Transforming work practices of operating room teams: the case of the Da Vinci robot

Transcription

1 Transforming work practices of operating room teams: the case of the Da Vinci robot Research-in-Progress Anastasia Sergeeva VU University Amsterdam De Boelelaan HV Amsterdam The Netherlands Marleen Huysman VU University Amsterdam De Boelelaan HV Amsterdam The Netherlands Samer Faraj McGill University 1001 rue Sherbrooke Ouest Montreal, Quebec Canada Abstract Information systems researchers interested in the materiality of digital technology have frequently emphasized the need to study work practices and take a sociomaterial perspective on practice change. We address this need in our study on the introduction of a Da Vinci robot, an endoscopic surgical system for minimally invasive surgery, in a hospital operating theatre. Building on the insights from an ethnographic study in a major teaching hospital, we report on the process of how surgery practice changed following the introduction of the Da Vinci robot. We suggest that the robot brings about a new spatial distribution of roles and activities next to and away from the patients' body, mediates and transforms existing work relations, thus forcing a new order of space use, altering visibility and yielding expertise movement. Our findings have implications for understanding how digital technology transforms work practices in general and in complex medical teamwork in particular. Keywords: sociomateriality, work practices, robots, technological change, digital innovation, practice theory, materiality, teamwork, healthcare, high-reliability teams, professions, technology use Thirty Sixth International Conference on Information Systems, Fort Worth

2 Introduction Researchers have recently focused significant attention on untangling the relationship between concepts such as materiality, sociomateriality, space, technology and work practices (Fayard and Weeks 2014; Jones 2014; Kautz and Jensen 2013; Leonardi et al. 2012; Leonardi and Barley 2008; Orlikowski and Scott 2008; 2013). Often, grouped under the label of sociomateriality, these studies challenge more traditional approaches to studying technological change. For reasons of ontological separability and research tractability, most studies consider technology and the social as separate entities and focus on how technological artifacts and social relations influence each other (e.g. Barley 1986; Edmondson et al. 2001, Davidson and Chismar 2007; Leonardi 2011). Alternatively, researchers adopting a sociomaterial perspective question the inherent separation between the technology and the social and instead propose to recognize their interpenetration and co-evolution (Cecez-Kecmanovic et al. 2014; Orlikowski 2007; Mol 2002). An important challenge remains; how to go beyond the recognition that all practices are materially constituted and to develop new conceptual explanations of how practices evolve that do not favor either the social or the material but allow a deeper understanding of technology-dependent organizational change. We address this challenge in our study on the introduction of a Da Vinci robot, an endoscopic surgical system for minimally invasive surgery, in a hospital operating theater. The practice of surgery in hospitals is generally seen as highly reliant on the skilled performance of specialists and thus is relatively immune to technological transformation (Gawande 2002). Surgery requires a multidisciplinary team of professionals, working collaboratively. The team usually consists of surgeons, residents, anesthesiologists, scrub nurses, and circulating nurses, who work together to move the patient through the procedure safely. Hospital surgery takes place in a sterile operating room (OR), and is mediated by numerous instruments (e.g. scissors, scalpels, needles), equipment (e.g. monitors) and other artifacts (e.g. operating table, surgical trays, bandages, threads, medications) that are carefully positioned in specific locations. The practice of surgery is highly dependent on expertise within a discipline but also on knowing how to use the space and artifacts in the OR. The work relies on protocols which clearly delineate actions, roles, and responsibilities for each discipline, and for who does what when material conditions change (e.g. unexpected bleedings or equipment malfunctioning). These protocols may even specify where each team member will stand in relation to the patient and equipment. The introduction of new equipment such as the Da Vinci robot triggers a significant reshuffling of surgical practice. A Da Vinci robot is an endoscopic surgical system that facilitates the performance of complex surgical procedures in a minimally invasive manner. Using small robotic arms, miniature jointed instruments and a high definition camera, Da Vinci allows surgeons to move instruments in a highly precise manner via small surgical incisions. The robotic system consists of the surgeon s console, patient side cart, articulated EndoWrist instruments and a vision cart. Robotic surgery is designed to be performed remotely, i.e. by a surgeon sitting at a console away from the operating table, manipulating patient-side arms through control joysticks. It is one of the recent innovations in healthcare and is claimed to provide a number of new affordances for performing surgery. Several are commonly emphasized in the medical literature, such as increased precision of surgical movements, enhanced dexterity of instruments, better ergonomics and a decrease in the number of team members required. In some cases and for some procedures, surgery performed with the Da Vinci robot is claimed to provide superior outcomes in terms of minimizing invasiveness, reducing rates of complications and decreasing length of recovery time (for an overview of applications of surgical robots see, e.g. Lanfranco et al or special issue of the journal Surgical Clinics of North America on the use of robotics in surgery, 2003). The distinctive feature of this system is the affordance for a surgeon to operate not directly on the patient, but remotely, on a three dimensional image of the body, while seated at a console away from the operating table. Comprising several large stand-alone carts, the Da Vinci robot takes up a considerable amount of space in the operating room and changes the traditional spots that different team-members usually occupy. Our study therefore asks the following research question: how does the Da Vinci robot influence the sociomaterial enactment of surgical practices? In the balance of this paper, we report on an ethnographic study in a major teaching hospital. We suggest that the robot brings about a new spatial distribution of roles and activities next to and away from the body, mediates and transforms existing work relations, and thus forces a new use of space, alters visibility and yields expertise movement. Thirty Sixth International Conference on Information Systems, Fort Worth

3 Theoretical background Previous studies of technological change taking a sociomaterial perspective have started to provide insights about how the introduction of new technologies reconfigures work practices and relations in the workplace. For example, in a study of robotic pharmacy, Barrett et al. (2012) have shown that the introduction of a digital robotic configuration for automatically stocking and dispensing medications changed the spatial layout of the pharmacy and reduced the visibility of the work done by a particular professional group (pharmacy assistants), producing a boundary neglect and reinforcing their low status. In a study of the introduction of a computer-based clinical information system in a hospital critical care unit, Jones (2014) demonstrated how the introduction of a vertical computer screen at the bedside created a visual barrier between nurses and patients and changed how nurses moved around the bed, how they performed surveillance of the patient and produced tensions in what nurses considered to be a proper nursing care. Likewise, in a study of electronic patient records in a multi-disciplinary practice, Oborn et al. (2011) found that many medical professionals chose particular locations to use tablets with electronic patient records, specifically not using them in the consultation rooms during patient encounters. Together, these studies on sociomaterial practices in healthcare indicate that space use and non-use play an important role when reconfiguring the practices following the introduction of the new technology. However, existing theories still do not sufficiently account for how exactly space matters. Prior research has examined use of space in collaborative practices (e.g. Hutchins 1991; Bechky 2006; Heath and Luff 1992; Scupelli et al. 2010; Klein et al. 2006; Nardi et al. 1993; Bailey et al. 2012). One finding relates to the significance of co-location and how it shapes the visibility into what other people are doing, so that team-members can dynamically monitor and adjust their actions in relation to each other (e.g. Bechky and Okhuysen 2011; Heath and Luff 1992). For example, in teaching trauma centers where residents have to learn skills of critical care, this means that the attending physicians stand close by and observe the residents actions, ready to intervene any time. This affords the dynamic delegation of authority and an opportunity to swiftly step in to ensure safe care (Klein et al. 2006). Further, the configuration of the space defines what kind of access team members have to the so-called empirical interface or common information space (Hutchins 1995; Bailey et al. 2012; Bean and Orlikowski 2014), i.e. providing shared visibility into the object of work. For example, physicians and residents performing night rounds together can jointly observe the patient under treatment and therefore have access to complex information about the patient's condition, such as the changes in blood pressure, changes in mood or reactions to the adjustments of therapy (Bean and Orlikowski 2014). Finally, artifacts and their positioning in space serve as a site of knowing, also referred to as the silent work of artefacts and infrastructures (Nicolini 2011: 610). This means that the positioning of team members and the artifacts they are using in a particular place are not random or neutral, but rather each participant of the practice will have a particular spot and this spot embeds the expertise and knowledge. In our case, the Da Vinci robot serves as a trigger for team-members to reconsider their and other artifacts positions in the workspace of the operating room. Given that robots are large, obdurate and technologically sophisticated contraptions, it is not surprising that they occupy significant space next to the patient. Making room for a robot is a challenge to the surgery team, as space allocation around the patient reflects expertise of the professionals and a view of the patient. For example, an anesthesiologist is typically positioned at the head of the patients body due to their need to access the respiratory system. A location close the patient also provides visibility into the patient s condition and is required for clinical intervention and the application of one s expertise. Finally, it provides crucial visibility into the actions of other specialties, an important requirement for surgery where work is highly interdependent and protocolized. Thus, space is highly staked and change can be highly contested, as each specialty needs optimal access to their objects of work. Introducing the robot into the operating room means that not only the robot occupies valuable space around the patient, but also that it acts and transforms longstanding work relations in the surgical team in unexpected ways. Research design and methods The setting of our study is a surgical unit in a large academic hospital in the Netherlands. The primary sources of data are ethnographic observations and in-depth interviews. At the moment of writing, the first Thirty Sixth International Conference on Information Systems, Fort Worth

4 author has conducted 62 hours of ethnographic observations, during which 12 surgeries have been observed. After each visit to the field, she wrote detailed field notes that capture the complexity and richness of the surgical practice. Right from the beginning, we noticed that one of the intriguing aspects of the use of Da Vinci robot is the increased distance between the patient, the surgeon and other team members. Therefore, we focused our observations and analysis on how the robotic console which is situated in the corner of operating room and the robotic cart that is occupying significant space next to the operating table re-shape the positioning of actors and artifacts towards each other. To make these field notes richer and telling, we also made use of maps and photographs of the settings to convey the visual representation of the practice. In addition to the observations, we have conducted 11 in-depth interviews (2 surgeons and 8 operating room nurses and 1 manager of operating rooms), which lasted from 35 to 70 minutes. Interviewing surgeons, we asked them to describe the process of adoption, e.g. how they personally experienced the introduction of the Da Vinci robot and other events in the hospital. We also asked them to reflect on how they learned to use the surgical robot, as well as the changes in knowledge and skills that the use of Da Vinci robot has created, and the changes that the use of the robot brought to their work in the team. When interviewing nurses, we asked them to reflect on their activities and interactions with team members while assisting in three types of surgical procedures: open (traditional), laparoscopic and robotic ones, as well as to reflect on any changes in the knowledge and skills Da Vinci robot might have occasioned. Findings Figure 1 provides an overview of setup of the operating room with the Da Vinci robot. The surgeon is sitting away from the operating table, manipulating the console. The assistant (typically a surgical resident in training) and the scrub nurse stand at the operating table next to the patient s body. Figure 1. Map of operating room and actors of the surgical team in a robotic procedure [2015] Intuitive Surgical, Inc. A typical robotic procedure goes through the following steps. After the patient is anesthetized, the surgical team members make small holes in the body of the patient (about 1-2 cm) which serve as ports to insert endoscopic instruments inside the abdomen. After the holes are made, the so-called trocars are inserted inside the body, to serve as portals to insert and manipulate the various instruments, such as scissors, graspers or staples. After the trocars are inserted, the next step is to wheel the patient side cart (with robotic arms) towards the patient on the operating table. The patient cart with the arms and instruments are settled above the patient in a fixed position (see Figure 2). Thirty Sixth International Conference on Information Systems, Fort Worth

5 Figure 2. Configuration of operating table with the robotic cart placed above the patient s body and the surgeon operating the console in the corner The next task is to insert the instruments into the robotic arms and through the trocars. After the instruments are inserted, the surgeon sits at the console from where he manipulates the controls that direct the movements of the robotic arms. The console is situated in the distant corner of the operating room in order to provide some free space around the patient for other team members to walk freely. The console is configured in such a way as to let the surgeon sit in an ergonomically comfortable position. Peeking through the console, the surgeon sees a high definition 3D image of the patient s body on the console screen. The 3D image allows the surgeon to perceive depth and to become completely immersed in the operative field. This view creates what some surgeons refer to as floating in the body of the patient. The transformation of surgery practice One of the most pronounced consequences of introducing the Da Vinci robot into the work of surgical teams, according to our respondents, was the significant change in the tasks and the roles of scrub nurses, as scrub nurses took over several tasks that traditionally were performed by surgeons. The following quote from an interview with one of the senior nurses, specializing in robotic surgery, illustrates this: Robotics has become very popular [among the nurses]. Six years ago nobody wanted to do that. It had a very bad name, because we only were allowed to make the instrument tables ready and everything ready, but after that we did not participate and at the end of the surgery we could clean up the whole mess. And we did not really have a role. And now we are starting to have a role in things, and we can do things that surgeons do. And it makes it a lot more exciting! And also for the residents it s important because then they can also take a seat behind the console and do their things there. (Lesley, OR nurse, lead in robotics) Having identified this change, we zoomed in to understand how the change came about and the implications it had for the surgical practice. We identified three broad phases of practice transformation and detailed the shifts between different team-members tasks over time. The basic outline of changes over the phases is summarized in Table 1. Thirty Sixth International Conference on Information Systems, Fort Worth

6 Phase 1: Separating teammembers Phase 2: Reshuffling roles and spaces Phase 3: Scattering actors Changes in spatial positioning of actors Robotic cart with the arms takes up the bulk of space at the table Surgeon leaves the operating table and sits at the console in the corner Resident and scrub nurse stand at the operating table Resident leaves the operating table and sits next to the surgeon and occasionally operates the console Scrub nurse stands alone at the table Residents and surgeons sit in the corner and spread out across the room on chairs Resident and surgeons move freely in and out of the OR Scrub nurse stands alone at the table Activities Surgeon and resident: inserting the trocars (make holes in the patient) Surgeon: core surgical intervention (e.g. removing tumors) Resident: assisting (i.e. changing instruments in robotic arms, suction, placing clips) Scrub nurse: instrument preparation, handing in the instruments to residents and cleaning up Surgeon and resident: inserting the trocars Surgeon or resident: core surgical intervention Scrub nurse: assisting, instrument preparation and cleaning up Resident and scrub nurse: inserting the trocars Resident starts and surgeon continues core surgical intervention Scrub nurse: assisting, instrument preparation and cleaning up Visibility of the patient Surgeon: only sees the core operating area (1.5 cm view inside the body) Resident and scrub nurse: the same area mediated by camera through the screen + the area outside (e.g. physical body of the patient, instruments, tubes) Surgeons/residents: the core operating area through the console Scrub nurse: the core operating area (through the screen) + the outside physical body and artifacts Surgeons/residents: the core operating area through the console Scrub nurse: the same operating area (through the screen) + the outside physical body and artifacts Visibility into the actions of others Surgeon cannot see anyone s actions outside and rely on verbal communication Scrub nurses and resident follow the actions of the surgeon via the monitor Resident follows the operating surgeon's actions through the screen and interacts with the surgeon (for learning purposes) Surgeon follows the operating resident s actions through the screen (for supervision purposes) Scrub nurse follows and adjusts to the actions of surgeons through the screen Other surgeons and residents come in the room to observe the intervention on the monitors Expertise movements Surgeon does the core surgical intervention, relies on the residents for assisting tasks Resident supports the actions of surgeons (to know what instrument to hand in) Scrub nurse supports the actions of the resident Resident and surgeon sit next to each other at the console area in order to sensemake and discuss the intervention s progress Surgeon starts to allow resident to perform the core surgical intervention Scrub nurses performs the assisting tasks that require surgical skills and knowledge of anatomy Resident, and increasingly nurses, insert the trocars independently from the surgeon Surgeon increasingly allows resident to perform the core surgical intervention Table 1. Changes in the surgical practice upon the introduction of Da Vinci surgical robot Thirty Sixth International Conference on Information Systems, Fort Worth

7 Phase 1: Separating the team members In contrast to traditional procedures, robotic surgeries require repositioning the actors in the OR space. First, because the robot is located in the farthest corner, this creates a maximum distance between the surgeon at the console and other team members at the operating table. Second, because the console is configured in such a way that surgeons need to press their head into it to create a full immersion experience (see Figure 2), the peripheral vision of the surgeon is blocked and the visibility of the actions of other people is limited. Third, the console allows the surgeon to operate five arms simultaneously, using the foot pedal to switch between operating arms. These material changes had the following effect on the practice configuration. First, the robot functionality reduced the reliance of the surgeon on the assistant who previously (in laparoscopic surgeries) had to hold and manipulate the endoscopic camera, as this task was now done automatically by the robot. Second, because the distance between the surgeon and other team-members increased, it limited the learning and teaching possibilities for residents. Before, the residents could dynamically switch the instruments with the surgeon to try their hand at performing core surgical tasks. Being away from the console, residents could not do that anymore and were left to perform peripheral tasks such as inserting and changing the instruments into the robotic arms and suctioning. The scrub nurses task was to stand next to the residents and hand them the instruments to be inserted (see the schematic layout of the OR on Figure 1). Finally, because of the increased separation of the surgeon and the rest of the team, surgeons were confronted with the challenge of decreased horizon of observation (Hutchins, 1991), not having a clear overview of what others are doing: And here [in robotic surgery] you ask a lot. Yeah. And what s very strange, if you ask, you say: can you please put in a clip? and they [scrub nurses] are searching on the table because they did not expect that. And you wait, and you don t know did they hear me? You are just sitting there [he shows how he sits at the console and peeks in the screen] and you are like [wondering]: did they hear me? And then you say, like: Can I have a clip? And they are like: Yes! I am getting the clip [in a annoyed tone] it s not going fast enough?! and I am like: I don t know I just cannot see what you are doing over there! You have to say to me I am looking for the clip, wait a moment! And they forget that they have to give the verbal feedback to me, because I cannot see them! I can only see this little piece in the patient, so it s a very different way of communicating with each other (Jack, urologist 2). Phase 2: Reshuffling roles and spaces The increased distance between the surgeon and the rest of the operating team was important, specifically for surgical residents, who now had fewer opportunities to learn surgical skills because tasks could not be delegated as dynamically and on the spot as before. Delegating would require that the residents walk back and forth to the robotic console across the room, take on and off sterile scrubs, and switch places at the console with the surgeon, instead of instantaneously switching hands holding an instrument. Moreover, even when the resident could take a place at the console for several minutes doing some easy tasks, it would imply that somebody still had to stay at the operating table in order to change the instruments and manipulate sharp instruments inside the body of the patient. The residents did not learn anything besides suction and well, after 10 or 20 times you have had enough of that! The residents come here to learn surgery, to learn to become a surgeon, and not to learn assisting, and that s one of the biggest problems I think of the robotics, that you have to create a situation where everybody should learn the things that they should learn. And in robotics the only way to make sure that people [residents] learn their surgery is behind the console. And the only way you can solve that problem is when you have nurses that can do the job! (Lesley, lead nurse in robotics) Therefore, the new positions created problems for the practice of teaching residents, which culminated at a point when, during one surgery, a resident explicitly refused to perform assisting tasks and asked one of the most experienced nurses, Lesley, to take over the assisting task so that he could go and sit at the console to practice his skills. The success of this event increased the confidence of surgeons that they could actually delegate such tasks to experienced scrub nurses. Over time, the lead nurse Lesley became exceptionally skilled at the assisting job and became for surgeons often a more preferred assistant than Thirty Sixth International Conference on Information Systems, Fort Worth

8 the residents. She in turn started to be active in promoting the change and advocated for the delegation of assisting tasks to other nurses as well, taking on a coach role to train other nurses in the tasks of assisting robotic surgery. This gave residents the opportunity to practice their skills at the robot and learn how to do a procedure. A new way of doing the surgery, where the tasks and roles were reshuffled, started to emerge. Nurses were more and more expected to stand at the table and assist, while the residents increasingly sat next to the robotic console and the surgeon in the corner. Phase 3: Transforming and scattering actors Consequently, in the next phase of the practice transformations triggered by the Da Vinci robot, the following changes took place. First, the scrub nurse now stood alone at the table instead of standing next to the resident and handing him/her the instruments. In addition, the scrub nurse was now directly physically manipulating the instruments through the trocars inside the body of the patient, a task that was so far never performed by the nurses, signaling their role enrichment. The fact that scrub nurses could now stand at the table alone and assist also had an effect on what residents and surgeons did and where they were positioned in the OR. First, residents started to spend more time in the corner of the OR, where they worked the console and manipulated the robot for easy parts of the procedure. The surgeons helped and guided the resident by standing next to the console, looking at the screens to monitor the resident's movements and giving verbal directions when necessary. Occasionally, the surgeon used the screen where he could draw lines directly on the image to guide the actions of the resident. For the rest of the procedure, the surgeons and residents increasingly stayed away from the operating table, sitting on chairs and watching monitors and talking to each other or other observers present in the operating room (e.g. medical interns, visiting colleagues, researchers). Therefore, the way of doing robotic surgery started to look like a more distributed practice, where actors sat in a relaxed way on the chairs around the room, observing the actions of one console operator (surgeon or resident) and the scrub nurse through the screen (see Figure 3). Figure 3. Scattered actors durint robotic surgery (Looking at the screen are the surgeon and the residents. In the corner at the console another surgeon is doing the procedure. Next to the operating table with the instruments and the patient is a nurse in sterile scrubs) Conclusion and future research This research in progress paper reports preliminary findings of an on-going study on the use of the Da Vinci robot in operating rooms. The data collection and analysis for this study are ongoing. We plan to focus on unpacking in greater detail the process of how robotic technology transforms space and practice. We hope to contribute to the literature on organizing in healthcare and the impact of digital technology on medical collaborative work. Previous studies in this field have shown that effective organizing and coordinating in high-reliability settings depends on various conditions such as shared team knowledge structures (Rico et al., 2010), psychological safety (Edmondson et al., 2001), dialogic coordination (Faraj and Xiao, 2006) and reaching provisional settlements to manage ambiguity (Bean and Orlikowski, 2014). We hope to build on these studies by paying specific attention to the material dimension of this organizing, highlighting that coordinating and organizing is grounded in materialized performances. Our early findings suggest that the robot brings about a new spatial distribution of roles and activities next to and away from the body, transforms existing work relations, and thus forces a new order of space use, alters visibility and yields expertise movement. Thirty Sixth International Conference on Information Systems, Fort Worth

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