Opinion

Designing virtual and physical clinical spaces to build trust

The clinical spaces that surround us are not passive; they can enhance or hinder our effectiveness as health-care providers. Research has shown the built environment can affect a number of outcomes for patients ranging from stroke recovery to infection control, as well as improve workplace safety and satisfaction for providers.

But can clinical spaces impact the trust we build with our patients? Trust is at the heart of person-centered care and the relationship we build with patients, which in turn can significantly influence patient health and mitigate physician burnout. Trust is both a result of effective care as well as an enabler of that care. Essential to trust are the expectations of privacy and confidentiality.

Designing safe and inviting public spaces contributes to building the social trust that exists between individuals and groups within communities. Though the links between architecture and patient trust in health care have not been well elaborated, the literature suggests accessible and welcoming environments where patients and health-care providers meet are likely to promote well-being. For example, in hospitals, attention to design elements like proper wayfinding, access to social areas for families, and respite areas for private reflection or grieving aim to improve patient experience. In so doing, the implicit message is that the hospital is a place designed to care. However, architectural features can also create barriers that inhibit building trust; for instance, when spaces are not accessible to those who need them or are not welcoming to vulnerable or marginalized people. These barriers may impact how patients regard the health-care system as a whole, and how willing they are to seek care. Architects, builders and designers grapple with creating physical spaces that are inclusive, therapeutic and functional.

Little is known about how to design these spaces to build trust and foster relationships.

Now, we need to consider these same principles when designing the virtual spaces in which we increasingly are providing health care. Yet little is known about how to design these spaces to build trust and foster relationships.

How do we re-create the ingredients necessary for positive physician-patient relationships in a virtual space? How do we ensure privacy and confidentiality are maintained, on both the physician and patient end of a virtual visit?

Christopher Allen, a social software blogger, has written about “progressive trust” and “progressive disclosure” as they relate to building online platforms for financial systems. He discusses ways in which trust needs to be built to complete online transactions efficiently and securely when parties do not know and cannot see each other. Trust is achieved by a series of authentication steps, allowing for increasingly sensitive information to be shared over a short period of time. There are parallels with these concepts in health care. While routine problems may require a baseline level of trust (e.g., trusting that the physician has the requisite expertise), more complex or sensitive problems may require a higher “trust bar.” Feeling recognized is an important ingredient to building trust but this may be more difficult to achieve when the patient (and provider) are disembodied voices or lines of text.

And how do we ensure that virtual spaces themselves can be trusted to ensure confidentiality when patients disclose highly sensitive information? Traditionally, these types of visits have occurred face to face in a private office, with the benefit of a discrete entrance and a clear view of who is in the space. Virtual care presents new challenges that have yet to be fully resolved, including adopting uniform vendor and platform security standards. Emerging “digital trust technologies” such as digital identity and the paradoxically named zero trust architecture may be useful tools to adopt for online visits. However, most virtual visits currently are conducted over the phone, blinding both provider and patient to the other’s physical environment, including who else may be privy to the information exchanged.

The convenience of virtual visits is part of their appeal, but the fact that they require little to no preparation or transition from whatever the patient (or provider) was doing seconds earlier may be problematic. (Many of us have had the experience of conducting a virtual visit while the patient is in line at the grocery store or driving in a car with others.) The physical space that the patient and provider inhabit during a virtual visit may alter the encounter and the ability to trust that the information shared will be confidential. 

Given the immediacy with which one can transition from other activities to a medical visit, do we need to consider designing a virtual patient-care intimacy gradient, a term first coined by architect Christopher Alexander? The notion of an intimacy gradient suggests that entry into certain spaces is only granted to those most trusted. While a waiting room may accommodate all patients and accompanying caregivers in a common, semi-public area, patients may then choose to enter exam rooms alone, or with a trusted care partner.

As the pandemic subsides, the appetite for virtual care clearly will not diminish.

So, what might this look like in a virtual environment? Would a landing space where the patient is greeted and  screened serve that purpose? A direct translation of what we do in physical spaces is not possible and may not be desirable. Even as the pandemic subsides, the appetite for virtual care clearly will not diminish. We have the opportunity and imperative to go beyond simply functioning to optimizing virtual spaces to deliver care and build trusting relationships. However, we do not yet know what will be optimal. This will require careful exploration into the benefits, limitations and unintended consequences of shifting many health-care interactions to virtual spaces. Alongside traditional physical spaces, we should consider the full range of technologies we will use, from the telephone to the metaverse, as forms of workspaces. In re-designing health-care workspaces, the questions we ask will drive the outcomes we will get.

Let’s ask ourselves and those we provide care for: What is worth preserving? What can be improved upon? What needs to be re-imagined? Approaches such as participatory design and co-design can help inform this work. Collaboration between health-care professionals, patients, architects, information technology planners and others will be crucial.

If we want to build both physical and virtual spaces that foster therapeutic relationships centered on trust, we must design them with that in mind. If we do not, we risk forfeiting the benefits for patients and providers alike.

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Authors

Milena Forte

Contributor

Milena Forte is a family physician at Mount Sinai Hospital. She is an associate professor and the postgraduate lead for the Office of Education Scholarship in the University of Toronto Department of Family and Community Medicine.

Milena.Forte@sinaihealth.ca
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