The Pain Pressure Cooker

Reducing Pain in Procedural Healthcare

Queensland Children’s Hospital and Clinical Excellence Queensland

HEAL – the Healthcare Excellence Accelerator Lab – is a partnership between QUT Design Lab and Clinical Excellence Queensland designed to connect healthcare professionals across Queensland with designers, who will work together and use design approaches to transform thinking, spaces, places, processes and products, and positively transform healthcare.

As part of HEAL, Professor Evonne Miller and Associate Professor Marianella Chamorro-Koc from the QUT Design Lab led a one-hour co-design sprint at a major Queensland public hospital as part of an ideas festival in late 2020. In this rapid “pressure cooker” design sprint, we triggered significant ideas and discussion about how to reduce pain in procedural care – and briefly outline our approach, tools and processes here. 


Challenges facing healthcare and the value of participatory and experience-based co-design 

Across the globe, healthcare systems are working towards the quadruple aim: improving clinical outcomes, unit cost of delivery, staff experience and the patient experience (Bodenheimer & Sinsky, 2014). Traditionally, healthcare improvement initiatives were led from the ‘top down’ but, over the last two decades, collaborative ‘bottom-up’ and participatory approaches have become mainstream  (Bate et al., 2004). Palmer et al. (2019) describe the current emphasis on citizen engagement and participation, and related concepts of co-production, co-creation, co-design and co-innovation, as the “new Zeitgeist – the spirit of our times in quality improvement” (p. 247).

This new spirit of participation rightly argues that the voice and lived experience of users – staff and especially consumers – must be privileged. It reflects what Bate and Robert (2006) describe as an evolution in patience influence: from complaining, to giving information, to listening and responding, to consulting and advising, to the contemporary approach of experience-based co-design. After as, Don Berwick (2003) wisely suggested nearly two decades ago now, healthcare “workers and leaders can often best find the gaps that matter by listening very carefully to the people they serve: patients and families”.

Experience-based co-design (EBCD) recognizes that health service users – both consumers and staff – are experts of their own lived experience, and encourages them to share their expertise, ideas and knowledge. Borrowing from participatory design and user experience literatures, in the typical healthcare experience-based co-design process staff, patients and carers collaboratively reflect on their experience of a service and work together to identify and test opportunities for improvement over a year.

Participatory design approaches changes people from being “merely informants to being legitimate and acknowledged participants in the design process’ (Robertson & Simonsen, 2013, p. 4–5), where the future users of a design participate as co-designers in the design process – engaging in the design of their own futures. This participatory approach gives voice to personal experience, respecting these different voices and positions healthcare consumers as “vital to the design and delivery of services, working with professionals and front line staff to devise effective solutions” (Cottam & Leadbeater, 2004, p.22).

Four transformative goals for change in paediatric pain (Eccleston et al., 2020)

 

Design Challenge

How might we… reimagine procedural pain?

Identifying a clear aim is critical to any co-design session, especially when it is rapid. In this project, clinical stakeholders had been working towards reimagining procedural care, and had three key aims for the session:

    1. to understand the experience for children, young people and their families, and staff who are involved in procedural care;
    2. to brainstorm and design ways to achieve optimal (more calm, more comfortable) procedural care for all stakeholders
    3. to identify the next steps to achieve this.
 

 

 


Stakeholder Engagement

Often design thinking workshops start off with an ice-breaker activity, but as the 25 participants (healthcare stakeholders) here knew each other, we jumped straight into the activity after a brief overview of current activities and the value of design thinking – they were asked to create a group name, however, and the time constraint helped foster a sense of urgency which encouraged participants to quickly drop concerns about status or being wrong, and to more openly share ideas.

Step 1: Empathy

The very first step in the design thinking process is empathy. Daniel Pink (2009) defines empathy as “standing in someone else’s shoes, feeling with his or her heart, seeing with his or her eyes”, with nursing scholar Theresa Wiseman (1996) identifying four key attributes:

(1) to see the world as others see it;

(2) to be non-judgemental;

(3) to understand another’s feelings; 

(4) to communicate that understanding.

The four-minute video Empathy: The human connection to patient care[1] powerfully illustrates what empathy would mean in the context of healthcare consumers and professionals, and often in co-design workshops, a video is created as a tool to trigger deeper understanding and empathy. Participants may also be asked to think of and share the perspective of the target user group, or to conduct research to understand their unique perspective. Here, we created two personas to generate empathy.

Personas, as Stickdorn et al. (2019) note “help a team to get onto the same page, to build empathy with customer groups, and to step into the shoes of different stakeholders, understand their needs, and review their tasks” – and this shared empathic description provides a basis for action, with some companies even developing life-sized cardboard cutouts of their personas to bring to meetings as a reminder of a certain perspective.

We created two personas: 5 year old Annabelle and 16 year old Tiffany (see bottom of page – appendices). Participants were asked to pick one persona (or create their own) and, in teams, collaboratively complete an empathy map about what she would be thinking, feeling and fearing about her trip to the hospital today for an MRI with cannulation.

Through a process of empathy mapping, participants were encouraged to take off their shoes” and step into Tiffany or Annabelle’s perspective.  

In groups of five (minimum), participants discussed the categories outlined in the figures below – what she might say, think, do and feel, and the “pains and gains” from the experience. Empathy maps vary in formats, but typically position the user at the centre of a large sheet of paper, which is decided into quadrants that explore the user’s external, observable world, and internal mindset. Each group worked together to complete the worksheet, discussing and sharing their own experiences and bringing Tiffany or Annabelle’s attitudes, behaviours and experiences to the front of mind. After 5 minutes, one group shared their empathy map. To further create atmosphere, background music from the 1980’s teen pop star singer Tiffany played.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Step 2: Define

Step 2 in the Design Thinking process is to define the problem: the definition of a meaningful and actionable problem statement brings clarity and focus – and ensures everybody is clear about the goal. A good problem statement is human-centered and user-focused – here the starting problem was :“how might we create a more comfortable, calm experience”, and groups did not further refine it.

Step 3: Ideate

The third step in the design thinking process is to ideate – to think HMW (how might we) create more comfort and calm for Annabelle and Tiffany, and their families. Here, we added an extra layer of perspective taking. As well as asking groups to explicitly think about key touch-points in the patient’s journey map – before, during and after the procedure – we also instructed each person at the table to advocate for a specific perspective – that is what could be done to improve the experience from the perspective of: the patient, the family, the staff, the space, and technology.

Each group was asked to generate a minimum of 10 ideas in 20 minutes – with the purposeful perspective taking and rapid pace designed to purposely encourage rapid, innovative, out-of-the-box thinking – with teams encouraged to use the phrases if “I like, I wish, What If”.  Groups wrote the team name on each post-it, and a different colour was used for each perspective and solution (e.g., technology was purple post-it notes, space was blue). They also noted where in the patient journey – before, during, after (B, D, A) – their idea belonged, as the figures below show.

After the groups had ideated and brainstormed, they were asked to pin up their solutions on butcher’s paper around the room. Everyone looked at and read the other group’s ideas, and using red sticky dots, voted for their favourite: each person had people had 5 dots to vote with. This voting process generated much discussion and extended ideas, as participants saw what ideas other groups had.

The facilitators sorted each row into rows of “Before / During / After”, to help with idea sharing, and also shared the most popular ideas – and team – with the entire group. At all times, an atmosphere of positive energy was fostered and felt.

The ideation task, with guidelines
After the groups had ideated and brainstormed, they were asked to pin up their solutions on butcher’s paper around the room. Everyone looked at and read the other group’s ideas, and using red sticky dots, voted for their favourite: each person had people had 5 dots to vote with. This voting process generated much discussion and extended ideas, as participants saw what ideas other groups had.

The facilitators sorted each row into rows of “Before / During / After”, to help with idea sharing, and also shared the most popular ideas – and team – with the entire group. At all times, an atmosphere of positive energy was fostered and felt.

Step 4: Prototype

Having been inspired by the ideas of others, teams were now tasked with generating one preferred solution. Working back in their groups, teams had 10 minutes to decide on and prototype one solution that they would pitch to the room.

Teams sketched their ideas on butcher’s paper, and then presented them – in less than one minute – to all. All groups again voted for the winner, who received a handmade paper hat proclaiming them the “Design Visionary” – as we see in in the image below.


 

Research

Procedural pain is short live acute pain associated with medical investigations and treatments, for example from blood tests, immunisations, IVs/Port access, dressing removals and changes, and nasogastric tube insertions. As every infant, child and adolescent will experience pain during their life, a recent Commission in The Lancet Child and Adolescent Health has outlined four transformative goals to deliver transformative change in paediatric pain: (1) make pain matter, (2) make pain understood, (3) make pain visible, and (4) make pain better, as the graphic from Eccleston et al. (2020) illustrates.

Many healthcare providers have also committed to The Comfort Promise, a pledge to do at least the following four things (numbing, sucrose or breastfeeding, comfort positioning, and distraction) to lessen pain and fear during procedures. Preventing procedural pain is connected to paediatric medical traumatic stress and trauma-informed care, can help reduce staff vicarious trauma (which, unaddressed, leads to compassion fatigue and burnout). As Eccleston et al. (2020) argue, we must continue to innovate and think differently about pain as “how much of what we do (or fail to do) now for children in pain will come to be seen as unwise, unacceptable, or unethical in another 40 years?

 

 

 


Outcomes

Stakeholders’ had many design ideas to increase comfort and calm for kids and families, as captured in the table below. Additionally, we had stakeholders “fast-forward” to the future – 2040 – and imagine what care might look like there, which again helped move participants to a positive, solution-orientated mode. For a one hour co-design discussion, there was much positive and reflective dialogue, and insightful, ideas for purposeful action. Highlighted in yellow are those ideas that were most popular, and we are in discussions about what and how to prioritize those.

The design thinking workshop was a powerful approach for connecting with, clarifying, and mobilizing participants’ energies and priorities, growing an existing movement for improvement and change in procedural paediatric pain. And, as this first activity focused on staff, future work will actively engage consumers – children, youth and their families –as co-creators of any initiatives.

 

 



Project Team

Professor Evonne Miller – Design Sprint Facilitator, Director of the QUT Design Lab 

The ‘Pain Pressure Cooker’ was one of the shortest in time creative design sprints I had facilitated, and I was originally quite worried about the participant experience and the quality of outcomes. Of course, managed well, time pressure can facilitate creativity – and that is what we saw here: numerous wonderful ideas about facilitating meaningful change for children undergoing painful health procedures, which hospital teams are taking forward to improve clinical practice and the healthcare experience. It also gave busy clinicians some hands-on experience with design thinking tools, from empathy to rapid ideation and prototyping”  –Prof Evonne Miller


Appendices

Personas

   

 

 

 

References

Bate, P. & Robert, G. (2006). Experience-based design: from redesigning the system around the patient to co-designing services with the patient. Quality and Safety in Health Care, 15(5), 307-310.

Bate, S., Robert, G. & Bevan, H. (2004). The next phase of health care improvement: what can we learn from social movements? Qualitative Safety Health Care, 1362–1366.

Berwick, D. (2003). Improvement, trust and the healthcare workforce. Quality and Safety in Health Care, 12(1), 2-6.

Bodenheimer, T., & Sinsky, C. (2014). From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider. The Annals of Family Medicine,12(6), 573-576.

Brandt, E., Binder, T., & Sanders, E. (2013). Tools and Techniques: Ways to Engage Telling, Making and Enacting (pp. 145-181). In J. Simonsen, & T. Robertson (Ed’s.). Routledge International Handbook of Participatory Design. Routledge.

Brown, T. (2009). Change by design: how design thinking transforms organizations and inspires innovation. HarperCollins.

Donetto., S., Pierri, P., Tsianakas, V., & Robert, G. (2015). Experience-based co-design and healthcare improvement: realising participatory design in the public sector. The Design Journal, 18(2), 227-248.

Eccleston et al. (2020). Delivering transformative action in paediatric pain: a

Lancet Child and Adolescent Health Commission. The Lancet Child and Adolescent Health, early access online

Palmer, V., Weavell, W., Callander, R., et al. (2019). The Participatory Zeitgeist: an explanatory theoretical model of change in an era of coproduction and codesign in healthcare improvement. Medical Humanities, 45, 247-257.

Pink, D. (2009). Drive: The Surprising Truth About What Motivates Us. Riverhead Books.

Simon, H. (1969). The Sciences of the Artificial. MIT Press.

Stickdorn, M. & Schneider, J.  (2012) This is Service Design Thinking: Basics, Tools, Cases. Wiley.

Wiseman, T. (1996). A concept analysis of empathy. Journal of Advanced Nursing, 23, 1162-1167.