the relationship between technology and changing professional
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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
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
GeographyGeography
Nurse led Nurse led community community clinics in clinics in
primary care primary care supported by supported by
teledermatologyteledermatology.
Store and Forward Telemedicine
Mail Server
Telemarque Server
UnitTraining
DataBase
NHS Net
Remote GPwSI
QMC Dermatology Unit
UnitLive
RemotePCT Clinics
TeledermatologyTeledermatology
Store & ForwardStore & Forward
• Digital CameraDigital Camera
• Lap TopLap Top
• EmailEmail
MethodsMethods
Case Study DesignCase Study Design• Embedded single case designEmbedded single case design
• Single case – community clinicsSingle case – community clinics
• Subunits- all those involved in Subunits- all those involved in patient journey (patient journey (GP, Patient,Nurse, GP, Patient,Nurse, Dermatologist and others)Dermatologist and others)
Patient JourneyPatient Journey
M anaged by D erm atology Nurse S hared care w ith Pr im ary C are T eam
S urgery C onsulta tion L ight the rapy M anagem ent Plan
T e lederm atology to C onsultant D erm atologis t
D ay T rea tm ent Pa tch T es t A dm iss ion
S econdary C are S ervices
PC T C lin icNurse L ed Service
G PReferra l to loca l PC T C lin ic
Nurse L ed Service
SampleSample
• Purposively selectedPurposively selected
• 2 patient journeys:2 patient journeys:GP, Patient,GP, Patient,
Nurse, Dermatologist and othersNurse, Dermatologist and others
Data CollectionData Collection
• Semi-structured interviewsSemi-structured interviews
• Observation of the nurse / patient Observation of the nurse / patient consultation consultation
• Data obtained from clinical records Data obtained from clinical records and databases.and databases.
Data AnalysisData Analysis• The analysis and interpretation of the data The analysis and interpretation of the data
was performed manually.was performed manually.• Based on an ethnographic approach and Based on an ethnographic approach and
influenced by the principles of grounded influenced by the principles of grounded theorytheory
• Description of the case (How and Why)Description of the case (How and Why)• Comparative analysis of the data sets :Comparative analysis of the data sets :
( interviews,observations and records)( interviews,observations and records)• Analysis of the emerging themesAnalysis of the emerging themes
Results/Discussion
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’sall electronic. It’s actually supporting the nurses who are acting intheir 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)
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
Patients
• Like the service, and are unconcerned about the profession of the person seeing them
• GPs value the expertise of the nurses
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
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.
How was it possible ?
1 Policy push
2 Skills of the nurses
3 Agreement & support from the consultant & the GPs
4 The technology
A bit of theory
• ANT ?
• Social construction of technology
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