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Authority as an interactional achievement: Exploring Deferenceto Smart Devices in hospital-based resuscitation

Citation for published version:Patel, M, Hartswood, M, Webb, H, Gobbi, M, Monger, E & Jirotka, M 2017, 'Authority as an interactionalachievement: Exploring Deference to Smart Devices in hospital-based resuscitation' Computer SupportedCooperative Work (CSCW), vol 26, no. 4-6, pp. 489–525. DOI: 10.1007/s10606-017-9274-0

Digital Object Identifier (DOI):10.1007/s10606-017-9274-0

Link:Link to publication record in Edinburgh Research Explorer

Document Version:Peer reviewed version

Published In:Computer Supported Cooperative Work (CSCW)

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http://dx.doi.org/10.1007/s10606-017-9274-0

https://www.research.ed.ac.uk/portal/en/publications/authority-as-an-interactional-achievement-exploring-deference-to-smart-devices-in-hospitalbased-resuscitation(ae9652a7-3089-4256-a014-9c6ef2c0e316).html

Authorityasaninteractionalachievement

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Authorityasaninteractionalachievement:ExploringDeferencetoSmartDevicesinHospital-BasedResuscitation.MenishaPatelPhD,BA,ResearchAssociateWolfsonBuilding,DepartmentofComputerScienceUniversityofOxford,[email protected],MSc,BSc(Hons)(CorrespondingAuthor)SeniorResearcher,WolfsonBuildingDepartmentofComputerScience,UniversityofOxford,OX13QD01865270550Fax:+44(0)[email protected],MA,BA(Hons),SeniorResearcherWolfsonBuilding,DepartmentofComputerScienceUniversityofOxford,[email protected],PhD,MA(Ed),DipN,DipNEd,RGN,ProfessorialFellow(NursingEducation)FacultyofHealthSciences,UniversityofSouthampton,SO171BJ,[email protected](Hons)RGNFHEA,LecturerinCriticalCareNursingRoomE3013Building67,FacultyofHealthSciences,[email protected],MSc,BSc,ProfessorofHumanCentredComputingWolfsonBuilding,DepartmentofComputerScienceUniversityofOxford,[email protected]


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1 AbstractOvertheyears,healthcarehasbeenanimportantdomainforCSCWresearch.Onesignificantthemecarriedthroughthisbodyofworkconcernshowhospitalworkerscoordinatetheirworkbothspatiallyandtemporally.Muchhasbeenmadeofthecoordinativerolesplayedbythenaturalrhythmspresentinhospitallife,andbywebsofmundaneartefactssuchaswhiteboards,post-itnotesandmedicalrecords.ThispaperdrawsuponthecoordinatingroleofrhythmsandartefactstoexplorethenestedrhythmsoftheCardio-PulmonaryResuscitation(CPR)protocolconductedtorestoretheproperheartrhythminapatientwhohassufferedacardiacarrest.WeareinterestedinhowtheteamsdeliveringCPRusevarious‘smart’assistivedevices.ThedevicescontainencodedversionsoftheCPRprotocolandareabletosense(inalimitedway)thesituationinordertogiveinstructionsorfeedbacktotheteam.Usinganapproachinformedbyethnomethodologyandconversationanalysis(EM/CA)weanalysedvideooftraineenursesusingthesedevicesastheydeliveredCPRindramatizedtrainingscenarios.Thisanalysishelpedustounderstandconceptssuchasautonomyandauthorityasinteractionalaccomplishments,thusfillingagapinCSCWliterature,whichoftenglossesoverhowauthorityisformedandhowitisexercisedinmedicalteams.Italsohelpsusconsiderhowtorespondtodevicesthatarebecomingmoreactiveinthattheyarebeingincreasinglyimbuedwiththeabilitytosense,discriminateanddirectactivityinmedicalsettings.

2 KeywordsAuthority,Autonomy,Resuscitation,TeamWork,SmartDevices.

3 IntroductionThispaperexplorestheuseoftwoSmartDevicestoassistwiththeresuscitationofpatientswhohavesufferedacardiacarrest,andexaminesinclosedetailhowtheyhavethecapacitytobothdisturbandassistexistingpractices.Weadoptanin-depth,qualitativeapproachtoexaminethepracticaluseofthesedevicesinsimulatedresuscitationscenarios.Ouranalysisdemonstratesthatthesedevicesplayaninteractionalroleintheongoingsimulation,and,thatinsomeinstancesanasymmetryisconstructedinwhichthedevicemightbeseentoexert‘authority’overteamsofnursesdeliveringbasiclifesupport.ThisopensupquestionsaroundautonomyandauthoritythatareimportantbutrarelydirectlyaddressedwithintheCSCWliterature,particularlyinthecontextofhealthcareteams.Aswithotherwalksoflife,SmartDevicesarebecomingincreasinglypervasiveinmedicalsettings.AutomatedExternalDefibrillators(AEDs)andSmartInfusionPumpsarealreadycommonplace.Increasinglysophisticateddevicesarebeingrolledout,suchasSmartBedsthatcanmonitorapatient’svitalsignsandintelligentlyadapttotheirposture.ThereareseveraldriversfortheincreasinguseofSmartTechnologiesinhealthcare.Forexample.,automationisseentoprovideawayofmeetingthepredictedincreaseddemandforcareoftherapidlyagingpopulation1.SmartDevicespromisealsotoimprovetheeffectivenessofhealthcare,orpromotewellbeingviatheparadigmofubiquitoushealth(e.g.Orwatetal.,2008).Harmreductionprovidesafurthermotivationtodevelopintelligentsystemsabletomonitordrugdosesandcheckforadverseinteractions(e.g.Rothschildetal.,2003;1http://www.extremetech.com/extreme/207130-terapio-autonomous-medical-robot-can-assist-nurses


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Ammenwerthetal.,2008).Finally,commercialinterestspresumablyplayaroleindrivingattractiveproductenhancementsasanincentivetorenewandupgradeexistingequipment.WhilethereareundoubtedlypositivebenefitstoinnovativeSmartDevices,therearealsopotentialnegativeeffectsinrelationtopatientsafety,theintegrityofteamwork,professionalroleandidentity,andthevaluesattachedtocare(CummingsandMcGowan,2011;ElginandBergero,2015).ThefirstdevicethatweinvestigateisanAutomatedExternalDefibrillator(AED)whichisabletodetectandcorrectanabnormalheartrhythmbydeliveringanelectricshock.AEDswereoriginallydesignedtosupportalaypersonindeliveringCPRinpublicplaces,butarenowincreasinglyreplacingmanualdefibrillatorsinhospitals.ThesecondisaprototypeSmartWatchapplication,whichwasdevelopedwithinourprojecttoprovidefeedbackabouttherhythmandcorrectdepthofchestcompressionsasCPRisadministered.Thecontextforourstudyisasimulatedhospitalsettingwheremultidisciplinaryteamsinteracttoperformresuscitationaspartofatrainingsimulationforstudentnurses.The‘patient’isarobotknownasSimMan®2.Weusethissettingtoexamineindetailtheinteractionsbetweenthenurses,amoreexperiencedpractitionerandthetwokeySmartDevices.Teamresuscitationinhospitalsisapressuredandemotionallychargedactivitywherethetimingandqualityofinterventionsiscriticaltopatientsurvival.ResuscitationinvolvesenactingastandardisedUnitedKingdomandEuropeanprotocol(ResuscitationCouncil2015)andistypicallyconductedbyad-hocteamsformedatthemomentacardiacarrestisdiscovered.Deliveryoftheprotocolrequiresintricatelevelsofcoordinationbetweenteammembers,whohavetoestablish,maintainandrenegotiaterolesspontaneouslythroughouttheprocedure.Effectiveleadershipwithinthesead-hocteamshasbeenassociatedwithimprovedCPRoutcomes.Whiletheprotocolhasanunderlyingrhythm,itisalsocomplexandincludeselementsofrepetitivephysicalactions,monitoring,evaluationandproblemsolving.TheclinicaldecisionmakingprocessespromotedbytheCPRalgorithmmaynecessitatefurtherconcurrentactivity,somedrivenbyfurtheralgorithms,toaddressunderlyingorassociatedclinicalproblems;forexample,ifapatientisdiscoveredtobehypothermic,diabetic,orseptic.Machines,equipmentanddevicesareintegraltotheperformanceofhospital-basedresuscitation.Theyfeatureintheteamchoreographyincomplicatedways,sometimesservingmoreasaproptohelpmaintaintheflowofactivity,andatothertimesmoreprominentlyasanactorexertingauthorityoverthesituation.Bytakingafine-grainedqualitativeapproachouranalysisisabletoidentifytheintricatewaysinwhichteammembersincorporatetheSmartWatchandAEDintotheirongoingactivities.Inthispaperweillustratetwophenomenaofparticularinterestanddiscusstheirimplicationsforpractice.InthefirstweobserveascenarioinwhichagroupofstudentnursesorienttoaSmartDeviceinwaysthattreatitashierarchicallysuperiortotheirownactionsandlikelyunderstandingoftheresuscitationprotocol.Thisorientationhastheeffectofdivertingthestudentsfromdeliveringacomplicatedprotocolthattheyareonlyjustbeginningtogettogripswithandcreatingtroubleintheongoingactivity.InthisinstancetherearemissedopportunitiesfortheDevicetoprovide‘appropriate’cuestoassisttheactivityasacompetentprotagonistinthesuccessfulaccomplishmentofresuscitation.Inthe

2http://www.laerdal.com/gb/doc/86/SimMan


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secondphenomenonofinterestanursepractitionerplayingtheroleofadoctorinthesimulationarrivesonthesceneandoverrulestheinstructionsvoicedbytheAED.AdifferentkindofhierarchyisconstructedandalltheteammembersultimatelyinteractwiththeDeviceinaverydifferentwaythanobservedinourfirstscenario.Thenurses’asymmetricalrelationshipwiththeDeviceischallenged;newformsofinteractingwithitareopenedupandlegitimised,perhapstobedeployedbythenursesinfutureencounters.Ouranalysisofthedataisinformedbyinsightsfromethnomethodologyandconversationanalysis(EM/CA).WethendrawonthesefindingstodiscussbroaderconceptsconcerningtheenactmentofauthorityandautonomyinthedeliveryofCPR.ThisincludestheroleplayedbySmartDevicesor‘activeartefacts’(CarbitzaandSimone,2009)intheconstructionofasymmetriesinthesetting.Weconcludewithdesignprinciplesfordevices,protocolsandtrainingtoreducethecounter-productivedisruptivepotentialofthedevices.

4 Background:Rhythms,TemporalityandTeamworkOvertheyears,healthcarehasbeenanimportantdomainforCSCWresearch(FitzpatrickandEllingsen,2013).Onesignificantthemecarriedthroughthisbodyofworkconcernshowhospitalworkerscoordinatetheirworkoverspaceandtime.Muchhasbeenmadeofthecoordinativerolesplayedbythenaturalrhythmspresentinhospitallife,andbywebsofmundaneartefactssuchaswhiteboards,post-itnotesandrecords.Atfirstglance,manyfeaturesofthisearlierworkarevisibleintheworkofemergencyresuscitation.ThesequenceofactivitiesspecifiedbytheCPRprotocoloccurinaseriesofnestedrhythmsthatalsoplayanorganisingroleinthatthereare‘naturalpauses’whereinformationmaybegathered,tasksinitiatedandrolesexchanged.Artefactsplayanimportantcoordinativeroletoo.Hospitalbasedresuscitationinvolvesawiderangeofequipment,drugsandotherartefactswhicharepre-organisedandpre-arrangedinaStandardOperatingConfiguration(BardramandBossen,2005)sothattheyareeasilyandconvenientlyavailableasandwhentheprotocoldemandstheybeused.Butthereareanumberofdifferencestoo.TherhythmsofCPRoperateovermuchsmallerspatialandtemporalscalesthantherhythmsconsideredbyReddyetal.(2006),witheachcycleofcompressionsandbreathstakingonly30secondstocomplete,andwithanaverageresuscitationeventlastingonly20minutesintotal.Moreover,previouslyconsideredrhythms,suchaswardroundsorlabresultavailabilityareanemergentpartofthehospitallife-world,andtheirproductionismoreorlesstakenforgranted.WithCPR,theproductionandperpetuationoftherhythm,andinparticular,thefidelitytotheprotocol,isacrucialfeatureofresuscitationandcriticalforthesurvivalofthepatient.Workfocussingspecificallyonresuscitationpracticeshasconsideredissuesoftemporality,forexample,KusunokiandSarcevic(2015)considertherequirementsoftemporalawarenessinatraumaresuscitationteam.Theyfindthatperceptionoftimemaybedilatedorcompressedduringthefast-pacedactivityofresuscitationandidentifyhowteammembersorienttotemporalawarenessforstagingofprocedures,assessingteamperformanceandtheoverallprogressoftheresuscitationattempt.Dynamicallyformedad-hocmedicalteamsrespondingtourgentoremergencysituationshavealsobeenconsideredintheCSCWliteratureintermsoftheirconstitutionandcommunicationrequirements.Lee


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etal.(2012)observethatsuchteams,aswellasbeing‘ad-hoc’,arealso‘looselyformed’,withteammembersjoiningandleavingwhiletheteamisactive.Badram(2000)analysesthetemporalcoordinationofinterdependentactivitiesoccurringwithinsurgicalteams.Oneaspecthedrawsoutpertainstodynamicteamwork,which,is‘characterisedbycontinuoussynchronisationofthemanyactionsandactorsinvolved,accordingtotheconcreteconditionsinthework’(pp.165).Thisfocusonco-locatedactorsworkingsynchronouslywithinateamcentreduponthepatientcomesclosertothesituationofresuscitationwithinourstudy.Inthiscontext,Bardramidentifiesthreetypesofcoordinationactivities:Communicativecoordination(viautterancesorgestures);Instrumentalcoordination(basedupontheawarenessofactivitiesofothers)andScriptedcoordination(viaasharedscheduleorprotocolwhichallorientto).Inasimilarvein,Pine’s(2012)studyofchoreographyinmidwiferyidentifiesdiscrete‘choreographypractices’–Moving(bodymovements,glancesetc.),Synching(interleavinge.g.documentationwithothertasks),Juggling(simultaneouslyperforminganumberoftasks),Prepping(anticipatingfuturetasksandorganisingthecurrentworkspacetomaketheseeasier),Collaborating(mutualassistancebetweennursesandanongoingre-divisionoflabour),andTriaging(continuousassessmentoftheimportanceoftheseparatetasksthatneedtobeattendedto).However,aspectsofleadershipandauthorityare,forthemostpart,absentinmanyofthedepictionsofteamcoordinationandchoreographypresentintheCSCWliterature.Thisisstrangeasitrisksimplyingthattheteammembersplayanequivalentroleinperformingorinitiatingactivitiesatalltimes.Itisasif,withinthesestudies,wearecontinuallypointedtothesynchronisedperformanceoftheorchestraplaying,butnevershowntheworkoftheconductorwholeads.OneexceptionisSarcevicetal.(2011),whohasexploredthenatureofleadershipinthecontextoftraumateams,observingdifferentmodelsofsharedleadershipwithintheirextensiveethnographicvideocorpusoftraumaresuscitations.Whilstwecanfindinourcasestudyseveralofthecoordinativepracticesoutlinedabove,wegobeyondthesetoexplorehowthetaskstobeaccomplishedaregiventheirrelativeimportancesothatprioritymaybeassigned,andhowdeterminingthisrelativeimportancecanbeseenaspartoftheinteractionalaccomplishmentofauthoritywithinthesesettings.

4.1 PerspectivesonProfessionalAuthorityandProtocolsWhilstissuesaroundauthority,andrelatedconceptssuchasautonomy,havenotbeenfrequentlydiscussedintheCSCWliterature,theyhavebeendiscussedelsewhere,particularlyinrelationtoprotocolsandguidelines(suchastheCPRprotocol)thatservetoguidepractice.Conceptsofautonomyandagencyarealsoimportantwithinthenursingprofession,asnursingcontinuestoseekitsownprofessionalidentitytoovercomebeingdefinedasa‘serviceprofession’todoctors(e.g.Weston2008).Newtechnologiesarefrequentlyperceivedasathreattoprofessionalauthority,particularlywheretheyenhancesurveillance(Eplingetal.,2003)ormandateclinicalprocess(Kentetal.,2015).However,suchfearsarenotnewandhavebeenexpressedbeforeinrelationclinicalguidelines,evidence-basedmedicineanddecision-aids.Yetinpracticetheseinnovationshavebecome


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widelyestablishedwithoutsignificantlyunderminingprizedandguardedprofessionalauthorities.Onereasonforthis,TimmermansandKolker(2004)argue,isthatthereneverexistedasingleunambiguoussetofpowerrelationshipsforprotocolsandguidelinestoruleover.Instead,thereisawholemessoftemporallyevolving,heterogeneous,institutionalandprofessionalsourcesofclinicalknowledge,anddisparatefoundationsforlegitimatedecision-making,allavailablesimultaneouslywithintheclinicalprofessions(ibid).Fromarelationalviewofautonomy(Donchin1995;McDonald2002),guidelinesenterthisnexusasyetanotherresourceforactionthatmaypreserveexistingauthorities,asmuchasdisplacethem,whichcanbeseeninhownursesutiliseprotocolsasaresourcetolegitimisetheirowndecision-making(ManiasandStreet,2000).Whileasingulartargetforanyauthoritarianeffectofguidelinesremainselusive,sodoesthelocusofpracticeasasiteofauthority:

‘Theillusionoftotalbureaucraticsupervisionandcontrol,prevalentintoomanytales(bothdystopianandutopian),isachimera:themultiplicitiesandcontingenciesembeddedintheworkingsofaprotocolcannotthemselvesbecontrolled.’(TimmermansandBerg,1997)

TimmermansandBerg(1997)showhowtheactiveparticipationofpractitionersisessentialtoanimateguidelinessotheyareabletoinfluencepractice.Thustheveryauthoritythatguidelinesseemtothreatenisactuallypartofwhatallowsthemtoworkinthefirstplace,preciselybecausetheclinician’sdiscretionaryinterpretationisneededtoadapttheletteroftheguidelinetothenon-complianteverydaycircumstancesinwhichtheguidelineswouldotherwisestruggletofunction(ibid).Insummary,thispriorworksuggeststhatweshouldseeauthoritiesasrelational(shapedbycircumstanceandcontext),asmultiple(jostlingtogetherinadynamicthatevolvesovertime)andasmutuallyinterdependent(oneauthoritydependingontheexerciseofanotherforitsrealisation).WereturntotheseissueslaterinthepapertoconsiderwhathappenswhenprotocolsareassertedbySmartDevicesviaarangeofinteractionalcapabilities,asopposedtobeingrepresentedonpaperinadocileway.

5 ResuscitationandTrainingInthissectionwedetailresuscitationeventsincorporatingAEDsinparticular,andweofferacontextualbackgroundtosomeofthekeyfactorsassociatedwithresuscitationpractices.Cardiacarrestisarelativelyrareevent,andisoneofonlyafewspontaneouseventswheretheactionsthatimmediatelyfollowhaveasignificantinfluenceonwhetheranindividuallivesordies.Theeventswhichcardiacarresttriggers,theresuscitationattempt,generallybeginswithoneindividualwhosummonsarapidresponsefromateamwithexpertise.Thismaybebycallinganambulance–usuallybyalaybystander,orinhospitalbycallingthecardiacarrestteam–usuallybyanurse.Aswellassummoningexpertise,thisinitialcallleadstothearrivalofequipment,mostnotablyanAED.Theinitialresponsewithlimitedpersonneland/orexpertiseiscalledBasicLifeSupport(BLS),whichinvolvestherescuerperformingchestcompressionsandmouthtomouthbreathing.ThoseperformingBLSareknownasfirstrespondersandinahospitalsettingusuallycompriseoflocalclinical


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personnelbasedinthevicinity.BLSusuallycommenceswithonepersonandisideallyundertakeninvolvingthreepeoplesubjecttotheiravailability:onetomaintaintheairway,onetoundertakecompressionsandathirdpersontogatheranduselocallybasedequipment.ThenextsteponthecontinuumisAdvancedLifeSupport(ALS)whichtakesplacewhenateamofexperiencedspecialistsconvenearoundthepatient.ThecoreBLSactions(compressions,airwaysupportandifavailabledefibrillation)continueuntiltheyareaugmentedbymoreadvancedresuscitationtechniques.TheALSteamisdrawnfromresuscitationexpertswhoundertaketheirnormalclinicalroleswithinthehospitaluntilanemergencycallisreceived.Theteamusuallycomprisesadesignatedanaesthetist,medicalpractitionerwithresuscitationexpertise,atechnicianandaseniornurse.Asaconsequence,theseteamsareadhoc(Robertsetal.,2014),theyarenotwellformedandmembersmaynotevenknoweachother.TheALSteamareunlikelytoknowthefirstresponders.Theteammayarriveatdifferenttimesintoanunfamiliarenvironmenttomanagetheresuscitationattempt,andco-ordinateboththemselvesandtheenvironment’sstaff(Milleretal.,2012).Typically,someonefromthepatient’ssupervisingmedicalteamwillbecalledtoadviseontheimpactofanyconcurrenthealthconditionsthatcouldinfluencethepatient’smanagement.Ascanbeseen,severalpeoplewillbeengagedintheresuscitation,eachonewithdifferentroles,levelsofexpertiseandarrivaltimes.Asthemembershipoftheteamaroundthepatientexpandsnumericallyduringthecourseoftheresuscitation,butspecificallywiththearrivaloftheALSteammembers,thenthemanagementoftheindividualspresentbecomesincreasinglyimportanttoensurethattheirskillsaredeployedappropriatelywithinthecontextoftherecommendedguidelinesandthepatient’scondition.Hence,theUK2015guidelinesadvisethatBLStrainingforstaffwhoregularlyperformCPRshouldinclude‘non-technical’trainingthatincorporatesskillsincommunicationandteambehaviours.Leadershipskills,andhowtobeaneffectivememberofaresuscitationteam,areincludedwithintheseguidelinesforthoseundertakingAdvancedLifeSupporttraining.Foranyhospitalbasedresuscitationevent,theALStraininginstructstheALScertifiedstafftonotonlyassumetheleadershiproleuponarrival,butalsotonominateandarticulatetheirdesignationtothefirstresponderspresent.ALScertificationisnotprofessionspecific,andthereforeanurse,ifthefirsttoarrive,maytakeinitialleadershipandthenpassontheresponsibilitytoananaesthetistorseniorphysicianwhentheyarrive.NormallyALSmedicalstafftakeovertheleadershiprolebecausetheirscopeofpracticeincludestheabilitytoprescribeandinitiatetreatmentsbeyondthatofotherhealthcareprofessionals.Thepotentialforproblemswiththeperformanceoftheseadhocteamsisunderstood,andadherencetocomplexalgorithmsischallenginganderrorsarefrequent(Yamadaetal.,2015).NationalstandardisedtraininginALSwasestablishedin1993toprovidestructuretotheresuscitationattemptasameansofcontrol.So,the‘script’forundertakingALShasbeenwell-definedbuttheroleswhichindividualstakeinpracticeandhowtheyperformtheseinthemomentislargelyunestablished.Therearedifferentwaysofapproachingthisproblem(WackerandKolbe,2014;McLandersetal.,2015),butitisclearthatno-onehasyetundertakentheworkrequiredtoprovidemoresolidclarificationofissuesinenacting


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thescript.Inparticular,thereappearstobelittleworkanalysingeventsbeforethearrivaloftheALSteam.Wehavealreadymentionedthatsuccessfulresuscitationeventsrequireeffectiveteamrelationships,whichincludeeffectivetaskmanagement,leadershipandcommunicationskills(Castelaoetal.,2013).Certainstylesofleadershiparefavouredinsuchteams.Thesestylesofleadershiptermed‘Horizontal’or‘Lighthouse’leadershiparewheretheleaderremainspracticallydisengaged-takinganoverviewoftheongoingsituation,askingquestionsandgivingpreciseinstructions,butatthesametimeisresponsivetothecapabilitiesoftheteamandtheirabilitytoself-organiseandconducttaskswithoutexternaldirection(Schenarts2007;CooperandWakelam,1999).

Criticaltopatientsurvivalisearlydefibrillation,reducingwhatisknownas‘handsofftime’(namelybreaksinthecyclesofcardiaccompressions),withthequalityandrhythmofthecompressionsandairwaysupportbeingothercrucialfactors.Whilethereareexistingvalidatedandreliablemeasuresofindividualandteamperformanceinresuscitation(seeMcKayetal.,2012),andtheUK2015Resuscitationguidelinesspecifytherolesoftherespectiveteammembers,theuseoftheAEDsandotherdevices,littleattentionhasfocussedspecificallyuponthehumanfactorsrelatedtotheeffectofthedevicesuponperformanceandviceversa,yetempiricalstudiesofAEDuseinhospitalsrevealstheycontributetosignificant‘hands-off’timeduringresuscitation(Smithetal.,2011).Itisnoticeableinthesystematicreviewofteamco-ordinationthatCastelaoetal.(2013)undertakeandthestudybyAndersenetal.(2010)concerningbarrierstoteamworkinCPR,thatwhiletheimportanceofsubtasksandresourcesarementioned,thereisnoreferencetotheimpactofthetechnologicaldevicesonteamco-teamworkordinationoreffectiveness,asidefromdevicefailure.Interestingly,Section2oftheUK2015guidelinesdrawsattentionnotonlytotheimportantroleofsocialmediaandinnovatetechnologiesinimprovingpatientoutcomes,butalsoencouragestheirevolution,developmentandanalysis.

ItisknownthattherearetensionscausedbytheparadoxcreatedbyAEDvoicecommandadherenceduringbasiclifesupport,theadvicetohaveminimuminterruptionstochestcompression(ResuscitationCouncil2015),andthedelaysorinterruptionstoperformancecausedbythevoicecommandsthemselves(e.g.Monsiuersetal.,2005).Similarly,theextenttowhichSmartDevicesareattunedtothecompetenceleveloftherescuerandthecontextoftheresuscitationappearsneglectedintheliterature.Ironically,becausebasiclifesupportisconductedpriortothearrivaloftheexpertsandmulti-disciplinaryteams(MDT),itisonlythroughsimulationorinvivoobservationthattheeffectofthedevicescanbefullynoted.

6 TheSmartTechnologiesInvestigatedInthisstudy,thetwosmarttechnologiesusedwereamodelofAEDcommonlyusedinpublicandhospitalsettings,andaSmartWatchprototypedevelopedwithinourproject,toassistwiththecompressioncomponentoftheresuscitationprocedure.PriortothedevelopmentoftheAED,theonlywaysomeonecouldreceivedefibrillationwasbyALStrainedprofessionalsusingunrestricteddefibrillatorsrequiringprofessional


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discretion,guidedbytherelevantalgorithm.TheALSprofessionalcoulddeterminethefrequency,strengthandappropriatenessofdefibrillation.AEDsweredevelopedtoreducethetimefromcollapsetodefibrillationbyenablingalaypersontoinitiateanautomaticprocessthatcouldnotbealtered.Thismeantdefibrillationcouldtakeplaceinpublicspacesandeverydayenvironmentssuchasretail,sportsvenuesandschools.However,itsoonbecameapparentthattheAEDcouldbeusedbyfirstrespondersinhospitals,whowerealsounabletoadministerunrestricteddefibrillation.Similarly,thishadtheeffectofreducingthetimefromcollapsetofirstdefibrillation.However,therestrictionsoftheAEDmeanthattheALScompetentpractitionerscouldnotusetheirprofessionaljudgmentswiththeAED.Hence,somemodelsofAEDweredevelopedwiththecapacityforamanualoverridetogiveflexibleadministrationofdefibrillationwhenALScertifiedstaffarrived.Currently,healthcarestudentsdonothavethetrainingnorscopeofpracticetooverridemanuallyanAED.However,theyaretrainedtotrytoreduce‘handsoff’compressiontime.TheAEDmeasuresandanalysesapatient’sheartrhythmandthenifitisrequired,providesanappropriateshocktothepatient’sheartinordertorestoreanormalheartrhythm.Giventheprimaryprotagonistisanon-professionaluser,assumedtohavelittlemedicalknowledge,thedesignoftheAEDintendstoprovideahighlyauthoritativeandlinearstructureforwhatisrequiredtobedonewhenusingit,inordertoresuscitatethepatient.Theprocessisnowdescribed.TheAEDdevicecomprisesacontrolboxwiththreesimplewrittenandpictoralinstructionswhichguidetherescuerto(1)openthedevice;(2)turnitonand(3)followthevoiceinstructions.Inourstudy,thesequenceofvoicepromptscanbesummarisedinthisway:1) Applyelectrodepadstobarechestofpatient2) InsertpadconnectornexttoflashinglightonAEDdevice3) Donottouchpatient4) Analysingheartrhythm-Pause

a) NoshockadvisedcontinueCPRORb) ShockadvisedDonottouchthepatient

5) Charging6) Donottouchthepatient7) Delivershocknow8) Presstheorangebuttonnow(todelivertheshock)9) Shockdelivered10) Pause11) StartCPRifnecessaryThefirsttwostagesarepartoftheprocedureforinitiallyapplyingtheAEDwithintheresuscitationalgorithm.OncetheAEDisapplied,thesequencethenrunscyclicallyeverythreeminutesfromstep3whichinterruptstherescuersresuscitationactivitiesofcardiaccompressionandairwaysupport.Foradults,thecurrentsequenceofcompressionstobreathsis30:2.ItwastoaidtheacquisitionandperformanceofcompressioncompetencethatthesecondSmartDevicewasdeveloped.ThesecondsmarttechnologyusedwasaSmartWatchdevelopedwithinourprojecttofacilitateandpotentiallyimprovetheprovisionofcompressionsduringCPR.ThissensorbasedSmartWatchisdesignedtobewornbythenursewhoisresponsibleforphysically


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conductingcompressionsinaresuscitationattempt.Whenused,thewatchwillmeasurethespeed,depthandnumberofcompressionsthatthenurseprovides.Thepurposeofthistechnologyisfirstlytodeliverkeycredentialsofcompressionsintheongoingsituationtofacilitatetheinformationneedsofparticipants.Forexample,itmayindicatetoanursethathercompressionsaretooshallow,allowinghertoreshapeherpracticeandthus,providing‘better’treatmenttothepatient.Importantly,suchinformationrelatedtocompressionscanallownursestounderstand,throughphysicalpractice,howtoimproveanddeveloptheirskillsindeliveranceofcompressionsforfuturesituations.Nursesareinformedthroughtheoryofwhatanappropriatecycleofcompressionsshouldinvolve,andtrainedusingmannequins.Inthissituation,itmaybedifficulttounderstandorgetfeedbackregardingtheexactshapeofthecompressionstheyproduceandhowtheyaligntowhatisrequiredbytheirtrainingalgorithms.Thiswatchprovidessuchfeedback,whichcouldhavepotentialbenefitsforaligningthenursestothestandardofwhata‘good’cycleofcompressionsmayfeellikeinpractice.ThetechnicaldetailsofthedevelopmentandpilotdeploymentoftheSMARTWatchareoutlinedinGrünerbletal.(2015).

7 TheCaseStudy:SmartDevicesinSimulatedResuscitationThestudywassetintheClinicalSkillsLaboratoriesintheUniversityofSouthamptonFacultyofHealthSciences.Thissimulatedwardenvironmenthassixbedspaceswithassociatedcontrollablecamerasandhangingmicrophoneswhichcaptureandstoreaudioandvideofeeds,similartoaCCTVrecordingsystem.Adjacenttothewardthereisasmalleroperationsroomwherethetrainers,orattimestraineenurses,canobservetrainingsimulationexercisesoccurringinthemainward.Thisallowsforobservationofsimulationswithoutbeingdisruptive,andtheactivitycanberecordedtoallowfortrainingpurposesorretrospectivereflectiononmaterialsfollowingatrainingexercise.Duringtrainingsessions,theroleofthepatientisplayedbyatechnologicalsimulatorcalledSimMan®whichcandisplayvitalsigns(e.g.pulse,breathing,blinking,speech)thatarecontrolledremotelyviaadedicatedlaptop.SImMan®isamobile,portable,interactiverobotmannequindesignedtoenablehealthcareteamstopractisepre-programmedemergencyortechnicalsituationswhichrequiredteamwork,clinicaldecisionmakingandproceduralskills.SimMan®haslifelikeanatomyandclinicalfunctionality.ConcurrentmanagementoftheSimulationenablesreactiveconsequencestobeinitiatedinresponsetoteammemberactions(e.g.examplecessationorreturnofbreathing,retchingsoundsandchangestotheheartrhythm).ThecomputerlogsofSimMan®wereavailableforanalysis,togetherwiththe360-degreeaudiovisualcameramaterial.

7.1 MethodologyOurapproachtoexploringtheseissueshasbeentoexamineinadetailedwaytheuseofthesedevicesinasimulatedpracticeenvironment.ThemaincorpusofourdatawascollectedduringseveralsessionsoftrainingsimulationsoverfourdaysatSouthamptonUniversity.


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Figure1:traineenursesinteractinginthesimulatedpracticeenvironmentStudentnurseswererecruitedfromtheyear2cohortsofthePostGraduateDiplomainAdultNursingandAdultBachelorofNursing.PermissiontoapproachthestudentswasobtainedfromtheirProgrammeLeadsandthestudentswereinvitedtoparticipatethroughabriefpresentationduringaProgammeManagementSession.Fivedaysbeforethetrainingsimulations,interestedstudentswereprovidedwithanintroductoryletter,ParticipantInformationSheetandConsentForm.Eighteenstudentnurseswererecruitedtoparticipateinthestudy.Thestudentsexpectedtoengageinsimulatedpracticescenarios-similartothosetheyhaveundertakenintheirProgrammes.WhiletheyhadreceivedtraininginbasiclifesupportandtheuseofAEDsduringtheirfirstyear,andundertakenapproximately1500hoursofrealclinicalpracticeatthisstageoftheirtraining,veryfewstudentswouldhaveparticipatedinarealresuscitationevent.The‘trainers’andstaff‘actors’(e.g.thedoctor)wererecruitedbyapproachingFacultyResuscitationtrainersdirectly.

7.2 EthicsandgovernanceThestudyprotocolwasapprovedbothbytheUniversityofSouthamptonFacultyofHealthSciencesEthicsCommitteeandtheCentralResearchEthicsCommitteeattheUniversityofOxford.Particularattentionwaspaidtoensuringthatstudentparticipantsunderstoodtheissuesofanonymityandconsentastheyappliedtothevideodatawhensubsequentlydisseminatedinthepublicdomain.Studentsreceivedfeedbackontheirperformancefortheirownpersonaldevelopmentaswellasforthepurposesoftheresearch.Studentswereencouragedtoprovidefeedbackontheprocessofthestudyandtobecoparticipantsinthestudywithrespecttotheusetothetechnologyaids.

7.3 DatacollectionWeconductedatotalofsixsimulationsessionslastingaroundthirtyminuteseach.Theproceduresforcollecting,reviewingandanalysingvideodatawereinformedbythosesetoutinHeathetal.’s(2010)descriptionofvideo-basedfieldworkandtheUniversityofSouthampton’sbespokeProtocolforResearchandEducation/EthicsintoVirtualInteractivePractice(MongerandGobbi,2006).Ineachtrainingsession,agroupofuptofourtraineenurseswereprovidedwithascenariosurroundingtheconditionofapatientthroughaninitialbriefingbyatrainer.


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Thiswouldemulatewhatistermeda‘handover’betweenteamsatahospital,wherenecessaryinformationforthecareandresponsibilityofapatientispassedbetweendifferentpractitioners.Followingthis,thenurseswouldstarttoworkcollectivelytowardscaringforthepatientwithminimalinterventionfromthetrainers.Theconditionofthepatientwouldbedeterioratedbythetrainers(positionedatadistance,oftenbehindacurtainwithintheward)atsomestageinthescenario,tonecessitatetheuseofCPR.Inthemajorityofsessions,thenurseswereaskedtousetheAEDwhenresuscitatingthepatient.Atsomepointintheirscenario,adoctorplayedbyanexperiencedALScertifiedpractitioner,alsointervenedinthesituation.Throughthescenario,thestudentshavetheopportunitytoexperiencethearrival,assertionandenactmentofleadershipmadebyanALSpractitioner.Followingthissession,thenursesweredebriefedbytrainers.Thisisimportantfornursingeducation,allowingthemtoreflectuponandtherebydeveloptheirskillsinaquasi-naturalisticsituation.OurobservationalmaterialwasavailableintheoperationsroomthroughCCTV,andcollectedviatheaudio-visualinfrastructureembeddedwithinthesimulationward,allowingforthecollection,observationandconsiderationofhighqualityvideodata.

Figure2:thesimulationwardHavingcollectedthevideodatawefollowedaninductiveapproachandreviewedtheentirecorpus to identify areas of interest relating to the ways in which the participants in thesimulationsessionsinteractwithotherandwiththetechnologiesbeingusedintheirtasks.Our analytic interest lay in how the activities taking place in the sessions unfold in amoment-by-moment, sequential manner. We therefore sought to identify sequences ofinterestwithinthewiderdata,andfocussedoninstancesinwhichaSmartDeviceisdrawnintotheongoingtaskandinwhichithasthepotentialtocausesomekindofdisruptiontotheactivitiesbeingundertakenbythehumanparticipants.Wemadeacollectionof theseinstancesandanalysedthemtoahighlevelofqualitativedetail–inparticulardrawingontheinsightsofethnomethodologyandconversationanalysis(EM/CA).Thesemethodological


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approaches are based on the fine-grained analysis of naturally occurring interactions andhelpus tounderstandtheways inwhichtheparticularoutcomesofsimulationsessions–andmorespecificallythecapacityforsmartdevicestohaveapositiveordetrimentalimpact–arenotpre-determinedbutratherarecontingentonthe interactionstakingplacewithinthem.Ofparticularusewasworkdescribingthecharacterof institutional interactions(forinstance, Drew and Heritage, 1992). This work highlights the relevance of institutionalidentities (nurse, doctor, patient etc.) to the accomplishment of tasks at hand and thetendencyforasymmetriesandconstraintsoninteractiontoexistininstitutionalsettings.Forinstance, inmedical settings it is very rare that practitioners talk about their own (ratherthan theirpatient’s) illnessesand insurgicalones it is typical forhierarchies toemerge inwhichexperiencedpractitionersaremorelikelytospeakandbelistenedtothanjunioronesatpointsofemergency.Membersoftheresearchteamwerealsopresentduringthesimulationsessionsandwereabletocollectfieldworkdatatosupplementthevideorecordings.Thesetooktheformofethnographicobservationsplusinformalinterviewswiththetraineenurses,trainersandalsothedevelopersofoneofthesmarttechnologies-theSmartWatch-thatwasusedtotreatthepatient.Thisanalysisrevealedpatternsofactionandinteractionoccurringacrossthedataset,whichhighlightsalientissuesintheconfigurationofsocio-technicalenvironmentswheresmarttechnologiesareused.Thispaperdiscussestwodatafragmentswhichillustratethekeythemesoccurringacrossthewiderdatacollection.Ouranalysisprovidesanempiricalbasisforwiderconceptualdiscussionofauthorityinthesessions.Weuseittodiscussthewaysinwhichauthorityappearstobeconstitutedatalocallevel,throughmoment-by-momentinteraction.

7.4 AnalyticFindings:TeamworkandNurseResuscitationIn this section,wepresent someof our key analytic findings relating to theuseof SmartDevices insimulationsessionsandtheircapacityto(positivelyornegatively) influencetheconductofmedicaltrainingtasks.WefocusontwoexemplardatafragmentsandtwotypesofSmartDevice:theautomatedelectronicdefibrillator(AED)andtheSmartWatch.Fragment 1: Smart Watch In this data fragment a group of trainee nurses are using the AED and Smart Watchtechnologiesinordertofacilitatetheresuscitationofthe(simulated)patient.AtthestartofthefragmentweobservethattheSmartDeviceappearstobeincorporatedsmoothly intotheconductoftheresuscitation.Astheactivitygoesonhowever,aproblemoccurswhenthe Device measures compressions asynchronously with the compressions actually beingconducted. We present a detailed analysis of the interactions occurring in this datafragmentinordertoshowthat:

• the ongoing activities in the setting are accomplished through the interactions ofthosepresent;

• this includes interactionsbetweenthenursesandthenurses’ interactionswiththeSmartDevice;


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• in this particular scenario the nurses orient to the Device inways that treat it ashierarchicallysuperiortotheirownactionsandlikelyknowledgeoftheresuscitationprotocol;

• theconstructionofthisinteractionalasymmetryresultsinthetechnologyappearingtoshapetheconductofthesimulationanditsoutcome.

Thetranscript(seeTranscript1,below)showsverbatimthespokenutterancesthatoccur(includingthoseoftheAED).ItalsoincludessomefeaturesofJeffersoniantranscription(Jefferson1972)standardinEMCAtodetailtheoccurrenceofpauses–shownasnumbersinbrackets–andmicropausesofbelow0.3seconds–shownas(.).Uncleartalkisshowninbracketsandsquarebracketsareusedtoindicateoverlapbetweenparticipants.Wealsousescreengrabimagesfromthevideorecordingtohighlightkeyvisibledetails–suchasthephysicalpositionofthenursesandpatient.Arrowsareusedtolinktheimagetotherelevantpointinthetranscript.

Asthefragmentbegins,theAEDhastakenameasurementofthepatient’sheartrhythmandconsequentlyinstructsthatashockshouldbedeliveredtothepatient.ThisshockisadministeredthroughthepressofabuttonontheAED.Onceithasbeengiven,compressionscantakeplace–andtheSmartWatchcanbeusedtohelpregulatethepaceofthisprocedure.

Figure3:Thenursesarelabelledonthetranscriptaccordingtotheirpositionaroundthebed;N1:isoperatingtheAED;N2:isbasedattheheadofthebed;N3:isresponsibleformaintainingthepatientairway;N4:istaskedwithundertakingcompressionsatrelevantjunctures;AED:referstovoiceoftheAED.

Figure4:IllustratesthepositioningoftheSmartWatch,whichisdifficulttomakeoutonthesubsequentimagesaccompanyingtranscript1.


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Transcript 1 1. AED: deliver shock (.) shock delivered

(0.6) ↑ ↑

2. AED: Pause (0.8) 3. AED: if needed start CPR (0.2) ↑ ↑

4. N4: okay

[11 lines omitted] 16. N4: okay oh (.) 17. N4: oh (0.4) 18. N1: its uhm ↑ ↑

19. N2: ( 3its like moved) ( )( it was on 0 and then

it went to seven) (.)

20. N1: okay

3Abracketedutteranceindicatesthatitwasnotfullyclearwhatwasbeingsaidatthatmoment,andinsteadthereisaninterpretationofwhatislikelytohavebeensaidgivenavailableaudibledata.Whereanutteranceisentirelyinaudible,bracketswillenclosenotextatall,andinsteadmarkthattheoccurrenceoftheutteranceratherthandetailsofwhatthatutterancewasoraninterpretationofthis.


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Inthisshortfragment(lastingfor71secondsintotal)thetwotechnologiesbecomerelevanttotheongoinginteractionsinthesettingandtheaccomplishmentofthetaskathand.TheAEDinstructsashocktobedeliveredtothepatient(line1)andthisiscompletedbyoneofthetraineenurses -N1.N1thenplacestheSmartWatchonthechestof thepatient.TheAEDadvises to start CPR ‘if needed’ and another nurse,N4, begins compressions.At thispointwecanmakesomeobservationsonthewaysinwhichtheparticipantsinteractbothwitheachotherandthetechnologiespresentwhenaccomplishingtheiractivities.In administering the shock and beginning compressions the nurses draw on theirinstitutional knowledge of the AED sequence, conducting the different steps required ateach appropriate point. The particular ways in which these steps are accomplished arecontingentonphenomenawithin the setting itself.We can see the activities occurring inthis fragment as taking the form of sequences of action,with the conduct of one actionorientedtobytheparticipantsasprojectinganextrelevantactiontofollow.For instance,N1treatstheAED’sutterance‘delivershock’inline1asmakingrelevantthepressingofthebuttonontheAED–notonlyintermsofperformingtheactionbutalsoinitstimingsothatitoccursdirectlyaftertheutterance.Shethentreatsthepressingofthebuttonasmakingrelevant the placing of the Smart Watch on the patient’s chest. In turn this placementprojects the involvementof thewatchas relevant to thenextaction thatwilloccur– thecompressions,whicharethenconductedbyN4.Asequenceisunfoldinginwhichoneactionbuilds on another and activities are accomplished via collaboration between participants.We observe that the AED is oriented to as a (non-human) participant in this setting; itsutterances are listened to and responded to. In fact, its utterances in lines 1 and 3 aretreatedasinstructions,withthenursesrespondingtothemimmediately.SotheinclusionofthisSmartDeviceappearstoresultinakindofhierarchyorasymmetrybetweenactors.WealsoobservethattheSmartWatchismaderelevanttotheongoingsequencethroughthe actions of the participants.WhenN1 places it on the patient’s chest she projects itspresence as relevant to what is about to occur – the compressions. She places it in aparticular way so that its face can be easily seen by N4, who will be conducting thecompressions. With this action N1 displays sensitivity to the ongoing task at hand, theparticularwaysinwhichthetaskwillbeachievedandtheneedsofherco-participants.Asaresult theWatch becomes available to be used at the appropriatemoment andwithoutdisruptingtheongoingprocedureinanyway.IntheopeningphaseofthisdatafragmentboththeAEDandSmartWatchare integratedintotheactivitiesbeingundertakenbythenurses.Thisappearstobeachievedinarelativelyseamlessway that does not disrupt the clinical tasks being undertaken. Furthermore,wecanobservethattheAEDisbeingtreatedasanasymmetric,non-humanparticipant,abletoissue instructions. Its treatment is asymmetric because its instructions are given priorityover the nurses own knowledge of the protocol. As the fragment continues the SmartWatchalsobecomesattendedtoasplayingakindofasymmetricrolebutinthisinstanceitbecomesproblematictotheaccomplishmentofthemedicaltaskathand.After the AED’s utterance in line 4, N4 begins compressions on the patient – once againtreating the device as legitimately able to issue instructions. According to the standardprocedure, N4 is required to undertake a cycle of 30 compressions, made in a steady


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rhythm. As she completes her first compression, N1 moves her right arm to theWatch(Figure5);asshecompletesthesecond,N1tapsthefaceoftheWatch.WhathashappenedisthattheWatchhasnotturnedonandisthereforenotmeasuringthecompressionsasitissupposed to.N1’s actions attempt to switch theWatchonand continue (Figure5) asN4carriesoutthethirdandfourthcompressions.Infact,N4takesalongerpausebetweenthethird and fourth compression than previously – an actionwhich appears designed to aidN1’s attempts to switch on theWatch. In this way both N1 and N4 treat theWatch ascontingent totheongoingtaskandtheabsenceof itsmeasurementasproblematic.Theirattemptstoresolvetheprobleminturndisrupttherhythmofthecompressions.

Figure5aand5b:N1movesrighthandtowardswatchinanattempttoswitchitonThis disruption continues over the fifth and sixth compressions with N1 continuing toattempt to switch the Watch on and N4 producing a longer than usual pause betweencompressions.TheWatchhasbeen turnedonbycompression7andN4 resumesa fasterandsteadierrhythm.TheWatch isnowoperatingbut isasynchronouswiththeactionsofN4.ThisresultsinfurtherproblemsonceN4hascompletedthecycleof30compressions.AttheendofthecycleN4movesslightlyupwardsbutremains leaningforwardstowardsthepatientwith her hands clasped together in the ‘CPRposition’ (Figure 6). She thenmovesslightly further upwards and moves her hands into a kind of claw shape (Figure 6). Shevisiblymaintainsreadinesstocarryoutcompressionseventhoughthecycleof30hasbeencompleted.ShewhisperstoN3(onherright),whothenappearstopointtothescreenoftheWatch.N4movesbackdowntowardsthepatient,claspingherhandstogetherinawaythat suggests she is about toperform further compressions.As shedoes soN2 shiftshergazeaway fromthe screen toher rightanddown to theWatch.Theattentionofall fournurses is directed towards theWatch and the particularmisalignment that has occurredbetween the compressions it has measured and the compressions that have beenperformed. N4 then gives the patient further compressions – going against standardprotocolbutfollowingtherequirementsoftheWatch.


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Figure 6a and 6b: N4 moves back into undertaking compressions despite havingcompletedacycleof30In the first phase of this fragment we observed the Smart Devices being integratedseamlessly into the activities of the simulation. However, analysis of the second phasereveals that the Smart Watch becomes problematic when it measures compressionsasynchronouslywiththecompressionsactuallybeingconductedbyN4.Thenursesattendtothismisalignmentasproblematicintheirvisibleandspokenactionsandtheirattemptstorectify the problems are disruptive to the conduct of the compressions and result in abreachofstandardCPRprocedure.Inthisenvironment,somethingasapparentlymundaneasnotbeingabletoswitchtheWatchoncauseswhatcouldpotentiallybeaseriousobstacletothesmoothcompletionoftheresuscitationprocedure.Wecanobservethatthestartofthe compressions appears to be a particularly vulnerable moment in which this kind ofobstaclemightemerge,giventheimportanceofestablishingarhythminsynchronywiththemeasurementsoftheWatch.ItisimportanttonotethatitisnotsimplythepresenceoftheWatchortheoccurrenceoftheproblemswitching it on thatdetermines that thedisruption to theprocedureoccurs.Rather, thedisruptionemerges throughtheparticularways inwhich thenursesattendtothe Watch – and made continued attempts to switch it on. The nurses respond to thedirectionsoftheWatchaheadoftheirownformalknowledgeoftheprocedure,treatingitas having a hierarchically superior status in the ongoing activity. In other scenarios thetechnology isnottreatedashavingthisstatusandthisasymmetrydoesnotappear intheinteraction. In fragment 2 asymmetrical relationships in the setting emerge in a differentway,withboththenursesandtheAEDcomplyingwithinstructionsgivenbyadoctor. Fragment 2: Experienced Practitioner InthisseconddatafragmentagroupoffournursesisonceagainconductingasimulatedresuscitationprocedurefacilitatedbytheAEDdevice.Inthisinstanceanexperiencednursepractitionerispresent,playingtheroleofadoctorinthesimulationandthereforereferredtoas‘Doctor’inthetranscript.TheDoctorissuesinstructionstothenursesthatcontradicttheutterancesoftheDevice.Ouranalysisillustratesthat:


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• theSmartDeviceonceagaintakesaroleasanon-humanparticipantintheongoingactivity;

• however,adifferentkindofhierarchyemergesastheDoctorcontradictstheutterancesofthedevice;

• thenursespresentorienttotheinstructionsgivenbytheDoctoraheadofthoseissuedbytheDevice;

• theDoctorongoinglymanagesandmaintainsthatasymmetricalrolethroughembodiedinteractionatkeymomentsinthesituation.

The fragment lasts for 27 seconds; as it begins N1, positioned to the left of the doctor(Figure7),isplacingpadspadsonthelowertorsoofthepatientsothattheAEDcanbegintomeasuretheheartrhythm.N3isgivingcompressions.

Figure7: Thenursesarelabelledonthetranscriptaccordingtotheirpositionaroundthebed;N1:isplacingthepadsonthepatient;N2:isbasedontherightofthedoctorattheheadofthebed;N3:isresponsibleforcompressionsandisanexperiencequalifiednurse;N4:isoperatingAED;AED:referstovoiceoftheAED;D:referstothedoctor

Transcript 2 1. AED: Analysing heart rhythm (0.9) ↑

2. AED: do not=4 3. D: =okay= 4. AED: =touch the patient (.) ↑

4the‘=’symbolmarksaveryrapidtransitionfromoneutterancetothenext.


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5. N4: okay stand by 6. D: stop for a moment while ↑

it analyses its gonna ↑

(2.2) 7. AED: shock advised= 8. D: =start- you start CPR for the moment (0.4) ↑

9. AED: charging= 10. D: =let it charge (.) 11. AED: stand clear of the patient 12. N4: okay stand 13. D: =let it charge


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14. D: let it charge (0.4) 15. AED: deliver shock now 16. D: stand clear ↑ ↑

17. AED: press orange button (.) shock delivered (.) 18. D: okay start CPR=19. N3: =okay= 20. AED: =pause (0.6) 21. AED: if needed start CPR Once again the AED here takes a role as non-human participant in the resuscitationprocedure.Inline1itmakesanannouncementthatitisanalysingtheheartrhythmofthepatient.As itdoesso,N1completesplacingthepadsonthepatient’s lowertorsoandN3continuescompressions. Inlines2-4theAEDsays‘donottouchthepatient’.Aswithfragment1wecanseethisastheAED issuingan instruction.However in this instance, this instruction isnot treatedasrequiringan immediate responsebyallof theparticipants in thesetting.As theAEDsays‘Do not’ N1 removes the pad wrapper from the patient’s leg and moves away. Sheanticipates the instruction from the AED and complies with it, even whilst it is beingproduced.BycontrastN3remainsgivingcompressions.Itappearsthatsheisdrawingonherownformalknowledgeoftheprocedureasmoreimmediatelyrelevantthantheinstructionofthedevice.

Inline5N4says‘okaystandby’.ThisreformulatestheutterancefromtheAEDnottotouchthepatient and therebyalignswith the instruction it has given. It canalsobe seenas anattempttoencourageothers–forinstanceN3–toalignwithit.TheDoctorbeginsaturninoverlapwith her line 6. He speaks in a loud voice and says ‘Stop for amomentwhile itanalyses it’s gonna’. As he says this he raises his right arm to a height just above thepatient’schestandbringsitpalmdown,visibletoallthenursesandclosetoN3.N3stopsgivingcompressions.Ashecompleteshisutterance,bothN1andN3takeastepback,awayfromthepatient.Bythispointthreepotential instructionshavebeengiven:onebytheAED,onebyN2andoneby thedoctor. It is only theDoctor’s instruction that receives immediate compliancefrom all the nurses. It appears that a different kind of asymmetry is emerging in this


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interaction:at leastonenurse(N3)treatstheAEDasnotnecessarilytakingprecedenceofher own formal knowledge of the procedure and the Doctor is treated as holding ahierarchicallysuperiorstatusthanboththenursesandtheAED.ItisworthnotingthatN3isanexperienced,butnotALS(advancedlifesupport)certified,practitionerandthismayhavesomebearingonhowsheinteractswiththeAED.Doctorsofcoursearetypicallyunderstoodtohaveahighstatus(duetotheirlevelofexpertise)inmedicalsettingssowecanobservehere that institutional and professional identities are being played out to construct thisparticularhierarchy.ItisalsousefultonotetheparticularwayinwhichtheDoctorgiveshisinstruction – with a raised voice and amarked bodily gesture that is visible to all thosepresent.WecanseetheseasapracticalenactmentofboththeDoctor’sformalhierarchicalandALSleaderstatusand,combinedwiththenurses’response,asthemoment-by-momentachievementof‘authority’inthemedicalsetting(seeFigure8,below).As the fragment continues we see further ways in which the actions of those presentconstituteanasymmetry inwhichtheDoctorhasahierarchicallysuperiorstatus thantheAEDandthenurses. Inessence, theDoctorgives instructions thatcontradict thoseof theAED and the nurses comply with them rather than responding to the smart device. TheDoctor’sactionscreateamisalignmentwiththedevice–ratherthaninFragment1wherethemisalignment isprecipitatedby the technology itself –and treat thismisalignmentasunproblematicforthesuccessfulaccomplishmentoftheprocedure.Wecanseethisagainasinstancesoftheoperationof‘authority’ininteraction.Ashecompleteshisinstruction‘Stopforamomentwhileitanalysesit’sgonna’,theDoctorlooks towards thescreenonhis right,whichdisplays informationabout thepatient’svitalsigns.Thisgiveshimanopportunitytoanalysethepatient’scondition,eventhoughthis iswhattheAEDiscurrentlydoing.HetreatshisownindependentanalysisasrelevantinthissituationandtheAED’sanalysisas(potentially)notenoughonitsown(seeFigure8).

Figure8:thedoctorholdshishandoverthepatienttoindicatethepauseincompressions


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TheAEDthenadvisesthatashockisgiventothepatient.(line7).Thenursesremainstill;incontrast toFragment1, theydonotappeartotreattheAED’sutteranceasan instructionrequiring immediate compliance. The Doctor turns away from the screen and points hishandtowardsthepatient’schest.Hethengiveshisowninstructioninline8‘start–youstartCPRforthemoment’,directedtowardsN3.ThisinstructionisindirectcontrasttotheAED’sadvicetoshockthepatient.N3movesintopositionandbeginscompressions.ShetherebyalignswiththeinstructionoftheDoctoraheadoftheadviceoftheAED.Theothernursesalsoslowlyshiftforwardstowardsthepatient,alsoaligningwiththeDoctor’sdirection.From lines 9-11 theAED first states that it is charging and then advises those present to‘standback’.This is standardprocedureas thedevicewilldelivera largeelectric shock tothe patient that can be dangerous to others. The Doctor however directs the nurse tomaintain compressions during the time period when the device in charging. During thistime, N3 continues giving compressions. Her actions align with the instruction from theDoctorratherthantheAED.AstheAEDutterstheword‘shock’(inline15)thedoctorsays‘standclear’firstsweepinghishandbacktowardsthewall,andthenphysicallymovingbackwardstowardsthewallbehindhim.HerehegivesaninstructioninadditiontotheAEDbutonethatalignswithitratherthancontrastsit.AshehaspreviouslyoverruledtheadviceoftheAEDwecouldconsiderthisadditionalinstructionanecessaryindicationtothenursesaboutwhattodo,asatthispointitmightbeuncleartothemwhetherornottheyshouldalignwiththedevice.OnceagaintheDoctorusesanembodiedgesturetoaccompanyhisinstructionandthisplaysaroleintheembodiedexerciseofhisasymmetricalpositioninthisscenario.Ontheword‘clear’,N3finisheshercompressionandsheandtheothernursesmoveawayfromthepatient,therebyaligningwithhisinstructiongiving.Witheveryoneintheroompositionedawayfromthepatientatanappropriatedistance,N4pressesthebuttontodeliverashocktothepatientandtheAEDthenconfirmsthatshockhasbeengiven(line17).Followingthis,thenursesanddoctorremainintheirpositionsatadistancefromthepatient.Afewmomentslaterthedoctorgivesanewinstruction‘okaystartCPR’andthenmoveshisleftarmtotheneckofthepatienttocheckthepatient’spulse.Hismovementindicatesthatitisnowsafeandrelevanttomovebacktothepatient.N3alignswiththisinstructionbymovingbacktothepatientandbeginningcompressions.Whilstsheisgivingthem,theAEDissuesfurtherinstructions,firstto‘pause’andthentobeginCPR.SothisisafurtherinstanceinwhichtheDoctorhasdrawnonhisformalknowledgeratherthantheAEDtodetermineappropriateactiontotakeandinwhichhisinstructionsareorientedtobythenursesasrequiringcomplianceaheadoftheAED.Analysisoffragments1and2revealssomeimportantinsightsintotheuseofsmartdevicesinmedicaltrainingscenarios.Firstly,theyshowthattheroleplayedbythesedevicesisnotpre-determinedbutisrathercontingentonthemoment-by-momentunfoldingofactivityinthesetting.Itappearsthatdevicescanbeseamlesslyintegratedintoongoingactivities(firstphaseoffragment1)creatinganopportunityforthemtofacilitatethetaskathand.Theycanalsohavethepotentialtobedisruptive,withmisalignmentsbetweenthetechnologyandtheconductoftheactivity(phasetwooffragment1)creatingproblemsthatneedtoberesolved.Inbothfragmentsthereweretimeswhenparticipants’ownformalknowledgeof


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theprocedurecontrastedwiththeinstructionsgivenbythetechnology,howeverthewaysinwhichtheseruptureswereresolveddiffered.Infragment1thenursesfollowedtheadviceofthetechnologywhereasinfragment2theDoctorledthenursestodisregardsomeofthedevice’sinstructions.Wecanarguethattheinstitutionalhierarchiesandasymmetriesinherenttomedicalsettingsplayaroleinconstitutinghowmisalignmentsbetweenformalknowledgeandinputfromthetechnologyaredealtwith.Infragment1thenurses’responsestotheSmartWatchcreatedanasymmetryinwhichtheadviceoftheWatchwastreatedassuperiortotheirownknowledge.Bycontrastinfragment2,theDoctor’sactionstreatedhisownknowledgeandexpertiseassuperiortothatoftheAED.Intheiractionsthenursescompliedwiththis,creatingascenarioinwhichtheDoctorissueddirectionsforthenursestofollowandthedevicewasattimesoverruled.Consequently,thereareimportantissuesaroundautonomyandauthoritytoconsiderwhendiscussingtheuseofSmartDevicesinthesekindsoftrainingsimulation.Thisisdiscussednext.

8 DiscussionInthefieldworkanalysisabovewesawhowCPRisconductedinahighlytechnologisedenvironment,involvingamulti-focalchoreographyofindividualpractitioners,itemsofequipment,devices,andthepatientitself.InthisdiscussionwefirstlytouchupontheimportanceoftherhythmicaccomplishmentofCPRandsomeissuessurroundingthepracticalitiesofthisaccomplishment.Followingthisandverymuchrelatedtosomeoftheinitialissuesthatwedrawupon,weconsidertheasymmetriesexhibitedatdifferentmomentsbetweentheSmartDevices,thejuniorandseniorpractitioners,andhowtheseasymmetriesareconstitutiveoftheauthorityoftheactorsandhencetheirabilitytotaketheleadintheaforementionedchoreography.Thetime-criticalrhythmsthatscaffoldandunderlietheprocessofresuscitationarecrucialtoitsundertaking.Thesuccessfulresuscitationofapatient,inalargepart,dependsontherepetitionofasequenceofactionsthathavetobereproducedwithhighfidelity.Thisbroaderrhythmincludesthedifferentphasesthattheparticipantsmovethrough,includingtheestablishmentofCPR,thearrivalofaseniorpractitionerandbringingCPRtoaclose.Ourfine-grainedanalysisshowsthatwithinthisbroaderrhythmisthenestedrhythmofCPR,comprisingmoment-by-momentrhythmicelements-includingthepaceanddepthofcompressions,theswitchingbetweenbreathsandcompressions,andtheperiodicpauseswhicharetakentoassessthepatient.Theaccomplishmentofthemultiplerhythmsisconstitutedofsequentialinteractional,whereanactionisshapedbywhatoccurredpriortoit,andgoesontoshapethenextaction.Withinthese,thefluidinterrelationofandbetweenthesemultiplerhythmsplaysanimportantroleincoordinatingthepractitioners-bothindividuallyandcollaboratively,andtheirtemporalinterrelationshiptothespacetheyworkwithin,andthetoolsandartefactsthattheyuse.Therearecertainfeaturesoftheinteractionthatprovideopportunitiesfortherhythmtobedisturbed.Inthetransitorypointbetweeneachofthebroadphasesandeventhemoment-by-momentaction,juncturesexistwherebythereisthechancethatarelevantnextactionisdelayedornotinitiatedatall.Akeyfindingthatemergedandthatshallbeconsideredinmoredetailaswemovethroughthediscussion,isthatthecollaborationofthedifferent


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participantsinthesettingissensitivetocertainasymmetriesbetweenthem.Theseasymmetriesarevisibleinthemannerinwhichinteractionalcuesareproducedbyanactor,andhowthecuesoffellowactorsandtechnologiesarerespondedto.Forinstance,importanttotheundertakingofCPRistominimisethe‘handsoff’time,thatisthetimeawayfromthecyclicrhythmofcompressionsandprovisionofairtoapatient.Weseethatthemoreexperiencedpractitionerorientstominimaltimeawayfromthisrhythm,forexample,avoidingstringentlyabidingbythelongpausesthattheAEDattemptstoembedwithinthesituation.Quitedifferently,thenursesarehighlysensitivetothecuesoftheAEDandthesmartwatch,thusincreasingthe‘handsoff’timeanddisruptingtheoverallrhythmoftheprocedure,andinsteaddeferringresponsibilitytothetechnologies.Sowhilstthesmartwatchprovides‘abeat’totheencouragethefluencyofcompressions,inthisinstanceitprovestobedisruptive,especiallywhenitprovidesstraycueswhichthenursesorienttoasapriority,insteadofthepatient.Also,whenorientedtoastheauthorityinthesituationtheAEDservestohinderthetemporalprogressionoftheCPRforlongerperiodsthanarenecessarywhenusedbylessexperiencedpractitioners.Thedifferentialknowledgeofwhattechnologiesdo,andexperienceofusingthemappeartoplayapartincreatingasymmetries,whichimpactshowandhowwelltheprocedureofCPRisundertaken,andtheongoinghierarchywithinthesituation.Ourdatashowsnormativestatushierarchiesbeingplayedoutwithintheresuscitationsimulations.Althoughwearguethatwhatwearewitnessingishowthosehierarchiesarebeingreproducedoraccomplished,ratherthansimpleactsofdeferencebasedoninternalisedresponsestoformalprofessionaldesignations.HerewefollowSchneider’sethnomethodologicalanalysisof‘power’:

‘Power,inthisview,isnotadiscreteentitythatissomehowconferredonpeopleorofficesbyvirtueoftheirpositioninanorganizationalhierarchy.Itis,rather,somethingthatmustbeaccomplishedoverandoveragainineverysocialinteractionbythosewhowouldsayandhaveitsaidaboutthemthattheyhavepower’....‘Powerisnotsomethingthatonecaneverhave;itcanonlybeaccomplishedthroughaccesstointeractionalresourcesthatallowonetohaveone’srealityclaimsacceptedasthefactsofthematter.’(Schneider2017)

Thisisnottosayformalstatusdesignationsareunimportant,butwedoneedtoseehowtheyarebroughttolifewithinaninteractionalframe.Statusiscertainlysignificantwithintheresuscitationprotocolitself,whichcodifiesspecificdesignationsandappropriatepatternsofdeference.Thus,theprotocolgrantsanursewithALStrainingahigherauthoritythanajuniordoctor.Infact,anALSresponderistaughtto‘declare’themselvesonarrivaltolegitimatetheirauthority–thustheprotocolandassociatedtrainingareasourceof‘interactionalresources’thatthoseassumingauthoritymaydrawupon.Forthispaper,theideathatpower(authority)is‘...accomplishedbyaccesstointeractionalresources’(ibid)isakeypoint.Sowhenthedoctorentersthescene,thenit’snotsomuchhisdesignationasadoctorthatgrantshisauthority(he'snotactually,he'sanexperiencedALS-trainednurseplayingadoctor),itisthatheisabletodeploycertain‘interactionalresources’thatarenotavailabletotheotherparticipantstotheresuscitation.Althoughhisdesignation(andexpectedarrival)providesanimportantcuefortheotherparticipantsto


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orienttheirinteractiontohimasadoctor,thisorientationwillonlybesustainedifheongoinglydeploystheinteractionalcompetenciescommensuratewithhisstatus.Thisexplainshowauthoritycanbothbesomethingthatisusuallyroughlyalignedtoorganisationalhierarchies,butalso(somewhat)fragileandcontingentandopentothepossibilityofbeingreordered,particularlylocally.ThissituationisreminiscentofCircourel’sobservationthatauthorityassignedtodiagnosticinformationrelieduponthecredibilityofits‘sources’,whichneednotalignwithinstitutionallysanctionedhierarchies,butdependedinsteaduponacontinualinformalsocial(re)assessmentofthatcredibilityamongstlocalnetworksofclinicians(Cicourel1990).Inananalogousway,wesuggestthatthecapacityofclinicianstodisplayauthoritythemselves,andmanagesituationswheremaybemultipleorcompetingauthorities,dependsheavilyuponinteractionalcompetenciesgainedthroughexperienceortraining,whichmayonlylooselyalignwiththestatusnormallyassociatedwithprofessionalroles.Thedoctor’sexogenousexperiences,accruedbyvirtueofhistrainingandhismanyyearsofexperienceindeliveringadvancedlifesupport,providehimwithvitalresource,bothfortranscendingtheframingthattheAEDimposesonthesituationandforexertinghisauthorityoverthehumanactors.Hedeployscomplicatedcombinationsofinteractionalresources,includingtoneofvoice,timing,gesture,the'content'ofhisutterances,andthespatialpositioningheadopts,allofwhichputconstraintsontheinteractionalpossibilitiesavailabletotheotherparticipants,particularlyiftheyaretocontinuetocollaborateinreproducingthisstatushierarchy.Forexample,takingovertheroleofairwaymanagementputshiminthe‘director’sseat’,andarolewithenough‘handsoff’timetoenabletheuseofextendedgestures.Thehandgesturehedeploystoholdtheresuscitation(figure8)claimsthespaceoverthepatient’sbody,limitingtherangeofresponsespossibleforthenursesthatstillacknowledgethedoctor’sauthority.Hisutterancesareformulatedofclearinstructionswithoutanyroomfordiscussionordispute,andweseehimasserthispositionbyinstructingthenurseundertakingcompressionstodoso,overridingtheAED,andalsowhenheinterjectsasanothertraineenurseisattemptingtocoordinatetheroom.Heclearlymaintainsacoordinatingroleintheroomthroughtemporallysensitiveembodiedinteraction,thatisshapedbypriorinteraction,andshapesnextaction.Itisnotthatoneresourceisalwaysused,morethattheuseofresourcesandthemannerinwhichtheyareusedisverymuchtailoredandsensitivetothemoment-by-momentinteractionandcontingenciesofthesituation.Whistthedoctor’sinteractionalresourceshavebeenacquiredfrompriorexperienceandtraining,thisepisodeprovidesopportunitiesforthenursestoacquireinteractionalresourcesoftheirown.WhenthelegitimacyoftheAEDischallenged,thedoctor’sactionsbecomearesourceforthetraineenurses,forwhomhisactionsserveasademonstrationofhowtheCPRprotocolcanbemoreaggressivelydeliverediftheauthorityoftheAEDisoverruled.Atthesametime,thisdisplayprovidesnewlegitimategroundsforoverrulingtheAED.Althoughsuchalessonmaynotbeentirelyassimilatedfollowingasingletrainingevent,thepotentialforthenursestonowreassesshowtheyrespondtoanAEDinaresuscitationeventisquiteevident.Soakeyquestiontheniswhatinteractionalresourcesdoesthetechnologypossessandhowisthisshapingtheunfoldingsequenceofactions?Forexample,theSmartWatch


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interactsbydisplayingacountofcompressions.Thisconstrainstheinteractantstocompletethecompressionsifthelogicofusingthewatchistobepreserved.Thereisasortofaccountabilitythatthewatchcreatesforthenursesintheperformanceofthecompressions–afterall,compliancewiththeprotocolistheeffectthatthewatchisdesignedtoachieve.Similarly,theauthoritativetoneofthedefibrillator,anduseofimperativestatements'StandClear!'againdemandsacertainresponseinturninorderthatthelegitimacyoftheAEDisongoinglyratified.Theproblemfortheboththewatchandthedefibrillatoristhattheirembodimentoftheprotocolisnotsensitivetocontext–theAEDdoesnotknowthatithasbeendeployedinthehospital,notapublicspace;andthewatchdoesnotknowthatithasbecomemisalignedwiththerhythmofCPR.TohaveutilityinhelpingnursestoreproducerhythmsofCPR,particularlyinahospitalcontext,theseartifactsneedtoadmithumandiscretionastowhentheir‘advice’shouldbeadheredtoordisregarded.8.1AcquiringinteractionalresourcesThereisastrikingasymmetryofthejuniornursesinrelationtothetechnologywherebythejuniornursestendedtotreattheinstructionsoftheAEDandSmartWatchwithgreaterlegitimacythantheirowninterpretationoftheprotocol.Whilethedoctor’sauthorityisinsomesense‘fullyformed’,thenursesareveryjuniorandstillverymuchintheprocessofacquiringtheinteractionalcompetencesthatwillsupporttheirbeingabletoactwithauthority.Herewedrawonsomeofourwiderethnographicobservationsthatrevealhowthestudentnursesaredevelopingandexploringtheboundariesoftheirauthoritywithintheinstitutionsofmedicine.Thatthenursesarenovicesisvisibleintheirinteractions,includingthewaythattheylookforexternalcues,andexpresshesitancy,inviteandanticipatedirectionfromothers.Thenursetrainers,whilstobservingthesessionsremotely,commentedfrequentlyonthe‘bodylanguage’ofthenurses,theirlevelofalertnessandengagement,andthewaythattheyadoptedorfailedtoadoptspecificrolesindeliveringCPR.Thetrainerslookedspecificallyforahierarchytoemergewithintheteam,wherebyoneofthenursesmighttakeonacoordinatingor‘leadership’role.ItisinterestingthatimplementingthenestedrhythmsofCPRdependsuponanasymmetricdivisionoflabourwithintheimplementingteam,withafocalauthoritybeingneededtocoordinateanddrivetheprotocolforward,andthatthetrainersarelookingspecificallyforthistoemerge.Intheabsenceofastrongleaderemergingfromtheranksofthetraineenurses,itiseasytoseehowtheAEDcanassumeauthorityandinfluencetheteamtoanunduedegree,whichwasnoticedbynursesandthenursetrainersasthesimulationsprogressed.Inonepost-sessiondebriefthegroupoftraineenursesexpressedconcernthattheywerestillnotsmoothlyimplementingtheCPRrhythm,evenaftergettingcoupleofsimulationsundertheirbelt.Aftersomediscussion,thetrainerscommentedthatthetraineeswerefocussingtoocloselyontheinstructionsoftheAED,whichinterferedwiththemachievingasmoothchoreography.ThetrainersrecommendedthatthetraineesperformthenextresuscitationwithoutusingtheAED,sothattheycouldfocusmoreonanuninterrupteddeliveryoftheunderlyingprotocol.Whentheydidthis,theteamoftraineesweremoresatisfiedwiththeoutcome.Weobservedanumberofdiscussionswheretheextentandlimitstothenurse’sauthoritywereforegroundedandtreatedasopportunitiesforpedagogybythenursetrainers,particularlyinthebriefingsbeforeandaftereachsimulation.Forexample,whenbriefedfortheveryfirstscenario,thetraineeswereinstructednotto‘actbeyondtheircapacityas


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studentnurses’,butworkingoutwherepreciselytheseboundarieslaybecameapressingissuewhenperformingresuscitationpriortothearrivalofmoreexperiencedhelp.Duringonesession,thenurses,workingalone,debatedastowhethertheywerepermittedtousean‘epipen’toreversesuspectedanaphylaxis,whichthenbecameatopicfordiscussioninthepost-sessiondebriefing.Inthisdiscussion,thenursetrainerspointedoutthat,throughouttheircareer,theextentoftheirauthoritywouldexpand,butwouldalwaysalsoremainbounded,andthatrecognisingandmanagingthoseboundariesisanimportantcapacityforanursetopossess.Moreover,thesediscussionsandobservationstoucheduponhowtherearemany‘greyareas’andinconsistencies,suchaswherenursesarepermittedtoconductaprocedureinoneHospitalTrust,butnotanother.Inalloftheseexamplesweseevariousrelationalaspectsofthenurses’authority-howgeography,personaldevelopment,andcircumstancesmayacttograntorrestrictnurses’capacitytoactinagivensituation.ThisleadsustoaseeminglyparadoxicalsituationwhereadepthofexperienceandnewtypesofexpertiseareneededtouseSmartDeviceseffectively,yetsuchdevicesaretypicallyaimedatenablingtaskstobeconductedbylessexperiencedpersonnel,whosecapacitytomakejudgementsabouttheinstructionsfromautomateddevicesisstillbeingformed.Whileonemightacceptthereisalwaysatrade-offinusingSmartDevices(e.g.earlierdefibrillationversuslessrigorousCPR),therearealsolegitimateconcernsastothesortsofshiftsincompetencythatwidespreadandindiscriminateusemaybringabout.

9 ConclusionsHerewespelloutsomeconsiderationsarisingfromourstudyfornursetraining,technologydesignandfortheCPRprotocolitself.ThispaperhasexploredthecomplicatedwayshumanauthoritiesandautonomiesareincreasinglyinfluencedbytheSmartDevicestheyuse.Clearlythenurses(andevenseniornurses)aresusceptibletotheAEDwhichmayleadtoadisruptiontothetime-criticalandmultiplerhythmsofCPR,andthuslesseffectiveCPRbeingdelivered.Ourproblemisthatmachinesacquiretheirinternationalresourcesbytheirdesign-andpeoplethroughexperience.Sohowcanitbepossibletodesignmachinesandtrainingsothatinappropriate(orevendangerous)interactionalasymmetriesareavoided?Howcanweensure,throughdesign,thatthe‘handsoff’timeawayfromapatientiskepttoaminimum?Examplesofthewaysthatpeopleadapttousingperemptorydevicescanbefoundinliteraturesthatlookatalertsandnotifications,Forexample,Iqbal(2010)andLicoppe(2010),showhowpeoples’choiceofmusicalringtonesis,inpart,awayofsofteningtheimperativenatureofthisparticularnotification,andexistsaspartofawidersetofstrategiesforrenderingthecallaspotentiallyignorable.Suchdiscretionarypracticescanbehardertoworkheavilyinstitutionalisedsettingssuchasmedicine,whereissuesofliabilityandsafetymitigatetowardsimmutable,non-personalisedcontrols.Ontheotherhand,alarmsonpiecesofequipment,suchasrespirators,sometimesdohavetailorableranges,whichareadjustedtomatchtheexperienceofthedutynurseasmuchastheconditionofthepatient(Randell2004).BelowweexploresomeofthepossibilitiesforfosteringanenvironmentandpracticesaimedatbettercalibratingresponsestowardsassertiveSmartDevices.


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9.1 NurseTrainingAnimportantlessonfromthisstudywouldbetoconsiderhowwecanadaptnursetrainingtobemoresensitivetoencounterswithauthoritativedevicesinpractice.ItwouldbepossibletobemoreexplicitaboutsomeofthedangersofusinganAEDdevice,particularlywhenitmaybeignoredlegitimatelyandtheimportanceofmaintaining‘hands-on’timeirrespectiveofthedeviceinstructions.AtrickierquestionishowwehelpnursesmoregenerallycopewithSmartDevicesofvaryingtypesthattheymayencounterwithouthavinganypriorexperience.Keytothisisequippingnurseswiththeappropriateinteractionalresources–butthistoorunsintotheproblemthattheseoftendependonextensiveexperiencetoacquire.WesuggestthattrainingshouldhelpdevelopactivereflectivepracticesthatencourageacriticalstancetowardsSmartDevicesastheyareusedinreallifeclinicalpractice.Thiscouldbedonebydevelopingtrainingmaterialswhichshowpractitionerscanstayincontrolintheirinteractionwiththedevices,bothbydemonstratinginteractionalcuestheymaybesusceptibleto,andmomentswhereitislegitimatetoignoretheadviceofadevice.Themixofactorspresentvariedacrossthetrainingsimulationsweobservedsuchthattraineeseitherexperiencedsituationsbythemselves,orwithvaryinginteractionalasymmetriesinrelationtotheotheractorswhohappenedtobepresent.Thiscreatedanumberoflearningopportunitiesforthetrainees.Inthesituationswhentheteamoftraineenursesperformedalone,beforeseniorhelphadarrived,theywereabletoexperienceandquestiontheboundariesoftheirownauthority(e.g.whetherornottheywere‘allowed’toadministeranepi-pen).Onanotheroccasion,whenthetraineespracticeddeliveringCPRwithouttheassistanceoftheAED,theywereabletohonetheirperformancewithoutfeelingcompelledtoadheretotheAED’sstaccatointerpretationoftheprotocol.Finally,inthesimulationinvolvingthe‘doctor’thetraineeswereexposedtoanalternativeinteractionalasymmetrytotheirown,andgivenanobjectlessoninhowtoexertauthorityovertheAED.Whilstthesevariationsoccurrednaturallyasthesequenceofsimulationsunfolded,theypointtowaysthatsimulationscenariosmaybemoreexplicitlydesignedtoincludeexposuretodifferentauthority-relationshipstoaidnursestodeveloptheirowninteractionalresourcesfordealingwiththoseauthorities.

9.2 DesignoftheTechnologiesOnemightseetheauthorityoftheSmartDevicesasemergingfromcharacteristicsofthedevicesthemselves,byvirtueoftheirsupposedfidelitytotheprotocolandassertiveinterjectionofbeepsanduseofaloudauthoritativevoice.Andwhileweagreethatthesefactorsplayapart,itisalsothecasethattheAED’sauthorityisinpartgrantedbythenurseswhoorienttoitsadviceanddirectionaslegitimate,andratifythisbyrespondingtothedevicesinstructions.WealsosawanoccasionwheretheSmartWatchwasdisruptivetotheCPRroutineatmomentswhenthenursesinappropriatelyfolloweditsadvicetotheletter.Despitetheseorientationofthenurses,theAED’sauthorityisactuallyillegitimateinthehospitalsituation,sinceitwasactuallydesignedforlayuseinpublicspaces,andtheversionsoftheCPRprotocolitcontainsis‘watereddown’toensurethatitwouldbemanageablebyalayperson5.5Thereisanever-presenttensionandtrade-offbetweenthe‘purity’oftheCPRprotocolandthepracticalitiesofitsapplication(Timmermans,2010).


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ItisworthdrawingacomparisonbetweenSmartDevicesthatactivelyencouragecompliancewithaprotocol,andmoreneutralorpassivewaysofconveyingtheprotocol,suchasflowchartsanddocumentation.Thisbringsusbacktotheliteratureweoutlineearlierinrelationtoautonomyandclinicalprotocols.Althoughweacceptthat,aswithpaperprotocols,thatSmartDevicesdonotpresentanirresistibleandtotalisingthreattoclinicalautonomy(Timmermansetal.,2004),ourexampleshowsthatforcertainstaffataparticularmomentintheirprofessionaldevelopment,theremaybegreatersusceptibilitytoauthoritativedevices.Moreover,thereisaqualitativedifferencebetweenSmartDevicesand(paper)protocols.IssueofautonomyandauthorityseemsmoresalientforSmartDevicesastheygiveanauthoritativevoicetotheprotocol,animatingthemandbringingthemtolifedeepwithinthemomentsofclinicalpractice.Itisasiftheprotocol,afterplayingasupportingroleformanyyears,nowwantstotakethelead.OnedesignapproachtoaddresstheseproblemsmightbetothinkabouthowtoadapttheAEDtodifferentcontexts.So,whilethetimingandpaceoftheAEDvoiceweredesignedtointroduceintentionalpausesforlaypeople,thetimingandpaceoftheinstructionscouldbeadjustedfordifferentuserstoenablemore‘handson’timefordifferentuserswithvaryingdegreesofexpertise.Anotherapproachmaybetoconsidermorecarefullythephrasinganduseofinteractionalcuesusedtogiveinstructions,suchasvoices,bleepsemployedbytheAED,aswellasvisualimperatives,suchasthecounteremployedbytheSmartWatch.WhilewesawthedoctoroverrulingtheAED,thistookeffortandaddedtensiontothesituation,sincethedevicestillemittedpotentcuesthathadtobeignored.Clearlytheauthoritativenessofthedevicebecomesitselfadesignconsiderationandquestionsariseatwhenthedeviceshouldborrowhumanauthoritativetraits,suchasanauthoritativevoice,andonwhatoccasionsshoulditemployamoreneutralorpassiveinteractionalstyle.Drawingonourinteractionalanalysis,thenlessauthoritativemachineutteranceswouldbeonesthatthatdidnotnecessarilymandatecomplianceasthenextlegitimateturn.Afurtherpossibilityisthat,whilstthedevicesinthisstudyareconfiguredtoalwaystakea‘leaderstance’,itmaybepossibletointroducecontrolsthatallowthedevicetobe‘nudged’(perhapsatdifferentmomentsduringtheresuscitation)intochangingthecharacteristicsofitsinteractionstowardssothatitexhibitssomethingclosertoa‘followerstance’(Fairhurst2008).

9.3 DesignoftheProtocolInacardiacresuscitationtherearedifferencesintheprotocolsutilisedwithandwithouttheAED,andbothrequireestablishmentofauthoritytosteertheteaminacommonpurpose.Novicesinthissituationwillbepronetodeferringtotheir‘authority’–eitherguidancebytheteamleader(expertdoctor)orthevoiceoftheAED.ThereisaclearprotocolwhenthereisnoAEDpresent.ThereisaclearprotocolassociatedwiththeAEDitself.WhatourfindingsshowisthatthereisnoavailableprotocoltocombineprofessionalexpertisewiththeuseofanAED,andthisleadstoconfusionoverwhichauthoritynovicesshouldfollow.TheCPRguidelinesdoexhortto‘minimiseinterruptions’whenanAEDisbeingused,buthowfardoingsoentailsdisregardingtheAED’sinstructionsismuchlessclear.Ourobservationsrevealhowsignificantthisgapcanbeforsomeinexperiencedstaff.SoitwouldseemhelpfulfortheCPRguidelinesthemselvestooffermuchmoredetailedadviceaboutdealingwithassistivedevices.Earlierwesawthatapplyingaguidelineisamatterforprofessionalexpertiseinfittingtheregularitiesoftheguidelinetothecontingenciesofreal


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worldpractice(TimmermansandBerg1997).Itispossiblethatwhenembodiedindevices,andactivelydeliveredthatthistypeofworkbecomesmoreofanuphillstruggle.Thusitmaybehighlyvaluabletomakeexplicitandassistthedevelopmentofthesesecond-orderpractices–practicesthatarearguablyjustascrucialtotheinterpretationofactiveSmartDevicesastheyareintheperformanceofpassivepaper-basedprotocols.

10 AcknowledgementsThisworkwassupportedinpartbyEUFP7FETSmartSocietyproject(http://www.smart-society-project.eu/)undertheGrantagreementn.600854.ItwasalsosupportedbytheCLEAR(ComparisonofLearningEventandActualResuscitation)projectwhichwasfundedbyasmallgrantfromtheWebScienceInstitute(UniversityofSouthampton)StimulusFundinSept2014.

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