Homes In Norway Research Articles

Nursing home leaders' perception of factors influencing the reporting of elder abuse and neglect: a qualitative study

PurposeThe purpose of this study is to explore the factors that influence the reporting of adverse events related to elder abuse and neglect in nursing homes from nursing home leaders' perspectives. Good leadership requires in-depth knowledge of the care and service provided and the ability to identify and address problems that can arise in clinical practice.Design/methodology/approachA qualitative explorative design with data triangulation was used. The sample consisted of 43 participants from two levels of nursing home leadership, representing six municipalities and 21 nursing homes in Norway. Focus group interviews were undertaken with 28 ward leaders and individual interviews with 15 nursing home directors. The constant comparative method was used for the analyses.FindingsBoth ward leaders and nursing home directors described formal and informal ways of obtaining information related to elder abuse and neglect. There were differences between their perceptions of the feasibility of obtaining formal reports about abuse in the nursing home. Three main categories of influencing factors emerged: (1) organisation structural factors, (2) cultural factors and (3) abuse severity factors. A main finding is that in its present form, the Norwegian adverse event reporting system is not designed to detect abuse and neglect.Originality/valueThis paper provides an in-depth understanding of patient safety and factors related to reporting elder abuse in nursing homes in Norway.

Place of death among older people in Finland and Norway.

Aims: This study aimed to find out how place of death varied between countries with different health and social service systems. This was done by investigating typical groups (concerning age, sex and end-of-life trajectory) of older people dying in different places in Finland and Norway. Methods: The data were derived from national registers. All those who died in Finland or Norway at the age of ⩾70 years in 2011 were included. Place of death was analysed by age, sex, end-of-life trajectory and degree of urbanisation of the municipality of residence. Two-proportion z-tests were performed to test the differences between the countries. Multinomial logistic regression analyses were performed separately for both countries to find the factors associated with place of death. Results: The data consisted of 68,433 individuals. Deaths occurred most commonly in health centres in Finland and in nursing homes in Norway. Deaths in hospital were more common in Norway than they were in Finland. In both countries, deaths in hospital were more common among younger people and men. Deaths in nursing homes were commonest among frail older people, while most of those who had a terminal illness died in health centres in Finland and in nursing homes in Norway. Conclusions: Both Finland and Norway have a relatively low share of hospital deaths among older people. Both countries have developed alternatives to end-of-life care in hospital, allowing for spending the last days or weeks of life closer to home. In Finland, health centres play a key role in end-of-life care, while in Norway nursing homes serve this role.

Between Privileged and Oppressed? Immigrant Labor Trajectories in Norwegian Long-Term Care

An increase in older people coupled with growing life expectancy has created a higher demand for long-term care (LTC) services in the global North. Recruitment of staff with an immigrant background has been a solution to meet this demographic challenge. Research shows that linguistic barriers and cultural differences can influence immigrant carers’ abilities to offer adequate care, while less is known about workplace training and intra-collegial support. This article explores systems and practices of training offered to new employees with immigrant backgrounds, and how the qualification process unfolds in daily work in nursing homes in Norway through an intersectional perspective focusing on the interlocking of gender, class and migrancy. The article shows that organizational conditions together with incomplete training combined with attitudes of ‘willful ignorance’ maintain privilege and oppression in these workplaces. The increased immigrant participation and their labor trajectories indicate the emergence of a new immigrant niche in the lower tiers of the LTC sector. The article contributes to the literature of migration, gender, healthcare services and labor by exploring immigrants’ situated labor experiences within changing institutional conditions in LTC.

Singing as a health-promoting activity in elderly care: a qualitative, longitudinal study in Norway.

BackgroundThe current standards of care of the older person recommend employing non-pharmacological approaches to challenges, including safe approaches to managing pain and stress, enhancing symptom relief, and fostering independent lifestyles with the highest quality of life possible. More research is needed to enable nurses and other medical staff to use singing and music-based interventions, to access singing-based programmes, and promote a greater use of choirs in nursing homes. A solid basis of positive experiences and feedback through evidence in practice is required to help promote support for such activities.AimsTo identify, explore and describe experiences, attitudes, beliefs, issues, processes and changes among nurses, carers and leaders in reference to implementation of the educational programme ‘Singing Nursing Homes’, Norway. To increase knowledge and understanding of how an educational song programme could become an integral part of nursing practice and quality of care in nursing and care homes, and identify why this would be constructive. Since its inception in 2015, ‘Singing Norway’ wanted to offer a professional, evidence-based programme for nursing homes throughout the country.MethodsA longitudinal, qualitative and explorative approach. In-depth interviews and focus group interviews of female employees (n = 19) from three nursing homes in Norway, 2018.ResultsNursing home employees perceived singing to have potential benefits for their patients, such as reducing uneasiness, increased comfort, well-being and joy, improved sleep, and believed singing had the potential to reduce the need for medication and prevent accidents among their patients. By facilitating opportunities for learning and practice, staff in nursing homes were able to use singing as part of their ‘art of caring’, enhancing environmental care for the older person. Singing was found to have positive effects for the patients, their relatives and the staff, which improved the psychosocial working climate overall.ConclusionsSinging interventions could be a vital component for the enhancement of health, well-being and quality of life for the patients and staff in nursing homes.

Development and analysis of hourly DHW heat use profiles in nursing homes in Norway

Representative profiles for domestic hot water (DHW) heat use are the main instruments for improvement in operation and design of DHW systems in buildings. To improve the existing method for DHW heat use profiles development and analysis, investigations in the three nursing homes in Norway were conducted. Statistical methods to assess the similarities of the profiles by days of the week and seasons were proposed. The analysis allowed us to identify two seasons of DHW heat use: the warm season from June to October, and the cold season including the rest of the year. In addition, it was investigated that the DHW heat use in the working days was significantly different from the weekends. According to these results, unified profiles for the months and days of the week with similar characteristics of the DHW heat use were developed. After, the method for statistical grouping of the DHW hourly heat use was applied to recognize the timing of the peak, average, and low heat use. Finally, the profiles for the DHW heat use obtained for the nursing homes were compared with profiles in the national and international standards. The drawbacks of the standards were identified.

Perspectives on activities in nursing homes

Abstract Introduction: Access to meaningful activities is an indicator of quality of nursing homes, and contributes to wellbeing and dignity. Lack of activities can lead to boredom, apathy, disruptive behaviour or lack of confidence or meaning. Recent inspections undertaken by the authorities in nursing homes in Norway show lack of activity provision, which is in line with research. This indicates that the government’s policy and new regulations to increase the level of activities in nursing homes has not succeeded, probably related to challenges in developing care practices. However, nursing homes should strive to incorporate meaningful activities for residents to occupy their time and provide a sense of purpose. Few studies have discussed the meaning of activities as well as the challenges in developing a practice focused on activities. Therefore, we want to point out some important perspectives which policy makers, researchers and practitioners can reflect on. Aims: A scoping study was undertaken to discuss what constitutes meaningful activities as well as the opportunities to develop a person-centred practice focused on activities. Conclusions and implications for practice development: The understanding of activities in a residential nursing home setting needs to be reconsidered, broadened and further developed. For example, what most people might recognize to be passive activity, may be interpreted by nursing home residents as an activity. Activities must be person-centred recognising and accepting individuals wishes. The goal is to transform practice cultures to enable person-centred ways of working.

Modeling Indoor Relative Humidity and Wood Moisture Content as a Proxy for Wooden Home Fire Risk.

Severe wooden home conflagrations have previously been linked to the combination of very dry indoor climate in inhabited buildings during winter time, resulting in rapid fire development and strong winds spreading the fire to neighboring structures. Knowledge about how ambient conditions increase the fire risk associated with dry indoor conditions is, however, lacking. In the present work, the moisture content of indoor wooden home wall panels was modeled based on ambient temperature and relative humidity recorded at meteorological stations as the climatic boundary conditions. The model comprises an air change rate based on ambient and indoor (22 °C) temperatures, indoor moisture sources and wood panel moisture sorption processes; it was tested on four selected homes in Norway during the winter of 2015/2016. The results were compared to values recorded by indoor relative humidity sensors in the homes, which ranged from naturally ventilated early 1900s homes to a modern home with balanced ventilation. The modeled indoor relative humidity levels during cold weather agreed well with recorded values to within 3% relative humidity (RH) root mean square deviation, and thus provided reliable information about expected wood panel moisture content. This information was used to assess historic single home fire risk represented by an estimated time to flashover during the studied period. Based on the modelling, it can be concluded that three days in Haugesund, Norway, in January 2016 were associated with very high conflagration risk due to dry indoor wooden materials and strong winds. In the future, the presented methodology may possibly be based on weather forecasts to predict increased conflagration risk a few days ahead. This could then enable proactive emergency responses for improved fire disaster risk management.

Death and liminality: An ethnographic study of nursing home staff’s experiences in an encounter with the dead body

This paper investigates nursing home staff’s experiences of the “final journey,” when a resident’s dead body is taken to the cold room. The account is based on data from ethnographic fieldwork in two nursing homes in Norway. Accompanying the dead body, staff found themselves “betwixt and between” – an anxious and ambiguous state, bordering on the uncanny. Liminality became a useful theoretical device in the data interpretation. The last offices – a rite of passage governing liminal states – provided a containing structure for this final journey but were not sufficient to banish the uncanny from the staff’s experience.

Staff perceptions of competence in a multicultural nursing home in Norway

Nursing homes throughout the Western world are seeing a steady increase in migrant workers. Although migrant staff members' multicultural background may be perceived and used by management as a resource in the workplace, studies indicate that the qualifications and competencies of these workers are often underestimated. Numerous studies have examined and theorized on the challenges related to workplace diversity and the deskilling of migrant workers. However, our knowledge of how competence may be conceptualized in inclusive ways in diverse staff groups remains scarce. This study examines minority and majority staff members' perceptions of competence in a strategically selected multicultural nursing home unit in Norway with 15–20 years of experience in recruiting and including minority staff members to various levels of the organization. We performed a thematic analysis of in-depth interviews with 22 healthcare providers and found that in this nursing home unit, contrary to what has often been found in other organizations, competence was not primarily discussed as a matter of educational level or background, skin complexion or whether staff members spoke the majority language with a foreign accent. Rather, a competent care worker was perceived as a) having good professional knowledge on how to care for nursing home residents (regardless of the worker's educational level), b) either having the ability to speak well or working hard to improve one's skills in the majority language, c) exhibiting ‘a genuine interest’ in working in a nursing home despite the relatively harsh working conditions, and d) having the ability to prioritize to ensure that all tasks and duties were completed on each shift. Staff members' perceptions of competence were hence interrelated with educational, racial, linguistic and social dimensions, but in unexpected and transgressing ways, paving the way to ethnic equality among staff.

The inferior position of the Sámi language in a bilingual nursing home in Norway

ABSTRACTThis is an article on the relation between the market for Sámi language in a contemporary bilingual Norwegian nursing home and the Norwegian history of the Sámi language. Bilingual nursing homes are supposed to invest in the Sámi language and thus increase its value. It was, however, difficult to identify investments in the Sámi language in the institution although nearly 50% of the residents were registered as Sámis by the head of the nursing home. The inferior position of the Sámi language seems to have become an unarticulated, unconscious, embodied part of the language practices in the nursing home, as if discrimination accumulates across spheres and generations. The study is based on Bourdieu’s theory on the symbolic power of language, on praxeological methodology and interviews with nursing staff.

Forskrivning av antipsykotika til hjemmeboende eldre 2006–18

It is generally agreed that prescribing of antipsychotic drugs to older patients should be reduced, but figures for the prescribing of these drugs to older patients living at home in Norway are not available. The study aimed to investigate developments in prescribing of antipsychotic drugs among older patients living at home from 2006 to 2018, and whether there were differences in prescribing rates between the age groups 65-74 years, 75-84 years and 85 years or older. Data were retrieved from the Norwegian Prescription Database. All persons aged 65 years or older who were dispensed at least one antipsychotic drug in 2006, 2010, 2014 and 2018 were included, and gender-specific prevalence for the ten most widely used antipsychotic drugs was calculated. The proportion of patients aged 65 or older who were prescribed antipsychotic drugs in the period decreased for both sexes. For the age group 65-74 years, an increase was found from 2014 to 2018. There was a clear decrease in the prescribing rate for prochlorperazine and levomepromazine, whereas prescriptions for quetiapine increased. Attention should be paid to the increase in prescribing of antipsychotic drugs for the youngest age group of older patients (65-74 years) in the last four years, along with the increase in prescribing of quetiapine for older patients.

Using Action Research as the Basis for Transforming a Workplace Culture so that Integration of Overseas Registered Nurses to the Nursing Home Clinical Setting be more Adaptive, Inclusive and Mutually Supportive

Research question: How to integrate overseas registered nurses into the clinical setting of a nursing home in Norway? Research problem: Newly arrived overseas registered nurses experience difficulties adjusting to the clinical setting in one of the institutions for old people in Norway. Purpose: The purpose of the study shall be to develop a basic knowledge that will stimulate and improve competence in multicultural nursing in the clinical area. It will help develop research studies in nursing education and practice in relation to working conditions in a multi-cultural teamwork. Theory: Multicultural nursing is a part of nursing that appreciates and accepts person/s` culture, not in the sense of approving all aspects of those cultures, but learning and understanding how a given culture can express care values, illness, health and behavior of its own members [1].Method: Qualitative research with a hermeneutical perspective is used. Action research [2] is the chosen method for this research due to its collaborative, reflective and evolutionary process of bringing about change. To ensure the effectiveness and trustworthiness of the study, focus group discussions and critical reflections are used. The data analysis is done through the hermeneutical approach according to level of interpretation. Ethical considerations: Respondents received information about the research and other related matters in which the respondents are to participate. Ethical principles about confidentiality, anonymity and voluntary consent strictly observed. Permission granted from the head of the county where the nursing home is located. Results: Results reveal that diversity issues such as in communication, different educational background, attitudes, values and cultural expectations, power dynamics and social avoidance and rejection are the underlying challenges of overseas registered nurses in adjusting to the Norwegian clinical setting. Implications: Findings imply that the institution needs to provide a working climate that will promote professional and social integration to both the Norwegian registered nurses and overseas registered nurses.

Why energy retrofitting in private dwellings is difficult in Norway: Coordinating the framing practices of government, craftspeople and homeowners

Retrofitting private homes to meet strict energy demands is a prioritised goal in climate mitigation policy. In this article we approach the challenge by analysing how retrofitting is framed differently by the government, homeowners and craftspeople acting as energy consultants. We follow a programme designed to support substantial retrofitting of homes in Norway from its introduction in 2012 through 2016, documenting how the programme was developed and modified to make it attractive for homeowners, and how it somehow never succeeded in becoming attractive. We suggest framing analysis in order to highlight the challenges government actors face in aligning their policy to homeowners and intermediaries. We find that the governmental framing of energy retrofitting is characterized by a particular distance between a handful of bureaucrats and 2.2 million private homes to be governed; we call this a ‘distance in scale’. Three distinct ‘bridging’ activities are set up to handle this distance. We suggest that difficulties in aligning with the framings of homeowners and intermediaries relates to the dynamic between these bridges. We point out how it is necessary to consider and coordinate the various framings of all stakeholders when implementing energy policy.

Facilitation of a workplace learning intervention in a fluctuating context: an ethnographic, participatory research project in a nursing home in Norway

Facilitation of a workplace learning intervention in a fluctuating context: an ethnographic, participatory research project in a nursing home in Norway

Small-scale implementation with pragmatic process evaluation: a model developed in primary health care

BackgroundResearch often fails to impose substantial shifts in clinical practice. Evidence-based health care requires implementation of documented interventions, with implementation research as a science-informed strategy to identify core experiences from the process and share preconditions for achievement. Evidence developed in hospital contexts is often neither relevant nor feasible for primary care. Different evidence types may constitute a point of departure, stretching and testing the transferability of the intervention by piloting it in primary care. Comprehensive descriptions of aims, context and procedures can be a more useful outcome than traditional effect studies.Main textWe present a model for small-scale implementation of relevant research evidence, monitored by pragmatic evaluation. The model, which is applicable in primary care, is supported by Weiner’s theory about organizational readiness for change and consists of four steps: 1) recognize the problem – identify a workable intervention, 2) assess the context – prepare for inception, 3) pilot the intervention on site, and 4) upscale and accomplish the intervention. The process is evaluated by exploring selected relevant aspects of experiences and outcomes from the first to the last step. Process evaluation is a logical precondition for outcome evaluation – attempting to assess either the efficacy or the effectiveness of a “black box” intervention makes no sense. We argue why evidence beyond effect studies and evaluation beyond randomized controlled trials may be adequate for science-informed evaluation of a small-scale implementation project such as is often conducted by primary health care practitioners. The model is illustrated by an ongoing project, in which a strategy for upgrading the management of depression in nursing homes in Norway is currently being implemented.ConclusionsA flexible and manageable approach is suggested, in which the inevitable unpredictability of clinical practice is incorporated. Finding the appropriate middle ground between rigour and flexibility, some compromises must be made. Our model recognizes the skills of practical knowing as something other than traditional medical research, while maintaining academic values such as systematic and transparent reflection, using adequate tools. Considering the purpose and context of our model, we argue that these priorities, emphasizing relevance and feasibility, are strengths, not limitations.

Managers\u2019 experience of success criteria and barriers to implementing mobile radiography services in nursing homes in Norway: a qualitative study

BackgroundIn order to meet the future challenges posed by ageing populations, new technology, telemedicine and a more personalized healthcare system are needed. Earlier research has shown mobile radiography services to be highly beneficial for nursing home residents in addition to being cost-effective. Despite the benefits, mobile radiography services are uncommon in Europe and Norway. The purpose of this study was to explore success criteria and barriers in the process of implementing mobile radiography services, from the point of view of the hospital and municipal managers.MethodsEleven semi-structured interviews were conducted with managers from five hospitals and six municipalities in Norway where mobile radiography services had been implemented. Core issues in the interview guide were barriers and facilitators in the different phases of implementation. The framework method for thematic analysis was used for analysing the data inductively in a research team.ResultsFive main categories were developed through the success criteria and barriers experienced by the participants: national health policy, regional and municipal policy and conditions, inter-organizational implementation projects, experienced outcome, and professional skills and personal characteristics. The categories were allocated into three higher-order classifications: macro, meso and micro levels. The main barriers experienced by the managers were financial, procedural and structural. In particular, the reimbursement system, lack of management across healthcare levels and the lack of compatible information systems acted as barriers. The main facilitators were external funding, enthusiastic individuals in the organizations and good collaboration between hospitals and municipalities.ConclusionsThe managers experienced financial, structural and procedural barriers. The main success criteria in the process were external funding, and the support and engagement from the individuals in the organizations. This commitment was mainly facilitated by the intuitive appeal of mobile radiography. Changes in healthcare management and in the financial system might facilitate services across healthcare levels. In addition, compatible information systems across healthcare levels are needed in order to facilitate the use of new technology and mobile services.

Significant reduction in indoor radon in newly built houses

Results from two national surveys of radon in newly built homes in Norway, performed in 2008 and 2016, were used in this study to investigate the effect of the 2010 building regulations introducing limit values on radon and requirements for radon prevention measures upon construction of new buildings.In both surveys, homes were randomly selected from the National Building Registry. The overall result was a considerable reduction of radon concentrations after the implementation of new regulations, but the results varied between the different dwelling categories. A statistically significant reduction was found for detached houses where the average radon concentration was almost halved from 76 to 40 Bq/m3. The fraction of detached houses which had at least one frequently occupied room with a radon concentration above the Action Level (100 Bq/m3) fell from 23.9% to 6.4%, while the fraction above the Upper Limit Value (200 Bq/m3) was reduced from 7.6% to 2.5%. In 2008 the average radon concentration measured in terraced and semi-detached houses was 44 and in 2016 it was 29 Bq/m3, but the reduction was not statistically significant. For multifamily houses, it was not possible to draw a conclusion due to insufficient number of measurements.

Long-Term Pain Treatment Did Not Improve Sleep in Nursing Home Patients with Comorbid Dementia and Depression: A 13-Week Randomized Placebo-Controlled Trial.

Objective: Previous research indicates that pain treatment may improve sleep among nursing home patients. We aimed to investigate the long-term effect of pain treatment on 24-h sleep patterns in patients with comorbid depression and dementia.Design: A 13-week, multicenter, parallel-group, double-blind, placebo-controlled randomized clinical trial conducted between August 2014 and September 2016.Setting: Long-term patients from 47 nursing homes in Norway.Participants: We included 106 patients with comorbid dementia and depression according to the Mini Mental Status Examination (MMSE) and the Cornell Scale for Depression in Dementia (CSDD).Intervention: Patients who were not using analgesics were randomized to receive either paracetamol (3 g/day) or placebo tablets. Those who already received pain treatment were randomized to buprenorphine transdermal system (maximum 10 μg/h/7 days) or placebo transdermal patches.Measurements: Sleep was assessed continuously for 7 days by actigraphy, at baseline and in week 13. Total sleep time (TST), sleep efficiency (SE), sleep onset latency (SOL), wake after sleep onset (WASO), early morning awakening (EMA), and number of wake bouts (NoW) were evaluated. In addition, daytime total sleep time (DTS) was estimated. Pain was assessed with Mobilization-Observation-Behavior-Intensity-Dementia-2 Pain Scale (MOBID-2).Results: The linear mixed model analyses for TST, SE, SOL, WASO, EMA, NoW and DTS showed no statistically significant differences between patients who received active pain treatment and those who received placebo. Post hoc subgroup analyses showed that there were no statistically significant differences between active treatment and placebo from baseline to week 13 in patients who were in pain (MOBID-2 ≥ 3) at baseline, or in patients who had poor sleep (defined as SE < 85%) at baseline. Patients who received active buprenorphine showed an increase in TST and SE compared to those who received active paracetamol.Conclusion: The main analyses showed that long-term pain treatment did not improve sleep as measured with actigraphy. Compared to paracetamol, TST and SE increased among patients who received buprenorphine. This could indicate that some patients had beneficial effects from the most potent pain treatment. However, based on the present findings, long-term pain treatment is not recommended as a strategy to improve sleep. Clinical Trial https://clinicaltrials.gov/ct2/show/NCT02267057.

Mobility and cognition at admission to the nursing home \u2013 a cross-sectional study

BackgroundEarlier studies show that the main reasons for admission to long-term nursing home care are cognitive impairment and functional impairments of activities of daily life. However, descriptive evidence of mobility is scant. The aims of this study were to describe mobility at admission to nursing homes and to assess the association between mobility and degree of dementia.MethodsWe included 696 residents at admission to 47 nursing homes in Norway. Inclusion criteria were expected stay for more than 4 weeks and 65 years or older. In addition, younger residents with dementia were included. Residents with life expectancy shorter than six weeks were excluded. Mobility was assessed using the Short Physical Performance Battery (SPPB) and the Nursing Home Life Space Diameter (NHLSD). The Clinical Dementia Rating Scale (CDR) was used to describe the degree of dementia. The associations between mobility and degree of dementia was analysed using the Chi-square and the Kruskal-Wallis test (KW-test). When the KW-test indicated a statistical significant difference, we proceeded with planned group comparisons with the Mann-Whitney U-test. In addition, we performed multiple linear regression analyses to control for potential confounders.ResultsForty-three percent of the residents were not able to perform the balance test in SPPB. Twenty-four percent of the residents were not able to walk four meters, while only 17.6% had a walking speed of 0.83 m/s or higher. Sixty-two percent of the residents were not able to rise from a chair or spent more than 60 s doing it. The median score on NHLSD area was 22 (IQR 17) and the median score on NHLSD dependency was 36 (IQR 26). Residents with severe dementia had significantly lower levels of mobility than residents with moderate dementia. Cognitive function was associated with SPPB and NHLSD dependency in the adjusted models.ConclusionNursing home residents form a frail, but heterogeneous group both in terms of cognition and mobility at admission. Mobility was negatively associated with cognitive function, and residents with severe dementia had significantly lower levels of mobility than residents with moderate dementia.

Nurses and nurse assistants' experiences with using a design thinking approach to innovation in a nursing home.

The aim of this study was to evaluate nurses' and nurse assistants' experiences with a design thinking approach to innovation used in a nursing home in Norway. A design thinking approach to innovation that focuses on users' needs can be employed to address many of the challenges facing health care providers in a field facing a growing ageing population, complex diseases and financial shortfalls. This study is based on a thematic analysis of four focus group interviews with nurses and nurse assistants (n=23). In the initial phase of developing the new service model, which included defining staff roles and responsibilities, participating nurses and nurse assistants felt engaged and motivated by the designers' inclusive and creative methods. However, during the new model's testing phase, they were critical of management's lack of involvement in the model`s implementation and therefore became less motivated about the project. The findings of the study highlight the importance of the designers cooperating with management and staff for the duration of the innovation process. Challenging innovation processes require strong managers who engage with designers, patients, staff and volunteers throughout all phases of an innovation process using a design thinking approach.