Improving Patient Discharge Communication (Journal of Technical Writing and Communication) -- ONLINE...

Article

Improving PatientDischargeCommunication

Catherine C. Gouge1

Abstract

Transitional care communication events—such as discharge from hospital—are com-

plex and dynamic: impromptu questions are asked and answered, documents are

discussed and signed, and health-care professionals and patients with different know-

ledge must work together to establish understanding. This article examines a set of

patient discharge instructions that bear substantial traces of impromptu conversation

in the patient discharge communication process and argues that we need to do more

to account for such exchanges as a part of the complex information our documen-

tation must coordinate and make accessible for end users.

Keywords

patient communication, usability studies, universal design, health and medicine,

speculative usability

First Paragraph

The increasingly specialized nature of biomedical practice and its attendantcomplexity has been accompanied by significant attention to the monetaryand human cost of poor communication in health care. Older patients andthose with lower literacy skills are considered by many to be the most vulnerableto the effects of ineffective communication (Flacker, Wansoo, & Sims, 2007);and scholars in medical communication document an increased rate of mortalityfor seniors with “marginal literacy” and cite a correlation between low patient

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DOI: 10.1177/0047281616646749

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1English Department, West Virginia University, Morgantown, WV, USA

Corresponding Author:

Catherine C. Gouge, English Department, West Virginia University, PO Box 6296, Colson Hall,

Morgantown, WV 26506-6296, USA.

Email: [email protected]

literacy skills and an increase in health care costs of as much as $8,000 perperson per year (Polack & Avtgis, 2011, pp. 164–165). And because hospitalsmake more money from increased frequency of visits than from dur-ation—because payers provide a set fee for each admitted patient according totheir diagnosis—shorter stays in hospitals have become the norm, resulting incompressed in-hospital treatment schedules that have made it even more criticalto successful care that hospitals find ways to communicate effectively and effi-ciently. In this climate of specialization and compressed treatment schedules, asthe chief of social work at a large U.S. hospital has described it, “Handoffs havebecome much more critical” (Gittel, 2009, p. 9).

One in five Medicare patients is readmitted to the hospital within 30 days afterdischarge, accounting for roughly two million people a year and costing the gov-ernmentmore than $17 billion annually (Rau, 2012). Because of this, a provision inthe Patient Protection and Affordable Care Act (2010) has, since 2013, been pena-lizing hospitals with excessive readmission rates,1 and communication withpatients when they are discharged from hospitals has been identified as one criticalopportunity to reduce readmission rates to hospitals (Hansen et al., 2011; ProjectRED, 2015). Recognizing the critical exigency of this to transitional care commu-nication practices as well as to the ongoing conversation in technical communica-tion about document usability and complexity, this article proposes that we domore to account for impromptu exchange as a part of the complex information ourdocumentation must coordinate and make accessible for end users.

As patients, caregivers, family members, and health-care professionalsask and answer questions about prescribed medication and other home careinformation, communication in the discharge communication event travels inmultiple directions and in ways that cannot be fully anticipated. To demonstratehow patient discharge instructions (PDIs) can be problematic for end users(patients and their caregivers) when documents are not designed to supportsuch improvisational exchanges, this article examines a set of PDIs that bearsubstantial traces of impromptu interactions and considers the ways that theychallenge current mechanisms for organizing complex information in the patientdischarge communication (PDC) event. Finally, the article proposes that toproductively address this design and usability issue for PDIs and other processdocuments, technical communicators need to adopt a design approach that cando more to recognize and support the improvisational exchanges of such events,such as the universal and speculative design modifications to usability studiesproposed by Dolmage (2009) and Rivers and Soderlund (2015).

The Patient Discharge Instructional Document: Usesand Limitations

When people are discharged from acute care facilities, most often a dischargenurse delivers to the patient and goes over with her or whoever is there to take

2 Journal of Technical Writing and Communication 0(0)

her home a set of paper instructions that include the attending physician’sapproved discharge plan. The average time spent on this exchange is 3 minutes(Baldwin, 2013). Most patient discharge instructional documents are procedure-or department-specific forms—like those seen in Figure 1—that give basic infor-mation about what medications to take and what to look for in a wound ordeveloping condition.

Once in use, forms like those in Figure 1 begin to register the complexity ofthe exchange of which they are a part, the perceived affordances and constraints2

of the forms, and related communication practices. Recognizing the ways inwhich forms index such affordances and constraints is critical since, asNorman (1988, 1990, 2011) discusses, knowing what end users perceive to beaffordances is central to effective design as is understanding what objects canand cannot do—especially, I would add, when end users need or want them to beable to do more than the current design affords. PDIs in use can illustrate, forexample, that there is much about the discharge communication process that isunpredictable—especially with regard to what is still by far the most commondelivery mode for discharge instructions: the paper form delivered by a dischargenurse (Clark et al., 2005). And PDIs can index how end users tend to exploit thephysical affordance of the paper form by writing on it in ways that can bothsupport and undermine the intentions of the document designer. Though PDIsoften begin the discharge process as a generic form—one designed to be used asa matter of protocol for all patients being discharged after a specific procedureor from a specific department—that form and the information it contains areprovisional for those who handle it; it is subject to modification as the instruc-tions are explained by a discharge nurse, handled and marked by her, and per-haps also further annotated by the patient or her at-home caregivers.

Improvisation, as one music theorist describes it, is about the “interaction ofchoice and constraint” (Berkowitz, 2010, p. 3). To appreciate the extent to whichthese discharge documents can be modified by improvisational exchanges oncein use, consider the PDIs pictured in Figures 2 and 3.3 Statements, such as“These are your discharge instructions. Please follow them carefully” andother second-person references throughout the document clearly indicatepatients are the primary audience this care facility has in mind for these PDIs.This particular set of PDIs was delivered to an 84-year-old woman and her sisterwhen the woman was discharged from a care facility, before which she had beenin an intensive care unit due to complications resulting from her second open-heart surgery. The woman’s sister signed these PDIs before she brought thewoman home, indicating that she understood them and that she would helpthe woman follow them. However, 2 days after the woman was discharged,the woman, her sister, and a newly hired aid who is a second-language speakerof English ended up arguing about what the instructions meant and the best wayto make sure the woman would get the right medications at the right time. Thewoman was still extremely weak and suffering from some post-ICU/morphine-

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induced dementia. Her sister is very hard of hearing and tends, by her ownaccount, not to have an easy time following instructions. And the new aid,who had not been present at discharge, was really anxious about the confusionbecause it was going to be her job to make sure the woman got the right medi-cations at the right time.

It is not hard to identify several ways in which these discharge instructionsviolate many of the design principles for which scholars in health and medicalcommunication advocate (Frampton & Charmel, 2008; Heifferon, 2012;Osborne, 2005; Polack & Avtgis, 2011; Stuart, 2007). These include less criticalgraphological issues as well as more critical graphological ambiguity andpharmacological explanations. For example, the document does not consistentlyuse legible typography and size or ensure that leading (spaces between lines) andkerning (spaces between letters) facilitate reading. Graphics, visuals, and imagesare not used to aid comprehension. There are no clear methods used foridentifying, prioritizing, or otherwise drawing attention to the most criticalmedications. Medications are not listed in order of importance. Some medica-tions are listed twice; some are crossed out. The instructions do not helpsequence or schedule medications. There does not appear to be anythingdesigned to motivate users to use the document by connecting to patient goalsand values (“Do X so that you can do Y.”). They are not interactive. They donot allow for checking off doses taken, for example. The critical medicationDigoxin, used to treat atrial fibrillation (which is incredibly serious, given thewoman’s reason for being hospitalized), is marked identically to Zantac, used totreat acid reflux. Further, there are several discrepancies in the visual designrelating to critical content in the instructions: Though the instructions at thetop direct patients to “Take only the medications checked below,” two differentkinds of check marks appear alongside Xs and other marks that are not clearlyassociated with a particular desirable behavior (like, “Do this, especially this,don’t do that.”). Also critical for the woman who had a stroke several years ago,the blood thinner, Warfarin, is listed as “Dose to be determined,” withoutindicating by whom or when. The woman and her caregivers knew how criticalWarfarin is and found this omission particularly confusing and stressful.

Beyond the many ways the basic form could have better adhered to specificvisual design principles prior to being shared with the woman and her caregivers,however, these PDIs in use invite us to recognize the ways that caregivers andpatients challenge the constraints of generic forms with their impromptuexchanges. Evident in the crossing out and rearticulating of certain drugs onthe PDIs in Figure 3 is what Schryer and Poel (2005) recognize as meaningfulwhen they note the “tensions and improvisations of each genre performance”(p. 271). Indeed, as the word improvisation—which derives from the Latin termimprovisus, meaning unforeseen—is meant to signal, each transitional care com-munication event is an intra-active (Barad, 2007) performance, an enactmentthat can not be fully scripted in advance: Details are supplied; annotations are

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made; sometimes things are underlined, checked, X-ed, and crossed out; thingsare said; questions asked and answered orally. Because marks made on suchforms are generated as a part of a complex, multimodal communication processthat includes the oral exchange of concerns and information, it is improbablethat any two discharge communication processes, even with more responsiblyarticulated standard PDIs than those pictured in Figure 3, will ever be identical.Moreover, the relative chaos of the marks on the set of PDIs in Figure 3 andtheir revealing traces index at least three critical aspects of such documents thatwe ought to keep in mind in our attempts to improve them:

1. Documents in circulation are enacted in ways that cannot be known ahead oftime and so the discharge communication process is, therefore, to some extentalways improvised;

2. Complex information and actionable knowledge in the discharge process arenegotiated, exchanged, and mutually formative–not fixed and unidirectional;and

3. We have quite a lot to learn from the enactment of documents and the nego-tiation of actionable knowledge revealed by traces of that enactment.

Improving Patient Discharge Communication:Identifying Challenges, Responding to Constraints

The fundamental challenge for those working to improving patient dischargecommunication (PDC) has been that it is a “wicked” problem (Buchanan, 1992;Conklin, 2005; Wickman, 2014), one that is difficult to define and addressbecause of its inherent complexity. Like with other wicked problems, the dis-charge event’s dynamic interplay of systems, goals, and stakeholders makesclearly defining its parameters and accounting for all possible points of inter-vention extremely challenging. As Wickman (2014) argues building onBuchanan’s doctrine of placements, “rhetorical production in the context ofwicked problems demands a valuative effort to account for the relationshipbetween signs, things, actions, and thoughts” (p. 30). Any approach to solvingsuch problems, therefore, must be flexible and comprehensive as “there is noseparating individual parts from the collective whole” (p. 30). However, this isprecisely what many studies designed to improve PDC have tried to do: isolatevariables in order to measure the relative effectiveness of specific interventionsover others (DeMaria, 2012; DiMatteo, 2004; Showalter, 2011). Indeed, furthercomplicating efforts to find ways of improving discharge communication, thesestudies have used compliance with or adherence to medication instructionsdelivered by PDIs as the metric for effective communication—meaning thatwhen patients do not adhere to a plan of care, the discharge communicationis considered to have been ineffective.


This approach to studying this critical communication event, as I argue else-where (Gouge, 2016), combinedwith biomedicine’s attachment to compliance as aprivileged value and measurement studies as a method of study have led to prob-lematic assumptions about the purpose of PDCand the nature of understanding inthe discharge event. Consequently, though there is currently broad recognition ofthe critical importance of paying attention to access issues and related assumptions(Gutsell &Hulgin, 2013; St Amant, 2015), many studies about PDCbegin with theassumption that the primary purposes of effective PDCare to informandpersuadepatients to adhere to treatment recommendations. The logic of such studiesdesigned to improve PDC presumes that actionable knowledge in PDC eventstravels in one direction: from health-care professionals to patients or their families(Waisman, Siegal, &Chemo2003; Zavala&Shaffer, 2011). This is reflected in bothclinical studies spanning several decades and in the literature circulating abouteffective patient communication, all of which tend to advocate for unidirectionalmodels of communication (Holm, 1993;Makaryus&Friedman, 2005;Marinker&Shaw, 2003; Mullen, 1997). In response to such models of study, “mastery andcontrol” design rationales have emerged that reveal persistent ambivalence aboutthe role of the patient in transitional care communication events. On one hand,many acknowledge the multiple sources of knowledge in health communication,some of which are attributed to patients, and yet the same texts often cite patients’“failing” to follow instructions as responsible for rising health care costs (Avtgis &Polack, 2011).

This is not entirely at odds with the perspective of many in technical com-munication who struggle to find ways to reconcile the recognition that adapt-ability has value in robust design processes with the strong impulse to want to fixcritical information prior to circulation and close it off to modification when thestakes are high, as they often are in health and medicine. Indeed, when it comesto health-care documentation, “quick access to specific information, ease ofcomprehension, and assistance in acting” (Brumberger, 2010, p. 306) are oftenidentified as the most critical foci for redesign. The PDIs in Figures 2 and 3would certainly have benefitted from this attention; however, as Figures 2 and 3also illustrate, in a critically flexible, adaptive system like medicine, it is vital that(in valuing such principles of effective design) we do not design as though know-ledge and documentation are closed objects (Orel, 1995) that can be fixed, onceand for all, prior to their enactment. Because processes, understanding, anddecisions are complex and interpretive and cannot be enacted without the pres-ence of those bodies and people who make them meaningful, the potential con-sequences of designing process documentation as though knowledge is fixed andclosed prior to the document’s enactment can be troublesome, as they were forthe end users, an elderly woman and her caregivers, of documents in Figures 2and 3.

As Spinuzzi (2000) has shown, rigid design approaches can “marginalize, inhi-bit, and discourage certain types of users” (p. 215), and user-centered approaches

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often advocated for can hide this. Tominimize this and tomaximize the usefulnessof documents to end users, Gutsell and Hulgin (2013) have warned that “gooddesign principles and good technical documentation should continue to interro-gate the best ways tomaximize interfaces for asmany users as possible [ . . . ] insteadof certain characteristics seen as problematic, they should be seen as a benchmarkfor ensuring quality and accessible design” (p. 89). Considering these argumentsalong side Popham’s (2005) study ofmedical forms as “boundary documents” thatboth “create and reflect” the complex relationship between health-care profes-sionals and patients (p. 288), we ought to recognize that improvisational traceson generic PDC forms are especially important and worthy of our attention. AsBellowar (2012) has also argued, technical communicators need to do more torecognize the unofficial uses of medical documents because doing so treats thepractices of patients as “tactical and perceptive rather than passive” (325). Asmodifications that emerge in response to limitations of the original compositionof the form, the resulting annotations can be revealing for the ways that they indexthe negotiation of knowledge and attention in the PDC event—both what isincluded and how that is emphasized. Because not every question, concern, orother aspect of PDC events can be fully anticipated, this negotiation is an inevit-able feature of these transitional care communication events. While the design ofPDIs might attempt to define what is negotiable, the marks they bear once incirculation reveal that those interacting with them (both professionals andpatients) persist in negotiating.

Design theory has long explored the ways that people attempt to modifydysfunctional tools and, therefore, the ways that “neglect of usage patternscan transform simple, attractive items into complicated ugly ones” (Norman,2011, p. 124). Whether you find blank PDIs attractive, that a relativelysimple-to-begin-with medical form in use might be transformed into a complexmangle of annotation, emphasis, and modification is important feedback aboutwhat such forms need to be able to do for actual (not imagined or idealized)users and so is worth our attention. As Henze (2013) explains, even with stan-dardized forms “there remains a great demand for invention, judgment, andcreativity in how writers actually use genres. Each situation may call for certaindistinct types of responses, but each response is nevertheless unique” (p. 349).Part of this demand comes from the fact that a single patient discharge instruc-tional document is materially, discursively, and symbolically multiple once inuse. Though most PDIs begin the discharge communication process as standar-dized forms, a blank PDI is merely a starting point, a basis for the conversationthat follows from it. But because the form in use is subject to multiple material,discursive, and symbolic relations, it is always in the process of becoming, con-tinuing to change as the patient, her family members, and caregivers handle it,discuss it, and mark it further.

Indeed, once in use, a single, generic document can be many things: a lifelinefor the person being discharged, a list of expectations to be met or not, an


obligation fulfilled by the care facility, a symbol of progress for a person emer-ging from an extended hospital stay, a source of anxiety, a symbol of a failing orsucceeding health care system, or even the more mundane: yet another piece ofpaper to keep track of. These material, discursive, and symbolic characteristicsof such documents are bound together and the elements that compose them are“intra-active,” a term Barad (2007) uses to recognize that objects are always influx as they are transformed by their relation to other phenomena. Accordingly,no two PDIs in use will share the same material, discursive, or symbolic char-acteristics because they are enacted by different, always-themselves-changingconfigurations of people, technologies, units, institutions, and other intra-active phenomena. This is what Gries (2015), following Mol (2002), is talkingabout when she argues that “a single multiple [text] becomes rhetorical [. . .] itmaterializes in different versions” (p. 43). Though it might make some nervousto think of clinical encounters in health and medicine and their documents asimprovised, it’s important to consider that this may be an inevitable, valuable,and even necessary condition for the process—just as it is, say, for a surgeonwho, though she may have performed a procedure hundreds of times, mustadjust her technique to work with the specific allowances and constraints pre-sented by the idios of each body and other intra-active relata (the material,discursive, symbolic factors formed in relation to a particular moment) sheencounters once the procedure has begun. Acknowledging and accounting forimprovisation in the enactment of PDC is not what makes such events complex;rather, acknowledging and accounting for the enactment of documents allowsthe existing complexity to be made visible.

A thoughtfully designed form that follows from conventional user-centereddesign principles can certainly bring some temporary order to transitional carecommunication documents prior to their enactment; and there are other experi-mental forms for communicating instructional information at discharge–like aproduct called “Identimed” seen in Figure 4, which was designed by a familymember of an elderly woman when the woman and her at-home caregiversneeded to manage the administration of over 20 medications.4 Such a productcertainly does a much better job than the paper forms in Figures 2 and 3 ofidentifying and clarifying medication, dosage, scheduling, and rationale infor-mation for clearly identifiable pills. Identimed, in other words, does a muchbetter job of fixing expert and agreed upon medication information and helpingend users identify what to take and how.

However, because the plastic material the product is made of cannot be writ-ten on or otherwise modified easily, in doing a better job of facilitating certainuses, Identimed forecloses others. The innovation of Identimed, in other words,comes with a trade-off, a physical constraint that makes it difficult for thoseusing it to modify it—making it, perhaps, a useful addition to but not a suitablesubstitute for paper forms. Indeed, because the modifications of and annotationson PDIs can provide important feedback about the expert designs and

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prescriptions for patients, we ought to consider that the practices of modifyingand annotating documents are, like the divergent behaviors of patients (beha-viors often referred to as “noncompliant” or “nonadherent”), not most product-ively understood as behaviors that should be eliminated. Such adaptation ought,rather, to be studied and accounted for in the design process, and health-careprofessionals ought to be better equipped with strategies for interacting withsuch documents. They ought to be equipped not just to deliver critical docu-mentation but to enact it, to improvise, and to negotiate impromptu exchangesand incorporate them into the documentation in ways that will be accessible and

Figure 4. Identimed.


useful to end users—those being discharged and those who will be helping tocare for them at home.

Designing for Adaptation and Improvisation withUniversal Design and Speculative Usability Approaches

As Spinuzzi (2003) has discussed with regard to professional writing contexts, wehave a lot to learn from the “unofficial genres” that emerge from our impromptuinteractions with documents—namely, how people “solve problems and dissem-inate solutions and how their conversations and problem solving are instantiatedin artifacts” (p. 23). To improve the discharge communication process and,perhaps as an effect of that, improve the documents associated with it, weneed to approach the design process in a way that does not foreclose interactionwith documents. We need an approach that is capable of working with theembodied, situated, and distributed nature of knowledge in the PDC event,one that can both recognize and facilitate the improvisation that will alwaysbe a part of the process. We need an approach to PDC and other complexprocedural documents presenting as wicked design problems that is capable ofresponding to unpredictable and, perhaps, messy details—not as something toeliminate but as meaningful contingencies to be studied, taught, and practiced.

“Any viable solution,” Potts (2014) writes, “must push beyond the currentuser-centered design paradigms if we are to architect systems that provide solu-tions” (p. 3). For this reason, those designing patient communication would dowell, as Potts argues is true for technical communicators in general, to approachthe work we do as “experience architects” who understand the rhetorical situ-ations in which we intervene as “participatory ecosystems that must allow forflexibility and responsiveness” (p. 2). Such a formative premise for designingPDC might not only enable such efforts to facilitate impromptu, multidirec-tional exchanges and, therefore, be more effective for patient and health-careprovider understanding, designing to facilitate improvised modifications wouldmake it possible for the process and associated artifacts to reveal emergentsolutions to problems of understanding and outcomes: solutions such as chan-ging a dose or a medication because a patient discloses that they cannot or willnot take it as indicated on the PDIs because it makes them feel bad, because theycannot afford it, or any other reason they might cite. Such solutions are lostwithout some way to thoughtfully account for and incorporate them in thedesign of systems, documents, and interactions. And capturing emergent solu-tions is especially critical in PDC since, in addition to the coordination chal-lenges posed by the increasing complexity of modern medicine, user-centereddesign principles can be limiting for the ways that they are designed to work onlyfor certain representative users.

One way of responding to this complex design challenge in order to “pushbeyond [. . .] current user-centered design paradigms” (Potts, 2014, p. 3) is that

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for which Dolmage (2009) has argued in other contexts combines both user-centered and universal design methods to draw on the best of each: To draw onthe feedback mechanisms of user-centered design that can feed into iterativedesign processes and combine that with the capability of serving a diversity ofusers enabled by universal design approaches. Dolmage and other disabilityscholars have noted the ways in which disability is created and/or exacerbatedby normative, ableist designs that marginalize or ignore some users: “the build-ings we work in, the roads we roll along, the language in the academy, and themediums we write in and through have already been designed for ease of use [ . . .] Disability is created, partially, as a result of the biases and proclivities of‘standard’ or ‘normal’ structures” (Dolmage, 2009, p. 169, emphasis in the ori-ginal). “An impairment only becomes a disability,” Davis (1997) argues, “whenthe ambient society creates environments as barriers” (p. 105).

If this is true and if “audiences that do not interact in ‘normal’ ways arediscounted from consideration,” as Meloncon (2013) has proposed is true ofmuch technical communication (p. 75), consider the very serious implications forthe discharge communication process during which, due to the mental and phys-ical stress of all participants, so many involved in the communication event areimpaired in some way—not just the patients but also their at-home caregiversand perhaps even discharge nurses and attending physicians who might be chal-lenged by intense working conditions, fatigue, or other aspects of the exchanges.Facilitating more effective PDC requires designing PDIs to enable patient-specific annotations, marks generated in response to the affordances and con-straints of documents and systems of care, to the specific needs and capabilitiesof individual patients. Rather than foreclose modification or discount themarkings visible on the PDIs in Figure 3, then, as a physician, dischargenurse, at-home caregiver, or patient failing to interact with the document incircumscribed ways, we ought to recognize the ways that such marks, andindeed any registered divergence from circumscribed procedures, might indexboth the innovations some have discovered for making them more supportive ofspecific needs and goals and the disabling effects of standardized forms andprocesses.

Deriving from the principles of universal design for learning (UDL), Dolmage(2009) recommends what he calls three vectors for improving instructional meth-ods: a focus on “how the teacher instructs,” a focus on “active learning,” and afocus on “multiple options of student design delivery and expression” (p. 181).Though Dolmage was writing explicitly about ideas for learning in the classroomsetting, versions of the vectors he identifies are easily relatable to approaches toimproving the discharge process in a way that recognizes impromptu exchange isa critical component of the complex information to which end users need access:

1. Considering the method of instruction with this in mind would mean recog-nizing the critical importance of impromptu interactional components of the


discharge process and the role of documentation in this—what is recordedand emphasized in the exchange and how.

2. Considering active learning would mean reflecting on the ways that patientsand their caregivers might be invited to respond to the prepared materials inmeaningful ways—via a combination of teach back (talking through theirunderstanding of at-home care instructions and describing what they planto do at home) and, perhaps, adaptations made to care instructions in con-sultation with those present at discharge if a patient, for example, indicatesthat he or she can’t or won’t take a medication as prescribed.

3. Designing multiple options for patients and caregivers to take agreed-uponcare information with them would mean providing end users with the resultsof the discharge communication process in multiple formats or combinationsof formats: aural/written/visual; paper/plastic; and perhaps, digital/analogue.

These versions of Dolmage’s UDL recommendations treat design “as an activeverb, rather than a set structure” (Dolmage, p. 180), a critical component ofcreating more enabling discharge processes capable of recognizing the variabilityof people, contexts, and resources.

Exploring more deeply the value of paying attention to the different goals ofusers and the unintended uses of designed objects, in their recent article in theJournal of Technical Writing and Communication (2015), Rivers and Soderlund(2015) introduce “speculative usability.” Traditional usability studies, they note,tend to test only to what extent users are able to perform prescribed uses ofobjects. Speculative usability, on the other hand, expands usability to “focus asmuch on discovering the multiple relations that an object has as it does onelaborating the specific dysfunctions that a user experiences in his or her encoun-ters with an object” (p. 3). Recognizing the prior work of Spinuzzi (2001, 2008),McGovern (2005), Simmons and Zoetewey (2012) and others, which has openedour attention to a “contextual model of study that requires usability testers torecognize the world around the object of study” (p. 9), Rivers and Soderlund arecareful to emphasize speculative usability’s value as an important add-on tousability studies, one that is even more open-ended and so can account foruses that exceed those imagined by designers.

Though Rivers and Soderlund propose speculative usability’s value as a para-digm for a more symmetrical approach to usability—one that avoids overem-phasizing the relation of objects to humans in order to explore objects’ relationsto other objects and phenomena—I see value in the open-endedness they explorefor usability studies of objects and texts in health and medicine that might retaina slightly more conventional metric: the way an object or text does or does notserve a diversity of end-users’ goals. In spite of the fact that the patient-centeredcare movement has been active for nearly half a century, there is still quite a lotof resistance to and ambivalence toward having open-ended, user-defined goals.This is evident in the way transmission-model metrics (like measuring patient

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compliance to determine whether instructions were delivered effectively) areoveremphasized in the design and evaluation of communication practices.

To adopt a design approach informed by speculative usability to study PDIsin use, then, those paying attention need to let go of the presumption that peopleonly interact with PDIs in order to be informed and persuaded by them. To betruly open to the diversity of ways PDI objects interact with both human andnonhuman entities in the PDC event, in other words, designers must remainopen to both unintended uses and goals and to the traces that index those. Forexample, because PDIs are often the starting point for a conversation aboutcritical at-home care responsibilities—a conversation that can be stressful for allinvolved—and because end users sometimes indicate to discharge nurses theirinability or lack of intention to follow specific guidelines or take specific medi-cations, excessive annotations on PDIs like those seen in Figures 2 and 3 canillustrate that efforts to understand in order to follow prescribed medicationsand behaviors postdischarge are only part of the story. That is, they are onlypart of how PDIs are being deployed for end users’ goals. PDIs following from aspeculative usability approach might, therefore, be designed to recognize anyexcessive functionality. They might be designed, in other words, such that theyare capable of recording the modification made to the documents about what todo and how in the transition to at-home care.

An approach that couples speculative usability principles with the universaldesign goals of designing objects to work for a wider range of users not justidealized “normal” users working in idealized conditions could lead to a com-munication design and feedback processes that consider versions of the ques-tions Rivers and Soderlund (2015) propose for speculative usability (p. 3):

1. How can we design a document that enables multiple users in a variety ofconditions to work productively with this object?

2. Is the design of this document flexible enough to account for multiple users’specific reasons for interacting with it?

A technical communication specialist using these questions to design betterPDIs would need to study the enactment of multiple documents with the goal ofconducting “non-normative evaluations of objects” (Rivers & Soderlund, 2015,p. 3); however, answers to these questions, as both Dolmage and Rivers andSoderlund emphasize in their respective articles, are not meant to substitute forfollowing visual design principles like those I mention earlier in my analysis ofPDIs in use nor to question the value of usability studies. Rather, they are meantto enhance existing usability approaches. The goals of such an approachinformed by universal and speculative design adaptations would be to “measurethe distance between an object’s use and acceptable levels of efficiency” (p. 3) forend users (rather than for institutions). They would have the additional goals ofconsidering multiple users rather than just “representative” ones (Dolmage), of


being “vulnerable to unique effects” (Rivers & Soderlund, 2015, p. 3) and expres-sions of such enacted documents for multiple users, and of enabling “anincreased inventional capacity for usability testing” (p. 3).

Conclusion

Because process documents, like PDIs, are called upon to work with theexchange of complex information that often exceeds the original content andthe original instructional intention of the design, what counts as complete andcorrect information in the patient discharge process will always be contingent.Consequently, it is important that those studying such transitional care commu-nication practices take seriously that the complex information documents mustmake accessible—information about managing critical and life-sustaining detailsabout medication and at-home care—often exceeds that which can be antici-pated by attending physicians. Though the knowledge that end users tend to dothings with designed objects in unforeseen ways is not new, design thinking hasstruggled to find a way to incorporate this awareness into design processes.Design historian, Victor Margolin (1988), argued several decades ago thatdesign thinking needs to change to recognize that designers cannot “foresee allthe ways that complex products will be used and must think in terms of multiplepossibilities rather than a limited set of functions” (p. 60). Following from this,Orel (1995) argues that end user responses to self-care products productivelychallenge designers to design for the “experimental user, who may modify thepurpose of use as well as the instructions for use” (p. 88). Similarly, we mustrecognize that designed documents are often responded to as if they were openby end users if we want to design more useful and accessible documents. Weneed to consider that a document capable of facilitating at-home care for endusers must be designed to work with that which exceeds prescribed and prede-termined plans, plans that cannot possibly anticipate all of the contingentvariables.

Adopting a design approach informed by speculative and universal designapproaches means letting go of hyperstandardization as an abstract ideal andaccepting that complex information for end users includes the adaptations theymust manage, like those required to pay for treatment and those required toschedule medications, meals, and necessary activity around care support andother resources. Keeping in mind that the purpose of PDC events is to shapeknowledge as well as share it, such approaches can help us pay greater attentionto the fact that effective PDC is always going to be contingent on local systemsof care. Such approaches can help us more productively treat PDC and itsattendant documentation as more than a health literacy issue for patients, anissue for which a focus on clearer explanations of and patient education aboutfixed knowledge as has been the answer for the last several decades (Bailey et al.,2015; Borgsteede, Karapinar-Carkit, Hoffman, Koer, & van den Bemt, 2011). If

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we hold fast to “strong-text” (Brandt, 2011, p. 104) ideas of literacy and resisttreating PDIs as open objects, subject to change and modification, the processwill be less efficient and effective as all parties involved are forced to work toovercome documentation as a barrier to self-care.

Though I have argued for the usefulness of a speculative design approachinformed by universal design adaptations to usability as ways of accounting forand responding to this excessive functionality, whatever approach we choose tofollow to address this challenge, we need to consider approaches that can recognizeand work with the improvisational aspects of transitional care communicationevents. Those with a role in designing discharge communication processes andother processes during which critical information is contemplated and generatedneed to consider more than the goal of designing documentation that is fixed,complete, and correct in advance. Designing accessible, enabling documentationmeans designingflexible, adaptive documentation, and soweneed to treat thePDCevent and its attendant documentation as an information coordination issue thatrequires attention to theways that documentsmust be designed to balance the needfor consistency and routine with support for the necessary improvisationalexchanges that are inevitably a critical part of the patient discharge process.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,

authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publica-tion of this article.

Notes

1. According to the Medicare.gov (n.d.) page for this: “Excess readmissions are measuredby a ratio, by dividing a hospital’s number of ‘predicted’ 30-day readmissions for heartattack, heart failure, and pneumonia by the number that would be ‘expected,’ based on

an average hospital with similar patients. A ratio greater than 1 indicates excessreadmissions” (http://www.medicare.gov/hospitalcompare/readmission-reduction-program.aspx).

2. Norman identifies three kinds of constraints in the Psychology of Everyday Things:

physical, logical, and cultural (1988). Physical constraints, according to Norman, aredefined by the possible uses of an object—very similar to what he calls real affordances.It is those constraints to which I refer here.

3. For this study, I received express written consent from the subject (who is a familymember) to use these discharge instructional documents for presentation and publi-cation purposes.

4. According to Identimed’s creator, though the product was being sold via Amazon fora period of time, it is no longer available for sale.


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Author Biography

Catherine C. Gouge is associate professor in the Department of English at WestVirginia University. Her recent scholarship has appeared in the Journal ofMedical Humanities and Rhetoric Society Quarterly.

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http://www.bu.edu/fammed/projectred/index.html

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