Methodologies for Understanding Clinical Work

At the core of approaches for understanding clinical work (and work, generally speaking) is the argument for a re-thinking of the status of “representations of work” (Bannon, 1995); a struggle, among researchers, to make work more visible by simplifying the complex and intertwining relationships that has beclouded the space of interaction between people and machines (Winograd and Flores, 1987; Suchman, 1987; Robinson and Bannon, 1991; Sumner et al., 1998; Dourish, 2004; Szymanski and Jack, 2011; Gabbay and le May, 2011); and, quite remarkably crucial, an adoption of the practice-theoretic perspective or, simply, the “practice turn” (Schatzki et al., 2001; Suchman 2002; Pace et al., 2010; Gabbay and le May, 2011). Work typically takes place at particular times, in particular places, and in relation to specific cultural, social and technological circumstances (Kemmis, 2009; Chaiklin, 2011); the linchpin of the practice-centred approach, therefore, is that work analysis and IS design strategies should reflect this. We review the theoretical and empirical approaches that have been applied towards a representation of real-world work beyond formal work processes, which that only denote, according to (Clancey, 2006), “inference[s] applied to facts and heuristics”.

2.4.3.1

Theoretical Approaches

Literature across health and social sciences and, more recently, IS and HCI is suffused with accounts of what (Gabbay and le May, 2011, p. 166) describe as social construction of “clinical reality”. The notion of clinical reality, arguably, highlights the fact that clinical work

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has a dual nature; i.e. any instance of clinical encounter (May, 2007) is so profoundly and inextricably influenced by prevailing social, organisational and environmental contexts that the encounter becomes remarkably different from any pre-existing theoretical construction of it. We discuss a number of theoretical conceptualisations that make evident the notion of social construction of clinical reality in relation to our concept of practice-centred awareness. The theoretical conceptualisations, among others, attempt to elucidate the hidden practicalities of the “space” within which people work.

The French Philosopher, Pierre Bourdieu (1977) was among the first to seek a deep-seated understanding of human work. In his field study of the Algerian Kabyle people, he develops, around the central concept of the habitus, a general account of how human action should be understood in relation to its cultural and social contexts. Bourdieu notes that local (instances of) problems are so complex with inherent “ambiguities and uncertainties of behaviour and situation” that it often requires the “art of the necessary improvisation” (p. 8) to achieve excellence.. The concept of the habitus applies reasonably well to clinical problem situations across boundaries; since clinicians, during decision making, often have to engage in actions that go well beyond the “rules” that could be abstracted from any clinical workflow. (Gabbay and le May, 2011) note that:

To watch a clinician manage a patient competently is to watch much more than the application of a set of rules or guidelines. It is an act of extraordinary sophistication and complexity … (p. 168)

Equally underlying this crucial, but blurred, nexus between clinical action and clinical problem context is the idea of “common sense” and “local knowledge” (Geertz, 1983). Geertz has observed that for all individuals in all cultures, it is “only in isolating what might be called its stylistic features, the marks of attitude that give it its peculiar stamp”, such as “natural- ness”, “practical-ness”, “immethodical-ness” and “accessible-ness”, “that common sense … can be transculturally characterised” (p. 85). Gabbay and le May (2011) extends Geertz’s concept of common sense to formulate the term “clinical common sense”. They observe that:

When clinicians arrive … at decisions that “just make sense” but which they can’t explain …, it is arguable that part of their inarticulacy is due to exactly these attributes of the “clinical common sense” that are the hard-won basis of their professional capital. (p. 168)

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Though messy, inconsistent and difficult to articulate, clinical common sense includes what Geertz calls “stylistic features” that makes it a convenient tool, as a “local knowledge”, to support a clinician in navigating the contextualised and “disorderly terrain” (Gabbay, and le May, 2011, p. 168) of their local practices.

In his work focusing on a search for a new foundational approach to HCI, Paul Dourish (2001, 2001a) proposes the concept of embodied interaction. Underlying embodied interaction is the notion of embodiment, which reflects both “a physical presence in the world and a social embedding in a web of practices and purposes”; it is “the property of being manifest in and as a part of the world” (Dourish, 2001a). Dourish's work, which draws heavily on twentieth century philosophical accounts of the phenomenological tradition, argues that the context or setting within which an activity unfolds should not be treated as mere background, but as a fundamental and constitutive component of the activity. If we take, as we do in this work, the view that clinical work practice comprises the context and setting of clinical work, then the concept of embodied interaction becomes not only a “constitutive component” of work, but also provides a set of propensities to guide the decision-making pattern of a clinician, albeit non-rigidly, and to address a wide range of contextual modulators for all likely occasions within a local work environment. The idea of bringing context or practice out of the background resonates equally well with Chaiklin’s (2011) arguments on the crucial role of practice in mediated work environments. The author argues that approaches for analysing work need "consider activity as organised in relation to practice" as a necessary means of scaffolding people’s cognitive capabilities and shaping work in the real-world. Equally related to our concept of practice-centred awareness are Suchman's much cited concept of situation action (1987) and Christina Haas' theory of embodied practice. The pivotal point of Hass' theory, which grew from her years of empirical research on the effects of using the computer to write (Haas, 1996), is that "technologies and other artifacts "encode" the knowledge of a community and allow for certain kinds of cultural activity and not others" (p. 45); thereby impacting on the individuals who use them. Other theories and ideas that have attracted the attention of researchers seeking to understand work “in practice”, most of which, like embodied practice, draw on contemporary Vygotskian studies, include the concept of social situatedness, situated learning, situated cognition, and situated activity (Lave and Wenger, 1991; Hendriks-Jansen, 1996; Lindblom and Ziemke, 2002).

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Within the field of healthcare, the ethnographic study of ‘Lawndale’ practice by (Gabbay and le May, 2011), has provided a formidable insight in the nature of clinical work. The authors argue that neither formal domain knowledge nor organisational guidelines as employed by expert clinicians to 'technically' guide heuristics, pattern recognition or categorisation – ‘illness scripts’ (Gabbay and le May, 2011, p. 56) during diagnosis is sufficient to account for the whole of range of issues and variable factors (e.g. lack of precision tools for early detection of breast lumps, or how to manage the psychological trauma of a bereaved patient) that a clinician has to deal with during diagnosis and treatment. The study notes that “clinical reasoning is far more situated and flexible than even the most complex clinical algorithm can express” (Montgomery, 2006), and introduced the concept of “clinical mindlines” to describe the set of internalised, collectively reinforced and tacit guidelines, which are informed by clinicians’ professional training, practical experience and their understanding of local circumstances and systems, and which serve as their “knowledge-in-practice-in-context” (Gabbay and le May, 2011, p. 65) in dealing flexibly with the contingencies of clinical practice. Originating from the field of medical practice, study has brought to the fore the hitherto difficult to acknowledge fact that clinicians often do not follow the “idealised model” of technical medical knowledge (Cabana et al., 1999; Gawande, 2002), but rather choose to draw, as circumstances warrant, from their clinical mindlines to address patients’ needs in varying situations. Arguably, the outcome of the ethnographic study, which is compatible with the result of our user-centred study (see Chapter 4), has provided a fodder for the design of clinical decision support systems based on the correlation between local circumstances and patterns of clinical practice. In a related work, which focuses on unintended and undesired consequences of the use of HIT, (Harrison et al., 2007) proposed the concept of interactive socio-technical analysis aimed to capture common types of interaction and recursive processes within a clinical work setting. The study notes that effective use of technologies in clinical settings requires understanding the gap between HIT design and the healthcare organization’s socio-technical system, including its workflows, culture, social interactions, and technologies (Dayton, 2000; Respício et al., 2010; Burstein et al., 2010).

Many of the ideas considered in this section still appear too under-developed to pass for a theory, and some have been criticised for being over-ambitious or too vague, or for the lack of precision about how the dual dimensions of work exactly interplay in a real-world context for

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the construction of clinical realities. Nevertheless, most of them do command considerable currency among researchers, and provides a productive framework for conceptualising the idea proposed in this thesis – namely how to design e-health systems for cross-boundary clinical decision support based on the notion of work practice. They have the potential to foster a clinician’s awareness of complex clinical situations across boundaries of work settings.

2.4.3.2

User-Centred Methodologies

A high-level concern of investigations of human work, which draws from the cultural- historical tradition, is not to understand the “user” per se, but rather to understand the human mind, or what (Nardi, 1996) refers to as “consciousness”, within a work context, i.e., the meaningful, goal-oriented, and socially directed interaction between people and their material environments; and to apply that understanding to inform technology design (Card et al., 1983; Carroll, 1997). A number of user-centred methodologies by which researchers can gain an understanding of work exist. They are most usually multidisciplinary, and often combine both quantitative and qualitative methods; however, they all emphasize the centrality of the user’s work context, and have been well employed in numerous studies of clinical practices and decision-making (Gabbay and le May, 2011; Hannan, 1999; Edwards et al., 2006; Ozen et al., 2004; Appleby et al., 2011). In this section, we consider a number of such approaches that can be used to understand and represent clinical work.

In HCI and IS research, the most commonly used of the approaches is ethnography, or the more theoretical approach, ethnomethodology13 (Garfinkel, 1967), which is originally associated with socio-cultural anthropology (Geertz, 1983). An excellent account of work practice studies employing ethnography, among others, can be found in (Plowman et al., 1995; Luff et al., 2000; Gabbay and le May, 2011). Ethnography is a qualitative, interpretative technique for data collection, which involves the researcher engaging in some degree of immersion and participatory observation of work in its natural setting over a period of time

13 _{The terms, ethnography and ethnomethodology are often used synonymously in HCI, CSCW and IS (Dourish,}

2007; Dourish and Button, 1998). However, ethnomethodology denotes the more theoretical approach, while ethnography refers to a qualitative methodology. Ethnomethodological ethnography, which seeks “to uncover the moment-by-moment nature of work as it is constituted by the participants” (Fitzpatrick, 1998, p. 17), came into common use in IS design following Suchman’s seminal workplace study of photocopier use (1987).

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with the aim of providing a "detached" interpretation of people’s experiences and engagement with the work. The strength of ethnography lies in its focus on the study of work as it occurs, while, at the same time, enabling the researcher to provide an unbiased account that is devoid of any imposition of preconceived research questions or hypothesis. According to ethnography, people’s interaction with technology, their social conduct, exhibits “improvised character”, carried on in real-time in the course of their work (Dourish, 2001a). A growing concern about the use of ethnography in HCI and IS research, however, is how to harness suitable, and measurable, design implications out of a, hitherto, sociological and phenomenological form of inquiry (Dourish, 2006). In view of the wide range of forms of ethnographic studies in HCI and IS, (Dourish, 2006) notes that there is still considerable debate over what ethnography means for HCI and IS research and how it can best be employed in design contexts.

A related user-centred (theoretical) approach to understanding clinical work, which works with ethnographic data, is a sociological theory known as symbolic interactionism. A basic assumption of the symbolic interactionist tradition is that people act toward things on the basis of the meanings they ascribe to those things, which arise from within the society itself and out of the processes of interaction between members of society (Blumer, 1969; Cuff et al., 1998). As noted by (Fitzpatrick, 1998), the focus of symbolic interactionism, as such, is “to understand the symbolic meanings that people attach to situations and how these evolve over time through interpretive communicative activity between people” (p. 17). The real challenge from the perspective of cross-boundary decision support is to understand how local settings and circumstances influence variations in problem-solving and decision making, and how different people seek to adapt commonly available resources, e.g. online information, in order to achieve their goals based on the tools they have and the challenges they face.

One approach, which draws extensively from the tradition of symbolic interactionism, is the grounded theory developed by Glaser and Strauss (1967). According to (Strauss and Corbin, 1998), grounded theory is a “qualitative research method that uses a systematic set of procedures to develop an inductively derived grounded theory about a phenomenon.” The primary idea behind grounded theory is to inductively generate a theory out of empirical data in contrast to theories acquired by logico-deductive methods. The grounded theory

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methodology is designed to help researchers produce "conceptually dense" theories (Vyas, 2011, p. 32), which represent the “patterns of action and interaction between and among various types of social units” (Strauss and Corbin, 1998) and which accounts for most of the variations in change over time, context, and behaviour in the studied phenomenon. The aim, in grounded theory, is not to create the "objective truth" but rather to conceptualise "what's going on" on the basis of empirical data.