Persistent institutional breaches: Technology use in healthcare work

Highlights

• New healthcare technology use is inherently disruptive.

• Institutional legitimacy-claiming involves safeguarding responses.

• Institutional legitimacy-claiming involves the case-building responses.

• Institutional breach persistence arises from the moral dimension of legitimacy.

Abstract

Various mobile phone applications (hereafter apps) challenge instituted ways of working in healthcare. This study explores the institutional breaches arising from the use of apps in doctor-patient interactions. This paper argues that institutional breaches, however small, are important occasions for observing the contextual intersections between healthcare, regulation and technology in a hospital setting. Based on healthcare professionals’ normative judgements, the paper offers an empirically grounded understanding of institutional legitimacy-claiming; safeguarding responses deployed by the instituted regime, and the case-building responses deployed by the instituting persuaders. Institutional breach persistence arises from the moral dimension of legitimacy and is grounded in asymmetrical dynamics between two virtuous healthcare narratives. The paper concludes with a discussion of the contextual intersections between healthcare, regulation and technology, paying particular attention to institutional breaches as experimentation, the contestation of normativity and patterns of technology indulgency in healthcare work.

Introduction

New healthcare technologies that offer benefits to public health emerge almost daily. These new technologies often challenge instituted ways of working in healthcare (Greenhalgh and Stones, 2010; Mort et al., 2005; Petrakaki and Klecun, 2015; Currie et al., 2012a, 2012b; Lockett et al., 2012; Petrakaki et al., 2012) and are therefore disruptive – unsettling – not least because of regulatory and policy effects. Most studies exploring healthcare institutions emphasize the importance of developing stable, predictable, and trustworthy organizations (Yeung and Dixon-Woods, 2010). Recognising the importance of the broader institutional dynamics in healthcare work, a special issue of Social Science & Medicine (see Currie et al., 2012a) called for more inter-disciplinary interaction between medical studies and organization studies, particularly in understanding the significance of institutional dynamics in healthcare work (Currie and White, 2012; Lockett et al., 2012; Currie et al., 2012b). Drawing from this emerging literature stream, this paper explores how healthcare professionals respond to institutionally disruptive new technology, particularly non-clinical technology that is used in a clinical setting and as part of professional work. This inter-disciplinary literature draws attention to the importance of institutional dynamics in producing and regulating stable healthcare work (Currie et al., 2012b; Lockett et al., 2012), to keep at bay disruptive challenges, and ensure that a completely legitimate healthcare “organisation would be one about which no questions could be raised” (Tost, 2011: 688).

In this study, we use “institution” in the way that Barley (2008: 495) defines it: “as social forms or templates composed of clusters of conventions that script behavior to varying degrees in given contexts”. In this way, healthcare institutions entail meanings that are often taken-for-granted and formed in earlier times and places (Berger and Luckmann, 1966), and consequently constrain and shape emerging possibilities. However, studies also show that institutional environments are plural (Kraatz and Block, 2008), with complexities and contradictions that compel reflexivity and enable actors to question taken-for-granted meanings and organizational conditions, and challenge the status quo (Greenwood et al., 2011). Nowhere is this more evident than in the interplay among healthcare professionals, the institutional ways of engaging in healthcare work – habitual, purposive, and practical – and the emerging possibilities of new technologies.

While there exist studies demonstrating that technology, particularly organization-wide IT systems, improve healthcare work practices (McGivern and Fischer, 2012), not all technology use follows this organization-wide pattern (Daskalopoulou et al. 2019b, 2020). In this study, we aim to bring analytical attention to what Star (2002) refers to as the ‘institutional fringes’ in healthcare work, where relatively minor new technology use can become a lively talking point, where judgements and values are questioned and scrutinized in the day-to-day practice of healthcare professionals. In as much as a formal large-scale IT system can bring about organization-wide change, new studies also recognize the importance of small-scale technology “activities which take place on organizational floors but bear the mark of the larger institutional waves that flood them” (Hallett and Hawbaker, 2020: 7). For example, there are various mobile apps including, Doctor on Demand, Epocrates, Medscape, MedPageToday, Read by QxMD, UpToDate, which help healthcare professionals to calculate dosages of medications or to identify more easily rare medical conditions by having access to online repositories of information as part of their daily consultation praxis.

Notwithstanding that these apps offer numerous benefits to healthcare professionals' work; the informal use and discretionary nature of these apps can present a spectrum of vexing challenges towards the taken-for-granted instituted ways of working in healthcare. Within a clinical setting, for instance, app use can (i), challenge the way patients perceive a non-clinical device being used in a clinical setting and the associated unprofessionalism of that activity; (ii) compel reflexivity on the boundary conditions surrounding the perceived intrusiveness of such devices as a result of the visual and audio recording capacity of mobile devices and patients’ fears of doing this without their consent; (iii), weaken and blur the boundaries between work and non-work activities, while also eroding traditional notions of epistemic medical authority, setting new precedents of alternative ways or models of patientcare (Daskalopoulou et al., 2019a, 2019b). Despite being comparatively minor in nature, institutional studies show that when commonly held understandings are questioned, these can become a lively talking point within a profession, leading to field-level change (Micelotta and Washington, 2013; Currie et al., 2012b; Lok and De Rond, 2013). Institutionally, whenever commonly held understandings are questioned, then an institutional breach is seen to have occurred; that is, any unexpected act that violates or challenges norm-governing social relations and order (Zelditch, 2001).

This paper therefore makes the case for a greater focus on the contextual intersections between regulation, technology and healthcare work practices at the institutional fringes and the way that individual healthcare professionals handle threats to healthcare stability arising from disruptive challenges – something we illustrate through an in-depth exploration of the use of mobile apps by healthcare professionals (doctors) in a hospital setting. Exploring the use of mobile apps within healthcare is timely and is contextualized within the growing use of smartphones more generally. First, doctors are increasingly gaining ad hoc access to various technological platforms to cognitively support and enhance healthcare work. As these platforms have advanced and become more pervasive, traditional institutional scripts (i.e., handbooks of rules) have arguably become more fragmented, detached and inaccessible. Consequently, rules on the use of mobile phones are a focus of legitimate concern, with consensus still lacking amongst healthcare professionals. On the one hand, mobile phone use is increasingly judged as legitimate because its use is seen to espouse healthcare virtues, making a positive impact on patientcare. On the other hand, mobile phone use at work contests the traditional notions of epistemic medical authority, setting new precedents of alternative ways or models of patientcare.

Second, most health and social care employers have policies concerning the use of mobile phones at work, with mobile phone use at work generally viewed as ‘a nuisance’. Typically, these regulatory policies clarify when, where and what mobile phone use is prohibited when healthcare staff are on duty and in certain areas of healthcare delivery. Mobile phone visibility ensures that it is fairly easy to identify what it means not to follow the policy. However, doctors who intentionally deviate from and contest the appropriateness of such hospital policy, render mobile phone use problematic.

Third, drawing upon the idea that regulatory disruption does not occur solely through ‘traditional’ instruments such as policy rules, the use of mobile phones by doctors, it could be argued, is not consistent with the expressive or symbolic signatures of healthcare values or virtues. For example, mobile phone use arguably attacks the value of ‘human-to-human’ relationships which are considered crucial for positive evaluations of medical outcomes (Petrakaki et al., 2018). Moreover, mobile phone use, is often seen as more expressive of ‘recreation’ as a practice. Overall then, the growing presence of mobile phones in hospitals and concomitantly the greater range of mobile apps used within healthcare settings, raises questions on their legitimacy – and this makes this a perspicuous setting to study.

Using an institutional perspective, several studies have shown how regulatory policy ‘breaks down’ on an individual basis within existing institutional orders (Heaphy, 2013; Herepath and Kitchener, 2016). These studies view regulatory disruptions as a form of institutional breach – that is, violating commonly held understandings, which, in turn, requires a variety of intervening practices to return to ‘normalcy’. Research conceives of institutional breaches as ‘a process of repair’ via the skilful use of rules (Heaphy, 2013), comprising ‘temporary or momentary breakdowns’ (Barley, 1986), and consisting of ‘small tears in the institutional script’ (Lok and De Rond, 2013).

The intricacies of the healthcare context pose significant challenges for restorative interventions and ways to repair those institutional breaches in the normalcy of healthcare work. Institutional breaches typically prompt authoritative responses: restorative interventions that repair and thus maintain institutional legitimacy. The most visible forms of responses include, using the legitimacy of rules to restore, clarify, or initiate changes to maintain institutions (Heaphy, 2013), or the legitimacy of public inquiries to redress severe breaches (Herepath and Kitchener, 2016). Another powerful response, we argue, is institutional members' responses to maintain institutional stability in the face of disruptions. Here, the emphasis is placed on the evaluator's normative judgements to appraise, influence, and convey through communication, what behaviours or practices meet with approval or disapproval in mandated structures or practices (Meyer and Rowan, 1977). Critically, this perspective also offers an appreciation of the alternative sides of the institutional breach – one that is instituted and retains the status quo and another one that is instituting as a new practice. In doing so, it underlines regulatory policy disruption occasions where there are not always strict interpretations of rules, as right and wrong, or straight-forward procedural forms of enforcement, but conduct is guided by norms or beliefs about what is appropriate and approved of in a given healthcare context.

In order to study this, we pay attention to micro-foundations of social judgment formation (Bitektine, 2011; Tost, 2011) to develop an understanding of how healthcare professionals handle policy disruptions vis-a-vis normative judgements. This study draws on social psychology perspectives on legitimacy and a sub-set of the institutional literature in order to analyse healthcare professionals' judgements of everyday institutional breaches. This study has three main theoretical contributions. First, we contribute to healthcare literature by providing finer granularity of how regulatory policy ‘breaks down’ on an individual basis within a healthcare setting. This contribution is developed, first by showing how the informal use of new technologies results in institutional breaches, and second by broadening our understanding of how individual healthcare professionals' normative judgements, particularly high-status individuals', are consequential. In doing this, we respond to calls to shed light on the internal dynamics of legitimacy-claiming – a perspective from within rather than a perspective of external stakeholders – and analytical variation in forms of agency beneath the field or organisational level of analysis (Heaphy, 2013).

Our second important contribution concerns the nature of institutional breaches. By identifying the normative judgements working on disruptive policy breaches – safeguarding and case-building – we demonstrate the two-sided dynamics of institutional breaches in the course of everyday healthcare work. We highlight the ‘softer aspects’ of institutional restoration beyond the ‘hard tools’ of repair (rules or public inquiries, see Heaphy, 2013; Herepath and Kitchener, 2016); the importance of the institutional fringes in working with new technology (Star, 2002), in this case mobile apps, but also the breaking down of long-established instituted ‘encrusted obstacles’ (Suchman, 1995) and medical practices.

Our third contribution shows how the persistence of breaches is a fruitful means of understanding institutional maintenance. Our analysis departs from, but complements, the institutional breach as ‘a process of repair’ perspective and shows the persistence of institutional breaches grounded in the moral dimension of legitimacy and the asymmetrical dynamics between two virtuous healthcare narratives. Each side of the breach can be equally right. Our findings show a complex intersectional context, rather than a binary opposition between two normative positions. Here, there are no short-term resolutions to reinstate the social order, with mobile technology given ‘just enough’ agency to prevent institutional harm, to safeguard and with ‘rumblings of repair’ (Clark and Newell, 2013) to integrate within the institution. This helps to understand a different side to institutional breaches – the persistent one – and this has been largely missing in previous research on legitimacy in healthcare settings.