Keywords

Design thinking is a problem-solving approach that places humans at the centre of the process, prioritizing empathy, collaboration, and creativity. It has gained widespread acceptance in healthcare, where design-led approaches and related concepts such as participatory co-design, co-production, co-creation, and co-innovation are regarded as the “new Zeitgeist of quality improvement” [1, p. 247].

There are at least three reasons why design thinking and co-design approaches have become so popular in healthcare: empathy, collaboration, and creativity. Firstly, one of the fundamental principles of design thinking in healthcare is empathy. Empathy means understanding the feelings and experiences of patients, their families, and other stakeholders. It involves ‘putting oneself in their shoes’ to gain a deep understanding of their needs, desires, and challenges—and then altering and co-designing processes and systems to better meet user needs. Through deep empathic understanding of the challenges and experiences of stakeholders, the argument is that the resulting solutions will be more effective, efficient, and satisfying for everyone involved.

Secondly, the design thinking process provides a framework for collaboration between healthcare professionals, patients, and their families, with this process fostering a sense of ownership and shared responsibility for the solutions developed. Design thinking approaches acknowledge that ‘all of us are smarter than any one of us’ [2, pp. 26–27]. Thirdly, the process encourages participants (healthcare professionals, patients, and their families) to be creative—to think ‘outside the box’ when developing solutions, and then to prototype them, to test and refine solutions in a rapid and iterative manner. There are, as Dell’Era et al. [3] note, four kinds of design thinking: solving wicked problems by leveraging creativity (Creative Problem Solving); accelerating the development process to quickly and effectively launch new solutions/products (Sprint Execution); engaging staff with new innovation mindsets, approaches, practices, and methodologies that foster innovation and change (Creative Confidence), and creating innovative visions that support new strategic directions (Innovation of Meaning). The diverse sprints HEAL have run have been a mix of all of these.

As Fig. 1 illustrates, design thinking is a typically iterative approach comprising of six key steps: empathise, define, ideate, prototype, test, and assess (these steps will be described in detail, later in this chapter). The ‘magic’ of a design thinking sprint is that each of these steps intentionally side-steps existing or traditional solutions in favour of innovative, collaborative, and creative problem solving.

Fig. 1
A chart represents the six key iterative steps of the design thinking approach as follows. 1. Empathise. 2. Define. 3. Ideate. 4. Prototype. 5. Test. 6 Implement.

The six key iterative steps of the design thinking approach

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1 This Design Sprint Challenge: Reducing Procedural Pain for Children

This chapter documents the rationale, processes, and value of running a shorter time-condensed (1 h) design sprint focussed on a specific challenge: how might we reduce procedural pain for children? Procedural pain is short-lived 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, four transformative goals have been identified to deliver transformative change in paediatric pain: (1) make pain matter, (2) make pain understood, (3) make pain visible, and (4) make pain better [4]. Many healthcare providers have also committed to The Comfort Promise, a pledge to do at least 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, and can also help reduce staff vicarious trauma (which, unaddressed, leads to compassion fatigue and burnout). And, as Eccleston et al. [4] 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?” (p. 75).

This design sprint on how we might reduce procedural pain for children was held at the Queensland Children’s Hospital, during their annual week-long event Dream Big. Clinical stakeholders had been working towards reimagining procedural care, and connected with the HEAL team to potentially run a design sprint on this topic. They 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; and (3) to identify the next steps to achieve this. Before describing the activities and outcomes of this specific design sprint, I will first reflect on the origins, role, and philosophical underpinnings of design sprints.

2 Design Sprints—Origins, Role, and Philosophical Underpinnings

The specific design and duration of design sprints approaches varies, from half a day to a week to months. In business, teams engage in co-design sprints that range from half a day to a week (for example, see [5]), working through a series of brief and structured activities designed to facilitate collaboration and creativity, sharing knowledge, skills, and experiences whilst generating new ideas and user-centred solutions in this focused, time-bound period. Given the context of this project—specifically, the existing interest in reducing paediatric pain and the aim to run this sprint during a week-long event with busy clinicians—the decision was made to condense the sprint time down to one intense hour in order to: (1) introduce clinicians to the value of the design thinking processes for seeding innovations and building collaborations; and (2) demonstrate that—with the right structure, design activities, and facilitation, even a 1 hour design thinking sprint can be a positive transformative learning experience.

3 Creating ‘Liminal Spaces’ for Transformative Learning Experiences

Regardless of the time duration, design sprints and co-design workshops are a power tool for educating and engaging staff with healthcare improvement initiatives. My approach is grounded in an appreciation of Mezirow’s transformative learning theory [6] (see chapter “Thinking Differently: Six Principles for Crafting Rapid Co-design and Design Thinking Sprints as ‘Transformative Learning Experiences in Healthcare”—[7]), and Meyer and Land’s [8] threshold concepts. Meyer and Land developed the threshold concepts framework to convey that a ‘crossing over’ is needed for certain learning that is critical to a particular discipline, resulting in an ‘irreversible conceptual transformation’ in learners. The idea is that learners enter a transitional or liminal state, with this learning process both ‘troublesome’ and ‘transformative’. At their best, design sprints are characterized by this liminality—a threshold or transitional moment ‘in and out of time’, where a new perspective opens. As Matthews and Wright [9] discuss in chapter “Exploring Clinical Healthcare Challenges and Solutions Through a Design Thinking Education Program for Senior Health Professionals” of this book, while non-designers are unlikely to move beyond a ‘novice’ level of design expertise, the experience may trigger an interest in design-led approaches—and could even transform how participants think or feel or believe. This liminal space is ambiguous and creative, as people try out new ways of understanding and being, reappraising their role and place in the world—and design sprints/co-design workshops provide the perfect place for such experimentation and transformation.

Drawing on an analysis of LEGO serious play workshops on service innovations, Piironen [10] defined collaborative workshops as creating three specific spaces: liminal space (transformative experiences), liminoid space (the experience is enjoyable, as people disengage for everyday routines, but not change-inducing), or everyday space (participants do not engage and/or are cynical during and after the experience). Facilitators, therefore, should be aware of (1) the transitional/transformative nature, while intentionally (2) moving people from everyday space into liminoid and/or, ideally, liminal space—so that they come out with a transformed way of perceiving, understanding, or interpreting a previously held view. As design sprints and co-design sessions involve working with diverse groups, with different ideas that disrupt their usual ways of thinking and challenges people’s existing beliefs, assumptions, and perspectives, this process provides a unique opportunity for a shift in perspective, a new way of thinking—that is, what Jack Mezirow [6] would label as a transformative learning experience. With creativity—and associated characteristics of cognitive flexibility, divergent, and convergent thinking—not always adequately developed in formal curriculum [11], participation in a design sprint/co-design session offers healthcare clinicians and consumers a different, liminal space for a potentially transformative learning experience.

4 The Six Steps in This Design Thinking Sprint

In this 1-hour design sprint, participants were introduced to the six-step design thinking process: Empathy—Define—Ideate—Prototype—Test—Implement, focused on how to create a pain-free journey for two personas: 5 year old Annabelle (in hospital for a MRI with cannulation) and 16 year old Tiffany (who has a chronic heart condition). The very first step in the design thinking process is empathy, which Daniel Pink [12] memorably defined as ‘standing in someone else’s shoes, feeling with his or her heart, seeing with his or her eyes’ (n.p.). Nursing scholar Theresa Wiseman [13] has identified four key attributes: (1) to see the world as others see it, (2) to be non-judgemental, (3) to understand another’s feelings, and (4) to communicate that understanding. In the context of healthcare, the 4-min video Empathy: The human connection to patient care Footnote 1 powerfully illustrates what empathy means for consumers and clinicians, 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.

At this juncture, it is important to note the importance of creating a psychologically safe space for participation. Design thinking sprints bring together a diverse range of stakeholders to ideate, prototype, and test solutions to complex problems—typically, the pace is intense, people have differing experiences and strong opinions, and there can be conflict, disagreement, and difficult conversations. It is the facilitators’ role to create a psychologically safe environment, where all voices, ideas, and perspectives are respected and heard, and creativity flourishes.

For this to happen, the facilitator must clearly set the ground rules for participation, and clearly communicate the process, rationale, and outcomes. This can be as simple as outlining basic rules of respectful communication, active listening, and being open to new ideas, to outlining that a design sprint is about thinking differently, stepping outside our comfort zone, and doing that requires becoming comfortable with uncertainty. It is essential to always respect people’s time, by starting and finishing on time—and, ideally, providing food and refreshments. Finally, being clear about the origins and purpose is key: who are the project owners/leaders, what is the process, timelines, and impact: who has ownership of the outcomes? What is the purpose of the day and who will see/action the findings? Participants are tired of ongoing ‘fake’ consultations, so it is important to be crystal clear about the purpose and how the outputs will be used—in many of these HEAL projects, we have served as outside facilitator for this process, and in fact other people (the clinician team) hold responsibility for taking the outputs forward—and participants need to be clear on the overall project objectives, their role, and where the design thinking sprint sits.

4.1 Step 1: Empathy-User Personas and the Empathy Mapping Task

In this design sprint, we started by asked the 50+ participants (sitting at tables in groups of 5–6) to engage with two user personas: Annabelle and Tiffany—see Table 1. User personas are fictional characters that represent the characteristics, behaviours, emotions, and pain points of a specific target user group. By providing a critical reference point throughout the design process, personas are an inspiring, compelling, and memorable driver for change that enable participants to (1) better understand, empathise with, and design for users’ unique experience; (2) identify and understand key pain points; and (3) develop creative, innovative, user-centered solutions. Typically, personas are co-designed and research-based, created from interviews, focus groups, observations, quantitative and qualitative data and may, in the medical context, draw on actual situations or cases to trigger the deep reflection and discussion needed to ensure outcomes respond to users’ real-world context. Personas can also be created before or sometimes during the workshop. As Stickdorn and Schneider [14] explain, the value of personas is that they enable a team to all get on the same page—to really build empathy and deep understanding of the needs, tasks, priorities, and experiences of specific user groups. It is this shared empathic understanding that provides a solid basis for action, with some companies even developing life-sized cardboard cutouts of their personas to bring to meetings as a reminder!

Table 1 Two personas—Annabelle and Tiffany
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Whether it is through personas, empathy, or journey maps, good design always starts with listening, understanding, and deep empathy. A successful design thinking sprint requires preparation and co-creating personas in collaboration with key participant groups (clinicians, consumers etc) who have lived experience of the issue is essential, as well as connecting with any data/statistics. The personas here were developed with clinical teams.

In a different project, focussed specifically on virtual care and remote patient monitoring in the regions, we presented three different personas for the one scenario: a GP, specialist, and a consumer, Anne who had COPD. The persona of Anne so resonated with one consumer during the design sprint that he publicly shared his wife’s journey with the group: his wife died in the car outside a regional hospital, was brought back to life, and then spent the next year in and out of hospital (living away from her regional home, in a large city), before receiving a lung transplant. The consumer, Geoff, shared his hope that contemporary technologies might have enabled him and his wife to stay at home, rather than have COPD disrupt their lives. That is the power of a well-crafted persona—it resonates, is memorable, and facilitates the deep, reflective group conversations that fosters the innovation, collaboration and creativity needed to tackle entrenched challenges.

After quickly creating a team name, participants in this sprint were asked to pick one of these two personas (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. 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 explores the user’s external, observable world, and their internal mindset. In groups, participants discussed the categories outlined in Fig. 2—what does their chosen persona “say, think, do, and feel, and the “pains and gains” from the experience. Each group worked together to complete the worksheet, discussing, and sharing their own experiences, and bringing Tiffany or Annabelle’s attitudes, behaviours, and experience to the front of mind. To further create atmosphere, background music from the 1980’s teen pop star singer Tiffany was played. As this was a time-constricted sprint, after 5 min creating an empathy map, one group shared their reflections with all.

Fig. 2
3 parts. 1. A worksheet depicts what Annabelle and Tiffany say, think, feel, do, pain or fear, and gain or gain. 2. A photo of a group of 5 people sitting around a table in a room. 3. A chart summarizes the says, thinks, fuels, and does in the second, first, fourth, and third quadrants, respectively.

Visualising user’s attitudes and behaviours using an empathy map

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4.2 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 to reduce procedural pain for children, which was refined to be: how might we create a more comfortable, calm experience?

4.3 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, I added in an extra layer of perspective-taking. As well as asking groups to explicitly think about key touchpoints in the patient’s journey (before, during, and after the procedure), each person at the table was instructed to advocate for a specific perspective—to think about what could be done to improve the experience from one of five different perspectives of: the patient, the family, the staff, the space, and technology.

This purposeful perspective-taking approach is one I have developed, which I term perspective-storming. It is inspired in part by Edward de Bono’s Six Thinking Hats [15] metaphor, where the conceptual wearing of a different coloured hat or perspective enables the wearer to think critically about how to approach a problem. For example, when wearing the black hat, the focus is on being practical and realistic, the green hat wearer embraces creativity, the yellow hat is optimism, and the red hat wearer values intuition.

My colleague Debra Cushing and I have developed an approach we term ‘theory-storming’ [16, 17], which explicitly encourages thinking about design solutions through different theoretical lenses: for example, nudge theory, then affordance theory, then biophilia theory, and so on. It extends the creative design-thinking process of abductive, divergent, and convergent thinking (in essence, thinking in different ways—abductive is the simplest, most logical exploration; divergent is non-linear, creative, emergent thinking; convergent thinking is narrowing down on a solution) to being guided by different theoretical lenses. In the ‘perspective-storming’ process, participants are encouraged to each ‘be the voice’ of a different perspective—and in other projects, we have in fact had people wear hats to signify the perspective that they were embodying. Perspective-storming encourages thinking about solutions through multiple different lenses, and helps to foster generative, innovative thinking.

Each group was asked to generate a minimum of 10 ideas in 20 min—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 of “I like, I wish, what if”. Teams iteratively shared all their ideas for change with the entire group. A different colour was used for each perspective (e.g., technology was purple post-it notes, space was blue), and teams pinned their post-it note ideas onto large butchers’ paper around the room. As well as writing their team name on each post-it, teams noted where in the patient journey—before, during, after (B, D, A)—their idea belonged, as Fig. 3 illustrates. There were five butchers sheets for each perspective (the patient, the family, the staff, the space, and technology), and, to help with idea sharing, the facilitators sorted post-it’s into rows of “Before/During/After”.

Fig. 3
A table at the top indicates before, during, and after for patient, family, staff, space, and technology. It also defines step 3, ideate. A photograph below captures groups of participants sitting around a table and discussing the activity in a room. A presenting screen and boards are in the background.

The ideation task, with guidelines (top), the teams working hard to compete the activity (bottom)

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After teams had ideated and brainstormed, everyone looked at and read the other groups ideas. Then, using red sticky dots, voted for their favourite: each person had five dots to vote with. This voting process generated much discussion and extended ideas, as participants saw and were inspired by the innovative ideas others had (Fig. 4).

Fig. 4
3 photos. Left. It captures a chart with sticky notes titled Space. Middle. It features 2 people writing down ideas in the foreground, with many people standing in the background and staring at the sticky notes pasted over the charts. Right. It features a chart with sticky notes titled Staff.

Sharing ideas and voting for favourites

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Interestingly, while there is a large literature on group facilitation practices, specific knowledge on how best to facilitate co-design and design thinking sprints is limited. Starostka et al. [18] recently developed a taxonomy of design thinking facilitation, outlining how the approaches they observed in their research were very different—either a method or cofacilitation approach. The two facilitators they observed were very different, doing design thinking (DT) either as (1) DT understanding—a set of tools/methods versus a mindset, (2) DT focus—on either the solution or the problem, (3) DT process—a planned or emergent approach to the workshop, and (4) DT leadership—the leadership was either individual or shared.

In reflecting on these two very different approaches, Starostka et al. [18] concluded that each approach has specific strengths and weaknesses, and the subsequent success of the DT session really depended on the group’s specific characteristics, development, and expectations—that is, DT facilitation practices need to adapt to the context of the group and the project. What is important, as Wrobel et al. [19] have noted, is that as external third parties, facilitators have the capacity “to ‘remain neutral’ toward the team, its members, and their ideas (in comparison to, for example, a team leader)” (p. 424)—and, indeed, that independence and neutrality was an important component of the HEAL ethos.

4.4 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 min to decide on and prototype one solution that they would pitch to the room. It is important to note that a prototype is the tangible representation of an actual idea ([20]—chapter “Prototyping for Healthcare Innovation”). Design prototypes vary in their degrees of fidelity—the level of detail and functionality. Low-fidelity prototypes may be made from paper and cardboard, while high-fidelity prototypes are closer to the final version. Prototypes, Brown [2] reminds us, should “command only as much time, effort and investment as are needed to generate useful feedback and evolve an idea” (p. 19), and so in this situation, the only materials teams had were large markers and paper.

Teams sketched their ideas on butchers’ paper, and then presented it the group—in less than 1 min. These solutions were then pinned around the room and participants voted for their favourite—dotmocracy (dot-voting) in action! The quick and simple method of dot voting is a fun way to visually capture the mood, views, and priorities of people in the room. As Table 2 illustrates, participants generated many innovative ideas to increase comfort and calm for kids and families—from distraction games/techniques during procedures (virtual reality, mindfulness, playing with equipment prior), to redesigning the car park so the journey is calm from the car to the clinical spaces (murals, apps, VR) or tasking a staff member to prepare proactively and thoughtfully for the child’s arrival (favourite music playing or screen showing a topic they love, e.g., cricket), as well as extending The Comfort Promise in staff actions.

Table 2 Some ideas generated to increase comfort and calm for kids and families
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While there was no time for Step 5: Test or Step 6: Assess, this condensed 1 h design-thinking sprint achieved its aim: it brought together a diverse range of stakeholders from across the hospital to discuss different approaches to managing pain, and generated much energy and enthusiasm for developing, testing and implementing some of the ideas generated. A critique of design thinking is that it simply takes too long, and that its is challenging for staff to renegotiate roles and expectations [21]: our approach shows the value of a condensed version, albeit in the first instance with staff only (participants included clinicians and service providers).

The rapid pace and purposeful perspective taking was designed to encourage innovative, out-of-the box thinking—but I think it is important that design sprints are enjoyable experiences: people give up their valuable time to participate—so they should both learn from and enjoy the experience! Whether it is chocolates, mints, post-it notes on walls and coloured pens and stickers on the tables, large poster-size personas pinned to the walls, or collaborating for the honour winning the infamous “design legend” paper hat (as the prize for the winning idea, I often have on offer a large colourful paper hat that the team leader is photographed wearing, in front of their wining idea), design sprints should foster a creative atmosphere of fun. This helps participants shift from a fixed, analytical approach to the more fluid, creative thinking needed for innovation, accessing the creative, imaginative, intuitive right side of their brain.

From a 1-h design thinking sprint, there was much positive and reflective dialogue, and insightful ideas for purposeful action—which the project teams took forward, to refine and develop further with larger teams of consumers (children, youth, and their families) and clinicians as co-creators of any initiatives. This design thinking sprint served as a powerfully engaging way to connect with, clarify, and mobilize participants’ energies and priorities, growing an existing movement for improvement and change in procedural paediatric pain. It also introduced clinicians to design thinking methods, and encouraged the sharing of ideas and knowledge, leading to greater buy-in, support, and more innovative ‘out of the box’ thinking and solutions. Good design sprints resonate, are memorable, and facilitate the deep, reflective group conversations that foster the innovation, collaboration, and creativity needed to tackle entrenched challenges.