| Summary: | The Norwegian healthcare sector, like the rest of the Western world, faces major challenges related to the need to coordinate work within and across institutional anddisciplinary boundaries. The main materialization of the ongoing efforts of streamlining healthcare services is the formalization of healthcare work through the Electronic-Based Record (EPR). In this thesis I explore one particular aspect of these efforts: nursing care and the formalization of nurse’s written accounts in the EPR-based nursing record. Nurses play an essential role in ensuring that there is a well-functioning organization and a seamless management of patient trajectories. With increased emphasis on integrated care as the standard model for delivering healthcare services, the contribution of the nursing profession to the overall delivery of care is increasingly acknowledged. This thesis explores how nursing is documented in practice and how the EPR-based nursing module is integrated in specific nursing work practices. Empirically the thesis is based on ethnographically inspired fieldwork at the Department of Rheumatology at St. Olavs University Hospital in Trondheim and the Department of Special Psychiatry at the University Hospital in Tromsø. In both cases I have studied nurse’s documentation practice and the integration of the EPR-based nursing record into their everyday work. The thesis has a strong focus on how things are done in practice. The set of papers presented as part of this thesis make some of the work involved in formalizing nurse’s written accounts visible and also present the EPR-based nursing record in practice. The main contribution of the thesis is a detailed, empirically underpinned exploration of the efforts of introducing the electronic-based nursing module in practice. I apply a process-oriented perspective on the nursing record that stresses how it is situated, its temporal nature, how it is regularly (re)negotiated and achieved in practice. Integrating the EPR-based nursing record with the aim of improving information sharing is extremely difficult. In the Trondheim case it is demonstrated how efforts of formalizing nurse’s work through the EPR introduced new types of informal elements. In fact, the informal, redundant and unstructured aspects of nurse’s work that initially were considered to be a problem became essential for the new formalized practice to work. Similarly in Tromsø, the standardization of nursing plans unintentionally subverted the possibilities for interdisciplinary cooperation. Rather, it was the existing and heterogeneous (informal/formal and oral/written) documentation and communication practice that contributed to interdisciplinary work and made up and served as a premise for a good nursing plan. The thesis contributes to theory by presenting a dynamic perspective on the nursing record as resilient, open and achieved in practice. The thesis contributes to the literature within Computer Supported Cooperative Work (CSCW) on informal documentation practices and expressions of redundancy by demonstrating how these are transformed when new technologies are being implemented. Also the thesis contributes to the existing CSCW literature by demonstrating the necessity of accommodating temporal differences that arise from separate and different intragroup processes. The aims and goals related to the EPR change and expand over time and in relation to multiple stakeholders. For example, in the Tromsø case the nursing plan, which started out as tool for nurses, gradually turned into a resource management tool. Such transformations of ambitions are typical in information system projects and should not come as a surprise - primary work transforms things into something different where technologies find new areas of application. In order to succeed in integrating tools such as the EPR-based nursing record with work, one needs to move beyond simplistic strategies of replacing the existing information sources. The strategy to pursue is to find mechanisms that strengthen the relations between the parts. For practice this implies balancing rational aims and practical applicability when designing and implementing new tools. Also, it involves paying closer attention to what is non-common, for example what types of information sometimes remains specific for the various professionals, and why. Methodologically, the interconnected and mutually dependent entities of material arrangements and practices of different professionals underscore the need for doing empirical studies in a work setting by following the whole process of implementing a new system (before, during and after). Also, in order to make research findings practically relevant, researchers should engage themselves in arenas that enable learning to take place, where knowledge can be shared and where local competence and capacity are cultivated. Rather than presenting a fixed set of requirements as implications for design, we should struggle to build relationships between politically contrasting interests, for example between vendors, managers and the users. Design implications are in this sense not fixed once and for all, but instead serve as a starting point for discussion, reflection and negotiated changes with various stakeholders. dr.scient. dr.scient.
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