Using computer decision support systems in NHS emergency and urgent care: ethnographic study using normalisation process theory

Abstract

BackgroundInformation and communication technologies (ICTs) are often proposed as ‘technological fixes’ for problems facing healthcare. They promise to deliver services more quickly and cheaply. Yet research on the implementation of ICTs reveals a litany of delays, compromises and failures. Case studies have established that these technologies are difficult to embed in everyday healthcare.MethodsWe undertook an ethnographic comparative analysis of a single computer decision support system in three different settings to understand the implementation and everyday use of this technology which is designed to deal with calls to emergency and urgent care services. We examined the deployment of this technology in an established 999 ambulance call-handling service, a new single point of access for urgent care and an established general practice out-of-hours service. We used Normalization Process Theory as a framework to enable systematic cross-case analysis.ResultsOur data comprise nearly 500 hours of observation, interviews with 64 call-handlers, and stakeholders and documents about the technology and settings. The technology has been implemented and is used distinctively in each setting reflecting important differences between work and contexts. Using Normalisation Process Theory we show how the work (collective action) of implementing the system and maintaining its routine use was enabled by a range of actors who established coherence for the technology, secured buy-in (cognitive participation) and engaged in on-going appraisal and adjustment (reflexive monitoring).ConclusionsHuge effort was expended and continues to be required to implement and keep this technology in use. This innovation must be understood both as a computer technology and as a set of practices related to that technology, kept in place by a network of actors in particular contexts. While technologies can be ‘made to work’ in different settings, successful implementation has been achieved, and will only be maintained, through the efforts of those involved in the specific settings and if the wider context continues to support the coherence, cognitive participation, and reflective monitoring processes that surround this collective action. Implementation is more than simply putting technologies in place – it requires new resources and considerable effort, perhaps on an on-going basis.

Research “push”, long term-change, and general practice

“…The ever changing landscape of health care policy and the receptivity of organizational contexts (Pettigrew et al, 1992) have bearing upon attempts to implement interventions and transcend the scope of the NPT (Pope et al, 2013;Knowles et al, 2013;Clarke et al, 2013). Extending this line of thought, it is possible to argue that understanding longer term implementation is dependent on more explicitly incorporating the influence of the interaction between macro-meso-micro factors.…”

“…This can relate to problems such as; initial uptake related to research participants not seeing the value for their work (Bamford et al, 2012;Sanders et al, 2011;Lloyd et al, 2013;Maxwell et al, 2013;Pope et al, 2013); research sites not actively dividing up work and allocating roles involved with interventions sufficiently (Lloyd et al, 2013;May et al, 2011;Maxwell et al, 2013;Pope et al, 2013); proposed new ways of working not fitting into current individual ways of working or clinical routines (Sanders et al, 2011;May et al, 2011;Bamford et al, 2012;Lloyd et al, 2013;Pope et al, 2013;Finch, 2008;Murray et al, 2011;Marceau et al, 2010); and whether or not existing organizational structures facilitate such processes and fit into how support staff already work (Pope et al, 2013;May et al, 2011;Murray et al, 2011;Elwyn et al, 2008;Atkins et al, 2011). Martin et al (2011Martin et al ( , 2012) noted the dearth of literature which empirically explored how or why interventions can be sustained in routine practice long term.…”

“…Martin et al (2011Martin et al ( , 2012) noted the dearth of literature which empirically explored how or why interventions can be sustained in routine practice long term. Research evidence has since reported the importance of intervention sites measuring and demonstrating impact (Lloyd et al, 2013;Pope et al, 2013) and macro-level issues such as resource constraints and service delivery structures that also impinge implementation of an intervention (Pope et al, 2013;Clarke et al, 2013).…”

Creating Learning Environments for Compassionate Care

“…Qualitative data will be analysed initially using systematic reading, familiarization and open coding, undertaken independently by at least two research team members and then in collaborative data analysis workshops [34]. At this early stage, we will avoid prematurely "fitting" the data into NPT domains.…”

Challenge Demcare: management of challenging behaviour in dementia at home and in care homes – development, evaluation and implementation of an online individualised intervention for care homes; and a cohort study of specialist community mental health care for families

“…Some of these have been developed in care homes 193 and have also been used to inform computer-assisted decision support systems in the NHS. 194 In this present study we adopted a retrospective approach, following completion of the ResCare trial (see Chapters 2 and 3), as some implementation variables may have changed during the course of the trial. For example, in a journal dedicated to practitioners, including care home staff and managers in the UK, Flint and Cream 127 conclude that there is a pressing need for e-learning programs to manage CB in dementia.…”