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:
- participation in information efforts and
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.
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:
- Åsa Cajander
- Diane Golay
- Christiane Grünloh
- Minna Salminen Karlsson
- Ida Löscher
- Jonas Moll
- Gerolf Nauwerck
- 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.
In order to familiarize myself a bit more with the medical domain in preparation for the DISA project, I decided to attend the lectures of the “Medical Informatics” course given at the IT department at Uppsala University. The course comprises several study visits, the first one of which consisted in attending a live-streaming of an open-heart surgical intervention at the Uppsala University Hospital.
The live-streaming, which consisted of a high-quality video feed without sound, was orchestrated and commented by a clinician. Before and throughout the three hours that lasted the streaming session (which, unfortunately, ended before the end of the actual operation), the clinician provided us with some background on the ongoing procedure and explained to us how the main machinery and tools in use during the operation worked – showing us real-life examples of what these tools look like.
Throughout the streaming session, we had access to three different cameras located at different places in the operation theatre and capturing different angles of the intervention. As such, there were three different “views” available:
- the operation theater as a whole, where we could see who was present in the room and how the medical staff was standing around the patient;
- the “surgeon’s view”, where we could see the (opened) chest of the patient, as if standing above the patient’s body;
- the vital signs monitor.
The main view used during the streaming session was the second one, the “surgeon’s view”. However, we switched several times to the general, operation theatre view, though for shorter amounts of time.
The live-streamed intervention revolved around placing an artificial valve inside the patient’s heart. In order to do this, the clinicians needed to:
- Open the patient’s chest (including the chest bone);
- “Connecting” the patient to the heart-lung machine (described in more detail below);
- Stop the heart;
- Open the heart;
- Fix (with stitches) the artificial valve inside the heart;
- Close the heart (with stitches);
- Restart the heart (a defibrillation was needed);
- Make an ultrasound of the heart (in order to check that the valve was working and well-adjusted);
- Set up draining tubes (in order to allow for the bleeding within the heart cavity taking place during the next few hours after the operation to be drained out of the body without re-opening the chest);
- Close the patient’s chest – a last step that we were unfortunately unable to witness.
To me, one of the most fascinating aspects of the surgery was the heart-lung machine. Its first function is to cool the patient’s blood (and, ultimately, the patient’s body) in order to minimize the risk of brain damage during the operation (which can be quite long). Its second, and probably main, function is to act as a substitute to the patient’s heart and lungs so as to enable the heart to be stopped while maintaining the patient alive. The heart-lung machine is handled by a specially trained nurse (called “perfusionist” in Swedish and “perfusion technologist” in English), who disposed of a screen (in addition to the machine’s two interface screens) with a specific MetaVision layout fitted to her particular needs.
Beyond the perfusion technologist, sitting at the heart-lung machine situated at some distance from the foot of the patient’s bed, the medical team actively taking part in the operations was composed of a main surgeon, an assistant surgeon, an operating nurse (notably in charge of handing instruments to the surgeons), an assistant nurse (notably in charge of handing equipment and instruments to the operating nurse) as well as an anesthetist and an anesthetic nurse. Interestingly, the anesthetist and the anesthetic nurse, standing at the head of the patient’s bed, were separated from the surgeons by a sort of curtain placed vertically between the chest and the head of the patient.
I noted two further interesting facts from the streaming. First, all team members except for the main surgeon are replaced at some point during the operation in order to prevent the risk for distraction- and tiredness-induced errors. As such, good “transfers of duty” seem to be an essential part of such complex and long interventions. Second, the surgeons and operating nurse did not seem to use any screen as support, and it is the anesthetist who is responsible to look at the result of the ultrasound in order to assess whether the result of the operation is satisfactory.
In summary, this was a truly fascinating and instructive “class”, though I was a bit disappointed by not having any sound – I had hoped to be able to hear how the medical team communicates and to understand when and how they use the different screens and computerized tools they are surrounded with. Hopefully I will get the opportunity to attend another operation within the next few years in order to answer those questions!
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:
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]