The Multiple Intersecting Sites of Design in CSCW Research ...

Computer Supported Cooperative Work (CSCW) (2015) 24:319–351 DOI 10.1007/s10606-015-9227-4

© Springer Science+Business Media Dordrecht 2015

The Multiple Intersecting Sites of Design in CSCW Research Pernille Bjørn1,2 & Nina Boulus-Rødje1 1

University of Copenhagen, Copenhagen, Denmark (E-mail: [email protected]; E-mail: [email protected]); 2University of California, Irvine, CA, USA (E-mail: [email protected])

Abstract. CSCW is fundamentally an interdisciplinary research endeavour investigating the basic nature of collaborative work with the aim of designing collaborative technologies. Yet, it is not pre-given where CSCW design takes place. This leads to the simple, yet important, question: Where can we find the sites of design in CSCW research? In other words, where does CSCW design actually take place? To answer this question, we follow a CSCW researcher as she creates various connections across multiple sites of design, takes on various roles, and engages with different types of interventions. We unpack the complex interplay between multiple intersecting sites of design and the transformation processes that result from the connections created. We explore the different types of interventions that were enacted by the CSCW researcher during a longitudinal study of the collaborative work and the design of healthcare systems within a paediatric emergency department. We further unpack the multiple intersecting sites of design, and show how the researcher exercises different analytical sensibilities, transforming the various design sites. We argue that the classic CSCW discussion about the relationship between ethnography and design no longer fully captures what a contemporary CSCW researcher does when she engages in various types of interventions across multiple sites of design in an interdisciplinary manner. Thus, we suggest distributing what constitutes a field site in CSCW research, including changing how we characterize roles and interventions in CSCW research. Keywords: Contemporary CSCW, Ethnography, Design, Analytical sensibility, Healthcare, Design workshop, Reflexivity, Multi-sited design

1. Introduction Interdisciplinarity is at the heart of the CSCW field (Grudin 1988). After all, CSCW emerged as an attempt to bring together social scientists and computer scientists in a joint effort to understand the basic nature of collaborative work with the aim of designing technologies to support the work (Schmidt and Bannon 1992). In the early days of CSCW, bringing together social scientists and computer scientists raised various disciplinary tensions, challenging some of the epistemological and ontological commitments found in each discipline. Thus, computer scientists and ethnographers had to find a way to define and situate the interdisciplinary project of CSCW (Suchman 1994). This generated many heated debates about the links between ethnography and design, posing questions as to whether the disciplinary discrepancies where too great to overcome (Grudin and Grinter 1995; Button and Harper 1996). Nevertheless, at the very core of the relationship between ethnography and

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Pernille Bjørn and Nina Boulus-Rødje

design lays the notion of interventions. As formulated by Schmidt and Bannon (1992), CSCW is Ba research area devoted to exploring and meeting the support requirements of cooperative work arrangements – CSCW is basically a design oriented research area. This is the common ground^ (Schmidt and Bannon 1992, p. 12). This sentence is followed by the phrase Benter, and you must change,^ (emphasis added) inviting ethnographers into the interdisciplinary field of CSCW while at the same time pointing to the interventionist agenda of the field. How this interventionist agenda is defined, however, remains problematic. CSCW arguably resides in somewhat of a vacuum with respect to detailed examinations of concepts like Bethnography^ and Bdesign^ (Schmidt 2000). Ethnography and/or fieldwork may have any number of theoretical purposes – or none at all. Ethnography may come with a range of epistemological and ontological commitments, or none at all. It may be conducted under the auspices of some quite strict methodological injunctions, or some very loose ones. It may take place under the auspices of a single discipline (e.g., sociology, anthropology), or may make a claim of being interdisciplinary. Its purposes may be quite specific, such as to evaluate the functioning of a specific piece of technology. Or the objectives may be broadly conceptual: to assess, for instance, what level of generalization or categorization is appropriate for the examination of the domain in question. Attempts have been made to clarify the various fieldwork approaches used by ethnographers in CSCW; however, these are typically left unspecified (Harper 2000). One might make exactly the same observation about the concept of Bdesign.^ Does the concept refer to usability issues? Conceptual foundations? Requirement specifications? Information systems? Technologies in a broad sense? Organizational change? What seems unarguable is that in one or more senses the CSCW agenda orients to the notion that ethnographies should relate to the process of change, even if the result is the argument that no change is needed. Therefore, we need to add to the mix the recognition that Bchange^ entails a set of political and moral decisions. In a recent article by Jeanette Blomberg and Helena Karasti (2013), the authors examine the past 25 years of ethnographic research in CSCW, arguing that the literature suggests Bdesign in the context of CSCW is perhaps best enabled through strategies that inextricably tie ethnography and design^ (Blomberg and Karasti 2013, p. 373). We agree, for not to accept that is to argue against any kind of interdisciplinary agenda and to lapse back into disciplinary concerns alone. The question then becomes how can ethnography and design be inseparably tied together, given the varying character and the relationship between the two domains? We propose the view of a non-deterministic relationship in which CSCW sensibilities, present in both ethnographic and design practice, inflect our approach. In this way, we suggest a relationship in which one practice implicates the other, but not that one causally leads to the other. This relationship views the researcher as neither solely ethnographer nor designer, but both at the same time in respect to their analytic orientation. To bypass the connotations that the labels Bdesigner^ and Bethnographer^ have, we use the label BCSCW researcher.^ The CSCW researcher is such a figuration melding together the

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ethnographic perspective as an integral and inseparable part of design in the CSCW arena. Thus, our research question explores how the CSCW researcher intervenes across the multiple intersecting sites of design and the complex transformation processes that result from these interventions. In this way, we move beyond the discussion about ethnography and design as two separate domains that need to be linked. Instead, we take the interdisciplinarity of CSCW as a prerogative, following the view that both domains are equally present in the practice of CSCW research. Thus, CSCW is no longer simply a field that brings together two distinct and separate disciplinary researchers, namely social scientists and computer scientists. Instead, the field is now increasingly composed of interdisciplinary researchers. These are contemporary CSCW researchers, like us, who carry an education that crosses several disciplines and are interdisciplinary by training. The ways in which we plan, engage, and conduct research distinguishes our practice from the social scientists and computer scientists who met back in the 1980s to establish the CSCW field. Being a product of this interdisciplinary field, we revisit the classic debate about ethnography and design, and discuss it vis-a-vis the interventions of the contemporary CSCW researcher. We will follow the CSCW researcher and unpack the various interventions and interactions carried out across multiple sites for design. These design sites do not simply exist out there, waiting to be discovered. Insights from anthropology (e.g. Amit 2000) and other fields have shown us how ethnographic reports are constructions formed out of choices about focus area, opportunities and recourses available, reporting style, and conceptual and epistemological conviction (Marcus and Cushman 1982; Marcus 1998). We argue that the sites for design are reflexively constructed by the interactions that the CSCW researcher has, selecting and bounding the sites, engaging with people and material artefacts (Blomberg and Karasti 2013, p. 389; Williams et al. 2014). Thus, interventions are constitutive of the sites of design. This means that we need to pay attention to the practices, roles, and activities across the broad spectrum of a particular inquiry. However, such choices and activities of connecting, selecting, and bounding the sites remain unarticulated and invisible to the reader, as these are often missing from published work (Ibid, p. 390). Therefore, in this paper, we explicitly take a reflexive approach and commit our interest to unpacking the ways in which the CSCW researcher constructs the sites of design and the object of study by closely tying dedicated interests across ethnography and design. We further illustrate how the CSCW researcher, the design sites, and the object of study are continuously transformed. Reading some of the key literature about ethnography in CSCW (e.g. Randall et al. 2007; Crabtree et al. 2012), we learn about topics such as how the ethnographers negotiate access and acceptance in the field, and the roles of insiders and outsiders. While these insights are indeed important and useful, they are all based on the premise of the distinct disciplinary interest of ethnography and reveal little about how to actually move from ethnography to design. We learn a little about what interventions actually look like, about the complexities of engaged commitment within the field site, and about how these are to be explored or dealt with, but

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arguably not enough about the steps required in moving towards some kind of design outcome. As mentioned, we view this relationship as non-deterministic since it depends on any number of variables, some of which we have listed previously. Therefore, in this paper, we provide an in-depth and reflexive account of the complexities involved in intervening by drawing upon a 2-year study conducted by the first author, and by analyzing the processes by which the CSCW researcher and the design sites emerged and transformed. The study focuses on examining the collaborative work practices between December 2006 and November 2008 at a Canadian paediatric hospital emergency department (ED). This research project aimed to 1) develop a conceptual understanding of the basic nature of triage work in EDs (Bjørn and Balka 2007; Bjørn and Rødje 2008), 2) participate in the design of a collaborative IT application (an Emergency Department Information System, or EDIS), and 3) collect empirical data about the system development process (Bjørn et al. 2009; Bjørn and Hertzum 2011). The study was part of the larger project, ‘ACTION for Health’ (Balka 2003), which carried the explicit interventionist CSCW agenda. The interventions in this project were not pre-determined, but rather were kept as emergent and situated features of the research. This paper explores the ways in which the CSCW researcher engaged with the empirical site and points to the complexities related to the interventionist agenda. In particular, we follow the interventions of the researcher as a strategy to identify where the sites of design emerged. Drawing upon reflexive methodologies, we acknowledge the co-construction of research and results, which is consequentially predicated upon specific interactions between the CSCW researcher, her informants, the research setting and process, the empirical data, and the modes of analysis (Alvesson and Skjöldberg 2000). The contribution of this paper is two-fold. First, the paper provides detailed and rich accounts of how interventions in contemporary CSCW research take several forms across multiple design sites. In doing so, we join others in defining the basic nature of multi-sited design (Williams et al. 2014) by adopting the strategies of multisited ethnography (Marcus 1995) in design practice. This leads us to argue that important sites for design intervention exist outside of what we normally perceive as design sites. These sites are important as they transform, and are transformed by, the researcher, the technologies, and the practices. Second, the paper provides a critical reflection on the methods with which the CSCW researcher adopted various roles, took different choices, and was transformed into a political actor in the field, and the implications that these activities and events had for the CSCW researcher’s future participation in the sites of design. We structure our paper in the following way. First, we situate the CSCW researcher as a figuration connecting ethnography and design. Second, we explore the nature of acting reflexively by drawing upon multi-sited ethnography (Marcus 1995). An important, not to say vital, part of this reflexive approach is the act of determining what the boundaries of the investigation will be. We argue this can only be done in the context of CSCW by understanding what the potential ramifications of both


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ethnographic and design interventions could be. We end this section by discussing how such boundary-defining work is done. We then analyze our empirical case: First, by exploring the CSCW researcher’s interventions that directly impacted the design of the IT system; and second, by following the associations across multiple and dispersed sites of design, including the design workshops, the hospital organization, and academic debates on healthcare IT. We argue that all three sites for interventions are an integral part of the design sites. Finally, we propose our conceptualization of analytical sensibility and argue how balancing politics is essential for the CSCW researcher’s manoeuvrability in the interventions, which become constitutive for how sites of design are bounded in future CSCW research. 2. Ethnography and design: an interdisciplinary agenda The relation between ethnography and design is possibly best enabled through tying inextricably ethnography and design (Blomberg and Karasti 2013, p. 373), which means that a CSCW researcher has capabilities, vested interests, and competencies in both ethnography and design. However, what does this mean exactly? We know that designers are experts in designing technologies, that ethnographers are experts in ethnography, and that users are experts in their own work practice. What then is the interdisciplinary expertise of the CSCW researcher engaging in both ethnography and design together with users? Obviously the link between ethnography and design has much greater potential than simply offering a set of techniques and tools for designers. Many researchers have investigated this potential in different ways, for example, co-realization, participatory design, and bricolage (Buscher et al. 2001; Hartswood et al. 2002; Kensing et al. 2009). This stream of research emphasizes the ways in which designers engage with the practice they are designing for, and how the users become co-designers. It explores interdisciplinary engagements between, for example, ethnomethodology and participatory design, or situated design and ethnography. While this stream of research is important and has brought about many important insights, we have a different interest in this paper. Participatory design research focuses on the ways in which designers enter the field of practitioners, engage with the users, and design new technologies and practices with users (Kensing and Blomberg 1998). In contrast, our interest is not in the tools and methods by which to engage with practice. Instead, we have a more conceptual interest in the ways in which sites of design in contemporary CSCW research are created and bounded through the activities and practices performed by the CSCW researcher. We want to explore the intrinsic constitutive relationship between ethnography and design as it appears in contemporary CSCW research. Let us explore this in more detail. Ethnography is more than a method; it is more than data collection tools and techniques (Randall et al. 2007). Ethnography is not simply chatting with people and recording what they say (Forsythe 1999). When CSCW researchers record, describe, and document what people say they also engage in the sophisticated analytical work

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of collecting and sorting information, drawing links between pieces of information, weaving out organizational patterns, etc. While Forsythe’s (1999) clarification of the misconceptions of ethnography is highly valuable, it can be said that she provides a generalized portrayal of designers as subscribing to simplistic views of ethnography. Forsythe also appears to be defending a discipline-specific notion of expertise. In her view, the CSCW researcher relies on anthropological insights, which in and of themselves provide the necessary space for engaging with and learning about design. We disagree. Our point is precisely that whether or not the intellectual auspices provided by exposure to anthropological, sociological, psychological (or even ethnomethodological) perspectives serve as useful precursors to design-related inquiries, they are not enough in and of themselves. We feel it is important to keep in mind the divergent interests at play: Designers focus on solving problems, whereas ethnographers focus on describing as well as questioning assumptions that have been taken for granted, while also problematizing practices. We suggest here that the disciplinary distinctions promoted by various parties to the debates about the role of ethnography in design tell us very little about the actual practices of the CSCW researcher who tries to bridge these worlds, and who has interests in both creating ethnographic accounts and in impacting the space for design. In the Human-Computer Interaction (HCI) handbook, the chapter on ethnographic methods points to six roles ethnographers could take in the design practice: 1) conducting specific studies for a given project or product, 2) project management, 3) acting as the Bfirst user^ of a prototype, 4) informing usability studies, 5) keeping up with literature, and 6) injecting the users’ perspective throughout the project (Nardi 1997, p. 362). The importance of bringing in the user perspective is particularly emphasized; however, we do not learn what that entails in practice. In a recent book, Doing Design Ethnography, Crabtree et al. (2012) carefully explain how to carry out ethnographic work and how to analyze ethnographic data. The book provides good coverage of the topics, and it does devote a full section to explaining how ethnographic inquiries can inform design. In the chapter BInforming Design,^ Crabtree et al. (2012) state that Brather than throwing generic, semi-intuitive findings to the designer, the challenge is how to actively engage ethnography in the creative process of design^ (Ibid. p. 137). They explain that ethnographic findings might shape requirements, but they are not requirements themselves. Rather, ethnographic findings highlight important critical features of work, which must be taken into account when making decisions for the design. But, in order to impact design, ethnographers Bare going to have to get down off the fence and get their hands dirty in real design work^ (Crabtree et al. 2012, p. 137). However, the book tells little about the actual practices CSCW researchers engage with when providing ethnographic insights to design – in other words, how the link between ethnography and design is enacted as an interdisciplinary endeavour. CSCW researchers try to gain knowledge about the design of the technologies and the actual work practices, but their expertise lies in connecting the two domains, meaning the technical with the social domain. We CSCW researchers function like


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the two-faced Roman god Janus: Faced with the present of what is; looking back to the past of what can be known of what is and why; and then reflecting on the future, or what could be created and how (Boland and Lyytinen 2004). Understanding the role of the CSCW researcher implies that the researcher is describing and reflecting upon the world, while at the same time constructing it and acting upon it. This also implies the ability to draw potential connections between past and present practices and future possibilities. Our intention in this paper is to demonstrate how the CSCW researcher not only sees and represents the world, but also changes it. 3. Acting as bounding the design sites In this paper, we provide a meta-ethnographic account of the practices and associations orchestrated by the CSCW researcher across multiple sites of design. The purpose of this exercise is to bring attention to the historical, situated, and socially constructed self as a multiplicity. This exercise also directs attention to the researcher’s own pre-understandings and assumptions, and how these contribute to the interpretive act between the researcher and the field (Marcus and Cushman 1982, p. 38). Our point, again, is that these pre-understandings cannot be understood in purely disciplinary terms but must emerge from an interdisciplinary commitment. Acting in practice as part of research implies acknowledging the co-construction of empirical findings, which depend upon the specific interactions between the researcher, the informants, the setting, the empirical data created, the modes of analyses, etc. It is about paying Battention to the complex relationship between processes of knowledge production and the various contexts of such processes as well as the involvement of the knowledge producer^ (Alvesson and Skjöldberg 2000, p. 5). Thus, acting implies that the researcher is no longer an observer simply representing an independent reality, but rather is someone who is integrally attached to the realities she is describing. In other words, the researcher has no option of standing outside the world she describes because she is also constructing reality in the process of describing it (Alvesson and Skjöldberg 2000). Thus, attention is directed towards how the reality – the field site – is co-constructed. In this way, we engage with the nagging doubts experienced in the field, while embracing interventions as opportunities for reflections on how practical circumstances impact the quality of the data (Rode 2011). Furthermore, acting in practice with the aim of examining interventions is a process of investigating the subjectivity of the research endeavour, a practice George Marcus refers to as confessional reflexivity, during which the author of such texts becomes Ba living, contradictory, vulnerable, evolving multiple self, who speaks in a partial, subjective, culture-bound voice^ (Foley 2010, p. 474). For this reason, we seek to present in detail the different ways in which the researcher enacted interventions in an openly subjective account. While such confessional reflexive approaches are not exactly common in CSCW publications, we believe that this strategy is helpful for articulating the practices by which we carry out our research endeavour. We argue that this is important as it provides insights into the

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world of research activities that are rarely included in final publications (Marshall and Mead 2005). For this purpose, we explore the various engagements and interventions undertaken during a CSCW research project conducted in a paediatric ED with the dual aim of developing conceptual understanding of the basic nature of the collaborative work in EDs and contributing to the design of a collaborative EDIS. In this way, this project can be viewed as similar to other research approaches such as design case studies and end-user design (Wulf et al. 2011). The research engagement with the ED stretched over a 2-year period, and was not a process that was planned in a straightforward way, but was rather a complex and emergent practice in which earlier choices of the researcher’s role(s) impacted future possibilities. Reflections on which path to follow at different stages in the project were critical to the success of the study. Our point in reporting from this study is to bring attention to the problems of thinking about the disciplinary relationships in such work – as being in some sense Bcausal^– that the ethnography in some (admittedly flexible) way leads to a design. Instead, we suggest conceptualizing CSCW research as the interdisciplinary relationship enacted across disciplines that are constitutive of each other. Thus, we investigate the practices of different types of interventions in general, by refusing to fit these into one of the two disciplinary streams of research: informing design or developing conceptual work (as mentioned in the previous section). The problem with the disciplinary separation is that it leaves out important insights into what CSCW interventions entail and where these take place. This leads us to the next question, namely, where can we find CSCW interventions and what are the sites of design? When studying a control room, for example, the physical walls of the control room determine the site. It is within that particular room that the interventions take place. Thus, in our case, it can be said that the site for interventions would be confined to the walls of the ED. However, if we are to point our gaze at the researcher’s endeavours, we find that such conceptualization—based upon physical spatial walls as a demarcation of what is inside or outside the Bsites^—does not fully capture the different kinds of interventions across multiple sites. Multi-sited ethnography (Marcus 1995) calls into question Bthe conventional view of ‘locality’ as spatially and temporally bounded (…). Here the studied phenomenon is understood to be constituted by mobility, intersection, and flow; with a focus on connections, associations, and relationships across space and time^ (Blomberg and Karasti 2013, p. 384). The site is not simply out there, waiting to be discovered, but instead is constructed reflexively by every choice the CSCW researcher makes. In other words, selecting Bthe site^ is a matter of interacting and participating with the material artefacts and the people engaged with them. In this paper, we follow the different connections created by the CSCW researcher as she engages in various interventions, entering and leaving different sites. Our intention is to


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understand what the spaces for interventions entail when related to design. As Marcus phrases it: In conducting multi-sited research, one finds oneself with all sorts of cross-cutting and contradictory personal commitments. These conflicts are resolved, perhaps ambivalently, not by refuge in being a detached anthropological scholar, but in being a sort of ethnographic-activist, renegotiating identities in different sites as one learns more about a slice of the world system. (Marcus 1995, p. 98) Examining interventions is thus a process of finding out where the sites of interventions exist, and what characterizes these interventions. A conventional suggestion for Blocating^ the sites for design interventions would be to turn to the design workshops in the ED project. These are workshops that the CSCW researcher participated in once a week for about 6 months. However, drawing upon the insights from multi-sited ethnography, we are encouraged to call into question the conventional view of locality as a spatially and temporally bounded entity in which ethnographers intervene (Marcus 1995). This means that the sites of design interventions are not merely bound by the ED, nor are they bound by the design workshops; instead, interventions should be understood as constituted by Bmobility, intersection, and flow; with focus on connections, associations, and relationships across space and time^ (Blomberg and Karasti 2013, p. 384). By this perspective, interventions become a practice of relationships that the CSCW researcher creates, enters, or disconnects over the course of the project, all with a closely tied engagement to understand diverse work practices and contribute to the design of collaborative technologies. Thus, searching for interventions, we have to include the practices that the researcher in our case participated in across various sites of design during the 2 years of the project. Furthermore, we wish to illustrate how the research project transformed over time and was shaped by the CSCW researcher. However, before we begin unpacking the sites of design, we need to provide some contextual background information on the empirical project. In December 2006, after 12 months of using an electronic triage system (Etriage), the ED had withdrawn the electronic system and re-introduced the paper-based triage practice instead. The reason for this radical move was that the electronic system had delayed the work in the ED and caused long queues. After 7 months of using the paper-based practices, the ED received funds to enter a process of designing a new EDIS system that was put into use a year later. The CSCW researcher had the unique opportunity to follow this whole process: from studying the problems with the old electronic system to examining the paper-based work practices in the ED; participating in the design process of the new EDIS; and finally, following the implementation of the system. Thus, this empirical case provides an opportunity to track the connections and practices through which the CSCW researcher participated, identifying the various sites for the interventions that occurred during the research project. In the next sections we follow the sites of design first by visiting the design

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workshops, and then following associations and connections across the various sites of design with the aim of characterizing the basic nature of interventions in CSCW research. 4. Interventions across multiple sites of design Exploring sites of design, our analysis of the researcher’s engagement produced several narratives about design interventions. In this paper, we point to three main sites for interventions (design workshops, hospitals’ organizational contexts, as well as the academic medical research field), each impacting in different ways the design of collaborative technologies for emergency departments. To account for the various sites of design, we first examine the design workshops as a conventional site for design interventions. To fully unpack the practices within these workshops, we explain in detail how the first author made connections and relations from the observed practice in the ED to the practice of design in the workshops. We then leave the design workshop and follow the design interventions outside these workshops, exploring first the hospital organizations and then the academic turf as sites of design. 4.1. Design workshops as site of design After the first 6 months of research, during which the CSCW researcher spent an extensive amount of time observing the work practices in the ED, the department received funding for the design of a new electronic system. This was followed by a set of design workshops organized by a range of people external to the ED, including two healthcare authorities, vendor representatives who served as technical experts, and ED nurses from other hospitals. Each of the design workshops was structured and executed differently. The discussions in these workshops covered various topics, such as privacy, responsibility, electronic triage templates, and electronic whiteboards. Each workshop had a certain number of ED nurses, doctors, clerks, or others who would be invited depending on the topic discussed. Nevertheless, there was a core group of five people who participated in all the design workshops, one of whom was the CSCW researcher. We opt here to present an in-depth narrative focusing on one pertinent topic from the design workshops. This topic involved many ongoing discussions that lasted over a period of several months, mainly because the design issue was not easily solved. The narrative concerns the design of Bthe consultant icon.^ To explain the complexity of this rather small part of the system and the issues surrounding the icon, we will provide some context. Consultants are medical specialists who are called to assist the ED when required according to a patient’s condition or circumstances. In the paediatric hospital there are many different types of specializations (e.g., ophthalmology, orthopaedic surgery, gastroenterology, oncology, and endocrinology). The high number of specializations is due to the fact that the paediatric hospital is a province-wide organization, and thus


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deals with all the special cases of children. The ED personnel are highly trained and specialized, having dual expertise in both emergency medicine and paediatrics. In most cases the ED personnel are capable of treating patients without external support. However, in special cases, for example, children with comorbidity (multiple illnesses, e.g., cancer and diabetes), the ED nurses call consultants from the in-patient clinics and wards to help examine the patients. In most cases, patients who require consultant visits need several visits from different consultants. That is, a special feature of paediatric work is that it is often multidisciplinary. Organizing the coordination of consultant visits to the ED is thus an important task for the ED personnel. This work was handled by the use of regular whiteboards and was expected to be supported by the design of the electronic whiteboard, which was part of the new EDIS system. 4.1.1. Pre-system work practices Prior to the introduction of the electronic whiteboard, the coordination of consultant visits was typically handled in the following way requiring three specific steps. First, the nurse calls the consultant(s) and leaves a voice message telling them they were requested. The nurse indicates completion of this step on the whiteboard by drawing an arrow pointing downward and writing the professional discipline of the consultant (e.g., ORTHO). Then, the nurse (or in some cases the unit clerk) calls the relevant department and leaves a message at the consulting department that the consultant must call the ED back. The completion of the phone call is indicated on the whiteboard by adding to the arrow, making it into an arrow pointing upward and downward (see Figure 1). Finally, the consultant calls the ED back to get more details about the inquiry and to see if it requires a visit. The nurse answering the call then indicates this by adding a stroke horizontally across the existing arrow on the whiteboard, pointing up and down. This symbol signals to the ED personnel that the consultant has already called back. Finally, when the consultant visits the patient in the ED, the nurse indicates this by adding a ^ to the top of the existing downward pointing arrow with a stroke across it. This way, the whiteboard indicates that all the trajectories organized by the ED personnel were completed, thereby completing the Bconsulting process.^ This system makes it easy for the staff to see the progression of trajectories. With a quick glance at the arrows, staff could learn whether the nurse left a message for the consultant (past tense), the consultant called the nurse back (present tense), indicating that the consultant will visit the patient shortly (future tense), or whether the entire consultant activity is finished. As can be seen here, the arrow system includes information about both the time and status of activities. 4.1.2. Initial design of EDIS The general design of the electronic whiteboard in the EDIS was structured around patients already placed within a particular location. For each patient row, there were different generic columns, such as length of stay, patient name, location, visit reason, etc. There was also a column labeled events, featuring different icons indicating the different actions that needed to be taken for the particular patient. For example, if a

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Figure 1. Reconstruction of the whiteboard with the different arrows.

physician had ordered an IV for a patient, the IV icon would appear on the electronic whiteboard, indicating that this activity needed attention. Once the activity was completed, the ED personnel would indicate this in the EDIS system. For each state of the icon, the time would be recorded and saved. This provided the opportunity to measure elapsed time from the moment an activity was initiated to the time of completion. Once a process was completed in the system, the icon would disappear from the event column. The initial design of the EDIS was based on the fundamental assumption that the electronic whiteboard was a two-dimensional to-do list, which meant that icons indicated activities that required attention. Thus, once an activity was completed, its traces were deleted from the whiteboard. This inaccessibility to the historical traces was highly problematic and could potentially lead to medical errors because future activities depended on this critical information. Although the information would still be recorded in the patient medical chart, it would not be so easily visible to all staff. This design of the EDIS was viewed as disruptive for the ED personnel, since their existing whiteboard was designed to capture the past, the present, and the future. The existing whiteboard could not only indicate the activities that needed to be done in the future, but also past activities that were already completed, thus containing important knowledge for planning the treatment.


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This fundamental difference between the existing whiteboards and the EDIS whiteboards triggered many initial discussions, including discussions about the consultant icon. The initial design of the EDIS system had an embedded process for handling consultant visits. Consultant visits were organized around the BC^ icon in the event column: The design stipulated that when a consultant was required to see a patient in the ED, the C icon would be registered in the system, capturing the starttime of the activity and displaying the C icon in the event column. When the consultant visit was done, the visit would be registered as completed in the EDIS, capturing the end-time, and the C would disappear from the EDIS whiteboard. The initial consultant process in the EDIS thus contained a two-step process, whereas the existing work practices within the ED involved a three-step process. Furthermore, the disappearing icon would fundamentally change the processes within the ED, and it was also unclear how the C icon would support the coordination of involving multiple consultants. While these design issues of the system design are interesting, what is surprising and noteworthy is that these problematic issues were evident to the CSCW researcher during the very first design workshop when the application specialists made a general presentation of the EDIS. At that time, the CSCW researcher was still very new to the particular situation, and even though she raised the design issue at the first meeting, she did not press the issue further at that time because the application specialist insisted it would not be a problem as the design issue would be revisited at a later stage. What was even more surprising was that the nurses who were present in the workshops could not quite relate to the abstract interface displayed on the projector, and they could not foresee the problem at that stage. This, however, changed as the workshops proceeded. As can be seen above, while the CSCW researcher identified a specific design issue, the nurses could not completely foresee or relate to the problematic aspects of this design issue, and the application specialist dismissed it by insisting it would be solve later. It can be said that from the application specialist point of view, it is perhaps reasonable to downplay certain views and delay certain matters in full, as some of these matters might be solved once the technology becomes better integrated with the local practices. Furthermore, the application specialists must guide and direct the redesign process by balancing user participation and proposals for redesign, while taking into account other influencing factors, such as costs, time frame, standardization agenda, etc. Nevertheless, since neither the nurses nor the application specialist acknowledged the problematic issue identified by the CSCW researcher, she decided to put this issue aside and focus on gaining a deeper understanding of the nurses’ work practices as well as establishing her epistemic authority and position amongst the nurses. 4.1.3. Iterations in design workshops At the third workshop, the fundamental difference between the to-do-list design and the existing work practices of documenting and displaying past actions on the

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whiteboard became much more apparent to the nurses. In this period, the CSCW researcher assumed a more active role in pointing to problematic design issues that became pertinent in the discussions and problematizing the design of the system from a work practice perspective. Typically, issues would first be raised by the CSCW researcher, and then later echoed by the nurses. The nurses were concerned about the design issues and demanded the application specialists find a solution to these issues. Since the CSCW researcher was not ED staff, she would normally phrase problematic issues as questions directed first to the application specialist concerning the technical design. Then she would direct any additional follow-up questions to the ED professionals concerning the work practices. If both answers confirmed the issue was indeed problematic, which was often the case, the CSCW researcher would present the paradox explaining the complexity of the issues and then pointing to how the design and work practices would not support each other. The electronic whiteboard is designed as a Bto-do^ list, which means that whenever an event is finished it disappears from the whiteboard. So, if a patient had an IV, that information would disappear. This is highly problematic and could lead to medical errors, because when it is very busy the charge nurse needs to know what’s going on, and this includes information about whether a particular bedside nurse is especially busy with a patient who needs a lot of Bevents^ to happen so other nurses can offer their help. So the nurses need a Bdone column,^ which can display completed events (such as IV, antibiotic, etc. – 11 in total) […] Before the discussions about the Bdone column^ took place, the idea was to place all this information in the comments field. But in the end, the decision was to add a new column […] It was also decided that the two columns, Bto do^ and Bdone,^ should not be too close to each other […] Also, as soon as an event in the Bto do^ column is completed […], it will automatically be moved to the Bdone column.^ (Researcher’s notes from the design workshop, August 15, 2007) In relation to the consultant icon, the first issue was the disappearing C, and since this led to a general discussion about documenting past activities, the application specialist solved the issue by adding an extra column in the EDIS whiteboard labeled Bevents done.^ Reconfiguring the EDIS system to include an Bevents done^ column was a significant achievement for the ED personnel. The day the reconfiguration was presented at the workshop, the ED personnel experienced a sense of empowerment in terms of being explicitly asked about their opinions of the new system, as they saw that they could influence both their own work practices and the design of the IT systems. The added column meant that the C icon would not disappear when an activity was complete, but instead the C would move to the other column. However, the problems between the two-step process and the three-step process remained (Figure 2). Although other problems were identified and resolved throughout the workshops, the three-step process for consultants remained unresolved. Then 1 day, the


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Figure 2. Electronic whiteboard: Adding the event done column.

application specialist proposed a solution, namely to display the C icon in different colours. This way, the initiation of a consultant visit (where a nurse would call the particular medical expert) would be indicated with a yellow C displayed in the to-do column. Then, when the call had been made to the in-ward department, the yellow C would turn blue in the EDIS. Thus, the blue C indicated that the call back had been made and the consultant was on her way to the ED. Finally, when the consultant had actually visited the ED and seen the patient, the blue C would move to the eventsdone column, signalling the task was completed. While this re-configuration of the EDIS made it possible to have a three-step process for consultants, the problem of accounting for multiple consultants with different expertise remained unresolved. As was mentioned above, patients often required visits from different types of consultants. Therefore, it was important for the nurses to keep track of which consultant was contacted, who called back, and who had already visited the patient. Distinguishing between the types of consultants had already been identified and flagged as a potential challenge by the CSCW researcher early in the process, and the concern was dismissed by the application specialists despite the researcher’s repeated attempts to raise the issue. At that time, 5 months of workshops had passed (July– December) and soon a number of things were supposed to be happening: the EDIS system was to be tested, training of the 100 ED staff was to be confirmed, and the deadline for the go-live date (March 2008) was to be met. Therefore, a decision was made by the application specialists to end all new re-design suggestions and simply define workarounds to solve the remaining issues. Thus, the multiple critical events and deadlines left no space for further redesign of the system. One of the major changes at that time was the invention of a Bcomment^ column. The comment column was a free-text field where the ED professionals could type text that would be displayed on the EDIS whiteboard. Together with the nurses, the CSCW researcher began finding workarounds to solve the consultant issue. They decided that the former arrow system from the whiteboards would be typed into the EDIS using an ordinary computer keyboard. Subsequently, the arrow down (initiating a process) was translated into < (pointing backward); the stroke across (the call had been returned from the consultant) became > (pointing forward); and the arrow up (completed) became ^. This way, the nurses

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could basically apply their former three-step process using the free-text field by indicating the consultant specialization, for instance BORTHO^ next to a Bkeyboard arrow.^ So, for example, if the patient was a 4-year-old child with cancer (ONCology) and diabetes (ENDOcrinology) who had a broken leg (ORTHOpedic surgery), then it would be dis pla ye d in the f oll owing wa y in the c omment field: BORTHO.^ This would mean that the nurses had called the orthopedic surgery department, but they have not yet received responses; that they had also called oncology specialists, who had already visited the ED and seen the child; and that they had called endocrinology specialists, who had returned the call and were on their way to the ED. Although the translation of the arrow system is very simple, it turned out to be an effective approach to solving the coordination and organization of the visits of the three types of consultants in the EDIS system. Also, we got discussions about Consultant and defined workarounds already, even before the system has been taken into use. This is interesting because my role back in August had been about Bobserving.^ Back then I believe that I didn’t push as much as I do now when something is problematic. I knew already when we discussed it from the beginning that this [the issues with the consultant] will be problematic. Should I have pushed more back then? (Researcher’s reflective notes after workshop, December 5, 2007) Interestingly, this workaround for distinguishing between the different types of consultants using the free text-field in the EDIS was created prior to the go-live date, and, as such, it constitutes a pre-system workaround. It meant that the consultant C icon would never really be used in practice because there was no way to distinguish between the different specializations of the consultants. The above events illustrate how the CSCW researcher gradually transformed, taking a more active role in these design workshops and co-constructing with the nurses workarounds to the system that was to be implemented. We also see how the nurses transformed from being somewhat passive recipients of design decisions made by, among others, the application specialist, into active users who have some influence on design decisions. Furthermore, we see how the design space consisted of various conflicting agendas, demands of different professions, as well as critical deadlines, which must be met. We described above the various interdisciplinary interventions conducted by the CSCW researcher within the design workshops. However, these workshops were not the only sites of design. Let us look at the other sites that are constitutive of the design process. 4.2. Sites of design outside design workshops Having examined the researcher’s role within design workshops, we now follow the associations and connections made from the workshop and into two other important sites of intervention, namely the hospital organization and the academic turf. This is


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not to say that these are the only possible sites of design, for clearly there are many sites. However, what creates a relevant site of intervention depends on the particular empirical case as well as the engagement of the CSCW researcher in terms of choices of participation or non-participation. The practices of the CSCW researcher are, as we have been arguing, constitutive of the field of intervention. 4.2.1. Organizational politics as site of design The very presence of the research project within the ED, and the association with the larger ACTION for health project and the university, became an integral part of the site of intervention. Associating the design of the EDIS system with research impacted its visibility within the ED and within the hospital as a whole. The fact that a researcher spends time in the ED and observes the nurses legitimizes the nurses as an important part of the organizational configuration. There was no doubt that one of the main advantages of the researcher’s interventions in the hospital organization was to shed light on invisible work practices, which are otherwise often inaccessible. The presence of the researcher in this context promoted the project to the whole hospital; for instance, the researcher was invited to present her findings for different hospital representatives. The researcher became part of the core group working with the design of the EDIS together with the nurses. Furthermore, she was invited to take part in teaching the new system to the 100 or so members of the ED staff. We are planning the training of the new system. First we thought we would get trainers from the health authority, since they have done it previously. However, we made so many changes and revisions to the system that it looks quite different from the original system. It is only those who have been participating in all the workshops that can teach the system, which means the [core group of four nurses] and me. They asked me to help teach the system. I want to help, so I said yes. But what are the implications of me doing the training? (ED study, November 2007) What is interesting with this training incident is that, while the researcher was one of only five people who knew the new EDIS system (including all the details about the processes developed around it) she struggled with the decision to accept or decline the invitation to train the staff. While she initially accepted, she changed this decision and finally declined. This was a tough decision to decline the training; however, the researcher was concerned that if she had accepted the invitation to train, it would have limited the space for observations when the EDIS system was implemented. Accepting the offer to teach the nurses about the new EDIS system would have problematized her role in asking the nurses questions about their use and experiences of the system. Eventually, when the EDIS project was nominated for a teaching award at the hospital, the researcher was listed as

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part of the award-wining group, despite declining to participate in the actual training. I said no to the training. It would jeopardize my role as an observer after the golive date. Now we are planning user testing, and I was asked if I could test the system next week. But how can I do user testing when I am not a user? I am not even educated as a nurse, so how could I act as one? (ED study, January 2008) As soon as the training issue was settled, a new issue emerged, namely the issue of user-testing. Due to the active participation in the design process, the CSCW researcher was asked to take part in the user-testing in the role of a nurse. However, the dilemma as to whether the she could take the role of a nurse was difficult. She wanted to help, but how could she act as a user when she was not even educated as a nurse? Our point here is to make it clear that being a CSCW researcher involves many dilemmas. It is by no means a straight simple path, and the CSCW researcher is by no means a hero, but instead a reflective participant who tried to navigate the complexities of acting in the world. Coming back to the site of design, the strong associations that the researcher established within the project through other types of participation made the hospital and the group highly visible. The visibility of the design project across all levels in the hospital organization made it into a political object. For instance, it became used on a strategic level in discussions between health authorities. If we are to unpack this in more detail, it is important to understand the overall strategy for the design and implementation of the EDIS system. Part of the strategy was that provincial and regional government wanted to standardize the electronic systems across hospitals. This standardization agenda meant that the provincial health authority (governing the paediatric ED) was collaborating with the regional health authority (governing seven ordinary EDs), all of which had different political interests vested in the design of the system. Due to this structure, the paediatric ED had only a minority voice in all cases of controversial discussions (e.g., the design of standardized electronic templates). However, having a researcher connected to the project gave the paediatric ED a relatively high level of legitimacy in their requests for particular redesign requests. It is obviously not our intention to claim that it was solely the researcher who determined the choices of certain design aspects of the EDIS system. Rather, we argue that when the researcher took an active role in the discussions during the workshops and constantly questioned the designers, this provided the nurses and the ED manager with a vocabulary enabling them to discuss issues at a higher organizational level about how and why particular changes were critical for the work practices. The researcher was presented as the Bscientific expert^ by vested parties, adding legitimacy to their arguments. Above we have illustrated how the sites of design in CSCW research do not exist solely in the design workshops, but are also connected to the political enactment and interventions conducted by the CSCW researcher both within the organizational context (the hospital organization), as well


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as across organizational contexts and different political agendas (including health authorities). 4.2.2. Academic turf as site of design The external legitimation of the nurses’ work both in the ED and in the hospital, as well as the recognition of how important it was to take into account their current work practices, also spread beyond the hospital to the institutional level of academic debates about IT in healthcare. This was particularly evident when the researcher invited the ED nurses to co-author an academic paper about their work. While the research area was not a medical discipline, the paper was viewed as important for the nurses. When the paper was finally published, the nurses hung a printed copy in the ED lunchroom, next to the many copies of research papers written by the ED physicians. The paper seemed to have provided the nurses with an academic boost both inside and outside the hospital, giving them greater epistemic authority as they now officially entered the academic debate about IT systems for ED professionals. As the ED head nurse expressed during a final interview at the end of the study: I found your [the researcher’s] role incredibl[y] helpful […] I find that there were times when we got stuck with stuff, that you…framed questions in such a way that they steered us to think of things that we were perhaps either stuck with or had not considered. And that was incredibly helpful because…you are under a lot of pressure to get work done […]. I think the possibility that there would be something published from it – from this department is very [important]… And…expos[ing] people to the opportunity to be involved in some writing […] – that’s fantastic. It’s the way we should be going, it’s the real collaboration – and I think the fact that you were seeing it in action versus just interviewing and hearing our interpretations of what happened brings a very different light to the whole writing and the work. (Emergency department head nurse, November 2008) In healthcare, the academic medical field is an integral part of the changes that are made to the medical practice. This implies that academic publications have, to a certain extent, strong and direct impact on medical practices within hospitals. Thus, it can be said that the link between academic publications on information technology and medical practice is much stronger than in other fields. Having said that, such publications often have a specific flavour, being largely defined by Bmedical knowledge^ and Bsystems expertise.^ Our point here is not to present a different kind of expertise as relevant, but precisely to argue that relevant knowledge and expertise is co-constructed by all parties. In this context, the CSCW researcher is not Ban expert from another discipline,^ but rather an interdisciplinary facilitator who is trained at articulating the experiences of others through their own reflexive learning and, more importantly, helps to voice these experiences at crucial times (Figure 3). Prior to the design process of the EDIS system, another electronic triage system named ETRIAGE was taken out of use due to serious delays and long line-ups at the

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Figure 3. CSCW Researcher in the ED when the EDIS was launched (left); Core group of EDpersonal involved in the design of the EDIS, during a field trip to see the EDIS in use at other hospitals (right).

ED. The designers of the ETRIAGE system were academic physicians who had also published papers about the design of the system advocating for its usefulness. The CSCW researcher published a paper about the concerns the nurses had with the ETRI AGE system and included a critical discussion about the research literature promoting the ETRIAGE system (Bjørn and Balka 2007). If nurses were to engage in this academic debate about electronic triage systems, all they could do to support their claims is refer to the different issues they encountered through their personal experiences. However, it can be said that such statements would not necessarily have much impact on the academic debate about electronic triage systems. By having Btheir own researcher^ to advocate on their behalf, a researcher who is both familiar with academic discourse and who can enter the debate through writing academic papers, the nurses were able to speak with a degree of epistemic authority. The CSCW researcher can be thought of as renegotiating the terrain on which discussions took place, by providing an alternative source of Bexpertise^ and by helping to mobilize the voices of other, hitherto relatively invisible, participants. The impact of the published papers became even more pertinent when the CSCW researcher – 2 years after the study had ended – received an email from one of the original designers of ETRIAGE and found herself suddenly in an academic debate about the concept of triage drift based upon one of the published papers (Bjørn and Rødje 2008). The argument in the paper was that the practice by which nurses choose to Bwork outside^ the standardized acuity scale (CTAS) when evaluating the urgency of patients entering the ED, referred to as triage drift in the medical literature, should not be seen as a problematic practice of the nurses. Instead, triage drift was part of the basic nature of work in emergency departments, and thus if we are to design electronic triage systems, the design of these systems should not be based on the standardized scale but instead be able to incorporate triage drift as well. In 2010, the first author received an email from David Meuer, expert in Clinical Health


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Informatics and Chair of Alberta Real Time Syndromic Surveillance Net Emergency Department and Urgent Care, in Canada: As previously stated, the understanding of ‘triage drift’ deviates from its definition by some of the other authors being referenced. The documentation and analysis of observations constituting the collection of processes engaged in while working the triage assignment is well done and warranted. There is no mention of true triage drift as associated with triage assessment acuity scores moving away from the median for that facility. It has been suggested in the past that true triage drift is impacted by triage nurse acuity habituation (higher or lower acuity environments) and sociopolitical pressures (i.e. a level 2 acuity patient cannot exist in the waiting room so make them a level 3). Both of the aforementioned issues can be partially mitigated using a standardized process for the triage assessment acuity score derivation component [of the triage work] so as to reduce variability in score assignment. Reduced variability in score assignment ensures that appropriate resouces for the care of the patient can be brought to bear in a timely fashion. In an era of scarce resources and constant reallocation, this helps nursing professionals adhere to core values (David Meurer, Email received April 16th, 2010). What the above quotation demonstrates is that there is a difference in how triage drift is conceptualized: As something to mitigate, or as something that evidently exists as part of the work in ED. The discussion is about the role of standardized schemes for organizing triage practice and whether these schemes are useful as a foundation for design. While it is out of scope to go into all the clinical details about the standardized CTAS scheme and triage drift in this paper, the point we want to make here is that clinical researchers developing and designing electronic systems that are being deployed in medical practice read and engage with academic literature on the topic and carefully spend time and effort in figuring out how to use such findings in new designs of practices and technologies. Looking at part of the response from the first author on this email string, we see how she continues to advocate of the behalf of the nurses about triage drift: We argue in the paper that this observation calls for a reassessment of the concept of triage drift, because triage drift is not necessarily a ‘bad thing’; the seemingly unstructured aspects of the observed triage practice are essential for making the triage in the pediatric ED we observed function. So yes, our conceptualization of triage drift is different than others, but it incorporates the same basic nature, namely when triage nurses do not follow the exact triage acuity scale. Now this insight is important if we want to design electronic triage systems, since it tells us that we should not base the design of such system upon the standardized scale as

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such, but take into account the work practices in which such future systems should be integrated (Pernille Bjørn, email sent August 18th, 2010). As can be seen from the above quote, the discussion very much concerned whether triage drift was a bad thing that should be mitigated or whether it was part of the normal natural trouble involved in triage practices. As was also the conclusion in an email 1 year later, where David writes: So it appears that our understanding of ‘triage drift’ is very nearly the same. Where we differ is whether or not the drifting of acuity scores is appropriate? (…) I think your findings are interesting and valid in the observations you made. The nurse adapted to the situation to ensure that the patient received appropriate care in a timely fashion. It is unfortunate that potentially sub-optimal patient flow management in the ED, compelled the nurse to deviate from a true acuity score assignment. The deviation from a truer triage score appears to be a symptom of this ineffective bed management policy and a lack of bed assignment flexibility in the ED. Appropriate triage acuity scoring help to highlight the failings in our health system to provide timely and appropriate care, in the best setting, to those that need it the most (David Meuer, Email received August 19th 2011, emphasis added). Our point here is not whether the point about triage drift was taken into consideration exactly as argued in the academic paper written by the CSCW researcher. Instead, our point is that academic researchers designing and deploying clinical systems in medical practice actually pay attention to published research in the health informatics field as well as to work published in CSCW venues. This is probably a unique characteristic of medical practice, and other measures are probably needed if the contemporary CSCW researcher wants to impact the practices of design for other fields, such as engineering or architecture. However, in this specific case, the findings from the CSCW research project were taken seriously and had become part of the general debate about electronic triage systems in the medical field. In this way, the researcher’s presence in the ED was used to bring forward a certain perspective on the design of electronic ED systems, stipulating how such systems have a large impact on the daily work practices of nurses and thus how their work practices need to be taken into consideration. Therefore, we argue that the academic turf in this case also served as a relevant site of design, since the loop back to the original designer and creator of the ETRIAGE system directly impacted the design of healthcare technologies. In other words, we see how the insights produced by the CSCW researcher served as a foundation for the design of a new IT system. We have illustrated above how multiple sites of interventions are an integral part of, and have influence on, the design process of technologies for EDs. We demonstrated that it is a somewhat simplistic perspective to view design workshops as the only site where design takes place. Instead, we argue that design workshops do not


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exist independently and separately from other relevant sites of design. We demonstrate how following the associations of the CSCW researcher across multiple sites illustrate how these collapse into and are made an integral part of the design of technologies. We followed the CSCW researcher from the design workshops and into the hospital organization and further into the academic turf, illuminating how the CSCW researcher, the nurses, the practices, and the technology were all transformed in different ways at different points in time. 5. Analytical sensibility and manoeuvrability Now zooming out from the details of the empirical case, we will explore the ways in which the contempory CSCW researcher bounds the sites of design through certain engagements. Sites of design emerge as part of the researcher’s engagement with the field – and the ways in which she manages to act critically and politically when bounding specific sites of design. The bounding of sites includes the enactment of analytical sensibility when balancing political engagement and manoeuvrebility. 5.1. The contemporary CSCW researcher enacts analytical sensibility The contemporary CSCW agenda implicates ethnography and design in a constitutive relationship. CSCW as a field is, or should be, involved in the business of mutual orientation between varieties of interested parties, provided by a commitment to a certain kind of analytical sensibility. Understanding how the CSCW researcher produces interventions in the field of design is, we argue, part of the process of understanding how analytical sensibility is worked towards and achieved. Now let’s look closer at the nature of analytical sensibility and how it differs from previous similar conceptualizations in the literature. The design workshops are an example of how interventions were driven by an analytical sensbility where the observed phenomenon (e.g. the icon) was constructed and interpreted by the researcher in relation to the role the phenomenon plays within the context (the ED). The Bnoticing,^ however, was not the only intervention. Articulating these issues persistently at the workshops entailed the CSCW researcher providing a perspective on the use practice that was – to begin with – different from what the users would provide. The researcher’s task was not simply to reproduce the user perspective, but instead to provide perspectives that were outside the nurses’ and the application specialists’ conceptual understandings and domains. We know that collaborative partners never know all details about the work of others; instead, it is a feature of collaborative practice that details of individual work are hidden away from others to reduce the complexities in handling articulation work (Schmidt and Bannon 1992; Suchman 1995). The CSCW researcher is thus the only one who knows enough detail about collaborating

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partners’ individual work to be able to produce a coherent description taking all nuances into account. Creating such a coherent description requires analytical sensibility in order to balance between exploratory inquiries and constructive solutions. In previous work, sensibility refers to the way in which CSCW researchers see and understand the world they study (Randall et al. 2007). The notion of sensibility or, more precisely, ethnographic sensibility, has been commonly used within anthropology, often to emphasize the understanding of insiders’ perspectives. To use Schatz’s words, ethnographic sensibility refers to Bapproaches that rely centrally on person-toperson contact as a way to elicit insider perspectives and meanings^ (Schatz 2007, p. 2). In contrast, we found that while understanding the users’ perspectives is important when enacting analytical sensibility, this is not the complete story. Enacting analytical sensibility in CSCW research includes important analytical practices of bringing together the diverse experiences and practices involved in the collaborative practice we explore. This means that while representatives of the different user groups (e.g., charge nurse, triage nurses, unit clerks) are experts in their own work, they are not experts in the work of the other groups or in making the connections between their situated work practice, the work of other groups, and the potential changes imposed by the new system. This is where the act of analytical sensibility comes into play, since analytical sensibility includes the analytical work of connecting and demonstrating a comprehensive account for the collaborative yet individual and distributed engagement. Whereas former usage of sensibility in ethnographic encounters emphasizes the direct and sustained contact with the practitioners and the ongoing interests in unpacking practitioners’ points of view (e.g. Randall et al. 2007; Jourde, 2009; Schatz 2009), our work points to the constructive endeavour of enacting analytical sensibility by bounding the field site of design, creating links between participants’ individual work tasks, while providing a comprehensive account connecting distributed and individual perspectives into one collaborative entity relevant for the design. Although the users participated in the design workshops in the empirical case and had continued opportunity to raise any issues, they were often not able to make the connections between the individual yet interdependent practices required in order to envision the consequences of the design of the new system. In addition to identifying and demonstrating the important relations within the field, the analytical sensibility enacted by the CSCW researcher includes new vocabulary. By introducing new concepts and a new vocabulary, the CSCW researcher enables the nurses to talk about their work practices and the system’s design in new ways important for design. For instance, by using the different labels introduced by the CSCW researcher (e.g., Barrow system,^ Bthe yellow note,^ or Bpre-triage^), the nurses were provided with a vocabulary they could use both within and outside of the design workshops. Prior to the researcher entering the empirical field, the practitioners did not reflect on, or at least were unable to clearly articulate, how they used arrows to coordinate several complex practices within and outside the


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ED. However, when the researcher flagged these practices and gave them a name, they transformed into objects for discussion during the design workshops. The CSCW researcher pays attention to assumptions that have been taken for granted, meaning the complexities and problematic issues in the field that could include the financial or time constraints of the project. However, for the interdisciplinary CSCW researcher, such constraints would never be the dominant points of departure. The CSCW researcher has a committed interest in how things work or do not work, and why. Thus, situations where things break down are of utmost interest to the CSCW researcher, and such situations are captured under the topics discussed within the CSCW field, for example, normal natural trouble, invisible work, and workarounds (Randall et al. 2007). Previous research points to how design practice involves sensibility in design as much as it involves models, predictions, and prescriptions (Anderson 1997). Sensibility in design practice has been said to provide the scope for design. When we turn to our conceptualization of analytical sensibility, we build upon this former work, while extending the role of sensibility in design. Analytical sensibility in design concerns the practices by which the boundaries for design problems, as well as the possible approaches for how to solve particular design problems, are created. Analytical sensibility in design thus becomes the ability to recognize what is important and significant at a certain point in time, and to generalize this observation in terms of constructive design solutions. In other words, the CSCW researcher enacting analytical sensibility has particular skills whereby she is able to place Bthings^ in context and to see the phenomenon from various perspectives – people, artefacts, metaphors, plots, biographies, conflict, etc. – and to bring those perspectives into the design practice. Analytical sensibility is not a static thing. Rather, just like any other skill, once acquired it Bcarries over into other settings, other policies, and other research questions^ (Pader 2006, p. 174). Thus, with time and experience, the analytical sensibility of the CSCW researcher grows and sharpens. However, the role of analytical sensibility in design practice is not something limited to the design workshops. Instead, we argue how analytical sensibility includes the ways in which sites of CSCW design are bounded in different ways (Bjørn and Østerlund 2014). In our empirical case, the sites of design included the academic papers, as well as the organizational engagement with the hospital as a whole. 5.2. The contemporary CSCW researcher balances manoeuvrability Our empirical case demonstrates how the practitioners used the researcher’s role as a vehicle to tackle political issues directed at the designers and mediated by the researcher. We found that it is difficult, maybe even impossible, to detach analytical sensibility from the political issues, since acting in practice will never be purely descriptive. This phenomenon is not limited to CSCW research, but applies to engaged research in general, since such research Binvites researchers to see and question political relations and political sites that are generally unseen or

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‘unidentified’…but which are nonetheless meaningful for local political actors^ (Jourde, 2009; p. 201). The political agenda of analytical sensibility thus prompts the researcher to be critical towards institutions within the field, as well as towards the dominant discourse of Bmeaning-making^ and the use of social labels. However, to navigate such political agendas within the field, extensive interaction and immersion in the world of the participants is required (Schatz, 2009; Jourde, 2009). Interdisciplinary CSCW research is always an inherently perspectival view, based upon the ethnographic perspective of seeing a social situation in certain ways that problematize certain phenomena (e.g. Forsythe 1999; Dourish 2006; Randall et al. 2007). Different disciplinary groups inhabited diverse sets of design sites: Former nurses working for the health authority, business experts in the IT application, and technical designers. This diverse group of designers are exposed to different political agendas involved in different levels of decision-making. For instance, the pressure for standardization across hospitals within the health authority jurisdiction pulled the former nurses now working for the health authority in other directions, especially since the agenda of standardization was strongly represented by the business experts. Interestingly, the technical experts would be open to discussing the issues and trying to find solutions; however, they were not part of the financial discussions, which clearly reduced the opportunity for redesigning the system. The interdisciplinary interest of the CSCW researcher, knowing both the nurses’ and the designers’ work, created a larger manoeuvrable space for intervention, where she could interact and speak the same language across disciplines. Pointing to the situated practices that were critical but also difficult (and in some cases impossible) to incorporate into the standardized system, the researcher was also asking questions about the agenda of standardization from the health authority and the business experts. Being interdisciplinary gave the researcher the advantage of entering a large manoeuvrable space for political interventions, but also involves risks as it implies expressions of loyalty to one group. This could raise doubts about the status of the researcher’s knowledge and how it is to be deployed. Mesman (2007) argues that the interventionist researcher has the opportunity to act from within an organization to make a difference; however, tensions may arise due to conflicting agendas present in the field. Thus, the different modes of engagement (e.g., participation, action, and immersion) raise questions about whether it is possible to preserve a critical stance while being so closely involved in the project (Mesman 2007). This also raises the problematic issue of taking sides versus maintaining neutrality. The point here is that loyalty and commitment are not, in and of themselves, at issue. Instead, reflexive engagement over a period of time allows the researcher to build a picture of the relevance of particular points of view, and provides a vehicle for their expression. Having said that, such commitments may be viewed as entailing loyalties of one kind or another. In the case described above, the choices made by the researcher influenced the ways in which she was able to intervene by extending her space for interventions from the academic space to the hospital and the design workshops, while excluding her from other spaces, for example, those of healthcare politics.


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To be able to ask critical questions, to build solid arguments, and to push agendas, it was essential that the CSCW researcher earned her space for interventions in the particular empirical field. The researcher needs to become an outsider with considerable insider knowledge (Forsythe 1999). This does not mean that the researcher simply replicates the insiders’ views, but instead that she is drawing analytical links and comparisons between the views of insiders and outsiders. Immersion and extensive participation in the field were essential prerequisites for acquiring indepth knowledge of the local practices (Pader 2006), and were required if the researcher was to truly participate in the design process. This outsider/insider position put the researcher in a position where she was free of institutional politics to some degree and could, therefore, openly ask any kind of question about things that were not being Btalked about^ (Ortner 1996), or about so-called mundane topics, while still being taken seriously. When raising issues by presenting different perspectives to the participants in the workshops, the researcher was able to make visible Btaken-for-granted^ assumptions and point to where these conflict. This required the researcher to make analytical connections within complex collaborative work practices, by seeking certain empirical details (Harper 2000) and viewing these empirical observations from various perspectives and roles. The CSCW researcher has the particular skill of always being able to contextualize Bthings^ and of seeing a phenomenon from various perspectives and across spaces (Marcus 1995). Enacting analytical sensibility with political agendas does not solely refer to questioning and noticing practices. Rather, it includes the ability to craft convincing arguments and to carefully explain possible conflicting future scenarios. As the project progressed, the researcher gradually introduced to the discussions a vocabulary that was adopted by the nurses and used in other sites. For example, co-authoring an academic paper with the nurses introduced them to the academic debates about standardizations and reconfigurations, which were relevant during the discussions about the standardized template. In other words, through the coauthorship process, the nurses were introduced to new concepts that they then applied in political discussions within the hospital space while negotiating the intersections between the EDIS system for the provincial and regional hospitals. In addition, the co-authorship also legitimized the work of the nurses (e.g., in terms of triage drift), as their work was then described in an academic paper that was placed on the wall next to the physicians’ papers. From the workshops, the CSCW researcher went into other sites of design and intervention, including the hospital space and the academic space. In this way, the CSCW researcher constantly exercised design intervention by re-enacting interventions across various settings and discussions. Thus, to understand the challenges involved in politics of design and how the politics create certain conditions for researcher’s manoeuvrability in the field, we need to explore the researcher’s ability to bound diverse sets of sites for design.

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5.3. The future of CSCW research We argue that constructing and bounding sites of design is a critical activity for future CSCW research. The way sites of design are bounded is based upon the decisions and ways in which the future CSCW researcher enacts analytical sensibility. Enacting analytical sensibility concerns about vocabulary is important – and is not just about adopting the users’ concepts about their own work. Rather, it includes the activities of developing a new vocabulary together with the users about their practices, which is fruitful for analytical purposes of design at different sites. Our concept of analytical sensibility is not only about bringing in the user perspective, but also includes the work of noticing and connecting the diverse set of users in their individual, yet collaborative activities. It is about visualizing the links and dependencies that exist but are outside the attention of the interdisciplinary practices involved in the collaborative field. It is thus about constructing the collaborative field of work we are designing for and thus is in focus in different ways in the various sites of design. Finally, analytical sensibility includes the work involved with moving out of the immediate collaborative space (in our case the emergency department) and bringing the insights developed here into other sites of design. These sites can take multiple different forms – like the academic debates on triage drift – and it is important that the future CSCW researcher reflectively decides how to bound sites of design. Analytical sensibility thus differs distinctly from the concept of sensibility in earlier work by including additional work of the CSCW researcher in bounding new sites of design throughout the research engagement. Bounding sites of design is work done by the CSCW researcher when enacting analytical sensibility. However, what is important to notice here is that the ways in which sites of design are bounded seriously impact the manoeuverability of the researcher. For the future CSCW researcher manoeuverability is essential when collaborating with practice. It is important to be able to follow particular interests, moving across different spaces and domains (physical and political) in such ways that we can trace the ever changing practice we are trying to capture. Each time a site of design is bounded, certain conditions for manoeuverability arise. If we take the concerns of certain sets of actors, we will limit our interest from other sets of actors. This is why in this paper we argue that while enacting analytical sensibility when bounding the sites of design, the future CSCW researcher must consider how to balance between politics and manoeuverability. The CSCW researcher collaborating with practice is often political, since the choices and selections of where to go next, what to do, which innovations to conduct – are always framed by the research interest. Research interests are not objectively coming from nowhere; they always come from somewhere, and thus are to some extent politically motivated. We argue that by joining different parties (e.g. nurses), the researcher chooses to follow certain associations across sites, while leaves others behind. These choices based upon analytical sensibility then bound sites of design in certain ways.


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6. Where are the CSCW sites of design? This paper focused on the simple, yet critical, question: Where are the CSCW sites of design? We argue that after 25 years of CSCW research, we need to move beyond the original debate about the relationships between ethnography and design, and ways of overcoming the disciplinary discrepancies between the two (Grudin and Grinter 1995). Instead, we propose embracing the interdisciplinarity of CSCW research, which serves a different disciplinary core than ethnography and design as two separate entities. CSCW research is no longer about bringing together social scientists and computer scientists – instead the contemporary CSCW researcher is interdisciplinary by nature, thus acting upon a different platform than 25 years ago. So where are the sites of design and spaces for interventions? We argue that design sites are constituted by the practices and choices enacted by the CSCW researcher. Sites of design cannot be seen as outside of the academic sphere, nor can they be seen as detached from the dedicated interest of the researcher in the practical circumstances. Relevant acting takes different forms and bounds design sites in different ways. Design sites might be bounded by the practice of questioning basic assumptions behind the future technical design while pointing to conflicting agendas. Constantly voicing the practitioners’ practices in order to dissent the proposed design artefact continuously interferes with the design practice. The researcher’s commitment to the design activities is performed by raising critical questions, as well as by giving the practitioners a voice and an apparatus to promote their requirements within these activities. Furthermore, because of the CSCW researcher’s role as an outsider, she can, to a certain extent, be free of institutional and political influence within the organizational context and therefore not be in danger of asking supposedly wrong questions. While this might not be surprising, few researchers have pointed out that the very practice of asking naïve questions creates a predilection on the part of participants to reflect on the purpose of the questions. In other words, they become reflexively involved in the formulation of answers. Thus, the role of the CSCW researcher when enacting analytical sensibility was to act as a curious and engaged outsider, allowing her to raise questions and place many items on the agenda supporting the creation of a comprehensive account for the complex collaborative situation. In this paper, we argue that the sites of design is no longer privileged territory for computer scientists which ethnographers are invited to enter and change (Schmidt and Bannon 1992). Instead, the sites for design are distributed and constitutive by the commitment and engagement that the CSCW researcher enacts in and with practice. As CSCW researchers intervene in and with practice in many different ways, each type of intervention can directly affect the design of collaborative technologies. As demonstrated by the case, academic participation can have direct impact on the design of electronic triage systems. This insight changes the fundamental ways in which we CSCW researchers can theorize about design. It forces us to scrutinize our own practices to find out where to pay attention, and how to bound sites of design in

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particular projects and in particular domains, and how to intervene across these different sites. This type of engagement raises new research questions and concerns. For example, what is the basic nature of involvement across various sites of design? How are the methodologies different yet similar to existing disciplinary methodologies for ethnography and design? What are the tools and techniques available for interdisciplinary CSCW research? What are the characteristics of different sites of design? What are the politics involved in sites of design, and how can these be manoeuvred by the CSCW researcher? We have illustrated how the site of design was inhabited by various actors, influenced by different and at times conflicting agendas. This included the diverse political pressures imposed by the health authorities, standardization agendas, time constraints, financial pressure, etc. These different pressures shape the sites of design. We have illustrated various attempts of the CSCW researcher to manoeuver in this complex landscape, by intervening across different sites of design. Drawing upon multi-sited ethnography (Marcus 1995) and multi-sited design (Williams et al. 2014), we argue that we must follow the associations enacted by the CSCW researcher. We must identify the relations between design workshops and the organizational context. We must identify the relations between the organization of work and the academic turf. By exploring these associations we will see how these sites of design collapse into and are made an integral part of the design space. We argue interventions carried by the CSCW researcher transform and collectively define and redesign the researcher, the practitioners, the application specialists, the design agenda, and the technologies and practices. Analytical sensibility is crucial in order to balance between exploratory inquiries and constructive solutions. Enacting analytical sensibility requires direct and sustained contact with research participants, but more importantly, it requires the ability to recognize what is important and significant at a certain point in time, and to generalize this observation in terms of constructive design solutions. Blomberg and Karasti (2013) have argued that the relation between ethnography and design is best enabled through tying inextricably ethnography and design. In this paper, we have attempted to tie these two by suggesting a relationship in which one practice implicates the other in a constitutive relationship. We provide a reflexive analysis of the practices carried out by the CSCW researcher who is equally committed to both ethnography and design. This case illustrated how the CSCW researcher Bgot down off the fence^ and got her Bhands dirty in design work^ (Crabtree et al. 2012). Through different types of participation and interventions, the researcher engaged across multiple sites of design. This transformation was neither led by a planned course of events, nor was it purely coincidental. Rather, it was the sum of opportunities and choices that shaped the space for interventions, and thus became part of what in the end constituted the researcher as a political actor. Acting politically is not always easy. Rather, it is coloured by persistent doubts about the effects of particular choices on future events, some of which are not always as anticipated. We argue, therefore, that in any open-ended exploratory CSCW research,


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such transformations are useful as an approach to learn about the field. However, such commitment to intervention, immersion, and participation requires analytical sensibility towards the sites of design, as well as reflexive investigations of these modes of interventions, since they are critical in the processes of bounding the diverse sites of design in CSCW research. Acknowledgments This paper emerged as a result of discussions with participants at the International Workshop of Infrastructure in Healthcare held in Tromsø in June 2013. Shaping and contributing to the argument were valuable discussions with Paul Dourish, George Marcus, Judith Gregory, Gillian Hayes, Melissa Mazmania, and Yunan Chen, while Pernille Bjørn was on sabbatical at University of California, Irvine. We also wish to thank the anonymous reviewers for providing us with detailed comments and suggestions, as well as the supportive and extremely valuable discussions we had with Kjeld Schmidt helping us to articulate our argument. Also we greatly appreciate the comments we received from Dave Randall on early drafts of this paper. Finally, we would like to acknowledge the collaboration with the healthcare professionals during the EDIS project: In particular we would like to mention: Sue Burgoyne, Vicky Crompton, Teri MacDonald, Barbe Pickering, and Sue Munro.

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