The Ripple Framework: the social value of a co-design approach for care home innovation

In this paper we present an analysis of the social value of a novel framework for co-design. The Ripple Framework (RF) was devised as a strategy to facilitate engagement by adult care workforce stakeholders in a three-year multi-disciplinary research project, Healthier Working Lives (HWL). HWL was one of seven in the UK’s Social and Behavioural Design Research Programme (SBDRP), the academic research programme of a national government funded Health Ageing Challenge. All projects in the SBDRP were required to include co-design as a significant component of their research and impact methodologies. Healthier Working Lives focuses on the recruitment, retention, and welfare of the aging workforce in the Scottish residential care sector. By seeking to familiarise staff with co-design methods and frameworks, we intended to generate not only one-off solutions to problems, but a conceptual space for ongoing creative autonomy and power.

The framework includes thirty co-design methods and management tools tailored to support the co-production of the co-design process (to borrow from the health and care domain terminology), to give collaborations the best chance of sustainability and to develop relevant concepts (Soares, Kettley, and Speed 2023). We found it effective in dealing with practical issues of access during the UK’s mandatory pandemic lockdown period, and later unpredictable management of access to care homes by managers due to local outbreaks, as well as the normal pressures faced by the sector.

We also find that, in line with other accounts of the relational value of co-design, the RF offers a principled way of working with social care communities of practice. This paper presents the social value of the first phase of the Ripple Framework, used with six care homes in Scotland between 2022 and 2023.


Introduction
The COVID-19 pandemic presented an unparalleled occasion for design to reflect on both research and practice. In this paper we illustrate our response to this situation, a flexible framework intended to help us work with high levels of uncertainty and unpredictability while undertaking co-design with the care workforce in Scotland.
The Ripple Framework (RF) was constructed to support a co-design process with diverse stakeholders in the care home sector including care workers, managers, entrepreneurs, and investors. The intention was to scaffold a process that would allow care home managers to co-produce a pathway of co-design activities that would work with their home’s unique and dynamic situation over a period of six months, minimising unpredictable as well as known barriers to participation for the sector.
Informed by Person-Centred theory (Kettley, Kettley, and Bates 2015), emerging definitions of Relational Design (Udoewa 2022), and Complexity Outcomes Theory (French et al. 2023), this approach was intended to build relationships and multilateral interaction between the care and design entrepreneur sectors in a meaningful way, avoiding the pitfalls of ‘faux production’ (Warran et. al. 2023, 3) in the co-production of care (Iedema et al. 2008).


Figure 1 - digital version of the Ripple Framework
(see https://ripple.designinformatics.org/)


Evaluating the framework
A pathway of five co-design activities was planned with each of six care homes between June 2022 and March 2023, informed in the first instance by observations undertaken by the HWL ethnography sub-team (Lewis and Zenz 2023). Each activity then informed the selection of the next, and typically provided content (eg. direct quotes) for subsequent bespoke activity cards and games (Soares, Kettley, and Speed 2023). This phase culminated deliberation to prioritise opportunities for change, and led into a second, development, phase in which care homes were paired with design entrepreneurs. In this paper we focus on the first phase, reflecting on the RF through the lens of Knutz and Markussen’s proposed model of evaluation, which accounts for three types of value: social, demand, and research (2019). We focus here on the social value of our framework in action. Co-design data was collected through audio recording and photography following Kings College London ethical processes and informed consent.
Social value
Our position is that the co-design process itself has change effects, and depending on how the process is configured, these may have value in and of themselves. In this we have drawn directly on the value and efficacy of the relationship in Person-Centred theory (Kettley, Kettley, and Bates 2015) and see alignment with cycles of reflective learning in Complexity Outcomes approaches (French et al. 2023, 85). For Knutz and Markussen, such qualitative change effects for and with people constitute social value and have the potential for adaptive change (ripples) (2019, 225). Articulating these values is important for how co-design and other creative approaches are enrolled in impact-driven research agendas (and we note that the SBDRP projects all involve co-design as a requirement). This paper therefore articulates instances that illustrate three key social values we find in our data: new knowledge of own working environments, perceptions of power to make change, and individual confidence and growth.
• new knowledge of own working environments
We adapted the Point of Care Foundation’s Circle of Care method (Soares, Kettley, and Speed 2023), and this resulted in staff learning about each other’s roles, revealing hidden operational issues, recognising existing positive initiatives, and reiterating a shared ethos. In checking out of one workshop, a domestic worker said “We’ll know us better now.”
• perceptions of power to make change
In a final deliberation workshop, one team identified barriers to the intentions of a manager to be hands-on: “… you’ve got to understand that we daena like bothering you, cause you’re busy.” This led to a discussion on current processes (‘flash meetings’) and the small improvements that could be made to these based on situated practical knowledge (“That’s something we can do”).
• individual confidence and growth
We have seen an increase in individuals feeling able to speak up, writing on and suggesting changes to workshop materials, and telling us that they are able to describe themselves now as ‘creative’. The convivial activities, often re-presenting staff with their own statements, have become familiar and actively welcomed by staff across the homes. One of the managers involved has told us that staff feel a new sense of “purpose and permission”. Another announced “I am a co-designer now!”.

Future work
This paper presents one small part of the multidimensional Healthier Working Lives project, contributing to discourse around new evaluative cultures, in which the stories of those with lived experience counts to illustrate impact of design research. There is more work to be done in articulating the demand and research values of our work, and to extend this to include the second phase of the project, in which innovation teams worked across sectors to develop responses to stakeholder-defined problems and opportunities. In addition, we look forward to analysing the extensive co-design data for more sociological understandings about the care workforce, and to articulating the epistemological complementarity of co-design and social science methodologies.

Acknowledgements
With thanks to HWL PI Professor Linda McKie (Kings College London), the project team, and the Knowledge Network. Healthier Working Lives was funded through UKRI Health Ageing Challenge Social, Behavioural and Design Research Programme grant number ES/V016156/2. Full details of project partners, and up to date newsletters can be found at https://www.kcl.ac.uk/research/healthier-working-lives-for-the-care-workforce.


REFERENCES

French, Max, Hannah Hesselgreaves., Rob Wilson, Melissa Hawkins, and Toby Lowe. 2023. Harnessing Complexity for Better Outcomes in Public and Non-profit Services. Bristol: Policy Press.

Iedema, Rick, Roslyn Sorensen, Christine Jorm, and Donella Piper. 2008. Co-producing care. Managing clinical processes in health services. Chatswood, NSW: Elsevier, 105-20.

Kettley, Sarah, Richard Kettley, and Matthew Bates. 2015. An Introduction to the Person-Centred Approach as an Attitude for Participatory Design. Proceedings of the 2015 ACM International Joint Conference on Pervasive and Ubiquitous Computing (UbiComp 2015), Sep. 7-11, Osaka, Japan.

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Lewis, Sue, and Bettina Zenz. 2023). Retaining Care Home Staff: Ethnographic Insights from Scotland. Paper presented at the British Society of Gerontology Conference, University of East Anglia (UEA), 5 -7 July 2023.

Soares, Luis, Sarah Kettley, and Chris Speed. 2023. The Ripple Framework: a co-design platform (a thousand tiny methodologies). Proceedings of the IASDR (International Association of Societies of Design Research) Conference. Politecnico di Milano, 9-13 Oct 2023.

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