Information and Organization 27 (2017) 100–115
Contents lists available at ScienceDirect
Information and Organization
journal homepage: www.elsevier.com/locate/infoandorg
Affordance potency: Explaining the actualization of technology
affordances
MARK
Chad Andersona,⁎, Daniel Robeyb
a
b
Department of Business Informatics, College of Informatics, Northern Kentucky University, Highland Heights, KY 41099, United States
Department of Computer Information Systems, Georgia State University, Atlanta, GA 30301, United States
AR TI CLE I NF O
AB S T R A CT
Keywords:
Affordance potency
IT artifact
IS theory
Healthcare
Given the importance of information technology (IT) in effecting organizational change, scholars
have strived for many years to theorize the ways in which IT can produce the changes intended
for it. Recent arguments claim that most information systems (IS) research has taken a limited
theoretical focus on the information technology (IT) artifact, which arguably should be at the
core of the IS discipline (Benbasat & Zmud, 2003). This research engages directly with the IT
artifact by evaluating the use of an electronic medical records system and its relation to
actualization of technology affordances. We conducted a case study at a large urban acute care
hospital in the Midwestern United States with registered nurses working on inpatient care units
as the clinicians of interest. Through interviews with nurses and other clinical stakeholders,
observation of nurse's work practices on three patient care units in the hospital, and direct
examination of the medical records system, we develop theoretical insights into the role of IT in
work practices. The novel concept of affordance potency is introduced as an integral theoretical
construct in our model of affordances, helping to explain actualizations of IT in use. Our
contribution provides a nuanced yet powerful way of understanding the nature of IT artifacts and
their relationships to technology users and work practice.
1. Introduction
Information technology (IT) is typically designed to enable change in individuals, organizations, and societies. However, the
relationship between IT and the change it is intended to facilitate is inconsistent, and much of information systems (IS) research is
focused on understanding this issue through a variety of theoretical lenses (Robey & Boudreau, 1999). Recently, a number of IS
scholars (Leonardi, 2011, 2013; Majchrzak, Markus, & Wareham, 2016; Markus & Silver, 2008; Robey, Anderson, & Raymond, 2013;
Strong et al., 2014; Volkoff & Strong, 2013) have considered affordance theory, drawn originally from the field of ecological
psychology, as a viable lens for theorizing IT-enabled change. Affordance is a foundational theory in ecological psychology and has
been utilized in other fields like human-computer interaction (HCI) (Norman, 1988; Sutcliffe, Gonzalez, Binder, & Nevarez, 2011),
engineering (Brown & Blessing, 2005; Maier & Fadel, 2009), and education (Dalgarno & Lee, 2010; Gamage, Tretiakov, & Crump,
2011). The recent interest in affordances within the IS field stems from a call to understand the material nature of IT and its
relationships with its social context of use (Orlikowski & Iacono, 2001). Our study lies within this stream of research by offering new
theoretical insights into IS affordances and their implications for IT-enabled work practices.
The term affordance was coined by psychologist James Gibson, who postulated that, “The affordances of the environment are
⁎
Corresponding author.
E-mail addresses: andersonc16@nku.edu (C. Anderson), dan.robey@gmail.com (D. Robey).
http://dx.doi.org/10.1016/j.infoandorg.2017.03.002
Received 12 July 2013; Received in revised form 2 March 2017; Accepted 31 March 2017
Available online 06 April 2017
1471-7727/ © 2017 Elsevier Ltd. All rights reserved.
Information and Organization 27 (2017) 100–115
C. Anderson, D. Robey
what it offers the animal, what it provides or furnishes, either for good or ill” (1979, p. 127). IS scholars adopting the concept have
adapted it by focusing on technical artifacts as the part of the environment directly relevant to IT users. For example, Markus and
Silver define a functional affordance as, “the possibilities for goal-oriented action afforded to specified user groups by technical
objects” (2008, p. 622). More recently, Strong et al. define an affordance as, “the potential for behaviors associated with achieving an
immediate concrete outcome and arising from the relation between an artifact and a goal-oriented actor or actors” (2014, p. 12).
Thus, affordance theory offers a promising perspective on IT-enabled change by focusing attention on aspects of the relationship
between an IT artifact and its users.
The context of this research study is healthcare, and the IT artifact studied is an electronic medical records (EMR) system used by
clinicians to provide and document patient care within an acute care hospital. Our aim is to use this context to further develop the
concept of IS affordance and its relationship to work practice. We build on existing affordance research by introducing the concept of
affordance potency as a novel theoretical construct within the nomological network of affordance theory. Affordance potency helps to
explain the influence of IT's material properties on work practices. We begin by reviewing affordance theory and developing the
concept of affordance potency. Following this theoretical development, we describe the research methods, present the findings, and
refine our contribution in a discussion of the findings. We conclude with implications for future research and practice.
2. Affordance theory
A number of scholars have issued calls for the study of technology affordances as an inroad to understanding IT-enabled social
change. In sociology, Hutchby (2001a, 2001b) posits affordances as a theoretical mechanism for understanding the constraining
influences of technology on human action. In organization science, Zammuto et al. suggest that affordances can provide an effective
lens for explaining the “increasingly symbiotic relationship between IT and organization” (2007, p. 752). Leonardi and Barley (2008)
hypothesize that material features of IT act as both affordances and constraints on individual user behavior, and argue for developing
a language of affordances that allows us to better explain and predict technology-occasioned change. Affordances have also assumed
prominence in IS research directed at understanding and solving societal-level problems (Majchrzak et al., 2016).
One approach to responding to such calls is to use affordances to complement existing theories used in IS research that limit their
treatment of the IT artifact. As Majchrzak et al. advise: “By looking at technologies as sets of affordances and constraints for particular
actors, IS researchers can explain how and why the “same” technology is used or has different outcomes in different contexts, thus
enriching general and substantive IS theories” (2016, p. 272). For example, Giddens' (1984) structuration theory provides little
guidance for understanding the theoretical role of IT artifacts. To compensate, Jones and Karsten (2008) suggest that affordances
could provide a way for IS researchers using structuration theory to construct a more consistent theoretical account of the IT artifact.
In similar fashion, Markus and Silver (2008) note that the concepts of “structural features” and “spirit” in Adaptive Structuration
Theory (AST) (DeSanctis & Poole, 1994) have seen little use by other researchers. Markus and Silver therefore suggest that, in
addition to “technical objects” and “symbolic expressions,” “functional affordances” could serve as an effective substitute for
“structural features” and “spirit” in research using AST to understand IT-enabled change. As seen in these examples, a theory of
affordances may not stand apart from existing theories of IT-enabled change, but rather serve to enrich and deepen the explanatory
power of theory by more precisely theorizing IT artifacts in relation to their social contexts of use. In the spirit of enriching theories of
IT-related change, we propose a new concept of affordance potency within the nomological network of affordance theory and explain
its added value for understanding IT-related change.
We adopt the definition of affordance from Strong et al., mentioned earlier: “the potential for behaviors associated with achieving
an immediate concrete outcome and arising from the relation between an artifact and a goal-oriented actor or actors” (2014, p. 12).
Thus, an affordance is dependent upon the relationship between other concepts, in this case an artifact and an actor, and therefore
does not exist independently of those concepts. However, relational views of affordance have not been universally held by scholars, as
some have argued that an affordance is a property of the environment.1 Initially, ecological psychologists understood affordances as
dispositional properties of the environment (Heft, 1989; Michaels, 2000; Reed, 1996; Turvey, 1992). More recently, Stoffregen
(2003) and Turvey (2009) argued that affordances should be conceptualized as emergent properties of the inseparable animalenvironment system. Fayard and Weeks (2014) offer yet another view of affordances as both dispositional and relational. We are
partial to Strong et al.'s definition, which resonates with Chemero's (2003) assertion that affordances are “relations between the
abilities of organisms and features of the environment” (2003, p. 189). This relational definition of affordances is also consistent with
other IS researchers (Leonardi, 2013).
Affordance theory in IS research also tends to distinguish between information systems and social contexts within which
information systems operate. A relational view of IS affordances maintains the relevance of the social context while emphasizing the
distinct role of IT artifacts in generating affordances. While the social context also consists of material artifacts, such as physical
human bodies and workspaces, it usually refers to abstractions like work routines, authority relationships, job responsibilities, and
incentive systems. A convenient way to approach social context is to focus on “work practices,” the recurring activities through which
individuals and groups direct their work-related efforts. The phrase is meant to refer in a general way to recurrent situated activities
rather than to stand on its own as a theoretical concept. Work practices may or may not be treated as “routines” (Feldman & Pentland,
2003) and our intent is not to contribute directly to a theory of routines. Rather, we use the term to denote the application of a
1
Divergent schools of thought emerged in part because Gibson's (1979) initial definition was ambiguous on whether an affordance is a property of the environment
or a property of the relationship between an animal and its environment.
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practice lens (Orlikowski, 2000) involving IT applications implicated in actual work, as in many earlier studies (e.g., Chu & Robey,
2008; Leonardi, 2012; Schultze & Boland, 2000; Vaast & Walsham, 2005). By considering the relationship between IT artifacts and
work practices, researchers may explain the consequences of IT use on social context. Using the relational framing of affordance,
scholars can avoid deterministic approaches to studying IT “impacts” and move to more nuanced studies of the interplay between
technology and work practices (Kling, 2000; Robey & Boudreau, 1999).
2.1. Affordance actualization
While most scholars follow the lead of Gibson (1979) in theorizing affordances as behavioral possibilities or opportunities, few
explicitly address how particular affordances are selected from the many potential affordances available at one time. Since there are
typically multiple behavioral opportunities available to an actor in the environment, it is worth developing explanations for the
choice to act or not act on a particular affordance that leads to the actualization of the affordance.
One reason not to actualize an affordance is a failure to perceive it. As part of his original idea that affordances existed
independently of their actualization, Gibson states that, “The observer may or may not perceive or attend to the affordance, according
to his needs, but the affordance, being invariant, is always there to be perceived” (1979, p. 139). By this reasoning, the set of
affordances available can exceed the affordances perceived to be available at any given moment. This logic became part of Norman's
(1988) basis for introducing affordance theory to the HCI field. Norman suggests that technology designers should make technology
affordances explicit to potential users so that intended affordances would be easier to perceive.
A second reason not to actualize an affordance is their disconnection from user goals. In Gibson's original conceptualization of
affordance he argues that, in contrast to the Gestalt notion of demand character or valence, which bestows meaning on physical
objects based on the needs of an observer, “The affordance of something does not change as the need of the observer changes” (1979,
p. 138). Stoffregen makes the same argument when he states, “Affordances are defined independent of the goals of the animal. The
opportunities for action are what they are regardless of what we may want or desire” (2004, p. 82). Therefore, the set of available
affordances may include many that do not correspond to a need or goal and consequently, those affordances are less likely to be
actualized.
The link between affordances and goals has also been studied in IS research. Leonardi (2011) found that when users were unable
to achieve their goals with their current set of routines and technologies, they changed either one or the other. For Leonardi, the
decision whether to change the routine or the technology is based on the user's perception of constraints and affordances. When a user
perceives the technology as a constraint, the user will look to change the functionality of the technology. When a user perceives that
the technology offers an affordance, the user will look to change the routines to take advantage of that affordance. Therefore, when
people evaluate technology they see either affordances or constraints based on how the technology fits with their current goals.
Strong et al. (2014) offer the most recent and most complete explanation of affordance actualization, which they define as “the
actions taken by actors as they take advantage of one or more affordances through their use of technology to achieve immediate
concrete outcomes in support of organizational goals” (2014, p. 15). In their study of the implementation of an electronic health
records system in a multi-site medical group, Strong et al. (2014) looked at goals and affordances at the individual and organizational
levels. As clinicians drew upon the affordances of the system to achieve their individual goals of patient care, they contributed to the
achievement of organizational goals to provide more effective health care at lower cost.
Affordance actualization is therefore conditioned by both the perception of the affordance and the relationship of perceived
affordances to current goals. However, affordance actualization observed in practice is not fully explainable through perception and
goals alone because there are times when a user is both aware of an affordance and has a current goal that the affordance could
support, and yet the affordance is not actualized. Strong et al. (2014) acknowledge this possibility through their conception of
affordance actualization as a process entailing “journeys” stretched over time as users interact with shifting technology features. This
process of actualization resembles Leonardi's (2011) concept of “imbrication” in which distinct elements, both technical and social,
are intertwined in practice over time.
Strong et al. identify three factors (abilities and preferences of the individual, features of the system, and characteristics of the
work environment) that both support and restrict an individual's affordance actualization. They suggest that future studies using their
affordance lens, “would contribute to understanding what it is about IT and its design, about organizations and actors, and about
their relations that matters in IT-associated organizational change” (Strong et al., 2014, p. 80). Our own study contributes to this need
by suggesting that affordances possess a “potency” that is a product of the three factors mentioned above.
2.2. Affordance potency
Our development of the concept of affordance potency is rooted in earlier studies of the complexity of affordances in relation to
users' choices of behaviors. For example, Warren (1984) conducted experiments on stair climbing and found that the affordance of
stair climbing is based on a ratio of riser height to leg length. Increasing the ratio makes the affordance more difficult until “a critical
point is reached at which the stair is too high to afford bipedal climbing, and the climber must shift to a quadrupedal (hands-andknees) gait” (1984, p. 686). Conversely, the affordance of stair climbing is least difficult at an optimal point, “yielding minimum
energy expenditure per vertical meter of travel - a candidate for the best fit between climber and stair” (1984, p. 686). Consequently,
while all affordances are behavioral opportunities, affordances that enable the same type of behavior may not be equivalent in the
amount of effort it takes to carry out the behavior.
McGrenere and Ho (2000) call the range over which an affordance is, on the one end, maximally easy to undertake, and on the
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other end, no longer possible to undertake, the “degree of affordance.” They further suggest that when designing technology,
affordances can be designed with a “degree of perceptual information,” which is the clarity of information available to perceive the
affordance. Together the degree of affordance and the degree of perceptual information produces a two-dimensional continuum
which they argue determines the usability of a technology.
We extend the idea that affordances differ in their power or utility to enable user goal achievement. Just as pharmaceutical drugs
may vary in their potency for treating medical conditions, we posit that technology affordances vary in their potency to help users
perform their work practices. Specifically, we define affordance potency as, the strength of the relationship between the abilities of the
individual and the features of the system at the time of actualization, conditioned by the characteristics of the work environment. This means
that, while technology designers may attempt to create affordances based on anticipated user abilities and design system features
within an expected context, the potency of affordances is always based on the abilities of the specific individual and the existing
system features within the actual context of use. Therefore, affordance potency, along with perception of the affordance and the goals
of the individual, is a necessary condition for affordance actualization.
We define the strength of the relationship as the ease with which the individual can actualize the affordance, which is a function
of the requisite energy, mental and/or physical, needed to carry out the actualization. An affordance with strong potency would
therefore require less energy to actualize than a similar affordance with weak potency. Higher energy requirements will translate into
greater difficulty and therefore, all else being equal, an affordance with weak potency will be less likely to be actualized than an
affordance with strong potency. Affordance potency will be unique to each individual since it is partially based on the abilities of the
individual and it can change over time as abilities, features, and the environment change, but it will always exist at a specific level at
the time the individual chooses to actualize the affordance.
Strong et al. (2014) suggest that future research on affordances should include the study of difficulties individuals encounter
during affordance actualization. Affordance potency responds to that suggestion by explaining why individuals encounter difficulties
during actualization and how that influences their decisions to actualize an affordance or to find ways to work around the difficulties.
That this notion has not been well-developed in IS research is surprising, given that many IS researchers focus on improving system
features. The tendency, however, is to design features into systems with a particular set of users and contexts of use in mind.
Alternative uses are not entirely unexpected, but are generally considered outliers to be dealt with infrequently and therefore the
difficulties experienced by “non-typical” users in actualizing an affordance are not sufficiently considered in the design of systems.
To develop the idea of affordance potency, we undertook an empirical study of EMR use in clinical work practices. The following
section details the methods for the empirical study.
3. Method
3.1. Research design
For Gibson (1979) and other ecological psychologists, affordances represent an important ontological premise for the study of
perception; that meaning can exist in the environment independent of meaning that is internally or socially constructed. In IS
research, critical realism (Archer, Bhaskar, Collier, Lawson, & Norrie, 1998; Bhaskar, 1978; Mutch, 2013) has been used to support
this ontological position through a philosophical perspective that takes “…a realist view of being in the ontological domain whilst
accepting the relativism of knowledge as socially and historically conditioned in the epistemological domain” (Mingers, 2004, p. 91).
Volkoff and Strong (2013)argue that affordances are the generative mechanisms of critical realism, and we find a realist view to be an
effective philosophical position from which to study and understand technology use that can be consistent across settings at times
while also being amenable to varying user appropriation. Accordingly, the research design used in this study provides a balanced
focus on objective system features, user goals and abilities, and the social context of IT use.
We employed a qualitative case study design (Eisenhardt & Graebner, 2007; Yin, 2003). The study's focus on healthcare was
shaped by the first author's background as both a clinician with experience providing care in hospital patient units, and as a vendor of
health IT systems designed for hospital patient-care units. He also trained nurses and other clinicians to use those systems. The broad
goal for this research was to study the role of IT in the coordination and delivery of health services, with a specific focus on direct
patient care in hospital care units. Among the many IT applications in use on hospital patient care units, EMR systems are the most
comprehensive and information-intensive systems in place today and are of particular interest given federal incentive programs to
promote their adoption and use.
We sought a study site in the geographic area where the first author had worked as a clinician and IT vendor, expecting that
familiarity would improve our chances of gaining access to an acceptable site, which it did. We were directed, by personal contacts, to
a hospital that had recently implemented an EMR system facility-wide in a short period of time, which required them to start with a
non-customized package and adapt it later to their specific needs. After speaking with the hospital's director of IT about their
implementation process, it appeared that the hospital would provide a potentially rich setting for studying the consequences of IT for
the coordination and delivery of health services.
For the remainder of the paper, the pseudonym “Urban Hospital” is used to refer to the study site. Urban Hospital is a 555-bed,
not-for-profit acute care facility located in the heart of a major metropolitan city in the Midwestern United States. It is a general
medical and surgical hospital with a staff of over 1000 physicians and more than 4000 employees. Since 2001, the hospital has been
consistently recognized as one of the top 50 hospitals in the U.S. by U.S. News and World Report. The EMR system implemented at
Urban Hospital on the patient care units was the EpicCare Inpatient Clinical System, and will be referred to as “Epic.”
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3.2. Data collection
A combination of interviews, observation, and document analysis were employed for data collection in order to strengthen
triangulation of evidence and broaden data gathering opportunities (Eisenhardt, 1989). Semi-structured interviews were conducted
to allow subjects latitude in expressing their thoughts and opinions while still being guided to the topics of interest. Interview guides
were initially constructed based on concepts from the literature and then modified to incorporate new concepts that were identified
as the data collection progressed. The initial interview guides are included in the Appendix. All interviews were audio recorded so
that the interviewer could focus on the respondent's answers and adjust questions as necessary without having to take detailed notes.
Two nurses asked not to be recorded, so for those interviews notes were taken during the interviews and written out in detail
immediately afterwards.
Epic was implemented throughout the hospital, but Urban, like most hospitals, contained a mix of different patient care units,
each with unique characteristics and a certain level of autonomy in how they chose to use technology. Through negotiation with the
hospital's nursing administration, access was granted to two medical/surgical units (3West and 5South) and one intensive care unit,
the cardiovascular ICU (CVICU). This yielded a diverse set of nursing practices in different physical settings. Access was also granted
to conduct interviews and observations on both day and night shifts, as work practices on patient care units vary between days and
nights.
Onsite data collection was conducted during the summer of 2010. The first author spent a total of 14 days and four nights over a
one-month period at Urban Hospital engaged in data collection and interviewed a total of 51 subjects, 33 of whom were registered
nurses (RNs) who were the clinician users of interest in the study. Data collection began with interviews of the hospital's nursing
administration and system support personnel with the expectation that understanding the system implementation process, features,
and intended purpose would provide a basis for gathering data from the clinician users. Hospital administrators included the Chief
Nursing Officer (CNO) and the nurse managers of each unit for which access was granted. Interviews with the nurse managers served
the dual purpose of identifying their expectations for and perceptions of the use of the system by the nurses on their unit as well as
establishing procedures for interviews with the unit nurses and observation of activity on the unit. System support personnel included
the five-member Information Technology team, which provided backend support to Epic and its integration with other related
systems; and the five-member Clinical Informatics team, which provided direct support to the clinical users of Epic. The interviews
with Information Technology and Clinical Informatics personnel were conducted in groups while all other participants were
interviewed individually. Three educators who provided ongoing system education and training to clinicians were also interviewed
for their perspectives on user abilities related to Epic's features.
Nurses were selected as the clinician users of interest for the following reasons. Patients admitted to a hospital are assigned a room
on a patient care unit and nurses staff those units to provide primary care to the admitted patients for the length of their stay. Nurses,
therefore, spend more time providing and documenting care to admitted patients than other clinicians, they must ensure coordination
of care across shifts, and they communicate regularly with physicians and other clinicians who interact with the patients. There are
several types of nurses on patient care units including Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Certified Nursing
Assistants (CNAs), and Patient Care Assistants (PCAs). Registered nurses have primary responsibility for implementing the physician's
plan of care for the patient while the other types of nurses carry out parts of that plan under the supervision of the RNs. Therefore,
RNs have the broadest range of responsibilities on the unit as they can perform all of the activities of the other nurses in addition to
their unique roles. Based on these factors, registered nurses formed the core of the data collection effort with a total of 33 RNs
interviewed across the three patient care units included in the study. For the remainder of the paper they will be referred to simply as
nurses. Table 1 provides a summary of all study participants.
In addition to interviews, 22 of the nurses were observed as they engaged in their daily work practices of providing patient care
and interacting with physicians and other clinicians on the patient care units. Observation sessions always took place after the nurses
had been interviewed and had consented to their participation in the study. The first author was given the freedom to move about the
units to observe nursing activities and could ask the nurses questions when clarification was needed on observed behaviors.
The first author was also given access to both the Epic production system and the Epic “sandbox” environment, which allowed for
self-testing of system functions to evaluate features that were discussed during the interviews. In studying the relationships between
IT and users, there can be considerable value in engaging directly with the IT artifacts rather than relying solely upon reports from
users and IT staff. Observations of physical artifacts, such as portable workstations on wheeled carts, in the hospital units provided
additional insight into IT features and their importance to work practices. This combination of data collection methods provided a
rich set of data and a thorough understanding of the case environment.
Table 1
Study participants.
Role
Unit
# of participants
Registered nurse
Registered nurse
Registered nurse
Nursing administrator
Nursing educator
IT and clinical informatics
3 West
5 South
CVICU
Multiple
NA
NA
13
14
6
4
3
11
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3.3. Data analysis
Recorded interviews were transcribed and loaded into nVivo software along with field notes for data analysis. The guidelines for
qualitative data analysis provided by Miles and Huberman (1994) were followed in the analysis of the research data. An initial round
of coding to identify descriptive and interpretive codes resulted in a total of 87 unique codes (e.g. medication administration record,
medication cart, notification flags, barcode scanner). nVivo's tree node structure was utilized to facilitate a code hierarchy with
descriptive codes organized under specific interpretive codes with the coding structure evolving over time through iterative periods
of coding separated by periods of reflection on both the data analysis process and the results of that analysis.
The first round of coding continued until all data had been analyzed and there was reasonable certainty that all relevant text had
been coded and no new descriptive or interpretive codes were forthcoming in the data. At that point a second round of coding was
initiated. This second round of coding was meant to produce what Miles and Huberman (1994) call pattern codes or meta-codes,
which are more inferential and explanatory in nature than either descriptive or interpretive codes. This second round of coding was
conducted to elaborate the influences of the Epic system on nurses work practices at Urban Hospital. The second round focused on the
codes that contained the most references in the data (e.g., charting, medication pass, handoff). By concentrating on the categories
that were given the most attention, we expected to obtain richer, more extensive data for the identification of robust pattern codes.
Identified pattern codes were then compared to the literature on technology affordances.
Through this process we iteratively developed the components of a model of affordances relevant to the social context of our case
including the novel concept of affordance potency. The empirical basis for the model is presented next, followed by a discussion
section in which the implications of affordance potency for IT-related changes in work practice are further explored.
4. Results
4.1. Social context of work practice: inpatient nursing
Urban Hospital provides both inpatient and outpatient care services. Inpatient care is defined as the admission of a patient for
treatment that will require at least one overnight stay in the hospital, while patient services that do not require an overnight stay are
considered outpatient care. Nurses' work practices differ significantly between inpatient and outpatient care and the decision for this
study was to focus on inpatient care services.
Like other hospitals, Urban Hospital organizes its inpatient care around patient care units, and patients admitted to the hospital
are assigned to a room on a particular unit. Urban Hospital has a mix of patient care units with each unit configured for the care of a
particular type of patient or condition or set of conditions (e.g., maternity, pediatrics, medical/surgical, cardiac care, etc.). These
units are physically separate from each other and have dedicated staffs of nurses and support personnel who provide 24-h care for the
patients admitted to the unit.
Patients admitted to a patient care unit spend most of their hospital stay on the unit and therefore the nurses assigned to the unit
become primarily responsible for their care under the authority and direction of physicians. These patients require round-the-clock
monitoring and care and therefore the units are staffed 24 h a day on rotating shifts. On the units studied at Urban Hospital, nurses
work 12-h shifts from 7 a.m. to 7 p.m. (day shift) or from 7 p.m. to 7 a.m. (night shift). Each unit is headed by a nurse manager and
one nurse per shift is normally designated as the charge nurse who functions as the shift supervisor.
The remainder of the results presents an account of selected work practices of nurses across three patient care units (3West,
5South, and CVICU) at Urban Hospital with each work practice selected to focus on a particular affordance that uniquely illustrates
the concept of affordance potency. Nurses engage in various activities during their shift including assessment, charting, handoff,
medication pass, patient education, care plan development, admissions, and discharges. The findings are organized into three of these
specific nursing work practices: charting, handoff, and medication pass. Each of these work practices was a pervasive part of nursing
within the units studied at Urban and was directly affected by the Epic system. Although many affordances exist and are actualized in
any work practice, we focused on one specific affordance for each work practice because that affordance was both associated with the
primary goal of the work practice and provided a compelling example of how affordance potency is conditioned by its component
parts. Table 2 lists the affordances, their associated work practices, and the three elements that contribute to affordance potency.
Table 2
Work practices, affordances, and contributors to affordance potency at urban hospital.
Work practice
Affordance
Technology features
User abilities
Social context
Charting
Documenting Care
Handoff
Coordinating Care
Typing skill, comfort with computers,
comfort with patient care
Typing skill, communication preferences
Care unit structure, patient
perceptions
Shift change, unit expectations
Medication Pass
Validating Medications
Work stations on wheels (WOWs),
Epic software
Dear Staff freeform textbox with
character limit
WOWs, barcode scanners and
labels
Nursing judgement, equipment use
Patient room layout, admin
expectations
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Fig. 1. Epic mobile workstation on wheels (WOW).
4.2. Charting and the affordance of documenting care
Prior to the implementation of Epic, the documentation of patient care at Urban Hospital was accomplished using a paper-based,
three-ring bound patient chart, and “charting” was the term generally used to denote the process of documenting patient care. With
the implementation of Epic, the patient chart was digitized and access was made available through both stationary and mobile
computer terminals. Of Strong et al.'s (2014) eight named affordances, “capturing and archiving digital data about patients” would
include Urban's process of charting in Epic.
The devices on which the nurses could chart varied by unit. The CNO explained that, “When we went live, we didn't really have
the time, nor did we have the construction ability to get computers in every room. There was just not enough time and there's really
quite frankly, not enough space in most of our rooms.” Consequently, most patient care units were equipped with mobile computers
called workstations-on-wheels (WOWs) and some fixed desktop computers in the hallways and at the nurse's station. The ICUs, in
contrast, had desktop computers at the patient bedside because ICU rooms are larger and the hospital had previously decided to
install computers in the ICU rooms to support another information system.
WOWs were the computers used most frequently by nurses on the 3West and 5South patient units. Fig. 1 shows a WOW that
includes a computer base with Wi-Fi, a flat screen monitor, a keyboard and mouse, a barcode scanner for scanning patients and
medications, power cord, and a battery pack, all built on a rolling frame that could be height-adjusted. There is also a wire basket to
hold supplies and a desktop surface on which to set objects or to write.
Both the WOWs and the in-room computers allowed nurses to chart at the bedside making documentation more timely and
accurate. One nurse explained, “I can chart right there when I'm in the room as opposed to when we did paper — you'd have to
remember, write something down, and then go and chart it.” Another nurse described how the WOWs changed her work practices. “I
take their medications in with me and I do a good assessment and I usually chart it all in the room so that I don't miss anything.”
Another benefit of a computer-based patient chart was that nurses and other clinicians had access to relevant data without having
to locate the patient's physical chart or other paper documentation. In describing the expected impact on the nurses, the CNO said,
“They don't have to hunt for a chart anymore; they don't have to hunt for a MAR [medication administration record] anymore; they
don't have to hunt and find all the papers from registration.”
The Epic software also provided flexibility in how information was accessed and documented, which was either a benefit or a
challenge depending on how the system features fit with a clinician's workflow.
“There's a lot of different places to chart the same thing in Epic and I think that can be good and that can be not so good, and the
good is that you can find it about anywhere you want. The not so good is that nurses have a harder time getting into the flow of,
what do I need to do next because they're all over the place instead of systematically doing it in order.”(Senior Clinical Informatics
Analyst)
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The change from paper charts to the use of Epic on WOWs and in-room computers was designed to increase the potency of the
affordance of documenting care because Epic enabled more ways to access information and document care than a paper chart.
However, the availability of multiple options could also reduce potency if nurses did not sufficiently understand the structure of the
electronic health record.
Another challenge for some nurses was that using computers in the patient rooms created a tension between caring for their
patients and documenting that care on the computer. The CVICU Clinical Coordinator said, “I think the biggest thing that concerns
me is the amount of patient contact that you have…looking at a computer screen.” And other nurses expressed concern for what the
patients thought of their use of the computers.
“I try to work in the room with the computer, but I try not to document in front of the patient because I've had so many patients
say to me that nobody really listens to them. It's very easy to be typing and talking to them, but their feeling is that you don't really
care or listen, you've just got to check your boxes.”(5South Nurse)
In this example, the expectation for documenting care at the bedside was not always actualized in practice because the potency of
documenting care was reduced by the nurse's discomfort with documenting care in the presence of the patient.
Issues with system features, like the login process, also created new difficulties for nurses in patient care and the documentation of
that care. Login time was slow and also fluctuated depending on network load. An ICU nurse explained:
“The logging in now is ridiculous. As soon as I walk in my patient's room I log in and then I address the patient. It's just something
that you have to get going or otherwise you're standing there and not accomplishing anything while you're waiting for it [the
bedside computer] to log in.”(CVICU Nurse)
Thus, while the potency for documenting care was high because the chart is always available at the bedside, the nurse had to first
get into the system, which wasn't always as easy as flipping open a paper chart. This impediment related to a system feature designed
to ensure security lowered the potency of documenting care on Epic.
User abilities were influential in the transition from paper to digital charts. Users had to switch from writing in the paper chart to
typing in Epic, and relative typing ability significantly affected the time it took a nurse to chart in Epic.
“It takes a lot longer sometimes to get things done in an EMR than it does to have that piece of paper that I can set on the bed and
put my check marks on…Typing skills are huge. If a person knows how to touch type they went through much less distress than if
it's a person that hunts and pecks… I think at first from some end-users it could have been as much as doubling their
documentation time if not more.”(Inpatient Clinical Team Lead)
General computer knowledge and comfort with computer systems was also a contributor to a nurse's ability to chart with Epic.
“I'm 58 and so I did not come up through computers…and this is where I find that I'm not as competent as nurses half my age…I
can't always see, okay, have I done all the parts of the chart that I'm supposed to?...When its paper you can flip through and you
can see it. When it's electronic, there's a little bit more to going through because it's just not quite as easy for me.”(5South Nurse)
Typing ability and general computer skills clearly influenced the potency of documenting care as some nurses struggled to make
the transition from paper to digital patient records.
In summary, Epic at Urban was designed to facilitate electronic creation, storage and retrieval of confidential patient records.
When placed onto mobile carts and/or in fixed locations within the patient care units, the system hardware was close enough to
patients to afford nurses the potential to both care for patients and access/record information about those patients as a continuous
work practice. However, the actualization of documenting care varied from nurse to nurse and unit to unit and that variability can be
traced to the potency of the affordance as influenced by differences in individual nurse's abilities, features of the implemented Epic
system, and characteristics of the patient care unit.
4.3. Handoff and the affordance of coordinating care
Coordinating care is necessary in inpatient care settings to provide continuity across multiple care providers and/or encounters
and multiple work shifts. As the main care givers on patient care units at Urban Hospital, nurses were primarily responsible for
maintaining coordinated care through the exchange of information between nurses starting and ending their shifts. The specific
procedures for coordinating care across shifts on each unit were at the discretion of the unit's nurse manager, but the general
expectation was that nurses ending their shifts would remain on the unit until the nurses starting their shifts had been sufficiently
advised on their patients. The procedures for coordinating care between shifts at Urban were collectively referred to as “handoff.”
Nurses began their shift by getting their patient assignments. Relevant information on assigned patients was obtained from the
patient chart, but the outgoing nurses typically had additional knowledge that was either not in the patient chart or not easy to locate
in the chart. For this reason, outgoing nurses were required to “give report” to incoming nurses on the current state of the patients in
their care. Prior to the implementation of Epic, giving report on 3West and 5South was done either verbally or by tape recording.
With verbal report, nurses sat down face-to-face and discussed each of the patients being handed off. The outgoing nurses
typically had notes accumulated during their shift which guided their reports to the incoming nurses. Some patient care units had
special “report rooms” where nurses had privacy to give report, while others used a common room, like the nurse's break room, where
all nurses congregated at the same time for verbal report.
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“We were face to face for half an hour before and after shifts and it just seems archaic now the way we used to do it. In fact we
laugh about how we all used to get together in one room and shout over one another and I don't know why we did that either. We
had a whole floor but we'd all be in the break room trying to shout over each other. In fact we were just talking about it the other
day, can you believe how we used to give report? That was so crazy!”(5South Nurse)
Another drawback to verbal report was lengthy time needed to give a full report on every patient.
An alternative method for giving report, which addressed this issue, was the use of tape recorders. Before the end of the shift, the
outgoing nurses audio recorded their reports on each patient using a tape recorder. The incoming nurses then listened to the taped
reports on their assigned patients when they arrived. The advantage to tape recording was that the outgoing nurses could make the
recording anytime during their shift, which reduced the time required to verbally handoff between shifts. The incoming nurses were
also able to listen to the recordings at their own pace and refer back to them if necessary after the outgoing nurses had left. These
features of recording technology were expected to increase the potency of coordinating care. However, the drawback to tape
recording was that information could only be accessed sequentially, and searching the tape for specific information was inefficient.
Thus, the benefit of being able to listen to the tape recordings did not strengthened the potency of coordinating care as much as
anticipated.
With the implementation of Epic and the recognition that existing handoff procedures were limited in their potency to enable
coordination of care, some of the nurse managers looked to Epic for ways to change their units' handoff procedures. Nurses' handoff
comments were intended to be “off the record” and not retained as part of the patient's permanent chart, and Epic did not have a
feature designed specifically for handoff. However, it did have a function called “Dear Staff”, which was a freeform textbox that,
unlike the rest of the documentation system, did not become part of the patient's permanent medical record. The Dear Staff function
enabled “off the record” communication between all medical staff, but there was a 2000-character limit on the information that could
be stored in the textbox and only one instance of the textbox was available per patient for the length of the patient's stay. All staff
wishing to use the Dear Staff function shared the same limited space and could delete, modify, or reuse any information previously
entered by any other staff member.
While not a perfect fit with the handoff process, some of the nurse managers decided to try Epic's Dear Staff function for handoff
on their units. Anything that was previously exchanged in the verbal report or included in the tape recordings could be written in the
Dear Staff textbox. This preserved the communications as “off the record,” thereby allowing the nurses to speak more colloquially.
For example, one nurse explained: “I had a guy that wouldn't get out of bed and in my electronic handoff I said, ‘I've used every skill
that I have to get this man out of bed other than dynamite!’ And I can use words like that because it's not part of the permanent
record.” The Dear Staff feature was therefore transformed from a space designed for “off the record” communication between all
medical staff to a tool that specifically supported the unit nurses' needs for handoff reporting.
The Dear Staff content could be modified as often as necessary, so as relevant information was identified during the course of a
shift, the nurses could update the content of each patient's textbox to serve as their handoff report for the following shift. A nurse
describing her new routine said, “I usually start updating my reports around one o'clock and then, after I make that first update, if
anything new comes up I will immediately update my report.” This had the effect of increasing the potency of coordinating care
because handoff content could be available whenever the incoming nurses wanted it.
“I don't have to come in like old times and say, where's this nurse? I can't find her so I guess I can't start report, I've got to wait.
Because that's happened before, I've been ready to get report and they were in another room doing a dressing change or giving
pain meds or whatever so you have to sit and wait.”(5South Nurse)
Because it was a freeform space, the Dear Staff textbox provided functionality similar to the tape recordings where nurses had the
freedom to structure their information as they saw fit. However, one significant difference was that information in the Dear Staff
textbox was carried over from shift to shift and could therefore be reused. With tape recording, the expectation was that a nurse
started from scratch and included the patient's entire history in each recorded report.
“You never have to go through the same story over and over again. You just have to update. Maybe you just have to add a couple
of sentences at the end of your shift instead of having to go through the whole thing…I mean tape recording would sometimes take
45 minutes and now updating a handoff takes a few minutes.”(3West Nurse)
This had the effect of increasing the potency of coordinating care because nurses could focus their attention on the content that
needed to be updated without having to repeat the patient's entire history at the end of each shift.
Of course, reuse also had a downside when nurses failed to keep information current. With tape recording or verbal report, the
incoming nurse knew that the information was current because it was either just recorded or conveyed verbally. With Dear Staff, the
incoming nurse did not necessarily know what information was current and what information was out of date because the system
didn't track or time-stamp changes made in the textbox. This reduced the potency of coordinating care, as expressed by one of the
nurses:
“People don't update the report as thoroughly or as appropriately as they should, because they say, “today had an x-ray and had
two units of blood” and that was on day shift. Then it goes to evening shift and they don't change it, so it's saying this shift got two
units of blood and you're thinking, okay they just had the blood and then you find out, no that was close to 24 hours ago. So the
thing about “today”, “tomorrow”, words like that don't get changed and then it can get confusing.(5South Nurse)
The 2000-character limit also became a problem for nurses when patients were in the hospital long enough for their Dear Staff
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textbox to reach that character limit. A nurse explained the difficulty with the character limit as, “Once you have a patient that's been
here so long it gets hard to go into much detail on the handoff because you have to go back and figure out what to delete so that you
can keep going. You try to delete things that aren't necessary or try to abbreviate things.” The character limit thus also weakened the
potency of coordinating care because nurses had to expend effort in manipulating the content rather than simply focusing on
providing relevant information.
The potency of coordinating care with the Dear Staff feature was also reduced for nurses who were not adept at typing. Although
nurses were expected to use Dear Staff for handoff, some verbal communication was often necessary at shift change. Nurses with
weaker typing skills therefore took advantage of the opportunity to revert to giving just verbal report. “I'm busy and I have six
patients, I might give you verbal because I haven't had time to type it up…I will give verbal if I don't feel that I can type it up fast
enough.”
In summary, a system feature that was initially designed for general “off the record” communication by all medical staff was
appropriated by nurses to better enable the affordance of coordinating care. The decision to change was the result of a perceived
problem with the potency for coordinating care using face-to-face or tape recording handoff procedures. The new handoff procedure
using the Dear Staff function was more potent because nurses could generate the handoff report during their shift, which reduced the
overlap between shifts to enable coordinated care, and relevant handoff information was more easily accessible after the shift
transition. However, the limitations of the Dear Staff feature (e.g., 2000-character limit, free form nature of the textbox, no time
stamps on individual pieces of information) along with nurses' abilities (e.g. weak typing skill) had the effect of reducing the potency
of the affordance. Coordinating care was therefore actualized in different ways as conditioned by the potency of the affordance in use.
Potency was affected by the length of stay of patients, technical features of Epic, and the skills of the nurses actualizing the
affordance.
4.4. Medication pass and the affordance of validating medications
One of the important patient care tasks assigned to nurses on inpatient care units is the administration of medications to their
patients. At Urban Hospital this procedure was known as “medication pass” and was performed at four-hour intervals during the day,
beginning at 9 am. When physicians gave orders for patient medications, they were added to the patient's medication administration
record (MAR) and ordered from the hospital pharmacy. It was the MAR, included in the patient's chart, which nurses used to guide
their medication passes.
An important affordance for the medication pass process was validating medications. Before passing medications a nurse needed
to confirm that five criteria were present: right patient, right medication, right dose, right route, and right time. The right patient was
determined by the identification bracelets worn on the wrists of all patients during their hospital stays. Prior to Epic, the nurses were
expected to visually check the bracelet to confirm the patient's identity before passing any medications. The labels on the medications
were then visually checked against the information on the MAR to confirm the medication, dose, route, and time. Once a match on all
five criteria was confirmed, the nurse could then safely administer the medication to the patient.
With the implementation of Epic, the hospital moved to an electronic validation process for medication pass. Specifically, Urban
began using barcodes to uniquely identify both medications and patients, and the MAR was incorporated into Epic. The patient
identification bracelets were printed with a barcode, and the pharmacy applied a barcode to all medication doses that it dispensed.
This change was expected to strengthen the potency of validating medications because the computer would be able to verify the five
“rights” and inform the nurse if the medication pass was valid or not.
As described earlier, the mobile WOWs included barcode scanners to be used for medication pass, requiring the nurses on 3West
and 5South to take a WOW into the patient's room to administer medications. A 5South Nurse Coordinator explained, “Now I have to
go get the computer, look at the pain medication, go to the Pyxis [medication dispenser], and get the pain medicine. Then I have to go
back and get the computer, roll the computer into the room, scan the patient...” Compared to the prior process, the potency of
validating medications was weakened by the extra effort required to consult the WOW and maneuver it into the patient's room to
complete the medication pass.
Once at the bedside, nurses were required to first scan the barcode on the patient's identification bracelet, which automatically
opened that patient's MAR in Epic. Some of the nurses did not realize that they had to scan the patient before scanning the
medication, and this led to an early increase in system reports of non-compliance with proper scanning procedures. A nurse on CVICU
described the difficulties she had with the new medication pass process: “You go in and you scan the medicine and if you haven't
scanned the patient first it pops up a little box. If you scan the patient at that time, well then that still reports you as not scanning the
patient on their reports. So they write you up over it.” In such instances, the inflexible technology features led to error reports even
where no medical errors were made, which further reduced the potency of validating medications.
However, the benefit of the new system was that it alerted nurses to possible medical errors before they happened. After scanning
the patient first and then the barcode, the nurse received a confirmation from Epic confirming that the scanned medication was
correct. If any of the criteria were inaccurate, Epic was designed to display a flag to warn the nurse of the discrepancy. The warning
occurred even when an early medication was justifiable, according to a nurse on 5South: “I've done this before where the pain
medication was five minutes early. You can give a pain medication by nursing judgement five minutes early if a patient needs it, but it
[Epic] will alert you that it's too early.” Nurses had the ability to override the flag in order to continue with the administration of a
medication that they determined to be appropriate, but the flags also identified genuine errors that needed to be avoided. A CVICU
nurse explained that, “Once or twice I've been saved from making a medication error, nothing drastic, but I think it's prompted me by
saying that the amount has been changed or it was the right drug but they changed the dosage…So it's nice to know that it will catch
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those mistakes.” The system features therefore increased the potency of the affordance of validating medications, which resulted in a
reduction in medication errors.
The new procedures for medication pass became the standard at Urban Hospital, and nursing administrators tracked nurses'
compliance with the prescribed procedures through Epic's capture of system events. Since Urban was legally liable for medication
errors, nursing administrators realized greater control by preventing deviations from Epic's mandatory work process. The CNO
explained the hospital's policy on compliance with the medication pass procedures:
“There's only one way to do barcode med administration and the policy says you have to do it at the bedside, so people who don't
do that are automatically in the discipline system. Now there are some exceptions to that in an [emergency] code situation or if
the scanners are down, but every month I get a report and so does every manager and every director. And I can tell every nurse in
this hospital how many doses of medication they gave, how many times they bar-coded the medicine and how many times they
bar-coded the patient. So if people are in what I call the 50/50 club, we have a very different conversation than the 95/5 club.
Meaning 95% of the time I did it versus 50%. We gave them some leeway in the beginning, they were learning, but now, if you're
in the 50/50 club, you're probably not going to have a very long tenure at [Urban] Hospital.”(Chief Nursing Officer)
The goal of 95% compliance conceded that there would be occasional circumstances that necessitated a deviation from the ideal
standard of 100% compliance, but exceptions were to be limited. However, there were a number of issues with the scanning process
that made some of the nurses feel that even 95% compliance was unrealistic.
One example, noted above, was inflexibility of the system to deal with the case of nursing judgement to give pain medications as
needed instead of at a specific time. A 5South nurse explained, “It [the prescription] says you can have ‘one to two’ tablets and you
just give them one and then three hours later you're going back to give them the second one. It's still within their time where they can
get the second one, but because it's a new scan of the same medication, it's coming up saying that it might be too early.”
The issue of timing also pertained to the administration of IV-based medications where adjusting the flow of the medication could
throw off the timing of subsequent doses. The pharmacy entered times for each dose, usually every hour from the start time, but as a
3West nurse explained, “Inevitably we'll never get it done because we'll have to decrease it and give it over two hours instead of one
hour so then it makes the meds late and overdue…and I don't think there's a way of getting around it because Epic won't allow you to
not time it.” In other words, the inflexibility of Epic to enable adjustment in medication timings by nurses on the unit had the effect of
reducing the potency of validating medications by generating inappropriate errors.
Another issue in the new medication pass process was that in some cases, the packaging of the medications made it difficult or
impossible to scan the barcode. For examples, many medications were prescribed as one or two pills that were packaged in a small
wrapper that was smaller than the barcode label. This made it difficult or impossible to scan the barcode. Also, bagged medicines
might crinkle the barcode because the container was soft and pliable. A 3West nurse stated: “So you know some of our meds won't
scan and we get dinged for pharmacy not being able to label it correctly.” Here, the physical characteristics of the medications
themselves had a weakening effect on the potency of validating medications, making it harder to achieve the goal of 95% compliance
with the medication pass standard.
In some cases, nurses intentionally bypassed the scanning process because they felt that following it would negatively impact
patient care. A nurse explained her decision to bypass the scanning process, “if you're in a hurry and it's an emergency you just give
the med, you don't worry about the scanning stuff. You take care of the patient before you do the computer.”
The system features that enabled medication pass and the affordance of validating medications were relatively modest (bar code
scanners), and they were relatively easy to employ as long as the WOW carts could be moved close enough to the patient. Even so, the
potency of the affordance depended on the ability of nurses to obtain clean scans and follow the exact process as regulated by Epic.
Since nurses needed to vary the timing of medication administration in the interests of patient care, minor deviations (5%) were
tolerated, but nurse administrators clearly did not tolerate nurses that regularly worked around the affordance of validating
medications. Validating medications thus enabled both nurses' goals to administer medications accurately and administrators' goals
to reduce liability for medication errors.
5. Discussion
As formally defined earlier, affordance potency is the strength of the relationship between the abilities of the individual and the features
of the system at the time of actualization, conditioned by the characteristics of the work environment. We selected three work practices and
one of the affordances within each of those work practices from our study to illustrate the concept of affordance potency. Table 3
summarizes our results for the affordances of documenting care, coordinating care, and validating medications and notes
characteristics of system features, user abilities, and the work environment (context) that either strengthened or weakened the
potency of those affordances along with representative quotes.
We started with the work practice of charting and the affordance of documenting care. The potency of documenting care was
intended to be strengthened through the implementation of Epic where information was accessible on multiple devices instead of
being limited to a single paper chart. In practice, however, the potency of documenting care varied from nurse to nurse based on their
relative ability to manipulate the electronic record and the ease with which they shifted attention between providing direct care to
patients and recording the delivery of that care. The technology itself was also varied in its influence. The computer login process
took extra time and also fluctuated based on the network load, and it always took longer to get into the system to find information
that it would have taken to flip open the paper chart. The environment also impacted the potency of documenting care. The
administration's expectation was for nurses to document care at the bedside, but patients' perceptions regarding care could alter the
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Table 3
Affordance potency at urban hospital.
Affordance
Documenting care
Coordinating care
Validating medications
Features that
strengthen potency
Abilities that
strengthen potency
Context that
strengthens
potency
Mobility of WOWs, flexibility of Epic
software
Strong typing skills, comfortable with
technology, skilled at patient care
Support from supervisors
Consistency of system to evaluate the five
rights
Familiarity with scanner and scanning
procedures
Expectation of compliance by
administration
Examples of
strengthened
potency
“I can chart right there when I′m in the
room as opposed to when we did paper
you'd have to remember, write something
down and then go and chart it.” (3West
Nurse)
Dear Staff feature accessible at any time,
“off record” capability
Strong typing skills, comfortable with
technology
Transitions between shifts are unpaid for
either the incoming or outgoing nurse,
clear expectations for structuring handoff
report content
“You never have to go through the same
story over and over again. You just have to
update. … I mean tape recording would
sometimes take 45 min and now updating a
handoff takes a few minutes.” (3West
Nurse)
Features that weaken
potency
Slow login, bulkiness of WOWs,
complexity of software
Abilities that weaken
potency
Context that weakens
potency
Weak typing skills, discomfort with
computers, discomfort with patient care
Patients that see the technology as a
barrier
Examples of
weakened potency
“It takes a lot longer sometimes to get
things done in an EMR than it does to
have that piece of paper that I can set on
the bed and put my check marks
on…Typing skills are huge. If a person
knows how to touch type they went
through much less distress than if it's a
person that hunts and pecks.” (Clinical
Team Lead)
Freeform structure and character limit of
Dear Staff textbox, open editing with no
time stamps of Dear Staff textbox
Weak typing skills, preference for verbal
communication
No fixed standards for content structure of
handoff report, no restrictions on reverting
to verbal handoff
“Once you have a patient that's been here
so long it gets hard to go into much detail
on the handoff because you have to go back
and figure out what to delete so that you
can keep going. You try to delete things
that aren't necessary or try to abbreviate
things.” (5South Nurse)
“I went to give a medication, I looked at
the medication, it sounded like, looked
like, acted like, but it was the wrong
medication. I went and scanned it and
[Epic says] there is no medication for this
… This is what they call a near miss! … the
computer just saved me from making a
med error.” (3West Nurse)
Rigidity of system to not accommodate for
nursing judgement, cluttered patient
rooms
Unfamiliarity with med pass procedures
Barcodes not always scan able, variations
in timing of med delivery
“So you know some of our meds won't scan
and we get dinged for pharmacy not being
able to label it correctly.” (3West Nurse)
nurse's decision to adhere to that expectation. These variations in the actualization of the affordance of documenting care can be
understood through the concept of affordance potency. At each moment of actualization the current state of the system's features, the
abilities of the nurse, and the environment come together to produce the potency of the affordance.
Coordinating care was the focal affordance within the work practice of handoff, which was enabled through Epic by nurses'
appropriation of the Dear Staff feature. The Dear Staff feature was attractive because of the limited potency of coordinating care
through either verbal handoff or tape recording. The Dear Staff system feature was not designed for the handoff process, but the
nurses found that it would more effectively enable their goal of maintaining quality care across shifts while minimizing the time
required to transfer necessary information between shifts. Here the potency of the affordance of coordinating care was shaped by the
material characteristics of the Dear Staff feature (e.g., a 2000-character limit, freeform structure, only one instance per patient), the
abilities of the nurses (e.g., typing skill and different ways of structuring information in the freeform textbook), and the environment
(e.g., time constraints to fill in the textbox before shift change). Once again, the actualization of the affordance, in this case
coordinating care, was influenced by the variations in potency of the affordance.
The barcode-based medication pass process was designed to function within a set of standardized parameters to maximize the
affordance of validating medications, but those parameters were not always aligned with use in practice. Deformed labels made it
impossible to scan some barcodes, and timing issues with certain medications produced errors that showed up as non-compliance on
administration reports. In some cases, errors resulted from misunderstanding how to perform the barcoding process (e.g., the
requirement to scan the patient's ID before scanning a medication), but in other cases nurses deliberately chose to bypass the barcode
system if they felt that patient care would be compromised (e.g., when the patient required pain medication before a scheduled time).
However, since barcode scanning was associated with a reduction of potential medication errors, as detected by Epic, the potency of
validating medications generally met nurse's goals to provide accurate patient care.
Our aim in this research is to offer a more complete explanation of affordance actualization. Clearly, technology features are
subject to a range of actualizations across users and work environments, previously reported in the IS literature as workarounds or
unintended consequences (Azad & King, 2008; Harrison, Koppel, & Bar-Lev, 2007). Our evidence affirms that affordances can be
actualized in a variety of ways by users seeking to attain specific goals. However, users' goals and perceptions must be understood in
relation to specific technology features, users' abilities, and the wider organizational context in which technologies are used.
While previous studies have generally treated affordances in binary fashion (McGrenere & Ho, 2000), our study reveals the
importance of an additional concept that we have labeled affordance potency. Rather than simply being either available or
unavailable for actualization based on the perceptions and goals of the user, affordances are available at different levels of potential
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Fig. 2. A Model of Affordances (shaded elements are the focus of this research).
based on the current state of implemented system features and the user's abilities within the actual context of use. For example,
documenting care using Epic was improved through the availability of WOWs that enabled documentation at the bedside, but was
also influenced by user abilities (e.g., typing skills) and the context in which the activity occurred (e.g., caring for patients and
meeting their expectations for attention). The potency of documenting care was limited due to the physical requirement to access an
available workstation and log in; yet it enabled greater efficiency in accessing patient charts and updating them. Handoff also varied
in its potency to enable the affordance of coordinating care based on the amount of information to be conveyed for each patient.
Because of the character limit in the Dear Staff feature that nurses appropriated for handoff, a variety of actualizations were observed
with different results. For example, some nurses reverted to verbal handoff because their typing skills were weak while others
expressed confusion about the timing of Dear Staff entries made during the prior shift. These limitations in potency could be traced to
both human abilities and technology features.
Validating medications was perceived to be a high potency affordance of the barcode-based medication pass process because
nurses and administrators expressed confidence that the system could catch medication errors. System features imposed discipline on
the work process of administering patient medication, with a resultant reduction in potential errors. Nonetheless, the strict discipline
could be bypassed by nurses who did not understand the system or by nurses who chose to administer dosages (e.g., pain medication)
over a longer time period than authorized by Epic. Variability in the quality of the barcodes and the need to get a barcode scanner
close enough to the patient also reduced potency and frustrated nurses' attempts to provide adequate patient care while meeting
hospital standards for compliance with required practices.
To encapsulate our insights, we construct a conceptual model of affordances, as shown in Fig. 2. The left side of the model depicts
how technology is typically designed and constructed to achieve a particular purpose, which is to enable a set of planned affordances
that are a relationship between designed system features and anticipated user abilities within an expected context. For example,
designers of Epic sought to enable the affordance of validating medications through the development of algorithms that work with
barcodes and the electronic MAR to verify the five “rights” of medication pass. Designers envision their system resulting in the
consistent actualization of that affordance when used by an imagined “typical nurse” with the ability to use the barcode scanners in
the prescribed way within a clinical context where hospital administrators have established standards for medication pass behaviors.
However, situated affordances may vary significantly from planned affordances because of differences in the way system features are
implemented and variations in the abilities of real users within the actual work context. In particular, these situated affordances, as
behavioral opportunities for action, possess a potency that is a product of that variability which, in addition to user's perception and
goals, influences the actualization of those affordances.
The horizontal arrows in Fig. 2 represent sequential relationships, not causal dependencies. They simply suggest the order in
which IS solutions are typically designed prior to actual use, and that affordances are actualized through the milieu of work practice.
This is, therefore, a process model rather than a variance model in which elements to the left are necessary but not sufficient
precursors of elements to the right. The solid vertical arrows within the left and center boxes of the diagram represent the components
of affordances at each stage of the model where together, system features and user abilities form affordances within a context of use.
In addition, while planned affordances could be conceptualized as possessing potency (e.g., arguments could be made that one
designed system feature will lead to a more potent affordance than another designed system feature), only situated affordances
possess potency in the context of actual work practice. The dashed vertical arrows in the right-hand portion of the diagram illustrate
that, in addition to potency, actualization of situated affordances are influenced by user perception and goals as theorized in prior
research (Norman, 1988; Strong et al., 2014).
Consequently, actualizations may deviate from intended outcomes as users vary their work practices in response to changes in
system features (Leonardi, 2011, 2012). Such deviations are often reported as reinventions, tweaks and workarounds in IS research
(e.g., Boudreau & Robey, 2005). The concept of affordance potency contributes to studies of unintended use by tracing the
antecedents of variant practices back to the relationship between user abilities and system features. Given that the social context of
use (work practices) help to shape user goals, resulting appropriations of IT features can be better understood as the actualization of
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affordances with greater or lesser potency.
As shown, our model does not represent a complete theory of work practice or IT-related organizational change. Rather, it is a
mid-range theory similar to that provided by Strong et al. (2014). Such mid-range theories might be fit into more encompassing
theories that are already used in IS research. For example, routines (Pentland & Feldman, 2008); learning (Boudreau & Robey, 2005),
and imbrication (Leonardi, 2011) have all been used to explain how changes in IT affect work practices. Rather than extend our
analysis outward to any one of these theories, our contribution is to develop further the “affordance module” that focuses on the
potency of affordances that are referred to in a variety of theories. We specifically augment the affordance actualization theory of
Strong et al. (2014) by adding the concept of affordance potency, a concept that helps to explain more completely how and why
specific affordances are actualized within the context of work practice.
6. Conclusions
Through a qualitative case study of EMR use on three hospital patient care units, we illustrated the elements of affordance theory
and assembled a model explaining the progression from intended design based on expected social context, to actual social context,
and to affordance actualization. By invoking the novel concept of affordance potency, we contribute to the nomological network
needed to understand the position of affordances in changing work practices. We used three specific affordances to demonstrate the
process of affordance actualization as articulated in prior research (Strong et al., 2014). As a mid-range theoretical contribution, the
nomological network of affordances may be incorporated into grander theories (e.g., organizational learning, routines, politics) to
explain IT-related organizational change.
Although our analysis depends on qualitative research methods, our ontological assumptions are realist in nature; we do not
ascribe to a purely interpretive approach. Accordingly, the research method includes direct engagement with the EMR artifact and
associated hardware (e.g., WOWs, barcode scanners) in the physical work setting. We combined this engagement with the technology
with methods designed to elicit nurses' and administrators' experiences with that technology. Through interviews and observation, we
obtained detailed accounts of changes in work practices. This inclusive approach to collecting data allowed us to theorize about the
relationship between the IT artifact and its social context, which is inherent in our concept of affordances.
The study is not without limitations. The data for this study were collected during a single month period and relied in part on
retrospective accounts of work practices and other activities occurring prior to the data collection period. Although perceptions and
interpretations may change over time, Leonard-Barton suggests that, “studies have shown that the participants in organizational
processes do not forget key events in these processes as readily as one might suppose” (1990, p. 250). Given the salience of EMR
implementation at Urban Hospital, we do not regard this limitation to be serious enough to invalidate our analysis. Nonetheless, a
true longitudinal research design could result in more accurate accounts of events as they occur. Leonardi's (2012) ethnographic
study is exemplary in this regard.
Affordance theory is clearly undergoing development rather than being fully formed. We traced the relevant controversies in
ecological psychology to gain a sense of issues that need to be addressed in IS research. Based on our review of this literature, we
adopted the relational view of affordances that appears to be favored in IS research (Robey et al., 2013; Strong et al., 2014). Our data
permit detailed analyses of relationships between human abilities and technology features, thus affirming the value of this relational
concept. However, affordance theory needs to be refined through future research in different types of work settings. Since IS
researchers are advantageously positioned to understand IT artifacts, we see a great opportunity for them (as opposed, say, to less
technically savvy social scientists) to develop affordance theory further. Advancing affordance theory would help IS researchers to
theorize the IT artifact more directly than has been the case in past research (Orlikowski & Iacono, 2001).
Our study offers implications for practice. Specifically, the insights regarding affordance potency may assist healthcare
administrators and clinical decision makers in their evaluation of new information systems for their organizations and the policies
they implement regarding the use of those systems. Taking an affordance perspective should lead to an evaluation of possible changes
in work practice enabled by the system in conjunction with clinicians' skills. Studies often show that end users adjust their work
practices in both intended and unintended ways (Markus & Robey, 2004), suggesting that a closer awareness of the adjustments to
work practice deserves scrutiny. First-line supervisors, in particular, would benefit from sensitization to affordances that emerge from
the relationship between human skills and technology.
In addition, we focus on a neglected category of the healthcare workforce: nurses. Most IS studies in healthcare organizations have
focused primarily on physicians and their use of health information technology (Davidson & Chismar, 2007; Kohli & Kettinger, 2004;
Reardon & Davidson, 2007). However, nurses are typically hospital employees (as opposed to physicians who practice privately), and
their work is subject to monitoring and evaluation. We found that the Epic system generated data useful to hospital administrators
regarding medication pass, suggesting the greater role played by EMR beyond direct patient care. While our focus is not on
organizational-level affordances, we detected some tension between the goals of nurses to provide effective personalized care to their
patients and the goals of the hospital to exert control over medical care more broadly by monitoring staff compliance with Epic's
procedural disciplines. Future research could examine how well individual actualizations of affordances align with the goals of the
organization (Strong et al., 2014). Advances in healthcare are associated not only with improvements in clinical outcomes but also
with organizational efficiencies related to human resource management and patient workflow.
Appendix A
Nurse
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• What are your work roles and responsibilities?
• Describe the current system and your use of the system.
• How much experience have you had with the system?
• Have you had experience with similar systems? If so how does the current system compare to those systems?
• What kind of training have you received on the current system? Was it sufficient?
• What features or functions do you use the most?
• Are there features of the system you are aware of but don't know how to use?
• Are you satisfied with the current system? Why or why not?
• Does the system function in the way it is supposed to? If not, what functions do not work properly?
• Are there features not currently available that you would like to see in the system?
• How has the implementation of this system affected work on the patient care unit?
• How has the implementation of this system affected the users?
Administrator
• What are your work roles and responsibilities in relation to the system?
• Why did you purchase a new system?
• Describe the process that was used to select the current system.
• What systems did you consider when making the selection?
• Why did you choose the current system? Where there any features which were particularly important in the selection process?
• How important was ease of use and training requirements in the selection decision?
• Are you satisfied with the current system? Why or why not?
• Are the users satisfied with the current system?
• How has the implementation of this system affected the patient care unit?
• How has the implementation of this system affected the users?
Support Personnel
• What are your work roles and responsibilities in relation to the system?
• What kind of training have you received on the installed system?
• How would you describe your understanding of the system?
• Describe the system and its installation.
• Describe the user training for the system.
• Describe the current maintenance of the system.
• What features of the system are most important for users to know about and use?
• Are there particular features that users have more difficulty understanding and using?
• Does the system have any recurring problems?
• Are there features the system does not have that users have asked for?
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