Category: Methodology

Can Digital Forms with Contextual Instructions Improve Medical Certificates for Sick Leave? – A Master Thesis Study

To get paid sick leave in Sweden, one must obtain a medical certificate from a physician and get it approved by the Social Insurance Office (Försäkringskassan). A recent report showcase that 9,7 % of all medical certificate forms are sent back to the issuing physician by Försäkringskassan (2017), needing completion or re-phrasing of the filled in data. The biggest culprit in the form is the field where one should describe how the patient’s condition hinders them from working.

In collaboration with EPJ, Region Uppsala and the company Inera, I will in my master thesis evaluate if a digital version of the form can help mitigate the frequent rejection of forms (due to phrasing). With a number of different prototypes, we will try to uncover if contextual instruction to each form field can help physicians fill in the form in a way that better corresponds with Försäkringskassans expectations.

The project has a great potential not only to ease the burden of an already strained health care system (and their patients), but also in regards of understanding physicians’ needs when it comes to IT. In the best of worlds, the results can help us design better health care systems and ensure a sound health care. It is truly exciting to work on projects that has the potential to impact many patients’ life quality, where an early approved medical certificate can mean the world to many.

Author background

Anton Björsell, Uppsala University. The study is my master thesis project within HCI and is planned to be executed throughout February to May this year. Except my focus on HCI, I also hold a bachelor’s degree in Media and Communication Studies. My favourite kind of research is the one which makes an honest attempt to understand humans and their needs. I am very excited about the project and grateful for having the opportunity to work with a topic that concerns so many people.

Summer School on Doing and Communicating Qualitative Research

Mid July, Diane Golay and Christiane Grünloh attended the summer school on “Doing and Communicating Qualitative Research” at Kingston University in London. This summer school has been offered already before and the main organisers are Evanthia Lyons and Adrian Coyle, authors of Analysing Qualitative Data in Psychology (Sage).

The summer school offered various workshops per day, from which the participants could choose. The workshops attended by Diane (DG) and Christiane (CG) were:

  • Principles and Practicalities of Qualitative Research (DG)
  • Doing Thematic Analysis (DG)
  • Doing Interpreative Phenomenological Analysis (CG)
  • Doing Narrative Analysis (CG)
  • Qualitative Interviewing: Individual Interviews – Focus Groups and Beyond (DG & CG)
  • Keys to Publication: Writing Qualitative Research (DG & CG)

The participants were quite active on Twitter during the week, using the hashtag #KUQRSS (Kingston University Qualitative Research Summer School).

Keynotes

Celia Kitzinger gave an inspiring keynote on “Making a difference with qualitative research”. Her current focus is on “exploring the cultural, ethical, legal and social dimensions of coma, the vegetative state and the minimally conscious state”, which you can learn more about on their website.

Reflecting on research and the “impact” we want it to have, one might wonder: How do you make a difference when you only have a small sample? Celia shared an example from her research, which was really powerful. They had interviewed relatives from patients in a vegative / minimally conscious state. Afterwards they gave them postcards, on which the interviewees could share something that they wanted the doctors and lawmakers to know. These postcards were then later made into an exhibition that doctors and lawmakers attended. Pictures from, for example, one doctor reading the postcards in that exhibition were then shown to the relatives. For these relatives, it made a big difference that the doctors had read their postcards. This showed us that with relatively low-key and simple tools, it is possible to make an impact – make people’s voices heard and establish a communication between groups of people that otherwise do not come into contact with each other (like for example in that case, lawmakers and patients’ relatives). Inspiring!

Celia had scheduled some tweets that were published on Twitter during her keynote, for instance this one:

Dariusz Galasiński gave a keynote on “Qualitative discourse analysis and psychology: Extending the possibilities”. As a linguist he shared interesting experiences, for instance, from an study on questionnaires. They used the “Think aloud” method while participants completed a questionnaire, because they were interested in how people interact / cope with questionnaires, their construction of their choice, and what did people say about the choice they were making. This was really interesting, as some of the questionnaires put a number to an emotion. He gave “despair” as an example and that you cannot have “little” despair, because being despaired is always “big”. A participant said, that he felt not despaired, but a little bit weak, so “let’s put a little 2”.

He also presented some very interesting findings from his research on men’s suicide notes, which led him (with some help from his daughter) to define the concept of “long suicide”. (He made this research into a book, which was recently published.)

Workshops

The workshops proved to be extremely helpful and relevant for our research. They provided theoretical background which we could then apply in hands-on exercises. We got many practical advice during the week, which are also relevant for experienced researchers. For example, in the workshop on IPA (Interpreative Phenomenological Analysis), it was recommended to conduct the first 2-3 interviews, transcribe them and then have a supervision and discussion with someone. The supervision focuses then on questions like: Do they really talk about things that you want them to talk about? It was also said that sometimes you notice small things; for example that you ask a lot of closed questions. The lecturer was then asked, if this supervision is also needed if the researchers is very experienced. Yes indeed, as it is unlikely that they have worked with these population group or asked these interview questions before.

The hands-on workshop on interviewing, already mentioned in a previous post, was definitely a highlight. It covered all the most significant aspects of designing an interview schedule and actually conducting an interview. At some point during this second phase, Diane was given the opportunity to put herself in the shoes of the interviewer for a while, and received valuable feedback on how to improve her interviewing skills. A very instructive experience!

Consultation Clinics

Every day, we had the opportunity to attend a consultation clinic – an hour of discussion in a small group with an experienced qualitative research, during which we could ask questions related to our own projects. This was an excellent opportunity for us to get expert advice on our current and even future research endeavours. Getting a fresh perspective on our projects, from people who did not belong to the same field as we did, was extremely interesting. It led to very constructive and creative discussions – so much so that the time always seemed too short, even after a whole day of active mental work!

We found the consultation clinics so helpful that we made use of them even on days where we did not have a particular question ourselves, because it was very valuable for us to get the opportunity to learn from the projects of others and the recommendations they received.

Visit at Hampton Court

On the last day, we visited Hampton Court Palace, which you can see on the picture accompanying this post. We were a surprisingly small group visiting, but we very much enjoyed both the visit and the company!

We wholeheartly thank the organisers – especially Prof. Adrian Coyle – for this fantastic week and highly recommend this summer school to everyone interested in qualitative research!

What we see and do not see – Some further notes on the observation studies…

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:

    1. 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. 
  1. 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. 

La la Ladok

Our research group has a long tradition of doing action research. Action
Research has been defined as having dual aims, research as well as involvement. The latter implies things happening, action, change–a bit like agile development if you wish. At the same time, this is relative to scale. In a small project, things are happening fast and various actions by practitioner and researcher alike have direct consequences. In large projects, this is not always so. In retrospect it will be easier to see the change and trace a trajectory. In real time, especially in the periphery of a large project, it can be hard to experience any action.

One of ongoing action research projects we are following the local preparations for a major new system implementation. Deadlines have been pushed forward on numerous occasions–by years.

The system in question is the nationwide Swedish Student Information System (SIS) – better known by the name Ladok. The system holds all student records for students in Swedish higher education and is critical from a legal perspective but it is also the backbone for most other student related ICT as it is used to generate directory information that is used by learning management systems (LMS), campus cards etc. The system is long overdue for an upgrade and a completely new version is just in its early phase of implementation. This is a 50 million Euro project with an estimated user base of 400 000 students and 50 000 staff in higher education.

We have been following the local preparations at one university, rather than the development as such. The collaboration has included activities such as:

  • coaching,
  • seminars,
  • participation in information efforts and
  • surveys.

The major effort though, were the vision seminars that were conducted with students and staff (users that is) in order to establish high level goals. Thus, our focus has been on local preparations for a huge change in work processes that the new system will require.

While the constraints and uncertainties can be at times frustrating this is also the reality behind many large system implementations. In the next few posts we will further discuss some of our experiences from the project – so far.