The influence of digital technologies on resilient performance: Contributions, drawbacks, and a research agenda

The growing use of digital technologies (DTs) has a myriad of implications to socio-technical systems, which are not yet fully recognised. This paper investigates the contributions and drawbacks of DTs to resilient performance (RP), an aspect that so far has received less attention in comparison to others such as efficiency. To this end, a survey questionnaire was applied to 79 academics and practitioners linked to resilience engineering. Data analysis involved descriptive statistics and a thematic analysis of the open-text responses to the survey. Mixed impacts were identified, with 10 themes related to contributions and 16 to drawbacks. Regarding the contributions, the results highlighted the use of DTs for monitoring and anticipating system performance. Machine learning seems to be the most promising approach for this purpose. A key drawback is the need for developing new skills across the workforce so that they can make sense of the outputs of DTs and are aware of their strengths and weaknesses. The human role is expected to remain crucial for RP, which makes the current coordination difficulties with DTs even more important to address. A research agenda composed of five topics is proposed, encompassing description, prescription, and assessment. The agenda emphasizes the need for mapping the attributes or functionalities of DTs onto resilience concepts, models, and frameworks.

Infection precaution adherence varies by potential exposure risks to SARS-CoV-2 and job role: Findings from a US medical center

BACKGROUND

Infection precautions (IP) facilitate standardized and safe patient care. Research has demonstrated several barriers to IP adherence among health care personnel (HCP) but potential exposure risk to SARS-CoV-2 and job role has not been considered.

METHODS

Researchers used self-reported baseline surveys with 191 HCPs at a university medical center to examine factors that may have affected IP adherence (eg, personal protective equipment [PPE] and hand hygiene errors) over the 2 weeks prior to the survey. Chi-square tests were used to determine if differences existed first, among job role and IP adherence, and second, the potential risk of exposure to SARS-CoV-2 and IP adherence. A binary logistic regression estimated if PPE nonadherence was associated with COVID-19 stress, job role, and potential exposure risk to SARS-CoV-2.

RESULTS

PPE nonadherence varied by job role. Those in the Other group (ie, nonphysician/non-nursing HCP) reported significantly fewer errors (9.6%) compared to Physicians (26.5%) and Registered Nurses (33.3%). Hand/glove hygiene errors between COVID-19 patient rooms varied by job role. Respondents who had higher risks of exposure to SARS-CoV-2 were 5.74 times more likely to experience errors.

CONCLUSIONS

The results provide implications for adopting systems-level approaches to support worker knowledge and engagement across job roles to improve IP adherence.

Daily work variability in falls prevention of hospitalized patients: nursing team's perception

BACKGROUND

The identification of safety incidents and establishment of systematic methodologies in health services to reduce risks and provide quality care was implemented by The World Health Organization. These safety incidents allowed the visualization of a vast panorama, ranging from preventable incidents to adverse events with catastrophic outcomes. In this scenario, the issue of fall(s) is inserted, which, despite being a preventable event, can lead to several consequences for the patient, family, and the healthcare system, being the second cause of death by accidental injury worldwide, this study aims to identify the variability inherent in the daily work in fall prevention, the strategies used by professionals to deal with it and the opportunities for improvement of the management of work-as-imagined.

METHOD

A mixed method approach was conducted, through process modeling and semi-structured interviews. The study was conducted in a public university hospital in southern Brazil. Study steps: modeling of the prescribed work, identification of falls, modeling of the daily work, and reflections on the gap between work-as-done and work-as-imagined. Medical records, management reports, notification records, protocols, and care procedures were consulted for modeling the work process, and semi-structured interviews were conducted with 21 Nursing professionals. The study was conducted between March 2019 and December 2020.

RESULTS

From July 2018 to July 2019, 447 falls occurred, 2.7% with moderate to severe injury. The variability occurred in the orientation of the companion and the assurance of the accompanied patient's de-ambulation. The professionals identified individual strategies to prevent falls, the importance of multi-professional work, learning with the work team, and the colleague's expertise, as well as suggesting improvements in the physical environment.

CONCLUSION

This study addressed the need for fall prevention in the hospital setting as one of the main adverse events that affect patients. Identifying the variability inherent to the work allows professionals to identify opportunities for improvement, understand the risks to which patients are subjected, and develop the perception of fall risk as a way to reduce the gap between work-as-imagined and work-as-done.

Implementation and use of technology-enabled blood pressure monitoring and teleconsultation in Singapore's primary care: a qualitative evaluation using the socio-technical systems approach

BACKGROUND

Telemedicine is becoming integral in primary care hypertension management, and is associated with improved blood pressure control, self-management and cost-effectiveness. This study explored the experiences of patients and healthcare professionals and their perceived barriers and facilitators in implementing and using a technology-enabled blood pressure monitoring intervention with teleconsultation in the Singapore primary care setting.

METHODS

This was a qualitative study embedded within the Primary Technology-Enhanced Care Hypertension pilot trial. Patients were selected purposively and invited to participate by telephone; healthcare professionals involved in the trial were invited to participate by email. Individual semi-structured interviews were conducted in English or Mandarin with thirteen patients and eight healthcare professionals. Each interview was audio-recorded and transcribed verbatim. Data were analyzed inductively to identify emergent themes which were then grouped into the dimensions of the socio-technical systems model to study the interactions between the technical, individual and organizational factors involved in the process.

RESULTS

Several emergent themes were identified. The factors involved in the implementation and use of the intervention are complex and interdependent. Patients and healthcare professionals liked the convenience resulting from the intervention and saw an improvement in the patient-provider relationship. Patients appreciated that the intervention helped form a habit of regular blood pressure monitoring, improved their self-management, and provided reassurance that they were being monitored by the care team. Healthcare professionals found that the intervention helped to manage workload by freeing up time for other urgent matters. Nevertheless, participants highlighted challenges with usability of the equipment and management portal, data access, and some expressed technology anxiety. Participants suggested patient segmentation for the intervention to be more targeted, wished for a more user-friendly equipment and proposed allocating more resources to the intervention.

CONCLUSIONS

The implementation and use of telemedicine for hypertension management can engender various benefits and challenges to patients, healthcare professionals and the healthcare system. Stakeholder feedback gathered on the sociotechnical aspects of the technology should be taken into consideration to guide the design, implementation and evaluation of future telemedicine interventions in primary care.

TRIAL REGISTRATION

This study was registered on ClinicalTrials.gov on October 9, 2018. ID: NCT03698890.

Methodology to identify demand-side low-carbon innovations and their potential impact on socio-technical energy systems

The rapid diffusion of demand-side low-carbon innovations has been identified as a key strategy for maintaining average global temperature rise at or below 1.5 °C. Diffusion research tends to focus on a single sector, or single technology case study, and on a small scope of factors that influence innovation diffusion. This paper describes a novel methodology for identifying multiple demand-side innovations within a specific energy system context and for characterizing their impact on socio-technical energy systems. This research employs several theoretical frameworks that include the Energy Technology Innovation System (ETIS) framework to develop a sample of innovations; the Sustainability Transitions framework to code innovations for their potential to impact the socio-technical system; the energy justice framework to identify the potential of innovations to address aspects of justice; and how characteristics of innovations are relevant to Innovation Adoption. This coding and conceptualization creates the foundation for the future development of quantitative models to empirically assess and quantify the rate of low-carbon innovation diffusion as well as understanding the broader relationship between the diffusion of innovations and socio-technical system change. The three stages of research are:•

Contextualization: surveys and desk research to identify low-carbon innovations across the ETIS;

•

Decontextualization: the development of a codebook of variables

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Recontextualization: coding the innovations and analysis.

A taxonomy of interactions in socio-technical systems: A functional perspective

Although the modelling of interactions has long been at the core of socio-technical systems theory, and is a key for understanding resilience, there is a lack of a holistic taxonomy of interactions. This study introduces a taxonomy of interactions to be used in association with the Functional Resonance Analysis Method (FRAM). The taxonomy has nine criteria: nature of agents, output nature, levelling, waiting time, distance, degree of coupling, visibility, safety and/or security hazards, and parallel replications. For each criterion, two descriptors are proposed: what the interaction looks like; and - when applicable - the variability level of the interaction. The use of the taxonomy is presented for three systems with clearly distinct complexity characteristics: cash withdrawal from an ATM, teaching a university course, and manufacturing operations. These case studies indicate the usefulness of the taxonomy for the identification of leverage points in work system design. They also show the value of modelling the variability of the interactions in FRAM models, in addition to the traditional modelling of the variability of the outputs of functions. Implications of the taxonomy for resilience engineering are discussed.

Subtle cues: Qualitative elicitation of signs of capacity strain in the hospital workplace

Through everyday care experiences, nurses develop expertise in recognition of capacity strain in hospital workplaces. Through qualitative interview, experienced nurses identify common activity changes and adaptive work strategies that may signal an imbalance between patient demand and service supply at the bedside. Activity change examples include nurse helping behaviors across patient assignments, increased volume of nurse calls from patient rooms, and decreased presence of staff at the nurses' station. Adaptive work strategies encompass actions taken to recruit resources, move work in time, reduce work demands, or reduce thoroughness of task performance. Nurses' knowledge of perceptible signs of strain provides a foundation for future exploration and development of real-time indicators of capacity strain in hospital-based work systems.

A socio-technical systems approach to the use of health IT for patient reported outcomes: Patient and healthcare provider perspectives

BACKGROUND

Patient-Reported Outcomes (PROs) can be used to inform the clinical management of individuals, including patient self-management, care planning, and goal setting. Despite a rapid proliferation of technology to collect and integrate PROs in clinical care, uptake by patients and healthcare providers remains sub optimal. A consideration of systems factors to understand these challenges is needed.

OBJECTIVES

To apply the socio-technical systems (STS) model as a framework for understanding the usability and functional requirements of patients collecting PRO data using applications (apps), and of healthcare providers using these data at the point of care in ambulatory settings.

METHODS

With questions guided by the STS model, semi-structured interviews were conducted with eighteen patients and nine healthcare providers to elicit feedback about facilitators and barriers to successful use of PRO apps and PRO data in ambulatory settings. Patient participants were selected to fit into two categories: older, low utilizers of technology with less than a bachelor's degree, and younger higher utilizers of technology with at least a bachelor's degree. Participants were from primary and specialty care practices. Data were analyzed inductively to identify emergent themes.

RESULTS

Younger patients were only interested in using a PRO app if they had an active health issue to track. The nine older patients preferred passive means of data collection if they were to track a health issue, and preferred direct contact with their healthcare provider and using office visits to share information. All patients desired optimal usability and emphasized bidirectional communication in an app that is transparent about privacy. All nine healthcare providers agreed that PRO data would be most useful and relevant if key patient populations were targeted based on the specific measure. In this case the healthcare providers noted potentially optimal utility of collecting physical function PRO data for patients 65 and older. Access to the data was highlighted by each healthcare provider stating that these data would be most useful if they were seamlessly integrated into the electronic health record.

DISCUSSION

Several emergent themes were identified under the five selected dimensions of the STS model (clinical content, human computer interface, hardware and software computing infrastructure, people, and workflow and communication). Findings highlighted the continued need for innovative methods to obtain more rapid cycle, continuous feedback to identify system factors impacting use of these technologies.

CONCLUSION

The STS model provides a comprehensive framework that can be applied to collect patient and healthcare provider feedback to better guide the design and implementation of new health information technology.

A literature review of human factors and ergonomics within the pharmacy dispensing process

BACKGROUND

Within healthcare, Human Factors explores the fit between people and their working environment to improve safety, performance and wellbeing. The pharmacy setting is an area of particular interest considering the high-risk nature of the work activities in relation to dispensing errors. Internationally, the pharmacy setting is experiencing significant workforce changes, including the introduction of pharmacy technicians performing accuracy checks, and the adoption of novel technologies such as automated dispensing.

OBJECTIVE

A literature review was conducted to identify studies which have explored the pharmacy dispensing process from a Human Factors perspective.

METHODS

The databases Medline, EMBASE and PsycINFO were searched on the 27th of November 2018. All study designs were eligible for inclusion from community and hospital settings. Key study findings were extracted and reported using a descriptive narrative synthesis method.

RESULTS

Thirty-two studies were identified, with most published from 2010 onwards. The review identified that a myriad of aspects influence safety within the dispensing process; that the dispensing process is complex in nature and can be depicted in many different ways; and lastly, that deviations from intended practice appear commonplace. Most studies used two or more data collection sources, and various theories, models and frameworks were applied. Although the focus of all studies was within the wider domain of Human Factors, 14 studies did not explicitly refer to a Human Factors approach within the manuscript.

CONCLUSIONS

The complexity of the pharmacy dispensing setting suggests that adopting a Human Factors approach to explore this context is appropriate. Future Human Factors research should explore the implementation of new technology and services and focus on obtaining empirical evidence that adopting a Human Factors approach improves safety and/or efficiency within pharmacy practice. Clear guidance on how to apply the range of Human Factors approaches would help support such research and facilitate the development of sound theory.

Self-Driving Cars and Engineering Ethics: The Need for a System Level Analysis

The literature on self-driving cars and ethics continues to grow. Yet much of it focuses on ethical complexities emerging from an individual vehicle. That is an important but insufficient step towards determining how the technology will impact human lives and society more generally. What must complement ongoing discussions is a broader, system level of analysis that engages with the interactions and effects that these cars will have on one another and on the socio-technical systems in which they are embedded. To bring the conversation of self-driving cars to the system level, we make use of two traffic scenarios which highlight some of the complexities that designers, policymakers, and others should consider related to the technology. We then describe three approaches that could be used to address such complexities and their associated shortcomings. We conclude by bringing attention to the "Moral Responsibility for Computing Artifacts: The Rules", a framework that can provide insight into how to approach ethical issues related to self-driving cars.

Adapting Urban Water Systems to Manage Scarcity in the 21st Century: The Case of Los Angeles

Acute water shortages for large metropolitan regions are likely to become more frequent as climate changes impact historic precipitation levels and urban population grows. California and Los Angeles County have just experienced a severe four year drought followed by a year of high precipitation, and likely drought conditions again in Southern California. We show how the embedded preferences for distant sources, and their local manifestations, have created and/or exacerbated fluctuations in local water availability and suboptimal management. As a socio technical system, water management in the Los Angeles metropolitan region has created a kind of scarcity lock-in in years of low rainfall. We come to this through a decade of coupled research examining landscapes and water use, the development of the complex institutional water management infrastructure, hydrology and a systems network model. Such integrated research is a model for other regions to unpack and understand the actual water resources of a metropolitan region, how it is managed and potential ability to become more water self reliant if the institutions collaborate and manage the resource both parsimoniously, but also in an integrated and conjunctive manner. The Los Angeles County metropolitan region, we find, could transition to a nearly water self sufficient system.

Action learning across the decades

Purpose The purpose of this paper is to explore how action learning concepts were used in two healthcare projects undertaken many decades apart. The specific purpose in both cases was to examine how action learning can contribute to shared learning across key stakeholders in a complex socio-technical system. In each case study, action learning supported joint design programmes and the sharing of perspectives about the complex system under investigation. Design/methodology/approach Two action learning projects are described: first, the Hospital Internal Communications (HIC) project led by Reg Revans in the 1960s. Senior staff in ten London hospitals formed action learning teams to address communication issues. Second, in the Better Outcomes for People with Learning Disabilities: Transforming Care (BOLDTC) project, videoconferencing equipment enabled people with learning disabilities to increase their opportunities to communicate. A mutual learning process was established to enable stakeholders to explore the potential of the technical system to improve individual care. Findings The HIC project demonstrated the importance of evidence being shared between team members and that action had to engage the larger healthcare system outside the hospital. The BOLDTC project confirmed the continuing relevance of action learning to healthcare today. Mutual learning was achieved between health and social care specialists and technologists. Originality/value This work draws together the socio-technical systems tradition (considering both social and technical issues in organisations) and action learning to demonstrate that complex systems development needs to be undertaken as a learning process in which action provides the fuel for learning and design.

Study protocol for evaluating the implementation and effectiveness of an emergency department longitudinal patient monitoring system using a mixed-methods approach

Background

Early detection of patient deterioration is a key element of patient safety as it allows timely clinical intervention and potential rescue, thus reducing the risks of serious patient safety incidents. Longitudinal patient monitoring systems have been widely recommended for use to detect clinical deterioration. However, there is conflicting evidence on whether they improve patient outcomes. This may in part be related to variation in the rigour with which they are implemented and evaluated. This study aims to evaluate the implementation and effectiveness of a longitudinal patient monitoring system designed for adult patients in the unique environment of the Emergency Department (ED).

Methods

A novel participatory action research (PAR) approach is taken where socio-technical systems (STS) theory and analysis informs the implementation through the improvement methodology of ‘Plan Do Study Act’ (PDSA) cycles. We hypothesise that conducting an STS analysis of the ED before beginning the PDSA cycles will provide for a much richer understanding of the current situation and possible challenges to implementing the ED-specific longitudinal patient monitoring system. This methodology will enable both a process and an outcome evaluation of implementing the ED-specific longitudinal patient monitoring system. Process evaluations can help distinguish between interventions that have inherent faults and those that are badly executed.

Discussion

Over 1.2 million patients attend EDs annually in Ireland; the successful implementation of an ED-specific longitudinal patient monitoring system has the potential to affect the care of a significant number of such patients. To the best of our knowledge, this is the first study combining PAR, STS and multiple PDSA cycles to evaluate the implementation of an ED-specific longitudinal patient monitoring system and to determine (through process and outcome evaluation) whether this system can significantly improve patient outcomes by early detection and appropriate intervention for patients at risk of clinical deterioration.

Experiments on Socio-Technical Systems: The Problem of Control

My aim is to question whether the introduction of new technologies in society may be considered to be genuine experiments. I will argue that they are not, at least not in the sense in which the notion of experiment is being used in the natural and social sciences. If the introduction of a new technology in society is interpreted as an experiment, then we are dealing with a notion of experiment that differs in an important respect from the notion of experiment as used in the natural and social sciences. This difference shows itself most prominently when the functioning of the new technological system is not only dependent on technological hardware but also on social 'software', that is, on social institutions such as appropriate laws, and actions of operators of the new technological system. In those cases we are not dealing with 'simply' the introduction of a new technology, but with the introduction of a new socio-technical system. I will argue that if the introduction of a new socio-technical system is considered to be an experiment, then the relation between the experimenter and the system on which the experiment is performed differs significantly from the relation in traditional experiments in the natural and social sciences. In the latter experiments it is assumed that the experimenter is not part of the experimental system and is able to intervene in and control the experimental system from the outside. With regard to the introduction of new socio-technical systems the idea that there is an experimenter outside the socio-technical system who intervenes in and controls that system becomes problematic. From that perspective we are dealing with a different kind of experiment.

The role of organisational support in teleworker wellbeing: a socio-technical systems approach

The prevalence of telework and other forms of mobile working enabled by digital technology is increasing markedly. Following a socio-technical systems approach, this study aims to examine the role of organisational social support and specific support for teleworkers in influencing teleworker wellbeing, the mediating role of social isolation, potentially resulting from a person-environment mismatch in these relationships, and possible differences in these relationships between low-intensity and hybrid teleworkers. Teleworkers' (n = 804) perceptions of support and telework outcomes (psychological strain, job satisfaction, and social isolation) were collected using an on-line survey of teleworking employees distributed within 28 New Zealand organisations where knowledge work was undertaken. Organisational social support and teleworker support was associated with increased job satisfaction and reduced psychological strain. Social isolation mediated the relationship between organisational social support and the two outcome variables, and some differences were observed in the structural relationships for hybrid and low-intensity teleworker sub-samples. These findings suggest that providing the necessary organisational and teleworker support is important for enhancing the teleworker-environment fit and thereby ensuring desirable telework outcomes.

Complex socio-technical systems: Characterization and management guidelines

Although ergonomics has paid increasing attention to the perspective of complexity, methods for its operationalization are scarce. This study introduces a framework for the operationalization of the "attribute view" of complexity, which involves: (i) the delimitation of the socio-technical system (STS); (ii) the description of four complexity attributes, namely a large number of elements in dynamic interactions, a wide diversity of elements, unexpected variability, and resilience; (iii) the assessment of six management guidelines, namely design slack, give visibility to processes and outcomes, anticipate and monitor the impacts of small changes, monitor the gap between prescription and practice, encourage diversity of perspectives when making decisions, and create an environment that supports resilience; and (iv) the identification of leverage points for improving the STS design, based on both the analysis of relationships among the attributes and their classification as irreducible/manageable complexity, and liability/asset. The use of the framework is illustrated by the study of an emergency department of a University hospital. Data collection involved analysis of documents, observations of work at the front-line, interviews with employees, and the application of questionnaires.

A socio-technical systems approach to studying interruptions: understanding the interrupter's perspective

The purpose of this study was to understand the cognitive processes underlying nurses' decision to interrupt other nurses. The Institute of Medicine (2000) reported that interruptions are likely contributors to medical errors. Unfortunately, the research to date has been quite homogenous, focusing only on the healthcare provider being interrupted, ignoring the true complexities of interruptions. This study took a socio-technical approach being the first to examine interruptions from the viewpoint of the interrupting nurse. Over 15 h of observations and 10 open-ended interviews with expert nurses in a Neuroscience Surgical Intensive Care Unit were conducted. It was found that nurses conduct a quick cost-benefit assessment to determine the interruptibility of other nurses and whether an interruption is value-added vs. non-value added. To complete the assessment, nurses consider several conditional factors related to the interruptee, the interrupter, and the nature of the interruption content, and different potential consequences of the interruption.

Socio-technical systems and interaction design - 21st century relevance

This paper focuses on the relationship between the socio-technical system and the user-technology interface. It looks at specific aspects of the organisational context such as multiple user roles, job change, work processes and workflows, technical infrastructure, and the challenges they present for the interaction designer. The implications of trends such as more mobile and flexible working, the use of social media, and the growth of the virtual organisation, are also considered. The paper also reviews rapidly evolving technologies such as pervasive systems and artificial intelligence, and the skills that workers will need to engage with them.

How a submarine returns to periscope depth: analysing complex socio-technical systems using Cognitive Work Analysis

This paper presents the application of Cognitive Work Analysis to the description of the functions, situations, activities, decisions, strategies, and competencies of a Trafalgar class submarine when performing the function of returning to periscope depth. All five phases of Cognitive Work Analysis are presented, namely: Work Domain Analysis, Control Task Analysis, Strategies Analysis, Social Organisation and Cooperation Analysis, and Worker Competencies Analysis. Complex socio-technical systems are difficult to analyse but Cognitive Work Analysis offers an integrated way of analysing complex systems with the core of functional means-ends analysis underlying all of the other representations. The joined-up analysis offers a coherent framework for understanding how socio-technical systems work. Data were collected through observation and interviews at different sites across the UK. The resultant representations present a statement of how the work domain and current activities are configured in this complex socio-technical system. This is intended to provide a baseline, from which all future conceptions of the domain may be compared. The strength of the analysis is in the multiple representations from which the constraints acting on the work may be analysed. Future research needs to challenge the assumptions behind these constraints in order to develop new ways of working.