Reconceptualising learning in student-led improvement science projects: an actor-network theory ethnography in medical education

The National Health Service in Scotland promotes improvement science methodology as an innovation for implementing rapid change in hospital practices. Student-Led Improvement Science Projects (SLISPs) have been developed as a result of this, where students work with clinical teams to identify, implement and monitor quality improvements in the workplace. Working with improvement science in working practices in a hospital environment presents opportunities for different ways to reconceptualise learning. This research critically examines professionals’ learning through practices that are enacted during SLISPs. The focus is on medical and pharmacy students in a hospital setting. The research traces the fine-grained activities, materials, spaces, behaviours and relationships that emerged during a SLISP, with the purpose of gaining a better understanding of what learning means in relation to improvement science. There are recent studies of the educative practices of quality improvement projects in the literature (Armstrong et al. 2015; James et al. 2016) and there are healthcare studies which use sociomaterial approaches (Ahn et al. 2015; Falk et al. 2017; Ibrahim et al. 2015), but this research combines education research, healthcare, improvement science and the sociomaterial approach of actor-network theory. The study described in this thesis draws from ethnographic methods combined with actor-network theory (ANT) to investigate the pedagogies of improvement science. Three ANT dimensions were explored: networks, symmetry and multiple worlds. From the fieldwork data, three ‘anecdotes’ were constructed: (1) antimicrobial prescribing; (2) insulin recording; and (3) pedagogies of improvement science. Each anecdote was analysed using each of the ANT dimensions. Networks were explored by attuning to relations and associations using the method of ‘follow the actor’ (Latour 2005). The notion of symmetry provided an alternative perspective of the data by exploring the treatment of humans and non-humans held together in heterogeneous assemblages. Finally, after-ANT concepts were explored through ‘multiple worlds’ by troubling ambivalences and unfolding practices. Five key insights were presented from this analysis: (1) conceptualising networks presents learning as disruption, as existing networks of practice collide with new networks such as improvement science; (2) materials can invite or exclude practices, leading to learning being shaped materially; (3) invisible or black-boxed activities can become visible through the practices of the SLISP; (4) multiple worlds of practice are manifest in the assemblages of materials which coexist through regulating difference; and (5) professionalism can be conceptualised as an assemblage where learning emerges through practices of ordering. The implications for medical education and education in general are that a broader range of pedagogies exist for improvement science by challenging the conditions of possibility. An ANT methodology contributes to this by noticing details of practice that might otherwise be overlooked and allowing for different enactments of improvement science to co-exist through multiple worlds

Machines and machinations: The integrated care record service in the UK national health service

This paper examines the use of Actor Network Theory (ANT) as a lens to get a better understanding of the implementation of the Integrated Care Record Service (ICRS) in the UK National Health Service (NHS). Actor Network Theory has been deployed in various environments to achieve a better understanding of the roles of not only the humans but also the artifacts that constitute, in this case, healthcare networks of services and organisations. The theory is used as a means of supporting real world interventions, providing a richer understanding of complexities involved and thereby helps management to make better decisions. This study also explores Latour’s concept of machines as machinations, whose role is to translate other actors into the network. We propose ICRS as a fruitful empirical context for the use of ANT to support decision making for actors in health care provision. Actor Network Theory (ANT) is well-suited for use in the socio-technical evaluation of IS into the ICRS project because this approach treats human and non-human actors symmetrically. This approach facilitates a more thorough examination of the ways in which information technology is enabled or restricted in social processes

Performative ontologies. Sociomaterial approaches to researching adult education and lifelong learning

Sociomaterial approaches to researching education, such as those generated by actornetwork theory and complexity theory, have been growing in significance in recent years, both theoretically and methodologically. Such approaches are based upon a performative ontology rather than the more characteristic representational epistemology that informs much research. In this article, we outline certain aspects of sociomaterial sensibilities in researching education, and some of the uptakes on issues related to the education of adults. We further suggest some possibilities emerging for adult education and lifelong learning researchers from taking up such theories and methodologies. (DIPF/Orig.

Why is it difficult to implement e-health initiatives? A qualitative study

<b>Background</b> The use of information and communication technologies in healthcare is seen as essential for high quality and cost-effective healthcare. However, implementation of e-health initiatives has often been problematic, with many failing to demonstrate predicted benefits. This study aimed to explore and understand the experiences of implementers - the senior managers and other staff charged with implementing e-health initiatives and their assessment of factors which promote or inhibit the successful implementation, embedding, and integration of e-health initiatives.<p></p> <b>Methods</b> We used a case study methodology, using semi-structured interviews with implementers for data collection. Case studies were selected to provide a range of healthcare contexts (primary, secondary, community care), e-health initiatives, and degrees of normalization. The initiatives studied were Picture Archiving and Communication System (PACS) in secondary care, a Community Nurse Information System (CNIS) in community care, and Choose and Book (C&B) across the primary-secondary care interface. Implementers were selected to provide a range of seniority, including chief executive officers, middle managers, and staff with 'on the ground' experience. Interview data were analyzed using a framework derived from Normalization Process Theory (NPT).<p></p> <b>Results</b> Twenty-three interviews were completed across the three case studies. There were wide differences in experiences of implementation and embedding across these case studies; these differences were well explained by collective action components of NPT. New technology was most likely to 'normalize' where implementers perceived that it had a positive impact on interactions between professionals and patients and between different professional groups, and fit well with the organisational goals and skill sets of existing staff. However, where implementers perceived problems in one or more of these areas, they also perceived a lower level of normalization.<p></p> <b>Conclusions</b> Implementers had rich understandings of barriers and facilitators to successful implementation of e-health initiatives, and their views should continue to be sought in future research. NPT can be used to explain observed variations in implementation processes, and may be useful in drawing planners' attention to potential problems with a view to addressing them during implementation planning

The politics of displacements. Towards a framework for democratic evaluation

The confrontation of values and interests and an impact in the public realm constitutes a broadly recognised political dimension of technological innovation processes. There is, however, a gap between empirical research into these politics of innovation and normative research into their democratic evaluation. Especially methods for evaluating the democratic quality of dynamic and non-formal forms of innovation politics are lacking. This paper aims to fill the gap by developing a framework for analysing the politics of innovation in terms of displacements of issues. Its first part reviews different theoretical approaches and concludes that decision-making about design and use generally takes place in a multitude of settings and that this circumstance calls for theoretical investigation of displacements between settings. In the second part, the notions of ‘issue’, ‘setting’, and ‘displacement’ are further elaborated and related to one another. A conceptual framework is construed that is suggested to be helpful in the democratic evaluation of the politics of displacements. The paper ends with a reflection on the applicability of recently developed democratic criteria. Because these criteria are devised for proceduralised and static decision-making processes, they needed to be reduced to three democratic principles that are general enough to capture local variation and specific enough to make a difference between good and bad politics.

Lost in translation? : negotiating technological innovation in healthcare

Technological innovation in healthcare is growing at a rapid pace. Developments in genetics, stem cell research, bioinformatics, imaging and screening techniques have broadened out the arena of health technology. These developments in sophisticated technology, it is suggested, have the potential to revolutionize the practices of medicine and healthcare by providing more proactive and powerful tools for the diagnosis, treatment, and prevention of illness and disease (Liddell et al, 2008; Webster, 2002). In support of such claims, available research findings suggest that the adoption of new innovative health technologies (IHTs) can result in reducing healthcare costs, increasing productivity, healthcare effectiveness, and improving the patient’s experience of care by better management of chronic diseases (Liddell et al, 2008; Healthcare Industries Task Force, 2004). At the same time, new innovative health technologies present many challenges. Evidence indicates that patient safety and proven clinical effectiveness are insufficient to ensure the adoption and implementation of new clinical technologies. The prevailing organizational and policy context is crucially important as this may present barriers which slow or even prevent uptake (Lehoux 2006). In recent years there has been a continuing debate around issues of clinical resistance, organizational/clinical restructuring, procurement and commissioning, public trust, and, more widely, around the ethical and social implications of techno-scientific innovations in medicine and health (Williams and Dickinson, 2008; Webster, 2006; Ferlie et al., 2005). Moreover, cost-effectiveness evidence is now required to inform decisions about the funding and procurement of new healthcare services and technologies (Fitzgerald et al., 2002). Overall, the value of the innovation has to be clearly evident to a number of different stakeholders if technologies are to be embedded into actual work practices. These potential barriers have given rise to questions related to the diffusion and adoption of emerging medical and healthcare innovations. This paper examines the dynamics and complexity of innovation adoption processes in the context of a rapidly changing healthcare policy landscape. Drawing upon the inherently socially negotiated character of meaning, this paper illustrates the ambivalent nature of technological innovation by examining the complex ongoing interplay of heterogeneous discourses in shaping the adoption of innovative health technologies (Law, 1987, 1994). Drawing upon Rye and Kimberly (2007) adoption is here understood as a distinct organizational process related to an organization’s potential interest in implementing a technological innovation. In so doing, this paper draws on the findings of a three year research project which examines the adoption of innovative clinical technologies in the UK NHS. In particular, we explore the nature, role and dynamics of heterogeneous discourses (technological, managerial/professional, clinical), in shaping the adoption of a retinal imaging technology in a UK hospital Trust. In this regard, we contribute to the development of alternative ways of describing, analysing, and theorizing the process of technological innovation in healthcare