Computer Supported Cooperative Work 12: 1–20, 2003.
© 2003 Kluwer Academic Publishers. Printed in the Netherlands.
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The Camera as an Actor: Design-in-Use of
Telemedicine Infrastructure in Surgery
MARGUNN AANESTAD
Deptartment of Informatics, P.O. Box 1080, Blindern N-0316 Oslo, Norway (E-mail:
margunn@ifi.uio.no; Phone: (+47) 22 85 29 35; Fax: (+47) 22 85 24 01)
Abstract. This paper describes the evolving interrelationship between a pre-established work practice and a new technology, with an emphasis on how the technology itself participates in the process
and introduces changes, while at the same time being changed itself. The case study concerns the
introduction of multimedia communication technology into a surgical operating theatre. Concepts
from Actor-network theory are found to provide a useful perspective on the description and analysis
of the case. The technology and the work practice are viewed as a new heterogeneous actor-network,
whose configuration changed continuously. These changes are conceptualised as alignment attempts
where the different actants’ interests are translated and inscribed into e.g. artefacts, rules or routines.
The alignment of this heterogeneous network was achieved through a continuous process of design,
test and redesign of different configurations of people, practices and artefacts. The relevance of the
findings is discussed, related to how we may think about design of open and generic technologies.
Viewing design as design of configurations; the creation of a well-working mix of people, practices
and artefacts, may be a helpful and relevant design metaphor.
Key words: actor-network theory, alignment, configuration, design-in-use, health care, inscriptions,
telemedicine, translations, video-mediated communication, work practice
1. Introduction
The interrelation between work practice and technology has always been the
central research focus within CSCW, with its aim to design technologies to support
human interaction in cooperative work arrangements. Ethnographic studies of
technologies-in-use have described how successful technologies were inseparable
from the situated activities in which they existed, and user-centered and situated
design was advocated (Suchmann et al., 1999; Greenbaum and Kyng, 1991). Such
situated, worker-oriented design might involve continuous further development,
design-in-use or tailoring (Bjerknes et al., 1991; Henderson and Kyng, 1991;
Mørch, 1995). The insight that the end-result of such processes may be unexpected
has been suggested by the notion of drifting (Ciborra, 1996), which points to the
deviations from the original goals and objectives and the unintended consequences
of introducing information technologies. At least part of the responsibility for the
drifting resides with the technology; due to its openness and plasticity the users can
appropriate it differently.
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Despite this, the role of technology in design-in-use has been little theorised, as
the focus of the CSCW field has been on human cooperative work, its characteristics and its requirements to design, more than on the technology as such.
Some empirical studies have focused on the technology’s role in work practices
and have described a variety of roles and tasks for technology (see e.g. Suchman
and Trigg, 1991; Luff and Heath, 1998; Berg, 1997; Berg, 1999; Lundberg and
Sandahl, 2000). However, there is still a lack of empirical studies that investigate
the dynamics of the process where technology and work practice evolve together.
The importance of understanding this dynamic interplay may become more
evident if we consider the change within information and communication technology in recent years. From the earlier company-specific and locally designed
information systems, more and more networked, standardised and off-the-shelf
products are used. Where communication technologies are concerned (as in this
paper), the technology is rather open and generic; the “proper” way to use it is not
specified and it can be appropriated in different ways. Using network technologies
necessarily involve other actors, over whose actions and choices one has limited
control. In this context design will happen more as design-in-use and less in defined
design projects. Design will also have a broader scope than software development
or tailoring, as the products are more or less packaged. We may envision that an
important part of design will be to create an interrelationship between the technology and the work practice (or other human activity), in other words, to design
technology use.
The aim of this paper is to contribute to the understanding of these broader
design-in-use practices by focusing on how technology may take part in such
processes. The paper presents a case study from telemedicine, where multimedia communication technology (cameras, microphones and loudspeakers) was
installed in a surgical operating theatre. This facilitated communication with
external viewers, and the intended use was to demonstrate medical procedures
to others, either to guests at the department or to remotely located surgeons in
training. However, the technology was not implemented in one batch, according
to definite plans. It was rather characterised by piecemeal growth, changes and
adjustments of both the technical set-up and of rules and procedures. Based on a
description and analysis of this process, a view of design as design of configurations is proposed. The paper describes how such design of configurations may play
out in very practical terms.
2. Case study and method
2.1. ABOUT THE CASE STUDY AND THE RESEARCH SITE
The Interventional Centre was established in 1996 at the National Hospital in
Oslo, Norway, to do research and development in image-guided and minimalinvasive therapies in medicine. Minimal-invasive or “keyhole” surgery is different
from ordinary (also called “open”) surgery in that it minimises the invasiveness of
TELEMEDICINE INFRASTRUCTURE IN SURGERY
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the procedure. Instead of a large cut to facilitate the surgeon’s direct vision and
manipulation of organs, surgical instruments and optics for a small video camera
are entered through small incisions that may be 5–10 mm wide. The surgeons’
focus is on video monitors that provide the image of the patient’s organs as well as
the instruments’ actions. Thus the surgeon’s visual and tactile information, as well
as the actions on the organs, is indirect or mediated by technology, i.e. the monitors
and the surgical instruments (see Figure 1). Usually an assisting surgeon holds
and moves the video camera according to directions from the main surgeon, and
both surgeons may have their own monitor to watch, as they often are positioned
on either side of the operation table. The scrub nurse hands over instruments to
the surgeon, either on explicit directions or based on anticipation of the surgeon’s
needs. Thus the mediated images are important also for the nurses in the room
as the images provide awareness of general progress and facilitate anticipation of
specific tasks. The presence of a mediating technology makes minimal-invasive
surgery a likely candidate for telemedicine. The video image is regarded as the
main information source for the surgeons during the procedure, and it is relatively
easy technically speaking to transmit this video signal. Minimal-invasive surgery
is a work practice that is heavily integrated with a lot of technology in continuous
development and change, so the introduction of new devices (e.g. communication technology) does not signify a change from a non-technical to a technically
oriented work practice. Rather, it is just one more addition to the array of tools.
This new technology is not a necessary tool for the primary object of work; it is
rather an additional, non-critical, and “voluntary” technology, which may facilitate
new forms of mediated communication not previously possible.
A lot of visitors to the Interventional Centre were anticipated when it was
planned. To avoid disturbing the operating theatre team more than necessary, as
well as let the guests avoid changing clothes when entering the sterile zone, a
local analog transmission facility was set up between the operating theatres and
an external room. Images from overview cameras in the operating theatres were
available; in the interventional suite (which is the theatre in focus in this paper,
see also Figure 1) there were one wall-mounted camera as well as one camera
mounted in the roof directly above the operation table. In addition, images from
several other sources, including x-ray, gastroscope, laparoscope, and ultrasound
equipment etc. could be transmitted and displayed in the external room. It was
possible to transmit and display images on 16 small monitors, and one of these
images could then be selected and displayed on a large monitor (Figure 2). Twoway audio through microphones and loudspeakers facilitated conversation between
the operating theatre team and the guests located in the external room. This room
was also the hospital’s studio for videoconferencing and the videoconferencing
equipment was connected to the local network, so that image and sound from the
local facilities could be transmitted to any ISDN-connected receiver. This possibility was intermittently used, but the external transmissions became more frequent
and regular during a large telemedical project, where image and sound was trans-
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Figure 1. A minimal-invasive surgical procedure in the operating theatre. The two surgeons
to the left, and scrub nurses in the middle and to the right. Note the two monitors with the
internal video image, and the microphones hanging from the roof.
mitted across an ATM network to receivers at other hospitals, mainly focused on
training sessions on minimal-invasive surgery.
The department employed several community workers, who served 14 months
service as an alternative to army service (conscientious objectors). They were not
regarded or paid as ordinary employees. The workers that were recruited were
mainly engineers with different kinds of computer science background. Due to
lack of space in the department, they were assigned this room as their workplace.
Managing telemedicine transmissions was not intended to be their main task, but it
became an important and large part of their duties as the activities expanded. It is
these persons who are called technicians in the paper.
3. Method
Participant observation was the main method used for gathering data. Around 50%
of the author’s time during one and a half years was spent at the Interventional
Centre, assisting in the planning, execution, and evaluation of most telemedical
transmission that took place during that period. My practical role in the execution
of transmissions was that of a technician, assisting with equipment set-up, camera
control etc. My impression is that I was perceived as an ordinary employee who
was pursuing a Ph.D. like several others among the engineering and medical staff,
rather than as an external researcher observing the local work practice. Some of
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Figure 2. The technicians and the equipment in the external video room. Note the rack with
16 small monitors.
the staff was employed part-time (still working in their “mother” department), so
my part-time presence was not unusual. Also the hospital was a teaching hospital,
which meant that there were very often guests and students present in the operating
theatres. At this particular department visitors were even more common, so the
operation team were used to strangers observing their work.
Participant observation may imply, among other problems, a lack of distance
and a bias towards partial representations. My role and identification with some
parts of the work practice is partly a result of active choice, partly a result of contingencies. From the empirical material a focus on nurses’ and technicians’ work
is evident, as well as a corresponding lack of focus on the medical-professional
aspects of the surgical work. The bias towards nurses and technicians’ work should
not be taken as a negation of the importance of the medical-professional parts of
the work practice. The integration of telemedicine into clinical practice is crucially
dependent on acceptance from the medical doctors, i.e. the surgeons in this case.
Clinical quality and safety are crucial to surgeons, and this is a topic that is complex
and important enough to require a separate study. With the limited focus here (integration into the work practices in the operating theatre) these issues are outside the
scope of this paper. Surgeons have a central role and position within the surgical
work practice, but their temporal and spatial presence (within the operating theatre)
is limited, and their responsibilities and tasks are clearly demarcated from those of
other groups. My conviction is that this in some ways shields them from much of
the “alignment work” that goes on inside the operating theatre, which is the topic
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of this paper. This work is most clearly to be seen in the general preparation work
of the nurses, as well as in the facilitation work of the technicians. These considerations are the basis for my pre-occupation with these groups’ work tasks, as well
as for the choice of participant observation as the data generative method. This
method provides the best way to get access to instances, problems and discussions
through a phase of learning and re-configuration. The issues and problems that
emerge in such an explorative phase may be thought of (by the informants) as too
trivial and mundane to be captured by formal interviews. Examples of such tasks
may be the technicians searching for cables of appropriate length, or the nurses
relocating the operation lamp so as not to block the camera view.
In addition to participant observation, a log was kept either by myself or another
technician over each transmission (date, time, duration, content, topic, support time
needed for preparation and execution, technical and other problems encountered,
free text etc.). This log provided documentation about when the issues discussed
below arose, which problems were encountered and how they were solved. In addition, personal diary notes were filled in on details, and textual documents including
project documents, documents from planning of transmissions, technical cabling
plans etc. have been available to me. Discussions between the technicians occurred
after each transmission and were focused on discovering causes and remedies for
technical or logistic problems. Informal discussions with the medical staff provided
information on how the transmissions were perceived. Also a couple of more
formal discussion meetings were carried out to bring out perceived problems and
suggested solutions.
4. Theoretical perspective
The field work was started without a pre-defined analytic framework, but the observations soon indicated the central role of the nurses’ and technicians’ work with the
technical artefacts in order to achieve the wanted benefits from the technology. A
theoretical framework should allow this aspect of the deployment process to stay
central. Although there are several candidate theories to account for the sociotechnical aspects, the wish to investigate specifically the technology’s contribution
required a framework where the technology would be acknowledged on line with
other actors. This is what has been perceived as actor-network theory’s main
benefit, and is also what motivated my choice of it (Berg, 1998, 1999; Monteiro
and Hanseth, 1995; Walsham, 1997). I use it as a perspective that throw new light
on the observations, rather than as a rigid framework to “explain” them. Thus the
benefits of the theory may be seen both in the structuring of the empirical data, and
even more so through the leverage it allows in the interpretation of the case.
Actor-network theory (ANT) is in practice not a unified body of concepts,
and an eclectic approach to it is widespread. This necessitates a brief overview
over the “ANT variety” used in this paper. An actor-network is a heterogeneous
network of human and nonhuman actors or actants (actant is used by some as
TELEMEDICINE INFRASTRUCTURE IN SURGERY
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a more neutral term than the human-centred actor) where the relations between
them are important, rather than their essential or inherent features (Latour, 1987;
Callon, 1986, 1991). The theory argues that it is analytically fruitful to reject any a
priori distinction between elements in the network, as e.g. the distinction between
humans and non-humans. Differences are instead viewed as effects (i.e. as achieved
or constructed) rather than as pre-given (Law, 1992). This quest for symmetry
has created a lot of controversy around ANT, both in general and within the IS
community (see e.g. the “chicken” debate (Collins and Yearly, 1992; Callon and
Latour, 1992)). The critique (at least within the IS community) has often focused on
the concept of material agency. Attempts to avoid the strong symmetry assumption
of ANT, e.g. (Jones, 1999) are evidence of uneasiness about granting non-humans
agency on line with humans. Jones suggests the possibility of viewing material
agency as capacity, lacking the intentionality component that is a distinctive feature
of human agency. However, to respect the epistemological foundations of ANT we
also need to keep in mind that agency is an emergent and not an essential or inherent
property of the actors. It is the network that provides the actors with opportunities
to establish and use agency (Law, 1992). In this paper the words “capacity for
action” or “capacity for influence” is used when analysing the agency of the camera
(i.e. the communication technology). A pragmatic approach to this debate might
be to argue that the network elements are not interesting per se (their agency as
isolated entities); rather the relations and connections between them in real life are
what we are interested in.
When it comes to network dynamics, ANT claims that the actors in the actornetwork have different and possibly incompatible interests, and that stability (or
order, agreement, success, goal achievement) is obtained when the network is
aligned (Latour, 1987). The alignment of the network occurs through a process
where the actors’ interests are translated (i.e. reformulated, modified, or changed)
into more generally agreeable expressions, so that several actors may support
the resulting translation (Callon, 1991; Law, 1992; Latour, 1991). The translation
may be inscribed into a medium, e.g. the characteristics of an artefact, a rule,
a procedure or a standard (Latour, 1991). The inscription attempts to define a
framework for possible action (a program of action), and it may be more or less
strong (Akrich, 1992). The inscription’s strength is not just a static entity, once
defined by the designer and inscribed into the object. It is also a dynamic and
relational feature that emerges in the actual network when actors are delegated
roles (Hanseth and Monteiro, 1997). Delegation is when an actor “stands in” for
and represents other actors and acts on behalf of them. As people may be delegated
roles in an organisation, actors (human or non-human) may be delegated a role in
the actor-network, with associated power, competence and responsibilities.
The actors in the network may follow, twist or oppose the inscriptions’ program
of action, depending on the inscription’s strength (Akrich, 1992). If the actors are
supporting (more or less voluntarily) a given translation and its inscription, they
have been enrolled and are cooperating (still more or less voluntarily) towards a
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common goal (Latour, 1987). If sufficiently many or strong actors are enrolled in
the network, the opposing interests (the non-cooperating actants) may be forced to
yield. A network may evolve towards a stable state with relatively irreversible and
unchangeable inscriptions (Callon, 1991), it may be in a state of flux and instability,
or it may be only temporary stable and aligned.
I also use the concept of configuration in addition to these “mainstream” ANT
concepts. Configuring was used by Steve Woolgar (1992) to describe how users
were ascribed identity (e.g. capacities and character) and how the users’ range
of actions were defined and delineated by computer designers. In this paper the
word configuration is used to denote a particular set-up or mix of entities, as a
kind of “instantaneous picture” of the actor-network. Both which elements that
are included, and how they are connected to each other is important aspects of a
configuration, as this defines their roles and relations and thus also their power
and capacities. This resonates with actor-network theory’s claim that it is in the
relations that capacity for action lie:
Action is a property of associated entities . . . Action is simply not a property
of humans but of an association of actants . . . Provisional actorial roles may
be attributed to actants only because actants are in a process of exchanging
competences, offering one another new possibilities, new goals, new functions.
(Latour, 1999, p. 182).
I attempt to use these concepts to describe how the interrelation between the
work practice and the technology unfolds. A new network emerged when several
actors with different interests were brought together, and the description of the
following alignment process is focused on the technology’s role and contribution.
5. The camera meets the surgical work practice
The following report of empirical data from the case study is separated into two
main parts, corresponding to a time-based structure. First, some of the effects
and consequences of the installation and use of the local transmission network is
described. This created some changes and disturbances to the pre-established work
practice, which spurred a process of modifications of both the technology and the
work practice. Second comes the description of the issues that arose when the local
network was expanded and connected to an external telemedical network.
5.1. THE LOCAL TRANSMISSION FACILITY
The local transmission facility was fulfilling a wish of both the operation team
(being relieved of visitors in the operating theatre during work) and of the guest
(who would avoid changing clothes). The room overview cameras were remote
controlled, which further relieved the operation team of the task of camera
operation (i.e. change the viewing angle, focus, or zoom), which would have
TELEMEDICINE INFRASTRUCTURE IN SURGERY
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been irrelevant tasks to their primary activity, the surgical procedure. However,
this particular solution had some unexpected effects and consequences as well.
Through three examples from the integration process we will investigate how the
matching of the different interests and demands was carried out.
5.1.1. Yielding to the demands from the technology
All the information that one wanted to transmit across the communication channel
had to be captured and made electronic. In order for the surgeon’s voice to be
audible to the remote listeners, there had to be a microphone in a position where it
captured the sound waves of the speech (and preferably not too much other sound).
In order to provide a view of the room or the operation table, a camera had to be
present, turned on and connected to the network. The medical imaging equipment
had to provide a copy of the image signal to be captured and transmitted via cables.
We could say that some of the communication devices required “feeding” of input
material.
These inherent inscriptions in the technology required changes in the work
practice by introducing new works tasks, mostly for nurses and technicians. The
nurses had to connect the imaging equipment to the network, turn on the cameras,
and ensure adequate positioning of microphones. These tasks became included in
the nurses’ general preparation work of surgical procedures when a transmission
was to take place. The technicians had to provide cables or other artefacts, devise
solutions to technical problems, and assist in connecting and managing the equipment. Another consequence of the introduction of the technology was changes in
the conditions of the work within the operation theatre. Several disturbances were
introduced, e.g. noise and sound through the audio lines and a generally “messy”
situation with cables on the floor and presence of technicians in the operating
theatre during the operation.
5.1.2. Inscriptions activated in the network configuration
The presence of cameras and microphones in the operating theatre that were linked
to screens and loudspeakers in the external room created uncertainty over surveillance issues. The new technology provided a possibility of “invisible spectators”, as
technically knowledgeable personnel (and others present in the room) could watch
and listen to the activities in the operation theatre without themselves being seen
or heard. This new possibility contributed to a shifting of control over the work
situation, and the department had to decide on routines and rules for usage. After a
while a key was installed beside the wall-mounted camera in the operation theatre.
This key had to be turned on by the operation theatre personnel in order for the
transmission of video signals to be possible, and when the key was turned a red
“on air” lamp was lighted. The sound transmission lines were not included in this
system, so it was still possible to listen to the conversation without the red lamp on.
This was remedied through a voluntary and explicit commitment by the technicians
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to never “listen” (i.e. actively send the sound signals to a loudspeaker) unless the
operating theatre personnel had activated the video transmission control.
5.1.3. Inscriptions created in the network configuration
The chosen technology and the installation of it implied a projection of expected
receivers and use areas. Both the department’s research activities and the specific
telemedicine activities had a strong focus on medical doctors (especially surgeons
and interventional radiologists), as opposed to other groups. The part of a surgeon’s
work that occurred within the operation theatre had a defined localisation in time
and space, it was performed after the patient and equipment was prepared and
occurred mainly around the operation table. One of the cameras was mounted in
the roof above the operation table, and also the microphones and loudspeaker were
located here. Thus the placement of the equipment in the room reflects this focus on
surgery. As most of the actual transmissions were performed for medical doctors,
the installation of the equipment was adequate. When the use of the network
deviated from the projected usage, this became problematic.
The operation or anaesthesia nurses’ work was distributed over much larger
space, from reception of the patient at the entrance, and across the whole of the
operating theatre. Nurses often worked in parallel with different tasks in different
parts of the room, and their work was stretched out in time with less uniform
intensity than the surgeon’s work. In order to document nurses’ work for an offline
video production, an additional mobile video camera was enrolled to be able to
capture the work that was distributed in space. The limitations were also related to
the audio part, as the microphones above the operation table was unable to capture
the verbal explanations when the workers were located elsewhere in the room.
Audio (explanations and comments) had to be laid on in the editing process.
The inscriptions evident in the installation of the technology were rather strong;
still it was possible to observe several instances of unintended use. For example
the technicians might use the camera to monitor who was present in the operating
theatre. Especially if one of the technicians was on the way to the operating theatre
to correct something, the camera might be directed towards the door to see when
he entered. Then the control room technician could phone or speak through the
loudspeaker to communicate with him. At some instances the cameras would also
be focused on cables and connections to try to detect the source of lacking images
or other problems. Sometimes when there were no transmissions or guests, the
audio lines would be used for transmitting music from the video room to the team
working in the operating theatre.
5.2. EXPANDING THE NETWORK
New challenges and changes were introduced when the local transmission facility
was hooked up to a telemedicine network. The old ways of handling the issues
were insufficient, and new alignment activities were necessary. These changes also
TELEMEDICINE INFRASTRUCTURE IN SURGERY
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reverberated “backwards” into the previously aligned network, and changed the
established and tested configurations.
5.2.1. Even more changes in work practice becomes necessary
The expansion of the network required enrolling more equipment, and as a result
a more complex material infrastructure emerged in the video room. Audio mixers,
several loudspeakers and headsets were purchased to be able to monitor and adjust
sound to and from the different participants, and more cameras and monitors also
became necessary to manage more image sources and destinations. In addition
several video recorders were included in the set-up, to be able to record transmissions. The resulting increase in complexity led to more dependence on technicians.
Earlier the departments’ medical doctors had been able to go into the video room
and initiate a local transmission for their guests, or to carry out an ordinary videoconference. With the new complex set-up they became dependent on the assistance
of the technicians in order to do this.
The support work changed in content, character and importance, and the technicians acquired a more intermeshed and crucial role in the network (Johansen et
al., 1999). In addition to managing the local equipment, new tasks for the support
technicians included establishing the connection to the other side, verifying proper
image transfer both ways and doing sound checking (which in its nature was
very interactive). Then the local network had to be activated and connected to
the external (telemedicine) network, with corresponding image and sound checks,
typically between nurses and technicians. The required images from the operating theatre had to be selected, the sound quality adjusted, and the transmission
monitored during its whole extent. Planning and coordination work, both internal
(with local participants/the work team) and external (with the other site’s technicians or receivers) became a larger part of the technicians work than before.
Other use areas outside the operating theatre (e.g. transmission of lectures and
meetings, off-line video recording and editing) were also important experiences, as
they provided the technicians with opportunities to learn to handle the technology
and exploit possibilities (Aanestad and Hanseth, 2000).
5.2.2. Problematic network configurations
The surgeon’s main focus during a laparoscopic procedure was on the video image
from the inside of the abdomen. However, during some procedures also other
image sources were used, e.g. ultrasound or X-ray images, which were displayed
on separate screens. Sometimes the surgeon switched focus between the different
images frequently and rapidly. This dynamic image use was not a problem when
students were present in the operating theatre, as the surgeon’s direction of vision
and other small bodily or verbal cues were easily detected. However, it turned out
to be difficult for the technicians in the control room to detect or interpret the
surgeon’s change of focus and consequently switch to the correct image source
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to transmit. This demanded constant and close attention to the verbal interaction
and all the available images from the operating theatre (on the 16 small 10 ×
10 cm, black and white monitors in the control room), a task that the technicians
felt tiring and demanding. They also lacked the medical knowledge necessary to
determine which image was in focus at which time. To be sure that the transmission
would be successful, the surgeon had to comment explicitly on the image use, a
task that was not necessary when the students were present in the room. At one
instance, a students’ facilitator was present with the operating surgeon, explaining
and commenting on the procedure. The explicit comments on image use greatly
helped the technicians to decide and switch images correctly. In other words, a
new work task needed to be performed by the surgeon, or a new role as a “medical
producer” may be called for. Other alternatives may be envisioned: The technology
may perform this task, e.g. via intelligent image switching, based on automatic
detection of surgeon’s direction of view. Or the task could be delegated to the
receivers if all available images were transmitted and displayed at the same time,
so they could choose for themselves which image to watch.
Teaching students, no matter whether they were co-present or distant, required
explanations and demonstrations. The form of these explanations and demonstrations changed when they were mediated through a communication technology.
The co-present students would have to be directed and positioned in the operating theatre in order to provide them with an adequate view of the activity. When
teaching distant students, the challenge was to provide them with the adequate view
in “the virtual space” and ensure that they would receive the intended information.
To achieve this the surgeon might have to request certain camera views from the
technicians or to pause action and minimise movements of instruments in order for
the transmitted image quality to be optimal.
5.2.3. Feedback and reciprocity
The discussions in the early phases about surveillance issues led to the enrolment
of a control key and a red warning light. This usually worked well, as the guests
present in the external room often were expected and known in advance, or they
were presented to the staff in the operating theatre. When the external transmissions (telemedicine) started, these measures were not sufficient. During the first
test transmissions some receivers (at the other side) would come and go according
to their local duties. The operation team did not know how many or exactly who
the receivers were, or whether they where present or not at any given moment. If
there had been quiet time periods without interaction, the operating surgeon might
ask explicitly who were watching. As the technology provided a two-way audioand video-connection, an image was actually transmitted also from the receivers’
site, but this image was (in the beginning of the project) only being displayed in
the video room, where the technicians were located. Later this image signal was
forwarded also into the operating theatre and displayed on a monitor. Then the
whole team could see who the receivers were. It would however, still be possible
TELEMEDICINE INFRASTRUCTURE IN SURGERY
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for a receiver to position oneself outside the camera view and thus be an “invisible
viewer”.
If the surgeon wanted to address the audience before the surgical procedure
started, he/she needed to know which camera (e.g. the roof- or the wall-mounted
room camera) that was currently active in order to simulate eye contact with the
audience. The natural impulse is to look at the image of the receivers when talking
to them. Also in other situations the surgeon or the team might want to know which
camera view was transmitted, how close it zoomed, or which of the other available
image sources was transmitted. In other words feedback was required in order to
manage and control the self-presentation.
Some transmissions were performed to large audiences at medical conferences
where not only images from the operating theatre, but also images from other
rooms as well as PowerPoint presentations and videos were transmitted. Then
the operating theatre was not “on air” all the time. Even though the images were
constantly transmitted to the control room, they were not transmitted any further
all the time. At these instances the operating theatre team was provided with the
outgoing image (the image sent to the receivers), and they could then relax when
they knew that they were not being watched. This image was displayed at the
same monitor as mentioned before, and consequently they were not able to see
a picture of the receivers. This was not felt to be interesting, as long as one knew
that there would be a lot of people watching anyhow. This shows the dynamic
character of the work practice’s demands to feedback and reciprocity, according to
different contexts. The two different genres of communication required different
configuration of the network elements (i.e. the monitors and image signals).
5.2.4. Less control over the rest of the network
External transmissions also implied less control over receivers’ values and norms,
and potential secondary use of information. Discussions arose over protection of
the patient’s rights and dignity. After some instances of discussions and disagreement, the nurses and the technicians agreed on some rules. There would usually not
be any recording or transmission during the early phases of the procedure, where
the patient was anaesthetised and naked. After the patient’s body was covered,
and only the area of interest to the surgeon was exposed, the camera system was
turned on. Focusing on the patient’s facial features was avoided, and patient information on X-ray images was blanked before they were transmitted. The feeling
of less control also led to increased efforts to create a shared awareness in the
department through organisational measures. Planned transmissions and off-line
video recordings were included as a note on the weekly work schedule, which
listed all the patients with their planned procedures, time and location, as well as
the participating staff. It was also requested that information about content and
purpose of planned transmissions should be given at weekly meetings between all
staff.
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6. Network configurations
The issues and problems that were encountered in the operation theatre are well
known, as the study of requirements to communication and interaction in virtually
collocated teams are central to the field of CSCW (see e.g. Hollan and Stornetta,
1993; Dourish et al., 1996; Mark et al., 1999). The problems of awareness, mutual
visibility, reciprocity and feedback, the handling of multiple views, articulation
work and coordination (Schmidt and Bannon, 1992; Schmidt and Simone, 1996),
and surveillance (Nardi et al., 1996), have all been documented earlier. However,
this paper has a somewhat different focus than to provide specific advice and design
recommendations. The aim is to more fundamentally investigate the technology’s
contribution to the continuous design-in-use, tailoring or drifting process. How can
the evolving interrelationship between technologies and work be understood? How
does the technology acquire its potential for making a change, and how does its
capacity for influence play out? Which implications do this have for design?
6.1. INVITATION AND CREATION OF AN ACTOR
The reason for the inclusion of the communication technology into the work practice was its designed features or inscriptions; its ability to create image and sound
signals that could be transmitted to remotely located receivers. The technology
was delegated a role of being the receivers “eyes and ears”. This role provided
the technology with its location in the actor-network and legitimised the costs and
disturbances that followed. However, the technology’s attributes (e.g. the camera’
image quality, zoom span, viewing angle, and the possibility for remote control),
besides being the reason for inclusion, also introduced unwanted effects like the
operation team’s perceived loss of control. These effects did not emerge before the
technology was included in the actor-network. An uninstalled camera lying in a
box wouldn’t create concerns of surveillance, but its inscriptions became activated
when it was installed in this particular location in the actor-network, between the
external room with unseen viewers and the operation room.
This illustrates that an artefact’s capacity for action or influence is relational and
not essential. It occurs or plays out in relations, when the artefact is part of an actornetwork; it is not a feature that is objectively present in an autonomous and isolated
entity. We may also see from the empirical material that an artefact’s capacity for
action may become curtailed or modified by the relations to the network around
it. An example of this is the installation of the red light and the control key in the
operation theatre, which arose from a wish to adjust this particular configuration of
the network with the aim to re-distribute control to the operation team.
TELEMEDICINE INFRASTRUCTURE IN SURGERY
15
6.2. THE ACTOR IS A NETWORK
Inscriptions occur not only “within” artefacts or network elements, but also from
the way these elements are connected. For example were definite inscriptions
present in the seemingly neutral and “obvious” design of the communication
facility, in how the equipment was installed with a focus on surgery. These inscriptions reflected more or less explicit organisational values, and they were more
or less chosen or intended. We saw, however, that as the network configuration
changed, e.g. with different use areas, the effect of these inscriptions varied. In
some instances it seemed possible to appropriate and capitalise on the present
inscriptions, in other instances the inscriptions seemed to constitute limitations
that must be circumvented for example by enrolling other artefacts. An artefact’s
capacity for influence is thus dynamic, not static and given once for all by the artefact’s attributes and its location. What is a powerful location in one configuration
of the actor-network may be a disadvantaged position in another.
The capacity for action is not only relational and dynamic; it is also a collective
feature and cannot be appropriated to specific network elements. Some tasks necessary for successful action were delegated to artefacts (the extra monitor as a
representation of the receivers, the red light as a warning of transmissions), and
other tasks were delegated to humans (providing “input” to the technology and
producing the context relevant to the receivers). In fact the achievement of alignment was not that easy to pinpoint and allocate to specific actors, it was rather
a network effect, where the humans plus the artefacts achieved the result. For
example, in order for the monitor in the operating theatre to represent the receivers,
several other human and non-human actants needed to act accordingly. A camera
had to be present at the receivers’ site, turned on and connected, and the receivers
had to position themselves in front of the camera. The transmitted image had to
be transmitted further to the operating theatre, a task that required technicians,
additional cables, an unused monitor, somebody to turn it on etc. Correspondingly, in order for the human actants to provide the technology with the required
“input”, they had to enrol microphones and cameras, as well as cables. There was
a network of human and non-human actants “around” or “behind” each actant;
nobody could act in isolation. Successful alignment of the network was a collectively achieved result. Also the effects or results of introducing the new technology
may be discovered only at the collective or network level, as displacements.
6.3. DISPLACEMENT – OR THE CONSEQUENCES OF INVITING THE ACTOR
Displacement can be understood as “the direction the collective takes once its
shape, extent, and composition have been altered by the enrolment and mobilization of new actants” (Latour, 1999, p. 194). Incorporating the technology into the
work practice definitely effected change and displacements that may be attributed
to the introduction of the technology. However, the changes are not an expression
of the technology’s pre-given capacity for influence in any deterministic sense, but
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emerge in this particular network configuration, or set of configurations. From this
case study we may see at least two features of this displacement.
6.3.1. Increase in complexity, power, and dependence
Through incorporating the new technology a more complex and enmeshed hybrid
of human and non-human actants emerged. The work practice expanded and
became able to both perform a surgical procedure as before and also to transmit
it to external viewers. The actor-network (the new work practice) became more
powerful and far-reaching, as it could extend itself and communicate with distant
receivers. This was the intended and wanted change. At the same time, control
and power was shifted out and became distributed across the network rather than
located to specific actants. The dependency of the actants on each other was
increased. This expansion thus also reduced the power, in the sense that there was
less control, and less predictability than before. We may say that the network technology’s capacity of influence has manifested itself in the introduction of network
dependencies. The focus of this paper is on the changes in the local work practice,
rather than the whole network of different cooperating partners and institutions,
but this point has profound implications for the development of telemedicine (or
other network technologies). Use of a common network means dependence on
other actors and a necessity of relating to their actions and choices. This implies
that no actor can act as it wants without constraints, but at the same time no
single actor is able to control the others and dictate their actions. Introducing
telemedicine or other network technologies, will therefore require open and evolutionary strategies, which are aimed at enrolling allies, rather than control-oriented,
specification-driven strategies.
6.3.2. From procedures to performances
A shift or displacement of the work practice towards a performance in front of
an audience was evident. The operating theatre literally became a theatre, a stage,
as it originally also was. The patient was the one most immediately affected, by
having images from the inside of the body transmitted to the outside world. The
patients’ interests were represented by the nurses and the surgeons, and the interests
have been translated into new rules for patient information and consent, as well as
restricting the camera’s view by defining rules for when it was OK to record or
transmit. This amounts to defining and managing the patient’s “role” in the performance. The operation team encountered a new work situation, and the discussions
around the surveillance issues as well as the wishes for feedback and reciprocity in
the communication situation were signs of the shift towards performance aspects of
the work. As one of the central persons in the work team the surgeon was affected
by being “in front of the camera”. The camera made the work more visible and
thus might increase the level of pressure to produce good results. It also influenced
TELEMEDICINE INFRASTRUCTURE IN SURGERY
17
the communication with the receivers (e.g. need for simulation of eye contact when
greeting audience, more explicit comments on image use).
Other parts of the work practice occurred “behind the camera”, either in the
very literal sense of physical camera control, or more generally the production
and support work. In order for the camera to “see” anything, a whole apparatus of
people, cables, connectors etc., had to be present behind it. Its presence demanded
new work tasks and new roles previously unknown in the surgical work practice. Other effects of the camera’s presence could be seen e.g. in the debates and
discussions in the department around routines and the attempts to create general
awareness. We thus see that the camera introduced increased visibility of (some)
work, and increased work to produce this visibility.
6.4. DESIGN OF CONFIGURATIONS
These displacements are expressions of the technology’s capacity for influence,
but at the same time they are emergent and non-deterministic. The activities
described above were situated in nature and attempted to define and delineate the
technology’s role in particular situations. There was no grand plan, and neither
was there only one possible solution to most of the problems encountered. The
importance of the configuration of the actor-network should be evident from the
above discussion, and the alignment work performed by the technicians and nurses
may be characterised as design of configurations. Different connections and relations between the different elements in the actor-network were devised, tested
and redesigned. Weak points or missing links were discovered and strengthened,
new elements (e.g. technical artefacts) were enrolled into the actor-network, or the
capacities of existing elements were worked at (e.g. the competence of users and
support technicians). Different configurations of the actor-network had different
distribution of burdens and benefits, and some were preferred over others. At some
instances, the effects of a given configuration were problematic to live with and
required adjustments or re-design. Then there may be several potential ways to
solve the problems, as the technicians’ image mixing illustrates.
This iterative and continuous work of creating, analysing, testing, and adjusting
network configurations, may be a salient feature of design of such open and generic
technologies. When the use is not pre-specified in any detail, the discovery of
well-working configurations of users and technology may become the core of
the design process. This would include both working with the different network
elements, their competencies and capacities, as well as the relations between them,
e.g. their location in the network and the links with other elements. Viewing
design as design of configurations captures the contingent, continuous and nondeterminate nature of the process, and also the multiplicity and heterogeneity of
the participants. In addition it may bring attention to the fact that as the process is
iterative and continuous, it will be costly and resource demanding (funds, competence, personnel etc.). To make and keep a network aligned requires care (Ciborra,
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1996), meaning attention, dedication and continuous work, as is also expressed by
the phrase “every day is a working day” (Latour, 1996, p. 86). A critical approach
to design may be facilitated, as “configuration” is a non-normative concept. Any
designed configuration is just one of several possible, and the designer can keep
in mind that “it could have been otherwise” and analyse different configurations’
distribution of burdens and benefits.
7. Conclusion
The process of introducing telemedicine technology into surgery has been
described. The alignment of the expanded actor-network was achieved through a
continuous configuring process and was emergent and situated rather than preplanned. The camera acquired its status as an actor in the network by being
delegated the role as the receivers’ “eyes and ears”. This defined its capacity for
action as relational and dynamic, changing with different configurations of the
network. The inscriptions present in the camera or in the installation became activated in the actor-network, but the effects of the inscriptions depended on how the
network around the camera was configured. Due to this relational and dynamic
character of the camera’s capacity for influence, the effects of introducing the
camera were only possible to identify at a network level, as composite effects or
displacement of the whole network. The displacements in this case was found to be
that the work practice changed into a more complex and enmeshed hybrid (introduction of network dependencies), as well as a displacement of this hybrid network
towards performance (visibility of work and work of visibility). The displacement
of the work practice is not a deterministic result of the technology’s “effects”;
it is rather a result of this particular network configuration. This, however, does
not exclude the assumption that similar effects of a similar configuration of work
practice and technology are likely to occur also in other contexts.
The empirical material thus clearly indicates the centrality of the network
configuration. When concerned with open and generic technologies, designers may
benefit from conceptualising the work as design of network configurations. This is
a notion that emphasises several salient features of the process. The case study
has emphasised the iterative and indeterminate character of the design, testing
and redesign of configurations. Recognising this aspect, as well as the resources
(time, skills, support staff etc.) that are required by such an open process, may
help designers to focus on issues that too often are neglected. Viewing design as
design of configurations provides a holistic approach as it recognises the materially
heterogeneous elements of the network as equally important in achieving the goal,
and it provides the possibility for a critical approach to design. Thus this focus may
contribute to better design practices.
TELEMEDICINE INFRASTRUCTURE IN SURGERY
19
Acknowledgements
I wish to thank Jonny Holmström, Ole Hanseth and Eevi Beck for helpful discussions and the anonymous reviewers for their suggestions. Also the staff at the
Interventional Centre deserves thanks. The work has been financed by a grant from
the Norwegian Research Council (grant no. 123861/320).
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