Doing observation studies is not always as easy as it may seem at first glance, and Diane has already written much interesting stuff in her previous posts on the topic. I agree with her meta-observations, and I just thought I should add some of my views on this topic as well. My experiences are from my two days of observations on the children’s hospital, and the ward for children with tumour and blood diseases. Although the doctors and nurses work with very serious issues, I only experienced a very constructive atmosphere during my two days.
Most of the time when we visit the hospital environment we are there to receive treatment or visiting someone who is. We see a lot of things, and in some way they make sense. We see the blinking numbers on the wards, and we see the different screens used by the nurses and doctors. We see the white coats with blue stripes and don’t think more about that. But when we set out to actually study what is going on in this environment we not only have to see but also interpret the observations into scenarios. Even when we want to study a single system, and its effects on the work, it quickly becomes very evident that the workspace is a very entangled mesh of interactions between people and people and between people and machines. Some of these interactions are very short but nevertheless less important, and they are easy to miss if you are not focused. Some interactions are longer and thus also easier to observe. But in some cases, the more long-term interactions are also easy to miss because they are not continuous and thus have to be observed not only in terms of the shorter sequence as a whole (for instance, see example 2 below).
So, what do we see during an observation visit? Lots of things, but it soon becomes clear that the things we do not (normally) see, are just as important, if not more. Just to give two quick examples:
In the ward, at every workplace there are two screens for logging into applications, such as Cosmic, and other supportive tools. What is not (easily) seen is the parallell information storage that is widely used by the nurses. After almost a day at the ward, I suddenly realised that all the nurses had a small paper notebook, which they consulted now and then. It was kept in the pockets of the coat but was very difficult to observe. When asked about it, the nurse told me that the notebook was used to keep track of the details about each patient. The notebook seems to be an important but almost externally invisible information carrier.
Another observation that caught my attention, not because it was evident, but rather because it was not, was the role played by the alarm bell. The alarm has two functions, one that is an emergency call and the other, which is just a call for help with toilet visits or similar. Both are noted on the same display, and with similar sounds (still clearly easy to distinguish). However, the reactions to the alarms are completely different. In the second case, one or two nurses go over to the room, as soon as they are finished with their current tasks. In the first case, the work spaces are emptied within a few seconds. All tasks are interrupted, and almost everyone rushes to the room in question. Since they rush in the middle of a task, the software applications need to be extra supportive and help the nurse getting back into what he or she was doing. This is not something that is easily visible but could be of great importance.
These two examples show in a clear way that observations can be multilayered and need to be both seen and put into the work context. In the case of the notebook, it was also something that was not really thought of by the nurses; it was so integrated into their work that they never gave it any thought.
This makes on-site observation studies both important and interesting but also difficult at the same time. How to systematically get at these ”invisible” observations is a difficult matter, and from my experiences, I think it requires a long observation time to find many of them.
This week Jonas Moll and Åsa Cajander from HTO participated in a two-day conference with around ten other researchers from the DOME consortium. The consortium has done research on medical records online since 2012, and it is really a flourishing group of people. Recently DOME has received funding for several new research projects, and the Disa project is partly a part of DOME.
Åsa Cajander has written a short blog post of the work done during day 1 of the conference, and day two had a focus on the future of the consortium. You can also find some blog posts on DOME in Jonas Moll’s blog.
To make the discussion about the future of DOME, and a reframing of the objectives of the consortium we had engaged a professional facilitator from Gothia Science Park to help us. I must say that the person we engaged did an excellent job, and that we had very good discussions related to our work.
We started off the work with DOME’s future during day one when we were asked to write post-it notes in areas related to an inventory of our assessments. Day 2 we then started to work with the invetory of what we have in regards to results, networks, experiences etc. We worked in pairs and rotated in the room to put notes on the different topics on different sections of the wall. The whole room was especially designed for this kind of workshop, and to facilitate creative discussions.
When the inventory was done we moved on to doing a SWOT analysis, and to defining the objectives with the DOME consortium that needed to be updated and agreed upon.
We were also asked to write down our own objectives with being a part of the consortium, which revealed that we are indeed a group of people motivated by improvement of heath care. This exercise also showed that many of us have the same goals, and that there were no contradicting goals in the group.
This strategic work was indeed very motivating, and really something I strongly recommend to all research projects, networks or research groups.
As always it was excellent to meet the other DOME researcher, and I am really looking forward to our next meeting in the fall. Until then we collaborate using Slack, Skype and other collaborative technologies. Not as fun, but it works really well too. 🙂
In my two last blog posts, I wrote about some of the positive aspects of participant observation I experienced during my first day out on the field as a researcher. I am now closing this short series of posts by addressing the side of this kind of observation I felt was more challenging:
The frustration of not understanding everything at once. There is something exhilarating about being immersed in a work environment that outsiders seldom get to experience and uncovering new knowledge about the work practice under focus. However, not everything one observes can be correctly understood or interpreted at once (especially when one is new to the domain of interest). Throughout this first day, I was thus often left wondering what the medical staff were doing and why they were doing it. I did not always get the opportunity to ask about what I had seen and when I did, it generally was some time after the observation of the specific event I had questions about. As such, I discovered that if I wanted to be successful as an observer, I needed to learn to be patient and accept that I might have to wait some time – maybe even until another observation day – before getting the answers to my interrogations.
The “behave as if I weren’t there” awkwardness. I was at times uneasy in my observer role, and struggled to find a way to observe that did not feel like I was “stalking” the nursing staff. Not knowing whether they felt comfortable with my watching over their shoulder (which I sometimes needed to do), I started to feel quite self-conscious about my being there. I was worried about my presence being distracting or even annoying to the people observed, something I of course absolutely wanted to avoid. I did not ask about how the situation made them feel at the end of my shift – should I have dared to? – but do wonder whether they thought the situation was as awkward as I felt it was…
Staying focused on the activities of relevance. A few times throughout the day, I let myself get distracted by events happening in the room that were not actually part of the scope of my research. For instance, I once became so entranced with the patient’s post-operative care that the operating nurse had to actually tap my shoulder in order to call my attention to the fact that she was going to start documenting the procedure…
Staying emotionally detached. Working within healthcare, it is obvious that one will be confronted to difficult circumstances, and it seems only normal to be touched and feel empathy for the people involved. However, it is at the same time important to develop strategies in order to keep a healthy emotional distance from the patients and nursing staff. This is necessary in order not only to do good work, but also to protect oneself and make sure that working out on the field does not negatively affect one’s own life. That being said, I found it very hard not to let myself become overly emotional over the situations I was witnessing during my observation day. This is something I feel I really need to work more on until my next day out on the field.
We had an exciting two day Kick-off meeting with the DISA-project in beautiful Sigtuna on Thursday and Friday last week. The first day the project team focused on getting to know each other, and to talk about what is done so far and future plans. Minna Salminen-Karlsson gave us insight of what a gender perspective of the project can be and we had a discussion about the PhD students work and how our interests fit into the project. After long and giving discussions we manage to get out just before sunset for our own organized city tour. We visited the historical sites of Sigtuna and took turns conveying its interesting history.
The DISA project has a reference group who was invited for the second day of the kick-off. This day started off with a speed-mingle, which is a form of team building exercise including questions like “how do you explain what you are working with to your friends and family?”. It was a great and fun way to get to know each other.
The day continued with a presentation about the overall goals and objectives of the DISA project by Åsa Cajander. Christiane Grünloh, Diane Golay and I also presented the three project tracks, Oncology, Surgical care, and Children’s care. The last hours of the day was spent on a workshop where we, together with the reference group, brainstormed about the effects of digitalization on the work environment of nurses. The workshop lead to interesting discussions, and it was a good opportunity to learn from the reference groups experiences from health care and from previous research.
The Kick-off was very well organized by Gerolf Nauwerck and it seemed like all participants were satisfied after the intense days! I had a great time and feel excited to work with the DISA-project and of course together with this group. I especially enjoyed the openness of the discussions and how everyone contributed with their own perspective and expertise.
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.
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 “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:
Minna Salminen Karlsson
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.
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.
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:
the project’s impact on work quality;
the project’s impact on work productivity;
the degree of risk related to the project;
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 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:
There is also a YouTube Channel where all the talks can be found. You find it here: