Aksel Tjora

The technological mediation of the nursing-medical boundary

Norwegian medical emergency communication (AMK) centres are staffed by nurses, who administer requests for ambulance services or access to a doctor. The central position of nurses and the fact that they communicate with doctors by telephone and radio, make this a setting where the doctor-nurse relationship is highly visible. A two-year study of AMK centres showed that much of the work of these centres proceeds quite independently of doctors, as nurses function as competent suppliers of advice or ‘medical oracles’. The doctor-designed Index for Medical Emergency Assistance is deficient as a tool for guiding nurses’ decisions, since it fails to take account of the dynamics of real nursing practice, which is based on experiential knowledge, support from colleagues and collective learning. Data on nursing work in the AMK centres suggest that these nurses have more influence and autonomy in the nurse-doctor interaction than most past studies have indicated.

Writing small discoveries: an exploration of fresh observers' observations

Taking field notes (or otherwise documenting observation) is at the very core of ethnographic research. However, relatively speaking, this task has hardly been covered in the research methods literature. With this as a point of departure, this article draws on an analysis of 247 short field notes taken in various situations by student observers. It aims to explore the immediate act of taking field notes while doing observation. By inductive analysis, 10 different ‘modes’ of observation are drawn from the field notes. This analysis demonstrates on one hand that fresh observers are capable of quickly grasping important aspects of observed interaction and on the other hand that principles of field note taking and researcher positioning need to be addressed further.

Maintaining redundancy in the coordination of medical emergencies

This paper reports from a study of Norwegian medical emergency call (AMK) centres, in which advanced radio and telephone communication technologies are handled by a team of nurses and ambulance personnel to coordinate medical emergency resources (ambulances, doctors, helicopters, and so on). The AMK centres have made use of a range of technologies since they were established 15-20 years ago. During the last 5 years, several of the centres have implemented an information system, AMIS to integrate several functions that before were handled by using separate specialised systems. By observation in seven medical emergency call centres and a survey covering 38 of 43 such centres in Norway in the period 1996-2002, this study focuses on collaboration and use of communication technologies in a teamwork setting. It is found that important aspects of the AMK centre teamwork include redundancy of communication, competence and technologies, as well as a well-developed overall attention from the operators. These aspects support a transparent social integration of technologies in use. The use of integrated systems, such as the AMIS, may challenge this transparency, by which one operator may follow the other operators actions. It is concluded that serious care must be taken to introduce larger information systems, so that basic principles, which have emerged during the teamwork practice to secure high service reliability, are maintained.

From fatness to badness: The modern morality of obesity

Obesity (or being overweight) is now considered a by-product of membership of developed societies. Moreover, it is considered a growing ‘global’ health problem. This article reports on a small qualitative study of adults who fell into one or other of these categories in Norway in 2010, and who have been faced with decisions about lifestyle versus surgical remedies. This decision making is contextualized and the principal criteria examined. Embodiment, bodywork, self- and social identity, stigma, deviance and issues around the idea of personal responsibility and public health emerge as key themes. The concluding paragraphs commend incorporation of a macro- or social structural perspective to the conceptualization and investigation of obesity.

Survival of the project: A case study of ICT innovation in health care

From twenty years of information and communication technology (ICT) projects in the health sector, we have learned one thing: most projects remain projects. The problem of pilotism in e-health and telemedicine is a growing concern, both in medical literature and among policy makers, who now ask for large-scale implementation of ICT in routine health service delivery. In this article, we turn the question of failing projects upside down. Instead of investigating the obstacles to implementing ICT and realising permanent changes in health care routines, we ask what makes the temporary ICT project survive, despite an apparent lack of success. Our empirical material is based on Norwegian telemedicine. Through a case study, we take an in-depth look into the history of one particular telemedical initiative and highlight how ICT projects matter on a managerial level. Our analysis reveals how management tasks were delegated to the ICT project, which thus contributed to four processes of organisational control: allocating resources, generating and managing enthusiasm, system correction and aligning local practice and national policies. We argue that the innovation project in itself can be considered an innovation that has become normalised in health care, not in clinical, but in management work. In everyday management, the ICT project appears to be a convenient tool suited to ease the tensions between state regulatory practices and claims of professional autonomy that arise in the wake of new public management reforms. Separating project management and funding from routine practice handles the conceptualised heterogeneity between innovation and routine within contemporary health care delivery. Whilst this separation eases the execution of both normal routines and innovative projects, it also delays expected diffusion of technology.

Invisible Whispers: Accounts of SMS Communication in Shared Physical Space:

The use of short message services (SMS) on mobile phones has gained huge popularity in most western and many developing countries — so much so that it has become established as the preferred medium for mobile communication especially among young people. This article explores SMS as used for discreet communication between people in the same physical space (‘shared physical space SMS’ — or ‘SPS-SMS’). Drawing from semi-structured interviews with young people in Norway, 10 different scenarios of SPS-SMS use are explored and analysed within an interactionist framework. These sites of SPS-SMS are presented here as ‘communicative affordances’. It is concluded that the mobile phone, by the application of SPS-SMS, affords communicative layers of transparency, by which various SMS users maintain semi-synchronous communication, both for care and coordination. Although a qualitative study of this nature does not lend itself to generalizations about SPS-SMS communication, it does demonstrate how detailed studies of extraordinary uses of mediated communication may be used to widen analyses of social interaction.

Interaction Pretext: Experiences of Community in the Urban Neighbourhood

It has been suggested that community, social cohesion and territorial ties in neighbourhoods may be characterised by three directions: the lost, the saved and the transformed. On the basis of a number of case studies in a Norwegian city, it is found that these three trends exist together, on the basis of various local interactive practices. The concept of an interaction pretext is developed to answer in a more nuanced way how various forms of social ties are developed, maintained and/or altered. By combining this concept with local activity, four community types are specified that may characterise different neighbourhoods and that may also exist in parallel at one place: the passing-by community, the tight community, the weak community, and the split community. Demonstrating the potential of a more detailed empirical approach to the community question, the paper warns against too analytically shallow suggestions about their development. By understanding how neighbourhoods develop socially in different ways, it may be possible to increase the probability of better community planning.

Communal Normalization in an Online Self-Help Group for Adolescents With a Mentally Ill Parent:

Although implications of parental mental illness are well documented, most children of mentally ill parents are left to manage their family situation with limited information and support. We explored the role of a Norwegian online self-help group for adolescents (aged 15 to 18) with a mentally ill parent. Through in-depth interviews with 13 participants, we found that the online self-help group provided “communal normalization” by which participants, through communication in the forum, made sense of everyday experiences and emotions arising from having a mentally ill parent. We identified three main aspects of this process—recognizability, openness, and agency—all of which were important for the adolescents’ efforts to obtain support, to be supportive, and to handle everyday life situations better. Communal normalization might provide resources for significantly improving the participants’ life situations, and could demonstrate similar potential for users in other situations characterized by stigma, loneliness, silence, and health worries.

VIDEOCARE: Decentralised psychiatric emergency care through videoconferencing

BackgroundToday the availability of specialists is limited for psychiatric patients in rural areas, especially during psychiatric emergencies. To overcome this challenge, the University Hospital of North Norway has implemented a new decentralised on-call system in psychiatric emergencies, by which psychiatrists are accessible by videoconference 24/7. In September 2011, the new on-call system was established in clinical practice for patients and health staff at three regional psychiatric centres in Northern Norway. Although a wide variety of therapies have been successfully delivered by videoconference, there is limited research on the use of videoconferenced consultations with patients in psychiatric emergencies. The aim of this study is to explore the use of videoconference in psychiatric emergencies based on the implementation of this first Norwegian tele-psychiatric service in emergency care.Methods/designThe research project is an exploratory case study of a new videoconference service in operation. By applying in-depth interviews with patients, specialists and local health-care staff, we will identify factors that facilitate and hinder use of videoconferencing in psychiatric emergencies, and explore how videoconferenced consultations matter for patients, professional practice and cooperation between levels in psychiatric care. By using an on-going project as the site of research, the case is especially well-suited for generating reliable and valid empirical data.DiscussionResults from the study will be of importance for understanding of how videoconferencing may support proper treatment and high-quality health care services in rural areas for patients in psychiatric emergencies.

Beyond the EPR: Complementary roles of the hospital-wide electronic health record and clinical departmental systems

BackgroundMany hospital departments have implemented small clinical departmental systems (CDSs) to collect and use patient data for documentation as well as for other department-specific purposes. As hospitals are implementing institution-wide electronic patient records (EPRs), the EPR is thought to be integrated with, and gradually substitute the smaller systems. Many EPR systems however fail to support important clinical workflows. Also, successful integration of systems has proven hard to achieve. As a result, CDSs are still in widespread use. This study was conducted to see which tasks are supported by CDSs and to compare this to the support offered by the EPR.MethodsSemi-structured interviews with users of 16 clinicians using 15 different clinical departmental systems (CDS) at a Medium-sized University hospital in Norway. Inductive analysis of transcriptions from the audio taped interviews.ResultsThe roles of CDSs were complementary to those of the hospital-wide EPR system. The use of structured patient data was a characteristic feature. This facilitated quality development and supervision, tasks that were poorly supported by the EPR system. The structuring of the data also improved filtering of information to better support clinical decision-making. Because of the high value of the structured patient data, the users put much effort in maintaining their integrity and representativeness. Employees from the departments were also engaged in the funding, development, implementation and maintenance of the systems.ConclusionClinical departmental systems are vital to the activities of a clinical hospital department. The development, implementation and clinical use of such systems can be seen as bottom-up, user-driven innovations.