Abstract

Introduction: Students in healthcare professions may assume they understand the principles of person-centered care (PCC) yet discover that they have knowledge gaps when they are exposed to the principles and impact of this concept. In particular, this may be the case in the specific application of Human Centered Design (HCD), which includes patients and families as active participants in the co-design of their care solution. This discussion will focus on the HCD element of PCC as implemented in a doctoral nursing course.

Description of Innovation: During the Fall of 2022, 76 nursing students participated in a 15-week asynchronous, online doctoral course entitled Person-Centered Care. In small groups, students completed a four-part assignment that culminated in a final presentation involving their application of HCD principles. Students selected and collaborated with a patient participant over the series of assignments, starting with identification of the patient’s key healthcare issue and followed by the co-design of care solutions to address that patient’s specific need.

Results: Students expressed increased understanding of the principles of HCD and ways that it positively affects patient outcomes. They found value in engaging with their teams and a patient partner while applying and working through the stages of human centered design on the co-design of a relevant solution.

Conclusion: The constructs of HCD support Person-Centered Care. Results from this pilot course indicate that teaching HCD provides tools for healthcare providers to engage in a holistic approach to the co-design of patient-centered solutions.

Introduction

Any conscientious healthcare worker would say “Patient-centered care? Of course, I do that.” However, the reality often is quite different. Without conscious reflection and application of patient-centered care principles, providers and health sciences faculty risk the common danger of focusing on the disease and not the patient. The Person-Centered Care course in the Emory Doctor of Nursing Practice program was created to address this challenge to optimize healthcare delivery.

Person-Centered Care is a new, 15-week online, asynchronous course. It consists of a series of Human Centered Design (HCD) assignments that support the overarching course objectives of examining concepts of person-centered care and in exploring their impact on health, quality, and safety outcomes. This course and its assignments were shaped by the newly revised Core Competencies for Professional Nursing Education developed by the American Association of Colleges of Nursing (AACN) (AACN, 2021). Specifically, the Domain of Person-Centered Care was fundamental to the development of both the overall course and the specific HCD assignments. While the AACN domain of Person-Centered Care provided key thematic elements for the course, the challenge lay in creating assignments that provided relevant context and opportunities for application. As well as helping students realize the impact on care outcomes when these skills are practiced and cultivated.

Using the broadest description, HCD is a construct that incorporates the active involvement of affected persons in devising solutions to their healthcare problems – the key words here being“active involvement.” The field of healthcare abounds in narratives from patients and families that identify problems and challenges; HCD takes the next step by including them in designing workable interventions to be tested. Its problem-solving approach has successfully optimized outcomes by healthcare institutions in a variety of settings, and in some situations also has improved trust in the healthcare system (Wheelock, A., Bechtel, C., Leff, B., 2020). While, system-level results are an important outcome to HCD, system change is a result of the insights gained by the person-centric application. HCD helps focus on the core needs of those who experience a problem and uses a systematic and person-centric approach guided by five phases: Empathy, Define, Ideate, Prototype, and Test/Iterate (DC Design, 2017).

Empathy is the most fundamental attribute of HCD. By immersing themselves in the lived experiences of patients who serve as their learning partners, student teams explore and try to deeply understand the needs shared by those they are designing for. The Define phase sets the stage for the remaining three phases as teams interpret what they have learned about the issue , what they are trying to solve, and defining or phrasing the problem in a way that moves them toward a specific action to address that issue. Brainstorming is a key element in the Ideate phase where teams work alongside their learning partner to co-design possible solutions by coming up with multiple ideas without judgement. Regardless, of whether these ideas are realistic, feasible, or even worthwhile. The last two HCD phases involve Prototyping followed by Test/Iterate. Prototyping enables teams to act on their ideas by creating, with their learning partner, a model of a virtual or physical product or service, and to determine which is most effective in addressing the defined need. Then, during the last phase of Test/Iterate, ideas and prototypes are repeatedly put to the test to identify flaws, optimize performance, and determine if the model/solution effectively addresses the learning partner’s issue. In the course discussed here, each of these phases is tied to a specific assignment, as described below.

Description of Innovation

HCD Assignment Part 1 – Empathy and Define:

Students self-selected their teams and identified a patient partner with a specific health issue or incident willing to reflect upon and share their healthcare experience. These partners were selected by consensus of each team, and were patients personally known to one or more of the team members. The aim of this assignment was for team members to start the HCD process using Empathy to deeply understand, actively listen to, and learn about issues from their partner’s perspective. They also were to clarify and define the issue so the team could work towards co-producing a meaningful solution with their partner.

HCD Part 2 – Ideate:

Students further explored their partner’s issue, brainstormed possible solutions, listed the multiple ideas they believed would address the identified issue, and then selected one idea for prototyping from their list, providing evidence-based rationale to both validate and support their selection.

HCD Part 3 – Prototype:

The team and their partner outlined and described a plan to develop, implement, and test the selected idea, including resources needed and any other considerations. This was to ensure the proposed solution could be effectively tested and potentially meet the partner’s identified need.

HCD Final Presentation:

As a culmination of the three prior assignments, teams synthesized and promoted their HCD work. Through the creation and delivery of a 10-minute, 10 slide, online synchronous oral presentation, they introduced their team members, each member’s contributions to the HCD assignments, and described how they applied the HCD stages to the problem. The final element of the presentation included a reflection of the team’s experience using the HCD process with their patient partner.

Results

Findings from the unfolding HCD assignments were qualitative and based on feedback. Feedback was gathered from informal student meetings with their respective faculty, analysis of content within assignment submissions, student questions when seeking clarity on instructions, and responses on an end of semester course survey. The following summaries from student postings reflect their grasp of the concepts involved in HCD.

HCD Assignments Facilitated Competency in HCD:

The majority of students’ comments indicated that they felt the HCD assignments facilitated their ability to build upon knowledge, skills, and competencies. Common themes in the course feedback included improved competency in involving patients in their care and successfully applying principles of HCD. A quotation shared in one team’s final presentation captured most of the groups’ sentiments: “This assignment with HCD truly immersed us in patient-centered care, allowing us to explore key issues in the patient experience and build a plan with the patient’s concerns at the forefront.”

HCD Assignments Enhanced Awareness of Systematic and Social Challenges in Healthcare: Specific to the HCD 1 assignment (identify the partner and their problem), as students submitted discussions of their partners’ issues, they also made observations about systematic and social challenges to healthcare delivery. Three issues commonly identified by students were: (a) poor communication with the patient: “She was never asked about her family history of illnesses, so lupus was never suspected… For this reason, she is not very confident in seeking medical attention at times.”; (b) inconsistent information: “…The lack of shared decision-making between C and her healthcare team has resulted in a less than optimal patient-provider relationship”; and (c) healthcare payment issues: “Mr. X’s ultimate point to me, which he said with exasperation, was ‘insurance companies are profit oriented, not medically or care oriented.’” These examples demonstrated both student awareness of systemic issues and empathy toward the dilemmas faced by the learning partner.

Specific to the HCD 2 assignment – exploration of the issue and identifying a solution – it was found that some groups had not fully met the intention of the assignment. Of the 16 groups, six were asked to revise and resubmit the assignment. Four of the six revisions were minor; in two groups the assignment needed to be completely revisited by the group members after faculty feedback. The major omissions were identification of the specific problem to be addressed and clear description of ways in which the partner would be involved. Students either re-posted the revised assignment, or discussed the revisions and reflected them in the final presentation.

In the HCD 3 assignment – prototype for a plan – the two concerns most often noted by the faculty were impractical or vague implementation ideas and poorly defined evaluation plans. Only one group was asked to completely redo their submission, but most groups received similar feedback.

The common challenges shared by some students concerning the unfolding assignment focused on flexibility with deadlines, timely feedback, and need for specific rubrics and detailed instructions.

Discussion

Implementation of HCD was successful, but we encountered several issues. Assignment timing, in particular, was a problem. A single due date was given for the entire unfolding HCD complex of assignments, which was the date of the final presentation. While this allowed students to progress at their own pace, having only one final due date may have compromised the value of working through a systematic process of HCD. It may have been more useful for students to have interim deadlines to keep them on track for their completion of the final team presentation; this will be considered in the future.

Another decision, that will be reconsidered involves the use of grading rubrics. Rubrics were not created for the unfolding aspects of this assignment because of the potential for students to respond rigidly to a rubric instead of the collaborative intent of the assignment. Instead, students were given guiding questions to help frame the assignment submission. However, because rubrics are common in most courses, students were requesting one for each of the four HCD assignments. Although rubrics were not created for this assignment series, we would suggest their use in the future. Additional benefits of having specific rubrics are that they can reinforce the goals for each individual part of the scaffolding assignment and may reduce the number of emails from anxious students asking for faculty expectations.

Competency based learning is gaining increased attention for all aspects of nursing education, and the concepts of HCD are applicable across health professions education. The unfolding nature of the HCD assignments in the Person Centered Care course provided a logical platform to apply this learning concept. Although, when students were off track or misunderstood the objectives, they had to resubmit those assignments, these interactions allowed remediation for inadequate understanding of the concepts. Based on this first iteration of this course, changes are suggested to incorporate more specific structure around timing and assignment expectations.

Conclusion

Although, both the content and method of delivery for this HCD assignment were new, the students demonstrated their understanding and ability to apply the concepts of HCD to a specific patient issue. In many cases, the patient learning partners for their assignment had experienced complicated and primarily negative encounters with the healthcare system. This assignment was intended to help students move past their own emotional reactions of dismay or sadness, implicit or extrinsic bias, and move towards a more empathic and intentional collaboration with the learning partner as an active participant in the co-design of a more personal and meaningful care solution. In the process of implementing this specific format of person-centered care, teams also learned the value and positive impact of placing the affected person in the center of healthcare delivery.

Acknowledgments

The authors gratefully acknowledge the inspiration and contribution from Dr. Bethany Robertson, the developer, and Faculty Coordinator for the Person-Centered Care Course. The authors had no financial support for this work and do not have any financial conflicts of interest.