Designing a New Type of Hospital Gown: A User-centered Design Approach Case Study
Sandy Black and Karina Torlei
Fashion Practice, Volume 5, Issue 1, pp. 153–160
In a life-critical environment such as a hospital, the total environment impacts both the patient experience and the efficacy of healthcare professionals’ work. This article examines a UK case study of the redesign of hospital clothing from a user-centered design perspective.
KEYWORDS: user-centered design, hospital gown, intensive care, patient experience
In 2010, the UK government Department of Health commissioned a program to investigate and improve the patient experience in British hospitals through design-led innovation. The Design Council acted as the lead organization, bringing together researchers, designers, clinicians, and industry to work on a number of project briefs that were defined through a collaborative process of consultation. One challenge to be met was how could design help improve patient dignity?1
User-centered Approach and Problem Finding
Karina Torlei was involved in the patient dignity project from an early stage, before design briefs were defined as part of a team of consultant ethnographers, and spent two weeks exploring, observing, and interviewing staff and patients at Wolverhampton hospital. With special access to wards, staff, and clinicians, this preliminary scoping exercise was used for defining problems, gaining insights, and understanding context and needs. This information was later organized and used to define seven design briefs that were given to teams comprising both industry and academia.
As a researcher at the Helen Hamlyn Centre for Design at the Royal College of Art, one of the commissioned research partners, Torlei took the lead at this next stage of the program on a brief loosely defined as “patient wear.” This design brief was rooted in the problem that the hospital gowns most often used on wards result in “one-size-fits-none” rather than the intended “one-size-fits-all” and patients frequently ?nd their dignity compromised as parts of their body that they would rather not be seen are unwittingly exposed. The gowns most frequently used in National Health Service (NHS) hospitals were in fact originally introduced as specialist “theatre gowns,” with an opening down the entire back to make it easy to put on and take off an unconscious patient. Their widespread adoption as a universal gown is a result of constant pressure to reduce costs and after further investigation it became clear why.
Through the initial research it was found that the patient and the nurse were not the only users/stakeholders of the gown. There is a whole system in place to manage the supply of clean hospital gowns to the wards and Torlei decided to follow this system step-by-step.
Gowns are usually taken off-site to be laundered. Most hospitals have made huge savings by outsourcing the management of gowns and laundry items to big companies such as Sunlight and Synergy Health. These companies own the gowns and provide a complete service including transport, restocking shelves, removing soiled items, off-site laundering, and so on. The fewer types of garments this system has to deal with, the cheaper it is to run. Over the years focus has been on saving money at the cost of patient dignity.
As a result of mapping this system (see Figure 1) Torlei made several important discoveries. One of the problems highlighted by one of the laundry companies was that large quantities of gowns go missing and the average gown only lasted seven or eight use-cycles, rather than the forty planned for.
Once the main requirements for the gown were clear, Torlei teamed up with a fashion designer, Matthew Miller, who helped prototype ideas using his pattern-cutting experience. Over two months fifteen toiles were made, initially focusing on concepts of how to design a new type of universal gown, an inclusive design that would work for everyone and in all types of hospital wards. As the ideas evolved they were taken back to nurses for feedback, five feedback sessions in total, learning more and gaining more insights from each meeting. For Miller this process of working with the end user was unfamiliar, but something he found incredibly valuable. It gave context to the discussions and helped both Miller and Torlei see the limits they were working towards.
Figure 1: Mapping of the hospital gown life cycle through stages of hospital usage and return, showing key points where losses occur. Courtesy of Karina Torlei.
One of the nurses they spoke to was a matron on an intensive care ward. Meetings with her were especially useful as her requirements seemed especially challenging. She would give frank opinions of what aspects of a design would work or would need changing. In fact she seemed to think that most of Torlei and Miller’s designs would not work as she painted a vivid picture of life (and death) on her wards.
She admitted that gowns often get cut open, either to gain fast access to a patient’s chest during a cardiac arrest or to accommodate lines and equipment. Gowns also often get soiled with blood and in all cases the damaged gowns are discarded. Torlei says of this important meeting, “It seemed I had found one of the main reasons for gowns going missing from the laundry cycle.”
Walking around the intensive care ward the designers witnessed some of the problems firsthand. The traditional cotton gowns were draped over the patients to varying degrees of success. These patients are frequently connected to a lot of monitoring equipment as well as drips, drains, and intravenous fluids. Most of these lines require a constant connection for reasons of either infection control or medical necessity, which makes it difficult to dress patients in a dignified way. Most often the “free” arm would be fed through a sleeve to help the gown stay in place, but the result would still leave a lot of flesh on display (Figure 2).
Figure 2: Typical scenario for an intensive care Critical Care Level 3 patient. Courtesy of Karina Torlei.
Most of the patients in this ward were described as “Critical Care Level 3,” meaning they are unconscious or in a drug-induced coma, immobile, and difficult for nursing staff to move around. Furthermore, their lack of mobility means they need to lie on a smooth surface to prevent bedsores developing. The designer/researchers were also told that nursing staff require quick access to inspect lines without having to undress or uncover large parts of the patient and spend time pulling the curtains around the bed. In addition, male and female patients will often receive care in adjacent beds and this makes the need to maintain both dignity and privacy even more immediate.
The idea for a new design brief came to Torlei whilst talking to the matron. She asked, “What if you could cut and modify the gown to meet the requirements of each patient and then just throw it away? – Wouldn’t that work better for you?” The matron immediately agreed and said she had not been able to find any product like that on the market that would be suitable for her patients. They discussed how a disposable item could work alongside the existing laundry system, as it could not be part of the same logistical system. A disposable gown even had the potential to reduce the overall cost.
Armed with a fresh direction and plenty of inspiration, Miller and Torlei took to the fashion studio with the aim of designing a gown that would transform from a flat sheet into something providing adequate cover when put on the patient. We acknowledged that for this special group of patients, the gown did not need a back as the best prevention for bedsores is lying directly on a smooth surface (such as the bed sheet). Using a combination of existing pattern blocks – originally for men’s shirts – a way of laying the pieces out was found that created the desired end result.
Figure 3: Final design of the Intensive Care Cover one-piece gown with tabs and surface pattern. Courtesy of Karina Torlei.
To combat the highly “medicalized” environments that can have both a dehumanizing and stressful effect on patients and visitors, Torlei and Miller wanted the gown to have a casual and friendly look. The solution they developed was the Intensive Care Cover – later named the Origown®.
The single two-dimensional shape is cut out from a non-woven, disposable fabric, made of synthetic fibers (alternate layers of spun-bonded and melt-bonded material) that also aid infection control. It is put on the patient by draping it over the person’s front and then secured in place, creating each sleeve by wrapping around the arms and neck and using peel-off adhesive tabs to secure around each arm. This design makes it easy to accommodate drips, drains, and monitoring equipment. The fabric can also be cut and modified as needed in each individual case. Perforated lines make it easy for staff to remove parts of the garment that are not needed, or to tear it open in an emergency. When fully in place, the Origown covers the shoulders and chest and gives the appearance of the patient being fully clothed.
Figures 4a/4b: Prototype gown. Courtesy of Karina Torlei.
One of the early prototype versions of the cover featured a printed surface (see Figures 3 and 4). The idea was to use printed text to communicate functional features such as the final shape and the sleeves. Printed surface patterning was also used to remove the clinical aesthetic and make the design more visually appealing. However, as the gown design was refined for manufacture, it became clear that this feature would become too costly, at least in the short run.
At present the gown has been through several service evaluations with NHS hospitals with mixed reviews.
Figure 5: Instructions for using the Origown Intensive Care Cover. Courtesy of Karina Torlei.
Initial feedback on functionality has been excellent, whereas feedback on the fabric has been less positive. There are variations of non-woven disposable fabrics used for many different applications in hospitals, ranging from surgical drapes, disposable gowns worn by surgeons and nurses, covers for mattresses, curtains, and much more. These fabrics are mostly made from man-made materials such as polypropylene and polyethylene that can be recycled. Other composite textiles combine natural and man-made fibers giving better properties, but adding cost and removing the option to recycle.
Together with a potential manufacturer, Torlei is currently investigating options to source a more optimal fabric and scale-up production to do more extensive trials, with a view to eventual commercial manufacture.
Hospital gowns currently used by the NHS are simple cotton gowns provided in one single size, designed to be washed and reused. They are assembled from four separate pieces comprising a main body and sleeves. They also feature fabric ties to secure the garment at neck and hip level. However, while the new design for an inclusive gown met most needs, as the original brief developed, it became clear that the concept of a “universal gown” was not feasible to meet all hospital needs and the intensive care requirements necessitated a different solution. The Origown® therefore features a single piece of fabric that is cut in such a way that it transforms from flat into a three-dimensional garment through the process of dressing the patient. It provides dignified cover to a patient’s body (keeping in mind he or she will be bedbound) by covering the arms, front, sides, and shoulders. The design is single use, it is secured by using adhesive stickers, and may be cut into and adapted to the fit and circumstances of each patient.
The Design for Patient Dignity projects demonstrate how designers, working closely with patients and healthcare experts in a user-centered design methodology, can bring new thinking to real and important challenges and design creative new solutions.