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.