Changing UTI Practice in the Emergency Department
4.2 Conceptual Development of the Initial Approach for the PAR Study
The aim of this stage was to identify alignments and common goals between the design and behaviour change processes. Numerous models for the design process can be found in the literature. Most of these accounts attempt to organise, systematise or harness the fluid and complex nature of design in practice. These include the Double Diamond Model, developed by the Design Council (2007); the meta-process of Frame
51 Another paper addressing an expanded inquiry process, some stakeholder activities and outcomes, and a different approach to analysis has been published later, in the journal European Geriatric Medicine (O’Kelly et al., 2019), including co-authorship of the researcher responsible for the present thesis.
145 Creation, presented by Dorst (2015); and the more specific Design for Sustainable Behaviour Process of Lilley and Wilson (2017). The Double Diamond provides a useful reference point in that it describes a generic, yet encompassing, design process, with ample application within and beyond the immediate design realm.
The Double Diamond model organises divergent and convergent thinking throughout the creative process by determining four distinct phases in which these forms of thinking alternate twice, each dominating at different stages of the process. Starting with a ‘problem’, in the first phase – discover – designers attempt to identify needs through various types of research, gather insights and provide rich descriptions of the issues at stake. The second phase – define – is when sense is made of the initial exploration and data gathered in the previous stage, resulting in a detailed project brief. An intensive iterative process involving concept and idea generation, as well as various forms of prototyping are the core activities of the third phase, when designers develop alternatives within a more defined scope of possibilities. Finally, in the fourth and last phase – deliver – ‘the resulting product or service is finalised and launched’
(Design Council, 2007; 2015).
In the participatory design literature, there is a greater emphasis on how to conduct the phases of any given design process (i.e. with an emphasis on stakeholder participation), than on what stages or phases actually constitute such process. Nonetheless,
publications by a number of relevant PD authors, such as Toni Robertson and Jesper Simonsen, do lay down the basis for outlining a sequence of stages or a model, which has been adopted by this research. PD process descriptions do not deviate substantially from more consolidated accounts of the design process such as the Double Diamond.
Rather, they frequently include the broad stages of co-definition, co-development, and co-implementation (see Robertson and Simonsen, 2012, 2013). These three phases roughly equate to the Double Diamond’s phases of discover and define (co-definition), develop (co-development), and deliver (co-implementation).
A core aim of this research was to investigate integration of stakeholder participation into behaviour change interventions within healthcare environments. Consequently, a
‘participatory agenda’ guided the work, permeating all stages of the intervention developed in the context of a participatory action research project. A vital step to accomplishing that aim was to outline a comparison between the stages of the adopted behaviour change framework – the Behaviour Change Wheel – and the overarching phases of a participatory design process. Understanding both as three-staged processes with clear alignments and similar goals has contributed to streamlining their combined
146 application in the context of a healthcare quality improvement project, in a way that was logical to both researchers and stakeholders (Table 4.1).
Table 4.1 A comparison between the phases of Participatory Design and the stages of the Behaviour Change Wheel
Following this initial alignment, a first collection of methods and tools was identified and then paired up with the appropriate stages of the intervention plan (Table 4.2). The tools were clustered into two categories: participatory design tools, and behaviour change tools. This categorisation was mostly to indicate the field and disciplinary tradition from which each tool had been sourced, not to reflect an actual division of how tools were presented to or used by the stakeholders – since, ultimately, the point was to investigate the concerted use of the selected methods and tools, via an
integrative approach to change.
PD tools and methods were selected using Sanders et al. (2010) and Brandt et al.
(2013) which look at tools and methods according to their intended use and stage of the design process, encompassing three broad categories of methods: for telling stories, for making things, and for enacting possible futures (Brandt et al., 2013). The BC tools come primarily from the BCW guide to designing interventions (Michie et al., 2014), but also incorporate an expanded scope of sources so as to better support the specific needs and tasks of the project. Tool and method selection and application was highly iterative and adaptive, evolving with the demands of the study, rather than being rigidly determined from the onset.
147 Table 4.2 Participatory Design and behaviour change methods and tools per stage of the intervention process
This integrated process was the basis for the emerging participatory approach to designing behaviour change interventions adopted in the data collection activities of this research project, as now described in three stages: understanding the problem-space; exploring potential solutions; and implementing appropriate interventions.
4.2.1 Understanding the Problem-Space
According to the comparative three-staged process outlined above, in the first stage, the central concern of the BCW is to determine what behaviour needs to be changed – accomplished by identifying what is(are) the problematic behaviour(s), who performs it and with whom, and where and how frequently it occurs. This stage of the BCW concludes with a definition of the target behaviour(s); that is, the desirable
behaviour(s) that will replace or provide an alternative to the problematic behaviours.
The co-definition phase of PD aims to provide a comprehensive description of the problem-space, considering the perspectives, priorities and concerns of the multiple stakeholders involved, and the sociotechnical characteristics of the context, pointing to potential directions for change.
4.2.2 Exploring Potential Solutions
At the second stage, both the BCW and PD intend to explore the solution-space: the former via identification of suitable intervention functions and policy categories that
148 relate to the specific determinants of behaviour which can predict positive changes; the latter via investigating alternatives in light of appropriate technologies, processes, products, services, that can respond to the current problems through the adoption or creation of new ways of doing and interacting with the physical, technological, and socio-political surrounding.
4.2.3 Implementing Appropriate Interventions
In the third and final stage, the BCW explores what change techniques and modes of delivery (means and technologies) are implementable, considering the APEASE criteria to guide appropriate choices. Correspondently, PD considers the ways in which
solutions can be collaboratively put into practice, to then be tested and adjusted according to the shared-vision of the stakeholders impacted by the proposed innovations. This process usually includes the use of varied types of prototyping techniques.
Due to limitations of time and scope, including practical restrictions imposed by the context, the implementing of intervention solutions was not fully covered in this study, and will, thus, not be completely reported here.