Navigating mutual vulnerability in complex services: co-designing narrative image transformative service initiatives (TSIs) Open Access

Baker et al. (2005) describe consumer vulnerability as a state of powerlessness resulting from an imbalance in marketplace interactions or dependence on external factors for fairness. In contrast, Raciti et al. (2022), in their strengths-based approach to consumer vulnerability, define it as a subjective perception of susceptibility that may lead to strength and resilience over time. The different perspectives taken by these authors result in definitions that frame consumer vulnerability as both a state of powerlessness and a potential source of strength and resilience.

From this, we can infer that while vulnerability can originate from an imbalance or susceptibility, it can be transformed into a source of strength through appropriate support and interventions. Power imbalances in service interactions can occur when consumers depend heavily on providers’ information and judgment (Echeverri and Salomonson, 2019). Wünderlich et al. (2020) suggest that service providers can reduce consumer vulnerability by designing and implementing supportive interventions. Similarly, Lee and Nathan-Roberts (2021) argue that consumers can empower themselves by enhancing their skills and knowledge. While such co-creative efforts can lead to improved outcomes like quality and customization, it may also introduce uncertainty and inadvertently limit access for some consumers (Kim, 2019).

Although previous literature has documented initiatives that support consumers experiencing vulnerability (e.g. transformative service initiatives [TSIs] for refugees accessing education), there is limited research on how to respond effectively to mutual vulnerability that can arise between consumers and service providers. Mutual vulnerability refers to the shared exposure to risk, uncertainty, or strain experienced by both consumers and service providers. When providers fail to adapt services to meet consumers’ evolving needs, it can result in disconnects and challenges in navigating complex systems and information (Bieler et al., 2022). For instance, a legal services client experiencing domestic violence may suddenly become homeless, escalating their vulnerability, while frontline staff may face emotional strain and ethical dilemmas as they attempt to provide support, illustrating how mutual vulnerability can manifest and transfer across service contexts. Thus, co-creating complex services requires firms to provide tailored support to ensure that consumers have the literacy and empowerment needed to make informed decisions and, if they choose, to actively engage in the process (Azzari et al., 2021; Schulz and Nakamoto, 2013).

Understanding the transformational nature of consumer service experiences has important implications for service academics and practitioners. However, examining consumer experiences in complex service contexts like healthcare remains challenging due to the intangible and ephemeral nature of service provision (Plewa et al., 2015). Visual tools like narrative images can enhance service inclusion by making information accessible and meaningful, especially for individuals with low literacy or from diverse backgrounds (Leong et al., 2018). Within the narrative paradigm, images provide context and structure to human behavior and events, and can more effectively convey personal values and assist in the decision-making processes (Megehee and Woodside, 2010). When combined with storytelling, narrative images can engage consumers and improve service inclusion in complex settings. With clear, visual information, services can be more effectively tailored to diverse needs, fostering better outcomes.

The aim of this research is to explore the dynamics of mutual vulnerability in complex services, specifically focusing on healthcare transitions from curative to end-of-life care. To achieve this, the study examines narrative-driven, visual storytelling methods to address the shared vulnerabilities of both consumers and service providers in these contexts. This often unpredictable or absent transition can result in distress, inadequate services and traumatic outcomes (Van Lancker et al., 2018). This overlooked “in-between” service stage (Appau et al., 2020), where curative care is no longer effective, but end-of-life care has not begun, often leaves individuals and healthcare workers feeling powerless.

Guided by Transformative Service Research (TSR), which seeks to enhance well-being through tailored service practices (Anderson et al., 2013), this study explores how narrative images can improve service inclusion within TSIs, especially in healthcare. The research objectives are as follows:

• (RO1) To understand how consumer and worker vulnerabilities interact to create mutual vulnerability, informing the development of a framework.

• (RO2) Develop a narrative image TSI (NI-TSIs) process aimed at mitigating vulnerability determinants from multiple perspectives.

The current research responds to interdisciplinary calls to enhance service inclusivity (Fisk et al., 2018), offer insights into improving TSIs for specific populations (Boenigk et al., 2021), and the need for a process that can assist organizations to co-design and implement humanistic TSIs across various vulnerabilities and contexts (Kabadayi et al., 2023). Specifically, for healthcare professionals, it provides a process for managers to design an intervention that can reduce mutual vulnerability when caring for persons with life-limited illness (Alshammari et al., 2022; Nevin et al., 2020). Anchored in the Fisher (1985), Visual Narrative Paradigm, the IMAGE process (Table 2) offers an organized approach to creating NI-TSIs that may enhance consumer engagement and inclusivity in service co-creation, potentially improving service provision to better meet diverse needs. As used here, a NI-TSI is a visual tool designed to engage consumers in storytelling about their values, experiences, and expectations. For health services, it can enhance health literacy and empowerment by simplifying complex information, fostering understanding, and encouraging active participation in decision-making.

The structure of the article is as follows: it begins by exploring various types of vulnerabilities, with a particular focus on end-of-life care. This is followed by a discussion on TSIs, emphasizing their role as a strength-based approach to enhancing consumer experiences and mitigate vulnerability factors, alongside insights into designing effective TSIs. The qualitative ethnographic approach used in the study is then detailed, leading to the presentation of findings, which include the transformative vulnerability-response (TVR) framework, and the application of the novel IMAGE process. The article concludes by outlining its theoretical and practical implications.

In end-of-life care, relationality offers a holistic perspective on how individuals’ experiences are shaped by personal relationships, and by broader socio-environmental factors. It emphasizes the interdependent nature of existence, particularly in vulnerable moments like dying, where influences from the natural environment, technology and cultural or ecological factors play a significant role (Bushell, 2020). This interdependence highlights mutual vulnerability, where both the dying individual and healthcare providers experience fragility, particularly in contexts that require mutual care and support (Angel and Vatne, 2017). Baker et al. (2005) emphasize consumer vulnerability as a state where individuals have a reduced capacity to cope with consumption-related risks due to internal (e.g. biophysical or psychosocial characteristics) and external (e.g. environmental or situational) factors. Vulnerability is context-specific and shaped by each person’s unique circumstances. Baker et al. (2005) stress the importance of understanding vulnerability from the consumer’s perspective, advocating for empowerment and consumer protection to address actual vulnerabilities rather than relying on stereotypes. However, Schulz and Nakamoto (2013) highlight that improving knowledge alone may not address an individual’s willingness or capacity to engage in empowerment or active decision-making.

Similarly, service workers also face vulnerabilities, influenced by the emotional and professional demands of their roles, as well as systemic pressures (Angel and Vatne, 2017). These workers are not isolated in their experiences of vulnerability. Rather, they are part of the same relational dynamic. Riedel et al. (2023) provide a model based on the job demands-resources theory, which shows how job demands (e.g. dealing with consumers, heavy workloads and organizational pressures) can negatively affect workers’ well-being. Conversely, job resources (e.g. support from colleagues, clear policies or personal traits such as confidence) can mitigate these demands. This dynamic highlights how the vulnerabilities of both consumers and service workers are interconnected, further emphasizing the relational nature of care.

Mutual vulnerability extends these individual experiences of vulnerability by highlighting the shared and interconnected nature of both consumer (patient) and provider experiences. It recognizes that both parties are vulnerable, not just due to external circumstances, but because they rely on each other in the service process (Angel and Vatne, 2017). This interdependence creates a co-creative space of shared inter-dependence, emotional exchange, communication and quality of service provision (shown in Figure 1). While this dynamic can improve service quality and communication, it is important to recognize that it can introduce challenges, particularly if the vulnerabilities of either party are not properly managed, potentially affecting the well-being of both consumers and providers (Carlini et al., 2025; Heaslip and Ryden, 2013). However, addressing worker vulnerabilities often requires systemic support, rather than being solely reliant on the consumers role in the interaction.

Vulnerability is present as individuals face physical decline, emotional challenges and existential concerns, often heightened by their dependence on others for care and support (Bushell, 2020). Acknowledging and addressing this vulnerability can contribute to a good death experience also reflected in the ability to maintain comfort, autonomy and meaningful connections when enduring terminal illness (Krikorian et al., 2020; Meier et al., 2016). For healthcare workers, this means assisting with pain management, honoring personal values and cultural preferences, and providing opportunities for emotional closure and reconciliation. Together, these concepts shape the holistic care and tailored approaches necessary to support diverse definitions of a good death (Bassett and Bussard, 2021; Krikorian et al., 2020).

In many Western cultures, the topic of dying is often avoided and met with discomfort, which can render those who are dying both stigmatized and invisible (Kang, 2021). In contrast, Eastern and African traditions frequently embrace death as part of a continuing journey. In addition to cultural differences, each person also has their own unique perspective on mortality and a good death. For example, American author, Helen Keller saw death as a transition, not an end: “Death is no more than passing from one room into another.” On the other hand, Russian author, Leo Tolstoy, in The Death of Ivan Ilyich, grappled with fear and uncertainty, reflecting: “What will come of it? Death? But what is death? I do not know. I do not want to die.” These reflections shed light on the varied ways people confront the reality of death, illustrating how personal and cultural beliefs shape the experience of vulnerability at the end of life.

Healthcare workers have an important role in navigating vulnerability when providing end-of-life care services. Both consumers and healthcare workers can experience mutual vulnerability (Heaslip and Ryden, 2013). As discussed in the earlier section, mutual vulnerability refers to the emotional and psychological challenges faced by service providers, which in acute settings can mirror the distress experienced by patients (Heaslip and Ryden, 2013). The healthcare workers perceptions and attitudes toward death can significantly influence the care they provide to the dying (Carlini et al., 2025). Misalignment of end-of-life needs can lead to poor-quality care and potential conflicts. Effective end-of-life communication and shared decision-making are essential for improving the quality of care, with studies showing that such practices result in less aggressive medical interventions and better well-being outcomes, such as reported quality of life for patients, and reduced impact on their relatives’ bereavement (Sinuff et al., 2015; Walczak et al., 2016).

Despite the importance of end-of-life discussions, they are often avoided due to uncertainties about the timing of a patient’s end-of-life needs and the emotional burden on healthcare staff (Carlini et al., 2022). For example, healthcare staff might hesitate to start end-of-life conversations too early because the timing of a patient’s death can vary significantly to whether death is sudden, steady or a slow decline (Lewis et al., 2021). Consequently, in most acute care settings, managing end-of-life care can be very stressful for healthcare workers (De Brasi et al., 2021). However, organizations can assist in mitigating mutual vulnerability by providing resources to help both consumers and workers to navigate the complexities of end-of-life care. This includes addressing barriers such as language differences and low health literacy, which can hinder the delivery of tailored and empathetic services (Van Orden et al., 2021). One effective approach to addressing these challenges is through TSIs, a strength-based method to improving service access.

To address consumer vulnerability and barriers to service access, Anderson et al. (2013) introduced TSR, focusing on improving the well-being of individuals. Later, the concept of TSIs was developed to create positive and lasting changes for individuals and communities (Anderson et al., 2013; Boenigk et al., 2021). TSIs are efforts by service organizations, including government, nonprofit and private entities, to enhance well-being through services such as education and employment (Boenigk et al., 2021), and market-based TSIs, such as those for Syrian refugees aim to improve service inclusion (Eslami et al., 2023).

To help organizations design TSIs, Eslami et al. (2023) developed a two-dimensional vulnerability and dignity framework resulting in four TSIs types:

1. Exclusionary TSIs fail to address the vulnerability needs and dignity of individuals, resulting in their exclusion from crucial services.

2. Opportunistic TSIs exploit vulnerabilities for organizational gain, rather than genuinely meeting the needs of those affected.

3. Paternalistic TSIs adopt a top-down approach, making decisions for individuals without their input, which can undermine their dignity and autonomy.

4. Humanistic TSIs prioritize respecting individuals’ dignity, involve them in design, decision-making and delivery of solutions, and aim to enhance their overall well-being by empowering them and addressing their true needs.

While humanistic TSIs are the most effective in creating intended well-being outcomes, little is known about how organizations can (Co)design and implement TSIs with individuals and stakeholders across different vulnerabilities and service contexts (Kabadayi et al., 2023).

The narrative paradigm proposes that humans are natural storytellers who make decisions based on “good reasons,” which are influenced by their history, culture and character (Fisher, 1985). Storytelling serves as a metaphor for human experience, where understanding arises from symbolic actions and compelling narratives rather than purely rational arguments. Narrative images, which combine characters, settings and actions, help consumers connect with, and understand stories (An, 2014). For example, ancient cave paintings, dating back over 45,000 years, exemplify early visual storytelling, conveying complex narratives and cultural values (Mullen, 2008).

Despite advancements in healthcare, a significant challenge remains the inability of many healthcare workers to discuss sensitive topics, such as death. Often, patients feel reduced to “a case” rather than being seen as individuals with unique stories and emotions. Narrative care offers a solution by focusing on the importance of understanding and engaging with peoples’ personal stories (Sonke et al., 2018). By using narrative images, healthcare providers can reduce power imbalances and enable patients, to create a more inclusive and empathetic care environment.

As Ma and Yang (2022) note, more broadly, visual aids, like diagrams, illustrations, videos and charts can complement verbal and written materials in patient education, and can be beneficial for patients with low health literacy, language barriers or cognitive impairments. For example, Lee and Nathan-Roberts (2021) found the use of visual prompts in patient education resulted in better comprehension and adherence to treatment plans, leading to improved health outcomes. Patients who can visually perceive information about their condition, treatment options or self-care practices are more likely to actively participate in their care, resulting in better medical adherence, healthier lifestyles and improved management of chronic conditions (Lee and Nathan-Roberts, 2021). Consequently, visual narratives can have an impact on emotions and behaviors compared to text-only materials, making them valuable in patient education (Harwood et al., 2020).

Unlike typical TSIs, which focus on service design or process improvements, NI-TSIs use visual storytelling to engage consumers, service providers and stakeholders (e.g. family and caregivers) in sharing their values, experiences and expectations. By incorporating visual and narrative elements, NI-TSIs can help to facilitate the sharing of values, experiences and expectations, fostering improved understanding, empathy and communication (Mbanda et al., 2021). This approach can help reduce mutual vulnerability by addressing shared challenges and enhancing collaboration, enabling individuals to better navigate complex services during vulnerable or transitional moments.

Recent studies highlight a gap in effectively empowering consumers experiencing vulnerability through co-design (Fisk et al., 2022; Raciti et al., 2022). Existing frameworks such as the SAIV process (Raciti et al., 2022), the 5R guidelines (Russell-Bennett et al., 2023) and EMPOWER (Figueiredo et al., 2023) offer strategies for engaging vulnerable consumers. However, these frameworks fall short in providing specific guidance for co-designing TSIs that address unexpected or mutual vulnerability.

To design humanistic TSIs, Kabadayi et al. (2023) emphasized the need to involve multiple stakeholders, ensuring diverse perspectives and tailoring initiatives to specific vulnerabilities. Participatory co-design approaches can help to address power imbalances and enhance service relevance by integrating individuals’ unique needs and preferences (Trischler et al., 2019). For example, the Community Forum (Becker et al., 2003) provides a structured process for engaging diverse community members in identifying social impacts, while participatory arts-based methods enable deeper, creative exploration of stakeholder experiences and insights (Govender et al., 2024). Participatory arts-based methods, such as graphic facilitation and visual storytelling, have shown promise in engaging diverse stakeholders and translating complex experiences into actionable insights (Govender et al., 2024).

When combined, these methods (i.e. the community forum and participatory arts-based) can enable more equity and inclusivity by empowering individuals in decision-making, while fostering a nuanced understanding of shared challenges between consumers and providers, as outlined in vulnerability models (Baker et al., 2005; Raciti et al., 2022). Combining these approaches can offer a useful method to address the critical factors such as stakeholder complexity, time sensitivity and cultural nuances when designing TSIs (Carlini and Wu, 2024). Next the research design and context of study is presented.

A major difficulty for healthcare workers in acute wards is transitioning persons with life-limiting illnesses from curative to end-of-life care service paths (Van Lancker et al., 2018). As a result, many people do not receive the care they prefer, for example, 70% of Australians prefer to die at home, yet fewer than 10% do so, with the majority dying in hospitals (Le et al., 2017). This service transition challenges healthcare workers and exacerbates their distress and potential for mutual vulnerability, stemming from interactions with patients and their families and the demands of fulfilling final wishes (De Brasi et al., 2021). Despite the growing emphasis on person-centered care, there remains a gap between current services and recommended practices.

This research was guided by a qualitative ethnographic approach recommended by Crespin-Mazet and Ingemansson-Havenvid (2020), allowing the exploration of the subject of interest within its natural setting. This approach facilitated a thorough examination of the research aim while acknowledging and accommodating the inherent complexity and mutual nature of the phenomenon (Vaughn and Jacquez, 2020). Conducted at a tertiary hospital in the city of Gold Coast, Australia, the research took place in a setting marked by consumer diversity, with a population exceeding 600,000 residents from various ethnic and cultural backgrounds, including Ireland, Scotland, Germany, New Zealand, England, China, South Africa and India (Australian Bureau of Statistics, 2021).

The research commenced in 2018 and concluded in 2020 as part of a larger project aimed at improving services for people with life-limiting diseases transitioning to end-of-life care. Led by a joint appointment at a university and hospital, the project involved a collaborative team including the Director of Palliative Care Services, a Renal Consultant, a General Medical Consultant, an End-of-life Care Quality Improvement Lead, and the Chair of the Consumer Group, and an end-of-life academic expert. This provided the research team with an extensive preunderstanding of healthcare operations and processes, the technical requirements of broader system changes required to operationalize service changes in the hospital, as well as access to key decision-makers in the organization. Extended immersion and prolonged engagement in the research context are usually considered key advantages of ethnographic approaches, as they provide bases for a deeper and holistic understanding of the research phenomenon in a natural setting (Mariampolski, 2006).

A summary of co-design workshop using Durl et al. (2017) six steps is detailed in Table 1. On November 20, 2018, 32 participants representing various health organizations (both public and private), non-government community-based groups and researchers participated. Later, the method was rationalized and presented as the IMAGE process in RO2 (Table 2).

Data were collected from recording procedures, photographing, taking field notes, charting and collating evidence. The research team documented the research process, capturing small group presentations and large group discussions through notes and photographs. Posters from small group discussions and participant comments were also collected and photographed. Each team member observed and recorded field notes to capture general views and contextual meanings.

Data analysis followed a qualitative content analysis approach, which involved examining both manifest and latent themes within the data (Elo and Kyngäs, 2008). The researchers maintained a reflexive stance throughout the process, remaining attuned to their position and influence on the analysis. In alignment with Ellingson’s suggestions for co-created data, the researchers embraced embodiment, recognizing the importance of valuing participants’ lived experiences and embodied emotions. Given the inherently emotional nature of end-of-life care, the team remained sensitive to the emotional complexities such as fear, anger, guilt, regret and grief (Camacho et al., 2017), ensuring that these dynamics were adequately represented in the analysis. This approach enhanced the study’s authenticity, credibility and verisimilitude (Ellis et al., 2011).

As recommended by Elo and Kyngäs (2008), the researchers used an inductive content analysis approach, independently clustering similar words, phrases or sentences into semantic units based on their inherent meaning. These condensed unit meanings were then condensed into themes that reflected recurring patterns and concepts within the data (see Table 3 for worked example). Following this initial clustering, the research team engaged in a process of comparison and reconciliation to ensure consistency and accuracy in the identification of themes, enhancing the validity of the findings (Phillippi and Lauderdale, 2018).

This section presents the outcomes of Research Objective 1 (RO1) and Research Objective 2 (RO2), which explore mutual vulnerability in healthcare transitions from curative to end-of-life care through narrative-driven visual storytelling, addressing shared vulnerabilities between consumers and service providers:

In response to Macinnis (2011) call for conceptual advancements through novel frameworks, this study conceptualizes and illustrates the relationship between healthcare workers and consumers using the transformative vulnerability-response (TVR) framework. As shown in Figure 2, this framework integrates key principles and prior literature.

First, the mutual vulnerability model (Figure 1) was contextualized with end-of-life care literature, as outlined in the vulnerabilities in end-of-life care review section. Next, concepts from TSR (Fisk et al., 2018) and TSIs (Boenigk et al., 2021; Eslami et al., 2023) were synthesized with the end-of-life literature to provide a comprehensive, context-specific perspective, as depicted in Figure 2 and explained below.

The TVR framework in the end-of-life care context (Figure 2) provides a comprehensive view of the interplay between healthcare workers’ emotional and job-related challenges and the vulnerabilities faced by consumers. It highlights how these shared vulnerabilities can lead to mutual interdependence (Heaslip and Ryden, 2013), which, if unaddressed, may result in negative well-being outcomes and depersonalized care. To mitigate these factors, the implementation of a NI-TSI is proposed. Consumers experience a range of vulnerabilities, including physical decline, emotional distress and existential concerns, which, combined with a need for greater dependence on others, can significantly impact the quality of care (Angel and Vatne, 2017).

Additionally, healthcare workers face their own vulnerabilities, such as emotional stress, professional demands and systemic pressures, which may affect their ability to provide compassionate care (Bieler et al., 2022). These intersecting vulnerabilities contribute to mutual vulnerability, where both parties rely on each other for emotional support, care and decision-making (Angel and Vatne, 2017).

The TVR framework suggests that outcomes, such as paternalistic decision-making or lack of dignity, can arise when these vulnerabilities are not addressed (Van Lancker et al., 2018). In this case, applying the NI-TSI offers a potential solution for improving service access (Fisk et al., 2018; Leong et al., 2018). As recommended by Kabadayi et al. (2023), the co-design of TSIs should involve multiple stakeholders to address diverse needs and power imbalances and ensure that both the consumer’s and healthcare worker’s needs and vulnerabilities are recognized, leading to better service and well-being outcomes (Eslami et al., 2023):

The IMAGE process integrates elements of the Community Forum approach (Becker et al., 2003) and participatory arts-based methods (Govender et al., 2024) to create a novel framework for co-designing NI-TSIs. The Community Forum emphasizes structured, participant-driven discussions to assess social impacts, fostering engagement and inclusivity. Meanwhile, participatory arts-based methods use creative expression to surface insights, enhance collaboration and communicate complex experiences visually. Combining these approaches harnesses the strengths of community-driven dialogue and visual storytelling to co-design TSIs that can address shared vulnerabilities, enhance service delivery and promote well-being for both consumers and providers. This synthesis bridges methodological gaps, providing an interdisciplinary tool for engaging stakeholders in service innovation.

The TVR framework (Figure 2) highlighted that mutual and shared challenges can lead to mutual vulnerability in complex services and that the implementation of a NI-TSI can improve well-being outcomes for service providers and consumers. This section details the development of the five-step IMAGE process: Step 1: Initiating Community Engagement, Step 2: Mapping individual and group experiences, Step 3: Articulating insights via graphic expression, Step 4: Generating creative briefs for design, Step 5: Executing artist collaboration for visual storytelling. Table 2 provides a stepwise approach to the IMAGE process. The IMAGE process offers guidance for academics and practitioners to develop co-designed context specific narrative images by engaging system stakeholders.

During end-of-life situations, patients and their caregivers, and healthcare workers often experience vulnerability, reinforcing the significance of compassionate and respectful discussions regarding end-of-life care that prioritize the individual’s well-being. This research adhered to ethical principles and received the requisite ethical clearance (AU/1/6577319). The research team thoroughly addressed the ethical dimensions of the context and the study, and these documented ethical considerations are available online (see https://ahrecs.com/conducting-research-with-not-on-consumers-in-health-exploring-ethical-considerations/).

To ensure comprehensive stakeholder engagement, the research team drew on a previous study by Pask et al. (2018) to identify and enlist various individuals and organizations involved in the end-of-life care ecosystem. This included healthcare workers, patients, families, caregivers, palliative care specialists, social workers, religious or spiritual advisors, and community organizations focused on end-of-life support. Inclusive invitations were extended to these stakeholders through the hospital’s email databases and strategically placed promotional materials in the hospital wards. Additionally, internal communication channels and social media platforms were used to reach a broader audience and encourage participation.

Thirty-two participants attended the 2.5-hour in-person event, comprising 11 health service staff, 11 representatives from other hospitals and community-based organizations, along with six members of the public and four research team members. The event commenced at 5 p.m. to enable community accessibility, a light supper and parking fees were included.

To promote robust discussions, the process was initiated with a sensitization phase which included a short presentation about the issue at hand and the research project accomplishments to date, ensuring participants had a thorough understanding of the topic and the context for subsequent discussions. Following this, facilitation began with participants randomly divided into groups of three to four individuals for small group storyboarding, facilitating more intimate exchanges and enabling deeper exploration of individual perspectives and experiences (Figure 3). These smaller groups were intentionally designed to create a safe and supportive environment, encouraging participants to freely express their thoughts and ideas (Pollock et al., 2011).

Within these intimate settings, storytelling emerged as a powerful mechanism that allowed participants to articulate their underlying desires and emotions regarding end-of-life care and achieving a good death. In many ways, the process fostered a sense of communal cohesion and empathic understanding among participants (Mitchell et al., 2015). Each small group creatively storyboarding what they perceived as an ideal death experience. The storyboards provided a visual narrative to communicate and elucidate their desires for end-of-life experiences.

Following the small group discussions, participants gathered in a larger room where each group presented their findings to the entire assembly (Figure 3). This larger discussion group served as a platform for broader participation to facilitate knowledge sharing and idea exchange within a supportive setting (Abelson et al., 2003). In this setting, diverse perspectives and insights were freely shared, enabling stakeholders’ collective wisdom to inform the design and refinement of good death experiences. After all groups had presented, incorporating insights from the wider group through sticky notes, the co-design session was finalized, and participants were invited to share refreshments before departing.

The co-design session yielded photographs, drawings, participant feedback, suggestions, observations of interactions and discussions, providing a diverse data set for analysis as discussed in the earlier Research Design section. Through the thematic analysis, valuable insights were gained into participant perspectives, needs and preferences regarding the preferred experiences for end-of-life care (Table 3). These insights served as a foundation for the subsequent development of artistic concept designs, and visualizations, ensuring that the envisioned solutions were rooted in a thorough understanding of user experiences and requirements gathered during the co-design process.

A comprehensive creative brief was developed to guide the creative process, drawing on established practices within the design field as exemplified by Blakeman and Taylor (2019). The creative brief emphasized alignment with community expectations and research objectives as discussed by Koslow et al. (2022). It clearly defined the project’s objectives, target audience and desired outcomes. The resultant themes (i.e. importance of family support in providing comfort and accessibility for end-of-life care at home, the need for culturally and spiritually appropriate care) and the condensed meaning were incorporated as key requirements in the brief (Figure 4).

A local artist, familiar with the healthcare system and known to the researchers, was commissioned to create the narrative images. After the project brief was reviewed for alignment with the objectives, the artist developed several concept drawings (Figure 4), which the research team reviewed. They provided suggestions to enhance the depiction of compassionate care, such as including a person patting a dog on their lap, focusing on the shoulder rather than the face, and adding a hand touching the dog. The team also recommended depicting a relaxed terrier and incorporating an ocean view to reflect the local community and create a cozier atmosphere. The team responded positively, describing the illustration as “beautiful and homely.”

After the iterative collaboration, the researchers confirmed the creative direction. The artist incorporated the feedback, culminating in the creation of four distinct narrative images depicting various individuals, activities and settings, as illustrated in Figure 5. These images were crafted for an end-of-life NI-TSI designed to provide support to individuals, families, caregivers and healthcare workers to achieve person-centered care. The finalized resource can be accessed here (http://hdl.handle.net/10072/421363).

The research aimed to address the gap in understanding the dynamics of mutual vulnerability in complex services, specifically focusing on healthcare transitions from curative to end-of-life care. To achieve this aim, the study fulfilled RO1 and RO2. In doing so, the study made the following important contributions.

The theoretical contributions of this study are threefold. First, this study introduces the concept of mutual vulnerability within TSR, marking a critical advancement in the services marketing literature. Mutual vulnerability highlights the interdependence and shared fragility in service interactions, particularly in complex settings. It recognizes that the vulnerabilities of consumers and service providers are interconnected, with challenges faced by one party influencing and amplifying those experienced by the other. Prior to this, vulnerability has been conceptualized by stakeholder group, such as frontline employees (Riedel et al., 2023) or consumers (Baker, et al., 2005). This contribution extends the theoretical boundaries of TSR by reframing vulnerability as a relational process, and offers actionable insights into the development of more inclusive and effective service ecosystems. It further addresses the gap in understanding how intertwined vulnerabilities shape service relationships, responding to the need for holistic approaches in complex, high-stakes service environments (Angel and Vatne, 2017).

Second, by broadening the understanding of mutual vulnerability within TSR, this study responded to MacInnis’s (2011) call for conceptual innovation with this study envisioning the relational dynamics between service providers and consumers in developing the TVR framework. Drawing on interdisciplinary perspectives, the TVR framework integrates insights from the mutual vulnerability model, TSR, TSI and the narrative paradigm to offer a comprehensive lens on service interactions. The framework introduces a novel perspective on how mutual vulnerability can emerge, particularly in healthcare settings. Healthcare workers face emotional demands and job challenges, while consumers navigate their own vulnerabilities. This interdependence highlights the shared mutuality of service relationships, emphasizing the need to address these intertwined vulnerabilities. Importantly, the TVR framework offers a solid foundation for understanding vulnerability from each party’s perceived perspective, rather than relying on stereotypes, as advocated by Baker et al. (2005). 

Third, this research contributes to services marketing literature by developing the IMAGE process, an innovative framework for co-designing NI-TSIs. The IMAGE process synthesized elements of the community forum approach (Becker et al., 2003) and participatory arts-based method (Govender et al., 2024), combining structured, participant-driven discussions with creative expression to identify shared vulnerabilities. This integration of ecosystem stakeholder engagement enhances collaboration (Kabadayi, et al., 2023) and prioritizes and respects individuals’ dignity by involving them in the design, decision-making and delivery of solutions, and aims to enhance overall well-being by empowering consumers and addressing their individual needs (Eslami et al., 2023). While practical in nature, the IMAGE process advances theory by providing a structured, interdisciplinary tool for engaging stakeholders in NI-TSI development. It bridges methodological gaps, offering a novel approach to developing services that improve well-being outcomes for both consumers and service providers.

By employing the IMAGE process in healthcare settings, organizations can foster a more inclusive and empathetic approach to service design (Carlini and Wu, 2024), benefiting both consumers and service providers. This process allows healthcare providers to engage consumers in co-designing personalized service solutions that address their specific vulnerabilities, thereby improving service delivery and consumer well-being. The IMAGE process holds potential for other complex service providers such as education and professional services like lawyers or educators (Plewa et al., 2015). It provides a structured approach for developing NI-TSIs that enable service providers to humanized complex services by enabling consumers to better understand and navigate complex information and decision-making (Lee and Nathan-Roberts, 2021).

In addition, the NI-TSIs can serve as valuable resources to support workers, potentially enhancing their well-being and improving both service outcomes and consumer experiences, while mitigating mutual vulnerabilities (Carlini et al., 2025). By using narrative images to stimulate dialogue, healthcare workers can foster a supportive environment that promotes effective communication and mutual understanding. Potentially, NI-TSIs derived from the IMAGE process can improve the accessibility and coherence of information, fostering autonomy and personalized support across diverse service contexts.

This study offers significant contributions to the development of NI-TSIs, but its limitations warrant consideration. First, the findings’ applicability may be constrained, as the research was conducted in the context of an Australian tertiary hospital. Cultural considerations also pose challenges; for example, First Peoples often prioritize dying on country, highlighting how cultural perspectives can influence end-of-life care decisions (Araújo, 2023). The COVID-19 pandemic disrupted the evaluation of the IMAGE process, leaving its efficacy untested. Moreover, acknowledging the diverse needs of healthcare professionals, particularly part-time or shift workers, is essential for tailoring support strategies that align with their coping mechanisms (Lo Iacono et al., 2024). Despite these challenges, the IMAGE process demonstrates potential for guiding the development of NI-TSIs. Future research should explore its applicability across diverse services, environments and consumer vulnerabilities, expanding its relevance beyond healthcare. Investigating the integration of AI-generated visualizations into this framework could further enhance its utility.

In healthcare, the drive for standardization and efficiency has often overshadowed the importance of personalized care, placing strain on healthcare workers and potentially diminishing the quality of person-centered services (Berry et al., 2024). The IMAGE process offers a means to address this gap, providing a pathway for co-designing services that acknowledge mutual vulnerabilities and support both healthcare workers and consumers. By bridging human connection with service innovation, the IMAGE process holds promise for fostering meaningful and inclusive care in complex service ecosystems.

The author thanks the Clinical Excellence Queensland for funding the Supporting Discharge from Hospital to Enable Dying at Home project. The author also extends her appreciation to the project committee members, the discharge process chair Kristen Ranse, artist Teneille Grace, and project lead Laurie Grealish. She also appreciates the thoughtful feedback from the reviewers, which significantly enhanced the quality of this article.