever be a case of self-harm within a maternity service. If we have patients like that, we generally try and co-manage them in a purpose-designed psychiatric facility.

But of course it would always be lovely to have one room in a ward that has taken those sorts of things into consideration if you're looking after someone who's very unwell and that is genuinely a concern.

For example, women who are really struggling and have got eating disorders and they're pregnant so it's certainly a possibility. It's not something that I've come across frequently. I don't think it's a high on the list of priorities, but certainly considering the mental health needs of at least one or two rooms within a maternity space is a very good idea.

David Cummins: Thank you so much.

Professor Leonie, I just think you are a powerhouse of amazingness. I think the level of knowledge you have in this space is phenomenal. I'm just so grateful for the opportunity to speak to you.

Thank you so much for your time and so much for your dedication to this field. I think without people like you and your research and your ability to drive things forward you've helped so many, so many women and children in this space.

I just think without someone like you, we would be a little bit behind the eight ball. So thank you so much for your constant dedication and research and ability to help so many people.

So I just really want to say thank you very much.

Leonie Callaway: Thank you very much, David.

David Cummins: You have been listening to the Australian Health Design Council podcast series, Health Design on the Go.

To learn more about the AHDC, please connect with us on our LinkedIn or website. Thank you for listening.

David Cummins: G'day and welcome to the AHDC podcast series Health Design on the Go. I'm your host David Cummins, and today we are speaking to Josephine Sukkar AM.

 Josephine and her husband Tony established Buildcorp in 1990. Josephine is on several private, public, and non-for-profit boards including Growthpoint Properties, the Australian Museum, Green Building Council of Australia, the Buildcorp Foundation, Australian Sports Commission, and the PCA.

 Josephine received an Order of Australia in 2017. In 2019, received an Honorary Fellow of the University of Sydney. We welcome Josephine here today to discuss women in construction and the importance of diversity in the industry.

Welcome Josephine, thank you for your time.

Josephine Sukkar: Thank you Dave.

David Cummins: I almost spent our 20 minutes just introducing you because of all the boards you're on and everything else you do.

That is an extremely big list, and I know I didn't get everywhere. How do you do so much and manage one of Australia's biggest construction companies.

Josephine Sukkar: I didn't try to do them all at once, I know it looks like it. To do some of those larger roles, I've had to step back from a number of the operating roles that I was occupying at Buildcorp.

And that was able to happen over time because the business is now 33 years old and we've got some great general managers and I don't need to do as much of the front facing running of the business, not as my husband as much, but in particularly, the Chair of the Australian Sports Commission, that takes quite a bit of time now on the two listed boards that I'm on.

And that's where a large amount of my focus has to go. And these days often Buildcorp wheel me out where they need me .

David Cummins: Yeah, it's very impressive. So Buildcorp's someone who most people in Australia would be aware of, certainly big in the health industry itself. Looking at your education history, you don't actually have a building degree, do you?

 It's something completely separate, isn't it?

Josephine Sukkar: Yes.

I have an honors degree in physiology and pharmacology, and I did my last year at the Garvan Institute of Medical Research and a diabetes research unit working with laboratory rats. We were looking at radiolabeled glucose uptake into their little muscles while they're exercising on treadmills and seeing where they ended up with.

It was a long time ago and we didn't know much about these things, you know, in the eighties, what happened with intermediate training and we did work with fish oil and rats. It was quite interesting. Yeah. But that's old news these days.

David Cummins: I'm obviously missing something.

So there's a big leap between exercise physiology and construction. So was that just the love of meeting Tony, or where did that come from?

Josephine Sukkar: Yes, we were engaged, he has a Bachelor of Building, he was working for Lendlease and there was a small job that was needing to be done at Lendlease in 1985, and it was just a processing job on a construction site, a paper processing job.

And I did that, agreed to a couple more small jobs on site and did say to Tony one day we should set up our own construction company because I could really easily do this. I didn't realise I'd love the industry. Clearly I had some transferrable skills. I've never built anything, but certainly that back office admin, running a business together, is something that appealed to both of us.

And that happened a few years later, in 1990, we started Buildcorp.

David Cummins: Yeah, so that's a long time ago. I mean, construction wise. So as a female in the 1990's to a female in 2023, you must have seen a dramatic shift in attitudes and societal changes towards women in the industry. Would that be fair to say?

Josephine Sukkar: Yeah. In 1985 was actually when I began on sites. And that was where the big change was because in those days we had a Builders Laborer's Federation (the BLF), they were pretty rough! Their leader, Norm Gallagher, got locked up for a period of time and they were deregistered. There were wild days in Sydney, it's probably fair to say, on sites.

By the time we'd begun Buildcorp in 1990, we had an opportunity to set your own culture and the way you want people to be and behave on sites. And so that became very different. But I have to say, I was 21 when I walked onto my first construction site, and I never saw, or never felt or was ever treated badly.

I was a very driven young woman. I just put my head down. I wanted to work hard, and I was probably a little bit nerdy and wanted to do my job well, and I just focused on that and people saw me working hard.

I used to say I was really lucky, and there's no question. I think that all luck when preparation meets opportunity, I do think that's a key. I just worked really hard and over the years people began to tap me on the shoulder for roles, but I wasn't looking for or alert to, did someone say something that might make me feel bad? I just was driven to get my job done and do it well.

David Cummins: Yeah. I think the interesting part about that is that you were there at the start of Buildcorp in the nineties where you were part of that cultural setting for the industry and certainly for your company because Buildcorp is synonymous with... I know you've got suicide prevention, you've got a lot of gender diversity, you've got a lot of equality, you've got a lot of respect, and certainly there's a few other ones in Australia.

There's a few other ones in Sydney, but certainly other construction companies probably didn't have that foundation with women there. There is a few out there, but certainly I think that was probably a key to establishing that culture.

Josephine Sukkar: Yeah, there weren't many women for sure, and in fact, at Lendlease, part of the business I was in in those days was called Civil and Civic. And when you'd wrap up a project, you'd go back into head office, which is in Australia Square, and it was a lovely place and everyone in there was just lovely. But the only other women who were there were the women in the typing pool, the women on reception and the Pay Mistress, whose name I still remember, even though she's long gone Sue Eden because there weren't many women.

 But I never felt it was an unfriendly place to women or any different to what was happening in the eighties and how women were being... women's place in society... not that I ever focused on that.

 A lot more women are focused on in the eighties, this didn't happen for me and that didn't happen for me. I guess, with Tony, we sat down and as a young married couple said, here's where we'd like to be and how do we get there together?

And never really focused on who should do what, who should work where, who should hang the washing out, who should go to work this day.

We never did that. We focused on the end goal and together, as a couple said to get there, how do we get there and who needs to do what? So at the beginning of Buildcorp yes, we'd always wanted to set up our own construction company, but the way it happened and the timing was not what we'd hoped for.

It was in 1990, Tony was working for a company called Girvan Corporation and they went into receivership and he was project managing some twin towers at Chatswood. And the client were two Japanese clients and the AGC for those who remember back in the day, the finance company.

 And they were going to appoint a large tier one builder to take the project over and appoint and the contractor was going to take Tony on as their senior project manager on it and all the team there. And we decided at that point in time, well maybe this is when we should do this. Now, it was a bit scary cause it was 1990, we were in the middle of a property crash.

Wasn't quite how we'd hoped to do it, but compounding the issues around that, our vision was for us to sit down and do this together, begin small and grow it. There was 47 million worth of work left to do on that job. That's 47 million in 1990, I don't know what the equivalent of that would be today.

And I was seven and a half months pregnant with our first child. So I wasn't even able to be there for the beginning of our journey. But do you know that agility of mindset right? And I think that's where we've got to continue to check ourselves every now and then. We can't be that someone moved my cheese, I plan to do this, and then someone moved it.

We need to be able to go, right, so it might look a bit different and we might need to go off-piste slightly, but it's still going to get us in the long run to where we need to be and where we hope to one day be. So that meant we brought in a couple of small partners into the business, sort of minor shareholders that we subsequently brought out over the years.

But they were amazing because they were there alongside Tony working on that project with him. And until I came out the other end, having had kids. But at that point in time, when I talk about having a vision that you build together it made no sense for me to do anything other than be at home.

Have children, stay at home and look after them. There was nothing I could do practically to help Tony. And it made no sense for Tony to be at home doing his share of fathering when we needed him to focus on building a business. So I'm often asked, you know, you must have sacrificed so much while Tony was able to set up the business.

I've never in my mind ever saw that, nor did he. And in fact, I get a little bit frustrated sometimes when I hear that because I feel like that's other people trying to take our lived reality of getting to where we needed to be, and bending it to shape their own storyline, which has nothing to do with what we did.

And of course we ended up getting there together, but it looked a bit different to what we planned.

David Cummins: It does sound like more, is it a sacrifice? It just sounds like strong, open, honest communication with a loving couple that had a common goal that worked together to achieve those goals, whatever that meant.

Josephine Sukkar: Whatever that meant. So I often tell, and we're talking, you know, pre-mobile or mobile phones that were attached to your phone in those days. I do remember when I was at home with the children, Tony would come, he'd leave home every morning about 5:30am, wouldn't get home till about 8:30pm at night.

He was working so hard and I would always have dinner ready on the table for him. And the thing that never made me think twice about that was because every time he left the office, before he left he’d ring and go, what can I pick up on the way home for dinner? He never expected me to do anything. He never, and I don't you dare spend a cent on anything for dinner.

We're budgeting really hard. We've got, so between the two of us, he was perpetually grateful for what I did. I was perpetually grateful for him leading this without me. And a couple of partners and... huge respect for him and so grateful for the respect he afforded me. That allowed me to stay at home, which I never thought I would do for six years, having two children.

David Cummins: So what about moving forward 30 plus years? What do you think young women and also probably young men face today? What you've painted is a picture which may or may not be relevant to some couples today where the primary parent might be male, or they could be gay, or they could be female.

Like there is so many more different pathways for young people these days. So there seems to been a change in shift with females and males on construction sites in the last 30 years. What do you think about what's happening today? Is there any advice you'll give those people starting out in their career?

Josephine Sukkar: Oh, I can tell you from our lived experience from Buildcorp, what young women needed when they came to Buildcorp, when they started families, now our men need. They want to partake in childcare responsibilities and pull their weight. And the reality is that I was able to stay at home. That is going to be very difficult for young couples today with cost of housing.

Especially if you live in a city like Sydney or Melbourne. Our children are 33 and 31 and I imagine that both of them are going to have to both, as couples, they will need to work together to be able to pay down and do what they did. But I think if you are in a relationship or you're not, imagining where you want to be, go to the end.

This year I turned 60. Imagine you're going to turn 60 and you're making a speech at your own birthday party or someone else is making it about you, what would you like them to say about you? And it's often where you ended up, not how you got there, but so long as you are surrounding yourself in a place where you are physically and psychologically safe to bring your best self to work.

So long as you are realistic, if you're working in it for an employer, particularly in times like now post Covid times as businesses are trying to rebuild and those that have been impacted by Covid, when you do need to or decide to, or not decide to step back temporarily from the workplace to, you know, in the long run, by the time you're 60 you can look back and go, I've had it all if that's what you want..

Make sure that your requests are actually realistic, because I've got to say, those employees of ours who have been able to flex with us we have flexed with them... that's great, I'm so excited that you're having a baby.. My EA is about to have a baby, my assistant, it's so exciting and her family are in the UK and the mum will come out and I'm really looking forward to that.

But, My lesson with women who have left Buildcorp and come back is to not let them plan too hard, too far ahead because these are times where you never know how it's going to be.

I usually say just come back in with a baby. Let us see the baby start up and let's just figure it out as we go along. Because often what we think we'll do can change, and often how we feel about the roles we play can change. So I think being mentally agile, and then look for being a bit realistic and thinking about the long game and having it all but not at the same time.

My great fear is we're going to break young people who may want to step back into caring roles. In these days we're seeing having to step outta the workforce for a bit to look after elderly parents or kids or partners.

These are all difficult times, and if we don't look at the whole self and say, well, what's happening here at work, I might need to pull back a little bit here.. But have reasonable expectations to say, maybe that might mean my job, might need to temporarily shift for a bit.. Roll with that.

I'll give you a live example. When I came back from work, having been at home for six years with my children I said to Tony "right, I'm ready, I want to be able to drop the kids to preschool and I want to be able to pick them up. That means my practical working days are going to be four, five hours max, whatever days the kids are at preschool. Do you reckon anyone at Buildcorp needs a hand"?

Now let's think about this. Owning half the company, I reported to a business development manager right? As the owner of the business I could have sat back and said, I own the business. Here's what I need. I'd like to sit on high and be a leader and be a manager. But in real world, what am I actually bringing to this? Because I did want to have the holidays with the children.

So I said what I practically could do and deliver in a real way in the office where people needed me. So ensuring I was productive and genuinely honest and this has happened for us at Buildcorp too, that type of transparency when people come to us and say, these are my circumstances that have changed.

The last woman that did that to me and resigned and I'm having a baby and moving to the Central Coast, I said, well.. "You can't resign, it's not a good enough reason. You're too productive. I need you here. Go away, have your baby, come back and talk to me with the baby a bit later and let's figure out what we do". And she comes in and out and works part-time and she's pregnant with her third now so I might lose her for another three years I reckon.

If you're talent, we fight to keep talent. When you're honest and straight up and practical about, now I've got another child, or Oh mom my way, here's what I'm doing... These open, trusted relationships, they go both ways, end up in employers like us saying " We'll fight to keep you".

David Cummins: I think for those listening to this podcast, you've just done the best recruitment drive for Buildcorp I've ever heard for women, especially because not everyone has that mindset that you're a good worker and we'll do whatever we can to work with you in whatever capacity.

So, as you said, some kids have school or whatever it is, they might only have five hours a day, but you'll fight to keep good work.

And that's so refreshing.

Josephine Sukkar: Make no mistake, David, 33 years.. Of course, we haven't got everything right, but our lived experience as parents, ourselves. We know how to do this and we know what we need for our business, which isn't going to be right for everybody, but if anyone is looking to work in an organisation, jump on their website, have a look at their values, make sure then their stated values or their stated code of conduct that you can see evidence of them actually living that day-to-day in other things you might read on their social media feeds.

Josephine seems to, you know, bang on about doing a lot for women. Really? Does she just jump online and go, you know.. "Those men are terrible" and you know, "this woman is fabulous". Is there any evidence of Buildcorp actually living those values? And when we talk living values, we're saying living values all the time.

So you know, integrity, honesty. Most of the time honest, that's not going to cut it. You know, I don't care if you're honest 99% of the time, if you can't bring yourself, to be honest and straight up, we'll always stand alongside somebody who's honest and not necessarily 100% where they need to be technically.

Because we can train technical skills. This works both ways and we haven't always got it right but gosh we work hard to continually improve on our processes and what we do.

David Cummins: Yeah. It's very obvious that you are an exceptional leader, and full transparency, we have worked together on a project in Sydney a few years ago, and it was very, very obvious that people follow you and will listen to your understanding of empathy, your understanding of sympathy, your understanding of values, and a balanced mindset to get the job done.

I'm sure we can all push people as hard as we need to, but unless you have a good understanding of your team, your team generally will fall.

So how important is female leadership in the construction industry, which is predominantly a male industry?

Desperately working to build a pipeline of women in construction, we have in our business a 50/50 male-female intake of women and men into our undergraduate program.

The challenge is to try and retain them in a sector that's really difficult to. You know, With hours our sites open at seven in the morning, trying to find women who want to be in front facing roles, site supervision roles, for example, finding tradeswomen who we don't directly employ.

But you'd be looking at less than 1% of tradies as women, right? And then overlay that with we wanting to improve indigenous participation as a sector. Inclusion in its entirety, aged, you know disability, whatever it might be, we're quite challenged, but certainly we've got a pipeline issue of women into construction and we want more visibility of women builders to school age.

 So just before we go. Obviously you've been in the industry for a long time. Where do you predict the next 30 plus years will be. What would you like to see with women in the construction industry?

Josephine Sukkar: I'd like to see women feel comfortable being able to step back for a period of time if they need to, or lighten up a period of time to genuinely enjoy some of the life decisions they might make.

Tony and I lost our dads through our period of Buildcorp, and there were a number of months there where we just said, I really need a hand, I want to spend these last few months with my dad.... or my new child, and not spent that whole time trying to think that my career will fall away if I take three years off, six years off for hard workers, driven workers, that will never happen, right?

That will never happen. And to come to the end of a life and go, I feel like I've had it all. That only happens when you feel like you are fully present as a parent, you are fully present as a partner, you're fully present as a worker. Wherever you are, be fully present, and you'll enjoy all of those moments.

David Cummins: Yeah,

It's been an absolute pleasure to talk to you, Josephine. It's been good to connect. I think people like you are absolutely paramount in the construction industry. You've been around for so many years, and your leadership and your understanding and your ability to communicate with your team, not only on a smaller scale, but at a much larger scale with all your charity work.

Josephine Sukkar: Thank you, David. A real pleasure.

David Cummins: Absolutely paramount.

I would like to personally thank you for all you've done to the construction industry and I've certainly seen a change in the industry over the last 15 years and I have no doubt that that's been because of you as well so thank you so much.

You have been listening to the Australian Health Design Council podcast series, health Design on the Go.

If you'd like to learn more about the AHDC, please connect with us on our website or LinkedIn.

Thank you for listening.

David Cummins: I would say, even in my experience personally, you do find these generally older managers who do feel that they do have this power over you because they've been there forever and they do say inappropriate things.

I've experienced that myself and I've witnessed that myself, and ultimately what happens is the person who's receiving those comments, Either feels bad about themselves, gets depressed, gets sad, and ultimately they leave. And they have to leave not only their job, but some people leave their career because some old manager feels they have this power to belittle someone because that's the way they did it a thousand years ago.

And so I do find it interesting that especially women in the industry, I would say that's a big factor of why there's so few women in the industry, purely because it's not a matter of not being able to handle it, but maybe they're smart enough to say, I won't accept that because it is very hard to take someone to HR, and I've done it myself where I've spoken to HR and they said, "that's just so and so", well, he shouldn't really be doing that.

Althea Papinczak: Or they say, oh, "we'll have to launch an investigation, we'll need to get witnesses". And that feels very overpowering as well. I've had that happen before about a comment that you wanted to report so that that person is spoken to.

But when they start using the words like investigation and witnesses, you go, oh, that's too much. And I don't want to go through that process.

David Cummins: I've had it where, "oh, he's the biggest income earner, so we can't do anything". I'm like, oh. Okay.

Althea Papinczak: I think the construction industry is getting a lot better. For someone like myself to have been able to say that there's probably been one or two instances in my 15 years in construction where I've had someone say something inappropriately or talk to me in a way that I found degrading.

I would say that every industry is going to have some people who will go through the same kind of experience. Whether it's construction or whether it's not, and I know Erin speaks quite openly about the fact that her biggest issue as a female project manager working in construction is often sometimes the unconscious bias that's put on her.

So she'll walk into a room and they'll immediately assume that the contract administrator standing next to her, who's a male, is the one leading the job, and they'll direct all the questions to him.

I think her way of looking at it is she could call 'em out and she could say, excuse me, and make a big deal out of it. But a lot of the time it is unconscious bias and it's just, that's the mistake that they've made. And as soon as she's said to them, "I'm the project manager leading this job, I'm happy to answer all of your questions".

They go, "oh, I'm so sorry". And then there's no issue from there. So I think a lot of it is, if you are able to talk very one-on-one to the person that maybe has made the wrong assumption about you, and you're able to give them the opportunity to prove to you and say sorry to you, and for them to make amends because maybe it was a mistake, that's step one.

But if it's someone who, like you said, is just out there belittling people regardless age and position and everything like that, there's a lot of people probably still in the industry in those very senior roles who've been there a very long time where that behaviour was probably tolerated for a big part of their career back in the day.

And it's not now, and it shouldn't be now, and it shouldn't be tolerated by companies and it shouldn't be tolerated by colleagues either. Colleagues need to be okay with calling it out and stepping up and supporting those around them as well.

David Cummins: Yeah, I totally agree. Well said.

So the One Hundred Percent Project do a lot of research, that's one of our biggest selling points in our unique selling point.

So at the moment, one of our latest research is about 'Breaking Dad', so the Breaking Dad research focused on psychological safety for men, particularly relating to their participation in flexible working conditions for families and their friends. The research found that men are likely to be stigmatised and being labelled as not been serious about their career.

If they request conditions such as long-term paternity leave, part-time working or remote working. Ironically, now thanks to Covid, many workplaces have proven that you can actually work from home and be quite productive. As one of my friends said, overheads are down, profits up staff retention is high, and client satisfaction is up.

However, there does seems to be this resistance for employers to actually. Benefit males working from home versus females working from home. In your experience, especially in, I suppose, more the design industry, have you found there's a bit of difference between males wanting to be the primary carer at home versus females?

Is it just always a female job or is it just always a male job? There seems to be an employer dis disconnect between the employees as.

Althea Papinczak: Yeah, definitely.

I was talking to a certifier the other day. So his wife had a baby about a year ago, and back when she was pregnant, they had a discussion and they made the decision that he wanted to go down to part-time.

So that after his two weeks of paternity leave had finished up that he would be able to spend the time going forward, having an extra day at home a week because he's like, I need to make sure that she's supported, and b, I want to be there. Those are really important critical years, and I don't want to miss out on the memories.

He had a conversation with his workplace and said, "I want to go down from five days to four" and they said "no", like, Exactly that. "You're in a senior role, it's a five day a week role". So he went and spent a year interviewing with other firms trying to find a four day a week role as a senior certifier and couldn't.

He ended up renegotiating with his current employer and they came to the party and said, "okay, you can do four, that's fine". But he said that he's pretty much worked five anyway. Since going to four days a week.

He said the whole process has really opened his eyes up because for his partner, she asked to go to three days a week when she was coming back from maternity leave.

And it just was not even the question. That was just something that was ticked off immediately for her, and they're very flexible with her hours. When I had my maternity leave, I did 10 months and I came back and I wanted to do three days a week and I wanted to do certain hours and they said, "yep, that's fine, not a problem".

My husband would absolutely have adored to be able to be a stay-at-home dad for that part of my maternity leave contract. But his workplace, and he's in finance, which is different, but they're like, "no, it's a five day a week role, we don't offer part-time". And I think there aren't many industries out there who seem to be willing to offer.

guys a part-time position, whether it's four days or whether it's three days, and he said it's the same thing. It's that stigma where people are like, oh, you're leaving at four o'clock to go pick up the kids and how nice for some, and he is like, well, we share, pick up and drop off. Is it that your wife does all the pickup and drop offs?

So I think there's a lot of stigma put on dads. And then I know other dads who were full-time stay-at-home dads in the design world, architects, and took time off to be stay-at-home dads. And then when they were coming back to work, felt in a way that they were just put on a pedestal.

People and other mothers and other women were just marvel at them going, that's so selfless of you. And if this parent was like, well, no, like that was my choice and that's what I wanted to do. She took the first six months off, I took the next six months off. That's what we wanted to do. But I think the more that families make a way to make it work for them and there's more males taking time off or doing part-time hours of doing flexible working, the more it's going to become normalised.

And they have to ask for it. I think more men have to ask for it because companies are going to catch up.

Companies always will eventually catch up to the requests and if you are losing good staff and they're leaving your company to go and work for another company that does offer that kind of flexibility for dads very quickly, it becomes a much more competitive industry as a whole, I think. So hopefully we see a bigger shift towards it being a bit more even in future.

David Cummins: I think you're a hundred percent right. Even the whole females who were traditionally doing five days, going to four days, all the research shows they were still doing five days worth of work.

Althea Papinczak: Yeah.

David Cummins: At less cost.

Althea Papinczak: Yeah.

David Cummins: And actually being more productive, and employers were still struggling to understand that process and I do think one of the benefits of Covid is that people actually can work from home, you can be productive.

And this whole idea of actually being the first one to work, the last one to leave when majority of the time people are on Facebook and not being productive, it just doesn't make sense.

So I do think that's one of the benefits of Covid. So I do hope that does continue.

Althea Papinczak: Yeah, and I think just quickly as well, like there's a lot of senior females I know in construction who might be a senior project manager or a project director, and they've said it's really hard if they want to go and have babies at later stages in their career, to come back into a senior role.

Is a project director able to work three days a week if they've been told no? Then I have heard about recently a few different employers who are now looking at, for those senior roles, getting two people to jobshare. So one will do three days and the other one will do three days. So they both do the three days and there's a day crossover where they're both in the office.

So they have to be highly organised, they have to be able to do really thorough, good handovers, and the employer is paying for that extra day of resourcing per week. But it means that he hasn't lost two senior females outta the business who couldn't come back and work the hours that they wanted to work after having a baby.

So I think employers have to become more flexible and they have to become more innovative in the way that they're looking at resourcing. And it's even for the guys too, like site managers.

Site managers who want to do three days or four days a week typically have never been able to do that before. But we had a site manager in our company who wanted to do three days a week cause he is on track to retirement and he's getting older and he wants to not do the five day a week and the big hours anymore.

And so they paid him as a site manager, as a floating resource to cover the days where one of the other site managers had an appointment or some of the sites were extraordinarily busy and they needed extra resourcing so they were able to take him in a part-time basis.

And offer that as something that I don't think you see a lot of, I don't know, a lot of other part-time site managers, so I think it's just employers being a bit more agile in the way that they look at resourcing in the future.

David Cummins: Totally. And there's so many benefits to that, understandably.

So what changes would you like to see in the construction industry for a more diverse and gender equality workplace for the future? because I just don't think we are there yet, but I definitely do see the changes in my career in the last 12 plus years, I have seen changes, but I do think we've got a long way to go.

Althea Papinczak: It was good that I went and had my baby in maternity leave and came back from maternity leave. To be able to kind of look at it full circle and see what all the different kind of challenges and constraints are at different stages.

In my early years, it was probably getting enough exposure and getting enough one-on-one training and mentoring and being given the opportunity to step up and being given tasks to be more autonomous as I was young and really energetic and wanting to just absorb all the learning that I could.

And then as you get more senior in an organisation, I think it's really important that you have male bosses around you advocating for you and putting you forward for the big jobs or the big projects. Putting you forward for promotion, being able to make sure that when you're going into those discussions around pay reviews or performance reviews, that they're looking at it and making sure that you are not just walking away from that conversation, too nervous to have it.

I think if more male and female bosses were more encouraging and even mentoring employees through that conversation, like it's a hard one because you, you think about it, businesses are there to make money, so it's a really difficult one, but I think if more bosses are there spending the time with employees to help nurture those negotiation skills that's going to really help females feel empowered and like they're being supported in the workplace.

And then as men and women want to go and start families, if that's what they choose to do, the conversation should be more normal. It should be more accepted that if I came to you and said, Hey, I'm looking at starting a family, that that would always be supported, that that wouldn't mean that all of a sudden you're dropping me down to the smaller projects because you're nervous that I'm going to get pregnant and finish up nine months later.

So, generally it's a lot on the employers to really make sure that they're there for the open, candid conversations and they're willing to have them, and that those open and candid conversations are met with the support that employees are looking for through the maternity leave phase.

I got paid maternity leave and that was amazing. I got 12 weeks paid maternity leave and that was a game changer for me. And then when I came back, I got daycare assistance for the first two years. So that again, I think is probably one of the most non talked about barriers for women and parents.

Returning from having a baby, because if you are coming back three days a week and you are paying through the nose for daycare, that's a big barrier. So for me, having daycare assistance and meaning that I was essentially around $20 a day out of pocket, I was happy to come back three days a week.

I was happy to come back five days a week. It wasn't a barrier anymore. I think that's a big one that could be really looked at in terms of those paternity policies is daycare.

And for me, that just took a lot of the stress away from figuring out financially how I was going to make it work, coming back to work, if I did want to come back less days a week, and how that would work with mortgage repayments and the rest generally.

Covid has been a really good one, and changing employers, being open to flexible work and understanding that we can all work from home and we'll have laptops, we'll have phones, so you're available whenever, but I think it's gone back the other way where you just never switch off now.

So I have to make a really concerted effort that when I finish work, I don't take my laptop home and I'm not on my phone looking at emails because it's with you 24/7 now, especially through lockdowns.

If you are locked down and you are working full-time, you are on screens constantly and it's really hard to switch off and make sure you have that mental time to yourself to unwind and everything like that.

I have seen that it's a very competitive market at the moment in construction and design and project management and all our related industries. It's a very competitive market. There's a lot of people moving around at the moment and so I think the employers who are going to best support employees are going to be the ones that do the best I think.

Employees know what they want now and they're going to get it, and if they don't get it with you, they're going to move and they're going to get it from someone else.

David Cummins: Yeah, I totally agree. Well done.

And so what does the future of WIDAC look like for you? Or what's the future hold? You've done so much and you've achieved so much. I do think it is the biggest in Australia.

 I was looking around the world, I haven't seen any as big as you, so I'm willing to say you've got the biggest network in the world. So I'm going to give you that title today unless anyone wants to challenge me. So what's the future look like for both of you?

Althea Papinczak: To be really honest. Really, really candidly honest, WIDAC was an absolute whirlwind that grew overnight and got really big, and then we had a couple of years where we're like, we're well established in three states, we're going to just keep doing what we know we we're really good at and get the business in the best position as we possibly can to get ready to grow into these other states.

And so we'd done some roadshow events in Adelaide and South Australia and Canberra, and we were ready to head over to Perth and Tasmania and Northern Territory, and then Covid happened and the last two years have been very tough for us.

Like everyone else, I know it was the most overused word of 2020, but we pivoted and we went digital and we went online, which for people like Erin and I who are face-to-face people who love that human interaction was really weird.

And I still would say that I'm not a big fan of digital events. I'll openly say that I'm not a big fan of digital events. I'd rather be seeing people face to face. I'd rather be standing there having a wine with you and having a conversation in a big room of people. But I think it's meant a lot for our business in terms of being able to reach other people that we might not have been able to reach before.

And now with borders opening up. We are ready to go back and continue expanding and meeting new people in those other states that we're not well established in yet. So we're really looking forward to heading to Adelaide and Canberra and Perth and South Australia again, and for us, I think the sky's the limit with WIDAC we really have looked at it and said, what is the secret sauce and what's the recipe that's meant that it has been so successful?

And I think for us, there's other industries that desperately need something similar as well. That might be industries like IT and finance, where there's not a networking platform as candid and open and honest and agile as we are.

So we definitely love the design, construction, and related industries. We feel like we've done a lot in this space and we want to grow further around Australia to mean that we can reach more people. But I do also think that in the future there's a lot of opportunity for us to keep growing the business as a whole and helping more women even outside of our group of industries.

So, It's a really exciting thing I think for Erin and I as business partners of five years, sometimes it's a really daunting thing to own a company where we're trying to figure out what's next and what's the next big move.

And we're both still working and trying to figure out at what point do we step back and do what WIDAC full-time or do we keep running with the amazing team that we have who are running the company and the events for us.

So we still don't know. And I think Covid through a big spanner in the works and made us stop and realise, but luckily we're a very agile business and coming back, people are desperate to get out and network is what we've seen. So next year's already looking huge for us. So it's exciting. I think whatever the future holds, it'll be exciting.

David Cummins: I have no doubt it'll be positive. Thank you so much for your time. All the best to you and WIDAC and the team. Hopefully I get to catch up with you soon for a beer and wine.

Althea Papinczak: Yeah, definitely.

David Cummins: We do thank you for your time and really appreciate everything you've put into WIDAC and everyone else as well.

Althea Papinczak: Thank you so much for having me, David it's been awesome.

David Cummins: If you would like to find out more about the One Hundred Percent Project, our research and listen to other podcasts, please visit our website onehundredpercentproject.com.au

Thank you for listening.

David Cummins: G'day and welcome to the AHDC podcast series, Health Design on the Go.

The Australian Health Design Council would like to thank the One Hundred Percent Project for allowing us to share their podcast with WIDAC.

WIDAC is Women in Design and Construction, which was founded a few years ago by Erin Oxley and Althea Papinczak, who started to work together at SHAPE a few years ago and discovered there had to be a better networking opportunity for women in the design and construction industry.

We look forward to listening to this interview as part of our Women's Health Series to celebrate . International Women's Day.

This interview occurred last year, but we found it so inspirational and so important, especially on International Women's Day that would like to share it with you.

Thank you to the One Hundred Percent Project, and thank you to WIDAC.

Hi, I'm David Cummins from the One Hundred Percent Project. In this series of podcast, we'll be discussing gender diversity within the construction industry and how it has impacted the industry. We'll also be investigating the steps necessary for making improvements for gender equality in the future.

 Althea Papinczak and Erin Oxley started to work together at SHAPE a few years ago. Both women started attending several networking events in the Brisbane area and were left a little dissatisfied with the offerings of the day. They were both looking for a networking group that was more welcoming, comfortable, and genuine, where the speakers were open, honest, and relatable, encouraging others to do the same.

Then in 2016 with no experience hosting a networking event, they got the ball rolling together with a few of their colleagues and friends and had the first WIDAC networking event with great success.

Since then, WIDAC has become a national brand helping provide a safe, inclusive, and respectful area for networking, empowering women to share their experiences from a design and construction industry.

WIDAC (Women In Design And Construction) aims to encourage the future generations of this industry to network and collabourate through a relaxed, informal, and genuine environment for all.

In the last few years, WIDAC has gone from strength to strength, even during Covid, where they have been able to hold monthly events, expand their organisation to include blogs, job boards, and mentorship programs, and educational scholarships.

The One Hundred Percent Project welcome Althea to our first construction series, to a look at gender diversity and equality within the industry and the impact it has to both women and men. Welcome Althea, how are you?

Althea Papinczak: Good, how are you David? Thanks for having me.

David Cummins: That's okay. Thanks for your time. I know you're busy.

I know you've got family and your job and your other job and this, I know you're quite busy, so we really do appreciate your time.

Can you tell us a little bit about. And the career path to date and how you've ended up being the founder of Australia's largest network for women in design in the construction industry?

Althea Papinczak: Yeah, it was a bit of a funny one, and we do often refer to it as our accidental business. I guess for myself, I've done fit out and construction for around 15 years now, stumbled upon it a long time ago when I was just looking for coordination, administration type role, ended up in construction and just absolutely loving it and getting the bug for it and working my way up.

And then I'd done retail and hospitality fit out for quite a while before making the change over to the commercial side. And it was about then when I went over to commercial and realised that I needed to go out and meet the different people in the commercial space.

So I didn't know who the consultants were that we would be working with and I needed to go out and meet clients and I needed to build that network in the commercial space.

And when I started going to some different networking events, like you said, it was just very informal or really expensive or, I wasn't connecting with the right kind of people that I was wanting to meet with and there wasn't anything in Brisbane at the time that really met my needs.

So I decided one day I went home to my husband and I said, "babe, I think I'm going to start a networking group". And he's like, "okay, great. Go for it! You've got my full support".

And our first networking event was 20 women in a pub, and they all loved it. They're like, "when's your next one"? That was just, really, really inspiring and genuine because we had some speakers get up who were both very candid in the stories that they shared.

And I think that set the tone for it and when they said "are you going to have another one"? Erin and I looked at each other, because she'd come along to the first one to help me out, and we were like, "I guess we are". And so it just. It really snowballed from there. And Brisbane grew very, very quickly. It was 20 and then it was 50, then it was 70, then it was a hundred, then it was 150.

And then Sydney came onboard about a year and a half after that. And then Melbourne came on board maybe another year after that. And since then we've had all the other states, we've done some roadshow events in each.

So it's been a really big rollercoaster ride, but I think looking back, Erin and I are really glad that every time the business was asking us to commit to it and help it grow that we did because we do both work.

We've always worked, still full-time in our construction jobs, while trying to manage the business on the side, but we're really passionate about it and we just love it. So whatever we can do to keep it going and keep seeing it grow and reach more people is what we'd love to do.

David Cummins: It absolutely is amazing.

I do remember reading a book the Julie Goard Women in Leadership book, and one of her life lessons for younger generations was about networking, and she said she wished she started networking earlier in her career and had more political contacts.

Do you feel that it's helped with your career as a whole and that your members have found the benefits as well in their careers?

Althea Papinczak: Yeah, definitely. And I think for me, when I decided to start going and doing networking, I wasn't very good at it. I was young and I was shy, and I either take a friend and stand in the corner and talk to my friend and get nothing out of it. But when I decided to go on my own and push myself and go and have those kind of moments where you walk up to a group of strangers and introduce yourself.

I think everyone realises very quickly we're all in the same boat. It doesn't come naturally to a lot of people, but it's that effort that you put in. That's the effort that's going to give you huge returns. Like for me, the number of people that I've met that I've either worked with or then gone on to be mentored by or helped find mentors for, or had just really great work relationships.

Or you can pick up the phone and ask them if you're on a project and you have a really technical question and you're not sure what the answer is. So your network also helps you in really surprising ways. When I finished at my kind of long-term job last year and then decided to make the leap into something new, I reached out and had phone calls with about 10 different people in my network.

And it's always just that kind of advice and that support that they're going to give you and those introductions that they might give you. So I think networking's a really valuable thing, and I honestly couldn't say that I would be where I am today if I hadn't had this amazing network that I've probably spent a good part of five years building.

So yeah, definitely the younger you can start doing it, the more confidence it's going to give you as well as you progress in your carreer.

David Cummins: There's another really good book called The Luck Factor, and there's a lot of research to show the benefits of luck where people actually do go out on their own and be more independent and actually speak to strangers versus the same people all the time.

So I think you're living proof of that, so well done. I've been to a few of your events and they are amazing. I've also been to a few that were not as amazing. You guys have survived at least, what is it? 5, 6, 7 years now?

Althea Papinczak: Five years in December? Yeah. Yeah.

David Cummins: So what do you think's been the secret to your success, knowing that so many have tried and failed in that space before, especially in the construction industry. And even more importantly, in a event dedicated to women, a lot of them that were around five, seven years ago, not around now. So what do you think is the secret to your success?

Althea Papinczak: I think a lot of it, and it sounds really cliche, but it's so driven by what members want to come and see at our events.

When I stood up there on the first day at our first networking event and said, "right, this is a networking group and I want to know from all of you, if you come back, what you'd like to hear about, what you'd like to learn about, what you'd like to see". And so every topic that we've ever covered has come from someone in our community, in our . Network.

One of our members saying, "I'd love if you could do a workshop on acoustic, I'd love you to cover the road to leadership and how I can eventually move into a executive type leadership role. And I'd love to come to an event on building code basics or mechanical masterclass".

So everything that we've done in terms of topics and content and the workshop series that we started, and then the mentoring program has been suggestions from the people who come to our events.

And so that's, I guess why the content's always remained really relevant because it's what's needed in the industry, it's what people want to go and learn about and what to see. And I think we've been very careful to make sure that our speakers, that we select for our events, are literally just people like you and me in their careers.

We don't have a lot of professional speakers and we don't have a lot of really senior speakers. I'd say that we try and get a really good mix of juniors all the way through to those kind of senior level roles, but it just means that there's the ability for anyone in the audience to connect and hear from people in the same circumstances, them as to the challenges and the different things and the different things that they've seen work for them at different stages of their career.

So I think that's why it's always been quite successful in that it feels very approachable, feels very real and authentic because it is, it's not professional speakers, it's people like you and I working in the design construction related industry, sharing their stories and experiences in a really candid way.

David Cummins: Yeah, I agree, I also found, I went to one that was about domestic violence and also about how to speak to your boss about having children as well. So I do find there's a lot of topics that would traditionally have been taboo where you wouldn't actually talk to on an open forum. But there was this huge thirst from the audience to hear about these stories that no one had talked about before.

And I remember in one of them, you were talking about approaching your manager about the fact that you were about to have children, and there was a huge gasp in the audience where a lot of them were saying, "I would never do that". So I do think you also break down a lot of barriers and it gives a lot of women are empowerment to know that there are things that they've thought about but no one's actually talked about in public, really.

Althea Papinczak: Yeah, it's a really tough one, and we try and never shy away from those sorts of topics, but we do make sure that we do them in a really practical and positive way.

We've never been at the networking group where we're there to whinge and complain about the things that we're struggling with. It's more of a conversation where it's a really open and candid conversation and you can share the struggles and you can share the challenges.

But we always want to know what we can do together or what we can do as individuals to kind of overcome those sorts of things. And the one that you're talking about, I think this baby-proofing your career, and that all came from a personal struggle of mine.

I had a really great relationship with my general manager at the time, and I said to him, "look, I'm going to start a family and I expect that I'm going to be pregnant really quickly, so FYI should probably start putting that on your radar for next year when I'm knocked up and I'm outta here".

But then for me, I had a really, really tough battle with IVF for two years, two really hard for years of IVF to actually get pregnant, and I'd shared that really candidly and really openly with everyone in my workplace. And he supported me the whole way and they supported me the whole way. And I've even shared that with probably thousands of people in the WIDAC Community.

There would be events where I'd be standing up there just so broken, crying to the audience going, yesterday was another failed IVF round for me, but being able to kind of share for me has always been very cathartic, and I understand that it's not for everyone, but we try and really build that into our events where if you are brave enough and you do want to share, this is the place to do it, this is the safe space to do it.

Because there's topics that we've covered before, like it's not only around having children, but going in for a promotion or a pay rise, like that's such a daunting conversation for a lot of people and they really struggle with it. And so we've done quite a few events on it, how to ask for what you're worth, and it's getting them prepped on the practical tips.

Being like, well, if that you're going to get really nervous in there and you're going to shy away from that money conversation, write it down on paper, have it ready to go in there with you. Have your bullet points, have the reasons why you're deserving so that you are not going to get flustered. You're not going to choke up, you're going to be able to talk about what you want and what you need and advocate for yourself and know that you're prepared for that conversation.

And I think people really appreciate the genuine nature of the conversations that we have because like you said, they're sometimes not workplace appropriate for some people. They don't like to talk about that sort of stuff at work.

So this is hopefully a space where we can do that outside of work, fit in the right forum with the right people.

David Cummins: I think to actually hear someone talk about in public where you can actually relate to someone as opposed to behind closed corridors. I think it, I think the more you normalise it, because it is a difficult journey for a lot of people, so why not do it and, and even to speak to your manager saying, "this is what I'm going to do",

I think a manager should respect that because he is future-proofing your career and your position and he's de-risking his work. So there's a lot of benefits to it, just not the norm. And I do think you guys are doing that. We are creating these norms, which is fantastic as well for your community.

Althea Papinczak: Yeah, thanks. And that was my thought process. I thought if I told him and I didn't like the way that that conversation went, I wouldn't want to get pregnant in a workplace where I knew that it was going to be a rough ride or it wasn't going to be supported. And I've always been probably a little bit too hard on sleeve and a bit too open and honest.

That's just who I am. I'm a very open book, but I think for me, honesty has always been the best policy and has always worked for me. So we try and really make sure that that's the same sort of messaging in our events.

David Cummins: Yeah

Althea Papinczak: To share your struggles and to open up, because vulnerability I think is a really underestimated strength to be able to be vulnerable and connect with people in that way, you'll find that people will just rush to you and offer their help and their support, and it's actually a lot easier when you feel like you have that support network and that team around you, no matter if it's IVF or if it's talking about the promotion that you're going for or bouncing it off some different people in the industry, whatever it is, it's always better if you've got that kind of input from others.

David Cummins: Yeah. Speaking about the construction industry, I know you have reported many times to a lot of people that you haven't had too many troubles in the construction industry based on your gender. I've been in the construction industry for 14 years, and personally I have as well, but also I have seen it as well with women in the construction industry.

Do you think maybe that vulnerability you bring and that honesty that you bring is one of the reasons why you probably haven't had as much challenges, or do you think there's other reasons.

Why would you say you're in the minority then?

Althea Papinczak: I was having a really interesting conversation about this with someone the other day I was talking to a friend of mine who's a project manager and she was sexually assaulted by someone that she was working with and she started that whole kind of blame game against herself going, I thought that I'd stand up for myself, I thought that I'd be different, I thought that I would be able to go to the police and tell them, and I said to her, "you never know what's going to happen to you in those moments where someone is making you feel really vulnerable in attacking you".

Whether it's emotional abuse or whether it was, in her instance, it was a physical attack that she went through. I think for me, the reason that I'm maybe in the minority of women who have struggled in some way in the construction industry with either bias or maybe being held back or not getting the opportunities or maybe being spoken to inappropriately, is that I've maybe got a very strong persona that people read and go, "she wouldn't tolerate it".

And I haven't.

I had a boss in a previous job say to me, "Althea, that tops really distracting, I can't have a conversation with you. You need to go away and put a jacket on". And I said, "don't you dare speak to me like that, I have no problem dragging in a HR right now and see if they think my top is inappropriate".

And so that kind of stopped that conversation there. And then I never had that kind of inference from him again, that he would be inappropriate and speak to me in that way.

But I think a lot of people in that same position, if they had someone speak to them like that, who didn't have the confidence maybe would react very differently and probably in some ways feel embarrassed and ashamed and responsible for what had gone on.

And so that's how it happens. It's really hard. I don't think there are a lot of people with that same kind of attitude and outward confidence that I have to call out, things like that. And maybe a lot more junior staff would think that that would put them in a worse position, calling out something like that.

And so I do understand it's a really tricky one, but I think maybe, the only way to tackle those sorts of things is really reaching out to the people around you and having a conversation about it.

If something's happened to you and you don't feel like you have the voice, at least share it with a few people so that they can give you the support that you need and they can have the conversation with you and maybe they can give you some ideas on how to deal with it if you are not able to.

I hope that kind of answers the question. It's a really tricky one.