Studies of small information systems including groupware applications that allow for quick iterations of design, use and redesign have stressed the importance of using the system for real work in order to learn about the possibilities and constraints imposed by the artefact. Anticipated change denotes the desired change that is planned ahead and occurs as intended by the originators of the change. As indicated in Figure 2. Emergent change is defined as local and spontaneous change, not originally anticipated nor intended.
Such change does not involve deliberate actions but grows out of practice. Opportunity-based change is purposefully introduced to take advantage of unexpected opportunities, events, or breakdowns that have occurred after the introduction of a new information system: Over time, however, use of the new technology will typically involve a series of opportunity-based, emergent, and further anticipated changes, the order of which cannot be determined in advance because the changes interact with each other in response to outcomes, events, and conditions arising through experimentation and use Orlikowski and Hofman , p.
Configurable frameworks include high-level configuration tools often XML based and embed standard interfaces for other systems as well as general business logic for specific domains.
Such generic frameworks substantially ease the creation of individual applications because much of the work is transformed from development of functionality from scratch to configuration of domain-specific building blocks. Configurable information systems may be implemented, used and evaluated as part of an overall iterative design process. This opens for an important aspect of the design process since only real and situated use of the system enables emergent and opportunity-based change.
Ethnographic evaluation studies provide an opportunity to become aware of unanticipated changes. Such evaluations might identify and analyze emergent and opportunity-based changes, hereby informing the subsequent design and implementation of the system. This reconstruction of the iterative prototyping approach is outlined in Figure 2. Hertzum Figure 2. The sustained participatory design process outlined in Figure 2.
Design Research: Synergies from Interdisciplinary Perspectives
The starting point of an iteration are the changes that are anticipated and aimed for. The anticipated changes are further specified, for example, in terms of what effects are expected from using the system. Actual use of the system allows for emergent and opportunitybased changes to occur and inform subsequent design iterations. The model in Figure 2.
The case The hospital in Roskilde, Denmark, is in the process of replacing paper-based patient records with electronic patient records. The case below concerns a neurological stroke unit that treats patients with acute apoplexy. The case is described in detail by Hertzum and Simonsen and Simonsen and Hertzum An advanced prototype of a fully functional EPR system was designed, implemented, used for real work, and subjected to an ethnographically based evaluation.
During the period of trial use, the EPR supported the clinical process and replaced all paper-based patient records. The clinicians used the system 24 hours a day throughout the five-day period of trial use. Iterative participatory design 21 Anticipated changes were specified in the first part of the project during five full-day participatory design workshops. A major activity during the workshops was the design and configuration of the system. Main parts of the system were designed and configured in three steps as depicted in Figure 2. At the following workshop, a preliminary noninteractive PowerPoint prototype was discussed.
At a third workshop, a running prototype was demonstrated and discussed. The vendor undertook the technical development of the EPR system. The system involved stationary and portable PCs and PDAs for bedside measurement of patient parameters such as temperature and blood pressure see Figure 2. A back office was established and staffed 24 hours a day, and Wizard of Oz techniques Maulsby et al.
If the clinicians initiated transactions that included other wards at the hospital other wards that were not included in the experiment , this would be captured in the back office, mailed in the conventional fashion, and when the results came back they would be entered into the EPR system. In this way, the clinicians experienced the Figure 2. The system involved portable PCs, PDAs for bedside measurement and a large shared EPR displayed on the wall during nursing handover and team conference.
EPR system as if it supported all transactions except for maybe a slight temporal delay. The nursing handover happens three times a day at the beginning of each nursing shift 7 a.
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During nursing handovers, one nurse is designated as the team leader. This nurse reviews the patient records immediately prior to the handover and then, during the handover, orally informs the other nurses about patient status and plans for the upcoming shift.
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The team conference lasts approximately 15 minutes and involves all clinicians. It takes place on weekdays within an hour after the nursing handover at 7 a. The current status of each patient is given orally by a the team leader from the preceding nursing handover, and an interdisciplinary assessment ensues. On this basis plans Iterative participatory design 23 are revised. An overview of the current plans is available on a large whiteboard or, during the trial period, on a shared EPR display projected on the wall.
The nursing handovers and team conferences took place in a designated room where the EPR was displayed by projecting a PC screen onto the wall using a standard projector mounted in the ceiling. We observed nine nursing handovers and five team conferences, all performed using the EPR system. Prior to the trial period, we became acquainted with these situations by observing six nursing handovers and seven team conferences. Each observation was done by one researcher acting as an observing participant Blomberg et al. The observations informing the ethnography in this chapter were focused and thorough: they focused on nursing handovers and team conferences only , yet they were thorough by aggregating 27 of these recurrent events.
We documented all observations by writing notes. In addition, selected observation sessions were audio and video recorded, and the full-motion screen interaction with the EPR system was recorded. During the trial period, the researchers were present at the ward during the day shift 7 a. This allowed us to ask clarifying questions when the clinicians were not busy as well as to arrange follow-up interviews. We conducted five interviews with three nurses, one physical therapist, and one speech therapist.
These interviews elaborated details from our observations and clarified our immediate interpretations. A few days after the trial period, we conducted a group interview with three nurses about their experience of using the EPR system. Finally, we interviewed the nurse acting as the team leader and presented our results from our ethnographic records, for verification. We audio-recorded all interviews and later wrote extended summaries. The evaluation and the anonymous involvement of patients were authorized by the hospital. Our observations, interviews, audio-, video- and screen-recordings were authorized by the stroke unit and approved by the participating clinicians.
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Ethnographic record Our observations of the traditional paper-based nursing handovers and team conferences prior to the trial period showed a common characteristic regarding the nurse who acted as team leader. This nurse would hold the paper record in her hand and read out key status information prepared before the meeting, while the others would listen to her presentation.
This oral reporting is a common practice for nursing handovers Strange where the team leader as the chair of the handover disseminating the information in the patient record. In the trial period, the EPR was displayed on the wall during nursing handovers and team conferences. By using such a large shared EPR display the content of the patient record is available to all participants see Figure 2.
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We observed an emergent change in the way of informing about patient status as the traditional oral reporting by the team leader changed to collectively reading the shared display. This was followed by observations of additional unanticipated changes to the 24 J. Along with continuous negotiation about how to navigate the patient record, a process of collective inspection, interpretation and learning unfolded, during which the clinicians assessed the status and condition of the patients.
A similar process was not observed during any of the nursing handovers and team conferences observed prior to the trial period. The nurses experienced how the shared display designed for the team conferences formed the agenda for these conferences. During the trial period, the nurses had the opportunity to initiate a change of this screen thus influencing the agenda of the team conferences.
The change consisted of adding a panel specifying selected nursing observations of relevance to the team conference. These observations, selected and promoted by the nurses, became more salient to the clinicians as they were forming their overview of the status of the patients. Thus the panel introduced more structure compared to the traditional chronological and narrative nursing report Strange The investigation involves a patient who has been admitted on suspicion of acute apoplexy, but the collective investigation causes the clinicians to realize that the patient actually suffers from acute kidney failure.
Immediate action is then taken to treat this life-threatening situation. Collective investigation of the patient record at the nursing handover The collective investigation was initiated when reviewing the patient during the nursing handover at 7 a.
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The handover was attended by five nurses: the team leader and nurses A, B, C and D. The patient record concerned an elderly woman from Pakistan who did not speak Danish. The Iterative participatory design 25 review of this patient lasted minutes and started with the team leader reading aloud information from the preceding shifts.