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Instant messaging at the hospital: Supporting articulation work?
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journal homepage: www.ijmijournal.com
Instant messaging at the hospital: Supporting articulation work? Tobias Buschmann Iversena,b,∗ , Line Melbyb,c , Pieter Toussainta,b a
Department of Computer and Information Science, Norwegian University of Science and Technology, Sem Sælandsvei 7-9, 7491 Trondheim, Norway b Norwegian Research Centre for Electronic Patient Records, Medical Technology Research Centre, N-7491 Trondheim, Norway c University of Oslo, Institute of Health and Society, Box 1130 Blindern, N-0318 Oslo, Norway
a r t i c l e
i n f o
a b s t r a c t
Article history:
Introduction: Clinical work is increasingly fragmented and requires extensive articulation and
Received 3 December 2012
coordination. Computer systems may support such work. In this study, we investigate how
Received in revised form 8 May 2013
instant messaging functions as a tool for supporting articulation work at the hospital.
Accepted 9 May 2013
Purpose: This paper aims to describe the characteristics of instant messaging communication in terms of number and length of messages, distribution over time, and the number of
Keywords:
participants included in conversations. We also aim to determine what kind of articulation
Instant messaging
work is supported by analysing message content.
Healthcare
Methods: Analysis of one month’s worth of instant messages sent through the perioperative
Articulation work
coordination and communication system at a Danish hospital.
Hospital information systems
Results: Instant messaging was found to be used extensively for articulation work, mostly through short, simple conversational exchanges. It is used particularly often for communication concerning the patient, specifically, the coordination and logistics of patient care. Instant messaging is used by all actors involved in the perioperative domain. Conclusion: Articulation work and clinical work are hard to separate in a real clinical setting. Predefined messages and strict workflow design do not suffice when supporting communication in the context of collaborative clinical work. Flexibility is of vital importance, and this needs to be reflected in the design of supportive communication systems. © 2013 Elsevier Ireland Ltd. All rights reserved.
1.
Introduction
Clinical work today has become increasingly fragmented due to high levels of specialisation, and the spatial organisation of medical work [1–3]. Clinical work is also highly collaborative and consequently requires extensive articulation and coordination of the tasks performed. In addition, coordination and collaboration takes place between practitioners of different professional training and backgrounds, and with
different practices and needs [4,5], adding to the already complex challenge of coordinating clinical work [2,3,6–11]. Articulation work is essential in coordinating these activities [1,6,12]. Articulation work may be understood as the invisible glue that binds the stages of the patient trajectory [6]. Such ‘invisible work’ may be comprehended as meta-work conducted in order to do the visible, ‘real work’. Cooperative work and articulation work are closely related, but Schmidt and Simone [12] propose the following distinction: ‘Cooperative work is constituted by the interdependencies of multiple actors
∗ Corresponding author at: Department of Computer and Information Science, Norwegian University of Science and Technology, Sem Sælandsvei 7-9, 7491 Trondheim, Norway. Tel.: +47 41 33 63 78. E-mail address: [email protected] (T.B. Iversen). 1386-5056/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijmedinf.2013.05.004
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in dynamic fields of work, whereas articulation work is constituted by a need to steer and connect the distributed nature of such interdependent activities’. Thus, articulation work may be understood as the coordination of cooperative work. The articulation of a cooperative effort may itself indeed be subjected to a cooperative effort of re-arrangement which in turn needs to be articulated, and so forth [12]. However, articulation work may carry negative connotations; it can be seen as disturbing the ‘real work’. If, for instance, a nurse needs the presence of another nurse or physician, a telephone conversation can disrupt the ongoing ‘real work’ activities of the other party [7,8,13]. However, we argue that this view of articulation work fails to acknowledge its intertwinement with and significance for ‘real’ clinical work. Computer support is often suggested as a means of facilitating articulation work [4,14–16] that minimises disruption to the execution of clinical tasks. In order to design proper support for articulation work, we have to look at the different options available. Strauss et al. [1] point to the development of standardised operational procedures (SOP) as a common solution. An articulation strategy is the construction of an effective system of communication. Computer-mediated communication can support articulation work with the aim of seamlessly integrating it into clinical practice [1]. Instant messaging (IM) is one example of computermediated communication. The use of instant messaging for professional purposes has become more common in workplaces during recent years [17,18]. Originally created to allow home internet users to converse with family and friends, IM has evolved far beyond personal use, and has opened up new avenues of communication and collaboration within the workplace [19,20]. Our study takes a socio-technical approach [2]. We feel that understanding users’ work practices should be the starting point for understanding their information system needs. In line with Berg’s argument [2], we see a need for addressing cooperative work processes rather than studying the discrete tasks of individuals. Following on from this, we apply Berg’s conceptualization of work practices as networks of people, tools, routines and other elements [2]. The overall objective of this study is to investigate one node of such a network in which technology, people and their routines come together, namely the IM system. More specifically, the purpose of our study is to look at how IM can function as a tool for supporting articulation work in the hospital context. Through extensive analysis of a corpus of messages sent through an IM tool used in a hospital environment, we address the following questions: 1. What are the general characteristics of the communication supported by the IM tool in terms of number and length of messages, distribution over time, and the participants included in conversations? 2. What is the content of these messages and conversations? What kind of articulation work is therefore supported? The rest of the paper is structured as follows: in the next section, we summarise relevant research on IM and articulation work. In Section 3, we outline the design and
methodological approach of the study, and in Section 4, we present our findings. In Section 5, we discuss the findings in relation to the research questions presented above, and in Section 6, we present our concluding remarks.
2.
Background
We have not found any studies on the actual use of IM systems in health care organisations, but we did identify one design study that presented a risk analysis of information security in mobile instant messaging and presence systems for healthcare [21]. However, several authors have reported on the use of IM in organisational settings other than health care organisations. Isaacs et al. [18] studied an IM system that aimed to provide essential information to distributed teams within AT&T Labs, finding that IM supported collaboration, the completion of joint tasks, coordination and accessing information in the workplace. According to Isaacs et al. [18], IM can support complex work discussions; only 28% of the conversations they studied were simple, single-purpose interactions and only 31% were about scheduling or coordination. Cameron and Webster [22] found that employees often preferred IM to other richer communication mediums. Voida et al. [23] found that IM supported multitasking well as end users felt that they did not have to view or respond to messages right away, and felt able to finish ongoing tasks before attending to them. IM was therefore experienced as being minimally disruptive. However, Nardi et al. [24] and Hansen and Damm [25] found that when topics were complex, users felt the need to switch to a richer communication medium such as telephone or face-toface conversations. According to media richness theory, IM is considered a lean medium that may not be effective for communicating messages of high or medium equivocality [22,26]. However, lean communication is considered effective for routine messages of low equivocality [27]. As stated above, we are interested in the role IM systems can play in supporting articulation work. There are a number of theoretical and empirical contributions that might enhance our understanding of this phenomenon. Strauss et al. [6] originally coined the concept of articulation work as work that aids the coordination of numerous activities into a coherent sequence of events. Since individual tasks do not automatically arrange themselves in a proper sequence, they have to be synchronised and arranged; they need to be articulated [6]. Articulation work, thus refers to the necessary work to ensure that individual efforts result in more than discrete and conflicting fragments of accomplished work [28]. More concretely, doing articulation work means assembling, scheduling, monitoring and coordinating all the steps necessary to complete a specific task, such as the completion of a patient trajectory [29]. Strauss et al. [1,6] state that all groups of personnel in the hospital are engaged in articulation work, albeit some more than others. They describe a hierarchy of articulation, at the top of which the main physician in charge of the case and the head nurse conduct the most explicit but least detailed articulation work. These actors are responsible for setting the course of a patient’s trajectory. Without the additional invisible articulation work performed mainly by nurses in the various wards,
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patient trajectories would hardly ever be completed [6,30]. As Strauss et al. [1] put it, ‘articulation work on the lowest level consists of the actual jobs, which consist of task clusters and sequences of tasks that need to be performed’. An example of this kind of work is the arranging and management of surgical patient transfers through the hospital. This involves activities such as making sure the surgeon briefs the patient prior to surgery, preparing the patient for surgery, communicating with the operating room (OR) coordinator about when the patient should be transported to the OR, and keeping in contact with the responsible patient recovery team. OR coordinators and charge nurses are examples of individuals with explicit coordinating roles that involve extensive articulation work [28]. In their observations of charge nurses, Moss and Xiao [28] found that their main articulation tasks were related to the coordination of equipment (38.7%), coordinating ‘patient preparedness’ (25.7%), and staffing (18.8%). In summary, we can state that IM systems have a role in supporting organisational communication because they are perceived as less disruptive than richer means such as telephone or face-to-face communication. However, they are less suited for complex conversations, for which a richer medium is often needed. Articulation work is unevenly distributed across different groups of health personnel. Furthermore, the need for articulation work seems to exist at several stages of the patient trajectory.
3.
sharing of certain types of information, and by providing actors with a simple means for communication (IM).
3.2.
Methods and analysis
We collected all of the instant messages sent through the POCCS at a medium-sized Danish hospital during one month in 2011. This month was strategically picked in order to avoid holidays. In total, the material consisted of 1329 messages. The inclusion criteria for messages we wanted to analyse were that they had to be complete and that they had to be comprehensible. Approximately 0.5% of the messages were destroyed in the transfer from the POCCS to the Excel file and were therefore not included in the study. All identifiable names pertaining to patients, staff and wards were anonymised using fictitious names. To investigate the messages, we applied qualitative content analysis, an inductive, empirically grounded approach in which the content of texts is classified in order to identify patterns [31–33]. Seventy of the messages were coded into two categories and are therefore counted twice in the statistics, thus giving 1399 messages in total. The analysis began with all authors reading all of the instant messages. As expected, almost all of the messages were related to articulation work. Our main interest was to determine what kind of articulation work instant messaging supported and represented. After discussions, all of the authors agreed to divide the messages into three categories:
Case and research design
The data collection was performed in a medium-sized Danish hospital. The hospital has approximately 1400 employees and treats 145,000 patients per year. The perioperative communication and coordination system (POCCS), within which the IM is implemented, has been in use for seven years.
3.1.
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The instant messaging system
The system used for instant messaging is a commercially available perioperative communication and coordination system (POCCS). The POCCS is intended to be an awareness system spanning the entire surgical patient trajectory from the ward through the pre-op, surgery and post-op stages, and back to the ward. The system is based on wall-mounted displays placed in areas (for instance at wards and at the OR coordinator) where actors need to coordinate and collaborate on their activities along the surgical patient trajectory. The functionality of the screens includes a visualisation of the plan for the surgical department for each operating room (as shown in Fig. 1), location-specific patient lists, an instant message function, and a resource overview showing personnel. Instant messages can be sent directly to key personnel, wards, operating rooms, or groups of personnel (for instance multiple ORs). The POCCS is meant to provide support across several perioperative processes, providing support for physicians, nurses, and technicians. It is designed as an awareness system rather than as a documentation system. As such, the POCCS’ functionality focuses on awareness and collaboration through easy
1. Messages concerning patients 2. Messages concerning staff 3. Messages concerning equipment The first author then coded all the messages. Messages that were difficult to understand, or that could be placed in more than one category, were discussed by all authors. Some of these messages were coded into two categories, and messages that still were hard to interpret after discussion were removed from the analysis. The third author reviewed the final categorisation. Descriptive statistics showed that the category of messages concerning patients was by far the largest. This led to a closer investigation of that particular category. The first and second author discussed the patient message category, and abstracted it into three subcategories: 1. Messages concerning coordination and logistics of patients 2. Messages concerning social information relating to a patient 3. Messages concerning medical questions relating to a patient
4.
Results
4.1. Part 1. Descriptive statistics: senders, IM length and temporal patterns The most frequent sender and receiver of instant messages is the OR coordinator. In 16% of the messages, the OR coordinator was involved in the communication. The most frequent
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Fig. 1 – Screenshot of the perioperative communication and coordination system (POCCS) used for instant messaging.
communication partners are the operating rooms (ORs) (35%) followed by the pre-operative wards (18%), surgical coordinators (17%), post-anaesthesia care units (PACUs) (12%), the day surgery centre (12%), and the central sterilisation unit (6%). Fig. 2 shows that IM is also used by many other actors, though the volume of use varies. The model shown is a visualisation of the network of instant messages sent in the hospital. The size of the nodes (coordinator, wards, ORs) is proportional
to the number of IMs sent. The thickness of the lines between pairs of nodes is related to the amount of IMs sent between these nodes, and the arrows indicate the direction of messages. For example, the OR coordinator is the most frequent sender (largest node) and receives fewer messages from OR 4 than she sends (as shown by the larger arrow pointing from her towards OR 4). The majority of the conversations are between two participants only. However, there are several conversations including
Fig. 2 – IM network.
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as well as information on unforeseen events that might influence work further along the perioperative patient trajectory. Instant messages are also used to reschedule surgeries and to ask medical questions such as which medicine to administer and when to give it. Requests to switch media are also seen when cases have to be discussed.
Fig. 3 – Average message lengths.
multiple participants up to a maximum number of nine. Multiple participant communication mostly occurs intraorganisationally, for example, between wards and ORs in the same department. Message length ranges from a single character to 315 characters. The average length of a message is 41 characters (approximately one line of text), with most of the messages falling within the 0–50 character range (Fig. 3). Only 11 messages contain more than 150 characters. In total, 233 messages (18%) contain just the standard reply ‘OK’ which is offered as a default (by just pressing the enter key on the keyboard). A distinct temporal pattern is visible in the use of instant messaging at the hospital (Fig. 4). Almost all of the messages (97%) are sent during normal day-shift hours, between 07:00 and 15:00. The highest message load is between 09:00 and 14:00, when the average number of messages per hour is over 200. The message rate peaks between 10:00 and 11:00 with 263 messages (20%).
4.2. Part 2: Descriptive categories: patient, communication, and coordination of equipment and rooms We found that most of the conversations concern the patient (60%). Second come staffing and staff-related communication (23%), with coordination of equipment and rooms coming third (17%). 1 Messages concerning patients The majority of instant messages (60%) communicate patient-related information such as instructing staff to prepare patients for surgery, to give premedication and to transport them to surgery. Staff also use instant messaging to broadcast and receive updates on patient and work status,
Patient example 1: IM communication between OR 4 and ward 5 OR 4: «Sue White should be prepared for surgery» 10:22 Ward 5: «Ok, she will be ready in 5 min» 10:31
2. Messages concerning staff The second largest category of instant messages concern staffing and staff-related communication (23%), for example broadcasting the allocation and coordination of staff and substitutes. This category also includes messages unrelated to work such as staff and role greetings, and planning of lunch breaks or free-time arrangements.
Staff example 1: IM from OR coordinator to OR 1, 3, 6 & 7 OR coordinator: «Substitute on [telephone number], C. Todd»
Staff example 2: IM communication between PACU and OR day surgery OR 3 PACU: «Can you tell A. Statham to talk with J. Clore before beginning the surgery?»
Staff example 3: IM communication between OR coordinator and OR 5 COP Coordinator: «H. Schulenburg needs to get in touch with A. Hunter. Best, Karen» 10:29 OR 5: «I’ll pass it on!!!» 10:34
3. Messages concerning equipment The last category is communication regarding equipment and rooms (17%). This includes the ordering of equipment and information or questions about specific equipment and rooms, such as problems with equipment, trying to locate equipment for particular cases, or preparation or repair of particular equipment.
4.3. Part 3. IMs concerning patients: coordination and medical and social information relating to patients
Fig. 4 – Temporal patterns of IM.
The main objectives of the clinical departments are the assessment and treatment of patients, and this is reflected in the vast amount of patient-related messages. The descriptive statistics showed that the patient category was the largest category.
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Equipment example 1: IM communication between OR coordinator and the sterilisation unit OR coordinator: «For tomorrow, I would like to order two shoulder prostheses with Latarjet instruments to OR 4 to nr 1 [the first case] and one uncemented hip prosthesis to OR 9, also to nr 1» 09:25 Sterile unit: «No problem, regards Martin:)» 09:26
Patient example 4: IM from OR 5 to OR coordinator OR 5 «We are starting to close up the patient in 5 min:0)» 12:08
administer, when to give it, and enquiries about surgical positions are frequently observed.
We will therefore proceed with a closer investigation of this category. 1. Coordination and logistics of patient care The most frequently observed instant messages in the patient category pertain to the coordination and logistics of patient care (88%), such as preparing patients for surgery, administering premedication, and transporting them to and from the operating rooms, and back to their respective wards (sometimes via the PACU).
Patient example 5: IM communication between OR 5 and OR 2 OR 5 «Harriet Schulenburg, femur fracture. Is she to be positioned prone or supine?» 11:28 OR 2 «prone, if Jake hasn’t told you» 12:26
Patient example 6: IM communication between day surgery OR 9 and PACU PACU «Should I give 1.5 g ZINACEP to nr 3? G S.»10:08 OR 9 «Please do:-) and a line in the right hand» 10:08
Patient example 1: IM communication between OR 8 and ward 2 OR 8 «Sue White is to be made ready for surgery» 10:22 Ward 2 «Ok, she will be ready in 5 min» 10:31
Broadcasting of patient statuses and occurrences of events, both planned and unplanned, that might influence work further along the perioperative patient trajectory were also frequently observed.
Patient example 2: IM from PACU to day surgery OR 7 PACU: «Rachel, your last patient arrives at 11.30 p.m. – to fast from 12.30 p.m.»
3. Messages concerning social information on patients Very few messages in our material pertained to social information related to the patient (2%). The only messages containing this information were related to patients that might be of danger to either themselves or the clinical teams. In Example 7, the patient is suffering from dementia and is occasionally acting out, posing a potential threat to the surgical team and surgical procedure if they are unaware of his condition.
Patient example 7: IM from the OR coordinator to OR 1 OR coordinator «Holly Hawkes has dementia. Acting out and removes her line. The patient is ready for surgery, so please call her down when you are ready. Regards, McCartney:-)» 13:23
Surgery often seems to take longer than anticipated, and estimated finishing times are often broadcasted by the surgical team. In example 3, we can see that an operation is not progressing as planned, and that the surgery team does not expect to be finished on time.
Patient example 3: IM from OR 6 to OR coordinator OR 6: «Things are quite crazy down here. We will not be finished before 15.00 p.m.»
As patient example 3 shows, the end time of surgery can often be unclear: ‘will not be finished before 15.00 p.m.’. However, as soon as staff in the OR had a clearer picture of when surgery would finish, a message was sent to the coordinator to keep her updated, as shown in Example 4. 2. Messages concerning medical questions Medical questions and their answers form a substantial part of the messages in the patient category (10%). We have not observed any extensive medical discussions, but short, simple medical questions such as what medication to
5.
Discussion
The main purpose of our study was to investigate how instant messaging functions as a tool for supporting articulation work. In order to address this question we first looked at descriptive statistics relating to IM use. Fig. 2 shows extensive use of IM in the environment we studied and that all actors are involved in articulation work. Unsurprisingly, the coordinator is a participant in the majority of IM conversations. However, more interestingly is that even actors that do not formally have a coordinative role are heavily involved in articulation work, and some communication does not involve the coordinator at all. This offers support to the observations of Strauss et al. [1,6] that health personnel on
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all levels of the hospital hierarchy are involved in articulation work, albeit some more than others. In Fig. 3, we showed that instant messages are, on average, quite short. The majority of the messages were in the 0–50 character range and 18% contained the standard reply ‘OK’. In the study conducted by Isaacs et al. [18], IM was seen to be used mostly for complex conversations; other studies, however, show that if the subject of the discussion becomes too complex, actors tend to shift to a richer communication medium [24,25]. According to media richness theory, this might be explained by the notion that IM is a lean media, and is thus ineffective at communicating messages of high equivocality [22,26], and more effective for messages of low equivocality [27]. The fact that we identified predominantly short messages may be interpreted as being supportive of this idea. The more complex discussions did not take place via instant messaging. The analysis of messages concerning staff demonstrates how frequently staff request a change of media. The need for media switching is expressed in different manners in the instant messages, often rather indirectly and thus hard to quantify. However, based on our content analysis, such requests frequently occur. This also supports the view that instant messaging is less suitable for complex discussions. However, asking for a change of media may also indicate that the person involved is not close to the POCSS and hence unreachable via IMs. As hospital work is very mobile work, it should not be surprising that staff are sometimes away from the stationary POCSS system. Due to the asynchronous character of IM it is, in theory, not certain that messages will be seen by the addressees. Thus, questions might never be answered and tasks never performed. However, having read every conversation during one month of IM, we did not observe any such occurrences. The system we studied can be said to have an informal workflow support of acknowledgements with the standard reply ‘OK’. This function is used extensively (18% of the messages), although other informal acknowledgements, as seen in Patient example 1, are also widespread. Furthermore, we observed no response errors. The only errors we noted in messages were grammatical, and these were mostly corrected in the form of a new message explaining the sender’s original intention. In cases where specific staff were unreachable by IM, other co-workers quickly stepped in and replied. This ‘informal workflow support’ is vital for flexible situated computing at the hospital [2,34]. Finally, in Fig. 4, we saw how instant messaging was predominantly used during normal day shift hours, and peaked between 10.00 and 11.00. This temporal pattern may indicate that the need for articulation work is at its highest just before noon. The fact that elective surgery is mostly performed during the day shift is a plausible explanation [35]. Consequently, there is less need for collaboration and articulation work during night shifts when there is less surgical activity. The temporal organisation of work in hospital is thus clearly reflected in the IM frequency pattern. The second research question we addressed turns the focus towards the content of the messages exchanged, and consequently what kind of articulation work is supported by IM. Bones et al. [21] presented concerns regarding possible misuse (i.e. private and social use) of IM systems in the workplace
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resulting in wastage of time and resources. We hardly found any messages within our sample that could be categorised in this way. The three categories we presented in Section 4 (messages concerning coordination and logistics of patients, messages concerning medical questions and messages concerning social information regarding the patient) are quite similar to the categories suggested by Moss and Xiao [28]. The main differences are that Moss and Xiao found the category ‘coordinating equipment’ to be the biggest, and that their patient message category was restricted to coordinating ‘patient preparedness’. One explanation for this difference may be that they focused on charge nurses, whilst we looked at a wider selection of several different roles. Our category ‘messages concerning patients’ contained three sub-categories, as explained in the results section. The largest sub-category was patient coordination and logistics (88%). This category is related to the ‘patient preparedness’ category described by Moss and Xiao [28]. This is also the category of information that, analytically, can be most confidently said to support clinical work rather than being a part of clinical work. Several studies draw this distinction between coordination and performing the clinical task itself [36]. However, within the sub-category ‘messages concerning medical questions’, Examples 5 and 6 seem to contradict this notion. Solving medical questions can be seen as the core of clinical work [37]. Our analysis shows that simple medical questions are asked and answered via instant messaging (10%) and that these are crucial for connecting the various activities that form the stages of the patient trajectory [1,6]. The sub-category that contains messages related to the attitude or behaviour of patients (social information related to the patient) is important in planning precautionary measures and/or acting appropriately towards patients. There were very few messages in this sub-category (2%). A reason for this could be that this is sensitive patient information which staff prefer to communicate orally, or that it is nuanced information that is difficult to formulate concisely, and is therefore communicated via other mediums such as the telephone [24,25]. How one should interact with a patient is clinically relevant information, and the instances of communication on this issue that we identified are prime examples of the interweaving of articulation work and clinical work. Our findings indicate that the separation of articulation work and clinical work, although useful for analytical purposes, is problematic in practice. The data we have analysed shows that articulation work and clinical work are intertwined when it comes to staff communication. This is perhaps not surprising if we take the nature of clinical work into consideration. The high level of specialisation has turned clinical work into an advanced kind of collaborative problem solving, in which solving the problem and coordinating the work have become two sides of the same coin.
6.
Conclusion
Our study has shown that IM supports articulation work at the hospital, and that it is used extensively to support articulation work concerning different aspects of the patient trajectory.
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Furthermore, we have seen that IM is used by all the actors involved in the perioperative domain, even though the frequency of use is not equally distributed. Actors that have a specific role in coordinating the work, such as the coordinator, are (unsurprisingly) the heaviest users of IM. In practice it is difficult, if not impossible, to separate articulation work from clinical work. The messages we analysed showed a blend of information exchange meant for coordination of work and information meant for informing clinical decisions. A tool that only supports the exchange of messages aimed at coordination of work, for example through forcing users to pick messages from a standardised list, would not properly support the symbiosis of articulation and medical work. Predefined messages and strict workflow design do not suffice when supporting communication in the context of shared clinical work. In a real clinical setting, flexibility is of vital importance, and this needs to be reflected in the design of communication supporting systems.
7.
• ICT-support is suggested as a means to improve articulation work in hospitals. • Instant messaging (IM) has proven its value in personal and enterprise work settings. • Little is known about the use of instant messaging in hospitals. What is added to our knowledge: • IM is extensively used at our hospital of study. • IM is mostly used for simple and short conversations. • IM supports articulation work aimed at coordinating different aspects of the patient trajectory. • Articulation work and medical work are often interwoven.
Limitations
This study only uses single-source data from a one month log of instant messages from a Danish hospital. We have studied instant messages without observing the actual use in the clinical environment. The study would have been richer if secondary data, such as interviews or observations, had been included.
8.
Summary points What is already known on the topic:
Future work
Our findings confirmed earlier observations that IM is used for short, simple conversations. However, more complex conversations are preferably done with richer mediums such as face-to-face meetings or telephone. It is, however, unclear what exactly is classed by users as a simple conversation and when conversations pass beyond this point and require richer support. This should be the topic of further research. Additionally, interviews and observations of the use of IM in practice should also be incorporated into future research, as these could provide insight into user satisfaction with these types of systems.
Author contributions Tobias B. Iversen contributed to design, data collection, data review and writing; Line Melby contributed to design, data review and writing, Pieter J. Toussaint contributed to design, data review and writing.
Conflict of interest No author has any affiliation with organisations that has financial interest, direct or indirect, in the subject matter or materials discussed.
Acknowledgements This work was supported by the VerdIKT-programme of the Research Council of Norway (grant no. 187854/S10). We wish to thank Thomas Riisgaard Hansen from Cetrea AS for providing the data material and organizing the on-site visit. We also wish to thank members of the COSTT project for invaluable feedback and comments. In particular, we wish to thank Gunhild Lund for work on a previous draft on this paper and Andreas Landmark for help with statistics.
references
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journal homepage: www.ijmijournal.com
Instant messaging at the hospital: Supporting articulation work? Tobias Buschmann Iversena,b,∗ , Line Melbyb,c , Pieter Toussainta,b a
Department of Computer and Information Science, Norwegian University of Science and Technology, Sem Sælandsvei 7-9, 7491 Trondheim, Norway b Norwegian Research Centre for Electronic Patient Records, Medical Technology Research Centre, N-7491 Trondheim, Norway c University of Oslo, Institute of Health and Society, Box 1130 Blindern, N-0318 Oslo, Norway
a r t i c l e
i n f o
a b s t r a c t
Article history:
Introduction: Clinical work is increasingly fragmented and requires extensive articulation and
Received 3 December 2012
coordination. Computer systems may support such work. In this study, we investigate how
Received in revised form 8 May 2013
instant messaging functions as a tool for supporting articulation work at the hospital.
Accepted 9 May 2013
Purpose: This paper aims to describe the characteristics of instant messaging communication in terms of number and length of messages, distribution over time, and the number of
Keywords:
participants included in conversations. We also aim to determine what kind of articulation
Instant messaging
work is supported by analysing message content.
Healthcare
Methods: Analysis of one month’s worth of instant messages sent through the perioperative
Articulation work
coordination and communication system at a Danish hospital.
Hospital information systems
Results: Instant messaging was found to be used extensively for articulation work, mostly through short, simple conversational exchanges. It is used particularly often for communication concerning the patient, specifically, the coordination and logistics of patient care. Instant messaging is used by all actors involved in the perioperative domain. Conclusion: Articulation work and clinical work are hard to separate in a real clinical setting. Predefined messages and strict workflow design do not suffice when supporting communication in the context of collaborative clinical work. Flexibility is of vital importance, and this needs to be reflected in the design of supportive communication systems. © 2013 Elsevier Ireland Ltd. All rights reserved.
1.
Introduction
Clinical work today has become increasingly fragmented due to high levels of specialisation, and the spatial organisation of medical work [1–3]. Clinical work is also highly collaborative and consequently requires extensive articulation and coordination of the tasks performed. In addition, coordination and collaboration takes place between practitioners of different professional training and backgrounds, and with
different practices and needs [4,5], adding to the already complex challenge of coordinating clinical work [2,3,6–11]. Articulation work is essential in coordinating these activities [1,6,12]. Articulation work may be understood as the invisible glue that binds the stages of the patient trajectory [6]. Such ‘invisible work’ may be comprehended as meta-work conducted in order to do the visible, ‘real work’. Cooperative work and articulation work are closely related, but Schmidt and Simone [12] propose the following distinction: ‘Cooperative work is constituted by the interdependencies of multiple actors
∗ Corresponding author at: Department of Computer and Information Science, Norwegian University of Science and Technology, Sem Sælandsvei 7-9, 7491 Trondheim, Norway. Tel.: +47 41 33 63 78. E-mail address: [email protected] (T.B. Iversen). 1386-5056/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijmedinf.2013.05.004
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in dynamic fields of work, whereas articulation work is constituted by a need to steer and connect the distributed nature of such interdependent activities’. Thus, articulation work may be understood as the coordination of cooperative work. The articulation of a cooperative effort may itself indeed be subjected to a cooperative effort of re-arrangement which in turn needs to be articulated, and so forth [12]. However, articulation work may carry negative connotations; it can be seen as disturbing the ‘real work’. If, for instance, a nurse needs the presence of another nurse or physician, a telephone conversation can disrupt the ongoing ‘real work’ activities of the other party [7,8,13]. However, we argue that this view of articulation work fails to acknowledge its intertwinement with and significance for ‘real’ clinical work. Computer support is often suggested as a means of facilitating articulation work [4,14–16] that minimises disruption to the execution of clinical tasks. In order to design proper support for articulation work, we have to look at the different options available. Strauss et al. [1] point to the development of standardised operational procedures (SOP) as a common solution. An articulation strategy is the construction of an effective system of communication. Computer-mediated communication can support articulation work with the aim of seamlessly integrating it into clinical practice [1]. Instant messaging (IM) is one example of computermediated communication. The use of instant messaging for professional purposes has become more common in workplaces during recent years [17,18]. Originally created to allow home internet users to converse with family and friends, IM has evolved far beyond personal use, and has opened up new avenues of communication and collaboration within the workplace [19,20]. Our study takes a socio-technical approach [2]. We feel that understanding users’ work practices should be the starting point for understanding their information system needs. In line with Berg’s argument [2], we see a need for addressing cooperative work processes rather than studying the discrete tasks of individuals. Following on from this, we apply Berg’s conceptualization of work practices as networks of people, tools, routines and other elements [2]. The overall objective of this study is to investigate one node of such a network in which technology, people and their routines come together, namely the IM system. More specifically, the purpose of our study is to look at how IM can function as a tool for supporting articulation work in the hospital context. Through extensive analysis of a corpus of messages sent through an IM tool used in a hospital environment, we address the following questions: 1. What are the general characteristics of the communication supported by the IM tool in terms of number and length of messages, distribution over time, and the participants included in conversations? 2. What is the content of these messages and conversations? What kind of articulation work is therefore supported? The rest of the paper is structured as follows: in the next section, we summarise relevant research on IM and articulation work. In Section 3, we outline the design and
methodological approach of the study, and in Section 4, we present our findings. In Section 5, we discuss the findings in relation to the research questions presented above, and in Section 6, we present our concluding remarks.
2.
Background
We have not found any studies on the actual use of IM systems in health care organisations, but we did identify one design study that presented a risk analysis of information security in mobile instant messaging and presence systems for healthcare [21]. However, several authors have reported on the use of IM in organisational settings other than health care organisations. Isaacs et al. [18] studied an IM system that aimed to provide essential information to distributed teams within AT&T Labs, finding that IM supported collaboration, the completion of joint tasks, coordination and accessing information in the workplace. According to Isaacs et al. [18], IM can support complex work discussions; only 28% of the conversations they studied were simple, single-purpose interactions and only 31% were about scheduling or coordination. Cameron and Webster [22] found that employees often preferred IM to other richer communication mediums. Voida et al. [23] found that IM supported multitasking well as end users felt that they did not have to view or respond to messages right away, and felt able to finish ongoing tasks before attending to them. IM was therefore experienced as being minimally disruptive. However, Nardi et al. [24] and Hansen and Damm [25] found that when topics were complex, users felt the need to switch to a richer communication medium such as telephone or face-toface conversations. According to media richness theory, IM is considered a lean medium that may not be effective for communicating messages of high or medium equivocality [22,26]. However, lean communication is considered effective for routine messages of low equivocality [27]. As stated above, we are interested in the role IM systems can play in supporting articulation work. There are a number of theoretical and empirical contributions that might enhance our understanding of this phenomenon. Strauss et al. [6] originally coined the concept of articulation work as work that aids the coordination of numerous activities into a coherent sequence of events. Since individual tasks do not automatically arrange themselves in a proper sequence, they have to be synchronised and arranged; they need to be articulated [6]. Articulation work, thus refers to the necessary work to ensure that individual efforts result in more than discrete and conflicting fragments of accomplished work [28]. More concretely, doing articulation work means assembling, scheduling, monitoring and coordinating all the steps necessary to complete a specific task, such as the completion of a patient trajectory [29]. Strauss et al. [1,6] state that all groups of personnel in the hospital are engaged in articulation work, albeit some more than others. They describe a hierarchy of articulation, at the top of which the main physician in charge of the case and the head nurse conduct the most explicit but least detailed articulation work. These actors are responsible for setting the course of a patient’s trajectory. Without the additional invisible articulation work performed mainly by nurses in the various wards,
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patient trajectories would hardly ever be completed [6,30]. As Strauss et al. [1] put it, ‘articulation work on the lowest level consists of the actual jobs, which consist of task clusters and sequences of tasks that need to be performed’. An example of this kind of work is the arranging and management of surgical patient transfers through the hospital. This involves activities such as making sure the surgeon briefs the patient prior to surgery, preparing the patient for surgery, communicating with the operating room (OR) coordinator about when the patient should be transported to the OR, and keeping in contact with the responsible patient recovery team. OR coordinators and charge nurses are examples of individuals with explicit coordinating roles that involve extensive articulation work [28]. In their observations of charge nurses, Moss and Xiao [28] found that their main articulation tasks were related to the coordination of equipment (38.7%), coordinating ‘patient preparedness’ (25.7%), and staffing (18.8%). In summary, we can state that IM systems have a role in supporting organisational communication because they are perceived as less disruptive than richer means such as telephone or face-to-face communication. However, they are less suited for complex conversations, for which a richer medium is often needed. Articulation work is unevenly distributed across different groups of health personnel. Furthermore, the need for articulation work seems to exist at several stages of the patient trajectory.
3.
sharing of certain types of information, and by providing actors with a simple means for communication (IM).
3.2.
Methods and analysis
We collected all of the instant messages sent through the POCCS at a medium-sized Danish hospital during one month in 2011. This month was strategically picked in order to avoid holidays. In total, the material consisted of 1329 messages. The inclusion criteria for messages we wanted to analyse were that they had to be complete and that they had to be comprehensible. Approximately 0.5% of the messages were destroyed in the transfer from the POCCS to the Excel file and were therefore not included in the study. All identifiable names pertaining to patients, staff and wards were anonymised using fictitious names. To investigate the messages, we applied qualitative content analysis, an inductive, empirically grounded approach in which the content of texts is classified in order to identify patterns [31–33]. Seventy of the messages were coded into two categories and are therefore counted twice in the statistics, thus giving 1399 messages in total. The analysis began with all authors reading all of the instant messages. As expected, almost all of the messages were related to articulation work. Our main interest was to determine what kind of articulation work instant messaging supported and represented. After discussions, all of the authors agreed to divide the messages into three categories:
Case and research design
The data collection was performed in a medium-sized Danish hospital. The hospital has approximately 1400 employees and treats 145,000 patients per year. The perioperative communication and coordination system (POCCS), within which the IM is implemented, has been in use for seven years.
3.1.
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The instant messaging system
The system used for instant messaging is a commercially available perioperative communication and coordination system (POCCS). The POCCS is intended to be an awareness system spanning the entire surgical patient trajectory from the ward through the pre-op, surgery and post-op stages, and back to the ward. The system is based on wall-mounted displays placed in areas (for instance at wards and at the OR coordinator) where actors need to coordinate and collaborate on their activities along the surgical patient trajectory. The functionality of the screens includes a visualisation of the plan for the surgical department for each operating room (as shown in Fig. 1), location-specific patient lists, an instant message function, and a resource overview showing personnel. Instant messages can be sent directly to key personnel, wards, operating rooms, or groups of personnel (for instance multiple ORs). The POCCS is meant to provide support across several perioperative processes, providing support for physicians, nurses, and technicians. It is designed as an awareness system rather than as a documentation system. As such, the POCCS’ functionality focuses on awareness and collaboration through easy
1. Messages concerning patients 2. Messages concerning staff 3. Messages concerning equipment The first author then coded all the messages. Messages that were difficult to understand, or that could be placed in more than one category, were discussed by all authors. Some of these messages were coded into two categories, and messages that still were hard to interpret after discussion were removed from the analysis. The third author reviewed the final categorisation. Descriptive statistics showed that the category of messages concerning patients was by far the largest. This led to a closer investigation of that particular category. The first and second author discussed the patient message category, and abstracted it into three subcategories: 1. Messages concerning coordination and logistics of patients 2. Messages concerning social information relating to a patient 3. Messages concerning medical questions relating to a patient
4.
Results
4.1. Part 1. Descriptive statistics: senders, IM length and temporal patterns The most frequent sender and receiver of instant messages is the OR coordinator. In 16% of the messages, the OR coordinator was involved in the communication. The most frequent
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Fig. 1 – Screenshot of the perioperative communication and coordination system (POCCS) used for instant messaging.
communication partners are the operating rooms (ORs) (35%) followed by the pre-operative wards (18%), surgical coordinators (17%), post-anaesthesia care units (PACUs) (12%), the day surgery centre (12%), and the central sterilisation unit (6%). Fig. 2 shows that IM is also used by many other actors, though the volume of use varies. The model shown is a visualisation of the network of instant messages sent in the hospital. The size of the nodes (coordinator, wards, ORs) is proportional
to the number of IMs sent. The thickness of the lines between pairs of nodes is related to the amount of IMs sent between these nodes, and the arrows indicate the direction of messages. For example, the OR coordinator is the most frequent sender (largest node) and receives fewer messages from OR 4 than she sends (as shown by the larger arrow pointing from her towards OR 4). The majority of the conversations are between two participants only. However, there are several conversations including
Fig. 2 – IM network.
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as well as information on unforeseen events that might influence work further along the perioperative patient trajectory. Instant messages are also used to reschedule surgeries and to ask medical questions such as which medicine to administer and when to give it. Requests to switch media are also seen when cases have to be discussed.
Fig. 3 – Average message lengths.
multiple participants up to a maximum number of nine. Multiple participant communication mostly occurs intraorganisationally, for example, between wards and ORs in the same department. Message length ranges from a single character to 315 characters. The average length of a message is 41 characters (approximately one line of text), with most of the messages falling within the 0–50 character range (Fig. 3). Only 11 messages contain more than 150 characters. In total, 233 messages (18%) contain just the standard reply ‘OK’ which is offered as a default (by just pressing the enter key on the keyboard). A distinct temporal pattern is visible in the use of instant messaging at the hospital (Fig. 4). Almost all of the messages (97%) are sent during normal day-shift hours, between 07:00 and 15:00. The highest message load is between 09:00 and 14:00, when the average number of messages per hour is over 200. The message rate peaks between 10:00 and 11:00 with 263 messages (20%).
4.2. Part 2: Descriptive categories: patient, communication, and coordination of equipment and rooms We found that most of the conversations concern the patient (60%). Second come staffing and staff-related communication (23%), with coordination of equipment and rooms coming third (17%). 1 Messages concerning patients The majority of instant messages (60%) communicate patient-related information such as instructing staff to prepare patients for surgery, to give premedication and to transport them to surgery. Staff also use instant messaging to broadcast and receive updates on patient and work status,
Patient example 1: IM communication between OR 4 and ward 5 OR 4: «Sue White should be prepared for surgery» 10:22 Ward 5: «Ok, she will be ready in 5 min» 10:31
2. Messages concerning staff The second largest category of instant messages concern staffing and staff-related communication (23%), for example broadcasting the allocation and coordination of staff and substitutes. This category also includes messages unrelated to work such as staff and role greetings, and planning of lunch breaks or free-time arrangements.
Staff example 1: IM from OR coordinator to OR 1, 3, 6 & 7 OR coordinator: «Substitute on [telephone number], C. Todd»
Staff example 2: IM communication between PACU and OR day surgery OR 3 PACU: «Can you tell A. Statham to talk with J. Clore before beginning the surgery?»
Staff example 3: IM communication between OR coordinator and OR 5 COP Coordinator: «H. Schulenburg needs to get in touch with A. Hunter. Best, Karen» 10:29 OR 5: «I’ll pass it on!!!» 10:34
3. Messages concerning equipment The last category is communication regarding equipment and rooms (17%). This includes the ordering of equipment and information or questions about specific equipment and rooms, such as problems with equipment, trying to locate equipment for particular cases, or preparation or repair of particular equipment.
4.3. Part 3. IMs concerning patients: coordination and medical and social information relating to patients
Fig. 4 – Temporal patterns of IM.
The main objectives of the clinical departments are the assessment and treatment of patients, and this is reflected in the vast amount of patient-related messages. The descriptive statistics showed that the patient category was the largest category.
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Equipment example 1: IM communication between OR coordinator and the sterilisation unit OR coordinator: «For tomorrow, I would like to order two shoulder prostheses with Latarjet instruments to OR 4 to nr 1 [the first case] and one uncemented hip prosthesis to OR 9, also to nr 1» 09:25 Sterile unit: «No problem, regards Martin:)» 09:26
Patient example 4: IM from OR 5 to OR coordinator OR 5 «We are starting to close up the patient in 5 min:0)» 12:08
administer, when to give it, and enquiries about surgical positions are frequently observed.
We will therefore proceed with a closer investigation of this category. 1. Coordination and logistics of patient care The most frequently observed instant messages in the patient category pertain to the coordination and logistics of patient care (88%), such as preparing patients for surgery, administering premedication, and transporting them to and from the operating rooms, and back to their respective wards (sometimes via the PACU).
Patient example 5: IM communication between OR 5 and OR 2 OR 5 «Harriet Schulenburg, femur fracture. Is she to be positioned prone or supine?» 11:28 OR 2 «prone, if Jake hasn’t told you» 12:26
Patient example 6: IM communication between day surgery OR 9 and PACU PACU «Should I give 1.5 g ZINACEP to nr 3? G S.»10:08 OR 9 «Please do:-) and a line in the right hand» 10:08
Patient example 1: IM communication between OR 8 and ward 2 OR 8 «Sue White is to be made ready for surgery» 10:22 Ward 2 «Ok, she will be ready in 5 min» 10:31
Broadcasting of patient statuses and occurrences of events, both planned and unplanned, that might influence work further along the perioperative patient trajectory were also frequently observed.
Patient example 2: IM from PACU to day surgery OR 7 PACU: «Rachel, your last patient arrives at 11.30 p.m. – to fast from 12.30 p.m.»
3. Messages concerning social information on patients Very few messages in our material pertained to social information related to the patient (2%). The only messages containing this information were related to patients that might be of danger to either themselves or the clinical teams. In Example 7, the patient is suffering from dementia and is occasionally acting out, posing a potential threat to the surgical team and surgical procedure if they are unaware of his condition.
Patient example 7: IM from the OR coordinator to OR 1 OR coordinator «Holly Hawkes has dementia. Acting out and removes her line. The patient is ready for surgery, so please call her down when you are ready. Regards, McCartney:-)» 13:23
Surgery often seems to take longer than anticipated, and estimated finishing times are often broadcasted by the surgical team. In example 3, we can see that an operation is not progressing as planned, and that the surgery team does not expect to be finished on time.
Patient example 3: IM from OR 6 to OR coordinator OR 6: «Things are quite crazy down here. We will not be finished before 15.00 p.m.»
As patient example 3 shows, the end time of surgery can often be unclear: ‘will not be finished before 15.00 p.m.’. However, as soon as staff in the OR had a clearer picture of when surgery would finish, a message was sent to the coordinator to keep her updated, as shown in Example 4. 2. Messages concerning medical questions Medical questions and their answers form a substantial part of the messages in the patient category (10%). We have not observed any extensive medical discussions, but short, simple medical questions such as what medication to
5.
Discussion
The main purpose of our study was to investigate how instant messaging functions as a tool for supporting articulation work. In order to address this question we first looked at descriptive statistics relating to IM use. Fig. 2 shows extensive use of IM in the environment we studied and that all actors are involved in articulation work. Unsurprisingly, the coordinator is a participant in the majority of IM conversations. However, more interestingly is that even actors that do not formally have a coordinative role are heavily involved in articulation work, and some communication does not involve the coordinator at all. This offers support to the observations of Strauss et al. [1,6] that health personnel on
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all levels of the hospital hierarchy are involved in articulation work, albeit some more than others. In Fig. 3, we showed that instant messages are, on average, quite short. The majority of the messages were in the 0–50 character range and 18% contained the standard reply ‘OK’. In the study conducted by Isaacs et al. [18], IM was seen to be used mostly for complex conversations; other studies, however, show that if the subject of the discussion becomes too complex, actors tend to shift to a richer communication medium [24,25]. According to media richness theory, this might be explained by the notion that IM is a lean media, and is thus ineffective at communicating messages of high equivocality [22,26], and more effective for messages of low equivocality [27]. The fact that we identified predominantly short messages may be interpreted as being supportive of this idea. The more complex discussions did not take place via instant messaging. The analysis of messages concerning staff demonstrates how frequently staff request a change of media. The need for media switching is expressed in different manners in the instant messages, often rather indirectly and thus hard to quantify. However, based on our content analysis, such requests frequently occur. This also supports the view that instant messaging is less suitable for complex discussions. However, asking for a change of media may also indicate that the person involved is not close to the POCSS and hence unreachable via IMs. As hospital work is very mobile work, it should not be surprising that staff are sometimes away from the stationary POCSS system. Due to the asynchronous character of IM it is, in theory, not certain that messages will be seen by the addressees. Thus, questions might never be answered and tasks never performed. However, having read every conversation during one month of IM, we did not observe any such occurrences. The system we studied can be said to have an informal workflow support of acknowledgements with the standard reply ‘OK’. This function is used extensively (18% of the messages), although other informal acknowledgements, as seen in Patient example 1, are also widespread. Furthermore, we observed no response errors. The only errors we noted in messages were grammatical, and these were mostly corrected in the form of a new message explaining the sender’s original intention. In cases where specific staff were unreachable by IM, other co-workers quickly stepped in and replied. This ‘informal workflow support’ is vital for flexible situated computing at the hospital [2,34]. Finally, in Fig. 4, we saw how instant messaging was predominantly used during normal day shift hours, and peaked between 10.00 and 11.00. This temporal pattern may indicate that the need for articulation work is at its highest just before noon. The fact that elective surgery is mostly performed during the day shift is a plausible explanation [35]. Consequently, there is less need for collaboration and articulation work during night shifts when there is less surgical activity. The temporal organisation of work in hospital is thus clearly reflected in the IM frequency pattern. The second research question we addressed turns the focus towards the content of the messages exchanged, and consequently what kind of articulation work is supported by IM. Bones et al. [21] presented concerns regarding possible misuse (i.e. private and social use) of IM systems in the workplace
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resulting in wastage of time and resources. We hardly found any messages within our sample that could be categorised in this way. The three categories we presented in Section 4 (messages concerning coordination and logistics of patients, messages concerning medical questions and messages concerning social information regarding the patient) are quite similar to the categories suggested by Moss and Xiao [28]. The main differences are that Moss and Xiao found the category ‘coordinating equipment’ to be the biggest, and that their patient message category was restricted to coordinating ‘patient preparedness’. One explanation for this difference may be that they focused on charge nurses, whilst we looked at a wider selection of several different roles. Our category ‘messages concerning patients’ contained three sub-categories, as explained in the results section. The largest sub-category was patient coordination and logistics (88%). This category is related to the ‘patient preparedness’ category described by Moss and Xiao [28]. This is also the category of information that, analytically, can be most confidently said to support clinical work rather than being a part of clinical work. Several studies draw this distinction between coordination and performing the clinical task itself [36]. However, within the sub-category ‘messages concerning medical questions’, Examples 5 and 6 seem to contradict this notion. Solving medical questions can be seen as the core of clinical work [37]. Our analysis shows that simple medical questions are asked and answered via instant messaging (10%) and that these are crucial for connecting the various activities that form the stages of the patient trajectory [1,6]. The sub-category that contains messages related to the attitude or behaviour of patients (social information related to the patient) is important in planning precautionary measures and/or acting appropriately towards patients. There were very few messages in this sub-category (2%). A reason for this could be that this is sensitive patient information which staff prefer to communicate orally, or that it is nuanced information that is difficult to formulate concisely, and is therefore communicated via other mediums such as the telephone [24,25]. How one should interact with a patient is clinically relevant information, and the instances of communication on this issue that we identified are prime examples of the interweaving of articulation work and clinical work. Our findings indicate that the separation of articulation work and clinical work, although useful for analytical purposes, is problematic in practice. The data we have analysed shows that articulation work and clinical work are intertwined when it comes to staff communication. This is perhaps not surprising if we take the nature of clinical work into consideration. The high level of specialisation has turned clinical work into an advanced kind of collaborative problem solving, in which solving the problem and coordinating the work have become two sides of the same coin.
6.
Conclusion
Our study has shown that IM supports articulation work at the hospital, and that it is used extensively to support articulation work concerning different aspects of the patient trajectory.
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Furthermore, we have seen that IM is used by all the actors involved in the perioperative domain, even though the frequency of use is not equally distributed. Actors that have a specific role in coordinating the work, such as the coordinator, are (unsurprisingly) the heaviest users of IM. In practice it is difficult, if not impossible, to separate articulation work from clinical work. The messages we analysed showed a blend of information exchange meant for coordination of work and information meant for informing clinical decisions. A tool that only supports the exchange of messages aimed at coordination of work, for example through forcing users to pick messages from a standardised list, would not properly support the symbiosis of articulation and medical work. Predefined messages and strict workflow design do not suffice when supporting communication in the context of shared clinical work. In a real clinical setting, flexibility is of vital importance, and this needs to be reflected in the design of communication supporting systems.
7.
• ICT-support is suggested as a means to improve articulation work in hospitals. • Instant messaging (IM) has proven its value in personal and enterprise work settings. • Little is known about the use of instant messaging in hospitals. What is added to our knowledge: • IM is extensively used at our hospital of study. • IM is mostly used for simple and short conversations. • IM supports articulation work aimed at coordinating different aspects of the patient trajectory. • Articulation work and medical work are often interwoven.
Limitations
This study only uses single-source data from a one month log of instant messages from a Danish hospital. We have studied instant messages without observing the actual use in the clinical environment. The study would have been richer if secondary data, such as interviews or observations, had been included.
8.
Summary points What is already known on the topic:
Future work
Our findings confirmed earlier observations that IM is used for short, simple conversations. However, more complex conversations are preferably done with richer mediums such as face-to-face meetings or telephone. It is, however, unclear what exactly is classed by users as a simple conversation and when conversations pass beyond this point and require richer support. This should be the topic of further research. Additionally, interviews and observations of the use of IM in practice should also be incorporated into future research, as these could provide insight into user satisfaction with these types of systems.
Author contributions Tobias B. Iversen contributed to design, data collection, data review and writing; Line Melby contributed to design, data review and writing, Pieter J. Toussaint contributed to design, data review and writing.
Conflict of interest No author has any affiliation with organisations that has financial interest, direct or indirect, in the subject matter or materials discussed.
Acknowledgements This work was supported by the VerdIKT-programme of the Research Council of Norway (grant no. 187854/S10). We wish to thank Thomas Riisgaard Hansen from Cetrea AS for providing the data material and organizing the on-site visit. We also wish to thank members of the COSTT project for invaluable feedback and comments. In particular, we wish to thank Gunhild Lund for work on a previous draft on this paper and Andreas Landmark for help with statistics.
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