The relationship between technology and changing professional roles in

health care : a case-study in teledermatology

Dr. Stephen Timmons, School of Nursing, University of Nottingham

Mrs. Sandra Lawton, Consultant Nurse, Dermatology, Queen's Medical Centre,

Nottingham

Background

• Huge unmet need for dermatological care• Increasing referrals and waiting lists/times• Too few dermatologists• Difficult physical access to hospital• Patients seen by the most appropriate

member of the dermatology team• An equitable service across the district

GeographyGeography

Nurse led Nurse led community community clinics in clinics in

primary care primary care supported by supported by

teledermatologyteledermatology.

Store and Forward Telemedicine

Mail Server

Telemarque Server

UnitTraining

DataBase

NHS Net

Remote GPwSI

QMC Dermatology Unit

UnitLive

RemotePCT Clinics

TeledermatologyTeledermatology

Store & ForwardStore & Forward

• Digital CameraDigital Camera

• Lap TopLap Top

• EmailEmail

MethodsMethods

Case Study DesignCase Study Design• Embedded single case designEmbedded single case design

• Single case – community clinicsSingle case – community clinics

• Subunits- all those involved in Subunits- all those involved in patient journey (patient journey (GP, Patient,Nurse, GP, Patient,Nurse, Dermatologist and others)Dermatologist and others)

Patient JourneyPatient Journey

M anaged by D erm atology Nurse S hared care w ith Pr im ary C are T eam

S urgery C onsulta tion L ight the rapy M anagem ent Plan

T e lederm atology to C onsultant D erm atologis t

D ay T rea tm ent Pa tch T es t A dm iss ion

S econdary C are S ervices

PC T C lin icNurse L ed Service

G PReferra l to loca l PC T C lin ic

Nurse L ed Service

SampleSample

• Purposively selectedPurposively selected

• 2 patient journeys:2 patient journeys:GP, Patient,GP, Patient,

Nurse, Dermatologist and othersNurse, Dermatologist and others

Data CollectionData Collection

• Semi-structured interviewsSemi-structured interviews

• Observation of the nurse / patient Observation of the nurse / patient consultation consultation

• Data obtained from clinical records Data obtained from clinical records and databases.and databases.

Data AnalysisData Analysis• The analysis and interpretation of the data The analysis and interpretation of the data

was performed manually.was performed manually.• Based on an ethnographic approach and Based on an ethnographic approach and

influenced by the principles of grounded influenced by the principles of grounded theorytheory

• Description of the case (How and Why)Description of the case (How and Why)• Comparative analysis of the data sets :Comparative analysis of the data sets :

( interviews,observations and records)( interviews,observations and records)• Analysis of the emerging themesAnalysis of the emerging themes

Results/Discussion

The unimportance of technology

“No it’s not the main focus, I mean I don’t know why everybody goes on about it being the main focus, because it is telederm it’sall electronic. It’s actually supporting the nurses who are acting intheir own right for their own clinics. That’s what it’s about. It’s not about putting the information on and passing it on to me.” (Consultant Dermatologist)

Shifting boundaries : how ?

• By using teledermatology, individual and organisational practices have been adjusted

• Nurses collect information• But, crucially, decide when & how to refer• The nurses’ role now, effectively, includes

diagnosis

Patients

• Like the service, and are unconcerned about the profession of the person seeing them

• GPs value the expertise of the nurses

The GPs

“It’s not so much things I need a huge diagnosis on but ones I feel the patient will benefit from a longer time in terms of explanation, or if they have been having conventional treatment for a common disorder and things aren’t improving then sometimes I feel they might do better if they came to your clinic, the nurse-led clinic.”

GP

An ‘advance’ in nursing practice

• A contentious point (in nursing)

• Not just working to protocols (as often happens in ‘nurse-led’ services)

• Used existing skills and knowledge, and developed new ones.

How was it possible ?

1 Policy push

2 Skills of the nurses

3 Agreement & support from the consultant & the GPs

4 The technology

A bit of theory

• ANT ?

• Social construction of technology