Technological innovation and change of nursing work in an emergency department : a sociotechnical perspective

This thesis evolves around the identification and analysis of the particular sociotechnical factors and conditions that facilitate the implementation of new information and communication technologies (lCT) in complex clinical settings. Today most national health systems around the world link the need for best healthcare provision with the overall efficiency of their institutions. Such orientations undoubtedly require outcomes linked to lCTs so as to assign them with criteria and measures of success. On the other hand, implementations of such technologies in healthcare organisations, particularly under the Connecting for Health (CfH) IT programme, have not been equally successful. As science and technology studies (STS) scholarship shows, these technologies, despite their technical robustness, do not guarantee successful implementations. It is rather the intertwining of people, machines and spaces at the local setting that determines the fate of the new system. The four-hour waiting target (now a standard of hospital performance) for patients attending an Accident & Emergency Department (A&E) has undoubtedly become the most important catalyst of effective change towards a "whole system" approach in the provision of unscheduled care. This is, partially, because waiting times in A&Es have been acknowledged as one of the most prominent causes of dissatisfaction for patients interacting with the National Health Service (NHS). From the mid-1990s, Conservative and Labour, governments in the UK have developed and implemented a series of reform programmes to address this issue. After a long series of negotiations, which were intensified at the dawn of the new century, the Department of Health (DH), in accordance with the recommendations of relevant emergency clinical bodies and patient advocacy groups, stabilised, in 2004, the target (now a standard of hospital performance) to 98% of patients attending A&Es to be treated and admitted or discharged within four hours. During that time the DH also released a report with key recommendations on building layouts for these 3 hospital departments in order to positively influence efficient patient care by appropriating circulation spaces for patients, clinicians and visitors. This thesis uses a case study of the implementation of a clinical information system for patient registration and tracking in the busy emergency department of a large Acute Care University Trust in the East Midlands, UK. It explores the complexity of relations and subsequent negotiations between these heterogeneous elements during the formation of a new practice ordering for nursing work. For this, I draw on the work of ANT research, firstly, within the broad field of geography. I conceptualise space and time as invaluable non-human entities that need to be enrolled and converged at the local level in order for the inhabitants (clinicians, administrators, managers) and the visitors (patients and their carers) of this temporal network to enact prescribed movements, interactions, communications and relationships. From there, this thesis examines the way the above national policies (i.e. waiting time targets, built environment design) have come to facilitate the introduction, and subsequent stabilisation, of a clinical lCT in the local clinical setting. Based on the findings from the analysis of 30 semi-structured interviews with nurses, the change manager, the system administrator and assistants as well as from relevant policy documents, internal reports, building blueprints and implementation studies, I argue that the re-engineering of healthcare practice with the diffusion of a new technology is not a fixed and linear process, but more of an interplay of various fluctuant, performative and eo-constitutive technical and social factors. In particular, I first show that the DH strategically attempted at ordering the A&E towards specific outcomes of performativity by formalising procedures, interactions and generally the behaviours of these peripheral networks. Rooms and corridors were redesigned and timestamps are now being applied to every process so as to effect a new spatio-temporality in the planned circulation of patients and hospital staff in the A&E department. As a result, groups of users are being integrated or segregated according to particular (and rationalistic) conceptions of patient flows. 4 For the above purposes, the specific technology under examination arrives in the A&E as an efficient technological solution to a given waiting time problem. While issues of computer literacy and interaction with complex technologies remained a concern for the nursing staff during the implementation phase, these were substantially downgraded in the face of a new rigid policy which aimed at addressing one of the most prominent causes of patient dissatisfaction. The technology was gradually translated and transformed into an invaluable ally. Conversely, success includes not only the appropriate use of the system, but also the users' high dependence on it and finally the network's ability to act as a platform for continual, technologically mediated, reformation of its practices under specific strategic policies. Through an ANT conceptualisation, the thesis concludes by arguing that despite the various negotiations that take part between the centre of calculation (DH) and the local setting (A&E) offering, to the latter, some room for manoeuvre and discretion, in the end, the former is constantly enhancing its instrumental and obligatory passage role in shaping local action. It does this by strategically organising the opening of the black-box of its constituted healthcare institutions through the enrolment, the re-skilling and, after that, the mobilisation of specific intra-organisational networks. 5.EThOS - Electronic Theses Online ServiceGBUnited Kingdo