Research in the Healthcare Design Practice: Design Practitioners’ Perspective

Abstract

Objective:

This study explores design practitioners’ level of knowledge about research, their attitude toward research integration into the design practice, and the barriers to its application in the design process.

Background:

Design practitioners tend to heavily rely on previous design experience and precedents rather than utilization and application of research. Research can facilitate the evaluation and creation of innovative design solutions. Integrating research has been a challenge for the design industry.

Methodology:

The study utilized an online survey to solicit feedback from architects and interior designers in the healthcare sector through a snowball sampling approach. The survey comprised closed-ended and open-ended questions categorized into three distinct sections, each focusing on one of the study objectives. A total of 115 participants completed the questionnaire.

Results:

Practitioners tend to integrate research into the early design phases and programming. It is recognized as a tool for design enhancement by 62%, while 7% considered it to be a hindrance to their creativity. Primary data collection methods include collaboration with colleagues and user groups rather than journals and trade magazines. Cost, time, and lack of expertise are the top three hurdles in applying research in practice.

Conclusions:

Practitioners have a positive attitude toward research, perceive it as an impactful design enhancement tool, and use it to promote their credibility. Lack of research expertise hinders the use and conduct of research. According to design practitioners, research is costly and time-consuming and impedes their ability to fulfill clients’ goals and the project timeline.

Keywords

research-informed design Practice-based research design research evidence-based design (EBD)Healthcare Design

The design of healthcare facilities is one of the most demanding and complex project types, requiring a diverse body of knowledge from the fields of medicine, technology, environmental psychology, and design (Brambilla et al., 2019). Design practitioners specialized in healthcare design should prioritize safety, efficiency, and improved experience for patients and their families when designing such complex infrastructures. In addition to warranting an effective healing environment, such healthcare outcomes are desired by clients. Utilizing research can tangibly demonstrate the value added by design in improving safety, efficiency, and the overall patient experience. Research provides tools for gathering information, subsequently informing the design decisions and assisting in measuring the impacts of these decisions on both patients and staff (Nanda & Harvey, 2014).

In academia, numerous research studies have been conducted over the last 3 decades that have found a relationship between design and healthcare outcomes. An example of these is the influential work by Ulrich (1984). Ulrich (1984) found a positive relationship between window views and the recovery time of the patients from surgery (Ulrich, 1984). Research conducted in academia has repeatedly shown that the physical environment can impact the health and well-being of both patients and staff, operational efficiencies, and patient and staff safety (Clancy, 2008; Freihoefer et al., 2018; MacAllister et al., 2016; Ulrich et al., 2010).

Nonetheless, adopting academic research in the design industry is challenging due to the required time, expertise, and level of rigor required. Design practice needs a distinct approach to research. Stichler (2016) describes the purpose of research as “regardless of the field or discipline, is to generate new knowledge and investigate the research questions in a systematic and rigorous process, following qualitative or quantitative research methodology” (pp. 7–12). However, design practitioners often use what is called the “best practice” instead of research (Hamilton, 2014). He further notes that the best practices emerge from design practitioners’ experience with the clients’ needs and the knowledge gained from design solutions developed for those needs. This has led to increased attention to approaches, such as evidence-based design (EBD), that bridge design and research while considering its applied nature.

The EBD is defined as “the deliberate attempt to base building decisions on the best available research evidence to improve outcomes while continuing to monitor the success or failure for subsequent decision-making” (The Center for Health Design [CHD], 2020). Research-informed design is often used interchangeably with EBD (Hamilton, 2014). EBD is distinguished from research-informed design in that EBD casts a broader net to capture evidence, as opposed to research-informed design, which only relies solely on research to develop design solutions (Peavey & Vander Wyst, 2017; Stichler, 2016). Hence, integrating research in the healthcare practice is an urgent need (Hamilton, 2015), but do practitioners devote resources and commitment to utilizing research to inform the design process?

A survey study indicated that design practitioners rarely refer to scholarly journals where these research processes and findings are published Huber (2016c). The study found that only 12% of design practitioners utilized research from scholarly journals to inform their designs. Healthcare practitioners are unsure of their ability to understand the language of scholarly research (Hamilton, 2007). As a result, these stakeholders are hesitant to interpret or draw conclusions from the research methodology and results and integrate it into the design process (Wagenaar & Mens, 2019). Their minimal experience with research can lead these practitioners to perceive scholarly research topics negatively (Huber, 2016b) or that the research topics are “too simplistic, deterministic, or unwarranted” (Fisher, 2004).

The current literature fails to understand healthcare design practitioners’ research expertise, their knowledge of research, and their attitude toward research-informed design and associated challenges. This study aims to bridge this gap and explore design practitioners’ (1) level of knowledge about research, (2) attitude and perception of integrating research in practice, and (3) research application and integration into the design process.

Method

To assess how research in practice is recognized, perceived, and adopted, this study utilized a survey method using Qualtrics web-based platform. The survey was answered anonymously. The questionnaire included a combination of closed-ended and open-ended questions categorized into three distinct sections, each section focusing on one of the objectives of this study. The open-ended questions aimed to provide an in-depth insight into practitioners’ perspectives on integrating research into the design process. The multiple-choice questions and Likert-scale-type questions constituted the closed-ended questions. Section 1 included three items, which were developed to measure practitioners’ level of knowledge on research. Two questions used a 3-point Likert-type scale of 1 (disagree) to 3 (agree), while the third question was multiple-choice focusing on the type of research training.

The second section of the questionnaire focused on the perception and attitude of the design practitioners toward research and included 10 questions. The first two questions used 5-point Likert-type questions about the willingness to use research and the degree of agreement on the positive role of research in design decision making. The remaining questions in this section included three multiple-choice questions and two open-ended ones focusing on the purpose and timing of research integration as well as its influence on business prosperity.

The third section focused on the application of research in the design process and included 20 questions. The questions included six 3-point Likert-type questions focused on their workplace’s approach to research application, where “1” indicating disagree, “2” indicating neutral, and “3” indicating agree. Further, six 3-point Likert-type questions focused on the likelihood of use of research with “1” being very unlikely, “2” being somewhat likely, “3” being very likely. The third section also included seven multiple-choice questions focusing on familiarity with conferences and other resources. The open-ended question asked for identification of facilitators for and barriers to research integration. Finally, participants identified their role within the firm, field of study, level of education, sex, and age-group.

To ensure the validity and reliability of the questions, the researchers sought feedback from five architects and interior designers and refined the questionnaire accordingly. Through a snowball sampling method, the online survey invitation email was distributed among architects and interior designers via direct invitations as well as national professional organizations including local chapters of the American Institute of Architects (AIA) and the American Society of Interior Designers (ASID). The survey was open for 30 days. A total of 165 participants participated in the survey of which 115 completed the survey, giving a completion rate of 70%.

Results

The Results section is categorized into the knowledge of research, perception and attitude, and application. Each category is answered by a set of closed-ended questions. Qualitative data are presented next.

Demographics

The field of study of 75% of participants was architecture, 18% was interior design, and 8% was a combination of design and nondesign degrees such as architecture and business. The most common level of education was master’s level with 52% (n = 59), followed by bachelor’s (39%, n = 45), postprofessional degree (3%, n = 3), and doctorate (6%, n = 8). Females made 51% (n = 58) of the participants, followed by 47% (n = 54) males and 2% (n = 3) who wished not to specify. Most participants were in the age range of 41–50 (24%, n = 27), followed by 31–40 and 51–60 (each 22%, n = 25), 23–30 (18%, n = 20), and 61–70 (12%, n = 13; see Table 1).

Table 1.

Demographics.

Characteristics	n (%)
Gender
Female	58 (51)
Male	54 (47)
Did not specify	3 (2)
Education
Bachelor’s	45 (39)
Master’s	59 (52)
Postprofessional	3 (3)
Doctorate	8 (6)
Field
Architecture	85 (74)
Interior Design	20 (18)
Combination of design and nondesign degrees	9 (8)
Age-group
18–22	1 (1)
23–30	20 (18)
31–40	25 (22)
41–50	27 (24)
51–60	25 (22)
61–70	13 (12)
71<	1 (1)

Knowledge of Research

Of 115 responders, 51% (n = 59) indicated that they are not trained in conducting empirical research, and 30% (n = 34) indicated they are not knowledgeable in conducting empirical research. The rest of the participants agreed that they are at least somewhat knowledgeable in conducting empirical research. When asked about training, 29% (n = 33) indicated they learned through collaborations with others (e.g., clients, mentors, supervisors), followed by 26% (n = 30) who had taken research-related course work, 14% (n = 16) with certifications, and 10% (n = 12) who were self-trained.

Perception and Attitude

The participants were asked whether they value research in practice, and 97% (n = 111) agreed that they did, 1% (n = 1) were neutral, and 3% (n = 4) disagreed. Further, participants were asked whether they are willing to financially invest in research, and 45% (n = 52) agreed that they are willing to financially invest in research, 50% (n = 52) indicated they are neutral regarding this matter, and the remaining 5% (n = 6) disagreed. When asked about their level of agreement about the role of research in improving design decisions, 98% (n = 113) agreed that research improves design decisions, while the remaining 2% (n = 2) were neutral. In response to the statement that research can limit creativity, 66% (n = 70) disagreed, 27% (n = 29) were neutral, and only 7% (n = 7) agreed. Being interested in integrating research into the design process resulted in 98% (n = 104) agreeing, 2% (n = 2) being neutral, and with no disagreements.

The perception of participants on the role of research was investigated with the majority (62%, n = 71) identifying research as a tool for design enhancement, 19% (n = 22) identifying it as a tool for communication with clients, and 3% (n = 3) identifying it as a tool for marketing. The remaining 17% (n = 21) described the role of research as a combination of all the above, and also as an education tool for self and clients, to help improve operational flows and health outcomes and to produce questions and data to enable clients to make informed decisions about the design challenges on their projects. The question allowed participants to add any other feedback regarding issues that had not been explored. In response, many indicated research is a tool for marketing, design enhancement, and communicating with clients.

Another question focused on timing—when do designers integrate research into the design process? Participants could select multiple responses to this question. Of all responses, “throughout the design process,” meaning predesign phase, during the design and documentation, and after the completion of the design project, was the highest rated response (35%, n = 73). “During the design process” was the second (28%, n = 59). “Before the start of the project” was selected as the third highest ranked phase (26%, n = 54), and “integrating research after the completion of the design project” was the lowest ranked response (11%, n = 24).

Application

Successful application of research in the design process requires workplace support, in addition to individuals’ positive attitudes toward research. When asked, all agreed that their workplace values research and its application in the design practice. About 75% of responders agreed that their workplace would financially invest in research by hiring external researchers. About 10% (n = 11) had no in-house researchers. On the other hand, only 4% (n = 4) indicated a lack of access to research materials, and only 3% (n = 3) had no encouragement to use research.

Barriers to research integration were mostly due to fast-paced projects (23%, n = 91), concerns around the potential increase in costs (21%, n = 83), and timeline issues with an overlap of design and construction phase (19%, n = 76). Other recognized barriers included a lack of knowledge and skills in implementing and integrating research (12%, n = 51) and a potential lack of understanding of research materials (9%, n = 37). Lack of access to research materials (8%, n = 31) and lack of support from supervisors (8%, n = 31) were the least influential factors in hindering the integration of research.

Participants were asked when they are likely to integrate research in the design process. “Programming” phase was ranked as the highest (M = 4.59, SD = 0.88), followed by “early design phase” (M = 4.65, SD = 0.87), “feasibility study” phase (M = 4.37, SD = 0.99), “request for proposal preparation” phase (M = 3.72, SD = 1.48), and “postconstruction” phase (M = 3.58, SD = 1.62).

Most participants (94%, n = 107) were aware of the peer-reviewed journals, and 67% (n = 75) of them indicated they have access to peer-reviewed journals. This made journals the third source of information collection about design strategies (18%, n = 71), after collaboration with colleagues (27%, n = 106) and user groups (20%, n = 77). Trade magazines (17%, n = 68) and books (12%, n = 45) were the other sources of information used by design practitioners. The remaining 6% listed a variety of sources such as conference, CHD’s website, professional meetings, the internet, advisory board, and in-house researchers. Regarding conferences, learning experience showed an average of 2.38 (SD = 0.61) on a scale of 1 to 3, with “1” being minimal (7%, n = 8), “2” being fair (49%, n = 51), and “3” being good (44%, n = 46). The participants could elaborate on other information sources by choosing the “other” option. The responses included the internet, continuing education units, in-house researchers and librarians, and CHD.

Further, the affiliation of participants was asked. Considering that participants may have multiple affiliations, the total number of responses was 252. About 31% (n = 78) participants were affiliated with the AIA, followed by 21% (n = 53) with Leadership in Energy and Environmental Design (LEED), and 14% (n = 35) with Evidence-Based Design Accreditation and Certification (EDAC). The rest of the participants have various affiliations with AIA Health Knowledge Network (12%, n = 31), American College of Healthcare Architects (8%, n = 20), ASID (3%, n = 8), American Academy of Healthcare Interior Designers (1%, n = 2), and other (10%, n = 25).

Qualitative Data

Qualitative data complemented the quantitative data by triangulating the findings. To investigate participants’ perspectives on the application of research in design practice, three open-ended questions were asked. The first question was focused on the facilitators of and barriers to research application. The second question inquired about the perceived benefits of research application for their designs and/or businesses. The third question asked about participants’ perception of harm to a design or their businesses, if they adopted research.

Barriers and facilitators

For qualitative analysis, the responses were categorized into three main groups. Then, each main category was thematically analyzed to determine main themes relating to facilitators and barriers. Each theme was further examined by extracting concepts within each theme to demonstrate what factors constitute each. The three main categories found are (1) access to research, (2) conducting research, and (3) applying research (see Tables 2 and 3).

Table 2.

Perceived Facilitators of Research Integration in the Design Process From Healthcare Design Practitioners’ Perspective.

Categories	Facilitators	Concepts	Example Quotes
Access to research	Research materials	Locating resources	“We seek out research of others or if needed, do our own research on a case-by-case basis when we can’t find research done by others.”
Conducting research	Expertise	Having the expertise Research rigor	“solid base of researchers in company is a real benefit.”
Conducting research	Organizational support	On the senior management level Leadership	“Facilitators: Advocates, Implementers, Leadership, Leaders who see the value and just do it as a part of their projects.”
Applying research	Team members’ attitudes Stakeholders’ attitudes	Client type and need	“Mostly the Client, some are very interested in research and willing to support it, others still seem not to see the value in research, and view it as added cost or Lengthening the project schedule.”

Table 3.

Perceived Barriers to Research Integration in the Design Process From Healthcare Design Practitioners’ Perspective.

Categories	Barriers	Concepts	Example Quotes
Access to research	Relevance	Specific topic	“Access to research based on specific needs.”
	Timeliness	Timely access to resources	“Access to research quickly is the biggest barrier.”
	Research materials	Finding up-to-date information	“Not knowing where to look for the most up to date research.”
	Research expertise	Not knowing how to conduct research Not understanding research findings	“being able to understand plainly what the results and directives are from the research.” “Not knowing where to start or how to conduct it in an unbiased manner.”
Conducting research	Time constraints	Research timeline not aligned with design/construction timeline Time investment The need for early collaboration with clients Lack of appropriate planning	“Schedule is the number one. Time to market has become critical for health systems and adding a research phase early in the project timeline can rarely be accommodated.” “the pace of research is often out of sync with the design and construction process.” “The timeline for research is much longer than design schedules usually allow for an integrated process.”
	Organizational support	Value recognition	“design teams not fully understanding how research can help outcomes.”
	Client-related privacy concerns
	Finances	Clients’ reluctance to add costs Clients’ buy-in is essential Cost to the firm Cost to client	“Financial dynamics in architecture and design. No one will pay for it, even our largest clients.”
Applying research	Team members’ attitudes	Lack of consensus on how to apply research	“Lack of consensus about how to apply the knowledge gained.”
Applying research	Stakeholders’ attitudes	Fear of change/unknown Clients’ willingness and cooperation Willingness from the project team No perceived value	“Fear of change or of being shown a better way than how you have done it before.”“There are certainly different types of clients and projects. Likely, the majority of clients and projects are more transactional in nature—a client has a need, and they select a design team to produce documents so that a problem can be addressed. This process offers little room for research and advancement. Unfortunately few clients and projects are given enough latitude, time, and fee to really investigate the problem, develop potential solution paths, and determine which approach will not just solve the current problem, but maybe take care of others in the process.”

The category of “access to research” identified four facilitators and barriers including relevance, timeliness, research materials, and research knowledge and expertise. Relevance referred to accessibility to research significant to the specific needs of the project requirement. Timeliness implied timely access to research is important. The third barrier to research was identified as research materials including content. This explained both the challenge of finding up-to-date information and being able to locate information and resources. The fourth theme was about research knowledge and expertise. Some participants indicated they find it challenging to access research when they do not have the expertise to fully understand the findings of scholarly articles or they do not know how to conduct research.

The second category was “conducting research.” Five themes were identified under this category, which included time constraints, experts, organizational support, client-related privacy concerns, and finances. Participants indicated that time issues are one of the main barriers to conducting research due to the following reasons: (1) research timeline not being aligned with design and construction timeline, (2) the significant amount of time investment needed, (3) the need for early collaboration with clients, and (4) lack of appropriate planning. For example, a participant explained that schedule is a priority, given healthcare systems’ high demand to build rapidly, which makes it challenging to conduct research in the early phases of the design project. Another participant added that research is time-consuming, which requires significant time investment and makes it unviable to progress parallel to the design development.

The second theme was about expertise. The responses showed that expertise and research rigor are the two main considerations when conducting research. Some responders acknowledged the importance of producing research that is rigorous, and others indicated that not having the expertise in the firm creates a barrier to conducting research.

Organizational support was another theme related to “conducting research.” Support from the senior management level and leadership, and recognition of the value were the two noted issues. The responders indicated that having leadership who sees the value in research and advocates for research is an important factor in the ability to conduct research. However, the responders also added that the research value should be recognized by design teams.

Additionally, conducting research was mentioned to be a challenge due to concerns regarding confidentiality about business entities or projects. Finally, finance was another frequently mentioned barrier. Relevant factors include clients’ reluctance to increase project costs including to firms and to the client. Client-related concerns, including “buy-in” to research, are the primary barriers identified.

The third category was “applying research” and consisted of two barriers, team members’ attitudes and their consensus on how to apply research and stakeholders’ attitudes. The lack of consensus on how to apply research was related to both agreement among the design team members and between the design team and the clients. Finally, barriers related to stakeholders’ attitudes included (1) fear of change/unknown, (2) clients’ willingness and cooperation, (3) client type and need, (4) willingness from the project team, and (5) no perceived value. Many responders agreed that most clients are driven to complete a project directly based on their needs and as quickly as possible, which imposes many barriers related to schedules, required time, and financial investment in research.

Perceived advantages of research integration

Participants described the benefits that research integration or application can offer to their designs or businesses. The responses were analyzed and categorized into six main themes including improved communication with clients, business prosperity, promoting innovation, outcome improvements, improved design quality, and informed design decisions (see Table 4).

Table 4.

Perceived Advantages of Research Integration.

Advantages	Concepts	Example Quotes
Improved communication with clients	Helps clients determine the value of design solutions Substantiates advice given to clients	“This gives assurance that we are recommending best operational practices for our clients.”
Business prosperity	Marketing Reputation and credibility Recruitment and retention of staff and clients Firm’s portfolios enhancement	“Good design is good business!”“More clients and designers are wanting to make decisions based on science, not just what ‘seems like a good idea’ or ‘Let’s try that’, potentially risking harm to Patients/Users and wasting financial resources. This can also help improve the culture of hospitals, when science supports the design of the environment, staff are more likely to be willing to adapt.”“Research can enhance firms’ portfolios of work and promote innovative approaches to their view of design.”
Promoting innovation	Evidence-based innovation Allow for creation of design guideline Allows seeing matters from others’ perspective	“I believe that conducting research throughout the life of the project can help the design team, owner and specific project stay in a dialogue with current research and innovative design solutions.”“It helps our ability to ground innovation and create the reasons why something should be adopted. In Healthcare it can improve healthcare outcomes.”
Outcome improvements	User well-being and healthcare outcomes	“…it is so important to prove if it works or not in order to improve our design outcomes and have data to support them.”
Improved design quality	Improved design thinking	“A project that has an emphasis on research ultimately sharpens the focus of the project team, and thereby enhances the thoughtfulness and quality of the design solution.”“Research helps create a better design that meet client’s needs when it’s integrated within the predesign and design process.”
Informed design decisions	Improving design decisions	“Data can help sway decision making when best practices are not enough.”“Programming and design decisions based on the results of qualified research can only enhance the final product.”
	Validating design decisions	“Research as a tool to validate design and making informed decisions.”

The responses showed that improved communication with clients is one of the benefits of the research, as it helps clients determine value in the proposed design solutions, and it substantiates advice given to clients. Further, research integration can improve businesses by being a means for marketing, enhancing reputation and credibility, sustaining recruitment and retention of staff and clients, and enhancing a firm’s portfolio. Promoting innovation was another main theme shown to benefit firms by producing evidence-based innovation, design guidelines, and by allowing designers to better see matters through the clients’ perspectives. Further, research integration can improve firms’ outcomes by validating the firms’ design strategies that improve well-being and healthcare outcomes. The improved design quality is another benefit for firms, which implies the final solution is usually of higher quality. Research can challenge the design intent and inspire designers to think outside the box and as such can enhance the design. Research integration can improve decision making by informing design solutions. Finally, research can be beneficial by validating the design response. Such validation demonstrates firms’ expertise and effective design decision making.

Perceived disadvantages of research integration

Participants were also asked to describe how they think research can harm their designs and businesses. A total of six main themes emerged: finances, conflict with design intent and clients, time requirement, compromised research quality, bias, and compromised creativity (see Table 5).

Table 5.

Perceived Disadvantages of Research Integration.

Disadvantages	Concepts	Example Quotes
Finances	Costly Extra/additional cost More than clients are willing to pay Does not pay for itself	“Research may be hard to incentivize with certain clients which would leave the financial burden of conducting or collecting research to the design firm.”
Conflict with design intent and clients	Conflict with clients’ wants Afraid of outcome not supporting design intent	“Some clients may be afraid of the outcome, usually because they know something isn’t work right to begin with and they don’t want hard facts to demonstrate that.”
Time requirement	Slows down the timeline Time-consuming	“The timeline for research is much longer than design schedules usually allow for an integrated process.”
Compromised research quality	Incorrect application due to misunderstanding the data Poor research design and conduct No supervision from research team during design phase	“…the details of the research could be misunderstood and therefore applied in the wrong way.”“Research can be expensive and can sometimes be inconclusive if it’s too broad.”
Bias	Used for marketing Misrepresenting	“…so the research doesn’t actually affect the design, it is used to ‘Confirm’ or ‘Sell’ previously held opinions.”“those who only want biased research to support ‘the way its always been done’ and not acknowledging or willing to consider other solutions.”“Businesses could be harmed if research is seen to be inaccurate or biased.”
Affects creativity	Limiting Hindrance to creativity	“We should embrace research but not rely wholly on it at the expense of creativity: the quantitative and qualitative must co-exist and support each other.”“It can feel like a hindrance to creativity at times. Sometimes it sparks ideas and other times it feels like you are chasing an idea trying to get it to work and not letting it create ideas.”

Finances were repeatedly mentioned as a disadvantage due to research imposing additional costs. The responders indicated research costs more than clients are willing to invest and hardly generates enough revenue to be self-sustaining. The second theme was the resultant conflict with design intents and not meeting the client’s expectations. Related factors were conflict with clients’ requests and fear of not meeting the design intent. Time requirement was another theme that indicated that the time-consuming nature of research can hinder the project timeline. The responders were concerned that added time to the project schedule might be “wasted time.” The fifth theme was bias, which reflected on an intentional bias to use findings for marketing or unintentional bias because of misinterpretation of the findings. Finally, the responders specified that research can be a disadvantage if it limits creativity in the design process. Although some comments indicated embracing research is important, it should not sacrifice creativity.

Discussion

Existing literature is limited but reveals the importance of research in practice and its role in evaluating healthcare facilities to promote health and well-being (Clancy, 2008; Zborowsky & Bunker-Hellmich, 2010), but the integration of research in the design process has been slow despite its significance (Freihoefer & Zborowsky, 2017). Thus, it is vital to identify the challenges associated with the integration of research in practice (Pasha & Shepley, 2013). This study looked at the healthcare design practitioners’ knowledge about research, their attitudes and perception of research integration, and how they apply research in the design process.

Knowledge of Research

The results of this study indicated that most design practitioners are either not trained in or not knowledgeable in conducting empirical research, which were like the findings of Huber (2016a). The qualitative data similarly revealed that lack of knowledge is one of the important perceived barriers to applying research in design practice. Design practitioners’ potential difficulty in translating research-driven information and metrics into design solutions may be a contributing factor to the pervasive and persistent misconceptions regarding the utilization of scholarly research (Huber, 2016a). Some participants indicated they do not have any formal training in conducting research, but the others, who stated some level of training, considered collaboration with others (e.g., colleagues, clients, in-house researchers) as their educational or training experience. However, differences between collaboration with colleagues versus clients were not distinguished. Interestingly, when asked about the most commonly used sources of information gathering, participants highly rated collaboration with others and user groups. Peer-reviewed journals were rated lower as a source of information, although most participants indicated they were aware of peer-reviewed journals.

More than half of the participants had a master’s degree; however, only half of the participants with a master’s degree had research-related coursework, perhaps due to the design focus of most professional degrees. Further, only a small percentage of participants carried EDAC compared to other certifications such as LEED, which is consistent with the number of certificate holders shown in current literature (Freihoefer & Zborowsky, 2017). Also, practitioners did not rate certificates highly as a source of research education or knowledge. This is surprising since EDAC is highly relevant to research in design practice, and maintaining it requires continuing education units, which are research-related materials (e.g., journal articles, conferences, and webinars).

Lack of knowledge and training prevents design practitioners from both using research and conducting research. Design practice tends to rely on previous design experience or best practice in developing design solutions as opposed to research. If practitioners and researchers translate research findings into tangible design ideas, over time, the research-informed design solutions can perhaps become considered to be the best design practices (Hamilton, 2018).

Perception and Attitude

Additionally, most participants recognized the value of research as a design enhancement tool and that research-informed design plays an important role in long-term outcomes in healthcare systems. This demonstrates an understanding of the role and relevance of research and its influence on the overall design industry and healthcare outcomes. The qualitative data showed a similar notion by identifying some of the advantages of research-informed design as having improved design quality and validated design decisions. Although the qualitative data showed that research can impact design decisions positively, the survey results revealed only few participants felt that research may limit their creativity.

Although the qualitative data showed that research can impact design decisions positively, the survey results revealed only few participants felt that research may limit their creativity.

In addition to the recognition of research value in making informed design decisions, participants believed that research could add value to their business model, increase their credibility and reputation in the market, and validate their communication with clients. Despite the positive business attributes, financial investment was consistently identified as a major dilemma in both quantitative and qualitative results. The survey showed only few disagreed that they are willing to invest financially. Further, most participants positively rated their workplaces’ support in research applications in various forms such as valuing research, providing research materials, and encouragement. However, data showed financial investment and timeline are the primary barriers to allowing research applications.

The practitioners’ perception regarding when and how to prioritize research in different stages of design and construction varies in different projects. Participants think that research should be used consistently through all phases of design and construction and most heavily in the design process itself. However, participants indicated that they mostly utilized and integrated research in the programming phase of the design, followed by early design phases, feasibility study, request for proposal, and postoccupancy evaluations to evaluate and validate their design strategies.

Application of Research

Nevertheless, the findings showed that research is unlikely to be incorporated through the entire design project timeline. Both quantitative and qualitative data elaborated on this by identifying timeline overlaps and fast-paced design and construction developments as two of the barriers to research application. Practitioners are eager to apply research, but due to the fast pace of the projects and time constraints, they find it challenging to do so. One of the practitioners expressed that the timeline for research is much longer than design schedules hence preventing them to incorporate any research-informed decision making, especially on smaller projects. Another participant linked the speed of the project, the timeline, and the willingness for financial investment to the scope of the project, meaning that larger, multiyear projects are more likely to have the capacity for research investment time-wise and cost-wise.

Findings further indicate that stakeholders’ attitudes including apprehension and resistance to change impede research integration. While some clients are interested in research and willing to support it, others still seem not to see the value in research and view it as an added cost or time in the execution of the project. Practitioners making a case to clients by presenting design decisions supported by evidence can help clients see the long-term added value, return on investment, and implications for other facilities in their healthcare systems (Nanda & Harvey, 2014). Such information aligned with clients’ needs might change clients’ perspectives on investing time and finances for research support (Hamilton, 2015).

The participants’ perceived barriers to research integration were mostly due to project timelines, concerns around the potential increase in costs, lack of knowledge and understanding of research materials, and lack of skills in implementing research. Research in the design practice aims to base design decisions on insight gleaned from relevant evidence. While research in practice is certainly committed to advancing the profession, it operates within the constraints of time, logistics, and finances (Pasha & Shepley, 2013). To establish best practices based on research-driven evidence, ongoing efforts in integrating research in practice is essential (Hamilton, 2018). Reinforcing these efforts could be possible by creative solutions around time and cost constraints and engaging other resources such as outside collaborators and educators (Pasha & Shepley, 2013). Research-informed design practices not only can grow the body of knowledge but can also improve healthcare outcomes.

Conclusion

The significance of conducting and applying research in the healthcare design practice has been growing especially with the emergence of research-informed design and EBD. However, as discussed and reviewed, many practicing firms still do not integrate research in the design process. This study investigated the level of knowledge of research among practitioners, how they perceive research, and how they apply it in the design process. Further, the study looked at facilitators of and barriers to research integration into the design practice.

Design practitioners perceive research as valuable and are willing to apply research in their projects. Despite a positive attitude toward research throughout all phases of design and its perceived impact on design quality and the firm’s reputation, a lack of research expertise within a firm is one of the major obstacles. The practitioners recognize the value of research as it pertains to healthcare outcomes and design decisions. Nevertheless, cost, logistics, schedule, clients’ reluctance to invest time and capital, and project team’s lack of knowledge toward research and research utilization impede the opportunity to integrate research. The practitioners feel the high cost and time investment impeding the ability to fulfill clients’ goals and timeline.

Including a research expert on the team can help translate the implications of finding to the design teams and clients. The experts can lead the research efforts in alignment with the project goals. Although costly, it is an investment in improving the credibility of the firm with potential long-term return on investment. Design practitioners strive to demonstrate their value to their clients, which can be accomplished by educating clients about the value of research and attempt to integrate research into the project contract. The evidence compiled from various research-informed design projects can inform future projects and establish best practices for the healthcare design industry.

Design practitioners strive to demonstrate their value to their clients, which can be accomplished by educating clients about the value of research and attempt to integrate research into the project contract.

Limitations and Future Research

This study came with limitations. Although the snowball sampling facilitated recruitment, future research should take a stratified sampling approach with random selection to ensure firms with various sizes and cultures are included to boost generalizability. The survey included both open-ended and closed-ended questions; however, given that the topic of this research is new, the use of other research methods such as focus groups would allow for exploration of more issues. Future research should also evaluate correlational relationships between variables of interest. Given the important role of clients in integrating research in the design process, a survey of both practitioners and clients would shed some light on potential resolutions for concerns such as timeline and costs. Collecting information about the role of architects and interior designers (e.g., medical planner, project architect) and their educational level can be informative. It is also worthwhile to investigate the perception of clients, including medical professionals, on the definition of research and its rigor in architectural fields. Future research should explore the attitudes toward using research among practitioners that specialize and are frequently involved in the same types of environments in the healthcare sector.

Implications for Practice

Due to the lack of research expertise being one of the obstacles for integrating research into the practice, adding research experts to the team could facilitate such integration.

Sharing the value of credibility and reputation building with clients may help justify their investment in research.

Since financial investment in research is a major obstacle, solutions could focus on justifying the value added to clients.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Sara Bayramzadeh, PhD, MArch

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