Tatau project report

tātou
Caring for the Carers
Responsive Studio Report
Ella Harnish
Workbook:
tumblr.com/blog/222453ellastudio

Contents
Introduction 02
Central Proposition 03
Aim 05
Design Approach 07
Design Strategy 19
Challenges 35
Conclusion 37
References 41

Glossary
Tātou - (pronoun) we, us, you (two or more) and I
(Maori Dictionary, 2018).
Hospice nurse - Hospice nurses provide
specialized patient and family-centered care called
palliative care. They prevent and treat the suffering
of terminally ill patients and provide support
for their families, primarily in the patient’s home
(Ramirez, A et al, 1998).
Compassion fatigue – The emotional strain from
exposure to those who are suffering, most often
in the lives of care providers. Contributing factors
to compassion fatigue are cumulative stress and
personal trauma (Figley, 2002).
Self-care - the practice of activities that are
necessary to sustain life and health, normally
initiated and carried out by the individual for himor
herself (Martin & McFerran, 2008).
Peer support - emotional or practical support
mutually offered and reciprocal. This is built on
shared personal experience and empathy, and
works towards the individual’s wellbeing (Mental
Health Foundation).
Behaviour change - can refer to any
transformation or modification of human behavior.
Behaviour change can be created through tiny
habits and a change in environment (Fogg, 2009).
Resilience – the ability to bounce back (Skovholt &
Trotter-Methison, 2016).
Wellbeing (hauora) - encompasses the physical,
mental and emotional, social, and spiritual
dimensions of health (Ministry of Health).
1

Introduction
I have created Tātou, a design service which
facilitates holistic self-care and peer support
for palliative care nurses to help improve
their resilience. Palliative care nurses provide
specialized care for terminally ill patients and
their families (Ramirez et al, 1998). This exposure
to death and dying can lead to increased stress,
burnout, and compassion fatigue (Frey, Robinson,
Wong, & Gott, 2018). Being around death and
suffering constantly is what differentiates palliative
care nurses from other healthcare providers,
hence why I chose to focus my design project
on them. To prevent compassion fatigue, Figley
(2002) suggests that a holistic self-care practise
is important. Through semi-structured interviews,
I discovered an entrenched patient centered
workplace culture which promotes self-care as
being self-indulgent, meaning palliative care
nurses are not currently practising self-care (Figure
1). Communication design can help by facilitating
a behaviour change through small actions of
holistic self-care and peer support (Fogg, B. J.
2009), using Te Whare Tapa Whā (Durie, 1985)
as a model for balanced, holistic wellbeing. This
helps palliative care nurses to feel supported,
validated, encouraged and empowered to care for
themselves and each other. My service shifts the
conversation from a patient-focused environment
towards one which considers care for the nurses,
to maintain both their own positive wellbeing and
quality of patient care.
2

How can communication
design facilitate self-care
and peer support to
improve the resilience of
palliative care nurses?
3

Supported,
empowered
less stressed
Time to practise
self-care
Check in -
current
wellbeing
+ reflection
Colleague
offers to
help with
patient load
Colleague
prompted to
offer support
Pressure to
work harder
‘I have no
time’ - less
breaks for
self
Work
disastisfaction
Decresed
feeling of work
competancy
Increased
patient load
Poor coping
skills
Difficulty
separating
work from
home life
Home/life
demands
Traumatic
thoughts &
memories
increased
self-awareness,
self-compassion
Lack of
support
feels isolated
Lack of help
and support
Situation
Think, say,
do & feel
Tātou
Stressed
Forms positive
habits
Negative
habits
Lack of support
feels isolated
Connection
and validation
Drained
‘I’m fine guys’
- denial
Group
self-care
activity
Workplace
environment
Norm -
‘self-care is
indulgent’
Exposure to
death & suffering
Trapped
& isolated
Traumatic
thoughts &
memories
Poor coping
skills
Anxiety,
dread
Empathy,
compassion
concern
Feels more
calm, less
stressed
Self-care
break
Figure 1 Harnish, E. (2018). Diagram of situation,
response, and Tātou. Author’s own.
4

Aim
Tātou’s service enables nurses to practise simple
and achievable self-care actions, individually
and in groups, creating connection, support,
empowerment and validation through a phone
application. Tātou addresses a holistic approach
to self-care through the concept of Te Whare Tapa
Whā (Māori health model) by bringing balance in
each aspect of your wellbeing. Tātou facilitates a
behaviour change through tiny habits and a shift
in the social environment (Fogg, 2009) within the
palliative care workplace.
5

Communication design
can facilitate self-care
habits and peer support,
to create a workplace
behaviour change that will
ultimately enhance the
wellbeing and resilience
of palliative care nurses.
6

Design approach
Research
With an empathetic design approach (Kouprie &
Visser, 2009), I conducted several semi-structured
interviews with palliative care nurses, supervisors,
and managers and took part in participant
observation. I discovered that work related stress is
a real problem for palliative care nurses, worsened
by the nurses not caring for themselves or each
other, due partly to a patient-focused environment
(Figure 2). I found that the workplace views on
self-care, time, and effort are current barriers
preventing nurses from practising self-care and
using current resources. The few current resources
provided are not very effective as they are not
empowering or engaging to use (Figure 3, 4, & 5).
From here I identified that the workplace stigma
around self-care needed to be addressed to create
empowerment for the nurses to take action to care
for themselves. The nurses needed facilitation of
quick and easy self-care actions that improve selfawareness
and wellbeing.
Figure 2 Harnish, E. (2018). Design research.
Author’s own.
7

8

Current resources
Figure 5 Hendry, T. (2018). 50 Ways to Take a Break.
Retrieved from http://www.triciahendry.com/
9

A Self-Care Plan
© Tricia Hendry www.triciahendry.com
What are my warning signs that work stress has built up too much?
EMOTIONS
How do I look after these?
BODY
How do I look after my body?
MIND
How do I manage my thoughts?
Changes I’d like to make?
Changes I’d like to make?
Changes I’d like to make?
RELATIONSHIPS
How do I keep my relationships healthy?
SPIRIT
How do I care for my spirit?
WELL-BEING AT WORK
How do I look after myself at work?
Figure 3 Hendry, T. (2018). A Self-Care Plan. Retrieved
from http://www.triciahendry.com/
Changes I’d like to make?
Changes I’d like to make?
Changes I’d like to make?
Figure 4 WelTec. (2017). Professional Supervision in the
Workplace. Retrieved from https://2018.weltec.ac.nz/courses/
health-and-community/professional-supervision-in-the-workplace/
10

Figure 6 Harnish, E. (2018). Testing at First Response.
Author’s own.
11

First Response
My initial iterations of my design system at the First
Response were focused on facilitating individual
self-care activities (Figure 6). I was encouraged to
look deeper into how to shift the workplace stigma
on self-care (Figure 7). Through further discussions
with palliative care nurses and their supervisors, I
discovered that current resources focused mainly
on individual needs, causing a lack of support and
encouragement for nurses. From here I realised
that there was a need for design to facilitate peer
support and encouragement in order to shift this
workplace stigma. I added a feature which allows
nurses to set up or join group activities, allowing
connection and validation to practise self-care
together.
12

13

Figure 7 Harnish, E. (2018). Bigger picture. Author’s own.
14

Super Crit
My feedback from the Super Crit was to consider
the extent of change design alone can make and
build on current systems in the space which are
working. The current handouts on holistic self-care
actions are grounded in research and would be
effective if used. I looked at how Tātou’s service
could engage, empower and remind the nurses
to take action (Figure 8). Part of Tātou’s service
would include a downloadable phone application.
This makes self-care facilitation more accessible
as hospice nurses have a phone with them all day
for calls and patient documentation. As hospice
nurses are out in the community visiting patients
in their homes, I added a location tracking feature
which sends reminders when nurses have returned
to the office or when they have been at the desk
without a break for too long. After discussion with
nurses, I discovered that they would appreciate
accessible advice on where to go for further
help, as Tātou is a resource for prevention rather
than treatment of stress related illnesses. I then
incorporated emergency contacts and advice,
including the nurses supervisors. I was able
to identify how Tātou could enhance existing
resources through addressing the nurses’ needs.
15

Figure 8 Harnish, E. (2018). Super crit.
Author’s own.
16

Testing
After testing the user experience through
wireframes on my peers, the feedback was to look
more into altering the tone of voice so that it was
more friendly, supportive and personalised (Figure
9). It was mentioned to emphasise how quick and
easy the activities are, to provide more motivation
for nurses. I refined the longer paragraphs of text
to just key information and added the time frame
of each activity, naming the activities mini-breaks
to emphasis their ease. Tātou’s interface colours
were initially cool and washed out. Warmer colours
evoke feelings of excitement and arousal (Hyodo,
2011). After further discussion with nurses, they
reiterated that warmer colours would create further
motivation and excitement. From here I worked
on altering the colours to evoke warmth and
energy, drawing on the vibrant work of Fanette
Mellier (2011) for inspiration. To create more of
a personalised experience, Tātou’s language
is friendly and casual like a conversation with a
friend, referring to the user by name. This provides
a non intrusive and encouraging experience.
17

Figure 9 Harnish, E. (2018). Testing. Author’s own.
18

Design strategy
Implementation
Within the palliative care workplace, Tātou would be
introduced to the nurses by management (Figure
10). After downloading the phone application
from Tātou’s website, small achievable self-care
actions are facilitated for individual nurses and their
colleagues. Figure 11 demonstrates the interaction
of a hospice nurse with Tātou in a typical day.
19

Before
Manager creates a hospice
group through their Tātou
account. This sends an email
invite to all nurses within the
workplace.
During
The email leads the nurses to
the Tātou website. The website
informs users on Tātou’s service
and invites them to download
the app.
Progress
Day
Month
Mon Today Wed
Tuesday 9 Oct
During
After downloading the app, part of
the set-up involves a 30 minute
mini-break workshop with all
members, introducing nurses to
Tātou’s service in a friendly way.
The app facilitates regular mini
self-care activities for nurses,
individually and in groups.
After
Palliative care nurses more
resilient. Behaviour change to
regularly caring for self and
supporting eachother.
Figure 10 Harnish, E. (2018). Implementation strategy
Author’s own.
20

Journey
Sleep
Home
Day
Journey
Home
Office
Patient 4
Patient 3
Patient 2
Patient 1
Work
Orange dots indicative of small
self-care actions, completed
individually or in groups
Figure 11 Harnish, E. (2018). Day Journey
Author’s own.
21

Website
Figure 12 Harnish, E. (2018). Tātou website
Author’s own.
22

Set-up
The initial set-up allows nurses to join their
workplace group, set customised reminders and
colours, and facilitates the first group activity.
23

Figure 13 Harnish, E. (2018). Set up
Author’s own.
24

Te Whare Tapa Whā
Figley (2002) suggests that a holistic approach
to wellbeing, addressing each aspect of an
individual’s health is important for building
resilience against compassion fatigue.
Underpinning Tātou is the concept of Te Whare
Tapa Whā (Durie, 1985) which focuses on bringing
balance physically, socially, spiritually and
emotionally to hauora (wellbeing). If an area of
wellbeing is feeling out of balance, Tātou suggests
quick, engaging self-care activities to work on
this area (Figure 14). If nurses require further help
Tātou provides emergency contacts and advice, as
Tātou’s service is a resource for prevention rather
than treatment of stress related illnesses
(Figure 15).
Figure 14 Harnish, E. (2018). Te Whare Tapa Whā
Author’s own.
25

Figure 15 Harnish, E. (2018)
Emergency. Author’s own.
26

Progress & Tracking
Daily reflection and self-awareness is important for
building resilience (Saakvitne & Pearlman, 1996).
Through research, I discovered that the nurses
are already encouraged to take part in reflection
at monthly supervision sessions, but more regular
self-reflection is needed for nurses. Tātou provides
a daily ‘check in’ which can be facilitated by
daily reminders. Nurses rate each aspect of their
wellbeing, and have the option of noting thoughts
and feelings (Figure 16). Wellbeing can be visually
seen through coloured shapes representing the
four aspects of wellbeing. Users can see their
progress of wellbeing over time, and the activities,
thoughts and feelings they have had on a given
day, helping them to notice which activities benefit
them the most. The friendly visual representation
of wellbeing can be shown to colleagues in groups
so that nurses can support each other to create
balanced wellbeing.
27

Figure 16 Harnish, E. (2018). Progress and Tracking.
Author’s own.
28

Tiny habits
Research suggests that shorter, achievable and
more frequent breaks leads to reduced fatigue
(Brennan, 2017). Tātou facilitates small selfcare
actions called mini-breaks for individuals
and groups based on the four aspects of Māori
wellbeing (Figure 17). The activities are adapted
from the list of effective self-care strategies for
building resilience by Saakvitne & Pearlman (1996).
In order for the nurses to complete a self-care
habit, Fogg (2009) suggests three elements must
converge; a trigger, ability, and motivation. Tātou
facilitates quick, easy self-care actions that are
motivated by peer encouragement and triggered
by a reminder (Figure 18). Location tracking allows
Tātou to send reminders when nurses have been
out with patients or at their desk for a certain
amount of time without a break. Further motivation
to complete self-care actions is provided through
reaching ‘streaks’, which are measured by
completing mini breaks each day for as many days
in a row as possible. Research indicates that it
takes around 21 days to form a habit (Maltz, 1969),
so encouraging nurses to complete a streak is
more likely to facilitate positive self-care habits.
Figure 17 Harnish, E. (2018). Mini breaks.
Author’s own.
29

Figure 18 Harnish, E. (2018). Reminders. Author’s own.
30

Peer support
Along with tiny habits, the second factor leading
to behaviour change is through changing social
environment (Fogg, 2009). Current ineffective
resources for self-care focus on the needs of the
individual, however peer support is important as it
creates increased motivation and encouragement
(Borek & Abraham, 2018). Tātou facilitates peer
support and connection through doing small
self-care actions in workplace groups. Nurses can
easily create and join group mini-breaks through
the Tātou app (Figue 19). Peer support provides
validation for nurses to feel encouraged and not
alone when practising self-care. This helps to build
a palliative care support network, an important
factor in preventing compassion fatigue and
burnout (Figley, 2002).
31

Figure 19 Harnish, E. (2018). Peer support.
Author’s own.
32

Personal messaging
Messaging allows nurses to connect with each
other in a private way, facilitating further peer
support. Profile photos have different background
colours, indicative of the area of wellbeing that the
nurse needs work on, also shown on their profile.
This allows nurses to check on each other and offer
support where needed.
Tātou recognises when individuals have not had
a break for a while and sends a notification to
another nurse prompting them to check in with
each other, creating further support. As Tātou is
synced to the patient schedules, it recognises
when a patient has passed away and will send
prompts to message nurses who were particularly
involved in the patient’s care (Figue 20).
33

Figure 20 Harnish, E. (2018). Messaging.
Author’s own.
34

Challenges
Through a user centered approach, I was able to
overcome challenges by returning to the needs
of the nurses. A tension I faced was creating
something fun and engaging but not intrusive and
forceful. Through focus groups, I clarified that I
needed to focus on motivating the nurses to use
the service through making it engaging, intuitive
and non-invasive, focusing on a straightforward
and easy to use service.
I was challenged to consider how the app
develops over time. After talking with nurses, they
clarified that self-care should be ongoing as every
day presents different challenges and new stress.
The app would continue to be used, even after
self-care habits have been formed as they would
still need reminding. New activities can be created
and customised over time to build an activity
library specific to a hospice group. The social
aspect to activities provides further incentive to
keep using Tātou.
Due to limited time and resources, the information
gathered through discussion and testing was from
nurses of two different workplaces. If I had more
time I would have approached more hospice
workplaces from rural and urban settings and
different cultural backgrounds to gain a more
extensive understanding.
35

Conclusion
‘Tātou’ facilitates self-care and peer support
through a behaviour change, creating
encouragement and empowerment for nurses
to feel validated to care for themselves and each
other. This project has the potential to collaborate
with a spatial designer to include a space within
the workplace including resources, where nurses
can go to rest and connect. The app could be
developed further to include artificial intelligence
learning, to be further customised for the user,
learning their routine and prefered activities.
Tātou’s group self-care actions could be expanded
to include facilitating meetups with other hospice
workplaces across New Zealand through Tātou’s
app, creating further connection and support.
‘Tātou’ also has the potential to be implemented
in other healthcare workplaces and settings to
ultimately improve staff wellbeing and quality of
patient care. The process and development of the
project Tātou, has grown out of my interest and
enjoyment of human centered design, in order to
realise the positive change that design can create
for users.
36

Figure 23 Harnish, E. (2018). Connection.
Author’s own.
37

38

References
Reference list
Hyodo, J. (2011). Can Colors Make Me Happy? The
Effect Of Color On Mood: A Meta-Analysis. Advances in
Consumer Research, 39, 858-867.
Kouprie, M., & Visser, F. S. (2009). A framework for
empathy in design: stepping into and out of the user’s
life. Journal of Engineering Design, 20(5), 437-448.
doi:10.1080/09544820902875033
Martin, E., & McFerran, T. (2008). A Dictionary of Nursing
Oxford University Press.
Maltz, M. (1969). Psycho-Cybernetics. New York: Prentice
Hall.
Mellier, F. (2011). Retrieved from https://fanettemellier.
com/en/
Mental Health Foundation. (n.d.). Retrieved from https://
www.mentalhealth.org.uk/a-to-z/p/peer-support
Mills, J., Wand, T., & Fraser, J. A. (2018). Exploring the
meaning and practice of self-care among palliative care
nurses and doctors: a qualitative study. BMC Palliat Care,
17(1), 63. doi:10.1186/s12904-018-0318-0
Frey, R., Robinson, J., Wong, C., & Gott, M. (2018).
Burnout, compassion fatigue and psychological
capital: Findings from a survey of nurses delivering
palliative care. Appl Nurs Res, 43, 1-9. doi:10.1016/j.
apnr.2018.06.003
Borek, Aleksandra J. and Charles Abraham. “How
Do Small Groups Promote Behaviour Change?
An Integrative Conceptual Review of Explanatory
Mechanisms.” Applied Psychology: Health and Well-
Being, vol. 10, no. 1, 2018, pp. 30-61, doi:10.1111/
aphw.12120.
Durie, M. (1985). A Maori Perspective of Health M. H.
Durie. Social Science & Medicine, 20(5), 483-486.
Farnham, K., & Newbery, P. (2013). Experience Design: A
Framework for Integrating Brand, Experience, and Value.
New Jersey: John Wiley & Sons, Inc.
Figley, C. R. (2002). Treating Compassion Fatigue. NY:
Routledge.
Fogg, B. J. (2009). A Behavior Model for Persuasive
Design. Paper presented at the Proceedings of the 4th
International Conference on Persuasive Technology,
Claremont, California, USA.
Fogg, B. J. “ Forget big change, start with a tiny habit:
BJ Fogg at TEDx Fremont” Online video clip. YouTube.
YouTube, 5 Dec. 2012. Web. 8 Oct. 2018.
Ministry of Health. (n.d., 18 May 2017). Māori health
models – Te Whare Tapa Whā. Retrieved 21 May 2018
from https://www.health.govt.nz/our-work/populations/
maori-health/maori-health-models/maori-healthmodels-te-whare-tapa-wha
39

Moorfield, J. (2018). Māori Dictionary.
Retrieved from http://maoridictionary.
co.nz search?idiom=&phrase=&proverb
=&loan=&histLoanWords =&keywords=T%C4%81tou
Ramirez, A., Addington-Hall, J., & Richards, M. (1998).
The Carers. ABC of Palliative Care, 316, 208-211.
Saakvitne, K., & Pearlman, L. (1996). Transforming the
Pain: A Workbook on Vicarious Traumatization. USA:
Norton.
Skovholt, T., & Trotter-Methison, M. (2016). The
Resilient Practitioner: Burnout and Compassion Fatigue
Prevention and Self-Care Strategies for the Helping
Professions (Third ed.). NY: Routledge.
40

Illustrations list
Figure 1 Harnish, E. (2018). Diagram of situation,
response, and Tātou. Author’s own.
Figure 13 Harnish, E. (2018). Set up
Author’s own.
Figure 2 Harnish, E. (2018). Design research.
Author’s own.
Figure 14 Harnish, E. (2018). Te Whare Tapa Whā
Author’s own.
Figure 3 Hendry, T. (2018). A Self-Care Plan. Retrieved
from http://www.triciahendry.com/
Figure 15 Harnish, E. (2018). Emergency.
Author’s own.
Figure 4 WelTec. (2017). Professional Supervision in
the Workplace. Retrieved from https://2018.weltec.
ac.nz/courses/health-and-community/professionalsupervision-in-the-workplace/
Figure 5 Hendry, T. (2018). 50 Ways to Take a Break.
Retrieved from http://www.triciahendry.com/
Figure 6 Harnish, E. (2018). Testing at First response.
Author’s own.
Figure 7 Harnish, E. (2018). Bigger picture. Author’s own.
Figure 8 Harnish, E. (2018). Super crit.
Author’s own.
Figure 9 Harnish, E. (2018). Testing. Author’s own.
Figure 16 Harnish, E. (2018). Progress and tracking.
Author’s own.
Figure 17 Harnish, E. (2018). Mini breaks.
Author’s own.
Figure 18 Harnish, E. (2018). Reminders.
Author’s own.
Figure 19 Harnish, E. (2018). Peer support.
Author’s own.
Figure 20 Harnish, E. (2018). Messaging.
Author’s own.
Figure 21 Harnish, E. (2018). Nurse on break.
Author’s own.
Figure 10 Harnish, E. (2018). Implementation strategy
Author’s own.
Figure 22 Harnish, E. (2018). Group self-care activity.
Author’s own.
Figure 11 Harnish, E. (2018). Day Journey
Author’s own.
Figure 23 [overleaf] Harnish, E. (2018). Connection.
Author’s own.
Figure 12 Harnish, E. (2018). Tātou website.Author’s own.
41

Ethics forms
My digital workbook contains all ethics forms.
URL: tumblr.com/blog/222453ellastudio
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