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PROBLEM BASED LEARNING: DEVELOPING
COMPETENCY IN KNOWLEDGE INTEGRATION IN
Different communities, organizations, and people hold different views on their own and
others wellbeing. It is often challenging to balance different perspectives during the design
process when the truth of medicine is competing with the truth of social media and the
everyday experience of wellbeing of patients, caregivers, family and friends. In the context of
the Masters of Health Design at OCAD University, we develop students’ competency in
working with truth through challenging students to engage with multiple ‘truths’ in the design
process, engaging deliberately in identifying and working with multiple truth regimes as part
of a problem based learning approach. This includes how truth regimes impact the
understanding of a challenge area, techniques for engaging with stakeholders, communicating
and developing concepts, and the process of seeking and working with feedback for refining
and iterating, and finally in communicating project solutions. By engaging in problem based
learning, students are exposed to the real challenges of different stakeholder perspectives and
in particular how different truth regimes serve to impact what counts as legitimate knowledge
and legitimate knowledge representation.
Keywords: Health Design, Knowledge, Process, Problem Based Learning, Stakeholder Engagement
The need to develop competency among Design for Health masters’ students in working with
different kinds of ‘truth’, arises out of a recognition that design in the health context, requires
negotiating and integrating knowledge from truth regimes that are very different from
knowledge that arises through the process of design practice. While design practitioners may
enjoy legitimacy in other domains, this is often not the case in medical or health related
settings where knowledge arising from the practice of design may be unfamiliar as well as in
competition or opposition to established truth regimes of the evidence base of bio-medicine,
humanistic medicine, or the patient experience1.
In the health sector, it could be said that there are several styles of truth regime commonly in
operation that a designer working in the health domain would need to integrate. At first
glance, the scientific truth of medicine would seem likely to dominate. This is the first
challenge for students. In the first stages of understanding a challenge area, recognition and
interpretation of scientific sources of knowledge may be unfamiliar to the design process for
many students and may need to be supported through technique development in seeking and
synthesizing medically related evidence for design. However, the role of the ‘doctor’ or
physician can be a particular and dominant one, and signals that the role of clinicians in a
design related project may involve negotiation by the designer in, or with, a truth regime that
is not based on evidence but on a humanistic approach. In the course of the M. Des in Design
for Health at OCAD U, we support students to develop competencies in integrating
knowledge from different truth regimes as part of their learning process, recognizing also that
design for health students themselves operate within their own truth regime, one that may
privilege designer, process, prototype and designed object. With this paper, the intent is not to
revisit conversations on design and science, discipline and practice2, but to share the
experience of a developing framework that prompts further thought on these topics in the
context of design for health.
A truth regime can be described as a “general politics of truth”, to quote Weir3, comprising of:
ways in which truth is identified and represented; techniques that indicate true or false
statements; techniques for how statements are evaluated/or not as truthful; and the status
accorded to those that speak ‘truth’.
The concept of the truth regime was discussed by Foucault in 1960s and 70s alongside ideas
about knowledge and power, and in particular in reference to scientific and quasi-scientific
truth in modernity4. Analyses of the concept of the truth regime and the implications of this
idea are scarce, however, a few examples of its use to interpret biomedicine and the
experience of health and wellbeing do exist5,6. The ideas described in this paper, for instance,
are drawn from the work of Lorna Weir3.Weir provides an interpretation of Foucault that
highlights different types of truth regimes in addition to scientific and quasi-scientific truth –
these form the basis of the framework proposed. Developing this work for relevancy to the
health context and to design practice, the framework also draws on the work of Sam Ladner7
who uses Weir’s work to advocate for the use of the truth regime concept in the practice of
ethnography in the private sector. Both Weir and Ladner emphasize several types of truth
regime that identify, represent, and present truth in different ways. In summary as:
•)Veridical truth – scientific truth based on the constant search both for error and new data
•)Governmental truth – principally concerned with governing behavior and quasi-scientific
•)Symbolic truth – represents truth through ritual and role, rending invisible truth visible
•)Mundane truth- truth that arises from everyday experience, common sense or common
While these truth regimes may be operating in any domain they are present in prominent ways
in the health sector. In this paper, a framework for understanding and working with these
different kinds of truth will be shared - including how it has been applied to knowledge
integration in the design for a geriatric psychology unit during a problem based learning
engagement for Design for Health master’s students.
Students of health design are supported in their exploration and mastery of knowledge
integration in design for health contexts through problem based learning supported by the
progressive development of design technique and critical thinking skills. Problem based
learning The curriculum of the MDes in Design for Health at OCAD U is organized into a
series of four problem based learning engagements, which are developed and carried out in
partnership health sector partners. Projects are supported through embedded activities with
health sector partners as well as studio based learning. The first two problem based learning
engagements are supported by seminar based learning and it’s in the context of these
supporting seminars that key concepts from medical anthropology are introduced, the social
science and critical sociology of biomedicine, and the concept of the truth regime.
The program itself includes students and faculty from many different design backgrounds
including architecture, interior and environmental design, graphic and communication design,
interaction design, engineering and product design, as well as students who are engaged in
patient advocacy, patient experience, and healthcare process and quality improvement. The
students themselves are challenged with teamwork that necessarily involves understanding
different design approaches and traditions. The supporting seminar structure provides an
opportunity to explore and discuss the development and role of different design approaches
and traditions, from the more veridical or scientific approaches of engineering, user centered
design and usability, to the critical design and conceptual design approaches that are perhaps
more symbolic, and the inclusion of co-design and participatory design techniques that that
may support the mundane or everyday truth of participants. Students, at the same time
respond to the problem based learning engagement, choosing what design approach to take,
how to organize their involvement with stakeholders, and how and what to research and
prioritize in the design process.
In the case of the geriatric psychology unit, the students were presented with a problem based
learning engagement with a local rehabilitation center. The stakeholders presented the
students with the purpose of the engagement – to develop a redesign of the unit within the
constraints of its existing footprint and with special consideration for the particular needs of
the patient population that it serves. The type of design work or area of focus was left open
with the expectation that any design discipline would be relevant. One of the first steps for
students was to try to understand what the unit’s purpose is, and what types of patients the
unit serves. With this first step in a project, students are engaging with different truth regimes.
How is the patient population defined? In medical terms? Or, in terms understood by nurses
and clinicians on the unit, by family and friends, or the long-term care homes where many of
the patients arrive from? Are they “Dr …’s” patients? Or are they defined by their behavior –
which places them in the unit as a result of governmental forms of truth about their
suitability/or not for a long-term care place? Students are challenged to explore the possibility
that different truths about the unit and its patients, as well as its staff, family and friends, may
be at play. In this way students learn from the challenge of negotiating different truths and
the viability of different outcomes in terms of design solution – a key aspect of problem based
learning8. It may be appropriate to decide to take a participatory approach in such a situation,
as participatory techniques are intended to support multiple stakeholders and the politics of
different positions9, but similarly, an evidenced based approach in which students interrogate
the evidence base for data on dementia, behavior, and designed elements such as lighting,
artwork, flooring, furniture and activities, may also be appropriate – in considering these
decisions as part of the learning process, students are asked to develop a rationale for their
choices that demonstrate an awareness of different truth regimes, indeed a rationale and plan
that makes use of different truth regimes in integrating knowledge to inform design.
2 TRUTH REGIMES IN HEALTH
Layering onto the choice of the design approach in responding to a problem based learning
engagement, its useful for students to understand how truth regimes operate in the health
context – for instance with the physician or clinician there may be ritual, codified roles, and
the storytelling (humanistic medicine) that reinforces certain beliefs and structures that can be
in conflict with bio-medicine or scientific evidenced based approaches10. Contrast this with
the everyday truth of the patient – their experience of their wellbeing informing their beliefs
and understanding of their situation and needs.
Setting aside governmental knowledge for now, Figure 1, illustrates three types of truth –
mundane (here characterized as “life”) symbolic, and scientific with reference to the concept
of wellbeing. In this brief exploration of the concept of wellbeing we see several aspects of
what Foucault describes as the “truth game”4, namely different roles or figures that are able to
“speak the truth”, and specific reference points for each type of truth – for example the
evidence or procedure of scientific truth. When we consider this representation, it illustrates
how certain types of truth regime may be in conflict with each other and how some may be
more open to change than others.
Figure 1. Three Truth Regimes in Relation to Wellbeing
In scientific truth, there is always the possibility for new evidence, new data or ways of
measuring that allow for a change in direction. In relation to the dementia patients in the
geriatric psychology unit, there is new science on dementia every day. In terms of a design
approach working with scientific truth, students are encouraged to develop skills in working
with the evidence base, interpreting scientific data, and synthesizing evidence. Part of this
process of building competency also includes a critical understanding of the development of
evidence based medicine and the way in which evidence based approaches are used in the
health sector to organize innovation and change. Models of healthcare intervention design are
compared to design approaches to identify opportunities and challenges for integration. In the
case of the geriatric psychology unit re-design, students developed evidenced based scoping
reviews that demonstrated to their stakeholders that they respect and understand the scientific
truth relevant to the unit. They then presented design concept scans that demonstrated how
such scientific truth can be reflected in design choices and outcomes.
The staff on the unit experience new patients on a regular basis, and patterns of behavior may
emerge through everyday experience of the work of the unit. The staff may share a collective
mundane truth about how the unit works, the type of patients on the unit, and how certain
designed objects or spaces serve to support or not the work of the unit. A common response
from staff would be “We know the bathroom needs redesigning” based on the everyday
experience of the difficulties persuading patients on the unit to accept intimate care (a term
that comes from the governmental truth regime operating in the health sector and a criterion
for deciding if a patient remains eligible for home or long-term care). However, further
probing and exploration of intimate care of older adults in care settings as well as some basic
design ethnography revealed that the ‘problem of the bathroom’ starts well before the
bathroom is experienced. This allowed a reframing of the problem away from the bathroom
itself to the experience of pre-bathing – undressing and preparing for bathing. As mundane
knowledge is open to change through everyday experience, students were encouraged to use a
mundane and everyday story telling technique to communicate this reframing to stakeholders.
In this way, the mundane truth of staff is respected, acknowledged and built on by students.
In the case of the geriatric psychology unit there is a barrier to interact with patients due to the
advanced level of cognitive decline, however, in many other problem based learning
engagements, working with patients, family and caregivers would be expected. The practice
of experience based co-design is a common approach now advocated in the health sector to
specifically address the inclusion of patient experience11. While there has been little attention
paid to forms of mundane knowledge generally, the domain of health is the exception.
Sociology and anthropology of health does seek to understand the relationship between
biomedicine and lay knowledge/experience. Experienced based co-design has emerged as a
counterpoint to evidence based approaches, with its emphasis on patient narratives, emotional
touchpoints, and video based story telling. In the same way as students compare design
approaches to evidenced based approaches, students are encouraged to compare and critique
experience based co-design, and decide whether or not the techniques central to experienced
based co-design will support the integration of mundane truth. One of the challenges for
students in this regard is the number of other design based techniques that come from design
approaches that also serve to represent mundane truth – personas and scenarios, for instance.
Symbolic truth manifests truths that are thought to exist but are not visible, and this
manifestation is often conducted in particular ways that often include ritual and storytelling.
Authorized speakers of symbolic truth are usually power holders, for example, the nurse
practice leader, the surgeon, or representative of a clinical specialty, or, can be counterweights
to those in power or those in dominant positions, for example, patient advocates,
representatives with lived experience, or campaigners for health care access and equity.
Organizations may also be ‘keepers’ of symbolic truth. The Mayo Clinic may hold symbolic
truth about practice change, for instance. Symbolic truth will be familiar to designers,
Jonathan Ive (Chief Design Officer, Apple Inc.) speaks the truth on design for Apple, for
example. The ritual of the studio ‘crit’ or critique in which the faculty speaks the truth about
whether a student’s work is ‘great design’ or not, is another example. It is interesting to
consider what truth regime may operate in design school – who decides what a great design
is? Is great design only visible when it is declared as such, if so, then declaring something a
great design is a symbolic gesture, and a claim that only certain individuals have the
legitimacy to be able to make. A design may be declared incoherent in that same way that
quasi-religious or symbolic truth regimes declare an opposing truth as ‘incoherent’4.
In the case of the geriatric psychology unit, and indeed across the long-term care and
retirement care sector, there is symbolic truth in the idea of “home” and its importance to
supporting the care of the elderly in contexts that are not “home”12. Indeed, stakeholders will
routinely state “this is their [patients] home.”, even though the average stay is 3-6 weeks, or in
dialogue on the kind of qualities that are important to consider in the re-design of the unit,
state that “it needs to look like a home”. Typically, those who make these statements do so in
public venues, in front of others, and speak from a position of authority over the unit, its staff,
and the design project. In considering the re-design of the unit, scientific truth together with
mundane truth, and the integration of knowledge from these through design, suggests a re-
design that does not replicate home. Students are then challenged with how to address the
symbolic truth of the idea of “home” and to communicate proposals that avoid being
interpreted as “incoherent”. Recognizing that symbolic truth is operating in a given context
can be a powerful idea in and of itself.
3 BUILDING COMPETENCY IN KNOWLEDGE INTEGRATION
Using a truth framework to support students’ understanding of problem based learning
engagements also supports the development of knowledge integration skills. In Table 1
below, which shows a blank framework, each type of truth regime is identified, along with
questions that form a “truth game” referred to by Foucault. Introducing this framework to
students in their first semester, the framework is used to support higher-level thinking about
the concept of health, wellbeing, and biomedicine. With an initial exposure to social science
and medical anthropology perspectives on health and wellbeing, humanistic medicine, and
biomedicine, students are ready to work on problem based learning engagements. Working
with the framework includes several activities: the framework provides a structure to seek out
new knowledge across truth regimes; the framework encourages reflection on the diversity of
stakeholder perspectives; the framework provides a reminder to students to actively integrate
knowledge across all truth regimes.
Who speaks the
Truth vs. Non-
represented by …
In addition, the framework prompts questions about the role of design, how truth regimes
operate in design and design teams, and how truth operates in the process of design. Truth
regimes engage in what Lorna Weir refers to as “signifying practices”4 – the representation of
truth as a second stage whereby truth is translated via speech, writing, and visual arts. In the
case of design, the prototype or model as a form of truth representation. The framework
implies that truth regimes share and represent knowledge in different ways and can be used in
concert with health sector models of knowledge integration familiar in public health13. For
instance, among carers for older adults with dementia, knowledge may not reside in the
evidence base, but it may be shared in sites for story telling such as online forums, and
community centers. Recognizing where and how knowledge is represented and shared
supports students in their planning and execution of design research activities.
The role of the designer is also brought into question by the framework – posing questions
about the role of the designer in integrating knowledge across truth regimes, the position of
the designer vis a vis the making judgements of value of certain types of truth over others. For
instance, does the nurse’s mundane knowledge of the everyday running of the unit take
precedence over the evidence base on flooring choices for dementia? What responsibility does
the designer have to different truth regimes and how can the design team integrate different
truths in a timely and practical manner?
The experience of developing and implementing the truth framework, to support knowledge
integration in problem based learning in health design, has been an additive experience for faculty and
students. Engaging intellectually with the idea of “truth” and then translating this to the practicalities
of design engagements with stakeholders, serves as a real test of the idea. It also serves to highlight
conceptual overlaps between design approach and truth regime which is proving useful in iterating on
design techniques and on hybrid approaches to design in health that integrate across truth regimes.
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