"Designing for Health" is a monthly, Web-exclusive series from healthcare interior design leaders at Perkins+Will that focuses on the issues, trends, challenges, and research involved in crafting today's healing environment.
The hospital is our laboratory—like it or not. When it comes to conducting environmental research of healthcare settings, we must look to the actual “bricks and mortar” as a primary theater for conducting sound, peer-substantiated investigative studies. While the actual settings are rich with potential pearls of wisdom, working analytically in the field also brings with it the perils doing just that. Granted, the complexities of harvesting data in the field are real. With a little extra effort and due diligence though, the insights that are revealed may be well worth the effort.
Out in the field
Design research begins by identifying a hypothesis and then determining the methodology for exploring this hypothesis. A methodology has two primary components: the manner in which data is gathered and the setting in which the study takes place. The two main settings types are laboratories or field environments. Laboratories are most useful when maximum control is needed over confounding variables, as is common in clinical science. Field environments are most appropriate when the specific environment is under scrutiny, or when there are a sufficient number of field settings to rule out the role of confounding variables.
The benefits and shortcomings of field studies
There is a debate regarding the benefits and shortcomings of field studies. A field study, as opposed to a laboratory study, is intended to capture activities in context, and for this reason is preferred by some researchers. According to Dr. Debra Harris, founder of RAD Consultants, a design research firm, field environments in some studies are more useful than laboratories because “the extrication of human activity from the ‘real world’ to laboratory settings creates an artificial environment that may or may not reflect real experience.” Additionally, field studies enable one to identify unexpected and underlying conditions that would be expunged in a laboratory setting. Field studies are an excellent method for inductively generating theories, which can be used later to formulate hypotheses that can be tested quantitatively in field and laboratory settings.
Perhaps the most significant advantage of field research for practitioners is the availability of environments in which to conduct studies. Every design project that we undertake can be a research setting for a study. Practitioner-focused facility evaluations (PFEs) require field techniques to determine the effectiveness of our buildings.
While field studies have many benefits, they also have shortcomings. Natural environments are profoundly complex. Multiple environmental variables are involved and it may be difficult to tell which aspects of the physical and social environment are causing the outcomes. Physical variables impacting outcomes may be noise, color, scale, proportion, configuration and a myriad of other environmental dimensions. Social variables may actually trump the response to a particular environment—care protocols may impact the healthcare environment experience more than the physical environment.
Another critical shortcoming of field environments is the randomization of subject participation. When subjects are randomly assigned to conditions then the statistical tests that are done on the resulting data are more sophisticated. However, in healthcare settings, patients are typically assigned to settings based on staffing or supervision, which could influence outcomes. In cases where subjects volunteer, the very act of their self-selection could also impact the results. Recruiting subjects and gathering data in healthcare settings is difficult and time-consuming. The Adopt-a-Room study (pictured; view photos by clicking the "more photos" link under main article image) at University of Minnesota Fairview Children’s Hospital involved surveys of parents and children regarding the effectiveness of certain environmental components (message board, ceiling design, etc.), as well as the PedsQL family and patient test modules (see Varni, et al., 2004 and Sherman, et al., 2006) that examine quality of life. The primary difficulty in the Adopt-a-Room designs was recruiting enough parents and children to enable statistical testing. Even though only 20 subject pairs were required, it has taken more than three years to gather this data. Debra Harris notes “my biggest criticism of field studies is the amount of data you need to test for outcomes…this data gathering can take an unpredictably long period of time.”
Support and findings
Another important element of field studies is identifying a champion on site who is willing to support the research. Without that involvement, it is difficult to recruit subjects and deal with inevitable complications that take place with real people in real environments. The Arlington Free Clinic pre- and post-occupancy study involved surveys that were distributed to staff, patients and families. During the pre-occupancy stage, there was a lot of enthusiasm for the study and recruitment of subjects was easy. During the post-occupancy phase, interest in the project waned, as subjects became weary of filling out survey forms. Fortunately, due to the encouragement of clinic administrators at the site, the overall level of participation was sufficient to allow for analysis.
One of the measures of good research is the ability to replicate findings. This is difficult to do in a field setting as real environments are constantly in transition. Field studies are also challenged by the ability to obtain informed consent by subjects who are not directly recruited for the study. Also, field studies in healthcare facilities must obtain Institutional Review Board (IRB) permission in addition to the IRB of the organization with which the researchers are associated.
Awareness beyond aesthetics
As with any research method, field studies must be approached with an awareness of their complications and benefits. As design professionals, we need to get smarter and better at how we design health care environments—and not just aesthetically. Our clients are demanding it. It should be a fundamental part of our professional practice. Through field research, we can be far more purposeful and intentional in the environments we propose and do so with the knowledge and wisdom we’ve gained from our “field laboratories.”
Sherman, S., Eisen, S., Burwinkle, T. & Varni, J. (2006). The PedsQL Present Functioning Visual Analogue Scale. Health and Quality of Life Outcomes, 4:75. doi:10.1186/1477-7525-4-75.
Varni, J. Sherman, S., Burwinkel, T., Dickinson, P., & Dixon, P. (2004). The PedsQL Family Impact Module. Health and Quality of Life Ourcomes, 2:55. Doi:10.1186/1477-7526-2-55.
Dr. Mardelle McCuskey Shepley, B.A., M.Arch., M.A. (psychology), D.Arch., FAIA, ACHA, EDAC, LEED AP, is director of the Center for Health Systems & Design at Texas A&M University. A registered architect with 25-years of experience in professional practice, she is founder of ART+Science, a firm specializing in applied design research. Mardelle has conducted research and published extensively on the topic of pediatric facility design. Her books include Healthcare Environments for Children and their Families, Design for Critical Care, and Healthcare Facility Evaluation for Design Practitioners. A specialist in building evaluation and programming, she is the William Peña endowed professor at the College of Architecture at Texas A&M.
Rick Hintz, AIA, ACHA, is a Prinicipal and the Healthcare Market Sector leader for the Minneapolis office of Perkins+Will. He brings nearly 30 years of specialized healthcare architecture experience to his position. He can be reached at email@example.com.