Abstract
Objective
The purpose of this mixed-methods study was to evaluate the utility of an interprofessional graduate-level design of healthcare delivery systems course comprising primarily nursing and engineering students. The primary research question examined whether interprofessional design-focused hybrid delivery improved students’ knowledge and applied understanding of the healthcare delivery system design. The secondary question explored how students described applying design knowledge derived from this course in their respective professional roles.
Background
Due to the interdependent nature of modern healthcare issues, interprofessional design teams integrate knowledge from multiple disciplines in the planning and implementation stages of problem-solving. Introducing graduate students to shared design methodologies, tools, and approaches encourages them to develop skills that will shape their professional identity as well as expanded understanding of how built environments and processes influence care delivery and outcomes.
Methods
Retrospective multi-year review of pretest/posttest knowledge assessment scores and qualitative reflection essay findings were synergistically interpreted by students and experts across nursing, engineering, and architecture.
Results
A total of 127 graduate students were evaluated, the majority from nursing programs. Statistically significant improvements were observed across all assessed design competencies, with the greatest gains in applying 5S principles (203.7% increase) and process mapping (98.5% increase; p < .001). Qualitative findings demonstrated students’ ability to translate design concepts into professional practice, particularly related to workflow, privacy, safety, technology use, and environmental influences on care delivery.
Conclusions
Findings suggest this educational model supports workforce readiness to influence healthcare delivery, patient outcomes, and the design of care environments.
Introduction
Clinicians in their daily practice, particularly nurses, operate at the interface of the care environment, patients, and the interdisciplinary team. Despite this central role, most clinicians receive little formal preparation to understand, evaluate, and influence design decisions (Gregory et al., 2022). In contrast, engineers, particularly in industrial and mechanical systems disciplines, bring expertise in systems modeling and process optimization but may have limited exposure to the variability of clinical workflows and the human factors that influence care delivery (Carayon et al., 2018). Similarly, designers may lack direct understanding of clinical environments and operational constraints within healthcare systems. As a result, these disciplines are often prepared in parallel rather than in integration, contributing to misalignment between care processes, built environments, and system performance. The consequences of misaligned, disconnected healthcare design are significant to safety risks and costly inefficiencies, particularly in contexts where hospitals and healthcare facilities are closing or consolidating (Christianson et al., 2014). As healthcare facilities function as critical anchors for community well-being and economic development, their ability to remain operational is essential (Coates et al., 2025). In this context, empowering nurses with design literacy and built environment design disciplines with clinical care literacy is central to improving care quality and safety. Furthermore, interprofessional collaboration skills support the long-term sustainability of healthcare services within their communities through collective problem-solving and empathetic design approaches (Johnson, 2025). Despite recognition of this disconnect, there is limited empirical evidence evaluating educational models that intentionally build shared design literacy across clinical and design disciplines and assess the translational impact on professional practice.
Interprofessional Design Education
Interprofessional education is essential for preparing future healthcare and engineering professionals to contribute meaningfully to the design and improvement of healthcare delivery systems. Effective collaboration in healthcare environments requires shared language and mutual understanding across nursing, engineering, and related disciplines to develop solutions that promote safety, efficiency, and patient experience while meeting regulatory and operational requirements (Carthey, 2020). A recent scoping review of design thinking in nursing education highlights its value in fostering agile thinking in dynamic care environments, as well as strengthening interdisciplinary collaboration and the ability to synthesize diverse perspectives in decision-making (Wang et al., 2025). Similarly, engineering education has emphasized addressing complex “wicked” healthcare challenges through design thinking approaches that promote problem framing, creativity, and comfort with uncertainty (Davies et al., 2023; Vassar, 2025). Across disciplines, these approaches support a more holistic understanding of healthcare systems, with evidence demonstrating increased diversity of solutions and curiosity in problem exploration (Davies et al., 2023).
The growing complexity of healthcare delivery systems necessitates early exposure to interprofessional project collaboration within design teams. Due to the interdependent nature of modern healthcare issues, interprofessional design teams are needed to integrate knowledge from multiple disciplines in the planning and implementation stages of problem-solving. Introducing graduate nursing and engineering students to interprofessional design collaboration encourages them to develop skills in systems thinking and interprofessional collaboration that will shape their identity as designers, as well as their understanding of environments and processes in their careers.
The conceptual model guiding this study (Figure 1) illustrates how course structure, including integrated didactic and applied design experiences, influences student learning and professional development.
Transformational learning framework for interprofessional healthcare design education.
The course was grounded in Adult Learning Theory, emphasizing self-directed, experience-based, and problem-focused learning aligned with students’ workplace contexts (McCray, 2016). Perry's Scheme of Intellectual and Ethical Development further informed the curriculum by supporting progression from dualistic and multiplicity-based thinking toward relativism and commitment, wherein learners apply contextual knowledge and professional judgment to complex design decisions (Marra et al., 2000). Transformational Learning Theory provided a framework for understanding perspective shifts prompted by exposure to unfamiliar design challenges, with critical reflection operationalized through a reflective essay serving as a mechanism for integrating new ways of thinking about healthcare environments and systems (Fazio-Griffith & Ballard, 2016; Merriam, 2004).
Purpose
The purpose of this research is to evaluate the utility of an interprofessional design of healthcare delivery systems course offering at the university for effectiveness and translational application to workforce readiness of professionals in the healthcare built environment, such as engineering and nursing. The primary question addressed in this research via pretest/posttest quantitative results is: Does an interprofessional design-focused graduate course improve students’ knowledge and applied understanding of healthcare delivery system design? The secondary question approached through qualitative findings is: how do students describe applying design knowledge derived from this course in their respective professional roles?
Course Description
The Design of Healthcare Delivery Systems course is a graduate-level, interprofessional offering from the university. As an interprofessional course, students across disciplines may enroll in either academic year (16-week) or summer (12-week) formats. As a hybrid course, asynchronous didactic content is delivered via a learning management system (LMS), while clinical observation activities are conducted in person within students’ local healthcare settings. Students complete a minimum of 45 hr of observation, including Gemba walks, stakeholder interviews with healthcare staff, and shadowing within core service lines such as supply management, laboratory, inpatient care, and pharmacy services. These clinical observation experiences function as environments for inspiration, feedback, and validation of students’ system assessment applications and design proposals throughout the course. Once monthly, 2-hr virtual “intensives” were held that support applied learning through guest lectures, design charrettes, and problem-solving activities. The course is required in the nursing program plan of study, while an offered elective course for engineering and dietetics programs, serving as an introduction to the design of care delivery systems and integration of each respective discipline into the design process. In both academic and summer formats, students are organized into learning circles, which are small groups to facilitate deepened discussion and exploration of course content through peer engagement (Collay et al., 1998). Each learning circle includes an introduction to the topic that enables students’ deeper exploration of healthcare design challenges through guided objectives, literature-based inquiry questions, discussion activities, and reflective application to professional contexts. This collaborative approach to learning is an especially effective way to build the community of learning in the virtual classroom (Collay et al., 1998; Dulfer et al., 2025). As students enroll from across the United States and Tribal Nations, learning circles also function as mechanisms to translate and exchange design concepts to locally relevant environments and practice settings. Course content is grounded in healthcare systems engineering, and a complementary textbook was selected for its integration of engineering, medical, and nursing perspectives and its applied use of design tools within healthcare contexts (Griffin et al., 2016). Course-level learning objectives, guiding questions, and exemplar assignments aligned with these objectives are summarized in Table 1.
Course Learning Outcomes, Exemplar Assignments, and Student Inquiry Questions to Guide Learning.
Experiential and project-based learning aligned to the learning outcomes is interwoven through the application of lean methodologies (processes promoting system efficiency) to the built environment and organizational operations appraisal across different aspects of a healthcare system: clinical care; pharmacy; laboratory; supply management; interprofessional team management; and basic project management principles of evidence-based healthcare design. Examples of Lean methodologies applied across each aspect include assignments to create visualizations using value stream mapping, Pareto analyses, A3 creation, and root cause analyses (Table 1). The 5S principles (i.e., Sort; Set in Order; Shine; Standardize; Sustain) were integrated in student learning as a stepped method to promote organization and workplace efficiency (Muotka et al., 2023). Project management principles and tools, such as stakeholder discovery and community health needs assessment appraisal, were applied in student learning circles (small group learning) to spark feedback via directed discussion in an open forum (Knowles, 1978). Engineering students were distributed across different learning circles to provide shared perspective exchange and exposure to an engineering lens, given lower enrollment compared to nursing.
Methods
A mixed-methods retrospective evaluation study was conducted to assess the effectiveness of the course design and pedagogical approach via pretest/posttest knowledge assessment student data, with complementary reflective essay qualitative findings. Pretest/posttest design is an embedded evaluation component to elucidate the difference in skills, knowledge, attitudes, and behaviors of students from the beginning to the end of the course (Rogers & MacCormac, 2025). Reflective essays, completed at the end of the course, prompted students to provide a constructive self-assessment of how they met course learning objectives (Table 1) and to describe anticipated application of course content in their professional roles.
Sample
Students across six academic and summer cohorts (N = 127) from Spring 2022 to Summer 2024 were included in the sample, which comprised 114 nursing students (89.8%), nine engineering students (7.1%), and four dietetics students (3.1%). Nursing programs represented include Doctor of Nursing Practice (either Psychiatric Mental Health Nurse Practitioner or Family Nurse Practitioner) and Master of Nursing in Clinical Nurse Leadership. Engineering students were enrolled in the Industrial and Mechanical Systems Engineering Doctor of Philosophy, Master of Science, or Master of Engineering programs, while dietetics students were enrolled in the Dietetics Systems Leadership (Master of Science) program. To be included in the sample, students must have remained enrolled through the full course offering and submitted at least one of the measured assignments: pretest, posttest, and reflective essay. Students who withdrew from the course at any time or those with incomplete assignments were excluded.
Measurement
Two forms of measurement were used to gain a holistic understanding of students’ knowledge gain and application of knowledge as outlined by the course of learning outcomes. Students completed a quantitative pre- and post-course survey, and at the end of the course, they completed a qualitative reflection essay detailing how they met the six learning outcomes. A total of 102 reflective essays were analyzed using iterative thematic analysis.
Quantitative Measurement
Student knowledge of healthcare systems, design, and workflow processes was measured using a 7-point Likert scale and short-answer questions. The assessment was utilized to evaluate students’ changes in their conceptual knowledge and applied reasoning, rather than rote memorization and technical proficiency. Questions were based upon the course learning outcomes and measured students’ changes in knowledge and reasoning in various domains, including the ability to use workflow processes to identify and propose solutions to operational or environmental problems, understanding of healthcare systems and processes, and self-reported understanding of course content on both nursing and engineering concepts. A short written response concluded the assessment, requiring students to describe an approach to evaluating an operating room (OR) for patient safety, provider experience, and environmental fit.
Qualitative Measurement
Students completed a reflective essay at the end of the course describing their experiences with interprofessional collaboration, as well as their growth in design literacy, problem-solving skills, and understanding of how organizational structures influence healthcare delivery and patient outcomes. A reflective essay approach was selected based on evidence suggesting stronger alignment with competency development through self-reflection compared to traditional assessment methods, such as examination-based grading (Gabbard & Romanelli, 2021). Essays were analyzed and coded to identify themes under each learning objective using content analysis (Creswell & Poth, 2018). Essays were de-identified and imported into a structured spreadsheet for manual coding, which allowed for cross-cohort comparison. The initial coding framework was developed deductively from course learning objectives and refined through iterative review of the data. Coding procedures incorporated in vivo coding to provide authentic student voice, process coding for actions and experiential progression, as well as versus coding to identify potential contrasts in perspectives and decision-making by discipline (Bengtsson, 2016). Codes were then grouped into higher-order categories and themes through aggregate comparison across cohorts and disciplines (nursing, engineering, dietetics). Authors independently coded all essays and met regularly to compare the applications of codes and arrive at inter-coder agreement via consensus through majority approval.
Data Management and Analysis
Data were kept in a secure, encrypted repository on the university server, separated by academic or summer term and year (e.g., Summer 2022). Only the research team approved by the university IRB was permitted to access the repository for the minimum use necessary. Pre- and posttest data were analyzed using Stata Corps BE software. Data were de-identified to maintain anonymity, with proper nouns removed and student names stripped of respective qualitative coding and quantitative datasets. Credibility was strengthened through the triangulation of methods, using both qualitative and quantitative sources to compare students' perceived knowledge gain, as explained in the reflective essays, to the more objective representation of their knowledge gain seen in the changes in pre- and post-course survey answers (Lincoln & Guba, 1986). Intercoder reliability was established by determining a coding framework that organized codes under each learning objective and essay, creating a conceptual framework that explained the codes in a manner congruent with the coding framework (O’Connor & Joffe, 2020). Authenticity was enhanced through in vivo quotes derived from student essays, bringing forth direct lived experiences and diverse voices of healthcare and engineering professionals (Lincoln & Guba, 1986).
Ethics
Data were downloaded from the LMS upon approval from the university IRB (2024-1719-EX) into a limited dataset consisting solely of pretest, posttest, and reflective essay content. Pretest/posttest data were kept separately from the reflective essay documents to dissuade any identification from written content to student scores. A waiver of consent was provided by the IRB, given the aggregation of data interpretation as an educational offering evaluation. Reflective essay exemplars were stripped of proper nouns and any identifying details.
Results
Quantitative Findings
Students completed pre- and post-course surveys rating self-efficacy for healthcare systems and design-related tasks using a 7-point Likert scale (Table 2).
Pretest/Posttest Scores in Student Knowledge Assessments.
*p < .05.
**p < .001.
Across all domains, paired t-tests demonstrated statistically significant improvements in self-efficacy. The largest gains were observed in applying 5S principles, followed by process mapping and root cause analysis, indicating substantial growth in students’ confidence with core systems and quality improvement tools. Although the increase in self-efficacy for completing incident reports was more modest, it remained statistically significant. In both the pre- and post-course assessments, students were given a short description of a hospital that is experiencing a high infection rate in the OR and were asked how they would determine the cause of the issue and propose solutions. Their answers were coded, and the codes were quantified. The pre- and post-course codes, along with their frequencies, were analyzed using a Poisson regression. The Poisson regression with robust standard errors showed that post-course answers contained more coded improvement ideas (e.g., describing use of value stream mapping or direct observation) than pre-course responses at a significant level (IRR = 1.90, 95% CI [1.77, 2.04], p < .001).
Qualitative Findings
A total of 102 reflective essays were analyzed using iterative thematic analysis. The six-course learning outcomes served as overarching themes, with subthemes emerging inductively from student narratives (Table 3). The first learning outcome focused on interprofessional roles in leadership, advocacy, and integration of care. Prominent subthemes included integration of care (n = 27) and leadership roles (n = 27). Students described an increased appreciation for coordinating across disciplines to improve patient outcomes (e.g., “Nurses and doctors must communicate … nurses and supply staff must communicate … nurses can’t care for patients without supplies or meds… [P62]”), as well as greater confidence in assuming leadership roles and initiating system-level change (e.g., “…evaluating the system and addressing problems that arise [P44]”).
Qualitative Findings From Student Reflection Essays.
The second learning outcome emphasized the use of organizational and systems engineering tools to improve workflow processes and was the most frequently represented theme (n = 55). Nursing students often described gaining familiarity with analytic tools, while engineering and dietetics students emphasized their application in clinical contexts. Dietetics students echoed the benefit of applying tools, such as value stream mapping, with one noting, Before the utilization of this map, I had never thought about what time is lost for a patient throughout the [Neonatal Intensive Care Unit admission] process…. This can ensure that engineers include these changes, and they aren’t dismissed because of a perceived lack of necessity [P85].
The third learning outcome addressed coordination and leadership in collaborative problem-solving (n = 38). Students emphasized the importance of communication, shared understanding, and reduction of disciplinary siloes in achieving effective system improvements (e.g., “We need to reduce communication siloes! When workflows make sense for employees, they serve patients better [P97]”). These reflections demonstrated increased awareness of the role of structured communication and interdisciplinary alignment in driving system-level change. The fourth learning outcome focused on quality and risk management, with root cause analysis emerging as a key subtheme (n = 18). Students described applying structured approaches to identify system failures and emphasized the importance of team-based analysis in reducing errors and improving patient safety (e.g., “…tackle root-cause analysis of the error and collaborate to implement improvement [P1]”).
The fifth learning outcome examined system interrelationships and resource stewardship within healthcare operations. Students reflected on the application of analytic tools, such as Pareto analysis, to interpret complex system dynamics and support data-informed decision-making, often describing these experiences as transformative to their problem-solving approach (e.g., “…paradigm-shifting for me [P102]”). The sixth learning outcome addressed the influence of internal and external forces, including cultural context, on healthcare delivery. Students demonstrated increased awareness of how social, cultural, and historical factors shape care environments and design decisions, particularly in relation to underserved populations (e.g., “…through improved cultural competency, we can establish a therapeutic connection… [P76]”).
Discussion
Consistent with Adult Learning Theory, students demonstrated significant gains in self-efficacy for problem-centered tasks, particularly those aligned with learning outcomes related to systems evaluation and quality improvement (e.g., value stream mapping, root cause analysis, and A3 reporting; Table 1). These gains likely reflect the integration of applied observation, structured analytic tools, and team-based feedback, which together supported translation of conceptual knowledge into practice. While these principles are established for industrial engineering, their successful application in healthcare requires leadership buy-in, training, staff engagement, and sustained monitoring to measure long-term impact (Kanabar et al., 2024). Reflection essays revealed that students drew upon their professional and observation experiences, engaging in self-directed learning to apply course material in their workplace contexts. In the essays, students also described their shift from dualistic thinking about design and healthcare systems to holistic systems thinking at the conclusion of the course, consistent with Perry's Scheme of Intellectual and Ethical Development as noted in Table 1 (Marra et al., 2000). This shift was reflected both qualitatively in reflective narratives and quantitatively in the increased number and complexity of improvement-oriented concepts identified in post-course problem-solving scenarios (IRR = 1.90). The interprofessional nature of the course appeared to function as a disorienting dilemma characteristic of Transformational Learning Theory. Nursing students were introduced to formal workflowand systems analysis methods, while engineering students were exposed to the realities of patient care in clinical environments. This mutual disruption supported perspective transformation, as evidenced by students' descriptions of expanded professional identity and increased readiness to engage in leadership and design-related decision making within healthcare delivery systems.
Nursing students were introduced to formal workflow and systems analysis methods, while engineering students were exposed to the realities of patient care in clinical environments. This mutual disruption supported perspective transformation, as evidenced by students’ descriptions of expanded professional identity and increased readiness to engage in leadership and design-related decision-making within healthcare delivery systems.
The findings of this study indicate that interdisciplinary, design-focused education can function as a practical way to strengthen professional preparedness as it relates to healthcare environments. Embedding design literacy and systems logic within graduate education allows students to engage with healthcare delivery systems while professional identities and collaborative habits are still forming, supporting more effective participation in interdisciplinary contexts once in practice. Additional studies validate findings in this research, which support the value of interdisciplinary education in healthcare as a catalyst for enhanced communication, achieved through the development of communication competencies (Kandhari et al., 2024). As this course was hybrid across online delivery of content and on-site clinical experiences, the benefits of this type of delivery are validated from reviews of similar course offerings, which demonstrated strength in knowledge development and collaboration among student peers when synchronous and asynchronous opportunities were provided to prepare for specialization secondary to primary program focus (Gola et al., 2020).
Implications for Healthcare Design Education and Practice
Students completing this course are better prepared to recognize the interdependence of clinical work, organizational processes, and the built environment. This preparation is particularly relevant for nursing students, who routinely interact with care environments but are seldom positioned to engage in design-related decision-making, as well as for engineering students whose future work directly shapes clinical settings. These interactions progressively shifted students toward a more analytical, multi-modal appraisal of environmental conditions on care practices and collective contributions to environmental sustainability efforts, which enable safer, more satisfactory conditions for staff and patients (McCray, 2016). Shared exposure to analytic tools and experiential learning suggests potential for improved communication and collaboration across disciplines, although this finding is limited by nursing students being most of the study sample.
Shared exposure to analytic tools and experiential learning suggests potential for improved communication and collaboration across disciplines, although this finding is limited by nursing students being most of the study sample.
Limitations and Future Directions
This study has several limitations. This course is available at a single institution and thus limited in its generalizability. However, as a hybrid course, students are enrolled from other states and global regions, which permit a broad range of perspectives and experiences to be captured in this longitudinal appraisal of course effectiveness. Qualitative data were derived from self-reported reflective essays aligned to course learning outcomes. While this approach may limit the scope of responses, it provides direct insight into students’ perceived knowledge gains and application of design concepts to professional roles. The pre- and posttest assessments capture short-term changes in knowledge over either a 16-week academic term or a 12-week summer term, limiting inference about long-term retention or sustained professional impact. Not all students submitted the assessment survey or essays, creating missingness in the final dataset. Finally, variability exists across cohorts due to changes in guest speakers, observation sites, and local clinical contexts. Despite this variation, a consistent course structure, including a minimum of 45 hr of clinical observation focused on healthcare delivery systems design and the same lead instructor, was maintained across all offerings. The 16-week academic term and 12-week summer term follow the same curriculum, content, and learning objectives; the summer offering represented a condensed format with adjusted pacing rather than substantive differences in structure or delivery. Additionally, the combined nature of instructional approaches (e.g., clinical observation, structured reflection, and learning circles) limits attribution of observed outcomes to any single component. The systematic evaluation presented in this study provides a foundation for future course component audits to better understand the relative contribution of each element and inform refinement of the most impactful aspects of the curriculum.
Future directions based on the observed success of the course include the development of a scalable course model to promote across institutions of higher education, mapping across the nursing Essentials (American Academy of Colleges of Nursing), and credentialing bodies for engineering and architecture to include additional disciplines crucial to evidence-based design. Additional efforts are underway to longitudinally track the professional impact of the skills provided in this course through capstone projects, dissertations, and careers post-graduation through surveys and case studies. In parallel, course content has been translated into continuing education and professional development offerings for practicing clinicians through partnerships with national organizations such as the Nursing Institute for Healthcare Design, Sigma Theta Tau Nursing International Honor Society, and the American Organization for Nursing Leadership. Additional programmatic development includes a proposed interprofessional certificate in healthcare design, policy, and an international summer field program focused on healthcare environments and systems in low-resource settings. These combined efforts will facilitate a deeper examination of the translation of this course and additional products (e.g., certificate program) on workforce readiness in healthcare design and sustainability of this course model with the ever-evolving demands in higher education. Future course iterations will enable the priority to balance interdisciplinary enrollment, which will support cross-disciplinary comparative analysis.
Conclusion
This study evaluated the utility and pedagogical approach of an interprofessional graduate course in healthcare delivery systems design involving nursing and engineering students. Findings demonstrate that shared design methods, direct clinical observation, and collaborative appraisal of real-world care delivery challenges may strengthen professional skill development and design literacy across disciplines. Students demonstrated increased self-efficacy, systems-oriented reasoning, and readiness to engage in interdisciplinary problem-solving related to healthcare environments and processes. Collectively, these results highlight the value of interprofessional design education as a mechanism for bridging clinical and design perspectives within healthcare. Expanding such educational models may support more effective participation across broad ranges of disciplines in the planning, evaluation, and improvement of healthcare delivery systems and care environments.
Implications for Practice
Interprofessional design education, particularly at the graduate level, has the potential to enhance collaboration among disciplines influencing the healthcare built environment, such as nursing and engineering.
The use of small group learning circle assignments coupled with in-person observation experiences and asynchronous resources supported the practice of using methods and tools for the design of care systems.
Students’ knowledge base, attitudes, and application skills increased significantly from start to completion of the course, demonstrating pedagogical efficacy.
Footnotes
Ethical Considerations
Montana State University IRB, #2024-1719-EXEMPT.
Consent to Participate
Waiver.
Author Contributions
EJ designed the study, analyzed the data, and manuscript development including revisions. NH collated and analyzed data and manuscript development. DP contributed to data interpretation and manuscript development. JZ analyzed the data and contributed to manuscript development. All authors approved the final manuscript.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.