The Danish healthcare system is characterised by extensive digitisation, systematic use of guidelines and protocols and introduction of new technologies to strengthen and develop the provision of care within the healthcare system (National Board of Health and Welfare 2017). In hospitals, developments in the use of technology are promising for bringing benefits for both the patients and staff by increasing patient safety and satisfaction, increasing efficiency in care and reducing healthcare expenses (Poncette et al. 2019). However, while considerable resources are invested not only in developing new technologies but also in adopting these technologies, the translation of different technologies into routine clinical practices is often a challenge, as it necessarily involves comprehensive changes in the clinical practice and ways of working (Dahler et al. 2018; Potthoff et al. 2019). In this article, we aim to explore health care workers’ perceptions and reluctance to use a new technology introduced in the department; a new interactive and technologically improved patient room at the post-natal ward at a Danish Regional Hospital. We propose the concept of sense-making which refers to those processes by which people seek to understand ambiguous, equivocal, or confusing issues or events (Colville et al. 2012; Weick 1995). The study delineates the complex interaction between health care workers’ conception of new technology and its implementation and how it relates to their professional roles in the organisation.
The past twenty years have seen an expanding engagement at the intersection of medical sciences and Science and Technology Studies (STS). This corpus of research supplements the established tradition of health technology assessment (HTA), with emphasis on the interaction between humans and technologies, and on materiality, e.g. how technologies, technological systems, devices, and artefacts are recognised as active agents within the relationship (Knopes, 2019; Langstrup et al. 2013; Winman 2012). Informed by STS, these studies consider the broader socio-material networks within which technologies are embedded and focus on their transformative effects on work, knowledge and power (Knopes, 2019; Pittinsky 2019; Langstrup et al. 2013). With regard to technologies in health care, an STS approach has primarily been applied in studies of the relationship between: design and use of technologies (Brodersen et al. 2015; Brodersen and Lindegaard 2014), and implementation of technologies (primarily telemedicine and electronic patient records) and how it affects care (Dahler et al. 2018; Hout et al. 2015; Pols and Moser 2009; Meldgaard Hansen and Kamp 2016; Nickelsen 2015). However, an expanding group of scholars within STS have developed post-phenomenological theory and research methods to address how human-technology relations vary and are dependent on the context. They are focusing on actual interactions between humans and technological devices and systems with an emphasis on meaning and subjectivity (Ihde 2008; Rosenberger and Verbeek 2015; Wellner 2015; Hasse, 2018). Several empirical studies on health care technologies explores the complexities of human-technological interaction within this conceptual framework (e.g., Aagaard et al. 2018; Blixt et al. 2019; Bødker 2019; Forss 2012; Rosenberger 2007). What is common to these studies are their investigation of ‘technology’ as the analysis of social networks and technological set-ups in conjunction. Our study adds to this body of scholarship with its non-technocentric focus on agency in its exploration of the relationships between health care workers and the new technology. This approach is offering new insights into why appropriation of new technology in a hospital ward is (to some extent) met with resistance by the professional care workers in their work practice (see e.g., Wallace 2012).
Theoretical Framework
For the purpose of this analysis the new patient room is understood as a technology rather than merely a space installed with technology. This means that for the nurses and midwives the room is an experience of materiality and a system of perception embedded in their working life. As such it mediates and disrupts the professional procedures, processes and structures that unfurl over the course of the working day. Thus, the introduction of the new patient room in the department presents new and potentially disruptive possibilities for action that may, in their foreignness, provoke people to turn from them. They do not have the inextricable intertwinement with the bodies of workers, which is disconcerting, yet they call out to them and entice them in, potentially, as well. We draw on Weick's concept of sense-making to explicate how agentic organisational members try to make sense of ‘shocks’ in their organisation; shocks that they experience through disruptions in their work flow (Weick 1995; Weick et al. 2005). We have used the framework of sense-making as a guide for our analysis and in the attempt to figure out why the organisational initiative to develop and introduce a new patient room is (or isn't) as easily appropriated as its proponents envisioned. When new technologies are to be implemented sense-making processes are initiated and they influence the health care workers’ appropriation of technology due to their focus on ‘extracting cues’, ‘the bracketing work’, their identity and strong habituated work practices, and their structuring of subsequent perceptions and actions (Weick et al. 2005). According to Weick et al., sense-making processes are grounded in identity beliefs of who we think we are as organisational actors, which then shapes what we enact and how we understand the environment (2005: 416). Identity and identification are central to how people make sense of their (work) environment, meaning that who people think they are in their context shapes what they enact and how they interpret events (McNamara 2015). A potential source of health care workers’ identity originates from their habitual professional practices (Verplanken 2018). Identity can be said to serve as a filter where the actors notice and interpret the change in a manner consistent with their professional habitus (see Jensen and Kjærgaard 2010). As identity over time becomes intertwined in the routines, beliefs, and procedures these are enacted in the socially constituted work practices and contribute to a sense of professionalism and security on behalf of health care workers. It is not ‘just’ work habits; it is linked to how professional judgements are conducted, and thus the change of routines and procedures might then implicitly pose a threat to the professionals’ understanding of who they are and what they do (Tripsas 2009).
The New Room: Research Setting
The empirical material that this article builds on is part of a larger study of new patient rooms, technologies and atmospheres in a maternity ward in a Danish Regional Hospital (Folmann 2020; Lorentzen et al. 2019). The study served as a pilot project for exploring new standards for hospital rooms for the construction of a new hospital in the region and was for that purpose monitored by researchers. The patients in the department are primarily healthy mothers, fathers/partners, and new-born infants, as well as hospitalised sick pregnant women. On a yearly basis approximately 5,200 patients and their relatives are admitted in the department. The department consists of a standard unit and an outpatient clinic and employs 25 nurses and midwives. It has a capacity of 19 patient rooms. Of them, 18 patient rooms are standard clinical rooms with medical equipment visible on the walls, a conventional single person hospital bed for the mother, a pull-out bed for the father, and a cradle on wheels for the infant. These rooms are furnished with robust, institutional furniture. As part of the innovation project on developing new standards for patient rooms, one room was designed differently with regard to interior design and atmosphere. In the room as much medical gear as possible is hidden behind screens. The room is fully furnished with Nordic décor, including chairs, a coffee table, and a rearrangeable sofa with coloured cushions. To stimulate the practical and psychological needs of the mother and the partner/father, acoustical sounds, music and video projections of different Danish landscapes on the wall is available from an Ipad. Furthermore, a large double bed is placed in the middle of the room accommodating the possibilities for the new family to be together. The patients and their relatives are generally extremely satisfied with their stay in the room, where they feel they are more autonomous and independent during their stay which in fact mirrors the core objective of their admittance (for Danish readers, see Folmann et al. 2019 for a throughout analysis of this). For this article, we focus on the health care workers’ use and interaction with the new interactive and technologically improved patient room and their daily practice during its early implementation phase. Of the 25 nurses and midwives in the department, we interviewed seven: three nurses and four midwives. All employees in the department are females between twenty-five and sixty years of age. One was a student nurse, and had been in the department for ten weeks, the others had been working there between one and a half year and thirty years. The participants were selected to represent different levels of experience as employees as well as with the new patient room. The study of the nurses and midwives’ appropriation of the new room is part of an ongoing long-term fieldwork in the department, by Birgitte Folmann, and observational data and unstructured conversations from the daily work, which is also part of the data that this article is based on.
Making Sense of the New Room
Approaching the analysis for this article we were puzzled by how the health care workers expressed enthusiasm about the new patient room, yet did not allocate many patients to the new room. In Weick and colleagues’ version of sense-making they include several aspects, but in our analysis, as mentioned above, we include three core elements of the sense-making process to unfold the findings, namely bracketing/extracting cues, the role of identity construction and enactment. Enactment is when you are interacting with the context and, from the interaction with the context cues are selected (bracketed) retrospectively as part of making sense of the interaction. The selected cues are turned into a story that is plausible and supports identity and experiences. The story is sustained and aligned with co-workers in the organisation and thereby influences future enactment and selection processes (Weick et al. 2005) In other words, sense-making is when people search for meaning of the experienced according to their professional habitus, settle for plausibility and integrate the understanding in future interaction.
Disruption of Existing Work Practices
The introduction of the new patient room created ambiguity and uncertainty among the nurses and midwives as their work processes, professional habitual practices, and existing routines were disrupted. Out of 19 conventional rooms, only one was technologically improved and redecorated and thus being a nurse or a midwife in the new room implicated very different work practices and routines than in the conventional rooms. The altered professional practice seemingly led to a practice of ‘not choosing the room’. The nurses and midwives had the opportunity to deselect the new room if the conventional rooms were vacant. However, due to the general flow of patients in and out of the department, the staff were often ‘forced’ to use the new room. Even though they were generally very positive towards the effect of the interactive features and the atmosphere in the new room, they nonetheless preferred ‘to allocate own patients to other rooms than the new one’.
At the time of our study, the new patient room had been in place for about six months, and all of the interlocutors had been attending to patients in the new room. For several of the nurses and midwives, the new room represented a disruption in their work in the sense that it provoked questions about their role as nurses or midwives in relation to the new parents. A sense-making process of negotiating their roles and tasks were set off. As a part of this negotiation process the nurses and midwives expressed concern in relation to the new room's ability to support the purpose of the stay for the parents and whether the new room with its technologies could enhance their experience of calmness and confidence. However, the expectations of improving the condition for the patients and their relatives through relaxing sounds and videos and the home-like interior were overshadowed by a concern about patient safety and their ability to act adequate in a potential emergency situation. For instance, several of the nurses referred to the physical design of the new room as a problem if something acute occurs:
‘I think, we don't feel safe to work with severe cases in there. … For instance, a patient recovering from a caesarean section (operation) … what if she is heavily bleeding and has to go back to the operating room in a hurry? … I know it is rare, but then … how fast can we move her and where to put the tubes, catheter bag, and IV bags?’
The adaptation of their work practices in the new room were manifested as disruptive and constraining the clinical practice. To some extent, the aspect of ‘what if’ in case of an acute (but rare) situation overshadowed the expected affordances and advantages for the patients, and this restrained the nurses’ use of the room.
The large double bed was also subject to the bracketing of opposing cues. The nurses and midwives explained how the bed was amazing for the parents and their new-born; it was described by several as ‘the heart of the room’. They also claimed that the bed was sustaining the core task of supporting the process of family formation for the parents. Despite of these affordances, they emphasised that it was too high for them to easily access the mothers (e.g. for assisting them breast feeding) and that it could not be moved, and therefore the patients had to be put on a stretcher in case of transport during an emergency. These aspects of the bed fuelled concern about it being impractical and potentially disrupting safe practice.
Also, in the process of bracketing, parts of the complexities that they experience related to the new room, several of the interlocutors questioned whether a bed, or the design of a room, possibly could make more than sensory differences for the patients. Even if some of the nurses and midwives acknowledged the positive impact of the new room, others pointed out that the prioritisation of technologically and sensory improved rooms in fact represented an implicit downgrading of their own work as health care professionals. One of the nurses framed her views like this:
I don't think it should be a priority … not even for the parents. … It is about the contact [with the professionals] that they get. That is what they are here for. Getting it to work—that they can get help. I think we [the nurses] are a much more important part of being here than the design of the room and its technologies.
Together, these examples indicate how the health care workers faced a sense of uncertainty about the meaning or consequence of the new room, and they had several unanswered questions about how to use it as well. This led them to focus on the cues that were bound to their professional habitus and existing work practices, to provide the best possible patient care. The introduction of the new patient room disrupted existing working routines these disruptions became cues that drew attention to their previous experience of their core tasks. Without this dialectic between cues and the existing context, meaning could not be produced. In the ongoing bracketing process, the professional habitus and identity construction of the nurses and midwives played an important role.
Sense-Making Is a Matter of Identity
Next to extracting cues and bracketing, Weick et al. emphasise the role of identity and identification as central to the sense-making process (Weick et al. 2005). This means that who people think they are in their context shapes how they extract cues and what they enact and how they interpret events and changes (Thurlow and Mills 2009; Weick et al. 2005). One of the midwives felt that the room provided a means for the establishment of relaxation not only for the parents but also for herself. She said:
With another family, they used the video projections; they had an imagery from Copenhagen docks on the wall. Their child was in light treatment, and I think it worked really, really well. … It created a relaxed feeling in the room, the calmness invited for a conversation. It was probably the music and moods. I don't know how we came to talk about it, but they told me about a hard time prior to the birth of their child with their families. I cannot quite put it into words, but it felt completely natural to talk with them. Maybe it was just the right time, or the room made them open up. When you enter the room, it kind of greets you with relaxation.
A nurse-student emphasised that the design of the room was refining her task of supporting both the new mother and the father and enhancing their chance of becoming a whole family:
‘In the morning, I sat on the edge of the bed, it felt natural. … The big family bed means that they are together, which means that when I am talking to the mother, I am talking to both. The bed becomes the place we all gather’.
Most of our interlocutors were familiarised with the new family's needs, and they were emphasising how the design of the new patient room was creating a relaxing atmosphere despite some reservations:
‘I believe that I get the same feeling as the families. A sense of home and the good atmosphere. … not the sterile, cold hospital-like look. The room accommodates a feeling of being met. It creates, how can I say this. … it promotes a sense of good mood and good energy’.
The patient room was, as seen above, evaluated in very positive terms, as its materiality and ‘homeliness’ reinforced their effort. When asked about the core task—to establish a sense of security in the parent's ability to manage when discharged to their home—one nurse answered: ‘Yes, that is what we aim at: for them to go home and think: we can do this!’
This shows that the nurses and midwives were bracketing various cues about how the new patient room could improve the condition for the patients and their relatives. At the same time, the expectations of improving existing work practices were also often challenged and became ambiguous in the ongoing sense-making process:
In my mind, the things we have in the room should be practical. And logical. What we don't need is to spend time on getting into things. It should be possible to have a place to put things, after all, we are in a hospital. But at the same time, it should also look home-like, with flowers, some shelves on the walls, and things like that. So, maybe a combination of the two—the new room, and the old ones, because in the old rooms, I really miss the opportunity to adjust the lightening.
Another aspect of the new room that were challenging for the nurses and midwives’ professional identity was how the room afforded the parents autonomy: ‘It is as if they [the parents] are more able to help themselves—they don't call us as much when they are in the new room’. Another nurse said, ‘I'd rather have some more hands [meaning: staff] than a fancy room’, indicating that the presence of a professional nurse or midwife was more important than a room that in itself supports the families’ independent family formation. The importance of professional identity in such contexts becomes especially evident when it is threatened. Facing a major change, as the introduction of the new patient room was interpreted, it can be understood as a threat to the health care workers’ identity (Maitlis and Sonenshein 2010). A threat to the identity and going against their professional habitus can constrain actions as they lose important anchors about themselves. Both nurses’ and midwives’ meanings about the new patient room were created in the light of their existing professional identity. At the same time, the affordances of the new room redefined their identity. It is common that during a change, identities are constructed in relation to a new context, and during the identity transformation, powerful existential problems arise that can create resistance to change. The health care workers sometimes found it difficult to identify ‘who they are’ and what their core tasks in the new room should be, when the patients and their relatives acted completely different than patients normally do. For instance, one nurse's resistance to the new room was linked to the fact that she struggled to make sense of her role and felt that the new furniture and installations left no room for her to act professionally in the room:
It is difficult to assist with breastfeeding. I know that we attempt to help them without using our hands, but it is sometimes necessary. In this case, it is difficult to reach the mother in the bed. … In fact, there is no proper place for the mum to breastfeed. That's pretty paradoxical, I think. How to help her? It is a sofa! But is it very suitable for breastfeeding? … I think it is a smart-looking sofa, but that's also the best thing to say about it.
As a result of her difficulties finding a place for herself, she avoided using the new patient room. In their interaction with the new room, the nurses and midwives developed a rationale about the room being a positive thing for the family formation process of the parents but at the same time being complicated for the nurses and midwives who felt that their professional standards were challenged. The room was ‘taking over’ some of the core tasks of the nurses, such as being able to provide a sense of security to the parents. As such, they advanced the support of the parents as a key value in their professional work, but the room imposed an identity of being ‘less useful nurse’. They expected the new room to lead to improvements not only to the patients but also to their nursing practices and were disappointed when it turned out to be wrong. The shared ideas of how to be a good care worker and fulfilling the core tasks, to empower the new families, is a shared identity, and it provides a vital anchor around which the professionals collective construct meaning and understand their experiences. However, working in the new patient room impeded their professional practices.
Enacting Expectations
The nurses’ and midwives’ expectations and preconceptions of the new patient room's limitation seemed to outweigh the positive aspects of the technology. Thus, the sense-making processes resulted in shared negative meaning which led them to refrain from using the room. Such expectations can both enable and constrain use and implementation. Some of our interlocutors said that they were reluctant to use the patient room because they were not properly introduced to the specific technological features in the room, and following from this they were criticising the technology for not being able to make a difference in patient care. Some emphasised that the new patient room on occasions hindered their professional work, for instance they believed they were ill equipped to handle an acute situation in the room. Since their expectations remained low, they had little incentive to change their existing professional practices. For some, this reinforced the deselection of the room and a reluctance or in fact rejection of a further exploration of the benefits of the new technology:
The reason, why I tend to deselect the new room for my patients is that they might ask about things related to the interactive wall or television when we are really busy. For one thing, I really have no clue about how it works, and secondly, in my mind, they have to figure it out themselves. Get out of it what you can! There are some possibilities, and perhaps you should be able to get some assistance, but you have to figure it out for yourselves.
Consequently, professional practices of the nurses and midwives in the ward tended to reinforce positive connotations towards their established work procedures rather than looking to develop new ones which kept their patients out of the new room. These examples illustrate how the health care workers’ expectations and sense of professional organisational practice formed their actions and their sense-making which sometimes hindered subsequent actions, and these actions then confirmed their expectations of the difficulties in using the new patient room.
Concluding Discussion
In healthcare, sense-making at the social and organisational level informs the process of making decisions about the delivering of care to individual patients. Change in the organisation creates reaction, as agents-in-context seek to evaluate its implications for what they do and how they see themselves. Instead of foregrounding technology, the sense-making perspective emphasise agency and offers a means of exploring how individuals construct and enact their understanding of the ‘realities’ not as an individual endeavour but rather as a shared, distributed, and social experience. Through that lens, and in the course of interactions among the nurses and midwives, the patients, and the environment (e.g., time constraints, difficulties in handling the technological features, and the design of the new patient room), using the new room appears as a challenge despite the management's focus on how the room can support patient-centred care.
Implementation of new technologies in public organisations tend to set off resistance and avoidance in the early phases (Jensen and Aanestad 2007). Since the new patient room is the only one of its kind out of the department's 19 rooms, the new room did challenge the professional practices established around the work in conventional patient rooms. The new and improved technologically room disrupted established ways of working and initiated a sense-making process. Analysing the sense-making process illuminates a paradox between the nurses’ and midwives’ feeling of the room as an improvement in supporting family formation and at the same time impeding their role of being a good nurse or midwife.
Our study reveals that the introduction of a new patient room in the post-natal ward caused disruptions and implied new tasks for the health care workers, alienating them from their professional working routines. During their initial encounter with the new patient room, they tried to extract cues and define its affordances and to reduce some of the ambiguity that the change entailed. They seemed to focus on cues that were bound to their professional habitus and their existing clinical frame to provide the best possible patient care. Several of the nurses and midwives described the new patient room as a place for them to enact their professionalism, and they defined the new patient room as a tool for the core task. But they also felt that the conventional patient rooms could be used for the same, and thus, the need to incorporate the new patient room into their routine professional practice were limited which prevented further possible extensive use of the technology.
Based on the empirical findings, we illustrate how the introduction of new technology is disrupting nurses’ and midwives’ work, challenges their professional habitual practices, and impedes the commissioning of the new patient room. With Weick's concept of sense-making, we argue to dissociate the technocentric view of technology use and instead put the social aspects of implementation of new technology at the core. When nurses and midwives at the post-natal ward are signed in to provide care in the new patient room, they are influenced by their professional habitus, trying to bring caring, competence, and their specific core task into focus, but they find it difficult. In their attempt to find meaning with the change in their work, they dynamically create new perceptions about their role as well as the utility of the technologically improved room, and this in turn alters how they conduct and understand their own role and activities. The preunderstanding and these perceptions affect the way that the technology is appropriated and hence mediate its impact on the work practice. In this context the health care workers have to find meaning and maintain a sense of professional agency on the background of organisational changes. This challenges their habitual practice and transforms their provision of care. The analysis illustrates how the new technology instils ambiguity in the nurses and midwives; on the one hand, they are evaluating the room as a nice, calm place with a supporting atmosphere for the new parents and themselves and, on the other hand, they are experiencing disruptions in their existing work routines in an inhibiting way. They are facing difficulties in aligning their existing professional habitus in relation to how to work with patient care, but at the same time, they emphasise the affordances of the new room for the parents, as one of the nurses told us: ‘It is somehow really a paradox … What makes it nice is also what makes it difficult’.
The study shows how important it is to focus on human agency in the techno-material reality of the clinical setting. Foregrounding health care workers’ sense-making processes can improve and facilitate implementation of the new technology to the specific practice. Understanding the sense-making process as a social act and as involving health care workers’ uncertainties, reactions, and actions, will enhance appropriation of new technology and raise work satisfaction among health care workers.
Acknowledgements
We would like to thank the nurses and midwives with whom we worked over the past years and who kindly gave us their time.
Birgitte Folmann and Regine Grytnes designed the study. Anthropologist Anna Helene Meldgaard Pedersen interviewed the nurses and midwives together with Grytnes. Folmann did observations and had multiple informal conversations in the department. Folmann and Grytnes did the data analysis and interpretation. Folmann wrote the first draft of the manuscript. Grytnes contributed to the subsequent versions of the manuscript and approved the final version for submission.
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