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Research based practice and

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Jan Golembiewski

on 15 December 2014

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Transcript of Research based practice and

[LUT, 2004]
Investigating a range of workable solutions
[STAGG "Ruimte voor Patienten" 2002]
Research based practice + practice based research
Mungo Smith, Dip Art & Design, Dip. Arch, RIBA
Jan Golmbiewski, BFA, BArch, MArch, PhD
Research is essential for improving the effectiveness of design.

There's a growing expectation that healthcare design (in particular) will be founded on research - much as surgery, pharmacology and other innovation in healthcare should be.

There are statutes to make sure that pharmaceuticals receive the highest standards for testing: Research is phased, and registration of 2nd (& higher) stages of trials is compulsory to be sure that even negative outcomes are duly reported.

But research isn't always so rigorous in other areas of medicine.

There are controlled empirical studies, and there's also a lot of practical 'on the spot' experimentation based on real-world experience. Most medical research is of this kind.
Research based practice + practice based research
Research + practice
From the outset MAAP bridged research and praxis.

Medical Architecture has always been research led - but holistically, leading with big-picture ideas (wherever clients want them) and improving them with empirical evidence gleaned from decades of uninterrupted experience AND from empirical studies.
origins in research
Mungo Smith joined the Medical Architecture Research Unit (MARU) at the London Metropolitan University in 1988 to run the 'Live Projects Office.' Soon he was the Acting Head of Research.
Delivering about 30 primary care facilities, developing design guidance and conducting POE's.

In 1991 Smith and and 7 others left MARU to set up Medical Architecture.

The scientific method is easily transferred.
It sometimes becomes propriety Intellectual Property (IP)
It often leads to highly quantitative data.
Without research, we can only justify continuing along the same course,

not because it’s better, but because doing the same as we always have is somehow defensible.
Sure it is. Experimental practice-based research is the foundation of modern medicine. It's essential for progress, for innovation. Every good clinician and medical architect does it. That's what makes them good.

It might not be about creating new tools,
but experimentation improves existing
paradigms by making them:
More effective,
or better in some other way.
Is practice-based research okay?
The scientific method:
Both practice-based research and scientific method studies are empirical in that both are:
• concerned with direct evidence (facts)
• backward looking

Advantages: empiricism improves and further establish existing paradigms.

Internal Validity
External Validity
Where internal validity of most empirical (incl.) practice-based research is high, the external validity is lessened outside of the study. For eg. the LUT study about bed access is useless for understanding genetics and looses applicability even if the bed size changes.

Theory however must have broad relevance and can explain and sometimes resolve complex and interdependent data - even beyond traditional discipline boundaries.

eg. Antonovsky's salutogenic theory
has good external validity.
But is innovation
always really wanted?
Paradigmatic shifts in the physical environment require a correlated shift in work-culture and treatment regimes: the 'model of care'.

Paradigmatic change is only needed where there is dissonance between best-practice models of care and the physical milieu.

Currently generic mental health facility design guidance for instance, is like specifying numbers of candles needed in an operating theatre. It's based on 18th century logic and standards that have been updated, but haven't been challenged in 250 years.

Evidence-based Design
EBD is a term that has been co-opted by EDAC – a private evidence-based design accreditation and certification body.

It’s a certification given to architects who can prove that they have engaged in empirical research.

EBD is useful, but only at honing old and possibly redundant tools. The success of EDAC is somewhat unfortunate, because big-picture thinking is lost in its bias.

The certification suggests that practitioners have engaged in the scientific method. Is this useful information?

Only in that is suggests that EBD Certified practitioners might be 'formatted' to resist theoretical approaches.
Mungo Smith, one of the founding directors of Medical Architecture is going to talk about how he and the team put these ideas into practice and set them out as exemplars for others to follow.

1. The patient room
The flagship of the modern general hospital

2. The staff station
The iconoclastic dismantling of the glazed staff stations in the in-patient mental health unit
Two case studies
The patient room
Medical Architecture
Case Study #1

The in-patient bedroom is the flagship of the modern acute hospital. A bed (as opposed to patient) centred model of care that invariably brings services and amenity to the bedside.

Separate studies have provided conflicting information for both designer and operator.

Typically these include:
Space around the bed
Same-handed rooms
View from the window
Ensuite location, access and configuration
Location of the clinical washbasin

Doing the research
STAGG (1992) "Area around bigger beds - floor areas in relation to costs."

Cason C, Evans J, Harvey T, Pati D, (2010) "An empirical examination of patient room handedness in acute medical-surgical settings"

Ulrich RS. (1984) "View through a window may influence recovery from surgery."

Maze C. (2009) "In-board, Out-board or Nested?"

Ulrich RS et al (2008) "A Review of the Research Literature on Evidence-Based Healthcare Design"

IN-PATIENT ACCOMMODATION 1995-2010 (Medical Architecture)
Health Building Note 04 – Inpatient Accommodation
vol. 1 Options for Choice 1995 - 1997
vol. 2 European Case Studies 1996 - 1998
Space Around the Bed 1999 - 2000
Ensuite Facilities Research & Development 2005 - 2006
Hillingdon Pilot Ward 2006 - 2013
Health Building Note 04-01 Adult Inpatient Facilities 2006 - 2008

Using mock-ups to the test the theory
Full scale mock-ups are used in developing standards and can help inform design
But what is really important in patient rooms?

The patient!
Worked example
The limitations of space
The fact is that a larger more expensive room could achieve all the requirements of the patient unit because it would be possible to provide all the desirable qualities within a certain minimum geometry. Evidence is used both to mitigate and to reduce cost, Capital Cost, although without proper research into Whole of Life costs, we do not know whether the extra investment in, say a longer life and looser fit would have been be a better investment.
of choice
[MAAP, U.K. Department of Health and York University]
Research based practice +
Practice based research

The staff station
Case Study #2

The glazed staff station harks back to a form of monitoring and security designed for 18th century prisons.

What is its relevance in 21st century mental health facilities?

Custody or recovery?
The typical cruciform plan and section:
Beds are disaggregated
No flexibility between bed areas
Centralised day space
Restricted outlook
Internal corners are difficult to plan
Dead end corridors
Dispersed outdoor space difficult to observe
Privacy in bedrooms compromised

A closer look
Space Around the Bed 1999 - 2000: Key findings
Research identified the need for clear zones of activity in the patient room and that more space was required around the bed.

Other issues to address included:
Increase privacy
Reduce staff injury
Encourage therapeutic activity
Reduced recovery time
Increase independence
Increase flexibility
Single rooms provide considerable benefits for patients, clinicians and hospitals
Reduced adverse clinical errors
Increase privacy, dignity and independence
Increased capacity
Control of infection
Reduce costs

Ensuite Design 2006 - 2013: Key findings
Transforming the plan
The centralised staff base (orthodox approach)

The central shared space and garden (alternative approach)
The single-storey plan
Urban multi-storey options
Springfield Hospital masterplan
Urban scale and integration
Victoria DoH adopted MA’s design principles following case study research and in-house review workshops with local architects

International peer review
Dandenong Hospital Mental Health Facilities, Victoria, Australia
[Bates Smart/Irwin Alsop Architects 2011]
[Elevation, section and plan of Jeremy Bentham's Panopticon penitentiary, 1791]
[UK Health Building Notes 04.01 2008]
the staff station:
the institution:
Two-storey courtyard plan
Hillingdon Hospital Bevan Ward
An on-going live research project investigating options for single bedrooms and ensuites
Not the space!

[Letterkenny AMH by A&D Wejchert Architects]
From guidelines to buildings: a disconnect between the recovery model and the panopticon parti.
the guidelines:

the buildings:
Custody or recovery?
The basic plan with
centralised staff station:

The plans multiplied:
no privacy in gardens
undefined public/private space
lack of identity
internally focused

[Avon & Wiltshire NHS Trust]
Assessment of space, configuration and location
Scaling up
Poor line of sight from the door
Skewed geometry makes pairing difficult
Poor exterior views
Can not be same handed
St Olav's
The really big picture is that we need all kinds of research to make healthcare better: Theoretical, Practice-based and experimental.
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