Dr. Stephen Timmons, School of Nursing, University of Nottingham

1. The relationship between technology and changing professional roles in health care : a case-study in teledermatology Dr. Stephen Timmons, School of Nursing, University of Nottingham Mrs. Sandra Lawton, Consultant Nurse, Dermatology, Queen's Medical Centre, Nottingham

2. Background • Huge unmet need for dermatological care • Increasing referrals and waiting lists/times • Too few dermatologists • Difficult physical access to hospital • Patients seen by the most appropriate member of the dermatology team • An equitable service across the district

3. Geography Nurse led community clinics in primary care supported by teledermatology.

4. Store and Forward Telemedicine QMC Dermatology Unit NHS Net Unit Live Remote GPwSI Data Base Unit Training Remote PCT Clinics Telemarque Server Mail Server

5. Teledermatology Store & Forward • Digital Camera • Lap Top • Email

6. Methods Case Study Design • Embedded single case design • Single case – community clinics • Subunits- all those involved in patient journey (GP, Patient,Nurse, Dermatologist and others)

7. Patient Journey

8. Sample • Purposively selected • 2 patient journeys: GP, Patient, Nurse, Dermatologist and others

9. Data Collection • Semi-structured interviews • Observation of the nurse / patient consultation • Data obtained from clinical records and databases.

10. Data Analysis • The analysis and interpretation of the data was performed manually. • Based on an ethnographic approach and influenced by the principles of grounded theory • Description of the case (How and Why) • Comparative analysis of the data sets : ( interviews,observations and records) • Analysis of the emerging themes

11. Results/Discussion

12. The unimportance of technology “No it’s not the main focus, I mean I don’t know why everybody goes on about it being the main focus, because it is telederm it’s all electronic. It’s actually supporting the nurses who are acting in their own right for their own clinics. That’s what it’s about. It’s not about putting the information on and passing it on to me.” (Consultant Dermatologist)

13. Shifting boundaries : how ? • By using teledermatology, individual and organisational practices have been adjusted • Nurses collect information • But, crucially, decide when & how to refer • The nurses’ role now, effectively, includes diagnosis

14. Patients • Like the service, and are unconcerned about the profession of the person seeing them • GPs value the expertise of the nurses

15. The GPs “It’s not so much things I need a huge diagnosis on but ones I feel the patient will benefit from a longer time in terms of explanation, or if they have been having conventional treatment for a common disorder and things aren’t improving then sometimes I feel they might do better if they came to your clinic, the nurse-led clinic.” GP

16. An ‘advance’ in nursing practice • A contentious point (in nursing) • Not just working to protocols (as often happens in ‘nurse-led’ services) • Used existing skills and knowledge, and developed new ones.

17. How was it possible ? • Policy push • Skills of the nurses • Agreement & support from the consultant & the GPs • The technology

18. A bit of theory • ANT ? • Social construction of technology