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Technologies don’t reduce the workload for nurses, but change the work tasks

Pols, Jeannette (2012). Care at a Distance: On the Closeness of Technology. Amsterdam: Amsterdam University Press.

Technological innovation in healthcare has long been caught between promises and fears of its potential impacts. On the one hand, technologies for remote care – often called “telecare”, “telehealth” or “telemonitoring” – have been expected to decrease healthcare costs and provide a solution for the insufficient numbers of healthcare workers in face of aging populations. On the other hand, many dread the idea that technology makes care “cold”, impersonal and detached (not even to mention the raising concerns of surveillance and non-transparent data collection). But how to evaluate telecare beyond such hype and nightmares?

The technique of randomized control trials, which are the golden standard of evaluation in medicine, doesn’t apply well in this case because it is based on strict conditions. Innovative interventions such as telecare aren’t stable enough to fit in fixed evaluative frameworks, mostly because people – healthcare staff and patients – tend to use the same device in different ways, and in this way they keep altering the actual intervention. And so, Jeannette Pols writes,

“It is simply unclear what telecare technology can achieve in care. Promises, nightmares, and dreams of efficiency have taken the place of knowledge and facts in the debate.”

Ethnography, Pols suggests, is more appropriate for the task of studying new technologies in healthcare. Instead of defining variables in advance and then testing hypotheses, ethnographic fieldwork allows for surprising and unexpected discoveries, as the researcher conducts open-ended, in-depth interviews and also observes how patients use technologies in their daily life and how healthcare professionals use it in their work.

In her ethnographic study, which took place in the Netherlands, Pols found that telecare didn’t promote efficiency in the way that many had hoped for. Introducing technological devices to monitor chronic patients at a distance didn’t mean that fewer nurses could be employed, which would lead to reduction in healthcare costs. Here's the thing: the nurses didn’t have to travel to patients’ homes in person anymore, but that didn’t automatically translate into less work. Instead, what changed was the kind of work that they did.

To start with, the nurses had to make sure that the patients understood how to properly use the telecare device. They also had to note all the conversations, decisions and actions in a detailed electronic record, and further, the tasks (and thereby responsibilities) had to be explicitly allocated among various healthcare professionals involved. Suddenly, the nurses found themselves looking after the telecare system rather than their patients. Shifting nurses from home care to sitting behind a webcam in the office influenced the organization of care and communication between different carers and added new administrative task. In the end, this resulted in more, rather than less work for the nurses. As Pols writes,

“telecare has established a change in the quality of care rather than a reduction in cost or improvement to efficiency by saving staff.”

Care at a Distance was published a decade ago, yet the gap between the hopes and concerns about technology remains, now commonly in association with AI and robotics in healthcare and beyond. As Pol's work testifies, ethnographic research is an excellent way to asses the impact of technological innovations on their users and their personal and professional care practices, and provides evidence to guide policies on technological implementation.


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