How to separate the trees from the forest – The workplace as a Swiss army knife

Continuing on the “forests and trees” metaphor from a previous post we will now see what happens when you try to separate the trees from each other. So, let us start with one single tree (or task). One tree does not make a forest, but it can very easily be distinguished as a tree of a certain kind. A Pine tree has long needles; A fir tree has short needles. And a tree without needles is a leafy tree (unless it is a Gingko tree, but that is another story).  However, once there are more trees in a lump, the categorisation becomes more difficult. 

Transferred to the issue of work and tasks: As long as we are only doing one single task or having one single role, it is also quite simple to see and study it, and also (at least to some extent) to understand how it works, and what the consequences are. This is not to say that this kind of work is simple or uncomplicated, a heart transplant is a complicated task, even though it is a single task and well specified at that. We may also still make design mistakes on this single task design, but these kinds of mistakes are mostly confined to the task environment we work in at the moment. 

In a way, as long as we have many instances of the same type of single tasks that we can handle more or less sequentially, we are still proceeding through something, which in the forest metaphor is like a well-managed orchard with the same kind of trees planted spaciously and in neat rows. We can still handle the situation with the same kind of specialised tools, and the tools may also have an easier way to communicate with each other, e.g., using the same terminology, the same data formats etc. since they are designed for the same task.

Now, when we consider the work situation for nurses at a hospital ward explicitly, their situation is completely different. Their work more or less constitutes the very definition of “fragmented work tasks”. First, there is planned fragmentation, where the person has to change tasks or responsibilities according to a schedule. Second, there are interrupting tasks in terms of alarms, visiting relatives, telephone calls and other randomly occurring events that also cause a fragmented work situation. There is a related blog post by Åsa Cajander “On Digitalisation and Fragmentation of Time” about this phenomenon.  

The interruptions that occur over a work day can have at least two major effects on the nurse. He or she has to switch context for the work, which in itself is a stressing action for the brain. In the case of sudden intruding tasks, there is also the problem of mentally going back to the interrupted task and continue from where it was discontinued, sometimes after many hours. This situation becomes almost, again in the forest analogy, like looking at a primeval forest or a rainforest. There are trees everywhere and of every kind, and they are all interconnected in some ways. You need both stamina and focus in order to find your way through the forest/work. 

This becomes even more problematic when we look at the computer support for work tasks in any workplace. The general computer system is in many cases designed in the same way as a Swiss Army knife. We use the same technical framework for all the tasks that should be performed, using a keyboard, a mouse (or a mousepad) and a screen for the stationary tasks, and mobile apps, in the best case redesigned for the smaller screens of mobile devices, for the tasks that are done on the run. Journal entries, medication dosage calculations, and many planning tasks are therefore performed in the same limited cognitive space, and there is no real support for the switching between those tasks, nor for the fragmentation of the ongoing work. 

In some cases, like writing down the notes for the daily ward round, the information is even taken down as hand-written jots on a paper form and has to be transferred manually into the journal later. 

A Swiss army knife is not really perfect in any of its functions (even the knife blade leaves a lot to be desired), it still works, and someone who is not a carpenter, mechanic or plumber might even think it is a good and practical tool. But for any professional, if asked, they would definitely prefer to use a specialized tool. Apart from being more efficient, specialized tools also pose a lower risk of accidents and slips. In the same way, non-specialized computer tools may, even though they can perform the desired tasks, still not be the best choice in a complex work situation.

When we design new computer systems for organizations like hospital wards, schools, etc. they are often positioned around one task at a time. We study one tree at a time in the forest. Even though we are much better off than at the beginning of the PC era, when we could only run one program at a time, we are still running several parallel processes that interconnect badly, if at all. 

During the study visit at Akademiska in Uppsala last year (the university hospital in Uppsala), I found ten different systems used in one of the wards, all running on the “same computer”. This amounts to having ten tools on the Swiss army knife. Of course, the individual programs are in some way specialized. We don’t use spreadsheets for everything. Each separate task has applications or programs that are explicitly designed for its purpose but not for the whole entangled web of work tasks. Furthermore, the interaction design is often completely different in the different systems, which means that the user has to switch from interaction style to interaction style, and from command structure to command structure.

One example to indicate what I mean: the notes that are made for each patient during the ward rounds are almost always written by hand at the ward where  I visited. However, after the ward round they have to be entered manually into the system, which has the double effect that it might be a slow process, taking valuable time from the nurses, and that there is also a high risk of misreading numbers and hastily jotted down notes.

The paper notes are not integrated into the computer system. While we note this, we might realize that we could need a more automated solution (which may still need proof-reading and checking). In this new solution, it would be possible for the doctor on duty to write, still by hand, on a tablet that may offer character recognition. This would reduce the tiring process of transcribing the text, making it much easier and also leave more time for other, more important tasks. 

Now, this is, in my opinion, where one of the problems with the systems in the hospital resides. We are so focused on the design of the single system, that we forget all the small details that could make the whole work situation simpler and more manageable.  Add to that that we also forget to look at the small details that should incorporate such things as:

  • specially designed portable devices, that are designed for a single task, such as taking notes for the information rounds. 
  • the development of distinct, but consistent interfaces to all the subsystems.
  • ncorporating support for the interruptions that occur during a day. Why not a “what did I do last”- kind of function? 

The conclusion of this observation is that we need to look at a work situation from a holistic and a reductionistic perspective simultaneously when we are planning and designing the digitised work place, resulting in a well planned and easily manageable rain forest of work tasks.

A social event in celebration of our new financial system

At Uppsala University, the administrative system Raindance has been updated to a new version. The HTO-group is doing collaborative work in relation to this project (the EASY project). Last Thursday afternoon, the project celebrated that the implementation phase in now complete, by inviting the users to a network meeting. Approximately 100 users came to the meeting. From the HTO-group, Gunilla and Thomas went.

The afternoon started with information regarding the process as a whole: from the procurement phase until today. Edrun Eriksson (Head of the Ledger Office unit at the Financial Administration and Procurement Division) reminded the users of what expectations and hopes they had forwarded themselves, early on in the process. She gave us some illustrative examples. Furthermore, she had made a printout of the complete list, which was put up on the wall, so that all participants could read them later on during the afternoon. She also presented a summary of all sub groups and sub projects that have been active in the process. They were quite many! For meetings, she had just marked the amount with a question mark – being a bit over conscious regarding the great number of hours put into the project!

Edrun also took the opportunity to express a big “Thank you!” to all the people that have contributed with energy, experience, and time! It is nice for everyone to be reminded about the great effort that has been put into the project, and to hear of everything that is already achieved. Furthermore, the audience was asked a couple of questions with the aid of Menti.com and participants’ cell phones. The first question was “In what area are you presently in biggest need of support?” By choosing from given alternatives, the answers showed up in a pie chart. The other question was regarding ideas for future improvements, which was a free text question; so that the participants could write whatever answers they wanted.

The presentation then continued with a section where we (Gunilla and Thomas) got the chance to present ourselves to the audience. We, of course, have not met so many of all the users previously. We talked in general about IT artifacts, and of how people in an organization often experience them at times of changes. IT artifacts holds not only the technological dimension, but also a social dimension. It is OK to feel lost sometimes, and one needs to hear someone tell you this. 🙂 We ended our section by talking more specifically about the survey we are preparing to distribute to the users. The purpose of the survey is to evaluate some issues that can – hopefully! – be described as successes, and to point out some specific areas where users would like to see further improvements.

After us, we all got some information regarding the closing of the year 2018, presented by Hanna Mörtberg (newly appointed University Director of Finance at the University Management and Management Council). She showed us some comparative numbers from the years 2010 until today. The university is growing at an amazing speed and has now reached over a 7 billion turnaround!

Spirits were quite high when the presentations were over and we started on some nice snacks with a glass of bubbling refreshments. Anyone had the opportunity to write down whatever ideas they wanted to share about the project, on a writing wall that was positioned at the back of the room. Still, I believe people mostly wanted to chat with friends, have some good food, and just relax after a great job done! Overall, the afternoon was a well-spent time to mark the end of the implementation phase. Now, the system will continue to change over time, as any IT system would. It is a never-ending story.

Digitaliseringen och arbetsmiljön

Idag var det officiellt boksläpp för Digitaliseringen och arbetsmiljön, en bok som professor emeritus Bengt Sandblad författat tillsammans med sina kollegor. Medförfattare är Jan Gulliksen, Ann Lantz, Åke Walldius och Carl Åborg – alla kända namn inom just digitalisering och arbetsmiljö.

Bokens redaktör Jens Fredholm passade på att ställa lite frågor till författarna. Bengt Sandblad slog fast att de flesta problem är onödiga idag, kunskap finns om hur de ska lösas. Åke Walldius fyllde i med att verktygen ska stödja, inte störa men att samverkan mellan alla parter är viktigt. Ann Lantz pekade på ständiga förbättringar som en viktig strategi. Carl Åborg underströk att vi måste sträva mot ett hållbart arbetsliv, det är inte hållbart om en ökande mental belastning ska göra att människor blir sjukskrivna. Jan Guliksen avrundade med att peka på att läget ändå är annorlunda idag, ledningen brukar vilja ta ett ansvar och det finns många fantastiska digitala verktyg vi använder utan problem.

På en fråga från publiken hur man nu ska komma till rätta med alla dessa problem var svaret givet: läs boken.

Shut Up and Write!

Writing is one of our main tasks as researchers: we author papers, books or book chapters, grant applications, blog posts, newspaper articles, etc. for a broad range of different audiences. However, setting time aside for writing is rather challenging, as it is so easy to fill up our schedule with the variety of other assignments we need to accomplish: teaching, supervision, administrative work, data collection, reviewing other researchers’ publications or grants, and more. In the HTO group, we have thus implemented several strategies to help us write more and better.

Following in the footseps of some of our colleagues at Uppsala University (see article above taken from Uppsala University’s magazine, Universen), we are launching afternoon “Shut Up and Write!” sessions every last Tuesday of the month. The idea is simply to sit together and write – each person working in silence on her or his own project – for a few hours at a time. We sit in a meeting room instead of our usual offices to create a change of scenery and atmosphere. The session schedule – the length of each writing slot – is decided beforehand. For example, we might write for an hour to an hour and a half, and then take a break together, possibly with a little fika. Then we move to the next slot. Since it is very focused work, three writing slots in an afternoon can result in significant progress.

Writing retreats, consisting of one or two days of writing in a row, have also become a tradition in our research group. We then gather in Åsa Cajander’s house in the countryside, and sit together the whole day, enjoying fika toghether between writing slots. We wrap up the day with a shared dinner we prepare together, which is a really nice teambuilding activity. Such writing retreats are thus not only an opportunity to be really productive and reach our writing goals, but also to get to know each other in a different context, and to develop friendly working relationships. The discussions that arise throughout the day also give us insights into what others are working on, and can inspire and guide us in our own work. Although writing for several hours is very energy-consuming, I always come back from such writing retreats with renewed motivation and fresh ideas!

Writing sessions and writing retreats can sound over-the-top, but they have definitley been opportunities for very productive work for me. In my experience, getting into the habit of writing often, for a few hours at a time, makes it possible to improve one’s writing and to become a more efficient writer. When are you starting?

The Year 2018 in Review

In retrospect, 2018 was a great year for our research group. So, as we move on to 2019, here are some of the hilights for this year.

The year began with Thomas Lind doing one of his first –but definitely not last– presentations as a PhD, on the topic of IT implementations in health care.

Just after that, the new course on Complex IT Systems in Large Organizations started, with Diane Golay as one of the teachers. In the field of education there were of course also a number of interesting master thesis (such as this, this, this and this).

The second quarter saw Åsa Cajander earn the title excellent teacher but more importantly she also became full professor. You can still view her inauguration speech here (in Swedish). As if that was not enough Bengt Sandblad’s new book on the digital work environment was published – and our colleague Rebecca had her half time seminar.

During the summer Shweta Premanandan visited us once again and she got to experience the Swedish midsummer festivities. Minna Salminen Karlsson escaped the same festivities and instead joined the OAP workshop in the Netherlands.

Of course there were a number of other conferences and events attended by members of the HTO group (here or there). Gunilla Myreteg enjoyed a workshop arranged by Birgitta Wallgren at EPJ (the department for Electronic Patient Records). The HTO group also was responsible for a workshop at Uppsala Health Summit on the topic of Using Data for Better Cancer Treatments.

Much of the research efforts were related to the DISA project. Among many other things Ida Löscher reflected on the use of Work Domain Analysis and Lars Oestreicher shared some observations on cognitive workspace design.

We celebrated Jonas Moll as he concluded his PostDoc in Uppsala, two years and quite a few presentations and papers later. The year finally ended in high spirits when Christiane defended her thesis and became Dr Grünloh.

So, what do we have in store for 2019? More courses, more papers and more conferences of course. Perhaps we could also land a grant or two, to fill the gaps of those who have moved on to new positions. But we will no doubt continue to collaborate with our HTO alumni, in academia you can check out—but you can never leave.

Lecture on Digitalization and our Work Environment

 

System development work is difficult, and many IT systems do not work satisfactorily despite intensive technology development. My research is about improving the situation and understanding what the problems are. I am working on developing improved working methods in the organizations and projects that develop and introduce IT. The focus here is user-centered methods, gender, sociotechnical perspective and agile development. I have also researched the skills that the people in the projects need to master to be able to work with the development of complex systems that support people in a good way.

If you are curious about my research – listen to the 12 min long lecture in Swedish

 

On Digitalisation and Fragmentation of Time

Diane Golay and Åsa Cajander did a presentation on Fragmentation of Time and Digitalisation for the Uppsala University Academic Senate this fall. This blog post captures some of what we said in the presentation.  Enjoy!

Digitalisation of work sometimes has the unintended side effect that it fragments our time. Fragmentation commonly refers to the separation of activities into many discrete pieces. It is usually calculated based on two different aspects: the length of continuous work episodes, and the number of interruptions. In those terms, fragmented work is characterized  by short work tasks and frequent interruptions, as opposed to a work rhythm made of few but long work episodes with no or few interruptions.

Several studies have pointed to the increasing fragmentation of our work.  For instance, a 2009 study found that people switched tasks about every 12 minutes. Two years later, another study found that a modern worker’s day comprised an average of 88 work episodes, most of which (90%) lasted for 10 minutes or less. The found average duration for those work episodes was of just under three minutes.

Work fragmentation is related to a perceived increase in work pace and work intensity. It is also detrimental to the actual work taking place. The causes of fragmentation can be both external, such as a phone call or a computer that stops working, or internal, i.e. self-initiated, such as looking up an information on the web while working on a report.

External interruptions have a particularly negative effect on work. A context switch requires cognitive overhead, and context- switching is related to time costs. Concrete negative consequences of external interruptions include errors, stress, work delay, difficulty resuming the interrupted task, and increased user frustration. Interruptions are however not always negative: inquiries, breaks, and adjustments can facilitate the primary task by providing valuable information or creating an environment that encourages increased productivity. Context plays a significant role in determining whether interruptions are considered to be beneficial or detrimental. In general, interruptions that occur outside of one’s current working sphere context are disruptive as they lead one to (sometimes radically) shift their thinking. In contrast, interruptions that concern one’s current working sphere are considered helpful.

However, it should be noted that fragmentation is also a natural part of our work. Work tasks are to a small or high degree woven together and fragmented in complex patterns. Workers seldom work with one task at the time. Interruptions are a to some extent also a natural part of our work. Breaks are for example crucial for collaboration and learning.

So we should not aim for a fully continuous workflow, but might want to try and reduce external and internal interruptions that are not related to the task(s) at hand. Finding an amount of fragmentation that works for us will enable us to boost our work performance, reduce our cognitive workload, and simply make us feel better at and about our work.

***

[1] Jin, J., & Dabbish, L. A. (2009). Self-interruption on the computer. Proceedings of the 27th International Conference on Human Factors in Computing Systems – CHI 09, 1799. https://doi.org/10.1145/1518701.1518979

[2] Wajcman, J., & Rose, E. (2011). Constant connectivity: Rethinking interruptions at work. Organization Studies, 32(7), 941–961. https://doi.org/10.1177/0170840611410829

Dr Grünloh did an Excellent Job Defending her PhD

We all knew that Christiane Grünloh of our team knows how to do great and important research. But we were still amazed by her skills at the defense! Also, the atmosphere was really super nice and the defense was really a discussion among true professionals more than a questioning. The opponent David Hendry did such an excellent job and was really well prepared. If you weren’t there you missed something special!

Minna Salminen Karlsson from the HTO team, who is indeed very experienced, said:

“This was one of the best PhD defences that I’ve been to!”

The title of the PhD thesis is “Harmful or Empowering? Stakeholders’ Expectations and Experiences of Patient Accessible Electronic Health Records”. The research deals with the national eHealth service in Sweden that gives people access to their electronic health records.

You can read more about the PhD thesis in Christiane’s blog found here

Two studies published on the effects of patient accessible electronic health records

Members of the HTO group recently got two journal articles published, on the effects of patients accessible electronic health records (PAEHRs) in Sweden.  Both studies were picked up by Swedish media after press releases had been published by Uppsala University.

The first article, “On threats and violence for staff and patient accessible electronic health records” was published September 28 and written by Ulrika Åkerstedt, Åsa Cajander, me and Ture Ålander. The open access article, which you can find here, is based on Ulrika’s masters thesis and presents results from a survey study conducted with healthcare professionals at the emergency and psychiatric departments at Uppsala University Hospital. Among other things, the study showed that the fear of being exposed to threats and violence from patients increased as a consequence of PAEHRs being launched in Region Uppsala. Shortly after the article was published this press release was published by Uppsala University. The news spread from there and Forskning.se, Dagens medicin, SVT Nyheter and Vetenskapsradion all published their own articles based on the press release. Åsa and I were also invited to write a popular science summary on Ciennce.se. The article by Dagens Medicin and the article by SVT Nyheter also took things further by e.g. adding interviews Åsa Cajander and representatives from the psychiatry department in Region Uppsala!

Our second article with a PAEHR theme, “Patients’ Experiences of Accessing Their Electronic Health Records: National Patient Survey in Sweden” was published November 1 and written by me, Åsa Cajander and Christiane Grünloh from the HTO-group as well as several other researchers in the DOME consortium (I introduced all researchers that are involved in the study in this blog post). In this article we focus on patients’ attitudes toward and experiences with PAEHRs in Sweden. It is clear from the results that patients really appreciate the possibilities that the Swedish PAEHR system, Journalen, gives them and that patients want access to new results in their PAEHR within a day after a new examination or visit. You can find many more results, and of course more details about the study, in the open access article published here (please help us share the news!). Even this article was presented in a press release from Uppsala University and the news was once again picked up by Forskning.se and we once again got an invitation to write a popular science version on Ciennce.se. This time around Inera (managing Journalen and several other Swedish eHealth systems), published their own press release about the study. The journal IT-Hälsa also wrote an article based on Inera’s release.