Making children's hospital design more child-centred
Submitting InstitutionUniversity of Sheffield
Unit of AssessmentSocial Work and Social Policy
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Public Health and Health Services
Summary of the impact
In response to a new NHS policy initiative to create child-friendly
hospitals, an ESRC funded research project (Space to Care, 2004-7)
explored children's own perceptions and experiences of hospital space by
seeking out the views of children aged 4-16 who were hospital patients.
Through revealing the importance of age as a key differentiating factor in
children and young people's views about hospital space, the result of
adopting this child-centred approach was to demonstrate that the
government's concept of a `child-friendly hospital' was failing to address
the different needs of all children up to the age of 16. The findings from
the study were therefore used to develop a set of key design principles
and evaluation toolkits for healthcare professionals, architects and
healthcare planners to help make hospitals more child-centred. These have:
(1) informed the health-care design practices of architects, nationally
and internationally; and (2) assisted health-care professionals in the UK
and Australia to improve their existing facilities.
Improving the built environment in which healthcare is delivered through
innovative planning and design is a central tenet of contemporary NHS
service planning in England and Wales. The ESRC funded Space to Care
study (2004-7) explored the implications of this for children's hospitals
where the stated aim is to provide child-friendly hospitals that meet the
differing needs of children of all ages. [see (2004) Health Building
Note 23. Hospital accommodation for children and young people;
(2003) Improving the patient experience — Friendly healthcare
environments for children and young people]. However, in these
policy documents there was little evidence to substantiate what the
concept of `child- friendly' means in the hospital context and no focused
consultations had been carried out, by policymakers, to ascertain
children's and young people's own understandings or experiences of
hospital space. Adult preferences about hospital space had been
transplanted uncritically into the policy documents shaping hospital
environments for children. This study of children's perceptions of
hospital space was therefore the first of its kind.
Based at Sheffield University, the research team comprised Professor
Allison James from Sociological Studies and other colleagues — Professor
Penny Curtis and Dr Jo Birch - from the Centre for the Study of Childhood
and Youth, Sheffield University. Together they brought the theoretical and
methodological insights of childhood studies to address this substantive
The original research explored children's perceptions and experiences of
both inpatient and outpatient hospital facilities within three different
types of hospital: an established children's hospital, a newly built
specialist facility and a children's ward in a general hospital. Fieldwork
and interviews with 255 children aged between 4 and 16 were conducted
using a range of child-centred methods, including a specially developed
photo-elicitation and spatial mapping tool. Children of different ages
were asked to comment on the physical and social characteristics of the
spaces provided for them in hospital: the space around their beds,
treatment rooms, corridors, canteens, bathrooms and play rooms. These
research methods enabled children to voice their own views and
understandings of different hospital spaces and also revealed what it
feels like to be a child or young person within such an institutionalised
setting (R2, R3).
Across all the different settings, both children and young people said
that hospital environments seemed to be designed with only babies and
infants in mind. Even children as young as 7 experienced hospital spaces,
such as play rooms, as rather babyish in terms of their décor and
recreational facilities (R1). Age was shown therefore to be a key,
differentiating factor for children and young people, especially in
relation to social and quiet spaces, recreational facilities, the
personalisation of bed spaces and the need for privacy (R4). Children and
young people also commented on the quality and sense of hospital space:
they disliked places that appeared dull, dirty or messy, preferring
instead those which looked colourful, bright, clean, tidy and comfortable,
with age appropriate art on the walls (R1). Treatment areas were
appreciated where the clinical aspects were disguised. These consultations
with children and young people revealed, therefore, that the hospital
environment is important to them in ways that are not currently being
addressed in adult assumptions about what constitutes a child-friendly
The project's findings were reported in the ESRC end of the award report
and academic publications. They were also used to develop a series of
toolkits for architects, health-care planners and professionals to
evaluate the `child-friendliness' of existing hospital environments. A
dissemination conference was also held, in 2007, which was attended by 50+
healthcare architects, health-care professionals and policy makers.
The original research led directly to a knowledge transfer project,
carried out at the request of Leeds General Infirmary in 2011, which
explored the problems experienced by parents and children in negotiating
their way around the hospital and also underpins a new project currently
being undertaken on behalf of Sheffield Children's Hospital (2013-4) to
examine how design and spatial issues might influence children's, parents'
and nurses' views of family-centred care.
References to the research
The research was funded by the ESRC RES-000-23-0765, Space to
Care: Children's Perceptions of Spatial Aspects of Hospitals
R1. Birch, J. James, A. and Curtis, P. (2007) `In search of the
child-friendly hospital' Built Environment 33 (4): 405- 416. doi:
R2. James, A, Curtis, P, and Birch, J. (2008) Care and control in the
construction of children's citizenship. In J.Williams and A. Invernizzi
eds. Children and Citizenship. London: Sage.
R3. James, A. (2011) `To be (come) or not to be (come): understanding
children's citizenship' Annals of American Academy of Political and
Social Science, 633 (1.): 167-179. doi: 10.1177/0002716210383642
R4. James, A. and Curtis, P. (2012) Constructing the sick child: the
cultural politics of children's hospitals, The Sociological Review,60
(4):754-773, doi: 10.1111/j.1467-954X.2012.02132.x
End of Award report (http://tinyurl.com/ou7z52e).
Details of the impact
The impact of this research has been to inform adult understandings of
the needs that children of different ages have in relation to social and
physical space whilst they are in hospital. The research has (1) shaped
the health-care design practices of architects, nationally and
internationally; and (2) assisted health-care professionals in the UK and
Australia to make their existing facilities more child-friendly. Indeed,
writing in the professional journal, Paediatric Health, McKenzie et
al (2010) commend this research for `illuminating the actual experience
of children and adolescents of the physical environment of the hospital'
and for outlining a `methodology for involving young people in
designing hospital environments'. [S1]
Informing professional architectural practice with more
`child-friendly' design of children's hospitals
Following the 2007 dissemination event, Avanti architects (London) wrote
to underscore the significance of the research for informing their own
practice: I was really challenged about my 'knowledge' of what children
and young people want from hospital environments. I am sure your
research will be very helpful in keeping the 'fluffy bunny approach' at
bay and trying to design something more stimulating and appropriate.
BDP architects (Sheffield) also attended the dissemination event and
afterwards wrote to say that they found the research `very interesting
and relevant to [their] on-going work, particularly some of the slightly
more counter-intuitive findings about children's lack of anxiety about
hospital attendance and limited interest in way-finding issues'.
Following the posting of the dissemination materials on the website,
James and Curtis were invited by John Laing Construction to visit the
construction site of the Great North Children's Hospital being re-built at
Newcastle. They were asked to assess the extent to which the building
would be able to meet the child-friendly criteria identified by the
research and write a report. An email from Laing states that the report `was
well received by the Trust in Newcastle who will consider the points you
raise when developing their plans for commissioning the hospital'
In 2010, James and Curtis were contacted by Balfour Beatty who had been
short-listed as contractors for building the new Alderhey children's
hospital in Liverpool, that had an estimated build cost of circa £288m.
This time James and Curtis were asked to act as consultants to the bid
team, as the architectural plans were being developed and refined. This
included: running workshops for the bid team - artists and architects
through to structural engineers and accountants - about the concept of
child-friendliness; assessing the child-friendliness of their initial
architectural plans in relation to the placement of playrooms, parent
facilities and types of decor; and commenting on the draft bid narrative
to highlight its child-friendly focus. A senior manager for Balfour Beatty
"The input we received from Dr Penny Curtis and Professor Allison
James was instrumental in helping our team to appreciate the
fundamentals of designing child focused spaces within a hospital
environment. The workshops and design reviews led by Penny and Allison
challenged our thinking in designing for children. They particularly
helped us with the design of spaces for families, the importance of
personalisation and the creation of spaces that can be used by a broad
range of children and young people". [S2]
In 2013 James and Curtis were again approached by Balfour Beatty to
assist with their bid plans for the redesign of the Edinburgh Sick
Children hospital (estimated build cost £150m) by: (1) outlining key
design principles for a child-centred hospital; (2) reviewing and
critiquing designs with respect to layout, way-finding and decor; and (3)
conducting simulation exercises to test designs from a child- and
The global reach of the original research is made clear in Johnathan
Wilson's feature article in the trade publication Hospital Build, 4.
Principal and healthcare leader for Anshen + Allen (architectural partners
in the global design group Stantec who are specialists in healthcare
architecture), Wilson endorses wholeheartedly the project's
recommendations `to improve and enhance the experience of being a child
in hospital, social relationships and getting around the hospital',
describing the findings in relation to hospital waiting areas and the need
for separate adolescent spaces as being particularly `compelling'
Making existing hospital facilities more `child friendly'
In 2007 the evaluation toolkits and key design principles were put on the
Department of Health Knowledge and Information Portal website, thereby
making them available for use by health professionals and NHS estates.
Evidence of their adoption include their adaptation by the Royal
Hallamshire Hospital to create a `child-friendly audit system' to
inform the work of their Stereotactic Radiosurgery Department and make it
more child friendly [S4]. International impact followed this in 2010 when
James and Curtis were contacted by Queensland Children's Hospital who also
requested access to the project's materials and findings. Subsequently,
Curtis visited Australia in October 2011 to discuss these with senior
managers at Royal Brisbane Children's Hospital who implemented them by:
including distraction art in treatment spaces, making space for young
people to personalise their bedrooms and restricting "babyish" images to
babies wards [S5].
In 2011 James and Curtis were contacted by planners at the Leeds General
Infirmary for advice about the problems children and parents were
experiencing with way-finding. A KT project was developed in order to
identify the key problem areas and a set of recommendations for
improvement was made. These were taken forward by the Trust and included:
making signs consistent and easier to follow, using the more familiar term
"children's" rather than "paediatrics" on signs, installing interactive
way-finding kiosks, revising the maps available for families on the
Internet and putting up child friendly wall art on the corridors [S6].
Sheffield Children's Hospital (SCH) has also drawn extensively on the
project's findings and recommendations. According to a senior manager, the
hospital "fundamentally reviewed [its] accommodation", and no
longer sees it simply in relation "to demand, capacity and the needs of
clinicians". Instead, they now view it from the "perspective of
[their] families". According to him, the project's findings were "central
to the principles in [the] design specification for the new Children's
Hospital Wing and also informed the design and specifications
for the teenage psychiatry wards at Becton, completed in 2011" [S7].
Building on the research findings about young people's needs, this
facility now offers bedrooms that allow for personalisation and is
equipped with gyms, soft rooms, games areas and outdoor recreational games
areas. Other parts of the main hospital have also been changed in
line with the children's recommendations from the research: for example,
age appropriate art has been installed, way-finding has been simplified,
with plain English and icons now being used on signs. Designated
adolescent areas are now provided in the Outpatient, Day Care and In
Patient areas. These are off limits to young children, reflecting
children's views about the need for age appropriate space. The Ryegate
therapy and hydrotherapy pool have been rebuilt to provide a less
cluttered and brighter kind of space. This was also identified by the
research as a major concern for children and young people.
The significance of the hospital's change in approach was further
demonstrated in 2013 by their decision to fund a new piece of research by
James and Curtis. The findings from this will inform the design of a
contract for the delivery of family centred care in the new single
occupancy cubicle facility currently being built and due to be completed
in 2015. As a senior manager writes: "The Space to Care project has
fundamentally changed the priorities of the hospital and trust"
Sources to corroborate the impact
S1. Mckenzie, S.,Norrish,S. and Parker,L (2010) ` Consulting with young
people about health care' Pediatric Health 4 (2): 157-166)
S2. Extract from email from Bid Manager, Balfour Beatty Investments who
can corroborate the consultancy work undertaken and the impact it had on
the bid design process.
S3. Wilson, J. (2011): Through the Eyes of a Child. Why hospitals
designed for children need to be special places.
S4. Email request from Royal Hallamshire Hospital to adapt the `tool kit'
S5. An email from the Project Manager, Children's Health Services,
Queensland Children's Hospital Brisbane corroborates the changes they made
by drawing on the research findings.
S6. An email from The Director, Corporate Planning Department, St James's
University Hospital, Leeds summarises the changes that were made as a
result of the KT project.
S7. Extracts and summary content taken from one email and a letter sent
by the Director of Nursing who confirms the changes made to various parts
of Sheffield Children's Hospital as a direct result of the research.