A new assignment
This week marked a shift in focus. After several weeks working on data access services - exploring state charts, object-oriented UX, and the underlying data models of administrative systems - I've been asked to support user research on a clinical product: a digital ward management tool being piloted at two NHS trusts.
The product is part of a broader data platform programme, developed in partnership with a major technology vendor. It digitises what was traditionally managed through physical whiteboards on hospital wards: patient status, bed availability, discharge readiness, and the various tasks required to move patients safely through the system.
The immediate brief is to conduct user research to understand how the product is being used and identify opportunities for improvement. But as with any design research engagement, the real work lies in understanding the problem space before jumping to solutions.
Reframing the problem: from "discharge" to "nursing care delivery"
Initial briefings positioned the product as a "discharge coordination tool". This framing is understandable - delayed discharges are a persistent operational pressure in the NHS, and anything that improves patient flow has obvious value. The product surfaces discharge-related information: which patients are medically optimised, which have outstanding tasks, which need transport arranged.
But spending time with secondary research - clinical guidance, nursing practice literature, and service design theory - suggested a different framing might be more useful.
Rather than focusing narrowly on discharge as an endpoint, what if we understood the product in the context of nursing care delivery as a whole? In this view, discharge is one outcome of a broader service: ensuring each patient's ongoing clinical and personal care needs are met on a day-to-day, shift-to-shift basis.
This reframing has practical implications. It shifts attention from the administrative task of "getting patients out" to the embodied, relational work of nursing itself. As Secomandi (2024) argues in recent work on service design, the forms assumed by human bodies in service encounters should be of central concern for designers. Nursing involves physical presence, movement, and constant re-evaluation of patients' wellbeing - what might be called "interactive labour" (Secomandi, 2024).
A digital product that supports this work needs to understand its place within these embodied encounters, not just the administrative workflow that sits alongside them.
The service encounter perspective
Service design literature offers useful frameworks for thinking about this. The concept of the service encounter - the period during which an organisation's human and physical resources interact with a customer to create service benefits (Palmer, 2005) - helps locate where a digital tool fits within the broader experience.
In ward nursing, each day involves repeated service encounters with patients: physical assessments, medication administration, personal care, responding to changes in condition. The ward management tool is not itself a service encounter; it's infrastructure that shapes how those encounters are planned, coordinated, and documented.
Penin (2018) observes that frontline workers often embody the behaviours and values of the organisation when they interact with users. In healthcare, this embodiment is particularly intense - nurses physically move around the ward, see and touch patients, adjust equipment, help with mobility. The challenge for any digital tool is to support rather than interrupt this embodied work.
Burns and Hajdukiewicz (2017) describe how ecological interface design (EID) emerged from the recognition that complex work domains require interfaces that make constraints and relationships visible to operators. Originally developed for process control environments, EID's emphasis on revealing the functional structure of work systems feels relevant here. A ward is a complex sociotechnical system; a useful interface should help staff understand the state of that system at a glance.
Initial secondary research
Before visiting the pilot sites, I spent time reviewing relevant literature:
Clinical guidance: The Royal College of Nursing's guidance on safe staffing and patient flow, which emphasises the cognitive load involved in coordinating care across multiple patients with varying acuity levels.
Discharge process research: NHS England guidance on discharge pathways, criteria to reside frameworks, and the various assessments (needs-based assessments, early discharge notifications) that constitute "medically optimised for discharge".
Service design theory: Particularly work that bridges design and healthcare - Jones (2013) on designing for care, and the growing literature on service design methods in clinical settings (Fry, 2018; Pfannstiel & Rasche, 2018).
Cognitive work analysis: My own background is in cognitive ergonomics, specifically cognitive work analysis (CWA) and ecological interface design. This week I've been considering how these frameworks might complement more conventional service design approaches to understanding the ward environment.
The methodological question
One tension I'm already noticing is between different analytical traditions.
Service design typically works with journey maps and blueprints - visualisations that show the user's path through a service over time, identifying touchpoints and pain points (Blomberg & Darrah, 2015; Meroni & Sangiorgi, 2012). These tools are powerful for capturing the experiential flow of service, but they can struggle with the vertical complexity of sociotechnical systems: the relationships between physical artefacts, digital interfaces, information structures, and higher-level purposes.
Cognitive work analysis, by contrast, uses abstraction hierarchies - models that show means-ends relationships between physical objects, processes, functions, and purposes (Stanton et al., 2017). These are excellent for revealing systemic structure, but they don't capture temporal flow or the lived experience of service encounters in the same way.
I'm curious whether there's value in combining these approaches: using CWA-style abstraction to understand the functional structure of the ward as a work domain, while using service design's journey-focused tools to capture how staff actually move through that domain over time.
Jones (2013) makes a similar observation, noting that "the abstraction hierarchy is a powerful aid to analysis and synthesis of essential functions and touchpoints in service design". The question is how to integrate these perspectives practically.
What's next
Next week I'll be visiting the pilot sites for observation sessions. The aim is to understand how the product is actually being used in context - not just what features exist, but how they fit (or don't fit) within the rhythm of ward work.
I'm particularly interested in:
- Physical context: Where is the product accessed? What devices? What's the relationship between the digital interface and the physical ward environment?
- Temporal context: When during the shift is it used? How does it relate to established rituals like board rounds and handovers?
- Social context: Who uses it? How is information shared between roles? What's said out loud versus what's read from the screen?
The goal isn't to evaluate the product against a checklist, but to understand the work domain well enough to identify where digital support is genuinely helpful and where it might be creating friction.
References
- Blomberg, J. & Darrah, C. (2015). An Anthropology of Services. Morgan & Claypool.
- Burns, C. M. & Hajdukiewicz, J. R. (2017). Ecological Interface Design. CRC Press.
- Fry, K. R. (2018). Why hospitals need service design. In Pfannstiel, M. A. & Rasche, C. (Eds.), Service Design and Service Thinking in Healthcare and Hospital Management. Springer.
- Jones, P. H. (2013). Design for Care: Innovating Healthcare Experience. Rosenfeld Media.
- Meroni, A. & Sangiorgi, D. (2012). Design for Services. Gower.
- Palmer, A. (2005). Principles of Services Marketing. McGraw-Hill.
- Penin, L. (2018). An Introduction to Service Design: Designing the Invisible. Bloomsbury.
- Pfannstiel, M. A. & Rasche, C. (Eds.) (2018). Service Design and Service Thinking in Healthcare and Hospital Management. Springer.
- Secomandi, F. (2024). Service design as formgiving: Breaking free from the marketing-dominant logic. Design Studies.
- Stanton, N. A., Salmon, P. M., Rafferty, L. A., Walker, G. H., Baber, C. & Jenkins, D. P. (2017). Cognitive Work Analysis: Applications, Extensions and Future Directions. CRC Press.