Emily Carr University of Art + Design has engaged in designing for complex problems in healthcare for many years, and recently formed a specific research area, the Health Design Lab, to gather a range of initiatives together into one centre. One of the lab’s partners is Vancouver Coastal Health (VCH), a publicly funded regional health authority that employs 13,000 full- and part-time workers, and offers a range of services to over one million residents of British Columbia. Yet it struggles with a myriad of large, complex systemic problems common to healthcare everywhere.
The challenge that VCH asked us to consider was that while patient lift aid devices were accessible to every residential care bed within their care, their use was not completely adopted by residential care aides (RCAs). The subsequent rate of RCA injury, according to VCH, cost approximately $8,000,000 per year in associated benefits and lost time [6]. VCH wanted to effect a behavioral change that would result in lower rates of injury. Communication design students Daisy Aylott,Craig Fleisch, Lan Yan accepted positions as research assistants for this initiative and were supervised by professors Jonathan Aitken and Deborah Shackleton.
Research Process
Client briefing
The VCH contacts for the project were Catherine Fast, (Executive Director, Workplace Health) and Helen Tam, (Project Manager). Both have responsibilities for safe patient handling within the VCH system. Their focus is on building workplace communities in which stakeholders share common values and beliefs, actively engage in learning from each other, and are sensitized to common desired behaviours. These principles were central to our design thinking about lifting safely as well as the make-up of the target audience. According to data provided by the client the majority of RCAs are between the ages of 40 – 59 years of age, predominantly female and have recently immigrated to Canada.
RCAs provide care for residents in need of constant attention. Many of the residents have limited mobility, and require assistance in daily activities. To this purpose, lift devices have been installed over almost every bed in VCH facilities. While lift devices are great tools, they are not always used correctly, leading to injury. Through our research, however, it became clear that misuse of lift devices was not the root of the problem. Although safety is the underlying issue for VCH, we found that in order to improve on it, three complementary areas would need attention. Our team proposed a behaviour change campaign focusing on improving community, communication, and wellness between staff and management to address the growing safety concerns.
Secondary research
Our research focused on behaviour change design, persuasive design, as well as previous projects tackling healthcare design, human-centred thinking and social marketing. The research scope was purposefully broad to gain real insight into the realm of health design.
A paper by Catherine Fast, whose Master’s thesis was about leadership at VCH facilities, gave great insight into the advantages of peer coaching and leadership in the field of healthcare design. Her thesis findings demonstrate the importance of leadership in the hospital environment and the hospital’s working hierarchy as factors that influence a care aide’s attitude and role in the hospital [1]. This research gave us our first look into the opportunities of changing safety behaviour by addressing the user’s thinking and habits.
Our research into persuasive design and basic psychology theory in design led us to the work of B.J. Fogg and his theory on triggered behaviour through design. He states that many familiar habits and actions are commonly caused by a “trigger.” Triggers are small reminders or visual connections that influence a desired action to occur [2]. Triggers in application can be as simple as an email reminder focused on eliciting the action of visiting a website.
We looked heavily into social campaigns and marketing precedents using principles of behaviour change to create successful applications. One strong example was an anti-smoking campaign, Truth, which was aimed at youths to influence their smoking habits. By examining the visual language and tone of brands already trusted by teens, Truth was able to better understand their audience. Researchers examined teen psyche as it related to smoking, and began to understand that the main issue driving this behavior is not that teens are uneducated regarding the dangers of smoking, but rather that the act of smoking is an act of rebellion and a symbol of control [3]. The resulting campaign’s messaging emphasized that: “it’s not about anti-smoking, or pro-smoking, it’s about the manipulation of the tobacco industry.” Addressing the rebellious attitude that leads to smoking, the campaign exposed the tobacco industry as manipulative and controlling, showing that smoking is just another act of following orders.
Ideo’s human-centred design toolkit provided a theoretical and practical understanding of approaches to gathering vital information through our primary research [4]. The toolkit introduced us to step-by-step examples of co-creation techniques and empathetic thinking in working with their audiences.
Primary research
Our primary research began with job shadowing, which took place at two different extended care facilities. Immersing ourselves in these work environments not only helped the team to learn about the problem from a much closer perspective, but also allowed us to learn more about the tasks performed by RCAs. This experience proved helpful during the co-creation session, as the team was well-versed in the various tasks asked of RCAs and was therefore able to converse with participants on a more educated level. This first-hand understanding of the daily workflow was a great advantage in all stages of the process, and guided most design decisions.
We hosted a co-creation session at Emily Carr, a neutral environment in which all participants felt comfortable voicing their opinions and concerns. Opening up the session with an icebreaker game helped engage participants with one another, and built a certain level of trust between the RCAs and our team. Three activities followed, each addressing a different area we wanted to learn more about. Through a mood board exercise, we were able to better understand the emotional side of an RCA’s work. The second activity was a questionnaire intended to reveal preferred communication modes and devices. Early on the process we had considered designing an app but the audit taken during this session showed that most of the RCAs present felt uncomfortable with this technology. Many of our assumptions were challenged during the co-creation activities, leaving us with a new understanding of the problem space. The final activity was a timeline that mapped out typical emotions felt during a shift; this helped us understand at which points in a shift RCAs felt the most stressed versus the happiest. The mapping became a guide for selecting when and where to interject our final designs.
Following the co-creation session, we explored many new ideas and once we had a few design directions, we hosted a user-testing session, again at Emily Carr. Many of our previous participants returned for the follow-up session and acted as session leaders. We gained feedback on the potential directions, both in terms of visuals and content. The RCAs engaged in the activities promoted by our designs and provided feedback regarding the experience. This session was a turning-point in our designs, and from it we gained a much more refined visual direction.
Final design
From our primary and secondary research, we developed the concept of Stay Safe, a behaviour change campaign developed to help strengthen community, wellness, and conversation in order to improve overall safety at VCH residential care facilities.
Stay Safe endeavors to develop a new culture into the VCH setting, a culture devoted to creating a sense of community, respect, safety and wellness for all involved with residential extended care.
As many individuals make up VCH, Stay Safe promotes the development of connections between staff and sees potential in building a learning community. Through the building of friendships, support, respect and wellness, a facility as a whole can become stronger. Multi-level involvement in this campaign, and not just management, would be necessary to ensure its success as well as enable equal opportunity, discussion, and growth.
In order to accommodate the variations and diversity between facilities, the Stay Safe campaign’s structure is customizable. After an initial phase shared by all participating facilities, the campaign divides into three directions, allowing each facility to select their next steps. The three directions, “Our Message,” “Our Reason,” and “Our Focus,” touch on different areas for improvement. The overall purpose of these campaigns, directly influenced by the co-creation sessions, was not to dictate change around lift usage, but to promote a more general sense of community around safety. This, in turn, would lead to a stronger cultural sense of safety, which would encourage better lift usage.
“Our Message” focuses on the celebration of RCA knowledge. A peer-to-peer education system is set up to recognize the importance of an RCA’s role in the facility and build comfort around the idea of asking for help. Asking RCAs to share their tips not only recognizes the wealth of knowledge that each care aide holds, but also establishes a rich learning environment in the facility.
“Our Reason” strives to create a comfortable, familiar environment at extended care facilities, and asks RCAs to consider their motivations for staying safe. Motivation can come from a number of sources–family, friends, travel, and hobbies are just a few examples. These reasons, however, are often forgotten in the workplace. “Our Reason” reminds RCAs of their personal motivation for staying safe through imagery and objects reminiscent of home.
“Our Focus” places emphasis on the physical well-being of the individual, and strategically promotes safety during an RCA’s work schedule. Encouraging healthy breaks and promoting relaxation as a positive habit are ways to create a better understanding of body mechanics. Through stretching prompts, visual triggers and relaxation specific areas, RCAs learn to personally manage their own wellness.
Our decision to include three directions was based largely on our primary research findings. Each facility faced a different set of problems, management involvement varied considerably and staff count was drastically different at each location. From these findings, we discerned that a single solution would not be appropriate for all facilities. Instead, our systems-based approach is variable and can be suited to the individual location. Stay Safe was met with great enthusiasm by VCH and proved to be a successful example of how design can have a positive influence on healthcare.
Analysis
Limitations of results
Firstly, while action research generally, and co-creative techniques specifically, should engender positive uptake of the designed campaigns by RCAs, there is no direct evidence from this case study that this will be so. The participant group sizes were small (fewer than 25 participants) and all were from a local urban context. Further, we had no direct control over participant selection, and the process was certainly not randomized. So while successful acceptance by a more general RCA population can be inferred, this cannot be confirmed until the next phase of testing has been completed.
Secondly, if the campaign is well received by RCAs, there may or may not be a resultant change of behavior in patient lift use. VCH will pilot test the campaigns in 3 or 4 facilities, measuring pre- and post-campaign levels of lift compliance. This measurement will take 6 months to a year, and is beyond the scope of this case study. The results, however, will be critical in understanding the efficacy of the campaigns, and the empirical relevance of the participatory design process.
Implications of results
If successful, which as discussed will not be known definitively for 6-12 months, the project will effect a behaviour change that could result in lower rates of RCA injury. Even a 25% reduction in injury would result in a $2,000,000 cost savings per year and immesurable personal benefits to workers.
Conclusion
Even with the limitations described above, the project can already be deemed a success in other ways. The nature of the participatory design process was new to this division of VCH and was very well received by both management and RCAs. It was perceived by the RCAs to be a genuine effort to assist them in reducing injuries, rather than being a “top down” economically motivated stricture. Rather limiting attendance to a small group of administrators, Fast and Tam invited facility supervisors, members of their executive, and RCAs. Even the RCA union was invited to send representatives (although they did not do so). This openness seems a genuine shift in attitude towards a desire to fully engage with the wider group affected and inclusion in the thinking and processes behind the implementation of the Stay Safe campaign. It could be inferred that the participatory nature of the design process influenced a shift towards a similar approach in decision-making and project implementation.
The depth of thinking and evidence-led research supporting the final campaign was also noted by VCH. Traditional design expertise in such skills as colour theory, art direction, typography and the designers intuition may not suffice when designing for complex problems in fields accustomed to empirical research. In Stay Safe, the rigor of research-led design methodologies gave tangible reasons for design decisions, grounded in evidence. While not eliminating the need for aesthetic judgment, this reliance on evidence allows for the acceptance of design in realms where it might previously have been dismissed.
References
- [1] Fast, Catherine. Not Just a Care Aide: Enabling Leadership in the Forgotten Front Line, the Role of Peer Coaching. MA thesis. Royal Roads University, 2009.
- [2] Fogg, B.J., Cuellar, G. and Danielson, D. “Motivating, Influencing, and Persuading Users: An Introduction to Captology.” The Human-Computer Interaction Handbook: Fundamentals, Evolving Technologies and Emerging Applications. Ed. Andrew Sears and Julie A. Jacko. New York: Taylor & Francis, 2003.
- [3] Hicks, J.J. “The Strategy Behind Florida’s “Truth” Campaign.” Tobacco Control 10 (2001): 3-5.
- [4] “Human-Centred Design Toolkit.” Ideo. Ideo, 2009. 28 November 2013. <http://www.ideo.com/work/human-centered-design-toolkit/>
- [5] Sanders, L. and Stappers. P. Convivial Toolbox: Generative Research for the Front End of Design. Amsterdam: Bis Publishers, 2013.
- [6] Tam, Helen. British Columbia. Provincial Health Services Authority. Provincial Safe Resident Handling Standards for Musculoskeletal Injury Prevention in British Columbia. Vancouver: PHSA, 2011.