...Design research does not actually begin with a master database. In this article, we explain the challenges of identifying the right problem and techniques for prioritizing problems. Seeking out a problem is part science and part art. Individuals new to design research or who desire textbook solutions will find their first efforts especially challenging. Seasoned PhD design researchers in practice recognize that seeking out problems requires a careful balance of rigor, flexibility, and discovery. It is, assuredly, the most important step in obtaining results that are both relevant and enduring to the design process.

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July 20, 2012
Research in Practice: Lesson 2
By By Nicholas Watkins, PhD, EDRA Chair; Erin Peavey, Associate AIA, LEED AP BD+C; Gena English, AAHID, EDAC, RAS; Upali
Nanda, PhD, EDAC, Associate AIA; Dale Pozzi; Derrek Clarke, AIA, LEED AP BD+C; Janet Kobylka, AAHID, IIDA, EDAC, LEED AP
BD+C
“Research in Practice: Lesson 1—Testing Same­Handed and Inpatient Rooms with Canted Headwalls Using a Master Database”
appeared in the May 2012 issue of HEALTHCARE DESIGN. In that article, we discussed the benefits of developing a design
research master database to investigate hard­hitting issues with inpatient room design.
However, design research does not actually begin with a master database. In this article, we explain the challenges of identifying the
right problem and techniques for prioritizing problems.
Seeking out a problem is part science and part art. Individuals new to design research or who desire textbook solutions will find their
first efforts especially challenging. Seasoned PhD design researchers in practice recognize that seeking out problems requires a
careful balance of rigor, flexibility, and discovery. It is, assuredly, the most important step in obtaining results that are both relevant
and enduring to the design process.
In this article, we’ll introduce readers to problem identification and will explain a little about pilot testing, an often­overlooked yet
effective technique to seek out and identify problems. Well­structured pilot testing can be enormously helpful for a project team
because it can be used to discern whether the problems originally identified are the right ones to target.
Which old problem? The wicked problem
The healthcare field is rife with multifaceted and interrelated problems. It is very common to find that the solution to one challenge
reveals (or is related to) another. It is some consolation that these tangled challenges have been the subject of inquiry for several
decades. They are formally known as “wicked problems” (Rittel & Webber, 1973) and have been recently characterized in design
research as “… complex, persistent, and contradictory problems relevant to broad groups of stakeholders, each having a different
potentially diametrically opposed perspective on an issue” (Hamilton, 2008).
Simply put, a wicked problem is, among other things, complex, ongoing, and enmeshed with other problems. Often, resolution of a
wicked problem requires a tradeoff based on what is most important to the organization.
Examples of the wicked problems that routinely confront healthcare facilities might include staff inefficiencies, patient falls, hospital­
acquired infections, and medication errors. For example, decentralization of medications can cut back on the number of medication
errors due to distractions.
On the other hand, it also may lead to fewer opportunities for collaboration, shared awareness, and informal learning opportunities
among staff. How you understand your problem tradeoffs can lead to different solutions.
Refining problems: An example where every step counts
Nurse walking distances can be a multifaceted problem related to other problems. How do you optimize nurse travel distances when
each facility has specific challenges, multiple drivers that contribute to nurses’ walking distances, and there are several possible
solutions? One popular solution is decentralized nursing.
However, there is a veritable menu of decentralized nursing options including room­side supply cabinets, workstations­on­wheels,
bedside computer terminals, nurses’ stations outside of each room, and nurses’ stations every few rooms. Which you choose
ultimately depends on a good understanding of your problem.
Examples from our project work illustrate how something as seemingly simple as nurse walking distances can be complex and
idiosyncratic. Statistics from one hospital with distinct and small inpatient units showed us that nurses walked beyond the industry
average largely because they were continually untangling cords around cluttered headwalls and outlets.

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At another hospital with several decentralized nursing strategies, statistics showed that increased walking was attributed to
documentation and medication retrieval at the main nurses’ station. Understanding the problem helped to refine it and enable
potential solutions.
Pilot testing: A twist on an old technique
How can you tell that nurse walking distances is a major issue for you? How can you find the causes in your organization?
A twist on an old technique, pilot testing, will help.
Traditionally, pilot testing involves a dry run of all the protocols and tools of a research study. If you are new to design research, you
can think of pilot testing as analogous to a mock­up of a key room for a new hospital. Testing your design research process down to
the smallest detail provides insights for the mechanics of the research.
For example, pilot testing can reveal the extent to which staff can be involved, how a study may interrupt the day­to­day flow of
existing operations, and how the location of study materials may affect workflow and infection control protocols. Even a relatively
simple study can seem highly complex when the details are worked out.
Most important, pilot testing can provide insight in crucial areas beyond fine­tuning details of your protocol. Added advantages to pilot
testing include the following:
It can help filter down to a definitive scope and schedule what seemed initially like a daunting and broad design research
project.
It allows the research team to seek out both small­scale problems and to test larger assumptions to hone in on what matters
most.
It affords a training opportunity for individuals assisting with data collection.
It is easy to underestimate the extent to which pilot testing can reveal and refine problems, even for existing design research
hypotheses that may be too narrow or underwhelming. Many times the pilot testing will help researchers develop new, exciting, and
previously unconsidered hypotheses to test.
Putting the park back into Parkland
Design research work at Parkland Hospital in Dallas, offers a perfect example of the potential of pilot testing to reveal problems that
matter most. Here, pilot testing not only helped prep for the main study but also defined the challenges unique to the organization.
An urban hospital that primarily provides care for the underserved communities of Dallas, Parkland Hospital is in the process of
creating a new $1.27 billion, 1.97­million­square­foot facility. The goal for the new hospital is, aptly, to “put the park back into
Parkland,” by creating an urban oasis that encourages healing with calming spaces and soothing environments.
Parkland’s presence at the heart of the Dallas community will affect healing and well­being within its walls and the urban fabric by
reinforcing accessibility to care and sustainable communities. Figure 1 illustrates one of several healing landscapes that connect the
existing and new Parkland Hospital to a new transit development and the Dallas urban fabric. The site will be accessible through a
link with the Dallas Area Rapid Transit (DART) light rail.
Like the design of the new hospital, study development challenges were ambitious:
Measure and explore links between patient­centered care and the patient’s journey (i.e., continuum of care) in and outside
the hospital, using experiences at Parkland’s existing facility as the baseline.
Measure and assess relationships among patient, patient visitor, and staff experiences to understand the FF&E needs of
patients along their journeys.
Use results from the investigation to inform the new Parkland Hospital’s FF&E selection and planning.
Where to begin? An initial screening of patient satisfaction scores from the hospital’s departments and an extensive on­site
assessment of these departments narrowed the study’s scope to two key areas along the patient’s continuum of care: inpatient units
and imaging.
Though we did our homework, pilot testing would prove useful. There was little precedent for research of these topics within the
design research field. Consequently, the problems were ill­formed for the field and the organization.
MRI anxiety and compliance
The first example relates to our research of waiting areas for magnetic resonance imaging (MRI) procedures. Initial literature reviews
and brainstorming led our team to assume that the most anxiety­producing window of time for patients undergoing an MRI would be
the period just prior to the start of the procedure. Logically, the appropriate area of focus in this case would have been on creation of
a design to minimize anxiety in reception and waiting areas.
The eye­opening results from two­day pilot testing, however, revealed implications for design interventions that spanned the entirety
of a patient’s MRI journey. What we learned was that patients at Parkland experienced the most anxiety not prior to the test but in the

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window of time following the test.
This shifted the design focus to the changing area used by patients after the test concluded, prompting our teams to explore a
“decompression and patient education zone” for the main study. These decompression zones are like those proposed for counseling
settings and used by survivors of trauma who experience memorials (Watkins & Anthony, 2007; Watkins, 2008).
Future tests will focus on high­impact and affordable art and furnishing interventions throughout the entire MRI experience. These
interventions are argued to lower anxiety both before and after the procedure. The lower anxiety may lead to reductions in patient
movement and sedative use during the actual MRI procedure. This, in turn, may improve post­procedural patient compliance and
attendance for future MRIs (as measured by a subsequent mail­in questionnaire).
Musical chairs (on inpatient units)
Pilot testing on three inpatient units suggested some unanticipated relationships between operational efficiencies and family­
centered care. Before the pilot testing, there was a lot of interest in learning more about where and how long patients’ visitors were
waiting on the unit.
The concern was that excessive waiting in waiting rooms, corridors, and elevator banks was detracting from family­centered and
patient­centered care. How could unit layout and furnishings prevent this? And which solution would matter more?
During the pilot testing, our team observed that patients with large families were moving chairs from the waiting areas into patient
rooms. This created a challenge for the nurses who had to dedicate time to clearing rooms of chairs following visits.
The chairs were also creating clutter inside inpatient rooms, which the statistical results suggested may contribute to patient slips and
falls. This game of musical chairs on an inpatient unit is hardly fun. It strains staff and may well contribute to patient safety risks.
Enter the wicked problem. Statistics also suggested that when patients were visited by more family members and these family
members assisted nurses and patients by managing several smaller tasks (e.g., assisting with patient bathroom transfers; opening
window blinds), patients were more satisfied with their care, felt more in control of their surroundings, and made fewer demands on
staff.
The musical chairs were contributing to inefficiencies but perhaps indirectly contributing to increased satisfaction.
The problem to explore next in the main study was not how to limit chairs in patient rooms. Rather, we needed to seek ways to
measure the impact of alternative seating arrangements within and outside the inpatient rooms. This might include examining the
value of a seated respite area separate from the waiting areas and patient rooms and/or fold­out chairs inside patient rooms. Figure 2
illustrates the universal patient room deployed at Parkland.
An ounce of prevention
If you do engage in pilot testing, be prepared to allocate time, staffing, and budget accordingly. Ben Franklin is famously quoted for
saying, “An ounce of prevention is worth a pound of cure.” His axiom holds for pilot testing. Pilot testing is a small fraction of the time
and cost of a full study. If you invest fully in your pilot testing, you will avoid several headaches and unnecessary costs during your
main study.
After pilot testing, be sure to account for the time needed to clean data, perform the data analyses, revise the research methods, and
revisit your initial hypotheses. It is a good idea to let the data inspire you to focus on problems you had not originally intended to
study within the main study and to clarify why you received a few unanticipated results.
Depending on your sample size, you may be limited to basic descriptive statistics for your analyses. Pay particular attention to
participants’ open­ended responses as they will help explain surprising results and refine hypotheses.
To dig deeper, schedule reviews of the findings with the client team. Remain realistic and open­minded during these reviews: clearly
convey to the client that you are sharing results from pilot testing to inspire ideas for the main study. The results are not conclusive.
Do not lose sight of the many journeys ahead—including the transition to the main study. The main study should come soon after the
pilot testing to keep information fresh in the minds of research assistants and to minimize re­training based on the changes made to
the study procedure. HCD
Acknowledgements
The authors would like to thank the staff of Parkland Hospital who took part in the pilot testing. Also, the authors would like to thank
contributing team members and colleagues, including Robin Bajema, Kathy Harper, Gay Chabot, Elizabeth Jones, Sheeba
Kuriakose, Bilu Mohid, Leslie Echols, Jodi Donovan, and Chris Korsh.
Nicholas Watkins, PhD, is HOK’s Director of Research & Innovation. The authors would like to thank the clinicians, patients, and
visitors who have taken part in the research and findings shared in this article. Correspondence concerning this article should be
addressed to Nicholas Watkins, HOK, 1065 Avenue of the Americas, 6th Floor, New York, NY 10018. He can also be reached by
phone at 646.385.7624, by fax at 212.633.1163, or by email at nick.watkins@hok.com.

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Hamilton, K. (2008). Wicked problems, black swans, and healthcare. Health Environments Research & Design Journal, 2(1):44­47.
Pena, W.M., & Parshall, S.A. (2001). Problem seeking: An architectural programming primer (4th Edition). New York, NY: John Wiley
& Sons, Inc.
Rittel H. W. J., & Webber M. M. (1973). Dilemmas in a general theory of planning. Policy Sciences, 4, 155­169.
Watkins, N. (2007). Connecting research and design in counseling settings. Research*Design Connections, 3.
Watkins, N. (2007). Mirror mirror on the wall: Ambiguous place attachment and the Vietnam Veterans Memorial. In J. Bissell (Ed.)
Proceedings of the Thirty­Eighth Annual Conference of the Environmental Design Research Association. Oklahoma City, OK: EDRA.
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