First observation day, part 2: the perks of immersion

When it comes to analyzing work practice, I have found that one of the main challenges for the researcher is to learn to “speak the language” of the observed population. The researcher needs to develop an understanding for those aspects of the work practice that practitioners don’t explicitly mention, but which nonetheless are a significant part of their work and work environment. The problem is that the more experience we have with doing something, the more difficult it becomes to verbalize how we go about doing it. In addition, many work environment factors are simply difficult to put into words.

Observation provides, to a certain extent, a solution to that problem as it makes it unnecessary for the observed individuals to verbalize every aspect of their work. Until recently, my experience with observation within healthcare was limited to watching video recordings of emergency medical interventions and a live streaming of an open-heart surgery. Those instances provided me with a basic understanding of the workflow of an operation and the specific role taken on by each clinician involved in the intervention. However, I realized during my observation day at the Department of Pediatric Surgery that I had overlooked several essential factors specific to the work environment of clinical nurses. This realization came from the fact that for the first time, I wasn´t an outsider looking in any more, but immersed in the work environment I wanted to learn about. This made for a very different, and instructive, experience.

Here are the different “perks” I have identified in relation to my immersion into nurses’ work environment:

  • More than just a clinical understanding for nurses’ work environment, I got an insight into the “feeling” of it. By wearing the same clothes, sharing the same space and following the same daily routine as nurses, I was able to experience, albeit to a limited degree, how it feels like to be a nurse. This led to my uncovering aspects of the work environment I had not thought of so far.
  • Being a participant observer, I felt that I disposed of a higher degree of freedom when it came to deciding what to focus on. I was able to move freely within the operation theatre (being of course careful not to be in anyone’s way in order not to disrupt anybody’s workflow) and could choose what and whom to focus my attention on. While it is the camera’s positioning that determines and limits the field of vision on a video recording, immersion makes it possible to continuously change observation angle and thus to look at anything that catches one’s attention.
  • In contrast to my previous experiences with video recordings, where one generally only has access to a specific sequence of the work practice of interest, I got a much more complete picture of the workflow this time around. Being there for a whole day, I was able to see not only how an operation unfolds, but also, among other things, how an operation theatre is prepared, how nurses are made aware that the operation is about to begin as well as what happens in the operation theatre once the patient has left. This gave me a better and more accurate understanding of the context in which operations take place at a hospital.

In my next and last blog post within this short series of posts about my first experience as a participant observer, I will address a few aspects that I felt were a bit more challenging in regard with being out on the field.

First observation day, part 1: facilitating interactions

Last week, I had my first observation day at the Uppsala University Hospital, more specifically at the Department of Pediatric Surgery. After introducing myself to the nursing staff attending the morning briefing, I was invited to spend the next few hours in company of an operating nurse and an assistant nurse working in tandem in one of the department’s operation theatres. The purpose of this observation day was not to formally collect data for a study, but rather to familiarize myself a bit more with nurses’ work environment in preparation for the DISA project. This first experience as an observer has led me to reflect on different aspects related to being out on the field as a researcher. I thus thought that I would write a short series of blog posts to share those reflections with you. This first post within the series is dedicated to interactions between researcher and members of the “target population” – and how I feel that observation facilitates this kind of exchanges.

Throughout my observation day, what struck me the most was probably how easy it was to interact with the nurses present – how friendly and open they were to my being there, and how naturally exchanges and conversations took place, even at unexpected moments.  For instance, an anesthetic nurse told me about a problematic aspect of using multiple digital systems while quickly fetching a cup of tea in the personal lounge, and another nurse expressed how energy consuming the introduction of a new system was while passing me in the corridor. Coffee breaks and downtimes during operations (for example while waiting for lab test results) were opportunities for longer conversations with the operating nurse and the assistant nurse I was paired with. During those conversations, I was even able to ask specific questions about what I had seen or heard, which gave me a more accurate understanding of how nurses use and experience IT systems in their daily working life.

As such, I realized that a very significant advantage of being an observer was that I was making myself available to the department´s nurses on their own terms. While interviews typically require participants to come and talk to the interviewer at a specific time and during a pre-determined duration, observation lets them free to choose whether they want to interact with the researcher. If they are willing to do so, they can do it knowing that they are the ones choosing what the conversation is about and how long it lasts, being free to interrupt the discussion and resume their work at any moment. I felt that this was a sort of “win-win” situation for the nurses and I, as they had the possibility to tell me about the aspects of their work with digital systems that they felt were significant without additional stress or constraints while I was able to get an in-depth insight into their work and work environment.

In my next post, I will address another aspect of observation that I experienced as particularly positive: the immersion into the work environment.

The Disa Project: “Between patients and computer programs: Digitization and its impact on nurses’ work environment”

The “Between patients and computer programs: Digitization and its impact on nurses’ work environment”, the Disa project, is funded by Forte. The project started in October 2016 and will run for three years.

You can follow the project work in the HTO blog, at Twitter under the tag #htoUU, and at ReserachGate.

The research questions include how digitization has affected the stress and well-being, control over the work situation, digitization effects on operational quality, and communication with patients and other stakeholders.

Data collection is done through interviews, participant observation and surveys.

Particular focus will be placed on effects on the nurses’ work from the ICT and gender perspective. 

The project is lead by Minna Salminen Karlsson and Åsa Cajander, and work is planned to be done in 1) Children’s care 2) Surgical care and 3) Oncology.

The project team consists of the following people:

  1. Åsa Cajander
  2. Diane Golay
  3. Christiane Grünloh
  4. Minna Salminen Karlsson
  5. Ida Löscher
  6. Jonas Moll
  7. Gerolf Nauwerck
  8. Lars Oestreicher

In Oncology the studies will be a part of the DOME consortium and concentrate on the effects of Medical Records Online on the nurses work environment. Jonas Moll is leading these studies.

In children’s care and surgical care the work is starting up, see for example this blog post from Diane Golay. 

The project has a reference group consisting of eight people that will guide the work. The project will result in new concepts and framworks for managers to use when introducing new IT in health care. Below is an image describing the study design of the project.

 

A (first) closer look at the outcome of the DISA project

The main goal of the DISA project is, according to the project application, the “creation a framework for decision support when new ICT solutions are to be implemented in healthcare […]”. However, this formulation leaves room for many questions. For instance, what decision-making process should this framework support? Who is expected to be using the framework? And what is the actual expected benefit of using this framework? In order to try and answer some of those questions, Ida and I arranged a meeting with the chief digital officer at the Uppsala University Hospital.

We learnt that the University Hospital is at the beginning of a phase of significant organizational changes, including, but not limited to, the implementation of a new digital strategy. There is a clear will to ensure that all IT-projects carried out in the future will effectively contribute to increasing the quality of care at the University Hospital. This should be achieved through a centralized project management and a systematized project application process. Concretely, this means that all project applications will be screened according to a framework composed of four different dimensions:

  1.   the project’s impact on work quality;
  2.   the project’s impact on work productivity;
  3.   the degree of risk related to the project;
  4.   the amount of resources needed to carry out the project.

The aim of this framework is to enable decision-makers at the department of digital development to select and prioritize IT-projects in an effective and efficient manner. The idea is also to push project applicants to motivate their project not based on technology (as in “I need an iPad”), but rather in terms of what needs to changed / improved in the affected work process (as in “I need to be able to see this data and discuss them with the patient while standing next to the patient’s bed”).

In light of this, we can re-interpret the end goal of the DISA project more as the identification and, probably, prioritization, of key factors related to the assessment of a project’s impact on nurses’ work environment than as the creation, from scratch, of a brand new decision-support framework. On the contrary, it seems at this point that finding a way to integrate the perspective of nurses’ work environment into the project assessment framework presented above is the more useful alternative. The need to visualize the different factors involved and their “weight” in the project’s assessment outcome was also underlined during the meeting.

We will of course need to dig a bit deeper into the problematic before knowing for certain what the outcome of the DISA project should look like. Considering that it is a 3-year project including three different specializations and many different studies, we are still at the very beginning of the process. Nonetheless, those first insights should be helpful in strategically planning our first steps within the project.

the Seminar Series at the BioMedIT arena at the Department

The HTO research group are a part of the BioMedIT arena at the department of Information Technology. The arena offers free lunch seminars for anyone interested in BioMedIT and related topics. We strongly recommend anyone to go who is interested!!

Information about the lunch seminars can be found here:

http://www.it.uu.se/research/arenas/biomedIT

There is also a YouTube Channel where all the talks can be found. You find it here:

The team behind a new large study on electronic health records in Sweden

In my last blog post on my personal blog I wrote about the application for ethical review, concerning a new large interview/survey/observation study with doctors and nurses at Akademiska Sjukhuset in Uppsala. The study, which will… [Read entire post]

 

Walkthrough of MetaVision and Orbit with two nurses from the Uppsala University Hospital

Paper-based forms for the daily documentation of a patient in the intensive care unit

With the DISA kick-off approaching, we have been working hard on acquiring the background knowledge necessary to getting the project started on the right track. In this context, Gerolf, Ida and I were given this week an exciting insight into the functionality and layout of two computerized systems that have recently been or will shortly be introduced at the Uppsala University Hospital, namely MetaVision and Orbit. MetaVision is a clinical information system intended to support patient monitoring in the intensive care unit and during operations. Its implementation started about one year and half ago and is now almost completed. Orbit, on the other hand, is an operation planning system whose implementation process will start at the end of the month at the Uppsala University Children’s Hospital.

Two nurses who have been actively involved in the implementation of, respectively, MetaVision and Orbit, kindly accepted to walk us through the main components of each system. In so doing, they also provided us with essential contextual information which enabled us to develop a more complete understanding of the current and upcoming situation at the University Hospital.

As I had never seen what a patient’s bedside looked like in the intensive care, I was impressed to see the number of devices connected to the patient. However, I was even more taken aback by the multitude of paper sheets that had to be filled in by nurses for each patient every day prior to the implementation of MetaVision. As the system now automatically gathers data from the different devices connected to the patient, the need for manual documentation is estimated to have been reduced of approximately 80%. The remaining 20% encompasses such information as the meals and drinks given to the patient, the activities related to personal hygiene provided by the nurses (hair washing, teeth brushing etc.), the patient’s position (back, right / left side) or the evaluation of the pupils.

In regard with operation planning, it is now handled by means of different physical folders containing waiting lists. Orbit is expected to replace those folders as well as to support the documentation of operations, where it would partly overlap with MetaVision’s functionality. However, as no integration of the two systems is possible at this point, the implementation of Orbit will require for nurses to enter twice certain pieces of information in order for patient data to be complete in both MetaVision and Orbit. This situation can be explained by the different origins behind the implementation of the two systems: MetaVision’s acquisition and implementation process was launched by the Uppsala University Hospital before the Uppsala County Council decided to have Orbit implemented as a measure to guarantee a safer operations planning.