Professor Trish Greenhalgh @ trishgreenhalgh

1. Teddy Chester Lecture 1st October 2013 Technology adoption: what’s the problem? Professor Trish Greenhalgh @trishgreenhalgh

2. Unlearning Structuration theory The technology dimension‘Contemporary’ STExample: Choose & BookExtended theory Empirical dataConclusions

3. Unlearning Structuration theory The technology dimension ‘Contemporary’ ST Example: Choose & BookExtended theory Empirical data Conclusions

4. We need to unlearn some stuff Simplistic Individualistic Devoid of context Positivistic Stereotypical Value-laden Pro-innovation bias Theories of individual adoption, based on cognitive psychology, explain a TINY % of technology adoption problems in the NHS

5. Flawed conceptual model of ‘resistance’Resistance = stupidity + skill deficit + fearSolution = behaviourist tactics (incentives, training, encouragement, ‘leadership’, ‘good management’)

6. Flawed behaviourist solution “People who have low psychological ownership in a system and who vigorously resist its implementation can bring a ‘technically best’ system to its knees. However, effective leadership can sharply reduce the behavioral resistance to change--including to new technologies--to achieve a more rapid and productive introduction of informatics technology.” Lorenzi & Riley: JAMIA 2000; 7: 116

8. The original diffusion of innovations study Standard Iowa corn (1950s) Hybrid corn (1950s)

10. Everett Rogers unlearns “Back in 1954, one of the Iowa farmers that I interviewed for my PhD rejected all of the chemical innovations that I was then studying. He insisted that his neighbours, who has adopted these chemicals, were killing their songbirds and the earthworms in the soil. I had selected the new farm ideas in my innovativeness scale on the advice of agricultural experts at Iowa State University; I was measuring the best recommended farming practice of that day. The organic farmer in my sample earned the lowest score on my innovativeness scale, and was categorised as a laggard.” Everett RogersDiffusion of Innovations, 5th Edition, 2003

11. Popular alternative 1: Socio-technical systems theory • Technologies and work practices are best co-designed using participatory methods in the workplace setting, drawing on common-sense guiding principles such as • staff should be able to access and control the resources they need to do their jobs • processes should be minimally-specified (e.g. stipulating ends but not means) to support adaptive local solutions • Chearns 1987 Limitation: The ‘socio-technical system’ does not include a rich theorisation of either people (e.g. doctors) or society (e.g. political context of NHS IT)

12. Popular alternative 2: Actor-network theory Humans and technologies are linked in networks These networks are generally dynamic and unstable To introduce a technology you need to stabilise the network Latour 1986 Limitations: Views humans and technologies as ‘symmetrical’. Views ‘agency’ as a product of the network – hard to integrate a theorisation of professional ethics or identity. Flat ontology.

13. Unlearning Structuration theory The technology dimension ‘Contemporary’ ST Example: Choose & Book Extended theory Empirical data Conclusions

16. “People are not passive recipients of innovations. Rather (and to a greater or lesser extent in different individuals), they seek innovations out, experiment with them, evaluate them, find (or fail to find) meaning in them, develop feelings (positive or negative) about them, challenge them, worry about them, complain about them, work around them, gain experience with them, modify them to fit particular tasks, and try to improve or redesign them—often through dialogue with other users.”

17. Structuration theory (Giddens) What society sees as correct, reasonable, affordable, legal SOCIAL STRUCTURES Script atTime t-1 Script atTime t Script atTime t+1 What individuals actually do INDIVIDUAL AGENCY

18. Structuration theory (example) What society sees as correct, reasonable, affordable, legal SOCIAL STRUCTURES Birthdayparty 1950 Birthdayparty 1980 Birthdayparty 2013 What individuals actually do INDIVIDUAL AGENCY

19. Unlearning Structuration theory The technology dimension ‘Contemporary’ ST Example: Choose & BookImplications Summary DIscussion

20. X-ray machine CTscanner MRIscanner Technology structuration theory (Barley) What society sees as correct, reasonable, affordable, legal SOCIAL STRUCTURES Imaging a patient Imaging a patient Imaging a patient What individuals actually do INDIVIDUAL AGENCY

22. HOSPITAL B Technician takes X-ray, doctor interprets X-ray Technician takes X-ray, doctor interprets X-ray Technician takes CT scan, and helps doctor interpret it Technician takes CT scan, doctor interprets CT scan CTscanner CTscanner Technology structuration theory (Barley) HOSPITAL A

24. upgrade upgrade upgrade upgrade upgrade Barley’s model of technology as an “occasion for structuring” Script at Time t - 1 Script at Time t static technology Problem: software is an evolving technology!

25. Unlearning Structuration theory The technology dimension‘Contemporary’ STExample: Choose & Book Extended theory Empirical data Conclusions

26. t1 What configuration of people, technologies and wider influences (cultural, economic, legal etc) is producing what action? And what are the outcomes of this action? t2 t3 Contemporary adaptation of Giddens / Barley’s theories to accommodate evolving technologies (Greenhalgh & Stones)

27. To understand the macro and meso, we must zoom in to the micro and look through the eyes of front-line actors

28. An ‘actor-network’ in which human agency is richly theorised (i.e. humans act, technologies don’t really) and we assume a ‘layered ontology’

29. Macro-level: the social, political, economic and technological context of wider society Meso-level: the organisation’sset-up, resources and ways of working Micro level: the people, the technologies and the front-line, as-it-happens detail

30. Macro-level National and regional policies and priorities Economic climate Technological developments Social movements Professional norms and standards Meso-levele.g. organisation Job descriptions, training, work routines IT systems and in-house knowledge Culture and support for innovation/risk-taking Micro-level (e.g. clinical encounter) People’s identities, roles, knowledge, skills What the technology can and can’t do in a particular situation and setting

31. Person A sees the strategic terrain in a particular way. S/he is more influenced by some social structures than others, and sees more potential in some technologies than others

32. Person B sees the strategic terrain, and the potential of technologies, differently

33. Technology X came from somewhere. Inscribed in it are ‘scripts’ (intended by its designers) and also potential uses that the designers did not anticipate

34. The clinician What is my background, identity, values, education, skills, IT-literacy etc? How do I see the strategic terrain (e.g. what do I see as ‘the Royal College view’ and ‘the way things are done in this organisation’)? • What is my clinical assessment of this patient and priorities for managing them? What do I think the patient thinks – and what do I think the technology can do? The technology What was I designed to do – by whom, and for what? What standards and assumptions have been built into me as codes, options or decision models? With what other people and technologies do (and don’t) I connect? What are my material properties and how do they play out in this situation? The patient What is my background, identity, values, education, skills, IT-literacy etc? In what way am I sick – and how does this affect my interest and capacity? What do I desire (my‘presenting complaint’ and my‘hidden agenda’)? What do I think the clinician thinks, and what do I assume about the technologies? Action in this situation What is actually done? What is the short-term impact in this clinical situation? What is the longer term impact on the way people think and behave?

35. Unlearning Structuration theory The technology dimension ‘Contemporary’ STExample: Choose & Book Extended theory Empirical data Conclusions

36. Choose & BookRemote booking of outpatient appointments by GP or patient (from home using a password and booking reference)Introduced in UK in 2004 to support a policy of ‘choice’ (of hospital) by informed, empowered patients

37. Choose & Book: Empirical study 2007-10Ethnographic observation in 4 GP practices over 2 years, including 29 GP consultations + 58 ‘admin’ referralsVideo and screen capture data on 12 consultationsNaturally occurring talk and ‘on the job’ interviewsDocuments, letters, email exchanges

38. Choose & BookLinked to a wider government-led ‘modernisation’ agenda: measure doctors’ work, make performance ‘transparent’, drive up quality through ‘informed choice’.C&B was adopted and then abandoned in most GP practices, despite financial incentives:“I was a pioneer user but I no longer use it at all” - GP

39. Choose & Book (8 years on…)

40. Macro-level: Neoliberalism, ‘choice’ policy; regulatory bodies (CQC); economy (& specific incentives); professional norms/values Meso-level: 4 GP practices with different cultures, IT infrastructure and ways of working Micro level:The clinical encounter and admin work

41. Unlearning Structuration theory The technology dimension ‘Contemporary’ ST Example: Choose & BookExtended theoryEmpirical data Conclusions

42. Human agents think and feel and care

43. A new [normative] theory of resistance Grounded in the ethics of professional practiceAsks ‘What is excellence in medicine / nursing?’ and ‘How does this IT help (or stop) me achieving excellence?’

44. What is excellence in clinical care? Medicine’s ‘internal goods’ (Alasdair MacIntyre) Good doctoring is “a relational competence, where empathic perceptiveness and creativity render doctors capable of using their personal qualities, together with the scientific and technologic tools of medicine, to provide individualized help attuned to the particular circumstances of the patient.” Schei: Perspecives in Biology and Medicine 2006; 49: 393

45. The ‘expert system’ (computer science)A way of capturing expert knowledge into rules and protocols so as to deliver this knowledge to the non-expert

46. The ‘expert system’ (sociology)“[a] system of technical accomplishment or professional expertise that organize[s] large areas of the material and social environments in which we live today”Giddens ‘The Consequences of Modernity’

47. The ‘expert system’ (sociology)Classification systems “describe the way things are”.Embedded rules and protocols impose a distant set of values and priorities on local situations  ‘empty out’ their detail. Mary Douglas, ‘How Institutions Think’, 1986

48. Hypothesis Clinicians’ resistance to big IT systems can usually be explained as rejection of the rules and classification systems embedded in an expert system because they conflict with the ‘internal goods’ of professional practice.

49. Ethnography (qualitative observation) can tell the story about people doing work with technology

50. Critical ethnography A methodology for studying resistance to expert systems. Empirical ethnography: Careful observation to document tasks and processes  “implications for design” Critical ethnography “… has the potential to rework a set of critical epistemological concerns around reflexivity, voice, stance and standpoint” Dourish and Bell: ‘Divining a Digital Future’