Research in Practice: Lesson 2

“Research in Practice: Lesson 1—Testing Same-Handed and Inpatient Rooms with Canted Headwalls Using a Master Database” appeared in the May 2012 issue of HEALTHCARE DESIGN. In that article, we discussed the benefits of developing a design research master database to investigate hard-hitting issues with inpatient room design.

However, design research does not actually begin with a master database. In this article, we explain the challenges of identifying the right problem and techniques for prioritizing problems.

Seeking out a problem is part science and part art. Individuals new to design research or who desire textbook solutions will find their first efforts especially challenging. Seasoned PhD design researchers in practice recognize that seeking out problems requires a careful balance of rigor, flexibility, and discovery. It is, assuredly, the most important step in obtaining results that are both relevant and enduring to the design process.

In this article, we’ll introduce readers to problem identification and will explain a little about pilot testing, an often-overlooked yet effective technique to seek out and identify problems. Well-structured pilot testing can be enormously helpful for a project team because it can be used to discern whether the problems originally identified are the right ones to target.                 

Which old problem? The wicked problem
The healthcare field is rife with multifaceted and interrelated problems. It is very common to find that the solution to one challenge reveals (or is related to) another. It is some consolation that these tangled challenges have been the subject of inquiry for several decades. They are formally known as “wicked problems” (Rittel & Webber, 1973) and have been recently characterized in design research as “… complex, persistent, and contradictory problems relevant to broad groups of stakeholders, each having a different potentially diametrically opposed perspective on an issue” (Hamilton, 2008).

Simply put, a wicked problem is, among other things, complex, ongoing, and enmeshed with other problems. Often, resolution of a wicked problem requires a tradeoff based on what is most important to the organization.

Examples of the wicked problems that routinely confront healthcare facilities might include staff inefficiencies, patient falls, hospital-acquired infections, and medication errors. For example, decentralization of medications can cut back on the number of medication errors due to distractions.

On the other hand, it also may lead to fewer opportunities for collaboration, shared awareness, and informal learning opportunities among staff. How you understand your problem tradeoffs can lead to different solutions.

Refining problems: An example where every step counts
Nurse walking distances can be a multifaceted problem related to other problems. How do you optimize nurse travel distances when each facility has specific challenges, multiple drivers that contribute to nurses’ walking distances, and there are several possible solutions? One popular solution is decentralized nursing.

However, there is a veritable menu of decentralized nursing options including room-side supply cabinets, workstations-on-wheels, bedside computer terminals, nurses’ stations outside of each room, and nurses’ stations every few rooms. Which you choose ultimately depends on a good understanding of your problem.

Examples from our project work illustrate how something as seemingly simple as nurse walking distances can be complex and idiosyncratic. Statistics from one hospital with distinct and small inpatient units showed us that nurses walked beyond the industry average largely because they were continually untangling cords around cluttered headwalls and outlets.