HTO Participating in Discussions about AI and Digitalisation

Many from the HTO group are working in the area of AI, automation and digitalisation. Bengt Sandblad is writing a book in the area related to security. Gerolf Nauwerck does a study on automation of an application process in Social Services and Åsa Cajander is interested in the area from a work environment perspective. Also, we follow some of the ongoing digitalisation efforts with automation in health care through the DISA project.

We are all going to this interesting event where the effects on working life and work is discussed.

See you there!

 

Inbjudan AI AW 5.4.19

Gendered Healthcare Hierarchies, Ethics and Information Systems

Minna Salminen Karlsson did a very interesting seminar last week from the DISA research project. It was based on the doing gender perspective. The starting point was that we all behave in a spectrum with femininity and masculinity. In this way of looking nursing is coded as more feminine. And computer science is coded more as being masculine. These two communities also have two ways of looking at the world, and they are very different.

For example: Technical rationality dominates the computer science way of looking at the world, whereas nursing is more based on caring ethics. One difference in their world views is that technical rationality is bases on linear time view, whereas nursing care can be circular, parallel to other things and not always linear. Minna Salminen Karlsson also mention several other interesting differences.

Some assumptions that computer scientists often make when designing the system is hence:

  1.  “Expecting autonomous individuals with linear time”. However, nurses the nurses document at the end of the day and the system is not built for this. Nurses instead do many things in parallel.
  2.  “Obstructing a holistic view of patients = patients are a sum of their conditions.” The summary of the diagnoses is not useful for nurses, since it is built on the idea that all diagnoses are equally important and a part of the summary.

The abstract of her talk was the following:

The hierarchy of healthcare is gendered. This matters in the acquisition and implementation of information systems. The issues in and consequences of implementation of IS in healthcare can be better understood if they are seen as influenced by relationship between technology, as something that is mostly “done” by men (e.g. developers) and care, that is mostly “done” by women (e.g. nurses), in a (societal) context where technology is valued higher than care, and where the digitalization of healthcare is pushed forward by perceived economic imperatives. This is exemplified by analyses of the data collected for the DISA project (The effects of digitalization on nurses’ work environment), using theories of gender in organizations and the concept of ethic of care.

We are looking forward to hearing more about this interesting research!

The DISA project embarking on its last stage

The DISA team had a workshop with their reference group earlier in March, to prepare for the last stretch of the project: creating the eWorkEnvironment framework. To start with, the reference group, representing both people working in healthcare and other researchers, was given an update of the last developments of the project. Both Diane Golay’s presentation about nurses’ invisible work and Thomas Lind’s presentation of an interview study with the people responsible for acquiring, implementing and maintaining the systems inspired a lively discussion about further problems and in particular the gaps between the different actors: decision makers, IT professionals and nurses, and how usability falls in these gaps. The survey presented by Minna Salminen showed that younger nurses sometimes can be more negative to increased use of ICT, and that attitudes to a digital tool are not only grounded in attitudes to technology, but also, for example, in attitudes to patients and patient empowerment.

The afternoon was spent in discussions where the DISA team got several inputs to their original ideas of what should go into the eWorkEnvironment framework. The definition of the target group was one of the tricky questions discussed: “Decision makers” in the process of acquiring and implementing digital tools for healthcare are the target group, but they can be found at many different levels and in many different roles in the healthcare hierarchy and, in addition, the organization varies between different regions in Sweden. Once these “decision makers” are conceptualized, strategies are needed to make them interested in and observant to the effects of digitalization on nurses’ working environment, for them to be interested in the eWorkEnvironment framework in the first place. The reference group had valuable ideas of what strategies could be used to get the message through.

While the message from the DISA team has been that nurses need to be heard when implementing new digital systems, the reference group pointed out that also outside eyes are needed in the process: in addition to nurses’ experiences, outside eyes may help to verbalize aspects that may go unnoticed by nurses themselves.

The DISA team and the reference group agreed that a major problem is the “parallel pipelines” approach to digitalization: there are several actors who all work for more digitalization, but nobody has a whole picture on how the situation looks from the daily working perspective of a nurse and the different systems are not integrated. The normal way of working in projects exacerbates the situation: each introduction is a project of its own, that not only is not connected to other projects running in parallel, but is also often terminated long before the new digital tool has become a natural and useful part of nurses’ daily work.

Having a diverse and competent reference group is certainly an important asset for a project! We are grateful for their time – and are further inspired to try to give something in return, both for the healthcare staff and for the scientific community.

IT and Nurses’ Daily Work: An Invisible Burden – a Licentiate Seminar by Diane Golay

Last week Diane Golay defended her licentiate degree thesis with an opponent. A licentiate degree seminar is very similar to a PhD defense in Sweden and you have an invited external opponent to discuss the research done.

After an introduction to the proceedings of the licentiate seminar by Åsa Cajander, the main supervisor, Diane Golay provides an excellent overview of her work towards her PhD so far in the DISA project, studying the effects of digitalization on the work environment of nurses. The licentiate thesis is based on three research papers:

    1. Golay, D., Löscher, I., Lind, T. (Submitted): The Impact of Information and Communication Technology on Work, Workers, and the Psychosocial Work Context: Research Trends from 2000-2017.
    2. Golay, D. (2018): Analyzing Work-Related Technology Use From a UX Perspective: The HolisticUX Method. NordiCHI’18. The paper is found here.
    3. Golay, D. (Submitted): More Work, Same Hours: Invisible HIT-Induced Tasks in Nurses’ Everyday Work.

In her work Diane Golay concludes that nurses daily work life with healthcare information technology has clear benefits, such as more efficient ways or working. But healthcare information technology also results in “unexpected, unintended adverse consequences”. According to her research typical issues include “loss in efficiency, extra effort to carry out routine tasks, and the creation of new, HIT-induced work activities”. Diane Golay also concludes that health technology leads to new kinds of work that are invisible in the sense that, for example, these new activities are not recognized by management as work nor something taken into account when introducing more HIT.

The Abstract for the Licentiate Thesis: 

Information and Communication Technology (ICT) has been an increasingly pervasive component of most workplaces throughout the past half century. In healthcare, the turn to the digital has resulted into the broad implementation of Healthcare Information Technology (HIT). The impacts of ICT on work life have been investigated predominantly through surveys, although some researchers have advocated for the use of a qualitative, experience-based approach. Meanwhile, the existing body of research on the impacts of HIT on clinicians has painted a mixed picture of digitalization. Despite some clear benefits, HIT has indeed been found to have unexpected, unintended adverse consequences for hospital staff. Typical issues include loss in efficiency, extra effort to carry out routine tasks, and the creation of new, HIT-induced work activities. Simultaneously, research outside of the healthcare domain has shown that ICT could require extra effort from some users in order for the sociotechnical system to function properly – extra work often invisible to developers. Based on observation, interview and focus group data collected at a large Swedish hospital, this thesis set out to investigate the impact of HIT on hospital nurses from an experience based perspective, resulting in four main contributions. First, a method supporting experience-based data analysis, the HolisticUX method, is introduced. Second, 13 forms of HIT-induced additional tasks in nurses’ workload are identified, five of which are not acknowledged in previous research. Third, task avoidance is identified as a consequence of nurses’ increased workload, negatively affecting patient safety, care quality and nurses’ professional satisfaction. Finally, four factors are argued to contribute to a suggested invisibility of the HIT-induced time burden in nurses’ work life to management and developers: 1) lack of a holistic perspective, 2) the hidden cost of a single click, 3) the invisibility of nursing work, and 4) visible data, invisible work.

After Diane Golay’s great presentation of her work, Lina Nilsson invites Diane Golay to a discussion about her research so far as well as her plans for the future.

The discussion, touching on all parts of the thesis and diving into the particulars of the three papers, is mainly centered on how to improve on the work even more and interesting venues and possibilities for this in the remaining studies towards Diane’s PhD thesis. The overall impression of the discussion is of Lina being impressed with the work done so far, and Diane being very grateful for the discussion about the future and the additional input and tips moving forward. The discussion also touched upon subjects such as reliability and validity in this type of research, cultural differences between research areas studying IT in health care such as sociology and computer science, and much else. Throughout, Diane had no problems defending and motivating her choices and proved well aware of the limitations and risks involved in her research. Her research so far has already provided us with interesting contributions to the knowledge in our field, and we are looking forward to her future studies! 

By the end of the day we celebrated the Licentiate degree being awarded to Diane Golay with a set of delicious cakes.

Seminar with Lina Nilsson on “Social Challenges when Implementing eHealth in Healthcare – Organisational Experiences from Research and Development Projects”

Lina Nilsson’s does research on implementation of eHealth. She is a senior lecturer at the Linneaus University and works in health informatics. She has a background in sociology with leadership and management.

Lina did her PhD project in Applied Health Technology (up until 2014), on using IT to improve communication between patients and healthcare staff. In her thesis, she identified social challenges when implementing Information systems in a Swedish healthcare organization: power, alienation, professional identity and encounters are aspects that may influence the implementation process.

Today, she is engaged in education but also research and development projects with focus on eHealth at Linnæus University.  

During her talk she discussed the professional identity of being a good nurse that is not the same thing as being good at IT systems. That working with IT was not seen as a part of the core professional nursing profession, and that previous bad experiences of implementations affect future ones.

Suspicions based on previous experiences of implementations, attitudes along the lines of “it didn’t go that well last time, why should we trust this one to be any better?” are challenging for an implementation project in health care. eHealth can provide tools that are appreciated by health care professionals, but also affect their work in ways that they do not. For example by affecting traditional power structures between professions.

Today Lina Nilsson has focused her research on nursing. One thing that she has found is that ICT implementations solve certain problems related to work, but that it also introduces new problems. She is also working in a project, ePATH, directed at supporting patients and empowering patients in care at home. In another project, she is involved in researching how small and medium sized enterprises can compete more fairly with larger actors on the market for providing HIT to health care organisations.

Three Key Note Speakers at the Next SuniWeb Conference

Join the HTO research group at the next SuniWeb Conference in Uppsala the 29 and 30th of April 2019! Three people from our research group will be keynote speakers.

All three researchers will be presenting on the 29th of April. First Diane Golay and Åsa Cajander will be talking in the morning about the latest research in the area of digitalisation and the work environment. This includes really interesting results from Diane Golay’s licentiate thesis related to invisible work and IT (from the DISA project). They will also touch upon fragmentation of time, changes in work tasks and the problems related to always being online.

Lars Oestreicher will be talking as the final keynote of the conference. His topic will be “How do you create communication systems for people with severe disabilities?”. In his talk, he will talk about web applications and non-excluding design.  In this way of doing design you focus on how to isolate the excluding factors already in the design process. He will also talk about his exciting research on young people with disabilities and music as a concrete example of to focus on abilities instead of disabilities.

Welcome to an International Summer School in User Centred Design and Health & Wellbeing in Finland

Welcome to an international course on interaction design!

This Nordplus funded class brings together practitioners, students, and teachers from Iceland, Finland, Estonia, Denmark, and Sweden to gain a higher level of digital literacy. The course provides the basic skills in user-centred, hands-on interaction design during two intensive weeks, including Google Design Sprint.

Experimental Interaction Design
29 July – 9 August, 2019
Aalto University, Finland (www.aalto.fi)

Applications deadline: 31 March
Acceptance notifications: 19 April
More information: https://blogs.aalto.fi/ixd19/

For questions, please contact:
Ilja Šmorgun, Lecturer of Interaction Design, Tallinn University ilja.smorgun@tlu.ee

Welcome!

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.

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?