Learnings for EDB
Learnings from CIID
#1 Harness the immense power of passionate, flat, diverse, small teams operating on the same norms
#2a Focus & right sequencing increases the speed of doing & learning (vs. doing in parallel)
#2b Learning compounds with focus & time, with a huge difference
#3 Test quickly, cheaply & often
#4 Build modularly
#5 Content is important, but context is king.Video storytelling conveys both
Context
Helping an older adult find a caregiver, delineating the caregiver’s tasks, monitoring the caregiver’s work with the older adult, and ensuring the caregiver’s own well-being*…can be…among* the most important interventions to ensure the well- being and safety of frail older adults.
– Dr. Louise Aronson, “Elderhood”, 2019
Aging is a demographic trend affecting many countries in Asia, Europe and America.
In rapidly aging societies like Denmark, the demands on institutional caregivers of elders will increase, worsening the stress of an already-demanding job in a talent-crunched profession. This is reflected in the high annual turnover rates for professional caregivers (~25% per year at a nursing home in Denmark).
“Slowly their empathy kinda drains: (the carers get) hardened…(This is) a huge problem…(elderly) people can get very angry when they’re not met with empathy & understanding…the lack of understanding can actually accelerate ‘bad behaviour’ (in elderly people).”
– Rachel, Activity Center Manager
Caregiver burnout also causes a loss of empathy, which in turn creates downstream problems of “bad elderly behaviour”.
Conversely, a Singaporean medical professional shared with me that
- Caregiver empathy can alleviate “bad elderly behaviour”, which is sometimes managed by sedation. An anecdote shared with me was about an elderly man with dementia, who initially needed to be sedated due to his bad behaviour; after his son hired a new caregiver who was much more empathic, the bad behaviour disappeared, as the new caregiver took the time to listen to him, asked him to repeat his stories, etc.
- There are caregivers of the elderly who work in the field for 5, 10, 20 years with a continued spark and no burnout.
This caused me to think about the possibility of the opportunity area, which became my brief.
Brief
What if we can help institutional carers of the elderly in Copenhagen to maintain their empathy & energy to care for 5, 10, 20 years?
This was my starting point for the project, which was selected with the help of a nursing home manager through a sorting-cards prioritization (pictured).
Concept
Stille – Concept video from CIID IDP on Vimeo.
Stille is a service which aims to help caregivers maintain their empathy and their energy to care, by supporting caregivers’ emotional well-being.
It does this through three modules, which
– Allow caregivers to emotionally support each other through sending audio messages of appreciation
– Provide timely prompts for caregivers to reflect on their day and visualizing the caregiver’s mood patterns
– Provide micro-breaks at a physical break station
1- Co-worker Care Module
This module allows the sending of audio messages of appreciation and thanks, between co-workers.
Research pointed to a lack of emotional support as a critical gap; at the same time, most caregivers I interviewed relied heavily on their co-workers for ad hoc emotional support. This can be difficult during the shift, as the pace can be very frantic. After the shift, the co-workers tend to split their own way, and sometimes do not see each other for days.
This service module is delivered digitally via a mobile app, allowing co-workers to record and send audio messages after the shifts. It was influenced by Design Principles 2, 3 and 5.
The sharing of audio messages of appreciation was tested via a Whatsapp chat group amongst some of the caregivers: the result was good enough that they continued with the practice even after my project was over (see pictures).Stille – Microbreak Module from CIID IDP on Vimeo.
3- Microbreak Station Module
This module augments the caregivers’ existing rest areas in the nursing home, with a physical vibrating “chestnut”* that helps take their mind away from their stress. It is activated by the caregiver surrendering their phone to the station, and by picking up the “chestnut”.
Research indicated that caregivers would “escape” to certain areas out of sight from the residents to get some rest and respite. Sometimes the caregivers would just look out the windows; sometimes they would end up engrossed with their phones. The soothing nature of tactile interactions (see Design Principle 4) was tapped on to augment the rest areas, to help create a break (see Design Principle 1).
(*Note: chestnuts have a special significance in Danish culture. It signifies the arrival of autumn, and many Danes carry a “lucky chestnut” in their pockets in the autumn.)
Design Principles
Research yielded five design principles, which were used to design the solution.
Address the Stress: create a break. The picture showed the emotional seismograph of a nursing home part-timer (sketched on a tablet): the thin line was her “happiness” chart, while the thick grey line was her “stress”. As she said to me, “happiness is not the same as stress.” Thus, it was not sufficient to create meaning, but there was a need to design for a break, even a small one.
Focus on the emotional, not the physical. Existing preventive measures at the nursing home were focused on physical well-being, and not emotional well-being.
Emotional support was ad-hoc and between co-workers. There was an opportunity to design for the emotional well-being of caregivers.
Reinforce social bonds & support amongst co-workers. Co-workers were an existing source of emotional support and well-being, but the support was currently ad-hoc and unstructured. This was an opportunity to deliberately systematize the social support amongst co-workers.
Tactile interactions to calm & soothe. A caregiver brought chestnuts during a shift, and throughout the evening, chestnuts were handed out to staff and residents alike; this had an observable calming effect on both staff and residents.
Non-written reflection mechanism. Almost all caregivers though about their work, and found it useful. However, five caregivers were given five notebooks to journal over two-weeks: this yielded only THREE pages of reflections. As one caregiver said to me, “If we had to write, it is just another task.” There was an opportunity to create non-written mechanisms that help caregivers reflect on their shifts and emotions.
Process
Research
I started with desktop research to understand the aging and motivation: the books I referred to included Aronson’s Elderhood, Gawande’s Being Mortal, as well as Dan Ariely’s Payoff: The Hidden Logic that Shapes our Motivations. Concurrently, I started volunteering at the nursing home where I eventually did my research, and was able to ask some of the staff on possible areas of research for my final project.
This generated a few areas in aging and eldercare, including:
- How might we help elders to maintain their daily routines?
- How could we help elders be calmer, and less agitated or sad?
- How could we preserve the “life space” of elders with mobility issues?
Eventually, I zoomed in on the brief by putting all these areas onto sorting cards, and asking a nursing home manager to prioritize. (See Brief section above).
After the brief was prioritised, the research process proceeded in two phases.
Phase 1 involved shadowing the caregivers of a single floor in the nursing home. I shadowed the caregivers for three shifts (total 21 hours): two day- and one evening-shifts. There were some co-creation sessions, involving sacrificial prototypes. The shifts were documented in the research video below, which shows a typical day in the life of a caregiver:
A Day in the Life of a Nursing Home Floor (Stille Research video, public) from CIID IDP on Vimeo.
Phase 2 involved a series of co-creation sessions with the caregivers (10 in total). The first co-creation sessions were initially used to refine concept ideas from Phase 1, with increased fidelity. This was a mistake, as the fidelity of the prototypes ramped up too quickly, and the feedback was polite but not candid. An advisor pointed out that I was still unclear what I should prioritize, and what should be physical vs. digital. It was also unclear how and where my solution would fit within the existing service ecosystem of the nursing home.
Thus I deliberately went back to the caregivers with sorting cards and a few blank Post Its, to get the data of what the caregivers would prioritize (this was “emotional support from co-workers” and “individual reflection time” respectively, which became the first two modules of my solution). Subsequent sessions involved deliberate testing of specific hypotheses using prototypes (see below), together with open-ended co-creation of possible solutions.
Prototyping & Iteration
Sacrificial Prototypes
Sacrificial prototypes were used to catalyze conversations with the caregivers during Phase 1, and to generate ideas on possible solutions with them. The concepts for these prototypes came from a group brainstorming with the whole IDP 2019 class, and are pictured below:
The Task Swapper was a concept to create a break (Design Principle 1) by swapping tasks between floors in the nursing home, using an app to facilitate the swapping of tasks with colleagues on other floors. This was quickly rejected, as the residents will only allow care from caregivers they are familiar with.
The Story Sharer was a concept of an app that allowed the sharing of stories between caregivers, about their memorable interactions or experiences with certain residents. This was designed to strengthen the bonds between co-workers (Design Principle 3). This ran into the privacy constraints (there were guidelines against naming or identifying caregivers); it was a trainee nurse who suggested sharing stories and appreciation for co-workers instead. This became the nucleus of the Co-Worker Module.
The Mood Bracelet was a concept to allow co-workers to more clearly signal their moods to each other, allowing for reinforced social bonds and also focusing on the emotional (Design Principles 2 & 3). A trainee nurse pointed out that this could be achieved by simply asking each other “how are you feeling” during their staff meetings: hard to beat that!
Hypotheses testing to find the balance between physical vs. digital The initial research and sacrificial prototypes yielded initial validation: as mentioned above, my initial instinct was to ramp up the fidelity, but the feedback was polite and not candid.
Consequently, I went back to using sorting cards. I also created a storyboard to test the different modules (co-worker care, self-care) using both digital and physical devices, and also used lo-fi screens (i.e. Post Its) and hi-fi screens to test and find out what needed to be physical vs. digital.
Evolution of Co-Worker Care Module This started with sharing of stories about citizens; due to constraints of privacy, on suggestion of a trainee nurse, the concept switched to vocal appreciation of colleagues. The immediate follow-up was hi-fi prototype testing, but feedback felt less candid, so I dialled back fidelity while testing which aspect of solution should be digital vs. physical.
The last trial involved WhatsApp audio messages, with me Wizard-of-Oz-ing as a machine-learning chat bot which sends prompts before, during and after the caregiver shifts.
Evolution of Self-Care Module The iterations for this were initially focused on just hearing messages from colleagues, as well as some breathing and relaxation exercises. But with caregiver feedback about the need for reflection and spotting patterns, it shifted towards a visual dashboard and the other screens.
Evolution & Construction of Microbreak Station Module I first iterated by using an animated screen with a physical chestnut. Then I tried using a digital chestnut, in order to explore the balance between digital vs physical.
Finally, I taped a vibration motor onto a chestnut, slapped a Post It on a box, and used that to test the interaction .
Remaining pictures show the process of building the final prototype.