Designing to enable cultural change at the Reproductive Medical Department at Rikshospitalet
from treating to assisting
A service & systemic design diploma project Paulina Buvinic
The Oslo School of Architecture and Design
A service and systemic design diploma project by:
Paulina Buvinic
The Oslo School of Architecture and Design (AHO)
Spring, 2019 Supervisors:
Natalia Agudelo and Josina Vink Collaborator:
Reproductive Medical Department, Rikshospitalet
Oslo Universitetssykehus
All photographs, illustrations and content by the author, unless otherwise noted.
from treating
to assisting
Abstract
Every year, both globally and in Norway, more people are depending on medical assisted reproduction treatments in order to fulfill their wish to become parents. But these types of treatments can be very invasive and demanding, and there is no guarantee that the treatments will be successful. Being aware of the difficulties of this process...
How can the Medical Reproduction Department at Rikshospitalet support better the people that are going through the process of medical assisted reproduction?
“From treating to assisting” is a service and systemic design diploma that explores how to enable cultural change at the Reproductive Medical Department at Rikshospitalet in order to make the service more supportive towards patients.
Working collaboratively with a healthcare team from the medical department, the project proposes three main principles to enable a transition from a production- oriented culture towards a culture of assistance. In order to support the process, cultural prompts were designed to evidence how each principle can be translated into new practices and/or tools.
Index Introduction Context
Approach, process and methods Medical Assisted Reproduction 16
The Reproductive Medical Department at Rikshospitalet 18
Project brief 20
Approach 24
A design process to support cultural transition
28
Methods
30
Designing to support cultural transition
Collecting current narratives 42
Capturing and visualizing current narratives
52
Creating collective understandings 64
A production-oriented culture 76
Understanding the existing culture 40
Building a common vision and principles to support it
82
Evidencing principles (+ design proposal) 84
Reflecting on the process and how to move forward
166
Personal reflections and conclusions 174
Acknowledgments 178
References 180
Transitioning towards a new narrative
80
Introduction
12
Assisted reproduction treatments are demanding and difficult to go through, and there is no guarantee that the treatment will be successful. Nowadays, the culture around assisted reproduction in many public institutions in Norway is primarily focused on effectiveness and success rates, making many patients feel like they are not being acknowledged as people, but that they are part of a production line. Every year, both globally and in Norway, more and more people are depending on these types of treatments to become parents, which has forced the production line to go faster.
“From treating to assisting” explores how to enable cultural change at the Reproductive Medical Department at Rikshospitalet in order to make their service more supportive towards patients, acknowledging their differences and the difficulties they go through during the process of assisted reproduction.
INTRODUCTION 12
13
The project was developed by combining service and systemic design approaches, and working closely together with a healthcare team from Rikshospitalet during the whole project.
The design proposal aims to enable a transition from a production-oriented culture towards a culture of assistance, by using counter-narrative principles and cultural prompts. Three main principles were co-designed:
#1
from assembly-line experience to team-based care
#2
from treating everyone in the same way to acknowledging diversity
#3
from a single view of success
to a holistic understanding of experience
from treating to assisting
Cultural prompts are intended to support the culture- transition process; hence, four prompts were designed to evidence how each principle can be translated into new practices and/or tools: a visual proposal to make it easier for the healthcare team to have access and understand the patient’s information; a yearly program with weekly practices to encourage the healthcare team to have better communication with patients and be prepared for unexpected situations; a patients’
diary to be used as a communication tool between the healthcare team and patients; and a new practice to measure patients’ experience to identify improvement points in an easier way.
Being aware that cultural change is a complex and difficult process, the project goal is to become the first step towards a new culture of assistance in the Reproduction Medical Department at Rikshospitalet.
It aims to sparkle cultural awareness and inspire the healthcare team to continue the journey of making their service more supportive for patients.
13
14
15
Context
About medical assisted reproduction and the project brief
16
Medical Assisted Reproduction
CONTEXT
One out of six couples struggles with involuntary childlessness worldwide, and every year the number increase by 8-9% (Fertility Europe, 2018).
One of the possible paths to take in order to fulfill the wish to become parents is through medical assisted reproduction.
Medical assisted reproduction are medical procedures that are used to assist human reproduction. These types of procedures can be developed within the woman’s own body or using someone else to carry the pregnancy (surrogacy).
Some of the most common examples using medical assisted technology are In Vitro Fertilization (IVF) and Microinjection (ICSI). In both of these cases, the egg is fertilized by sperm in a test tube outside the woman’s body (lab), to later on be implanted into her uterus.
Medical assisted reproduction treatments revolve primarily around the woman, being the one that needs to attend to the different appointments and take different types of medication. Men will be required to deliver the sperm sample if a sperm donor is not being used.
A challenging treatment
One of the most challenging aspects of the treatments is related to the hormone medications. Different medications are used through the process, these might include hormone injections, nasal spray, vaginal gel, among others. Hormones help prepare the woman’s body for the different steps in the process.
The side effects of hormone medications might change from woman to woman. In general, these include feeling heaviness or stitching in the stomach, abdominal pain, feeling bloated and mood swings.
Hormones also can having an impact in the patient’s daily life because each hormone injection must follow a strict schedule.
17 from treating to assisting
An uncertain process
Medical assisted reproduction treatments are not 100% certain that will end up with a pregnancy.
According to experts in the field, is very common to go for more than one attempt; and sometimes, it might end up with not being able to get pregnant at all.
This notion of uncertainty is also related to the patients’ role in the process. Even though it’s very important that patients follow the procedure thoroughly, in contrast with other medical treatments, in assisted reproduction there isn’t that much more patients can do to improve their chances.
The whole process is very emotional. You start to expect that now it will work, we will get pregnant. You start looking for signs if you are pregnant. But at the same time, you have this thing with the hormones and your
body, that you don’t feel quite like yourself.
Woman that had experienced ART
18
The Reproductive Medical Department at Rikshospitalet
CONTEXT
In Oslo, the only hospital with a Reproduction Medical Department is Oslo Universitetssykehus, performing approximately 1700 treatment procedures per year.
Is consider the country’s largest center on fertility treatments, having two clinics: Rikshospitalet and Ullevål.
To access to the Hospital’s treatment, a referral from the general practitioner or specialist in gynecology is needed, which includes an initial infertility investigation.
The Norwegian context
In Norway, approximately 60.000 children are born every year, of which 3-4% are from assisted fertilization. Assisted fertilization in different forms is offered both in the public and private sectors (Helsenorge, 2018).
These types of treatments are being regulated by the Biotechnology Act related to the Application of Biotechnology in Medicine, which stipulates that sperm donation is legal, but egg donation and
surrogacy are not allowed in Norway. By these norms, assisted fertilization is offered only to heterosexuals and lesbian couples (Helsedirektoratet, 2017).
In the public sector, infertility treatments are fully covered by the Norwegian Health Economics Administration (HELFO) to up to three attempts per child. It is also regulated according to the regulations of the Biotechnology Act, which include factors such as number of children, age of the woman (giving priority access to couples where the woman has not reached the age of 39 years old), caring ability, marital status or cohabitants, among others
About the process of assisted reproduction at Rikshospitalet
Approximately 450 consultations are developed every week at the Reproductive Medical Department at Rikshospitalet (source: leader of the department).
This considers around 200 different patients per week.
Each consultation lasts around 15-30 minutes each. But patients usually need to wait between one or two weeks between appointments.
Next to this, because of the high demand for the service, it’s difficult to have a specific healthcare team following one patient. This means that patients might interact with different people from the healthcare team through their whole treatment.
19 from treating to assisting
1ST ATTEMPT
2ND ATTEMPT
3RD ATTEMPT Referral
doctor and nurse
nurse
doctor and nurse
lab nurse
doctor and lab
Figure 01: Summary of the process of medical assisted reproduction at Rikshospitalet
A personal framework
In order to develop this project, I decided to establish a personal framework to address the topic of assisted fertilization. Nowadays this topic generates different discussions, being possible to conceive it from different ways or angles. Because of this, it was necessary to define a point of view based on my beliefs.
Designing for all parents
Even though I was designing for a Norwegian context, where medical assisted reproduction in the public sector is only offered to couples, I didn’t want to be restricted by the current regulations.
This project is being developed considering that assisted reproduction should be offered to not only couples but single parents as well.
A shift in the language
In the topic of reproduction and fertility, the word family planning has come up several times related to the act of planning to have/or not children. Working around this field for the project, I have made the decision of not using this term. The notions of families have evolved, therefore, being a family shouldn’t be defined just by having children or not.
CONTEXT 20
21
Project brief
How can Rikshospitalet support better the people that are going through the process of medical assisted reproduction?
The services of medical assisted reproduction are being more and more demanding. But these types of treatments are not as easy as they seem, and there is no guarantee that the treatments will be successful.
Working in collaboration with the Reproductive Medical Department at Rikshospitalet, the project explores how to support better the people that are going through the process of medical assisted reproduction, acknowledging their differences and the difficulties they go through during the process.
from treating to assisting
22
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Approach, process and methods
This chapter will present how the project was developed. It will explain the approach taken, the process, and the methods that were used through the whole project.
24
Approach
APPROACH, PROCESS AND METHODS
The project explores how to enable cultural change at the Reproductive Medical
Department at Rikshospitalet in order to make the service more supportive towards patients.
More visible
PRINCIPLES PRACTICES
& ROUTINES TOOLS &
ARTEFACTS
Designing for cultural change
This project focuses on designing to enable cultural change at the Reproductive Medical Department.
Edgar Schein, expert on organisational development and culture, define three main levels that help shape a culture. Artefacts and symbols are the most superfitial level, being the most visible elements to the observers. These are the tools, the physical spaces, the material in an organization. In a deeper level are the espoused values. This are the ‘rules of conduct’
in an organization, how their strategies are made into practical things. Finally, deeply embedded in the organization but less visible, are the underlying
Figure 02: Based on E. Schein’s model of organizational culture
Cultural Change
25 from treating to assisting
“A new service designed with the customer in mind yields ideal specifications for the
processes, participants, physical facilities and information
systems. However, these
specifications may not match the current service culture and may challenge various closely held beliefs and normative values leading to modified designs that deviate from the nominal ideal design”
F. Ian Stuart (1998)
But... why work with culture?
F. Ian Stuart (1998) highlights the importance of working with culture in service design projects. He explains that regardless how good the design process has been, not considering organizational culture can have a direct impact on the service final proposal. This can lead to the proposed design being rejected, changed, or never implemented because of internal forces, specifically cultural and political influences.
Therefore, in order to explore how the Reproductive Medical Department could be more supportive of their patients, it was necessary to understand how the organizational culture influences and shapes how the current service is being delivered.
assumptions. This are the unconscious behaviour. For the purpose of this project, Schein’s model has been adapted. Artefacts and symbols will be refered as tools and artefacts; espoused values as practices and routines; and underlying assumptions as principles.
In order to work with cultural change, is important to acknowledge and work with these three levels;
and understand that cultural change is complex and difficult, and that involves different processes through time. As Schein mentions “don’t over-simplify culture. It’s far more than “how we do things around here” (interview with Kuppler, 2016).
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Combining Service Design and Systems Oriented Design
In order to understand in a more robust way the existing culture, this diploma project is developed combining Service Design and Systems Oriented Design approaches.
Service Design approach:
The project analysis assisted reproduction treatments from a service perspective, understanding that their experience starts before coming to the hospital, and will continue after they have finished their treatments.
The project was developed using the five principles from the discipline (Stickdorn and Schneider, 2011):
1. Human-centered, by understanding the experience from a human perspective,
acknowledging the diversity of emotions and needs that are carried throughout the process.
2. Co-creative, working closely with a specific team from the Reproductive Medical Department.
3. Sequenced, analyzing the different interactions and touchpoints that develop through time.
4. Visual, to communicate the main findings, ideas, concepts. Visual elements were also used as discoursive tools to trigger reflections and discussions around the existing culture.
5. Holistic, in order to understand the challenges and implications of working around cultural change.
Systems Oriented Design approach:
The project incorporated a systemic approach to better understand the context of assisted reproduction. By using different mapping techniques it was possible to analyze the relations between the different stakeholders and areas that linked to reproduction; not only from the healthcare arena but also from a social level.
By using a combination of service design and systemic approach, it was possible to have a richer picture of the culture around assisted reproduction.
Co-creation as a key element in working with cultural change
A key aspect to work around cultural change was to work collaboratively with a specific team from the healthcare department and involve them throughout the whole process. This team included both leaders and also front-stage staff members.
APPROACH, PROCESS AND METHODS
27
Reproductive Medical Department Rikshospitalet
Head of section (Lab) and Research leader
Leader of the Reproductive Medical Department
Embryologist (Lab)
Nurse
Assistant leader (not present in picture)
28
A design process to support cultural transition
Understanding the existing culture
APPROACH, PROCESS AND METHODS
Collecting current narratives
Capturing and visualizing current narratives
Creating collective understandings of today’s narratives
con vergen
t
diver
gent Existing
culture
29
Transitioning towards a new narrative
from treating to assisting
Building a common vision and principles to support it
Evidencing principles by translating them into practices and tools
Reflecting on the process and how to move forward
Cultural Prompts Principles
Hospital
30
Methods
In-depth interviews
In order to hollistically understand the world of assisted reproduction it was important to not only address it from the healthcare perspective but to also include conversations with experts on the field of fertility such as organizations.
Understanding that reproduction can be a private matter and not an easy topic to address, interviews with former patients were developed through different channels: face to face in a calm and safe environment, through skype, phone calls, emails.
The main goal of these interviews was to reflect and understand the process of assisted fertilization from their point of view. It was very important to have a variety of experiences, results; especially acknowledging that the process does not always end with pregnancy. Next, to this, interviews also consider people that had gone through the process of assisted reproduction in other countries. This aimed to be open to other experiences, and learn and analysis possible patterns or differences.
Leader of the Reproductive Medical Department, Rikshospitalet Nurse at the Reproductive Medical Department, Rikshospitalet Medical anthropologist Family Therapist
2 representatives from Ønskebarn (Norwegian organisation for involuntary childlessness)
Representative for Fertility Europe (Pan-European organisation dedicated to infertility)
5 people that had experienced assisted reproduction treatments
- couples and single parents - different results
- different countries of treatment
APPROACH, PROCESS AND METHODS
31
Figure 03: Pictures from interviews with former patients (safe environment); and analysis of interviews during the initial phase of the project (bottom).
from treating to assisting
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Workshops and co-creation sessions
Different types of workshops and co-creation sessions were conducted through the whole project.
To better understand the world of assisted reproduction and the way we are approaching the topic from a social level, a social norms workshop was developed at the beginning of the process. This helped reflect and build existing social assumptions and norms around the topic of fertility, which connected directly with the experience that patients are having not only during their journey in the hospital but also the daily aspects they need to face before and after their treatment.
Together with this, three co-creation sessions were run with a specific team of the Reproduction Medical Department. In the majority of these sessions all team members where present. As mentioned earlier, this team included: leader of the department, head of section (Lab) and Research leader, nurse, embryologist, assistant leader.
In addition, one workshop was run with all the team of the Reproductive Medical Department of Rikshospitalet.
All of these workshops within Rikshospitalet had a specific goal and will be presented briefly in different moments throughout the report.
APPROACH, PROCESS AND METHODS
FROM A SOCIAL LEVEL Social norms workshop
WITH HEALTHCARE TEAM Mapping the patient’s experience
Creating collective understandings:
Co-creation session with healthcare team.
Seminar workshop with all team members from the Reproductive Medical Department.
Defining principles and cultural prompts to support a culture of assitance:
Co-creation session with healthcare team.
Reflecting on the process and how to mover forward: Final session with healthcare team.
33 from treating to assisting
Figure 04: Picture of the social norms workshop (up) and from the seminar workshop with all team members from the department. Picture taken by Karen Byskov.
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Shadowing and field observation
To better understand the patient’s experience as well as the healthcare team’s work routines, different shadowing sessions and field observations were developed.
Being aware that patients interact with different people from the healthcare team during their whole treatment, it was important to consider shadowing different perspectives from the team. Two shadowing sessions were conducted, were I accompanied a nurse and an embryologist during their whole work shifts as a silent observer. The goal of this was to gain a better understanding of their role in the service, observing the different tasks and responsibilities they have, with what objects and people do they interact with, when and how. To protect the patient’s privacy, I could only use sketches and notes as ways of registering.
Next to this, short observation sessions at the Reproductive Medical Department were developed in order to have a better understanding of the context. In this case, pictures could only be taken once the patient had left the department.
Nurse Embryologist
Figure 05: Pictures of notes taken during one of the shadowing sessions (up); and from the medical department.
APPROACH, PROCESS AND METHODS
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Mapping and visualizing
Mapping and visualizing was used through the whole project. Journey maps, actors maps, feeling maps, visualization of findings, ideas sketches, among others
Figure 06: Feelings map analysis (left) and a fragment of the printed version of the patient’s journey map.
from treating to assisting
were used not only as a way of analyzing information but also as communication and facilitation tools with the healthcare team during co-creation sessions.
36
Feedback sessions with the leader of the department
Through the whole process, especially during the last phases, it was important to have periodic feedback sessions with the leader of the Reproductive Medical Department. These sessions were developed in the majority of the cases face-to-face in the hospital, but
Figure 07: Feedback session with leader of the department (principles and cultural prompts).
APPROACH, PROCESS AND METHODS
it also included other communication channels such as emails.
The goal for these sessions was to keep updated the leader with the current process, as well as getting specific feedback on each step.
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Feedback sessions with former patients
Two feedback sessions with former patients where developed during the last phases of the project. This sessions were developed through email and Skype video calls.
Their main goal was to get feedback around the concept proposal, including principles and cultural prompts.
from treating to assisting
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Designing to
support cultural transition
This chapter presents in more detail how the design process helped to sparkle cultural awareness. The chapter is divided in two main sections: understanding the existing culture, and transitioning towards a new narrative.
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Understanding the existing culture
Designing to support cultural transition:
This section presents the first steps of the design process to support cultural transition. It covers key aspects of the collection (research) and capturing of the main existing narratives (analysis and findings). The section ends by identifying the existing culture.
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Collecting current narratives
Capturing and visualizing current narratives
A production-oriented culture
Creating collective
understandings
42
Collecting current narratives
UNDERSTANDING THE EXISTING CULTURE
The collection process required a mix of zooming in and out during different moments, starting from understanding the treatment itself.
The patient’s experience in the Hospital
The treatment of assisted reproduction in the Hospital involves interacting with different people from the healthcare team during the whole process. Patient’s don’t have a specific team that follows them during their process. Next to thid, patients don’t interact only with nurses and doctors, but receptionists and embryologists from the laboratory are also
Figure 08: Times during treatment (top) and patient’s journey (right).
WAITING TIME BETWEEN APPOINTMENTS MEDICAL APPOINTMENTS
WITH OWN SPERM AND EGGS
WITH SPERM DONNOR AND OWN EGGS
responsible for communicating information to the patients. For example during the appointment for the embryo transfer (ET), when the fertilized eggs is transfered to the woman’s uterus. No nurse will assist during this procedure, only doctors and embryologists.
Mapping the patient’s journey also helped to make visible the duration of the treatments, including waiting times between appointments. Each appointment lasts approximately 15-30 minutes while waiting times between appointments could be between one to two weeks. This time increases for treatments with a sperm donor, where the waiting time could even last up to three months to find a donor.
