Translating research into practice

How can we secure better healthcare environments for end users by ensuring that the holistic value of landscape is not excluded from final delivery?

In the face of climate change, economic disparity, ageing populations and mounting rates of mental illness, recent scholarship has called for a reappraisal of the connection between design and care; and a subsequent reorientation of education and practice towards an ethic of care. This scholarship tends to valorise a particular version of practice, one that engages with communities, non-governmental organisations and municipal authorities on projects intended to meet the needs of marginalised groups. Though a compelling theoretical proposition, much of this scholarship remains conveniently at arm’s length from the realities of contemporary practice, including the need for architecture and landscape architecture to remain financially viable professions. What if we broaden the definition of architects that ‘care’ to also include those who are committed to advocating for definitions of value beyond the economic, and that demonstrate both the willingness and the skill to fight for that value to be recognised throughout project procurement?

‘Difficult buildings and occasional battlegrounds’ is an apt descriptor for healthcare projects. I’ve researched the design of these environments for more than a decade, and architects consistently lament the flawed procurement systems that result in compromised design outcomes for end users. Many of these compromises occur in relation to landscape, where budgets are cut despite veritable mountains of evidence confirming the value, not just of landscape views, but of access to quality green space to improve the wellbeing of hospital patients, their families and healthcare teams. While cost is the excuse typically offered up for compromises deemed necessary, my research confirms what most design practitioners already know – compromises also arise from perceptions of risk related to innovation; conflicting stakeholder preferences; the constraints of government supplier agreements; the promise of short-term savings over longer-term economic returns; even cleaning procedures, and the desire to standardise them across a large building. All these factors play a role in obstructing the implementation of design solutions intended to support physical health, psychological wellbeing, learning (including that which is necessary during rehabilitation) and social connection. Yet the savings associated with these compromises are often negligible.

At a broader scale, what this tells us is that the capacity of built (and landscape) environments to extend care goes beyond the question of having reliable evidence. Instead, this is inextricably tied to the agency of the designer within a complex procurement ecosystem that often acts to constrain it.

Lags in the uptake of evidence by designers themselves have been lamented by academic researchers. Among the explanations tendered include the costs of research engagement for design practices and their clients; a lack of expertise relative to sourcing and evaluating research; and the risk of experienced practitioners becoming set in their ways. Yet little of this research examines the obstacles related to the procurement process itself. This fact is significant. Jos Boys has suggested that to understand the ways that designers ‘care‘, we should not consider built outcomes but ‘how one acts as a designer‘. This is inherently difficult, given such acts are often concealed behind the closed doors of confidential meetings, or buried within built outcomes that obscure the arguments fought and lost. Perhaps more important than the question of who these ‘caring’ designers may be is the question of how they manage to successfully navigate complex procurement processes to secure better healthcare environments for end users?

Conversations with a range of healthcare designers, both in Australia and internationally, reveal a shared set of practices. The most common is the justification of landscaped spaces as part of a project’s Environmentally Sustainable Design (ESD) strategy. I can point to examples of significant roof gardens, in paediatric and palliative settings alike, that barely survived the ravages of budget cuts and did so only owing to their necessary contribution to meeting ESD targets.

The presence of a ‘design champion’, someone working within a healthcare organisation but in support of the design team’s vision, is another factor to which architects commonly attribute successful outcomes. As one architect noted in relation to a medical professor arguing for openable windows in palliative care settings, “You can’t ignore a professor telling you... that a person with slipping consciousness is still going to register [fresh air] as fundamental.” What is curious about this is just how easily a designer saying the very same thing can be ignored. The utilisation of academic literature to validate a design response is another, sometimes successful, strategy. Yet the uptake of that evidence by key stakeholders seems, again, more important than the evidence itself. This speaks further to the critical role of a design champion in negotiating better end user outcomes.

While none of this is likely to surprise, more interesting is the role of deeper forms of engagement with end users, such as through co-design practices, that “empower clients to set higher quality briefs that enable design teams to deliver higher quality projects”. My current research traces the relationship between research informed design, procurement models, and the end user benefits embedded in the subsequent built form. Across the typologies of paediatric, palliative and mental healthcare, we are seeing extensive co-design processes with end users that architects credit with minimising compromise within value management processes. What can be provisionally hypothesised here is that deeper forms of end user engagement may be a powerful lever to support greater architectural agency within the procurement process. These stories of success deserve closer examination to better understand how the profession could be reorientated, not simply to aspire to care, but armed with the skills to successfully put this ethic into practice.

Dr Rebecca McLaughlan is a Senior Lecturer in Professional Practice, Architectural Design and Research at the University of Sydney. Her research examines the impact of healthcare environments on end user wellbeing across paediatric, oncology, palliative and mental health care settings.