Overview

This project was done in collaboration with Utviklingssenter for sykehjem i Oslo (the Center for Development of Institutional and Home Care Services in Oslo). The Center for Development is focused on improving elder care in the city of Oslo, and run many different projects at the same time. This particular initiative was focused on the daily routines of staff members and improving their communication initially focusing on their analog systems, books, papers, and binders for passing along messages. Torunn Wibe, the project manager, reached out to my school after a decision to include service design methods in their project. She had already gathered a project team with representatives from five different homes in Oslo. We started by looking for the reasons why small, daily tasks of nursing home employees get forgotten and fall through the cracks. The solution of course is obvious, just close the cracks. But after hours of observations, it was clear that larger issues were lying underneath the small forgotten tasks. The observations revealed the details and pressure of working in a nursing home in a way the project team had not seen before. We came to realize that there were also communication issues not just within the homes, but at a much larger scale. 

Many staff members felt that there were so many changes being made that it was hard to keep up. So many new rules and regulations that didn’t make sense once they were implemented in the homes. The depth of my observations wasn’t something they had seen before and I wanted to share what I had learned. That way future changes might reflect the way the homes really worked on a day to day basis. 

Employees in the homes have a wealth of knowledge, experience, and insight that should be a part of each new initiative. Previously, surveys, interviews, and even tracking devices were the methods used to gather information about medical staff in Oslo. My research contained more nuance and was rooted in the every day experience of the staff. 

Rather than using these research findings to move forward on one particular solution, the information I collected was used to build an interactive resource that will form common ground for many more projects. This work hopes to act as an advocate for the employees’ perspective. 

The result is a tool that contains information from my research as well as guidance and inspiration for future projects. 

Process

Research

The first phase of research consisted of interviews with the administrators in the five homes. They focused on the paper systems used to communicate between day, evening, and night shifts. This was a great way to get an overview and introduction into how the homes were run. Each of the interviews was between 1 and 2 hours long. They usually involved walking around the wards, but seldom got into the nitty gritty details. My perspective changed drastically when I started shadowing shifts. 

In total I spent 31.5 hours shadowing 3 nurses and one nursing assistant, usually from the time they entered the building until they were done and headed home. These observations had taken some time to schedule, which greatly influenced my note taking. Usually, doing observations I am looking at large, overarching patterns. This time, I wanted to absorb as much as possible. I wanted to know everything I could. I used a notation style that can only be described as obsessive. So eager to write every detail, I noted everything they did, who they spoke with, where they went, and the time as well. It added up to around 14 pages of notes per shift. Of course I also took the occasional photo and video clip. I would stop to ask them a question or clarify something when they were on break or when they were in the middle of a longer task. The only times I wasn’t present was during moments with patients who weren’t comfortable having someone observe a particularly personal procedure. I was also able to sit with several patients, and get their impressions of the homes.

This method was eye opening to say the least. At the end of each shift I was physically, mentally, and emotionally exhausted. I uncovered much more than I had during the initial interviews. As far as I was concerned, these people are time travelers. They manage to get so much done in every minute.

The staff was very much in the moment all day, responding to the environment as it changed around them. There was a pattern to the day and cycles that repeated themselves, but so much of it was improvised. I knew there was more to uncover, but I wasn’t prepared for where it would take me. 

Synthesis

I took my notes back to the studio and started to analyze them. Rather than just looking at the overall patterns, I chose to dig deep into the minutia. My first instinct was to build a timeline for each shift, because I knew minute by minute what was going on. I then used those timelines to find out how much time they spent on one activity or in one space. I also compared the notes from one shift to another. I marked when they changed rooms, washed their hands, and looked for other repetition. Above and beyond the highest marker was the amount of interruptions. The staff was constantly being interrupted and asked to shift their attention to something new: a patient request, a coworker needs help, a family member coming to visit, or the supervisor calling in. 

From Data to Information to Insight

I learned why the residents feel the homes are understaffed. I learned when the quietest part of the schedule was. I knew which tech systems were helping, and which weren't. I dissected the notes as far as I could. I mixed and matched pieces of information until I could start to understand why the homes were the way they were. I started to develop idea for improvements. I wanted to find ways to make family members feel more included in this environment, or learn how we can maximize the quietest times for the tasks that need focus and concentration. I put together a synthesis document and presented my findings and first ideas to the project group. Their response was not at all what I expected. 

Reframing

What I realized when talking with the project group is that they already had most of my ideas for improvements. They would say, "Oh, that's just like what they're doing over here." Or, "yes, we have proposed something similar." Rather than view this as a negative, that all my ideas were taken, I saw it as encouragement. This meant that my ideas were valid. I saw the nursing homes as people working in them every day saw them. They were taken aback, however, at some of the graphs and charts I had made. This kind of visualization and the detailed nuances that were uncovered are a sharp contrast to work that has been done before. They simply were not looking at the wards the way I had. Then again, most people don’t have a week of spare time to follow each other around.

This made me understand the larger value of the work I had done. I wouldn't be doing them much of a service to pile more projects onto what they already have. Rather than end in one project, my work will serve as a common ground for many more. They responded so well to the contents I had presented, I wanted to give them a more finished version, one that could provide more value than just spitting back facts.

That’s when I remembered the feeling of being in the ward, and not quite understanding. I’d ask why they do something a certain way, and they’d say, ‘well, that’s the rule’. Regulations were being imposed on the homes that didn’t make sense on the ground level. 

As one nurse told me, “The people who make decisions about my day are so high up, they don’t see what’s really happening.” 

 I suddenly had all this information about what the homes were really like. The staff often felt that they were not represented in these decisions, but maybe there was a way they could be. I decided to build a resource for anyone working on projects in this space. It would be amazing if every change maker had to shadow shifts for a week before implementing a project, but that’s not feasible. Instead, I wanted to find a way to give them a taste of the realities of working in the wards, and perhaps a few places to get started. That’s where the name comes from. I want the people making decisions to be able to see from the staff’s perspective. They need to stand in the shoes of the employees, even if only for a short while. 

OUTPUT

Contents

So what should this resource contain? I just listened to the project group.. They know better how to apply these findings than I do. That’s why the material is presented this way. It is intended to create as much value for the Center for Development as possible. It’s meant to be actionable, informative, and engaging, but also universal enough that it could apply to many homes, long and short term, publicly or privately run. 

They had specifically said the timelines were very helpful to be able to point to certain patterns and flows. I included the timelines and general findings in a Background section. They also wanted to include the charts that illustrated specific percentages, which I expected. One illustration that I put in for fun, to give the piece some levity, showed all the parts a staff member needs to complete their work. It included items like a stomach that never hungers, and a throat that doesn’t thirst. It was a play on a quote from an interview, saying “to work here, you need a cold brain, warm heart, soft hands, and strong legs.” I thought that sentiment was beautiful, but lacking a bit. They appreciated my humor and wanted this illustration included. 

I included it with the more detailed findings under three Project Themes. These themes were technology, culture, organization. I filled these themes with the most relevant findings, as well as tips on how to go about building a project within one of these themes. I looked back to my work with grant projects at the Mayo Clinic Center for Innovation. I knew that certain questions would help a team kick off the project in the right direction and build momentum. The goal is to communicate, with as much detail as possible, what it’s really like to work in a nursing home, and what you need to consider to start a new project. Really, it’s imploring the user to look closer at things they think they know. It hopes to keep the voice of those caring for our aging family members relevant and available. It isn’t meant to be a “Well we read this, so now we’re all set on research.” But rather, a good place to start. If this resource leaves its readers with more questions than answers, it’s done its job. 

The project team also wanted to include the direct quotes from staff and patients. Those brought a human quality to the numbers. This softer side also inspired what is, for me, the most important section of this resource. I noticed that there were larger principles emerging. These were obvious, painfully so at times, but necessary to include. 

The Project Foundations are five statements that capture a set of reminders. They’re too simple to be principles. Besides, they aren’t rules, they’re requests. Written from the perspective of the staff, they are simple requests to remember the basics of being in a home. My personal favorite, “Remember that there are only 60 minutes in each hour.” is a reminder that time is finite. Anything that gets added to the staff to-do list means that something else is bumped off. The days are packed, and unless time is freed up, new responsibilities won’t have a place to fit in, no matter how valid they may be. The Foundations serve as a way to ground future projects. These things frequently get forgotten, when they really are so central to the way any nursing home operates.

Form

So I knew what I needed to include, but what would it look like? It would be digital for sure, so that it was easily shareable. But I had only a few weeks left in the project to build the final version, so it had to be quick. I didn’t want to make it one long document that you had to scroll through. I wanted it to be possible to get the information you needed right away, but also explore and find new things as well. 

Making it interactive was a way to encourage exploration and keep the information from being too overwhelming. 

I decided to make an interactive PDF because it fit all the requirements. Users could click through to find what they needed, while avoiding extra information that might not be relevant. Team members could bookmark certain pages or add comments to particularly relevant findings. A PDF is also a format that everyone can open and read, without having to install specialized software or worry about font compatibility. The final file size, at 3.5MB, was well within email attachment restrictions, making it shareable. Most importantly, I knew I could make it with the time left in the semester. 

Value for Many Users

The resource is intended to be used by anyone working within the nursing homes to make changes or new developments. This could mean administrators, project managers, directors, or outside consultants like designers and architects. Because of the wide range of potential users, my goal was to break down the information into small, easily understandable pieces. That way, each page could offer something valuable on its own and you wouldn’t have to read every page to get something out of it. What I hadn’t expected was that this user group grew after I had completed the project. This resource created value at many different levels. Not only have administrators and leader groups responded positively, it has been shared with different nursing groups and has started conversations about how they work and how they examine new ways of working. For example, patients have reported that the homes feel understaffed. But hiring more employees is expensive, and might not solve the problem. From the observations, we know that the staff spends more than half their day in areas that are not visible or accessible to the patients. So perhaps the homes aren’t understaffed. Maybe the staff is just hidden. In Their Shoes is filled with insights like this, that are rooted in reality, and can explain reasons why people feel the way they do. The value it provides is perspective. It encourages changes and improvements to be made around what is actually happening, rather than basing new policies on assumptions. 

Testing

Once I had the contents settled and sketched through different possibilities, I made a quick mock up. It had most of the information, but I wasn’t sure what assumptions I had made about how easy it was to navigate. I met with the project team who gave great feedback on the content they thought was most relevant and interesting. I also ran the draft by a few designers who were unfamiliar with the project to see if it felt natural to use without having seen the content beforehand. They missed whole menus entirely, and made me rethink the visual weight of certain aspects. They also encouraged me to spread out the content. The interactive quality made it easy to forgive a high page count, as long as it didn’t affect the file size too much. These testing rounds made it easier to give the contents the space needed to be more easily understood. 

Reactions

When I presented the final version to project team, their reactions were overwhelmingly positive. I was nervous about the format, but one person said, “It’s a lot of information, but it never gets dull. It encourages the reader to search further for more findings because it is so easily accessible.” They were motivated to move this work forward and make sure it was shared with the right people. We started talking about certain regular meetings in different leadership groups and who should see this when. They spoke about the reality in the findings: “It’s what I think is the truth, and now you can see it. It’s been counted; it’s been measured over time. So I think it’s good. Very exciting.” I was able to assign quantitative findings to things that had only been suspicions before. But not everything supported commonly held beliefs, and the message needed to be shared carefully, “We should perhaps be careful with this message. At the same time, I think it’s high time that someone speaks up and says, ‘This is how it is.’” It’s difficult to drastically move an industry like elder care, one that has so many reason for being cautious. I was glad they were here to help introduce these findings in a way I couldn’t know without working there for many years. 

Impact

The biggest impact of this project stems from the methods used. I uncovered complications within the larger system that would make it difficult, if not impossible to implement any new service I could come up with. So rather than layering on another set of solutions and trying to prototype in such a high stakes environment, I reacted to what they needed. The project team needed to understand the realities of working in the homes and the employees needed a way to be represented in the process.

This is a project about the power of visualization and the rich depth of insight that comes from simply observing. It underlines the importance of listening, of designing with empathy. This project aims to support the Center for Development in their future work by keeping the voice of the employees, and the reality of the wards, relevant for each new project. 

The project team felt the contents of the resource showed an accurate representation of the homes and the current plan is to share it with leaders and also those working on the ground level. By sharing this resource with as many people as possible, it could serve to foster a bottom up approach to innovation. We are not presenting these findings with the attitude of “We found these problems, you must have them also.” Instead, we want to create an open dialogue of “We found these problems, are they familiar? If not, what are you doing differently?” We’ve begun sharing it with various groups within the industry in Oslo. So far it has been well received. 

A slightly unexpected impact was the shift in emphasis from technology to organization. When we started this project, the issue was focused on communication, and it was assumed we would find a digital solution. But I believe technology is a tool and not a blanket solution. I had hoped that the findings would highlight the less glamorous, organizational changes that could have a potentially massive impact. When we finished this project, the group was much more focused on the organizational changes that needed to take place before technology could come in. We talked about how expensive technology can be to implement, and how much potential they had with the teams that already work in the homes. Torunn explained it best, “Perhaps some organizational changes would be more important than the technological solutions. If we don’t do anything about the organization, then we still have big problems.” 

Torunn has also submitted a separate statement, as part of the manifestation.

• Project Name: In Their Shoes  
• Category: Non-Profit/ Public, Student
• Service Design Award 2016, nominated project for Student Award
• Organization: The Oslo School of Architecture and Design, Master's degree
• Author: Liz LeBlanc <audreyqbj@gmail.com>