Exploring wellness

Moyra Gill Masters of Design For Services

Exploring Wellness August 2014

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ontents

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Foreward

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Discover

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Secondary research Health

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Secondary research Design

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Secondary research Mindfulness

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Participants

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Primary research

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Getting out of the building

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Building relationships

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Define

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Sharing Understanding

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Sensemaking

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Ideating

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Develop

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Iterative prototyping

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Designing workshops

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Communication and sharing

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Feedback

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Designing and delivering workshops to test hypothesis

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A Brand

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Deliver

Final Design

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Next steps

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Acknowledgements

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Glossary

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Appendices

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oreward

convergent stages of the design process, showing the different modes of thinking that designers use’.

This report provides an overview of a Masters of Design for Services project.

It is a personal narrative which has been recorded to enable anyone interested in exploring opportunities for wellness within communities, thereby enhancing quality of life.

It can also be used for • Sharing how Design for Services can be used for innovation

Figure 1

• Bringing people together

Therefore the report will be structured as follows:

• Considering a service enabling community wellness and the implementation of it

Discover - Secondary (Literature base around Health, Design and Mindfulness) and Primary research

• Enabling communities in the benefits of using a participatory approach • Aiding reflection for future improvement

Define - Analysing and collating data and reframing the question.

• Challenging current ways of working

Develop - testing ideas and theories

Limitations

Dow (2009) suggests ‘design is often heavily time constrained. This can discourage designers from iterating’.

The project would have benefitted from further iterations of prototypes. However to enable this would require a longer period of project time.

Deliver - Insights and prompts for the future

There could have been more research within the local community such as workplaces, community professionals, and in the wider public arena. This would have influenced the project further and needs future consideration.

Further to this, a SWOT analysis was completed to understand learning throughout the process. You will find these illustrated in orange boxes (as below) throughout the report.

This process has in not been linear but iterative in nature, messy, complex and real world.

S - Strengths

Breakdown

W - Weaknesses

The report explores the different stages of the project through the design process, interpreted using the Double Diamond, (see figure 1). The Design Council (2013) suggest that the Double Diamond ‘maps the divergent and

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O - Opportunities T - Threats

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know remarkable ways of keeping well which are worth capturing and sharing with others.”

This section will more specifically explore the discovery phase of the Double diamond process, focussing on the secondary and primary research.

Dr Kramer states - (panel 1)

Dr Graham Kramer (figure 1) is a community doctor in Montrose. He is seconded two days a week to the Scottish Government, looking at enabling people in managing their own care and making health information understandable.

One of the challenges he submitted to the figure 1 Design for services challenge bank was:

In these early stages, it was evident that there was the need to explore the question with relation to Long Term Conditions (LTC), wellness and participation.

As a registered nurse with more than twenty years experience this question provided an opportunity to explore an exciting subject where the usual constraints were negotiable. The approach for improvement within the NHS is improvement science and the principles of Plan, Do, Study, Act (PDSA) (Glossary). However, seeing these in use, it has been a challenge to accept this as the only way towards innovation for healthcare. Driven by my personal values including participation and collaboration and wanting to make lives better, this challenge was compelling. and it increased awareness of others in healthcare who are thinking differently.

“What do you do to keep yourself well?

My challenge is how can we put that question to people in a way that will help them reflect on their abilities and enable us to capture these wonderful assets to share with others and help build a picture of what wellness is in my community?”.

Interestingly, during a presentation at the Healthcare Improvement Scotland conference 2013, Dr David Reilly challenged the group that there was the need to add listening as a prerequisite to the PDSA. This important statement, although apparently obvious, has the potential to open doors for design within healthcare. Design is more than listening however, a design approach, which is human centred and uses participation and collaboration, can find increased opportunities where PDSA is leaving gaps. The two approaches could work together towards finding more creative opportunities for navagating Healthcare’s complexity.

“As a GP I’ve been trained to try and fix things that go wrong with people.

People expect to be fixed. All very well until someone has a Long Term Condition which they have to live with and endure. Our focus on fixing what is wrong (a deficit approach) can often make people neglect what they themselves can achieve to promote their own wellness ( an asset approach). Asking the “what keeps you well?” question is a powerful one.

It can help people realise that they can be an active agent in improving their well being. Also many people

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Panel 1

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Rosalind Torres (2013) discusses leadership in the 21st Century and suggests “it is imperative that people think out of the box’ and ‘…crucial that we find the way to asking the right questions”.

(LTC) (Glossary) such as heart and lung diseases, diabetes and metal health problems. These are challenges for sustainability within healthcare, (Panel 2)

1/3 of people over 52 years in Scotland have difficulties understanding health information

This challenge being initiated by a healthcare professional is exciting and motivational for the project. For Dr Kramer this was a step ‘out of the box’.

It was encouraging to witness this type of leadership in action and have the opportunity to work with people open to exploring different ways for innovation.

Scottish Health Survey “...in the next 10 years there will be 700,000 fewer people aged 16 to 49, but 3.7 million more people aged 50 to State Pension age...”

Challenging the Improvement Science approach to healthcare with design methods offers a new opportunity to explore a different approach.

“Phenomenology makes us stop taking for granted the things that we normally take for granted and that is part of mindfulness…” Shapiro et al(1998).

Using this kind of approach enables increasing objectivity and reducing preconceptions. The opportunity was to be a mindful inquirer, Shapiro explains “Mindful inquiry is a creative act. It seeks not only to discover or to record what is there, but to allow what is there to manifest itself in a new way, to come forward in its ‘shining’. This means not only what is there, but the potential behind it, reveals itself”.

Government.uk Older people are also more likely to have more than one LTC “2 million people/40% of the Scottish population have at least one LTC” LTC in Scotland have risen from 41% to 46% between 2008-2012’ www.scotland.gov.uk Panel 2

This information can create a negative story, however, in Scottish Government initiatives such as Older People’s Care Agenda, Gaun Yersel and Better Health Better Care there is the emphasis on the need for patients to take the lead in their healthcare. How then can we enable a story where people become assets, and subjective knowledge, understanding and experience of these challenges becomes invaluable for innovation. This is key in relation to the question, understanding the need for being partners with participants and enabling the sharing of stories.

Historically, healthcare professionals advise and prescribe and patients listen and take. Bates et al (2006) discusses the

Making an inquiry into the subject, is about exploring the subject through other perspectives, documenting the findings, and seeking understanding in new insights. So to enable this there required contextual understanding.

Discover - Secondary research - Health The question is important to healthcare and the client because people are living longer with the possibility of having one or more Long Term Conditions

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move away from giving and receiving to listening and responding. These ideas are impacting positively on care relationships. However there remain reported challenges and health and social care continue to work towards improving healthcare experiences, (panel 3).

Healthcare has looked at ways of managing the complexity, e.g. The House of Care is a framework developed in NHS England to manage the impact and enable self management of LTC. The framework has had a positive effect in England and an adapted version is now being introduced in Scotland (appendix 1).

“... knowledge and experience held by the patient has for too long been an untapped resource. It is something that could greatly benefit the quality of patients care and ultimately their quality of life, but which has been largely ignored in the past”

This was helpful to understand in relation to where the question for the challenge came from, i.e. ‘Community Assets’ within the framework in NHS Scotland was adapted from the ‘Commisioning’ in House of Care, NHS England.

For a more in depth overview of the House of Care see www.england.nhs. uk/house-of-care

Department of Health Panel 3

Dan Roam, (2010) suggests “...visual thinking means taking advantage of our innate ability to see - both with our eyes and with our minds eye - in order to discover ideas that are otherwise invisible, develop those ideas quickly and intuitively, and then share those ideas with other people in a way that they simply ‘get’”.

S - Exploring literature for background context W - Perspective bias, due to Nurse role O - To be mindful and process led to find increased opportunities T - The potential o be influenced by outcome based approach

The House of Care framework was not personally motivational and encouraging. The concept and words are engaging however the visual created thoughts of segregation, boxed ideas and boundaries. Visually it could be more visionary to see signs of growth, sharing and partnership. This is about different perspectives, someone else could see the visual entirely different.

There have been many activities documented about enabling wellness within communities, e.g Perth & Kinross Healthy Communities Collaborative/ Community Wellness Service, Leicestershire Partnership NHS Trust, (figure 2), because healthcare is being motivated to find resource in people self caring and managing their health.

Discover - Secondary reseacrch Design

“…a service requires a fundamentally different mind-set to ‘design’ it. Service is dynamic and living. Service Design has to concern people and their figure 2

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experiences, and neither people nor experience can be planned or designed exactly. So what Service Design is really about is a community – a community that produces and consumes service through interactions…”

”The capacity to achieve an outcome is different from the ability to explore the world and understand the experience.”

This project is about enabling an inquiry into understanding peoples experiences of wellness and using this to find new knowledge, sharing it and with a participatory approach, create new opportunities for making peoples lives better together

Han, (2010).

So, how can using a design approach when exploring the subject make a difference? It is the intention to try things differently using a participatory approach, enabling the community to understand perspectives, find the questions and problems and in turn find the opportunities towards wellness in a truly collaborative sense. This would move away from communities following a plan or providing insights, towards being active participants and partners in making, delivering and executing a plan and project.

Therefore, rather than the promotion of wellness, the project is about the exploration of wellness and the sharing of it.

Shapiro et al(1998) states that “Mindfulness requires care for the lifeworld in which the inquiry occurs.

It questions the manner in which the inquirer enters the lifeworlds involved in the inquiry, taking care that they are left in a better state than they were before.” This is different to the outcomes based approach which is encouraged within healthcare and was an important challenge to experience. This approach enables the findings to lead to an outcome and reduces the researchers subjectivity ability to influence the project. It was liberating to release self from the comfort zone of the known ways of working and explore and embrace the positive energy of being empowered and enabled within this approach. The words of Rosalinde Torres (2011) echo this (panel 4).

Tim Brown (2010) encourages designers to ‘think big’, therefore if the situation and culture of relationships between Healthcare professionals and service users is to change, there needs to be the introduction of ways to make those changes. The initial question identified by Dr Kramer at first glance may have seemed uncomplicated and manageable, however when explored in regards to what it means in relation to peoples lives, history, expectations and the future, the nature of the problem became complex, intriguing and highly motivational.

Discover - Secondary research Mindfulness

We are a nation where health promotion and information is everywhere, encouraging us to maintain our health, so why then do we have so many problems with it? A mindful approach reflected Langer’s (2009) statement;

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It was important at this point of the journey to explore and prepare for “... the unknown possibilities of tomorrow...” and think about design partners and collaborators.

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Discover - Participants

of experience, (panel 5) knowledge and commitment which older people have. This enterprise could significantly influence the change of culture by enabling participation and collaboration, utilise unrecognised assets within communities and reduce increased elderly population impact on health and social care.

Personal contacts and the transfer of existing personal knowledge were assets to the project. Working with a local community previously, had led to the enterprise idea Wellderly, which was submitted and awarded for “The ‘Where are you looking to anticipate change?

As with any new concept it was crucial to capture the attention of people. It was helpful having previous experience

On your callender, i.e. who are you spending time with, how, where, what and how are you distilling this forward? Great leaders are not head down, they see around corners, shaping their future, not just reacting to it’

‘lacking social connections is a comparable risk factor for early death as smoking 15 cigarettes a day, and is worse for us than well-known risk factors such as obesity and physical inactivity.’

What is the diversity measure of your network?

Calbuste Gulbenkin Foundation, Campaign to end loneliness Connections in older people

Your capacity to develop relationships with people who are very different to you - Diverse network = show patterns and bring solutions

Panel 5 engaging with communities, (eg Wellderly) especially due to the interest of health and social care implementing design principles within their work.

Are you courageous enough to abandon a practice that has made you successful in the past?

Great leaders dare to be different - risk taking - they do it - they stand out - they prepare themselves for the realities of today and all of those unknown possibilities of tomorrow’

So in the context of Dr Kramer’s question, new understanding was reflected on from the ‘Wellderly’ experience and used within the process for this project.

Panel 4 Young Innovators Challenge 2014 (Scottish Institute for Enterprise). The Wellderly concept is a social design studio enabling older people to use creative processes to find opportunities for solutions to problems within their communities. This idea has the potential to influence the statistics for older people around increased loneliness and isolation, as well as utilise the assets

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S - Transferability of learning, ‘Wellderly’ learning influencing ‘Keeping well’ W - Early adopters for idea - Creating interest O - Using Design to impact healthcare T - Financial sustainability - How would this work be funded.

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The secondary research enabled learning and understanding. It highlighted and evidenced that people are at the centre of this project and that their participation, experiences and stories would be enlightening.

Historically patients are asked to take part within research, take roles and responsibilities and have a voice, however, on who’s terms? When are patients invited to join, where, how often and who with? Is healthcare designing services with individuals or for patients?

Having used PDSA it was an intriguing journey to look at the world through the eyes of design and to enable the question to be explored from this perspective. Proust suggests “The act of real discovery consists not in finding new lands, but in seeing with new eyes”.

view. Due to a career in healthcare, it was important to reduce personal preconceptions, so that the question was explored from many stories and perspectives, not only health and that real discovery was encouraged with the reduced risk of a single story. Therefore it was important to network to make new contacts and create introductions to new areas of expertise.

S - Enabled with knowledge and understanding of design for services W - The ability to have preconceptions influence the project O - Enablement for story telling T - The potential for limitted access to stories

The opportunity, therefore to enable others to explore design through participation and collaboration and working in partnership to find opportunities are key values within the project. This was developed when working with people using design methods and tools. Tim Brown (2010) suggests “The design of participatory systems in which many more forms of value beyond simply cash, both created and measured is going to be the major theme not only for design but for economy as we go forward”.

This understanding therefore led to the gathering of data during conversations with people sharing their stories.

Stephen Blank (2011) shares a story of being told by his new manager to go out and speak to people and not come back until he could tell them something that wasn’t already known. He now suggests to his students at Harvard Business School to “get out of the building”, and speak to people.

After a huge amount of information from the secondary research and a community to talk to, it was clear that Sanders (2011) explanation of the “…Messiness of the process” is not imagined.

However, trusting the design process and following it, enables an unbiased approach.

Discover - Primary research

The plan was to create interest and investment in people, (figure 3, Interest/ Investment chart)

Adiche (2009) discusses “The danger of a single story” and explores how hearing, responding to and developing one story will only ever provide one story. By hearing many stories and understanding them, people are enabled in seeing situations from different perspectives, therefore having a more holistic

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Secondary research is vital, however the rich insights are found when, as described by Gauntlet (2011) we are “immersed into all activity”. Getting out of the building led to listening, talking

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Interviews enabled the gathering of qualitative data (Glossary). Interesting connections were made with LTC support groups, which are positively impacting communities and interviews were like conversations where people started telling their stories. These stories were recorded, reported and then documented with story boards (figure 4 and Glossary), this enabled the sharing of them.

with and observing people. This enabled insights into peoples behaviours as well as the opportunity to share stories.

This was a path to understanding, these many stories were fascinating, humbling and developed thinking.

Discover - Getting out of the building

Adiche (2009) suggests that if we “… show people as only one thing, that is what they become…” and that the single story “robs people of dignity. It makes recognition of our equal humanity difficult. It emphasises how we are different rather than how we are similar… single stories create stereotypes…”. There needed to be many stories.

There was now the need to create connections with the community.

Contacts were made with relevant people, eg health centre, library, leisure centre and LTC Lead Nurse, to enable understanding. There were arrangements for interviews, observations, vox pop and workshops.

This is a key value of service design, Steen et al (2011) state “Co-design is critical to service design because different perspectives and a productive combination of different perspectives, are needed to understand both a services demand side i.e. users and customers needs and its supply side i.e. technologies and processes, in order to develop successful services.”

To enable more conversations places were chosen in Montrose (the location of Dr Kramer’s GP Practice) like the sports centre, library and town centre.

Personality types such as introversion and extroversion were considered when thinking about where to speak with people, Cain (2011), these different perspectives are needed. It was also figure 4

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figure 5 important to approach conversations in a common language, creating an environment where individuals know their perspective matters.

than prescribed or advised by healthcare professionals, and have valuable information which could be shared with the community.

To keep the project transparent, the conversations of many thoughts and many perspectives required capturing in a way that the participants could benefit from the results during engagement, therefore, questions were developed with an emphasis on the individual and their perspective. This way of researching, ie vox pop, (Glossary) created a space for people to share and document their thoughts about wellness.

The questions were hand written on 4 large pieces of paper on a table, (figure 5).

People were happy to participate. Some looked at others answers, some reflected on their own and others answers and some engaged in conversation, (figure 6).

There were many conversations, some shared personal information and there were some laughs. Street conversations, (figure 7) although challenging to start, were the source of an overwhelming amount of rich insights, however the key insights which have influenced the project are found on pg 16, panel 8.

People are keeping well in ways other figure 6

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figure 7 This was insightful for future ways of working and preconceptions, and previous understanding was challenged.

information which mattered to them, telling their story. The arranged place for the conversations was chosen by the interviewees, they were enthusiastic to share their stories and the information led the project direction. Tom Kelly (2008) advocates this, suggesting, “Storytelling is part of the fabric of humanity and when you respect story telling you acknowledge that you’re engaged in a human enterprise, you elevate your work, you create a common language, you begin to build a larger community.�

S - Showing the interest to enter into different environments to have meaningful conversations W - Feelings of vulnerability and anxiety O - Designing toolboxes to enable, eg businesses and organisations to vox pop T - The potential for negative or challenging conversations This enabled reflection about how we network and connect with people and encourage positive relationships.

Transparency again was important for the interviews. Conversations were documented using post its stuck onto A4 sheets of paper at the table, (figure 9).

Discover - Building relationships

This was an effective method of sharing notes and also enabled sense making.

The development of relationships was considered and. connections were initially made through contacts and interview requests, and spaces for community conversations were requested and arranged by email and telephone and consent was obtained, (figure 8).

After the conversations, the subjects discussed were themed easily with the post its. Conversations do not necessarily figure 8

The principles of participation and collaboration were implemented for conversations and the interviewee would be enabled in sharing

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topic of keeping well. Learning from the positive experience of the community conversations, a further prototype was tried again. The questions were written on large pieces of paper, hung on the wall and the questions were explored as a group.

The group conversed, shared and added to each others thoughts and answers. The comments were written around the questions for the group to see. During this activity the ambience of the room did not change from normal. The participants continued to be full of fun, laughing and joking, however they were able to discuss this serious subject in a light hearted way, and it produced a “Yes…and…” approach to the conversation.

figure 9 flow according to subjects, so using post its made it easy to separate the conversations into themes and patterns.

The conversations led to invites to two of the Chronic Obstructive Pulmonary Disease (COPD) (Glossary) support groups. This was a privilege and taking part in these groups enabled understanding about the impact the they are having on peoples lives.

People are being enabled in reducing admission to hospital and visits to GPs and experiencing better quality of life.

S - Entering into unknown environments for insight W - Limited connections O - Sharing knowledge of available assets

Attending and taking part in group activities created peoples interest in the project. It encouraged chat and allowed insight into the experiences of different peoples journey’s. Sharing stories again was a part of this process. Sharing was important, as one person told a story, then they looked for others to share. This was interesting and something again understood from a nursing background, it is important that people can relate to healthcare professionals and researchers, and storytelling enables this, Kingsley (2009) suggests “…it creates empathy…” and leads to more meaningful conversations.

T - Sustainabillity of ongoing visits

During a COPD support group meeting, an invitation was given to exploring the

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figure 10

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Define - Sharing understanding Maintaining communication and building trusting relationships needs commitment and connection between participants. The values of the project dictated this. There was a progress report provided weekly, either by email, Skype or a meeting for Dr Kramer. This enabled a relationship to develop where information was shared, discussed and added to, which then positively influenced the project.

This section of the report will more specifically explore the defining phase of the Double Diamond process, focussing on converging to understand and share meaning in relation to the question. “Empathy mapping helps to create a more holistic view of customers or users and considers what they hear, see, feel, think, say and do in their every day lives and the problems and opportunities. They help organisations and staff to consider what customers and users might want from a service or product, helping them to understand how services can meet their needs. This is vital to ensure effective and useful services.�

Define - Sense making

Themes and patterns developed from the research and it was important to share aspects from peoples stories, which encouraged realisations.

Visual mapping eg empathy maps (figure 10 and panel 6), story boards (figure 11), journey maps (figure 12 and

Sophie Hostick-Boakye - 2013 panel 6

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figure 11 figure 12

“A customer journey map is a visual representation of a user’s journey through a service, showing all the different interactions they have.”

Design council

panel 7

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panel 7) were used to make sense of the information collated from the primary research. Some of the information was developed into word clouds to communicate the findings with the client, (appendix 2, 3 and 4) which was effective and sensitive to time constraints.

Key Insights People create environments for meaningful conversations People have lots of stories to share with others

There was a wealth of insight from the community, however, GP interest and engagement was required. Due to time constraints, it was important to make contact without taking much time.

Initial contact was made by email with a request to complete a SWOT analysis in relation to their work and LTC care. One was received back, from a healthcare professional which provided a wealth of information. The framework enabled interesting insights, however, it was evident the process did not engage the recipients. It was important that a way be found that the research included these perspectives, so this learning experience was used in exploring alternative methods of engagement.

People have limited access in communities to other peoples journeys and stories

The data from other sources was increasing and therefore, if left unexplored there would be imbalance and a limited voice.

Support group process and progress documentation is limited

Wellness perspective is not determined by condition of health People are positive about helping themselves Traditional barriers remain within healthcare People with Long term conditions at times feel healthcare treat them as a condition rather than a whole person Long term condition voluntary support groups are positively impacting peoples lives

People have limited knowledge and awareness of assets currently available within the community

S - The framework has the potential to provide rich insights

panel 8

W - To be successful the method needed people to engage O - To find a way in engaging the time poor

How can a codesign approach enable individuals and organisations in collaborating and creating ways of sharing pictures and knowledge within communities?

T - No interest, lack of participation The key insights from the research are (see panel 8) The research insights had an impact on the initial question,�how do we put this to people�. Keers Dorst (2011) suggests “A problem can never be solved within

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figure 13

the context in which it first arose… design thinking creates a new context, better formulation of the problem in a different area and that helps to shift peoples thinking into areas from where the problem was always unsolvable into where it is suddenly solvable”. The question now had a different context and had changed (panel 9).

in keeping well and opportunities developed from visual mapping tools.

The process of ideating created a wall of post its with ideas which could have impact, however, it was important when participating that the ideas were pertinent to the needs and wants of the participants. This became an interesting process and the value of listening to perspectives encouraged ideas to develop in response to and with the participants. Whatever the ideas, the testing phase was to enable communities to find and understand their challenges and then enable participants in using design tools and methods to find opportunities in enabling themselves in finding solutions.

The difference is that people are no longer being asked ‘to do’ or ‘put’ or ‘have’, but together we are enabled to ‘participate’ in ‘sharing and learning’.

With this approach there is no dominance, it is about understanding together and making positive choices in partnership. Therefore, within this context, recognising patterns and themes enabled ideating (the development of ideas) in response.

The process led idea came from thoughts about ‘quick fixes’ or sustainability. During a career in an environment where recourses are limited and leadership vision at times constrained, there have been many

Define - Ideating

Ideas were developed from the gaps and challenges faced by participants

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quick fix ideas, which at times have been to the detriment of service users. It is appreciated that quick fixes at times are essential, however, ideas for enablement to find opportunities for wellness within our community, is about cultural change.

This is not a quick fix, this is sustainability.

S - Research and process led ideas W - Research not inclusive of all the population of the community O - Developing the idea for a service using the principles of the service T - Having participant investment from all perspectives of the community

The ideas on the wall were appropriate and could have an impact, so bringing them together led to a Service, (appendix 5)

This therefore led to designing and delivering workshops.

Using the Happy Startup Canvas, (Glossary and figure 13), converged the idea into the principles of sharing, mentoring and knowing and the idea of a service enabling wellness within communities.

So, could using the principles of sharing, mentoring and knowing with the method of participation enable people to find opportunities within their community for wellness?

figure 14

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figure 15

D

evelop -

using persona, (‘Persona are fictional characters created to represent the different user types’ (Lidwell et al 2010), empathy mapping and creating themes and patterns, to understand the needs and wants of the community within the subject matter, (figures 14, 15, 16 and 17).

This section of the report will more specifically explore the developing phase of the Double Diamond process, focussing on testing the theories in relation to the question.

Develop - Iterative Protoyping

The participants feedback stated, enjoying the process, finding the tools useful and being cohesive in their decisions, challenges and opportunities.

The Wellderly team was invited to work with a community group.

It is important that participants are aware of perspectives and work as a team to understand what the challenges and figure 16

opportunities are available and that everyone is enabled with a voice.

figure 17

The ‘Wellderly’ team designed a workshop for the group which consisted of health/social care professionals and volunteers. Using design principles and tools the group were enabled through

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The workshop had created a joint understanding. This learning encouraged thoughts about using this as a prototype (Glossary) for

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figure 18 the community in the same room as GPs for the purpose of innovation, meant finding more creative ways of exploring this. Introducing persona and encouraging participants to think about each others perspective, could impact interest and investment. Could the value of increased understanding of each other, increase opportunities for problem solving together? Through the principles of sharing, mentoring and knowing and creative practices can we find greater insights and more opportunities for community challenges?

And could the principles lead the exploration and testing of the idea?

‘Personas are fictional characters created to represent the different user types’ Lidwell et al 2010 testing how to bring people together and enablement in recognising the opportunities identified through the research. Again it was about creating interest and investment, encouraging involvement, motivation and enthusiasm in developing participants ideas. It is not about seeing if a group can carry out instructions to bring other peoples ideas to life. So using this as a prototype, a further workshop was designed.

It was important that the principles of the project led the process. Therefore sharing the idea with the client, mentoring in the use of tools and increasing ‘knowing’ was essential.

Develop - Designing workshops

From the primary research, persona were developed to represent people within the community, (figure 18) This is a way of creating empathy by bringing people to life. Quenesbery and Robbins (2010) suggest that “Crafting a story is aimed at ensuring that the story meets your goals, communicates what you intend, and is not misunderstood”.

These persona were stories about collections of people from the research.

The persona enabled the recognition about limited understanding of peoples lives and perspectives within the community. They enable participants to explore other perspectives by sharing.

Develop - Communication and sharing

There is the need to share insights with the client in a common language.

Although there was constant updating and dialogue between the researcher and client, where insights were shared, a researcher is immersed in the project and understands all aspects of it, whereas others may not be as clear.

Quesnesbery and Robbins (2010) suggest “People are natural story listeners, so it’s an easy way to share information…the power of stories allows us to see the world through a different

Understanding the challenges of getting

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lens”. To share the concept, a story was developed and mapped out on post its. During an online meeting the story of the concept was shared. The positive experience in this situation as with all suggestions during the project were met with a ‘yes…and…’ approach.

Ideas led to more ideas. Collaborating with individuals who are motivated, enthusiastic and visionary is a privilege.

Dr Kramer understood where the ideas had come from and how they could be implemented for improvement.

Listen When I ask you to listen to me and you start giving advice, you have not done what I asked.

When I ask you to listen to me and you begin to tell me why I shouldn’t feel that way, you are trampling on my feelings.

When I ask you to listen to me and you feel you have to do something to solve my problem, you have failed me, strange as that may seem.

Listen! All I asked was that you listen.

Not to talk or do – just hear me.

Advice is cheap. Ten cents will get you both Dear Abby and Billy Graham in the same newspaper.

And I can do for myself. I’m not helpless.

Maybe discouraged and faltering, but not helpless.

When you do something for me that I can and need to do for myself, you contribute to my fear and weakness.

But, when you accept as a single fact that I do feel what I feel, no matter how irrational, then I can quit trying to convince you and get to the business of understanding what’s behind this irrational feeling.

And when that’s clear, the answers are obvious and I don’t need advice.

Irrational feelings make sense when we understand what’s behind them.

So, please listen and just hear me.

And if you want to talk,

S - Sharing insights with the client W - Confusing the client with design ‘speak’ O - Sharing experiences and exploring a common language T - Maintaining interest and investment for time.

This was an enlightening process, however, consideration was needed for the participants - was this a helpful process? It was important therefore to consider feedback.

Develop - Feedback

During the course of the project and that of Wellderly, feedback was requested. Questions were developed for participants post involvement to influence improvement and help the project move forward. Interestingly the aspect which came from the community support groups was that they felt they were being listened to.

As Healthcare professionals we think that we are listening and working with patients, however, from the study it showed that we are still lacking in listening skills (panel 10).

wait a minute for your turn; Anonymous

There have been many changes in recent years to enable improvement,

panel 10

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however as professionals we recognise how the system is challenging health relationships e.g. “There are a small cohort of patients that it is recognised you can’t deal with in the traditional method of General Practice’ and ‘We give patients choices, then limit their access to information, i.e. notes, secondary care teams, physio etc” (anonymous, 2014).

Develop - Designing and delivering workshops to test hypothesis

“Prototyping can provide inspiration, confirmation or rejection of ideas based on quality of experience…” Suri (2000) Having prototyped a workshop with volunteers and social care professionals with Wellderly’, the design required refining and testing for enabling wellness.

Client feedback is also necessary for improvement, again thinking about the principles of the project, how could the client be enabled to share their perspective and enable the researcher to see through others eyes? “O, wad some Power the giftie gie us, To see oursels as others see us! It wad frae monie a blunder free us,…” Burns, (1786). It is helpful to understand if our behaviours represent our values. ‘The happy start up canvas’ (Spook studio, 2012) was being used to develop the idea and it was also being considered in relation to a workshop being designed for LTC support group chair people. The idea for the start up canvas is helpful and uses prompts to consider when thinking about a new start up for business.

Visually, this framework was challenging as it looks hierarchal in nature, so it was adapted to represent equilibrium.

Houde and Hill (1998) suggest “know your audience….”. Relationships had been built and maintained, so a workshop was designed for the chairpeople (Glossary) of three COPD groups in Angus. The chairpeople were at different stages within their chairmanship, one in a group,looking at handing over some responsibility, one in a group taking on more responsibility and one recently appointed.

figure 19

While using and adapting this, it led to a framework being developed for feedback, (figure 19 and Appendix 6).

Understanding Dr Kramer’s thoughts about the project would enable reflection for influencing future projects.

The aim of the workshop with LTC chairpeople was, 1 Understand if through design tools, could the group be enabled in understanding the challenges and opportunities of different individuals within their community?

Feedback enables projects to develop and positive the feedback received encouraged the next stage in the process. This was to test if the concept could work if participants are enabled.

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2 Together, could they share findings and opportunities and develop a plan for enabling someone in starting a support group.

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3 With support could individuals be enabled to find increased opportunities for their challenges and identify, understand and realise the benefits of sharing, mentoring and knowing.

comfortable facilities. Although there was a plan for the day, unlike with the previous prototype, an agenda was not displayed, to stay informal however, with the workshop being longer than anticipated, due to the conversation flow an agenda may have been helpful for the group. The participants engaged

The aim of the workshop with the GPs was understanding their espoused and latent values in relation to service improvement.

“The experience prototype is a simulation of the service experience that foresees some of its performances through the use of the specific physical touchpoints involved.”

The aim of the workshop plan with the client was about testing enablement of the health practitioner to use and benefit from design tools and prototype whether through the principles of the idea, i.e. sharing, mentoring and knowing. Could the client experience the idea within the prototype, (panel 11).

Suri (2000) panel 11 with the personas and chose which they would use. The group were intrigued with the personas when realising the information came from the primary research. They decided to use persona of people who’s perspective they did not understand. This was enlightening, the group were engaging and interested in how other people in the community think and feel and they collaborated in empathy mapping, (figure 21). The maps were put on the wall with the persona on

figure 20

1 - Workshop with LTC support group chair people

Collaboratively the venue, date and time was decided. Thoughts about branding and the name WellFayre (pg 29) gave the idea of taking paper cups, cakes and juice, in keeping with a ‘country village fayre’ aesthetic. This was given a warm welcome, (see figure 20). Each participant was comfortable and conversation flowed freely. When deciding the venue the participants health conditions were taken into consideration, i.e. need for lifts instead of stairs, well ventilated rooms and figure 21

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figure 23

the table, and using post its and sharpies the participants wrote their insights.

Due to the participants health condition it was important to consider hosting responsibilities, so group members were not getting up and down and in anyway feeling uncomfortable they worked round a table and as a host, post its were

commented ‘...you should do a persona of us with GPs, it might help them to see our perspective…’. This showed that the group understood the tools. The group then brainstormed some of the challenges and opportunities, however during a conversation later, the group highlighted more insights than during the brainstorming. It may be helpful with groups who know each other to ask what they think about the findings and host a conversation, rather than brainstorm. Due to time constraints, we missed out the journey mapping and used the adapted Happy Startup Canvas, (figure 23). This was used because each participant discussed challenges they faced starting up new support groups and creating interest to sustain roles for the groups. With the participants in different parts of their support group journey, this canvas was a way of testing whether people could be enabled to share their experiences, mentor others

figure 22

Chair-people feedback “friendly approach with openness and frankness”

placed on the empathy maps according to the groups instructions., (figure 22).

This led to fascinating conversations as they explored the persona. The participants expressed that they had not thought about others like this and that it was helpful. One participant

“everyone had an opportunity to speak’” “someone was listening to us” “working together, problem solving and seeing a positive outcome” panel 12

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These assets within a community exist already. This added to the findings of the ‘Wellderly’ workshop and showed that information is available. We can be enablers of capturing the assets using design tools and methods and creators of environments where people share their knowledge, experiences and enable others to do the same.

S - Enabling participants in using design tools W - Time keeping O - Hosting innovative conversations T - Lack of engagement with tools This workshop had provided influencial insights, so how can designers enable participants with very real challenges and constraints within their roles.

figure 24 with their challenges for increased opportunities and increase each others knowledge. The adapted Happy Startup Canvas was on the wall and the group conversed as they explored each section of the canvas and instructed the host what should be written. Together the group created a picture of what each support group could share and develop.

They referred back to the empathy maps and interestingly during this time, saw opportunities within the maps for the problems identified within the canvas.

2 - Workshops with GP’s

There are very real time constraints for GPs. Finding more convenient ways to enable participation led to alternative methods. One interview was carried out on Skype, exercises were explained and agreed and they were to be completed and emailed back. This was a positive conversation, however the exercises were not returned.

Face to face meetings worked well.

There was the opportunity to use a SWOT analysis, created from the main challenges explored for the client, ie removing traditional barriers, having better conversations and people having positive healthcare experiences, and an exercise thinking about values.

Interestingly the conversations were documented, with the tools, by the researcher, (figure 24). This may be a clue as to why there was little return of the exercises by email. There was engagement with the conversation and

The group provided feedback (panel 12). It was encouraging while conversing after the workshop as they explored ideas. This prototype provided the information to show that using tools for enablement, engage people and because of their prior knowledge, experience and understanding, they can share stories to enable others to understand and impact towards finding opportunities for improvement.

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figure 25

subjects, however, less with the tools. It would be interesting to find out if there was a longer period of time and with a workshop environment, would there have been a difference in engagement with the tools. To hold a workshop for GPs would mean planning a long time in advance and was not an option for this project time frame.

There is more time needed to explore this and needs further consideration.

The data collated from the exercises was formatted individually and sent back to the participant to reflect on, so providing something to take away from the experience. It would have been interesting to hear about reflections on any differences manifest between espoused and latent values of the GP participants and could also be a future consideration.

How people become invested and interested in projects will determine to what extent the idea can be tested.

Suri et al (2000) suggests “Information becomes more vivid and engaging when it resonates with personal experience. If clients and designers can have informative personal experiences, it is easier for them to grasp the issues and feel greater empathy with both the people who will be affected by their decisions, and the experiences users may face.” Part of the work within this project was about understanding the time constraints of GPs and the ability to invest time in opportunities for change.

3 - Client Workshop

During the process, the principles of WellFayre were implemented in the research and prototyping. Nesta suggest, “Prototyping…is where you have something you want to find out more about or test relatively quickly… it generates more upfront activity than traditional service development processes”.

This workshop was about increasing knowledge, and sharing the design process, as a way of mentoring.

GPs are time poor and roles are expanding. So how is investment and interest in innovation enabled as well as getting jobs done?

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Using personas increased knowing as well as helping in further realisations through empathy mapping. Customer

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journey mapping would highlight the gaps and challenges within different journeys, so build a picture of where the problems for people lie. A value proposition highlights the value of a service and doing these together could enable the client insight into how to use the tools within their practice and show how we can share information visually to increase understanding and awareness.

the next session. New tools can be challenging, so a step by step set of instructions were left with a completed journey map as an example. Again, through lack of time, the client was unable to complete the journey mapping by the next meeting. An interesting pattern was forming.

Face to face meetings engaged and were prioritised and therefore more productive.

The client was interested in the personas and how they could be used to positively influence patient care. This ‘yes…and …’ approach while collaborating within a project encourages positive energy.

The client was thinking creatively how persona could be used to enable holistic care. What support networks people have, what keeps them awake at night and what they enjoy. It would provide greater understanding into peoples lives and help towards more meaningful conversations. This led onto empathy mapping, (figure 25), the was client challenged by the need for this, however instead of answering when asked the need for it, the 5 why’s approach of questioning was used (iSixsigma). It was again not within the values of the project to tell others what should or should not be done but find the value of the experience through exploration.

The traditional approach in healthcare is outcomes focussed; perhaps for this reason encouraging the client to follow the process became challenging due to his need to imagine a result. It would have been interesting to find out if keeping with the design process would have enabled increased realisation and understanding of WellFayre - outcomes can be restrictive to our creativity.

S - Exploring a process led approach W - Enabling the client in this experience O - Providing a service which explores this T - Reductionist problem solving influence It was helpful therefore to share a prototype from previous work (Wellderly) to enable the vision of an outcome.

Due to time constraints, it was decided with the client that we journey map independently and bring them for figure 26

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figure 27 As a deliverable for the project, we decided a short video would be useful because of Dr Kramer’s interest in the the video made for Wellderly. The video had been created for submission to The Scottish Institute for Enterprise Young Innovators Challenge. Schrage (1999) suggests prototypes lead to the next prototype. When designing the video (see figure 26), the team started to, what Schrage (1999) describes as, ‘serious play. He suggests “…you can’t be a serious innovator unless you are willing to play”. The result of this serious play led to the video being shared, interest being created and the concept being understood. This prototype led thoughts about visual storytelling for WellFayre.

appreciation of existing or future conditions through active engagement with prototypes”.

It was important to the exploration of sharing, mentoring and knowing as principles, that they were used within this process. This meant enabling an environment for collaborative production. Using Wellderly as a prototype could enable us to explore how we share WellFayre.

Up until this point the idea was about a service implementing principles of sharing, mentoring and knowing, however, there needed exploration into how the service could be indentifiable, how would people know what to expect?

Working together then, we developed the script for the WellFayre video.

Both the client and the author brought together experiences of storytelling to the script and recorded the audio for the video (figure 27).

Using the principles of sharing, mentoring and knowing in practice was important to demonstrate belief in the concept in practice and not only in the theory. After recording the script modelling took place, using Wellderly as the prototype, (see figures 28, 29, 30, 31)

Suri (2009) states “In communication of issues and ideas: by enabling others to engage directly in a proposed new experience it provides common ground for establishing a shared point of view.”

Suri (2000) also explains “Experience prototyping as a form of prototyping that enables design team members, users and clients to gain first hand

1. Purposeful leadership 2.Compelling brand values 3. Employee engagement 4. Customer connectedness panel 13

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figure 28

figure 30

figure 29

figure 31

Develop - A brand

The Temkin group (temkingroup.com) suggest four customer experience core competencies for a brand, (panel 13).

These core competencies have been explored with interest by the author and are contained within this project and the principles of sharing, mentoring and knowing. The brand is more than just a logo, the brand of a service should reflect its values and intent. Godin, (2009) states “The brand acts as a guarantee of quality and originality” and suggests “If the customer (whether it is a business, a buyer, a voter or a donor) doesn’t pay a premium, make a selection or spread the word, then no brand value exists for that consumer.”

Prototype of ‘bunting’ logo, (figure 32 & 33).

figure 32

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figure 33

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eliver -

communities and how to access them and inform patients.

• People making differences in each others lives on a voluntary basis.

Final design

This section of the report will more specifically explore the deliver phase of the Double Diamond process, focussing on what the outcomes have been so far and providing ideas for next steps.

• Voluntary services reducing impact of Long Term Conditions on the health service.

• Differing challenges for different support groups regarding sustainability.

Kimbell states ‘…the delivery of a designed customer experience often requires redesigning processes and employees roles and paying attention to organisational culture and design.’

• Limited access to COPD support groups within Scotland and people feeling privileged to be accessing services in Angus.

• People travelling from other areas to benefit from support groups.

The research and process led final design for Wellfayre - a service founded in the principles of sharing, mentoring and knowing was prompted by the following issues:

• People within communities are making differences locally and nationally by involving MP’s and MEP’s.

• Predictions about increasing demand on an already stretched healthcare service

• Individuals being motivated to make care better.

• There are amazing qualities within the community, however many of journey’s have neither been captured or shared.

• People having limited knowledge of what was happening within their community and why.

• Health and social care professionals have limited insights into what assets for wellness are available within

• There are helpful opportunities within the community, however, limited understanding about it.

So, in relation to the question then:

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How can a codesign approach enable individuals and organisations in collaborating and creating ways of sharing pictures and knowledge within communities?

Value Proposition Canvas (panel 15 and appendix 8) Due to the current financial constraints, it is important to enable customers to see the value of a service.

There is the need for the consideration of a service enabling sharing, mentoring and knowing using participation and collaboration. This would provide access and enable use of methods, knowledge, stories and training to capture work, share it and increase awareness and knowledge in communities.

Service Blueprint (panel 16 and appendix 9) A service blueprint is a detailed visual representation of the total service over time - showing the user’s journey, all the different touchpoints and channels, as well as the behind the scenes parts of a service that make it work.Design Council, 2013

As stated previously, rather than the promotion of wellness, WellFayre is about the exploration of wellness and the sharing of it.

panel 16

To bring WellFayre to life and enable understanding in how, and why, it could function, please see the see following:

The blueprint enables the client to see how the service would work during a users journey.

Business model canvas (panel 14 and appendix 7).

The Happy Start Up Canvas (panel 17 and appendix 8) The Happy Start Up Canvas tells the story.

‘The business model is like a blueprint for a strategy to be implemented through organisational structures, processes and systems .

Osterwalder, 2010.

Happy start up canvas, ‘this type of canvas is for ‘Start ups that put people first and place happiness before profits’ and that this is about ‘…modellng culture’.

panel 14 Developing this was enabled by an initial prototype started for Wellderly and enables understanding of the key requirements for starting a business.

Laurence McCahil, 2012 panel 17 WellFayre - A short video (https://vimeo.com/102810447)

There is a widening gap beween what companies offer and sell and what customers actually value…

You can start to close the gap by truly understanding what your customers value, looking at your services, and how you interact with your customers…’ A business model alchemist, Wordpress

During the strategic information design module we thought about how information is shared and how the impact of the delivery can influence the viewer. The Wellderly video was shared with many people by email and twitter.

The client could use a video to share

panel 15

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the idea in a short space of time, as well as enabling people to see how a story could be told within a community, and how information and knowledge could be shared, if enabled and empowered to do so.

So what next?

Next steps

Method or Service? - Is WellFayre a method to be adopted within the existing health and social care system or is it it a stand alone service?

www.wellfayre.org (see figure 34)

This question needs to be resolved through further exploration, research, and prototyping.

It would benefit from the input of product designers, video makers along with health/social care professionals.

A website and social media strategy - this would promote method/service provision, brand values and the story of enabling community wellness.

Draw it, build it, act it - further exploration of tools for realisation, Sanders and Stappers (2008) suggest “We are designing for the future experiences of people, communities and cultures who are now connected and informed in ways that were unimaginable 10 years ago”.

figure 34 Reflection Some reflections, (see appendix 11) Being in part a healthcare professional, reflection Marks-Moran and Rose (1997) has played a large part within work and study.

Education - Could health education enable using design along with improvement science? Although Improvement science is currently the recognised way, the participatory approach of design, could enable students to feel comfortable with both approaches, so use them together to provide increased opportunities for navigating the ever increasing complexity of health and wellbeing.

During the course of this project reflection has provided the ability to critically enable self to share theories, practice and personal values.

Interestingly as a nurse, reflection occurs intuitively, however as a Designer it was important that enablement towards this was explored. By writing down critical reflections at least weekly, the ability towards making this an intuitive process for reflecting in and on action in this role became clearer. Using visuals captured many thoughts and was a way for remembering quickly why the reflections had been thought about. Using the method of written reflection along with a visual prompt is a method which has been helpful during this exploration.

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Conclusion Sinek (2010) asks “Why?” The reason for implementing WellFayre is because enabling sharing, mentoring and knowing with participation and collaboration will influence our

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communities in exploring opportunities for wellness in ways other than prescribed or advised by health. This will create sustainable futures where: • We will be empowered in understanding and choice.

• We will share knowledge, experiences and document, so others can benefit for years to come.

• We will be confident to share information, work more closely together and feel empowered in our decision making.

• Community groups are recognised because of their impact being marketed and documented.

• We hear stories about people we know through short videos, comic strips and leaflets available within the community and hear presentations when we attend local community events. These positively influence choices we make.

• Our children will watch short videos and read comic strips, telling stories they understand about people they recognise, and it helps them consider choices they make in their own lives.

• The impact of predicted statistics for healthcare in the future will be reduced ...and because, together we can find opportunities in our communities for sustainabilty, participating in creating cultures of wellness and working together to make our lives better .

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A

cknowledgements

With many thanks to Dr Graham Kramer, for your continual enthusiasm, encouragement and ability to share your knowledge and understanding. Without your enabling leadership qualities and inspiring approach, this project would not have been possible. Thank you

Thank you to Jon Gill aka playfulcommunications.co.uk for your video making skills Thank you to everyone who shared their story with me ...and thank you to my lovely family...

Many thanks to the three chairpeople of the COPD Support Groups in Angus.

I have been overwhelmed with your generosity in giving me time to work with you all. You have been motivational to this project through the difference you have made in peoples lives and have shown qualities which will continue to inspire me.

Many thanks to Forfar and Arbroath COPD groups for inviting me along to share your group experiences. Your input to the project was invaluable and I really enjoyed myself!

I would also like to thank the many people of Montrose who stopped to speak to me and write comments. You were all so generous with your time and have provided rich insights to the project.

Also thank you to Mr Fraser Bruce, my longsuffering tutor. Your guidance, support and questioning has been an endless source of encouragement.

Thank you to my fellow Masters of Design for Services students, it’s been a pleasure over the past year and especially to Keerthana Jayagopal and Jenni Inglis, co founders of Wellderly.

Thank you also to Rhona Guild (Long Term Conditions support Nurse, Tayside), Annat Bank Surgery, all participants who kindly shared insights with me and Hazel White and DJCAD for enabling me in Design thinking.

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lossary

Chronic Obstructive Pulmonary Disease (COPD) - The name for a collection of lung diseases, including chronic bronchitis, emphysema and chronic obstructive airways disease.

People with COPD have trouble breathing in and out, due to long-term damage to the lungs, usually because of smoking Customer journey maps - a useful way to understand a persons experience and identifies opportunities for improvement Design - a process defining problems and developing solutions Empathy maps - consider what persona hear, see, say, do, worry about, happy about, challenges and opportunities General Practitioner (GP) - a doctor based in the community who treats patients with minor or chronic illnesses and refers those with serious conditions to a hospital.

Long Term Conditions (LTC) - Health conditions that last a year or longer, impact on a person’s life, and may require ongoing care and support.

Improvement science - Plan, Do, Study, Act

Methods - Ways of systematically structuring the design process Mindfulness - being aware of and paying attention to self in the present Persona - a collective representation of people from primary research Prototype - testing of concepts or process Qualitative - a method of inquiry which aims to understand human behaviour Storyboards - visually tell a story panel by panel, like a comic strip Vox pop (Vox populi) - voice of the people, to get varied answers, opinions and points of view

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ppendices

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The question for the challenge came from thinking about community resources and assets

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Been adapted for Scotland by Dr Graham Kramer!

The adapted model (instead of ‘commissioning it is ‘community recourses and assets’)!

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what is the relevance to your organisation/project?!

how does it work?!

A framework for health to implement and enhance quality of life for people with long term conditions!

Collaboration!

Supporting individuals and their network in self management!

Recognising individuals as the experts

who pays for it?!

Government - Public sector

who runs it?!

NHS England!

Year of care partnership

who is it aimed at?!

People living with Long term conditions

swatch

knowledge!

! !

code

you can find out more here:! enquiries@yearofcare.co.uk!

Dept of health modernisation of health and social care channel

House of care - 2013, adapted from Chronic care model - 2001!

Toolkit - June 2014

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when does it run/when was it set up?!

House of care

name of organisation, project, activity!

A ppendix 1

Knowledge Swatch - House of Care

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ppendix 2 Word cloud - What does wellness mean to you?

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ppendix 3 Word cloud - What do you do to keep yourself well?

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ppendix 4 Word cloud - What are the challenges in keeping yourself well?

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ppendix 5 Ideas wall

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ppendix 6 Client feedback tool

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ppendix 7 WellFayre Business Model Canvas

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ppendix 8 WellFayre Value Proposition Canvas

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ppendix 9 WellFayre Service Blueprint

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ppendix 10 WellFayre Adapted Happy Start-up Canvas

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eferences

Adiche, C. (2009). The danger of a single story. TED [Online] Available: http:// www.ted.com/talks/chimamanda_ adichie_the_danger_of_a_single_ story#t-835137

Winhall, J. (2006). Transformational Design. Red paper 02 Design Council UK Cain, S. The Power of Introverts. TED [Online] Available: http://www.ted. com/talks/susan_cain_the_power_of_ introverts

Bate, P. and Robert, G. (2006).

Experience-based design: from redesigning the system around the patient to co-designing with the patient. Quality and safety healthcare, UK, 307-310

Coiff.J. (1997) Heuristics, servants to intuition in clinical decision making. journal of Journal of advanced Nursing.

26, 203-208

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