International Journal of Applied Science and Technology

Vol. 1 No.4; July 2011

Exploration of Usability Issues in Malaysia Public Hospital Spatial Design: Pilot Study
Siti Norsazlina Haron Built-environment, Universiti Teknologi Mara (UiTM MALAYSIA) Department of Building Survey,Universiti Teknologi MARA Perak, MALAYSIA E-mail: [email protected] Dr Md Yusof Hamid Department of Interior Architecture Universiti Teknologi MARA, Shah Alam, , MALAYSIA E-mail: [email protected] Assoc. Prof. Dr Anuar Talib E-mail: anuarfaqir@gmail
Abstract This paper explores the usability of healthcare spatial design in Malaysia public hospital as part of quality in-use evaluation. This study tries to understand of the complexity of end-users used facilities provided and to observe the patient feedback during journey experience in the hospital spatial design and it relationship. There are varieties of health-care evaluation either for the quality of design or service, as well as the impact of those factors to the patients but usability evaluation is appropriate in exploration of user experience. Usability approach is focusing on the method of collecting data, and it is based on the exploration of the user experience by knowing their perspective. It measured by three parameters; the effectiveness and efficiency of the design or facilities offered and users satisfaction. The methods of collecting data in this study are using walkthrough observation and interviewing patients and visitors from three public hospitals. The study, identified variety of usability criteria contributes to the quality of architecture in-use. Later, all those issues will be used as evaluation criteria for a main case study.

Keywords: Usability, Healthcare Spatial design, Evaluation, Quality in-use indicators. 1.0 Introduction
This pilot study is small in comparison as a feasibility study; it to help added anything new or important to main study. Moreover, it had done to achieve all the objectives of the researcher tryout, such as improving datacollecting routines, and checking the appropriateness of usability evaluation; to explore current scenario and usability issues Malaysia public hospital. From a review of pilot study purpose, according to Prescott and Soeken (1989) in Hertzog (2008) pilot studies can serve many purposes included assessment of (a) feasibility, (b) adequacy of instrumentation, and (c) problems of data collection strategies and proposed methods. To these they added: (d) answering methodological questions and (e) planning a larger study. In a more recent article, and according to Jairath, Hogerney, and Parsons (2000) contributed a sixth potential use of a pilot study: (f) obtaining sufficient preliminary data to justify a main study. Furthermore, it can greatly reduce the number of unanticipated problems because we have an opportunity to redesign parts of the study to overcome difficulties that the pilot study reveals. Besides, in this pilot, the researcher had tried out a number of alternative measures and then selects those that produce the clearest results for the main study. Therefore, the requirements of the pilot study are essential to facilitate the assessment of the actual site.

2.0 Research background

Currently, in Malaysia there are 136 public hospitals. The government hospitals in Malaysia are categorized into two types; regional or state and district hospital. The differences are in the provision of healthcare services, bed capacity and total of the number of medical specialist offered (Ministry of Health Malaysia, 2009). This study was conducted in a replacement hospital that had been choosing for the main case study. A replacement hospital is a new hospital built to replace the original hospital which had been closed or turned into the state health department or health clinic. 127

 Centre for Promoting Ideas, USA

www.ijastnet.com

Meanwhile there are 10 replacement hospitals peninsular Malaysia and three different category hospitals have been selected, in which the hospital began operating in the year 2000 above and offered medical specialist- A, B & C (table1). This pilot study focuses on the northern region area, is due to lack of researcher focus on this area and spatial design. This pilot case study conducted on the selected main case studies as a preliminary study. It covered on the first floor area related to patient and visitors service. Table 1: list of replacement hospital in Peninsular Malaysia
No. 1 Hospital A Year 2007 Type of hospital Referral / State Hospital /Total Hospital Information System'(THIS) /The Clinical Research Centre (CRC) Secondary Hospital District hospital District Hospital without specialist Secondary hospital District Hospital With specialist District Hospital Without specialist Secondary /Teaching Hospital District Hospital District Hospital * South area Size/beds 812 Patient/yr 80% Medical discipline (md) 22

2 3 4 5 6 7* 8 9 10

B C D E F G H I J

2007 2001 1996 1994 1994 1994 2005 2007 2008

550 250 160 314 270 90 482 110 28

72% 57% 50% 100% 76.5 % 51.9% 70.7% 33.0% 50%

11 6 Without specialist 10 10 6 & 5 visit m d 14 specialist Without specialist Without specialist

Northern area

East area

Source: Malaysia Ministry of Health (MOH) 2009 In this study, the usability evaluation criteria derived from Voordt 2005; 2009, seems it related to the assessment on healthcare architecture in-use. It is using nine dimensions,(1) Reach ability and parking facilities,(2) Accessibility,(3) Efficiency,(4) Flexibility,(5) Safety,(6) Spatial orientation,(7) Privacy, territoriality and social contact,(8) Health and physical well-being and ,(9) Sustainability. This evaluation adopted from NHS, Achieving Excellence Design Evaluation Toolkit (AEDET): its Post occupancy Evaluation (POE) Toolkit with the systematic questionnaire (Excel-based program) related to how building performed, provides three key areas; (1) functionality- use, access and space, (2) impact -character and innovation, form and materials, staff and patient environment, urban and social integration, and (3) build quality and standard performance, engineering and construction (AEDET evolution, NHS 2010)Voordt alteration on method of evaluation to suitable approach using observation and interview. In other to get the respondent more understand and in depth study to the usability scenario.

3.0 Aims of the pilot study

Purpose of this pilot is to achieve the main objective of this study is to explore the user experience of healthcare spatial design using usability evaluation criteria and to test methodology or procedure in gathering information. These pilot objectives are, such as; To observe the ease of use the hospital spatial design and explore usability issues and criteria that will support for the main case study. To obtain the feedback from testing the usability method and research design suitability for determining the assessment for quality in-use. To gather a perspective or view from hospital practice and consultant (medical planner, hospital support service) on the ability of design use by patients and visitors.

4.0 Methodology
Basically, this pilot explores and describes the situation or experiences of people with the three different type hospital environments, events and their relationships as a case study. Furthermore, this methodology is related the pilot study objective (figure 1).Moreover, according to Zainal 2007 case study research allows the exploration and understanding of complex issues and the life experience of a phenomenon for a person or group of people (Patton, 2002; Seamon, 2000; Yin, 2009). Consequently, the hospital is complex design and service to meet a variety of categories and type of end-users. 128

International Journal of Applied Science and Technology

Vol. 1 No.4; July 2011

Identify: 1. Scope and limitation of the main case studies. 2. Usability criteria and issues. 3. Refine a research design & method of usability evaluation

Defined and testing: 1. Usability evaluation method 2. Usability evaluation criteria

Exploration of usability spatial design issues: walkthrough journey experience: interview & observation

Analysis: Interpretation and data transcribing

Fig 1: The pilot study methodology In this pilot study, the usability evaluation is referred to process of collecting data as a proposed for main case study. It derived from usability research method; Systematic if Usability process by Sami Krn & Suvi Nenonen (2010) and from review of the usability methodology and research technique. Hence, it had been chosen as a reliable assessment method that thoroughly observes and explores the users action from their experience the real thing (Haron & Yusof, 2011; 2011).). 4.1 Method of Data Collection There are several approaches in usability evaluation, and it is related to the method of data collection. It is concerned with the attraction, experience and expectation of end-users to a situation, design or product. There are several methods used and tested in this study. 4.1.1 Document review Reviewing existing document, from the current and the previous report, healthcare design and facility guidelines, hospitals issue and finding from other researchers related to patient satisfaction also had been done to support the issues been highlighted in this study. 4.1.2 Semi-structured interview This qualitative study was conducted using semi structured interviews involving patient, family members and friends as a hospital visitors respondents. In the interview, they described a negative event from their own or friend/family members experience. The walkthrough technique been used during journey and waiting experience, in which participants are asked to describe an event about an ability of use the design environment in which, in their perception that they had not expected, or that they found unusual or inappropriate or misuse. This technique helps to obtain rich contextual information, as it uncovers tacit knowledge by allowing participants to describe what their thought processes and actions were during the specific event. These interviews also involve hospital staff doctors, nurses and administration and hospital support service: hospital consultant and medical planner. Its to get a feedback to the ability of design to patient and visitors. All interviews were recorded to allow for the verification and transcription for subsequent analysis. All interviews were conducted face to face on the interviewees own premises. The length of an interview lasted between half hour to four hours during the walkthrough session and some interview take too long because waiting for the service takes time. 4.1.3 Observation Method As mentioned before, we use walkthrough observation to user behavior activities been done by watching people use their environment and activities related to spatial-relationship and surrounding to determine the usability variables (Haron, 2010). It has done by analyses of the space and movements tour of the building assessing different qualities of functions of environment. In the same time Interviews had used to support humans without disturbing their activities, and it took place in a personally meeting, according to the expressed wishes of respondents. In addition, interviews useful to support behavior reaction, and we will know in-depth information around the topic and related issue. Moreover, it is an effort to describe what is going on in a given environment or situation. The action and reaction will be captured by video and photograph and sometime keeping the interview to direct observation to allow them more freedom to say what they think. Those methods being used to know the expected uses, new uses and misuses of design, recognized needs by getting the story behind a participants experiences.

5.0 Sampling strategy and size

In obtaining feedback on the usability criteria, 12 respondents consisting of patient, visitors, family and friends been interviewed. 10 respondents were selected on a voluntary basis from Healthcare practice or staff participants (where holding a variety of positions) - doctors, nurses and administration and hospital consultant; 129

 Centre for Promoting Ideas, USA

www.ijastnet.com

medical planner, engineer and hospital support service to gather a perspective on usable of design according to patient need and expectation. The value of involving patients and family members voices in the dialogue about healthcare facility environments is immense if societys goal is to meet peoples needs. Reports from The Picker Institute and The Center for Health Design these ultimate end consumers about what matters to them in the built environment, and about what supports their healthcare experience with considering consumers needs and expectation. It by measuring their satisfaction, as well as the result will provide important information to the best practices for healthcare planners, managers, architects, and interior designers who strive to create caring and supportive healthcare environments (Stern, 2003). As previously mentioned, pilot studies are carried out with fewer subjects than will be employed in the main study. From the body of literature the various factors affecting the size of sampling. However, there is no easy answer to the question of what are the appropriate number and specific recommendations or size of sample should be in the qualitative study (Burns and Grove 2005, Polit and Beck 2004, Johanson, 2009). The factors which influence the size of the sample will include of these factors, according to Treece and Treece 1982 in Johnson (2009) and Nieswiadomy (2008), recommend obtaining approximately 10% of the project study total sample size. It is recommended that a minimum 12 subject per group or observations in constructing a confidence interval be considered for pilot studies (Van Belle 2002; Julious 2005). Specific sample size depended on the nature of the decision based on the estimate, with samples as small as 1015 per group sometimes being sufficient (Hertzog, 2008). It same goes to Kieser and Wassmer (1996) indicate 1020 participants per group would be sufficient to implement to size of sampling. Nevertheless, for exploratory studies according to Isaac and Michael 1995 and Hill 1998 in Johanson (2009) suggested for pilot studies are between 10 and 30 have many practical advantages, including simplicity, easy calculation, and the ability to test hypotheses, yet overlook weak treatment effects. In addition, according to Marshall (1996) that everyone has an equal chance of being selected as a member of the sample. As well as for phenomenology study according to Creswell (1998), 5 to 25 are sufficient. Moreover, in qualitative studies size is not mattered, but the key point is our sample must be big enough to assure that we are likely to hear most or all the perceptions that might be important (DePaulo.P 2000). Moreover, each respondent has the same chance of being included and the main is the objectives of the study is achieved (DePaulo.P 2000). In addition according to Yin (2009), generalization of results from case studies, from either single or multiple designs, stems on theory rather than on populations. In other words, as this pilot is a case study method, it is a unique way of observing any natural phenomenon, which exists in a set of data (Yin, 2009). Consequently, different respondent may have diverse perceptions. Therefore, the smaller the sample size, the narrower the range of perceptions we may hear and explore from the answer. On the positive side, the larger the sample size, the less likely it is that we would fail to discover a perception that we would have wanted to know (DePaulo.P 2000) .In addition, it also influenced by level of accuracy required and constraints affecting the investigation such as cost and time constraints as well as by size and variability of the population (Hertzog, 2008). Based on the above factors, theres no specific target number of sampling (N), course of cost and time constrain, also associated to the hospital with a complex design and difficulty. The data collection process takes a long time (walkthrough journey experience, interview and observation). Moreover, the size or number of sampling influence by due to repeated result, which is same issues or usability criteria raised out during the interview process, and due to the data had achieved the objective of study.

6.0 Preliminary Finding

The results are divided based on the objectives of the pilot study. 6.1 To explore the ease of use the hospital spatial design and usability issues /criteria From this pilot, many patients reported problems related to an ability of design from their experiences and find it, the usability issues related to the effectiveness hospital offering either facility or design. Based on the observations and interviews, there are few factors reflect patients satisfaction: The frequency of the patient and visitor visit to the hospital frequency of patients and visitors comingeffectiveness -familiarity of the place and space: (a) visits the hospital infrequently and is quite uneasy there. (b) Visits hospital fairly regularly and is irritated by the long waiting time and (c) visits the hospital and is frequently extremely bored and feeling not comfortable. 130 Patient satisfaction is just not associated with long of waiting times, but it is related to the activities, atmosphere, environment and facilities offered during the waiting process.

International Journal of Applied Science and Technology

Vol. 1 No.4; July 2011

Related to the fulfillment of the needs and expectation from the patients family members and friends. The familiarity factors are influence by the frequent patient/visitors visit an experienced with the buildings. Associated with, the effectiveness and the efficiency of spatial designs offered in other to meet the patient and visitors or family members expectations, needs and goals. The facilities offered meet or suitable and able to use for every category of patients and visitors and family members, which come from various age, physical conditions and health. 6.1.1 Usability criteria From this pilot analysis found, in order to assess these usability parameters; effectiveness, efficiency and satisfaction there are few usability criteria explain those parameters by identifying the usability issues. Observation result: According to Voordt 2005; 2009, seems it related to the assessment on healthcare architecture in-use. It is Using 9 Dimensions and from observation and interviews only eight items touched by patients and visitors in addition to aspects of sustainability. Aspects 1 to 4 are related mainly to the user value of the building (table2). Table 2: Summary of observation reaction to usability spatial design
Usability criteria a. Reach ability & parking facilities b. Accessibility Usability issues /problems Case Study B

The bus-stop location is away from the main hospital lobby. It was difficult for patients and visitors to reach the hospital, especially for disable or physical difficulty. In addition there is insufficient parking space-not enough parking. A,C There is a difficulty on using the staircase to reach the upper floor, especially for respondent A,C with physical difficulty and using the wheelchair. There is a difficulty happens to a patient related to designing application such as position of B public phones that are unsuitable for disabled people, material selection for doors difficult for disabling to access. c. Efficiency Because patients and visitors had through the long journey made them tired and bored. From the A,B observation, most of the issues influence by the patient and visitor with the physical ability, age and health condition factors. d. Flexibility From the observation, there is lacking of an area for kids to play. Most of the area without A,B,C complete equipment/facilities. Besides that the respondent also needs the multifunctional activities or able or suitable facility A,B.C while waiting for service. They can do something else to eliminate the feeling bored and tired. These include the provision of reading materials, wireless facilities, and beverage facilities and to see surrounding (more open space) rather than just watching television. Not only that, the facilities should be adaptable to every type or category group of respondents. e. Safety There are few sitting units is damaged to invite danger to visitors and patients. Similarly, the use B,C of multilevel space to reach the specialist clinic also invited danger to use the staircase, especially to the patients and visitor with physical difficulty, elderly people and to the children. Although there are lifts close, but it was in the lobby and inpatient area, and most of the A respondent came direct from the outpatient entrance, causing them forget or not know that there is a lift to the upper level. f. Spatial There is a lack of signs, and it was too small to notice, and illogical placements of services only A,B,C orientation add to the confusion and make orientation difficult and sources of frustrating and stress to the respondent. The participants were confusing and access routes difficult to understand, they look tired and bored to find the service. There are lacking on orientation and way finding coded such as signs and landmarks, which is any design that brought different, variations or unique, rather than repeated design. It made the area easy to identify and to learn as well as the orientation became more user-friendly. The observation most often, participants would note that everything looks the same and confuse in identify the space. g. Privacy, Waiting area too crowded-uncomfortable waiting areas. A,B,C territoriality and There are visitors or patients who switch seats, so they prefer to chat with each other in a social contact comfortable position. There were also among those who are not sitting, course having to watch the children plays. From here we can conclude that the layout of space and furniture, especially seats play an important role in the optimum comfort to the patient members and visitors. Health and Most of the respondent, do not feel comfortable when sitting for too long as a seat material is too B,C physical wellhard and unsuitable for them. There is also a respondent of patients waiting outside the being examination room because the room was closed and lack of activities for him. In addition, some of the spaces or area lack of natural lighting made them feel uncomfortable. A Referral/state hospital B Small district hospital C Large district hospital

131

 Centre for Promoting Ideas, USA

www.ijastnet.com

Interview feedback: Most of the interview finds that the usability criteria were related to an ability of healthcare spatial design issues to a patient and visitors (table 3). Moreover, it related to usability parameters; effectiveness if the facilities, design and service provided; ease of learning, ease of use and efficiency if the facilities, design or service provided is easy to use and take less of effort/ time to solve a task or to reach a goal. Table 3: Summary of interview -the usability criteria
Usability criteria Accessibility Usability issues and problems Hospital A

Insufficient parking area. Not enough car parks provided. Lack of a signage and info board. There are no covered walkways from parking area to main entrance. Lack on landscaping area creating shading and more rest areas out of the building. Reach ability Facility provided especially against the appropriate baseline for the function of space. Lack on social area Just a space but lack on activities and facilities Problem to place the children when the parents meet the doctor. Insufficient area- some of the area is close to public. Limited shops with limited choices. Spatial Wayfinding: orientation Signage design or systems area confusing. The directional clarity from the spatial characteristic and access a route are not related to each others. Small signage or symbol to show the name of area or building Alternative wayfinding system for who could not read or not understand the language. Learn ability and memorability: Recognizable functional units, tracking by a landmark for space and design and all are showing their own identity or image, so that it is easy to remember. Confusing direction and layout, especially for systems in walkways to the main area. Efficiency Long distance and wayfinding issue will cause the patient tired and no pit stop area for rest especially for disable and elders people. Wastage of space and the lengthy corridor. Aesthetic Emotional comfort elements The interior environment not livelier and enjoy. Theres no window can view the external of the building. Physical comfort The selection of furniture not comfortablenot suitable for long use. Social comfort Comfort & Well The users concern on separation sitting area for men and women in waiting area being Lack of natural lighting at waiting area The sitting arrangement easy for communicate and interaction. Flexibility in Lack of multi-function activities in waiting area. design The area provided cant fully utilized by the various categories of users. Safety aspect Lighting not efficient especially in closed area and walk way. There was broken furniture, inviting the danger to the end users Separate area for men and woman woman feel safer and comfort. A Referral/state hospital B Small district hospital C Large district hospital

C AB ABC

ABC

C ABC

ABC

C ABC ABC C AC B C ABC C ABC BC

Source: Haron SN, Hamid MY & Talib A ( 2011) 6.1.2 Test of Methodology Evaluation: As mentioned earlier, this pilot is to test the sequenced of method proposed before applying it to main case study. From this pilot, find it walkthrough journey experience suitable to use course hospital is the complex building and multilevel floor and a lot of space and area that must be experiencing by the end-user. Moreover, these methods served useful in identifying issues in the evaluation methodology for the ability to complete tasks especially related to spatial orientation. Besides that, theres needed improvement on the data collection and analysis for the main case study. Use the layout plan as identification of respondent location and usability issues. 132

International Journal of Applied Science and Technology

Vol. 1 No.4; July 2011

Use of mapping techniques for analysis of space or detect usability issues, and it is important especially related to the spatial relationship/orientation and efficiency factors. Use of users expectation checklist, to help the interviewer to know the patients/visitors expectation and needs and target for walkthrough process step (figure 2).Consequently, it will be a guide for a main study in the data collection framework.

Fig 2: The process of patient and visitors experience Source: Haron SN, Hamid MY & Talib A ( 2011) 6.1.3 Feedback from Hospital staff (doctors, nurses and administration) and hospital consultant (medical planner and hospital support service). There a loop between the practice and patient feedback, most of them satisfied to what the hospital offered and what had been design. From the feedback, Hospital staff, more concerns on patient satisfaction regarding to the treatment and service offered. In addition, there are some usability issues, raised, and mostly for the benefit to the two parties patients and staff; less of parking area, cleanliness issues and not enough of a cafeteria. Besides that from the interviews with the medical planners and architect explained, most of the hospital design is repetition from the previous hospital design.

7.0 Discussion
In summary, from the experience, walkthrough with interview and observation methods are a suitable method in collecting data dealing with human needs. Especially when touched on field experience and reflection of experience. Otherwise from this pilot, we explore that usability is related to human action. It is a reaction between the applications or provision of service provided to the user, whether it is good or not. Based on the results and findings, it appears that the usability method of evaluation and applying usability criteria and recommendations could identify more usability problems in the main case study. However, from the usability issues show the component of layouts, and facilities provided plays an important role in measuring the performance of healthcare spatial design. 133

 Centre for Promoting Ideas, USA

www.ijastnet.com

Mainly, it involves with identifying the component of the spatial and facilities available by optimizing the usability of the design. Moreover, from that usability issues, we can conclude there are several factors of users experience and expectation affecting that usability criteria, especially on patient satisfaction. Which, it will be achieved if the respondents can complete the task in the easiest solution and the design/facilities offered meet their expectation. Acknowledgement We would like to thank Malaysia Ministry of Health (MOH) Medical Research Ethics Committee, MOH Clinical Research Centre (CRC), MOH Institute for Health Systems Research (IHSR) and MOH Institute for Health Behavioral Research (IHBR) and Malaysia Public Works Department (JKR) for supporting this research.

References
Aedet evolution NHS (AEDET), http://design.dh.gov.uk/content/connections/aedet_evolution.asp Burns N, Grove SK (2005) ,The Practice of Nursing Research: Conduct, Critique, and Utilization (5th Ed.). St. Louis, Elsevier Saunders Creswell JW, (1998), Reseach Design : Qualitative & Quantitavie Approaches Blackwell Science Ltd. Johanson G.A and Gordon P. B (2009), Educational and Psychological Measurement published online 18 December 2009 .http://www.sagepublications.com Haron,S.N .,Hamid ,M.Y., Talib,N.,(2010), Towards healthcare service quality: an understanding of the usability concept in healthcare design. Proceedings of the ASEAN Conference on Environment-Behaviour Studies . "Human Behaviour and Physical Setting : Community, Culture, Crime". Sarawak, July Haron,S.N .,Hamid ,M.Y., Talib,N.,(2010), Towards Health-Care service quality: An adaptation usability concept in healthcare design (method for studying user experiences ). Proceedings of Arte-Polis 3 International Conference. Bandung , July. Haron,S.N & Hamid ,M.Y (2011) Patient perspective: The usability evaluation approaches as assessment for quality service design. Proceeding International Conference on Environment Science &Engineering-ICESE & IEEE, ISI Proceeding, Bali, 1-3 April. Haron,S.N & Hamid ,M.Y (2011) Quality of Hospital in-use: usability evaluation method as an assessment, Journal of Sustainable Development 4(2),33-39 Haron,S.N .,Hamid ,M.Y., Talib,N., (2011) Quality of outpatient service design: an adaptation of usability evaluation as as sessment criteria for architecture in use. International Conference on Project & Facilities Management,I-CoPFM, 18-19 Hertzog A.M (2008) Pilot Sample Size , Research in Nursing & Health, 2008, 31, 180 191 Jairath, N.,Hogerney,M.,&Parsons,C. (2000).The role of the pilot study: A case illustration from cardiac nursing research. Applied Nursing Research, 13, 9296. Julious, S. A. (2005). Sample size of 12 per group rule of thumb for a pilot study. Pharmaceutical Statistics, 4, 287-291. Krn S & Nenonen S (2010). User feedback developing the system for gathering user information, CIB W111 Usability of Workplaces Phase 3, CIB reports 330 Rotterdam. Netherlands Kieser, M., & Wassmer, G. (1996). On the use of the upper confidence limit for the variance from a pilot sample for sample size determination. Biometrical Journal (Biometrische Zeitschrift), 38, 941949. Marshall, M.N. Sampling for qualitative research. Family Practice 1996; 13: 522-525. Malaysia Ministry of Health (MOH), (2009), Medical Unit Record. http://www.moh.gov.my Nieswiadomy, R.M. (2008). Foundations of Nursing Research (5th ed.). New Jersey:Pearson. Patton, M. Q. (2002). Qualitative Research & Evaluation Methods. Third Edition, Thousand Oaks: Sage Publications. Polit, D. F. & Beck, C. T. (2004). Nursing research: Principles and methods, Philadelphia: Lippincott, Williams & Wilkins. Seamon, D. (2000). A Way of Seeing People and Place. In: Wapner, S., Demick, J., Yamamoto, T. and H., M. eds. Theoretical Perspectives in Environment-Behavior Research: Underying Assumptions, Research, and Methodologies. Kluwer Academic/Plenum Publishers, New York, 157-178. Stern A.L, MacRae S,Gerteis M, Harrison T &Fowler E(2003), Understandfing The Consumer Perspective to improve design Quality , Journal of Architectural and Planning Research,20:1,16 Van Belle, G. (2002). Statistical Rules of Thumb. John Wiley and Sons, New York. p. 45-46 Voordt, T. J. M. V. D. (2009). "Quality of design and usability: a vetruvian twin." Ambiente Construdo, Porto Alegre 9,(2): 1729.characteristics on atmospherics in one academic medical center,Journal BMC Health Services Research7,(1):198 Voordt & Wegen ,(2005)Architecture in Use.An introduction to programming,design an evaluation of building..Architecture Press.Elsevier,Bussum.Netherlands Yin, R.K., (2009). Case Study Research: Design and Methods. Applied social research methods series ,Carlifornia, Sage Publications Inc Zaidah Zainal, (2007). Case study as a research method, Jurnal Kemanusiaan bil.9

134