Abstract
Some of the Health Environments Research & Design (HERD) readership is aware that I practiced architecture for 30 years, principally designing hospitals, and that I have spent the last decade in academia at Texas A&M University, teaching graduate students about healthcare design and its relationship to environmental research. Fewer HERD readers may be aware that I earned a social science master’s degree in organization development at Pepperdine and have more recently been pursuing further cross-discipline education at the doctoral level in nursing and healthcare innovation at Arizona State University. In my current dissertation research, I am studying the way critical care nurses navigate within the patient room and interact with features of the designed environment. I have so far spent more than 200 hr observing intensive care unit (ICU) nurses through entire 12-hr day and night shifts on multiple units. I will probably invest many more hours on two or more units before completing my data gathering.
I have been reminded during these observations of the importance of variation in minor design decisions and their major impact on the functionality of a completed design. It is all too easy for design to become a bit superficial, rather like a broad outline, which covers the basics without providing for the full expression of detail necessary to completely support high functional performance. In an ICU patient room design, for example, the location of monitors, computers, supplies, alcohol gel dispensers, sharps disposal containers, trash receptacles, and the ability to move equipment items with wheels all profoundly impact nursing performance. Design for hand hygiene, room size, bed orientation, configuration of life support systems, and decentralized charting position powerfully influence nursing behavior and efficiency.
During my active design career, I was always totally committed to learning from the users in a robust model of participatory design. Through observation, interviews, benchmark comparisons, and shared development of design alternatives, I always tried to fully understand the functional requirements of each part of the building being designed. Declaring design detail to be of importance should not be a surprising statement for most healthcare architects, design professionals, or serious architecture students. In my case, however, this has recently become much clearer.
It has become clearer, in part because I have now been exposed to content outside my own original discipline of architecture. Courses I have taken in human factors and epidemiology, for example, have provided new perspectives for me, as have the many doctoral courses in nursing science, analytic statistics, and research methods. It has become clearer because my personal opportunities for observation and inquiry have evolved and become more scholarly. I have been making a transition from a role as an architect in practice toward a new role as an academic research scientist. These roles and others acquired along the way are now becoming integrated, giving me a richer, cross-discipline perspective. It has been, and continues to be, an interesting journey.
Architecture Student
Architectural education at many or most U.S. schools hasn’t changed much in the nearly 50 years since I was a student. We spent a disproportionate amount of time in studio, based on a mixture of late 19th-century Beaux Arts and early 20th-century Bauhaus thinking, as if every graduate was destined to be a gifted artistic designer. We took a smattering of architectural history and theory, made an effort to understand structural engineering and the characteristics of materials, and had to sit through a professional practice course that was almost entirely about the owner–architect contract. We got nothing in the way of research methods, scholarly literature search, or connecting the results of research to design. It is still largely so in part because the National Architectural Accrediting Board (NAAB) has strict requirements by which a program can be accredited, and students can only enter the track toward professional licensure from an accredited program. The NAAB requirements fill the curriculum in a way that leaves little room for broad-based electives or a focus on a research foundation for the design process.
Although an undergraduate, I managed through advanced placement credit to have an uncommon experience with courses in literature, sociology and philosophy, and art history. I was reading the work of authors like Hall (1966), Sommer (1969), Lynch (1960), and Whyte (1980) who influenced my design thinking and attitudes about urban development. Christopher Alexander’s Pattern Language (Alexander et al., 1977) and Notes on the Synthesis of Form (Alexander, 1964) were a major influence on my thinking. I was profoundly influenced by Landscape Architect McHarg’s (1971) work with what I now recognize as evidence-based planning principles and methods. Although early hints were there, none of this exploration, with the possible exception of McHarg’s work, rose to the level of providing me with a model for incorporating research findings into real designs.
Scholarship in undergraduate education could be described as the exploration of multiple serious sources from within and outside the discipline to give the prospective practitioner a rich foundation for the future. It might be as simple as the description of a well-rounded education that goes beyond the minimum requirements of the chosen program. I suspect that many professional programs are not set up to produce scholars as well as professionals.
Design Practitioner
Upon graduation with a professional degree in architecture, my early career was that of an eager architectural intern who worked hard to become licensed as soon as possible. I learned from those with more experience and completed projects that were considered successful. A building that didn’t leak, a few positive anecdotes about the building’s performance, and a happy client were usually sufficient to mark success.
Our quality control reviews were most often based on structural or mechanical engineering, and material science to confirm that the design conformed to prevailing technical and construction standards. We made minimal reference to books or articles, confining our so-called research to picking the best product from a manufacturer’s catalog. Misapplication of the term “research” for product searches by practitioners continues to be a vexing issue today. For me, scholarship in practice means developing quality projects with thoughtful reference to credible material from science, literature, evaluation of completed projects, or expert opinion.
The aesthetic aspects of our designs were based almost entirely on subjective opinion. Colleagues whose design work was respected might have provided constructive criticism, but the designs were judged primarily by personal and arbitrary taste. My inexperienced colleagues and I were not interested in serious scholarship. Grateful to be out of school, we perceived that we had no time for it, and we did not measure the quality of our design work with consistent criteria. I now look back on that time as falling short in holding my work to a standard that could be measured with some consistency. For me, rigor in the design process can be described as consistency of objective measurement and evaluation standards as well as setting a high bar for project performance. I have criticized architecture as lacking sufficient rigor, observing that evaluations of designs are often subjective and somewhat arbitrary. Some of the absence of scholarship, rigor, and reference to research in my work, however, could be attributed to a professional architectural education at the University of Texas in Austin, which, like all accredited professional degrees of the time, did not include an emphasis on scientific research, research methods, or scholarly writing.
During the early period of my professional development, I was strongly influenced by Bill Caudill’s Architecture by Team (Caudill, Rowlett, & Scott, 1971) and found myself at his firm, CRS, in Houston. His premise was that in the modern world of highly complex projects, a multidiscipline team with complementary skill sets was the most effective way to deliver architectural quality. I have found this to be true and have always since worked in a collaborative team model rather than a hierarchical apprentice model. Willie Peña was another leader at CRS, and I was equally influenced by his book, Problem Seeking (Peña & Focke, 1969; Peña & Parshall, 2001), which described a consistent process for addressing the client’s goals, contextual facts, quantifiable needs, and preliminary alternative concepts as a means of reaching a defensible, data-driven problem statement. This led to strong project briefs or functional and space programs and gave me a framework for greater consistency in my own design method.
My role as an architect, designer, and planner of health facilities committed to a participatory design process meant that I had to acquire skills at inquiry and small group facilitation. I was self-taught as this had not been part of the architectural curriculum. I asked the users questions about their processes and about things I didn’t understand. I asked questions to confirm what I thought I knew. I sometimes shadowed staff members and nurses to better understand their work. My colleagues and I used gaming techniques to draw out user opinions and preferences before the drawings were started. I toured hospitals and other facilities whenever possible to better understand alternative designs and to build my understanding of the field. As designs were developing, we often used full-scale mock-ups to test and refine design ideas with those who were going to work in the planned space. Learning from each of my clients was a fundamental element of my practice, but documentation of findings was simplistic, limited, and almost never published or shared with the field. I began to constantly scour newspapers and the popular press for articles about medicine and healthcare.
As a practitioner, my professional growth and development came from experience and from observing different examples of the specialized building type with which I was involved. My focus was on learning what needed to happen in these spaces, and how the flow of people, supplies, medications, and information impacted design. What could I learn from the client to enhance my design? My focus was entirely on my work product, a new design. What could I learn from the designs of others that might be useful in my own designs? I consider this to have been learning by example rather than any sort of real research. It was possible over time, however, to obtain sufficient experience to become recognized as an expert in healthcare design.
I believe this will ring true for many in the field, as the principal way of learning our specialized craft. This is at least partially because there was little written about healthcare design at the time. The current emphasis on research-informed design, and the advent of focused magazines and a journal, is providing more resource material for design practitioners and changing the way contemporary professional development advances.
Practitioner Author
Although in practice, at a later point I suppose I could have been described as an architect who was also an author. I had the rare opportunity to work with Bill Caudill as an editorial assistant on one of his books, and he taught me that an architect can write. I began to write articles for the industry and professional magazines and went so far as to write and edit books published by my firm. These books focused on topics of interest to me and my clients. They were illustrated with photos, plans, and drawings, as might be expected from any design practitioner. Because I have always been committed to participatory design and a team-based practice model, these books contained articles by physicians, nurses, pharmacists, and healthcare clients, along with design professionals such as engineers, interior designers, landscape architects, and consultants.
The majority of my writing was professional rather than academic, which means they were chosen by sympathetic editors, and not peer reviewed. I used a minimum of citations and references to the work of others and offered much in the way of opinion based on personal experience. Peer review is an indicator of a higher level of scholarship. I believe, however, I was practicing at or above the standard for a healthcare architect at the time.
Scholar Practitioner
I began to make the transition to a higher level of scholarship through my work toward a master of science in organization development at Pepperdine University. Instead of classwork based on a single book and an overview of a topic, we were provided with multiple academic, peer-reviewed articles that probed more deeply into focused areas, providing alternative points of view.
Learning about organization theory changed my focus. I had a new appreciation for the work of my clients and their organizations, along with a deeper understanding of the implications of systems thinking and managing change in healthcare design. I could now conceive of architecture as a way of housing the intended organizational change, and I could see partnering with new types of organizational consulting to improve the outcome. It became especially clear to me that putting the old organization into a new building was unlikely to produce new results. My new mantra and personal commitment became to first design the organization and only then design the building.
The addition of new learning provided me with a growing level of strategic thinking that directly enhanced my architectural practice. It was while involved with this new cycle of education that I began to formulate new opinions about practice. I felt that designs could be measured by an assortment of organizational performance measures and became interested in the potential of surveys and questionnaires.
In addition to fascination with organization theory and change management, including my perception that sociotechnical theory (Appelbaum, 1997; Cherns, 1976) was specifically applicable to design projects. I encountered new material that was directly suited to developing consulting skills useful for a design professional. I was deeply influenced by the work of authors like Schein (1969, 1999) with his emphasis on a process in which the consultant is neither a simple hired pair of hands nor an infallible authority, but rather a partner with the client; or Schwarz (2002) whose evidence-based training for facilitation could have benefited me much earlier in my career.
Still an active practitioner, as a result of this new perspective I became aware that the social sciences were generally less subjective than architecture. Social science conclusions seemed to me to require greater evidentiary support when compared to the frequency of subjective opinion in architecture. I learned to find and use the scholarly literature and recognized the need for content based on the properly cited work of others in the field. My writing was now more often supported by reference to the work of other authors and included less personal opinion. I learned how to search the literature for specific topics, how to work with theory, and how to write for a scholarly audience as well as my previous professional audience.
Ulrich (1984) had published an influential, pioneering article in the journal, Science, which changed my thinking about design’s relationship to scientific findings. He confirmed my long-held belief that the designed environment could have positive impacts on the persons who experienced it. Eventually, Ulrich’s (1997) theory of supportive design would influence my writings about evidence-based design, framed with an understanding of evidence-based medicine (Sackett, Rosenberg, Muir Gray, Haynes, & Richardson, 1996). I found myself wanting to do more research and writing. My transition to scholar practitioner and the master’s degree allowed me to become eligible to join a university faculty.
Academic Scholar
After earning a serious mid-career master’s degree, I became susceptible to recruiting by faculty I greatly respected at Texas A&M University and made my transition from practice to academia. I entered as a scholar practitioner and began my new development as an academic scholar. The practitioner was welcome in the design studio where graduate students valued my perspective as someone with extensive experience in the real world. The scholar had to learn what is expected of faculty at a major research university.
Faculty members are expected to write and publish for advancement to tenure or for promotion. This is of course in addition to teaching and service responsibilities. The writing now needed to become more scholarly, including thoughtful organization, following expected patterns, and backing up assertions with evidence or citations from relevant literature. This is where one encounters patterns that include the use of abstracts to describe the contents of an article. The model for a research article includes an introduction, a review of the relevant literature, a detailed description of the research method, the resultant collected findings, a discussion of the findings and their implications, and a conclusion in which the author always indicates that there are further questions that need to be explored. This was not how I had written as a design practitioner. I was learning a new way of writing, and a new, more complex way of thinking about design for health facilities.
It was during this development of my academic experience at Texas A&M University that Jan Stichler and I collaborated to found the HERD journal. This required me to begin working with the work of research scholars and clinicians as well as playing an important role in the blind peer-review process of a serious quarterly publication. I began to have greater awareness of literature and research that was relevant to my areas of design interest (Frampton & Charmel, 2008; Hendrich, Chow, Skierczynski, & Lu, 2008; Pati, Evans, Waggener, & Harvey, 2008; Pittet, 2001; Ulrich et al., 2008). Access to these materials was now enhanced by my role on a university faculty. My own writing was now moving to more credible outlets with two books for reputable publishers. I was able to include scholarly citations to the work of others and to provide useful references for my readers.
Doctoral Candidate
In 2010, while serving full time on the faculty at Texas A&M, I enrolled in the PhD program in nursing and healthcare innovation at Arizona State University. I should be clear that they are not making me a nurse, as it is a nonclinical program designed to give me a research background. I will be qualified to be a nursing scientist, researcher, or educator but not qualified to care for patients. When I was taking classes the first 2 years, I only had to be there the first week of each semester. I was synchronously connected online with my classes the remainder of each semester. I am in the innovation learning community and getting a solid foundation in the theory and science of nursing and nursing research.
As a result of my recognition that architectural practice requires comparatively low levels of rigor and that scholarship increased for me in the social sciences and the pursuit of my master’s degree, I chose to seek a better understanding of the scholarly requirements of a clinical science. Although my program is in nursing science and innovation, doctoral education in any field provides a strong introduction to scientific study, research methods, statistical analysis, and investigation of scholarly literature. I felt this would be helpful to me as an editor, receiving and reviewing submissions from academic researchers and scholars in the field.
I have been exposed to large amounts of literature relevant to my cross-discipline interests during my doctoral studies. Carayon (2012) has a body of work in the area of human factors and ergonomics in health and medicine. Chamaz (2006) has influenced me with her constructivist grounded theory model in which results emerge from collections of qualitative data, instead of requiring confirmation of a hypothesis. Lincoln and Guba (1985) wrote Naturalistic Inquiry, which makes the case for post-positivist qualitative study. Spradley (1980) has written about scholarly methods for field observation. Each of these and others to whom I have been exposed through the doctoral program have altered my worldview and my understanding of a personal research trajectory.
I am finding the research activity associated with preparing a dissertation to be particularly exciting. The more than 200 hr of observations I have spent in the critical care patient room provide far more detail than my well-meaning shadowing of a nurse for 2 or 3 hr back when I had been in practice. The amount of reading I have done, based on my careful, systematic search of the literature, far exceeds the effort I had been accustomed to making in order to prepare for a design situation. Of course, practical considerations make it impossible for a designer in practice to treat each project like a dissertation topic, so I had never experienced this level of inquiry.
This combination of experience and cross-discipline educational exploration gives me a rich potential for greater insight into what I observe. I am able to see things differently. Although watching an ICU nurse move from bedside to the IV pumps, and supply cart, while preparing medication administration multiple times during a single shift, I notice things I would have overlooked earlier in my career. I can shift mental gears to examine things through a different lens. Best of all, I am less likely to arrive at premature and unsupported conclusions. Although I no longer practice, I am certain that my design work could be stronger as a result of what I now see, and my ability to discover so much more about the work of others.
Cross-Discipline Scientist
If all goes well, in another year or so I will have analyzed my collected data and written a dissertation. If I am able to successfully defend my dissertation, I will have reached the entry stage of a new career as a research scientist. As a researcher, I will of course continue to learn more with every project and each new study. My credentials will have grown, and I may be better qualified to seek important grants and external funding for significant research. I will certainly have met my personal goal to increase my understanding of rigorous, clinical research in order to better serve as a HERD editor. I have already benefited from the educational process of my doctoral studies.
The Benefits of a New Set of Eyes
It is not always easy, and occasionally complicates things, but the ability to bring multiple perspectives and points of view to a situation is a tremendously rich and powerful tool. Each new discipline explored has the potential to provide another useful perspective, offering a fresh set of eyes to see things in a new way.
I always perceive an environment based on my original education and the profession of architecture. The architect in me notes aspects of the environment and may be aware of some conditions and restraints that led to the way it has been designed and constructed. The human factors student is aware of design at a more detailed level, including the way persons interact with elements of the environment. The organization theorist may be acutely conscious of the work systems in place and the sociobehavioral implications of the environment. Recognition of process improvement opportunities and barriers to performance come from the study of change management. The nursing student may have a deeper appreciation for the complexity of the demanding work and the competing priorities in the highly technical workplace where human compassion and caring make a difference. The student of epidemiology may grasp how the environment is related to prevailing conditions of disease in the local population and whether or not it serves the need. Epidemiology is fundamental to infection prevention. The scholar understands the theory that may be involved and knows how to investigate the subject to discover what others have said or written about it. The research scientist may see ways in which further study of the environment might lead to important understanding and avenues for future improvement and will know how to conduct such a study.
In my case, I sometimes allow the architect in me to interrupt what the scholar and scientist are trying to accomplish. It is all too easy for me to think like a designer when I need to be inquiring as a researcher. In spite of these throwback moments, my life and career have only been advanced and enriched by the addition of education, experience, and understanding derived from exploring additional disciplines. The disciplines I have explored are not to be seen as a formula for others. There could have been many paths. I have considered, but not yet explored, environmental psychology, public health, landscape architecture, industrial design, and other subjects. Your path can be equally productive and exciting in any of a variety of combinations, but the big idea is to step outside of one’s first, dominant discipline.
So why, then, are serious scholarship, understanding of research science, rigorous evaluation criteria, and a commitment to evidence-based or research-informed design so important to me? Looking back, I believe my body of work as an architect could have been improved if these insights had come to me earlier in my career. I believe these things contribute to quality in design and can powerfully impact a client’s measurable outcomes in a positive way. The quest for improved designs and superior outcomes is a noble path for the practitioner. Although I struggled near such a path, understanding there was one, I wish I had discovered it much earlier in my design career.
Opportunities Abound
All of my graduate education has been accomplished without quitting my job or relocating to the university’s campus. Not too long ago, such a thing was impossible. There are now many new ways to acquire graduate education, not all of which require seeking a degree. Practitioners who share my thirst for new knowledge and life-long learning will find there are numerous ways to follow their dream without interrupting an established career, disrupting the family, or stopping the income stream, and many more such paths are being created every day. My experience has been richer than I could have imagined. I highly recommend it!