Over the summer, Leigh Hubbard served as a Strategic Design Research Fellow at the Center. Our ongoing collaboration with Leigh has been marked by a growing appreciation for our—by turns—compatible and contrasting ways of working and thinking. We asked Leigh to reflect on what it’s been like to engage with strategic designers.
Design in Health Care from the Registered Nurse’s Perspective
I am a Registered Nurse AND a designer. Sort of.
I’m kind of an imposter. But not really.
In 2019 I attended an open-invitation community Hackathon hosted by the Center for Biomedical Research Excellence on Opioids and Overdose at Lifespan, the aim being to DESIGN SOMETHING that would help curb the opioids overdose crisis. I sat at a table with the only other person I knew. Also at our table were two user experience designers, a public health researcher, and a (former) journalist who works for the Center for Complexity. As the only medical person at my table, I helped level-set the group’s foundational knowledge re: biology, medication half-lives, what an ER looks like, why health care providers may be frustrated, what it’s like to be lied to (as a healthcare provider), and what it’s like to see a positive impact. Fast forward: our beautifully designed 3-minute pitch won first prize, and our thrown-together group committed to continuing to meet and further our concept.
The concept: Redesign current care spaces to be more aligned with what people using drugs need (and people caring for those people need) in order to improve the likelihood of a successful recovery or, at minimum, safer behaviors. If care spaces allow for a low, soft, and slow experience, not the fast, hard, loud, bright experience currently endured in the back of an ambulance or ER bay, people who use drugs, we hypothesized, would be more receptive to help and less likely to flee without speaking with a peer.
This was the initial idea, but there were branches from this related to physical space design, training and staffing of spaces where people receive care, introduction of safe consumption space, ways to return dignity by removing stigma to those who use drugs, and much more. We called this place and ourselves mainstay RI.
I’ve worked in clinical settings for 20 years now. My nursing journey began in Med-Surg (hospital) nursing, took me into women’s health and abortion care, then more broadly into sexual health care, then back to the hospital to neurosurgery, then intensive care, then to surgical care, program management, clinical management, and most recently I looped back to sexual health and care of the LGBTQ+ community. Through this, I hadn’t ever worked with bonafide process or system or space designers before. I’m pretty sure my designer colleagues hadn’t ever really worked with a nurse or health care provider either.
We started our relationship meeting weekly in the evenings in the Center for Complexity studio space, and we began figuring out how we would work together to further our idea as a group of volunteers with $5,000. This multidisciplinary marriage was exciting to all of us, and we valued each other's expertise, but any sustainable relationship doesn't live on spark alone. It takes work, compromise, time, communication, and at times a reckoning when things aren’t working and need to shift. I want to share, from my nursing perspective, what it was like dipping a toe into a design world, and how this experience has shaped my outlook broadly and my nursing practice specifically.
There were key design concepts that were challenging for me to reconcile with my medical training. These involved the use/design/manipulation/iteration of OBJECTS and also the allowance of unstructured time to foster the dreaming/creating process. These are both elements of design that were foreign to me, and prompted me to ask many questions and become frustrated/antsy early on as our small group continued our courtship.
Objects, Iteration, Trial and Error
In medicine, interventions have consequences that could improve health or potentially cause harm. Care is taught and practiced within nursing, medicine, and other health sciences in a way that leaves little room for preference, style, or change (there is style, preference, and individuality, but on the periphery, and they are not changes that are core to the assessment, intervention, or device). This ultimately keeps people safe, prevents medical providers from experimenting on people, and allows for standardized protocols that easily translate to objective measurement. It also means that if you use a tool exactly per the manufacturer's instructions for use, you can expect a specific therapeutic response. To deviate from a process or a recommended use means stepping into a place of medical uncertainty, or possibly worse, harm. As a nurse working along the spectrum of care in multiple settings, I’ve witnessed the negative consequences of a provider deciding to bypass a process they thought was silly, or change a tool with a specific design to meet their needs. I rarely have the luxury of adjusting physical tools that I work with, or dreaming of what they could be like, and I definitely didn’t have the time to design or iterate them. Even if I did, there was zero comfort in experimenting or failing. This hesitancy that I felt came from a place of protection of self and others.
In the design space, revision, iteration, failing, learning, and trying again was normal, expected, and embraced. This took time for me to understand and begin to practice. In one of our Thursday evening group meetings, my colleague said to me, “I’ll write the sacrificial draft,” and I asked what they meant. A sacrificial draft is the draft you KNOW will not be the final. It’s the draft that others will critique and change, but it will get the process started. At that moment, the lightbulb went off in my brain. Starting is difficult, but if you embrace the concept that the start isn’t where you will finish, it becomes easier and safer. Even with this explanation, it took work to relearn what it could be like to consider changes and give/receive feedback without entering a place of anxiety and fear. Now I regularly volunteer to be the person to start the sacrificial document, drawing, or algorithm. I am proud to be the springboard for work done by my colleagues at CfC and in my clinical work. Conversely, the rationale for my initial hesitancy to iterate within the health care space helped my design colleagues understand the history of human subjects research, which is rife with misconduct and protected for good reasons. With a deeper understanding of the potentially negative downstream implications of change, we moved forward together in designing interviews and considering options for improvement that were sensitive to this history.
Unstructured Time
As a nurse leader, I facilitate numerous meetings within the health care space. These meetings are tightly scheduled: 30, 45, or 60 minutes. There’s usually another cohort waiting for the room, so keeping to an agenda, having a tight timeline, and leaving with clear action items and confirmed successes (to be reflected in the minutes) is imperative. In health care, projects are more like locomotives, barreling forward, never backwards. The effort and consequences to turning the thing around are too overwhelming to consider. There is rarely a willingness to “go back” and “consider” changing a plan. Depending on the project, reconsidering an intervention too far into the project may mean re-teaching a workforce, redesigning an integrated electronic medical record interface, or attending four more meetings for approval of revisions. The political capital lost for admitting that the original concept was flawed is, if we are being honest, a barrier to iteration also. The rigid timelines, need for a deliverable at the end, and linear structure to meetings and projects were my world.
Time to Think and Dream
I remember being confused at our first mainstay RI meeting, which was scheduled for three hours and had no agenda. Having large chunks of unstructured time to sit with a problem or a possible solution, pull away, and return with another question or idea was frustrating at first. My behavior in those first weeks and months was likely perceived by others as awkward, shortsighted, and hurried. As we met month after month, we would address a topic or question, resolve it, then come back to it later and review the old information and add new knowledge. Over time I have seen this process yield insights and outcomes that are much richer than any initial thought that could ever have come from a 15-minute agenda item during a 60-minute meeting. I now carve out three hour chunks into my clinical schedule and (try to) focus on one larger problem or project. I doodle, note-take, research, strategize, talk with someone close to the project. Time is a resource that is scarce in healthcare, but I’ve seen the power of unstructured time used to dream. I hope there is opportunity for nursing/healthcare to integrate more purposefully time that appears on the surface to be idle, but is anything but.
Nursing is often considered by the public to be very task-based, or it’s considered an art, or a calling. I never bought into those perceptions. I am a masters-prepared, licensed health care professional who assesses a patient's condition from a multitude of angles. I communicate with others, recommend actions, and implement changes to health care plans. I measure the patient’s, family’s or community’s response to my actions or to any other medical intervention. As the work of the clinical nurse has evolved over time, and as I continue my work with the team at RISD’s CfC, I would add INNOVATOR-slash-DESIGNER to the list of functions of the registered nurse. We constantly (but often unconsciously) consider alternative ways of doing, or alternative ways of designing, and only a fraction of the time are these innovations known to others. Through my work with designers and my recent introduction to design concepts, I have appreciated the time I have had to consider the care space and training redesign in the context of the opioid epidemic, and I see a need for other nurses to be exposed to these concepts in order to improve health care.
Field Notes
Applying Design Theory and Research to Solve Nursing (HEALTHCARE) Challenges: A Starter Course: Led by Leigh and Justin, American Nurses Association Rhode Island (ANA-RI) in collaboration with Center for Complexity will be offering a CE-credited workshop on applying strategic design to the challenges of nursing and health care. It is being held in Providence, December 13, 3:30-7:30pm.
Designer Amy Qu is working with us to pursue her ideas on better approaches to supporting people who use drugs. You can read about some of her early work in this interview in the Providence Journal.
10x100 is an organizing structure for rapid transformations. Its mission is to bridge strategic gaps between scientific consensus and appropriate action by accelerating learning and accountability. “10x100 has been initiated by Politics for Tomorrow and Dark Matter Labs, kicked off with many partners and prototyped in different contexts like Creative Bureaucracy Festival, European Forum Alpbach a.o. Based on the resonance, we plan to develop a machine-assisted, multi-actor approach, establish a digital cooperative with a membership structure and present a planetary strategy during COP28 in 2023.” We have joined this effort.
Worth Reading
Legible Practices. This book brings together a set of case studies accompanied by an explanation of the approach that typified Helsinki Design Lab's approach to system's change. It has, in turn, been a regular source of inspiration for our own work.
Hopepunk—against purity, for optimism and hard work. This essay is an overview of the Hopepunk literary genre and what marks it as different from other science fiction and YA dystopian fiction. It is a genre where the heroes are not fighting to restore an old way but to create a new way. It is a genre that celebrates the troubling process of messy hope and rejects the ideals of purity as part of being good.
Interesting Links
Call for Papers: The Arts in Society (July 2023 in Krakow): the 2023 conference, titled New Aesthetic Expressions: The Social Role of Art invites papers, workshops and panels on themes including the role of the arts in social, political and economic life. Early Proposal Deadline 5 December 2022.
Is it morning for you yet? Carnegie Museum of Art: Skip New York's various biennials and art fairs and go to Pittsburgh to see the 58th Carnegie International to see how artists are responding to the critical social, economic, political and ecological challenges of our troubled times. September 2022 to Apr 2023.