Research in Practice: Lesson 1
Pinch yourself. It is hard to believe that a research revolution in design practice occurred during the worst economy since the Great Depression. But it did.
Out of necessity or ingenuity, savvy companies dipped their toes into the design research ocean. Some took deep dives into design research. Those that braved the waters quickly learned what consumer goods, engineering, and pharmaceutical industries have known for a long time: Research creates a better product and innovations. This pays off.
As research in practice quickly becomes the mainstream, what are the best tactics? Some organizations have absorbed research into their existing fee structure as a differentiator on project delivery. Others have crafted nonprofit consulting divisions whose efforts support staff on the for-profit side. Yet others offer research on a for-profit consulting basis or have used research primarily as a marketing tool.
Finally, there are a rare few that have taken the initial steps to develop true research and development (R&D) groups.
Research in practice has been branded in many ways. They include evidence-based design, salutogenic design, generative space, design research, and others. However, all have a common origin in the field of environmental psychology. Organizations like the Environmental Design Research Association (EDRA) and International Association for People-Environment Studies have been the wellsprings of environmental psychologists for several decades.
About this series
This is the first in a series of articles to appear in HEALTHCARE DESIGN that provides practical advice for successfully implementing research in architectural practice. The articles’ material comes from the diverse and real-world experiences of researchers in practice at HOK.
Case studies from recently completed and ongoing healthcare design projects will illustrate important and unique ways research contributes to building project delivery, including renovations, guideline development, and greenfield projects. The position of the authors is that research is an essential service architecture firms provide in collaboration with clients, organizations, and academic institutions.
The service informs design decisions made during project delivery and leads to the best possible product.
Using data makes cents
Once a research project is complete, there is a lot of data to sift through. Much of this data is combed through to find particular nuggets of information that are relevant to the design project at hand. When the project is over, the rest of the data can often sit dormant. Moreover, there may be data collected from other and similar design projects that can collect and lay dormant.
In today’s market,it does not make sense or cents to let hard-earned data go dormant. First, the same data can be used in several different analyses over several years. This maximizes the value of the data for future projects and its return on investment.
Second, having results from data can spell the difference between winning and losing the next job. Trust in design solutions now comes from having real numbers from the field to back ideas proposed to clients. Clients want to know if a solution works in their unique organizational circumstances.
The first contribution to this series of articles will start with the heart of any research and development program with a vital pulse: master databases. An author of this article has performed several post-occupancy evaluations of medical-surgical inpatient units. For each client, data is analyzed and research findings are summarized in reports to guide design decision-making during project delivery.
The data from each hospital is comparable, because the team used the same questionnaires and work sampling techniques for each inpatient unit. Consequently, researchers were able to collapse all the data into one master database.
Innovation in search of validation: What works for the patient room?
Fewer topics in contemporary healthcare design circles are more debated than the optimal design for the inpatient room. Recently, specific hot button topics have included same-handed and inpatient rooms with canted headwalls.
Right is right, right?
On a same-handed inpatient room unit, all beds are standardized to be oriented the same way. Figure 1 compares mirrored and same-handed inpatient room configurations. Typically, on a same-handed unit, the beds are oriented so that clinicians approach patients from their right. One reason for this right-sided orientation comes from clinician training and because it is easier for clinicians to examine a patient from a patient’s right side (e.g., it is easier to cup the heart and feel the liver).
Other hypothesized benefits from same-handed units include improved muscle memory and response times by clinicians (e.g., an emergency; bathroom assists), patient safety, patient sleep quality, and efficiencies (e.g., equipment and supplies in the same and correct location) (Cahnman, 2006; Reiling, 2007).
The standardization that is provided by same-handed units makes intuitive sense from a patient safety and efficiency perspective. A clinician should not have to waste precious seconds figuring out where equipment and supplies are kept, especially during an emergency.
Given clients’ and the industry’s desire for studies of same-handed units, researchers at HOK in collaboration with hospitals and universities harnessed the HOKinpatient unit master database to conduct a study of the same-handed unit. The research resulted in the first refereed, published study of same-handed inpatient units (Watkins et al., 2011).
Using a variety of statistical tests, the researchers discovered several striking findings. The statistics indicated that the results were due to the same-handed unit. In addition, the analyses controlled for alternate explanations for the results including the following: bathroom location, IV pole location, and proximity of the patient room to a nursing station.
Patients in same-handed rooms complained of less noise and reported better sleep quality compared to similar patients in mirrored patient rooms (Watkins et al., 2011). Moreover, clinicians on same-handed inpatient units reported better organization of space at the patient bedside and more approaches to patients’ right sides.
These right-sided approaches were related to fewer instances of patients catching themselves from falling. This finding indicates that clinicians on the same-handed unit were more responsive to patient safety needs.
Can’t not cant?
An inpatient room with a canted headwall is angled toward the room window. Figure 2 illustrates an inpatient room with a canted headwall. It has been argued that there are several advantages to the canted headwall. First, the longer headwall introduced by the cant meets the minimum dimensions for an intensive care headwall. This allows a typical medical-surgical inpatient room with a cant flex to an intensive care room.
Second, the cant reinforces a sense of visual privacy for a patient who may experience constant distraction from traffic in the hallway. Third, the cant encourages patients to look out the window more often. This may speed up patients’ recovery and decrease their length-of-stay.
Lastly, the cant improves visualization of the patient’s body from the corridor. This has implications for clinician responsiveness to a patient’s needs.
Investigations of inpatient rooms with canted headwalls a
re nonexistent. This may be in part to the recentness and novelty of the concept. From conversations with healthcare designers, planners, researchers, and hospital administrators over email and at the EDRA international conference, an HOK researcher learned that there was a concern that an inpatient room with a canted headwall may contribute to patient delirium.
There is a body of environmental psychology research that demonstrates room angles and shapes can influence a person’s subjective state for the better or worse (Franz & Wiener, 2005).
A query using the HOK inpatient unit master database resolved concerns about the inpatient room with canted headwall and demonstrated its benefits. During the analyses, the researcher controlled for the window view and the duration for which blinds were open during the daytime. Patients in inpatient rooms with canted headwalls reported looking out the window more frequently than patients in rooms without cants.
The statistics indicated that the results were due to the inpatient room with canted headwall. In light of research that demonstrates the healing impact of a window view of nature (Ulrich, 1984), the cant offers patients opportunity to recover faster. Shorter patient length of stay translates into long-term return on investment for a hospital. In turn, the return on investment can pay for the upfront cost of canted headwalls.
Additionally, clinicians did not report higher delirium or disorientation for patients in the canted rooms. The results proved useful because they successfully demonstrated the value of inpatient rooms with canted headwalls to hospital administrators and facility managers engaged in design decision-making for ongoing building projects.
The master database advantage
HOK is pioneering a set of master databases for healthcare design research so that research can inform design decisions from a project’s inception. Key advantages to master databases illustrated by the examples of same-handed and patient rooms with canted headwalls include:
- An opportunity to leverage the untapped potential in dormant data;
- The amount of master database data is sizeable enough so that a researcher can draw strong conclusions about rarer incidences, such as adverse events;
- The diversity of the master database’s data (i.e., from multiple facilities) allows the researchers to ask several questions of the data;
- Due to the size and diversity of the sample, it is easier to generalize any findings to other hospitals;
- Results can be used to validate several innovations; and
- The master database can be queried for just-in-time research findings during project delivery or any effort.
If researchers are interested in master databases, they must be mindful that the benefits transpire from hard work. Master databases need constant upkeep, which costs time and money. For every effort a master database is used on, one needs to be sure to account for the time needed to update and organize the master database.
If embarking on a master database for the first time using typical statistical software, you can use some rules of thumb. For example, to estimate the time needed, double the hours it usually takes to add to or maintain an existing database of similar size. If you don’t know how long that is, ask other researchers with experience. The timeframe will allow substantial opportunity for the database’s initial construction and consolidation of data from several sources.
Though updating and maintaining an existing database may not be as time-intensive as constructing a master database from scratch, it takes a significant amount of time and effort. If you want to use an existing master database for a building project, be sure to set aside several hours in the project schedule to update the master database.
You can estimate these hours by performing a dry run of data entry from a pilot investigation. In many ways, maintaining an existing database is similar to an architect working with guide plates on a design project; although precedents are available, design still requires a significant time investment.
Future articles within this series will look at the foundations for a strong master database. These foundations are created using facility evaluation data from specific projects in a variety of subject matter areas. Several case studies will be explored, including a few from research and design, and benchmarking projects.
Nicholas Watkins, PhD, is HOK’s Director of Research & Innovation. Erin Peavey, Associate AIA, LEED AP BD+C, EDAC, is a Researcher and Medical Planner within the Health Care group at HOK. The authors would like to thank the clinicians and patients who have taken part in the research and findings shared in this article. Correspondence concerning this article should be addressed to Nicholas Watkins, HOK, 1065 Ave. of the Americas, 6th Floor, New York City, New York, 10018. He can also be reached by phone at 646-385-7624, by fax at 212-633-1163, or by email at firstname.lastname@example.org.
Cahnman SF. (2006). Key considerations in patient room design, part 2: the same-handed room. Healthcare Design. 2006. Available at http://healthcaredesi.wpengine.com/ME2/dirmod.asp?sid=9B6FFC446FF7486981EA3C0C3CCE4943&nm=Articles&type=Publishing&mod=Publications%3A%3AArticle&mid=8F3A7027421841978F18BE895F87F791& tier=4&id=21E17C4E6B314B66819324CC0C525D4E. Posted April 1, 2006. Accessed February 25, 2011.
Franz, G., & Wiener, J.M. (2005). Exploring Isovist-based Correlates of Spatial Behavior and Experience. In, Proceedings of the 5th International Space Syntax Symposium (pp. 503-517).
Reiling J. (2007). Safety by Design: Designing Safety in Healthcare Facilities, Process, and Culture. Oakbrook, Terrace, IL: Joint Commission Resources.
Ulrich R. (1984). View through a window may influence recovery from surgery. Science, 224(4647), 420-421.
Watkins N, Kennedy M, Ducharme M, Padula C. (2011). Same-handed and mirrored unit configurations: Is there a difference in patient and nurse outcomes? Journal of Nursing Administration, 41(6), 273-279.