People : technology and complex work in healthcare

Healthcare workers operate in settings that possess many of the characteristics associated with naturalistic decision-making: complexity, uncertainty, ambiguity, goal conflicts, shifting priorities, time pressure, and multiple agents. They use informational artefacts to support them in this work, both at an individual level (for example, aids to prospective memory) and on a workgroup level (coordinating work that is distributed across time, space, and workers, both within and among different professional disciplines). These uses occur throughout clinical work, but may be easily observed at certain points in time, such as transfers of responsibility for patient care. For example, workers going off-shift must transfer their authority, responsibility, and situational knowledge, assessments and plans about patients and their conditions, work in progress and remaining to be done, stance towards changes in plan, etc, to members of the on-coming shift. A variety of artefacts have been used to support this activity; they can be roughly grouped into three categories of increasing complexity: general purpose artefacts used in special ways (eg, paper notes, personal computers); manual, special purpose artefacts (eg, shared display boards); or special purpose, computer-based (eg, clinical information systems). This panel will present analyses of ethnographic observations from a variety of clinical settings, regarding how clinical workers use these different technologies in varying ways to support their work and in particular, their functioning as a joint cognitive system. The panel will last 60 minutes and will be structured into four brief (10 minute) presentations to allow ample time for discussion. The presentations and speakers will be as follows (in roughly increasing order of technological ‘intensity’): 1. Prof. Guglielmetti is a social psychologist with research interests in decision-making in complex settings. She will discuss ethnographic observations in a medium sized emergency department (ED) in northern Italy, focusing on workarounds that triagists use to overcome limits and rigidities of the personal computer mediated communication system adopted in the ED. Because there is a shared perception that the computer-based artefact loses subtle nuances of the triagist’s perspective, work practice observations have highlighted the triagists’ activation of verbal, direct, synchronous communication to direct physicians’ attention to crucial information to facilitate management. The risks and benefits inherent to this informal practice will be presented and discussed. 2. Dr Shawna Perry in an emergency physician and researcher in patient safety. Workers in EDs and hospital wards in the US and UK have spontaneously developed a shared artefact to support both individual and collective work. These take the form of large dry erase boards, originally used for tracking patient locations but over time extended to include a great deal of additional functionality. Because they have been developed directly by frontline workers, with almost no influence from management or external regulators, they offer a window into the issues that workers find difficult and important in their work. 3. Prof Robert Wears is an emergency physician and safety researcher with a background in software engineering. For a variety of reasons, the manual “whiteboards” described above are gradually being supplanted by computer-based information systems. These computerized systems emulate the form of the manual whiteboards but often have failed to capture some of their important functionalities. This presentation will describe a before-after study of the change from manual to computerized artefacts and the positive and negative effects of the change on clinical work. 4. Stephanie Wilson is a researcher interested in design of usable technology and in studying the use of technology, particularly in healthcare settings. Increasingly, computer-based artefacts are being introduced to support important coordinative and communicative aspects of clinical work. This presentation will draw on recent ethnographic studies of handover in varied healthcare settings to describe efforts to design these kinds of technological artefacts. We try to understand not just what information is conveyed in handovers, but why it is conveyed, and to think about how to move from the "as is" situation (which may or may not be a good one) to one that embraces new opportunities without impeding the work. Key issues include supporting good situation awareness, decisions, explanations for those decisions, tasks, accurate patient data (sometimes detailed, sometimes summarised) and the evolution of the situation.