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UNIVERSAL DESIGN IN HEALTHCARE SERVICESCAPES:

UNCOVERING MULTISENSORY CUSTOMER EXPERIENCES

AMONG VISUALLY IMPAIRED PATIENTS TO ENHANCE SERVICE

CONVENIENCE AND CUSTOMER INTIMACY.

Carmen Martens

Cécile Delcourt

Jasmien Herssens

University of Hasselt (Architecture ) & HEC Liège (Management)

Abstract: Healthcare services are subject to huge challenges such as improving user experience

while being (economically) sustainable. However, little attention has been dedicated on how to

create adequate healthcare servicescapes through an optimal architectural design to enhance

service convenience and customer intimacy. Hospitals often lack awareness for architectural

experiences and can even create disabling situations: this is especially true for visually impaired

patients as servicescapes heavily rely on visual components while those may not be

(sufficiently) perceptible to visually impaired patients. After an extended customer journey

throughout four hospitals, in-depth interviews with visually impaired patients are conducted to

uncover obstacles met by the patients and to identify multisensory qualities that patients would

value to enhance the service convenience and customer intimacy. This multidisciplinary

research will provide both managers and architects of healthcare facilities with insights on how

to best define architectural design methods to improve both service convenience and customer

intimacy.

Keywords: Multisensory experiences; Service convenience; Customer intimacy; Healthcare

servicescapes; Universal Design

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UNIVERSAL DESIGN IN HEALTHCARE SERVICESCAPES:

UNCOVERING MULTISENSORY CUSTOMER EXPERIENCES

AMONG VISUALLY IMPAIRED PATIENTS TO ENHANCE SERVICE

CONVENIENCE AND CUSTOMER INTIMACY.

Introduction

Although several studies indicate that healthcare services have a pervasive impact on users’

well-being, life, and economies (Anderson et al., 2013; Berry and Bendapudi, 2007), tangible

architectural environments that facilitate these services (Bitner 1990, 1992) often lack

multisensory customer experiences, service convenience and customer intimacy. Moreover,

sometimes these environments paradoxically contribute to the creation of disabling situations

in terms of physical, cognitive, cultural or social inclusion (e.g., unwelcoming environments,

disorientating corridors, bad acoustics, bad access for disabled people, bad smell, unpractical

sanitary environments, …) (Herssens, 2017a, b).

In the context of intimacy, paradoxically privacy policies (HIPAA, 2002; FOD 2002) protect

patients’ privacy and staff is not allowed to speak with/about patients in elevators (FOD, 2002;

Khullar, 2017). However, when entering a room with more than one patient, acoustics does not

always guarantee privacy or intimacy. Moreover, lack of acoustics makes many patients suffer

from insomnia (Ulrich et al., 2008; Khullar, 2017). Studies even prove that both staff and

patients withhold parts of the story or refuse extra exams in a double room (Mlinek & Pierce,

1997; Barlas et al., 2001).

To quote Dr. Khullar: “Hospitals are among the most expensive facilities to build, with complex

infrastructures, technologies, regulations and safety codes. But evidence suggests we’ve been

building them all wrong — and that the deficiencies aren’t simply unaesthetic or inconvenient.

All those design flaws may be killing us.” (Khullar, 2017). But what is missing? Herssens (2016,

2017b) states that insights in design methods that link customer experiences with design

principles is lacking. This is most visible in extreme contexts like hospitals in which “the

utilitarian building types have generally led to the main attempts at system building” (Lawson,

2006, p.102). Most hospitals are designed by means of using a rational problem-solving focus

on typologies, they meet technical needs for medical operations, but still lack a holistic

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multisensory and care-oriented approach. It is this focus on rational use, modularity and

standardization that has led to the lack of customer experiences. Places that lack physical,

mental or socio-cultural inclusion are considered as ‘architecturally disabled’ (Goldsmith,

1997) or ‘distorted spaces’ (Brosnan, 2003). It is important to leave the full creativity to the

well-informed designer. However, to some extent it might be interesting to have more insight

in bridging the gap between customer experiences and the necessary design principles.

Theoretical framework

Transformative Service Research (TSR)

As a research paradigm, Transformative Service Research (TSR) aims to create uplifting

improvements and changes in the well-being of individuals, families, social networks,

communities, cities, nations, collectives, and ecosystems (Anderson et al., 2011).

TSR in healthcare invites researchers to focus on reducing consumer vulnerability and

enhancing consumer agency because many consumers find themselves in a position of lesser

knowledge during a service encounter (Adkins and Corus 2009; Anderson et al. 2011).

Therefore, marginalized groups and disparities in the quality of services provided to various

groups are especially emphasized. Various studies show the discrepancies between healthcare

access, knowledge, experiences, and outcomes of privileged versus disadvantaged customers.

Also of interest are the contexts and service environments that promote physical health and

emotional and mental well-being (Jamner and Stokols 2001; Rosenbaum et al. 2007).

Steering toward highly inclusive and equitable healthcare services ask for a system which is

flexible and responsive to the needs of diverse users of healthcare services (Rendtorff, 2009).

Gallen and Black argue that patients play an important role in co-creating value in healthcare

services. Therefore, poor service quality within a healthcare system may derive not only from

service providers but also from patients, who may for example withhold important information.

Thus, Rosenbaum (2015) concludes, a service system and the patient must work together to co-

create value.

In sum, TSR is a call for service research that encourages improvement of personal and

collective well-being of not only individuals and citizens, but the entire global ecosystem. The

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paradigm stimulates researchers to create novel theories and to borrow theories from other

disciplines, to try to understand how service systems, providers, and other customers in service

settings can improve the consumer well-being. (Rosenbaum, 2015)

Universal Design (UD)

In the same vein, Universal Design calls for a shift in mentality and a different attitude among

designers (Herssens, 2011). ‘Universal Design’, firstly coined by Mace (1985) is an ability-

based design strategy that results into a design whereby users do not have to adapt but are

invited and supported in their actions and experiences in a positive and elegant way (Herssens,

2011, 2014, 2017). The strategy considers an inadequate environment as creating impairments

for its users which can cause disabling situations. As a result, a disability is now seen as related

to the environment (and not to the user), as a phenomenon that manifests itself in social,

physical and virtual environments.

Traditional design adds accessibility to inaccessible buildings/products. The underlying

principle of accessible design is the fact that there are two contrasting populations: the ‘normal

people’ and the ‘people with disabilities’, which results in isolation and stigmatization. In

contrast, UD considers only one population, formed by individuals with different characteristics

and abilities.

Although the domain of UD has clearly defined the theoretical eight user goals (i.e. Body fit,

Comfort, Awareness, Understanding, Wellness, Social integration, Personalization and Cultural

appropriateness (Steinfeld and Maisel 2012: 90)) and seven design principles (i.e. Equitable

use, Flexibility in use, Simple and Intuitive use, Perceptible Information, Tolerance for Error,

Low Physical Effort and Size, and Space for Approach and Use (Folette Story 2001:10.5)), the

domain lacks design methods to link these user goals with the design principles (Herssens,

2017a,b).

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Conceptual framework

Figure 1: conceptual framework

Healthcare Servicescapes

Health is a vital personal and social resource, as well as an economic one, and therefore a

valuable ambition for every society. Studies show that the physical environment can be

therapeutic if it removes environmental stressors, joins patients to nature, offers possibilities to

enhance feelings of being in control, and provides opportunities for social support and

relaxation (Malkin 2003).

The impact of natural environments is already known since ancient times. Locations of the

Asclepieia (i.e. the healing centers of ancient Greece) were carefully selected, using thermal

springs, designed on spectacular views, and creating buildings for leisure activities, closely

located to the medical buildings (Christopoulou-Aletra et al. 2010). Alvar Aalto and Richard

Neutra, leading architects from the modern period, also stress the advantages of well-planned

architecture, and the influence of nature for healing in their architecture (Sternberg 2009).

Contemporary science points out to the strong relationship between emotions and health and

has found evidences that confirm those connections, providing scientific explanations through

transdisciplinary researches. The built environment is strongly linked to the emotional health,

and at the same time, it is a widely accepted opinion that emotions directly affect the overall

health (Sternberg 2001). The relationship between human and environment is also discussed in

the management literature, where Bitner (1992) coined the term 'servicescape' referencing to

the built environment, which affects both consumers and employees in service organizations.

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This study focuses on health care environments as they represent a challenging service context.

Hospitals are places where comfort, care and intimacy are top priorities. Those are meeting

places for a diversity of users, in terms of actual use (e.g., patients, staff, visitors, …), socio-

demographic profiles (e.g. class, gender, ethnicity, ...), patient abilities (e.g., vulnerable,

disabled, top-athletes, …) and emotions (e.g., happiness, death, hope, fear, …).

Multisensory Experiences

Kotler (1973) introduced the term "atmospherics", indicating how the physical elements of an

environment affect a buyer's "purchasing propensity." Other research also denoted the

relationship between atmospherics and customer satisfaction, patronage, and advertising via

word-of-mouth (Bitner, 1990, 1992; Grossbart, et al., 1990; McElroy, et al., 1990). From a

customer's perspective, atmospherics involves not only the design of the physical environment,

but at the same time, incorporate the cognitive, emotional, and physiological influences on

customers (Hutton & Richardson, 1995).

Atmosphere is apprehended through the senses. Kotler states that the main sensory channels for

atmosphere are sight, sound, scent, and touch (Kotler, 1973). Although he considers taste as

unimportant in relation to atmospherics, the impact of the fifth sense is highlighted by the

instinctive reaction it can evoke in customers. Taste aversion is one of the only examples of

what psychologists name one trial learning. One single negative experience to something eaten

leads to consistent long-term avoidance (Garcia, et al., 1955). On the other hand, one can also

recall highly positive experiences of food consumption perhaps even more intense than a single

auditory, visual, olfactory, or tactile experience. Thus, taste can evoke both very positive but

also negative experiences in customers and cannot be ignored in this research.

As the focus on customer experience has advanced, a better comprehension of the importance

but also the complexity of this experience has become clear. Sensory marketing approaches to

enhance the customer experience has occurred (Hulten, 2011; Hulten et al., 2009; Krishna,

2013; Spence, 2002), and settings are increasingly being designed to appeal on both rational

and emotional levels, as well as across multiple senses (Spinney, 2013). This approach has been

further strengthened by findings arising from the field of cognitive neuroscience (Yoon et al.,

2012). However, most of the research on atmospherics focuses on a single sense in relation to

the environment while environments, and our perception of them are by nature, multisensory.

Herssens (2011) stresses that multisensory experiences are an indispensable key in the design

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of multisensory human-centred servicescapes, as customers perceive servicescapes holistically

(Bitner, 1990; Mattila & Wirtz, 2001). If an environment offers a range of sensory triggers,

people with different sensory capacities are able to navigate and enjoy that environment. Still,

most architects overlook haptic, olfactory, gustatory and auditory senses. As all sensory

sensations contribute to human behaviour, it is important not to limit the architectural

experience to that which is visual but to expand the knowledge and study every type of sensory

experience (Herssens, 2011).

Service Convenience

Service convenience, conceptualized by Berry et al. (2002) concerns users’ time and effort

perceptions related to buying a product or using a service. Healthcare environments create

customer value largely through services, and as service convenience is an essential

consideration for most customers (Berry et al., 2002), it becomes a critical concept in this

research. In many service exchanges, especially those requiring customers’ participation such

as healthcare services, physical, emotional, and cognitive effort are likely to be relevant (Berry

et al., 2002). The greater the effort users spent, the stronger their commitment to the service

outcome and the higher is his or her potential frustration (Hui et al., 1998). Inconveniences and

disabling situations can impede a favorable customer experience while key in the creation of

customers’ perceptions (e.g., service quality), customers’ attitudes (satisfaction) and customers’

behaviors (e.g., positive word-of-mouth) (Delcourt et al. 2016, 2017).

Users of healthcare services often pursue enduring relationships. They value communication,

the ability to build a relationship of trust, understanding, and empathy with the patient

(Blumenthal, 1996) and expect humanism, sensitivity and responsiveness (Carmel & Glick,

1996). Therefore, they allot time and effort in finding services in which they can be confident,

as healthcare services can be consequential, involving, complex, and recurring (Berry et al.,

2002). Other factors like the service facility location, parking availability, customers’

experience or familiarity with the environment (Brucks 1985; Rao & Monroe 1988; Sujan 1985)

affect the service convenience

In sum, users’ convenience perceptions will have a positive influence on their service

satisfaction, assessments of service quality, and perceptions of fairness (i.e. the balance of input

and output among exchange partners (Berry et al., 2002). We believe that healthcare

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servicescapes plays a vital role in service convenience as it is the physical environment that

represents and encompasses the provided healthcare service.

Customer Intimacy

The term intimacy has its roots in the Latin words “intimatus” (i.e. closely acquainted, very

familiar) and “intimus” (i.e. “inmost” or close friend). Since the 1970s the interpersonal

relations literature has conceptualized, and measured intimacy from a non-economic

perspective (e.g. Orlofsky et al., 1973; Repinski & Zook, 2005; Sternberg, 1997). Intimacy in

this literature stream is understand as closeness in personal relationships (e.g. Repinski & Zook,

2005; Sternberg, 1997). The focus on relational rather than transactional economic exchanges

in marketing arose in the 1980s (Berry, 1983). Although different research refers to customer

intimacy as an important concept to create and maintain fruitful customer relationships (e.g.,

Aaker et al., 2004; Johnson et al., 2006; Rust et al., 2000, p. 60; Yim et al., 2008) the concept

customer intimacy stayed quite unspecified.

Customer intimacy is categorized by Treacy & Wiersema (1993) as one of three value

disciplines on which leadership companies should focus to deliver superior customer value.

Kai-Uwe Brock & Yu Zhou (2012) came up with a working definition of customer intimacy

and express the concept as a customer’s perception of having a very close and valuable

relationship with a supplier, characterized by high levels of mutual understanding. They show

that customer intimacy is reflected by the three formative dimensions of mutual understanding,

closeness, and value perception.

As users of healthcare services often pursue enduring relationships, they value communication,

the ability to build a relationship of trust, understanding and empathy with the patient

(Blumenthal, 1996). We believe this concept of intimacy may indeed be achieved by the

relationship between customer and in this context, the medical staff. But we also believe that

the servicescape may influence customer intimacy, especially in healthcare facilities, where

privacy and intimacy are top priorities and customers may stay for a longer time (e.g. data

provided by Eurostat (2017) show that in 2015, the average length of a hospital stay for in-

patients ranged from 5.3 days in Bulgaria to 10.5 days in Finland. The average length of a

hospital stay for in-patients in Belgium was 6.5 days).

Patients, a good example of passive users, are less empowered and have low knowledge about

healthcare services. Therefore, they are often expected to cooperate and deliberately disclose

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very personal information/intimate parts of their body as it is about their own health (Berry &

Bendapudi, 2007). These patients may feel highly vulnerable (Anderson et al., 2013) and when

they perceive the environment as inadequate, they may feel uncomfortable and, accordingly,

may not self-disclose personal information while this information might be key in the healing

process. In the same vein, the high pressure and stress experienced by the staff can be reinforced

by poorly designed servicescapes. Research has shown that healthcare servicescapes possess

motivational potential for the achievement of goals through increased work engagement and

improved performance (Khasmisa, et al., 2016). Also, staff may need to reveal very personal

and negative information to patients, which is a delicate task that must be carried out in a

suitable intimate environment.

Accordingly, creating adequate environments, where staff can successfully perform their jobs,

and patients can receive and reflect on obtained information, may result in healthcare

servicescapes that foster intimacy for the well-being of all users.

Exploratory Research Design

Considering the exploratory nature of the study, we will start this qualitative research with a

(visual) ethnographic customer journey throughout four selected university hospitals in

Belgium (two located in Wallonia and two in Flanders). For analyzing the customer journey,

we should understand and map the journey from the patients’ perspective and, therefore, it

requires their input into the process. Together with the patients, multiple touch points are

evaluated that have a direct and more indirect effect on their customer experience. The whole

journey will be video recorded, using a Go Pro on the patients’ body to clearly observe and

identify the critical “moments of truth” throughout the customer journey that have significant

influence on key customer outcomes. Service blueprinting will provide a solid starting point for

this customer journey mapping (Lemon & Verhoef, 2016).

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Figure 2: service blueprint: considering all touchpoints met in the customer journey

Afterwards in-depth interviews are conducted to review the service convenience, to deeply

understand the obstacles met in the customer journey, and to identify olfactory, auditory, haptic

and gustatory experiences that these patients consider as facilitators of the customer experience.

Interview Guide

The interview guide provided open questions and consisted out of four parts. In the first part

the critical incident technique (CIT) (Flanagan 1954) will be used to collect detailed

descriptions of both the most convenient and inconvenient place the patients were confronted

with in the customer journey. The next part further explored the other touch points focusing on

the service convenience, multisensory experiences and important physical elements in the

health care servicecape. The third part mainly focused on customer intimacy. Participants were

asked to describe the concept of intimacy in a general way, and to define and grade the

importance of the concept in a healthcare setting, using word associations. The interview ended

again with the critical incident technique (CIT) to collect detailed descriptions of both the most

convenient and inconvenient place the patients were confronted with in any public environment.

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Sample and Data Collection

This research considers patients with visual impairments as experts for insights in multisensory

experiences (Herssens, 2011, 2017a). They are the ideal user-experts to create servicescapes

that are convenient to the greatest number of potential users. Although the experience of

visually impaired people has been under investigated, they have strong needs in terms of

servicescape design because they cannot rely on visual information whereas a servicescape is

often primarily visual (Warren, 1978; Herssens, 2011; Heylighen and Herssens, 2014).

Furthermore, previous research suggests that sensory-disabled populations – persons with

hearing and/or sight limitations – feel that mainstream service experiences could do more to

create value for this minority segment (Kaufman-Scarborough and Baker, 2005). Improving the

environment, focusing on other sensory experiences, will also enhance the overall customer

experience of all other users.

Two researchers will conduct the customer journeys and interviews in four selected university

hospitals in Belgium. Several patients are recruited among the network of acquaintances of the

researchers and they will serve to pretest the interview guide. In a later stage, doctors in

ophthalmology from the selected university hospitals in Belgium will be contacted and provided

with a call for participants. At least 30 visually-impaired patients from both the French and

Flemish speaking part of Belgium will be observed and in-depth interviewed.

The audio- and video-recorded data will be described, coded, and analyzed with NVivo.

Expected Research Findings and Contributions

This research aims at identifying inconveniences and disabling situations met by patients in the

customer journey throughout hospitals that strongly impact their customer experience.

We want to uncover and provide a definition for multisensory experiences and customer

intimacy in healthcare servicescapes. Working together with visually impaired people, will give

us more insight in multisensory experiences as both architecture and management are highly

focused on visuals. By focusing on those who have traditionally been overlooked, we believe

this research will help us to better understand the disadvantages these people encounter in

service contexts and offer recommendations to TSR researchers. In a later stage, we aim at

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bridging the gap between customer experiences and design principles by developing practical

UD design methods that can help architects to enhance multisensory and well-designed

servicescapes.

Research Limitations

Users of care environments are not restricted to patients alone: in addition of examining patient

needs in terms of design, the needs of other users like staff or visitors will need to be examined

as well. Mainly focusing on patients does not always lead to an ideal experience for all users as

Lawson states: “In a hospital, what is often convenient for the patients is inconvenient for the

staff” (Lawson, 2006, p.103).

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