Work practice and technology Investigating the dynamics of technical agency

Transcription

1 Work practice and technology Investigating the dynamics of technical agency Margunn Aanestad Department of Informatics, University of Oslo, Norway The Interventional Centre, The National Hospital, Oslo, Norway Abstract The topic of this paper is the evolving interrelationship between a preestablished work practice and a new technology, with an emphasis on the technology s contribution. For designers a better understanding of how technology changes and reconfigures work practice is important. The case study concerns the introduction of multimedia communication technology into an operating theatre, and as a conceptual framework actor-network theory is used. The alignment of the heterogeneous network of technology and work practice was collectively achieved through a dynamic and continuous configuration process. The technology s agency had a definite influence in this process, however, its effects are discernible only at the level of the whole network, as composite effects or displacements. Realising the continuous and open-ended character of the process as well as the work and resources required, might contribute to improved design practices. Keywords: work practice, technical agency, actor-network theory, inscriptions, translations, alignment, configurations. 1. Introduction Studies of work practice and technology have increasingly recognised the complexities of the interrelation between technology, humans and work practices. From an initial focus on design of transparent and supporting tools, one moved on to realise that tools may both constrain and enable work practices. Increasingly, the insight that technology (if successful) does more than facilitate or support work, it also actively changes and reconfigures work, has gained ground. This insight is in particular formulated by recent work inspired by actor-network theory. (Braa and Sandahl, 1998), (Hanseth and Lundberg, 1999), (Berg, 1997), (Berg and Goorman, 1998), (Berg, 2000). Work practice is here conceptualised as a heterogeneous ensemble of routines, persons, artefacts, norms and values etc. where change in one part (e.g. the technical artefact) may affect the rest of the work practice. These studies emphasise the heterogeneous complexity and the multiple roles of artefacts in the networks. Artefacts may act as agents and possess technical agency, they may e.g. trigger and coordinate work. The intertwined nature of humans and artefacts in work practice is clearly evident in this research. For designers it is important to understand more of the multifaceted and subtle ways in which the technology itself participates in design, implementation and use. Despite some notable exceptions (e.g. those cited above), there is still a lack of detailed empirical studies with a Proceedings of IRIS 23. Laboratorium for Interaction Technology, University of Trollhättan Uddevalla, L. Svensson, U. Snis, C. Sørensen, H. Fägerlind, T. Lindroth, M. Magnusson, C. Östlund (eds.)

2 particular focus on the dynamics of this evolving interrelationship. This paper is an attempt to contribute to this literature. It is an empirical analysis of changes and effects observed when multimedia communication technology was introduced into an operating theatre. The focus is on the local work practice and not the interaction across the communication network per se; the receivers at the other end only enter into the analysis at a few instances where they are relevant for the local focus. The explicit focus on both the work practice s and the technology s parts in the process lead to choice of Actor-network theory (ANT) as analytical framework. The process is described as a continuous process of creating and modifying translations and inscriptions in order to stabilise (align) the new composite actor-network (the heterogeneous ensemble of human and non-human actors, of the work practice and technology). The analysis focuses on how this particular technology contributes and shapes the process and the result. This can be seen as an investigation into the conditions for emergence of technical agency as well as the resulting effects of it. 2. Case study and method 2.1. About the case study and the research site The Interventional Centre was established at the National Hospital in Oslo, Norway, in 1996 to do research and development in image-guided and minimal-invasive therapies. It is a crossdisciplinary department, organised around technology more than according to traditional professional boundaries. Minimal-invasive (or keyhole ) surgery is different from ordinary (also called open ) surgery in that it minimises the invasiveness of the procedure. Instead of a large cut to facilitate the surgeon s direct vision and manipulation of organs, a small video camera and instruments are entered through small incisions that may be 5-10 mm wide. The surgeons focus is on video monitors that provide the image of the patient s organs as well as the instruments actions. Thus both the surgeon s visual and tactile information, as well as the actions on the organs, is indirect or mediated by technology (the monitors and the surgical instruments). Usually an assisting surgeon is holding and moving the video camera according to directions from the main surgeon, and both surgeons may have their own monitor to watch, as they often are positioned at each side of the operation table. The scrub nurse hands over instruments to the surgeon, either on explicit directions, or, as is mostly the case, based on anticipation of the surgeon s needs. Thus the mediated images are important for the nurses in the room as well as it provides awareness of general progress and facilitates anticipation of specific tasks. The presence of a mediating technology makes minimal-invasive (or image-guided) surgery a likely candidate for telemedicine. The video image is regarded as the main information source for the surgeons during the procedure, and it is relatively easy (technically speaking) to tap and transmit this video signal. Minimal-invasive surgery is a work practice that is heavily integrated with a lot of technology in continuous development and change, so the introduction of new devices (communication technology) does not signify a change from a non-technical to a technically oriented work practice. Rather, it is just one more (assumedly minor) addition to the array of tools. Also this new technology is not a necessary tool for the primary object of work, it is rather an additional, non-critical, and voluntary technology, which may facilitate new forms of mediated communication not previously possible.

3 Figure 1. A laparoscopic procedure in the operating theatre. The two surgeons to the left, and scrub nurses in the middle and to the right. Note the two monitors with the internal video image, and the tiny microphones hanging from the roof. A lot of visitors to the centre were anticipated when it was planned, mainly medical doctors (surgeons and interventional radiologists) and administrative personnel who were planning or running similar departments, as well as guests from industry. To avoid disturbing the operating theatre team more than necessary, as well as let the guests avoid changing clothes when entering the sterile zone ; a local analog transmission facility was set up between the operating theatres and an external room. Images from overview cameras in the operating theatres were available; in the interventional suite (which is the theatre in focus in this paper, see also Figure 1) there were one wall-mounted camera as well as one camera mounted in the roof directly above the operation table. In addition, images from several other sources, including x-ray, gastroscope, laparoscope, and ultrasound equipment etc. could be transmitted and displayed in the external room. In total 16 images from the two operating theatres were possible to transmit and display on 16 small monitors. One of the images could then be selected and displayed on a large monitor (Figure 2). Two-way audio through microphones and loudspeakers facilitated conversation between the operating theatre team and the guests located in the external room. This room was also the hospital s studio for videoconferencing, and equipment for transmission of image, sound and data at 384 kbit/s across the ISDN network was available. The videoconferencing equipment was also connected to the local network, so that image and sound from the local facilities could be transmitted to any ISDN-connected receiver. This possibility was intermittently used, but the external transmissions became more frequent and regular during a large telemedical project utilising an ATM network of 34 Mbit/s.

4 Figure 2. The technicians and the equipment in the external video room. Note the rack with 16 small monitors. The department employed several community workers, who served approximately one year s service as an alternative to army service. They were not regarded or paid as ordinary employees. The workers that were recruited were mainly engineers with different kinds of computer science background. Due to lack of space in the department, they were assigned this room as their workplace. Telemedicine was not intended to be their main task, but it became an important and large part of their duties as the activities expanded. It is these persons who are called technicians in the paper Method Participant observation was the main method used. Around 50 % of the author s time during one and a half years was spent at the Interventional Centre, assisting in the planning, execution, and evaluation of most telemedical transmission that took place during that period. My practical role in the execution of transmissions was that of a technician, assisting with camera control, equipment set-up, etc. My impression is that I was perceived as an ordinary employee who was pursuing a Ph.D. like several of the other in the engineering and medical staff, more than as an external researcher observing the local work practice. Part of the staff was part-time employed (still working in their mother department), so my part-time presence was not unusual. Also the hospital was a teaching hospital, which meant that there were very often guests and students present in the operating theatres. At this particular department visitors were even more common, so the operation team were used to strangers observing their work.

5 Participant observation may imply, among other problems, a lack of distance and a bias towards partial representations. My role and identification with some parts of the work practice is partly a result of active choice, partly a result of contingencies. Generally, I believe that partiality is a given fact of this kind of research, as there exists no privileged position for a researcher where the truth is clearly visible. The researcher s point of view and perspective is unavoidably influencing the research and is something that has to be made as explicit as possible, rather than attempted to be negated or glossed over. From the empirical material I think a focus on nurses and technicians work is evident, as well as a corresponding lack of focus on the medical-professional aspects of the surgical work. The bias towards nurses and technicians work should not be taken as a negation of the importance of the medicalprofessional parts of the work practice. The integration of telemedicine into clinical practice is crucially dependent on acceptance from the medical doctors, or the surgeons in this case. The considerations regarding clinical quality and safety that are crucial to surgeons is a topic that is complex and important enough to require a separate study. With the limited focus here (integration into the work practices in the operating theatre) these issues are outside the scope of this paper. Surgeons have a central role and position within the surgical work practice, but their temporal and spatial presence (within the operating theatre) is limited, and their responsibilities and tasks are clearly demarcated from those of other groups. My conviction is that this in some ways shields them from much of the alignment work that goes on inside the operating theatre, which is the topic of this paper. This work is most clearly to be seen in the general preparation work of the nurses, as well as in the facilitation work of the technicians. These considerations are the basis for my pre-occupation with these groups work tasks, as well as for the choice of participant observation as the practical method. This method provides the best way to get access to instances, problems, and discussions through a phase of learning and re-configuration. The issues and problems that emerge in such an explorative phase may be though of (by the informants) as too trivial and mundane to be captured by formal interviews. In addition to participant observation, a log was kept (by myself or other technician) over each transmission (date/time, duration, content/topic, support time needed for preparation and execution, technical and other problems encountered, free text etc.). This log provided documentation about when several of the issues discussed arose, which problems were encountered and how they were solved. In addition, personal diary notes have filled in on details, and textual documents including project documents (from the telemedicine project), documents from planning of transmissions, technical cabling plans etc. have been available to me. Also informal discussions with the technical staff (and to a lesser degree nursing and medical staff) after each transmission, and more formal discussion meetings with nursing and medical staff were carried out Theoretical perspective Actor-network theory (ANT) from the field of science studies presents fundamental challenges to traditional ontology and epistemology (Latour, 1999). However, it may also be taken up in a more pragmatic manner and used as a methodology, as it provides the researcher with an approach for research and analysis. The use of ANT within the IS community is often motivated by the theory s perceived suitability to describe and analyse the complex socio-technical issues in focus in this body of research. The wish to explicitly focus on both the work practice s and the technology s contributions in the implementation process lead to choice of ANT as the

6 analytical framework for this study. Actor-network theory is in practice not a unified body of concepts, and an eclectic approach to it is widespread, as it is to theory use in IS research in general (Walsham, 1997), (Monteiro and Hanseth, 1995). This necessitates a brief and superficial overview over the ANT variety used in this paper, and a short explanation of the concepts that are used (actor-network, actors/actants, interests, translations, inscriptions, program-of-action, enrolling and alignment). This overview is based on (Akrich, 1992), (Latour, 1987), (Latour, 1991), (Latour, 1999), (Callon, 1986), (Callon, 1991), (Law, 1992) An actor-network is a heterogeneous network of human and nonhuman actants (actant is proposed as a more neutral term than the human-centred actor) where the relations between them are important, rather than the actants essential or inherent features. The theory argues that it is analytically fruitful to reject any a priori distinctions between elements in the network, as e.g. the distinction between humans and non-humans. Differences are instead viewed as effects (i.e. as achieved or constructed) rather than as pre-given. This symmetry assumption has created a lot of controversy around ANT, both in general and within the IS community. (See e.g. the epistemological chicken debate (Collins and Yearly, 1992), (Callon and Latour, 1992)). The critique (at least within the IS community) has often focused on the concept of material agency. Attempts to avoid the strong symmetry assumption of ANT, e.g. (Jones, 1999) are evidence of an uneasiness about granting non-humans agency on line with humans. Jones suggests the possibility of viewing material agency as capacity, lacking the intentionality component that is a distinctive feature of human agency. However, to stay faithful to ANT we also need to keep in mind that agency is an emergent and not an essential or inherent property of the actants. The network provides the actants with their actantiality, i.e. with opportunities to establish and use agency. When it comes to network dynamics, ANT holds that stability (or order, agreement, success, efficiency, or goal achievement) in the actor-network composed of actants with different and possibly incompatible interests, is obtained when the network is aligned. The alignment of the network occurs through a process where the actants interests are translated (i.e. reformulated, modified, or changed) into more generally agreeable expressions, so that several actants may support the resulting translation. The translation may be inscribed into a medium, e.g. the characteristics of an artefact, a rule, a procedure or a standard. The inscription attempts to define a framework for possible action (a program of action), and it may be more or less strong. The inscription s strength is not only a static entity, once defined by the designer and inscribed into the object. It is also a dynamic, relative and subjective feature that emerges in the actual network when actants are delegated roles and competence (Hanseth and Monteiro, 1997). The other actants may follow, twist or oppose the inscriptions program of action aimed at stabilising (aligning) the network. The actants that are supporting (more or less voluntarily) a given translation and its inscription have then become enrolled and are cooperating (still more or less voluntarily) towards a common goal. If sufficiently many or strong actants are enrolled in the network, the opposing interests may be forced to yield. A network may evolve towards a stable state with (relatively) irreversible and unchangeable inscriptions, it may be in a state of flux and instability, or it may be only temporally stable and aligned. I attempt to use these concepts to describe how the interrelation between the work practice and the technology unfolds. The continuous process where the different actants interests meet, are translated and inscribed into artefacts (material or non-material) is described. A descriptive analysis of this process of alignment is also the story about how the technology s agency played out in the new actor-network.

7 3. The work practice and the technology The following report of empirical data from the case study is separated into two main parts, corresponding to a time-based structure. First, some of the effects and consequences of the installation and use of the local transmission network is described. The presence and use of this facility created some changes and disturbances to the pre-established work practice, which spurred a process of continuous refinement of the translations and inscriptions. Second comes the description of the issues that arose when the local network was expanded and connected to an external telemedical network The local transmission facility The local transmission facility was fulfilling a wish of both the operation team (being relieved of visitors in the operating theatre during work) and of the guest (who would then avoid changing clothes). The room overview cameras were remote controlled, which further relieved the operation team of the task of camera operation (i.e. change the viewing angle, focus, or zoom), which would have been irrelevant tasks to their primary activity (the surgical procedure). However, this particular translation and inscription (or materialisation into concrete physical artefacts) of the actors interests did also have some unexpected effects and consequences as well. Through three examples from the integration process we will investigate how the matching of the different actors or actants interests and demands, the alignment of the network, was carried out through translations and inscriptions. As noted, the analysis will have a special focus on the contribution of the technology, and on the grounds and conditions for its exertion of influence or agency Yielding to the demands from the technology One very strong inscription in the chosen technology was that all the visual and aural information that one wanted to transmit across the communication channel had to be captured and made electronic. In order for the surgeon s voice to be audible or available to the remote listeners, there must be a microphone in a position where it captures the sound waves of the speech (and preferably not too much other sound). In order to provide a view of the room or the operation table, a camera must be present, turned on and connected to the network. The medical imaging equipment must provide a copy of the image signal to be captured and transmitted via cables. We could say that some of the communication devices required feeding of input material, while also management of the output devices (loudspeakers, displays) was necessary. These inherent inscriptions in the technology required changes in the work practice by introducing new works tasks, mostly for nurses and technicians. The nurses new work tasks were mainly related to connecting imaging equipment to the network, turning on the control key for the transmission network, and ensuring adequate positioning of microphones. These tasks became included in the nurses general preparation work of surgical procedures when a local or later a telemedical transmission was to take place. Also the technicians had to perform work in order for the network to work; they had to provide cables or other artefacts, devise solutions to technical problems, and assist in connecting and managing the equipment. The demands from the technology were thus translated into specific work tasks and inscribed in a standard procedure. One consequence of these inscriptions (or demands from the technology) was changes in the conditions of the work. Several disturbances were introduced, e.g. noise and

8 sound through the audio lines and a generally messy situation with cables on the floor and presence of technicians in the operating theatre during the operation. The technology posed some absolute and strong demands on the work practice, and if the technology was to be used at all these demands had to be met. The work practice yielded to these demands and accepted the costs and disturbances introduced, while in general, other disturbing artefacts easily gets expelled from operating theatres. What legitimises the costs and disturbances in this case is that the technology has been given or delegated a role to fulfil, with an associated location in the actor-network. Thus the basis for the technology s influence on the work practice, or its agency, is related to the delegation of this given role, namely that of facilitating communication with remote receivers. The rationale behind this delegation is the choice made by the department of involving telemedicine in its activities Inscriptions activated in the network configuration The presence of cameras and microphones in the operating theatre linked to screens and loudspeakers in the external room created uncertainty over surveillance issues. The new technology provided a possibility of invisible spectators, as technically knowledgeable personnel (and others present in the room) could watch and listen to the activities in the operation theatre without themselves being seen or heard. The sound and images could also be transmitted across the ordinary ISDN network to potentially any ISDN-connected location in the world. This new possibility contributed to a shifting of control over the work situation and over the visibility of work and interaction, and the department needed to decide on routines and rules for usage. After a while the interests of the team in the operating theatre were inscribed into some physical artefacts as well as some rules. A key was installed beside the wall-mounted camera in the operation theatre. This key had to be turned on in order for the transmission of video signals to be possible (to activate the lines), and when the key was turned a red on air lamp was lighted. The sound transmission lines were not included in this system, so it was still possible to listen to the conversation without the red lamp on. This was remedied through a voluntary and explicit commitment by the technicians to never listen (i.e. actively send the sound signals to a loudspeaker) unless the operating theatre personnel had activated the video transmission control. Here we see an illustration of the previous proposition that an artefact s agency is related to its location in the network. Agency is relational, meaning that it occurs or plays out in relations or when the artefact is part of a network; it is not a feature that is objectively present in an autonomous and isolated entity. An artefact may have inscriptions, like designed features or attributes, and these are often the reason why the artefact is enrolled in the first place. However, these inscriptions do not effect anything alone. An uninstalled camera lying in a box wouldn t create concerns of surveillance, but its inscriptions (the designed features that makes surveillance possible) become activated when it is located in this particular position in the network. We also see that this particular configuration (mix of artefacts and people) of the network turned out to be problematic because of the way agency was distributed (who was in control). In order to align the network another configuration was attempted, where new artefacts and rules were enrolled to re-distribute agency Inscriptions created in the network configuration The chosen technology and the installation of it implied a specific projection of expected receivers and use areas. Both the departments research activities and the specific telemedicine

9 activities had a strong focus on medical doctors (especially surgeons and interventional radiologists), as opposed to other groups. A surgeons work (at least the part which occurs within the operation theatre) has a defined localisation in time and space, it is performed after the patient and equipment is prepared and occurs mainly around the operation table. One of the cameras was mounted in the roof above the operation table, and also the microphones and loudspeaker were located here. Thus the placement of the equipment in the room reflects this focus on surgery. The installed technology made the surgeons work easier to capture than e.g. the nurses work, which is distributed over much larger space (from reception of the patient at the entrance, and across the whole of the operating theatre, often in parallel) and through larger amounts of time (including preparation and clean-up). Also the other available image sources give only a selection of the local context (again with a strong focus on the surgeons image needs). Which parts of the work that are made visible depends on the actual usage of the technology (when it is turned on and off, which camera view is chosen, etc.), which again depend on pre-established practices of rendering somebody s work more visible than that of others. The inscriptions evident in the installation (and in the use) of the technology were rather strong. As most of the actual transmissions were performed for medical doctors, the program of action inscribed in the installation of the equipment was adequate. In other instances, when the use of the network deviated from the projected usage, the inscriptions became problematic. The installation was not flexible enough for the radiographers, the anaesthesiology team or the operation nurses to use without limitations. In order to document nurses work for an offline video production, an additional mobile video camera was enrolled to be able to capture the work that was distributed in space. The inscribed limitations were also related to the audio part, as the microphones above the operation table was unable to capture the verbal explanations when the workers were located elsewhere in the room. Audio (explanations and comments) had to be laid on in the editing process (necessitating also the enrolment of video editing hardware and software). On the other hand, it was possible to observe several instances of unintended use of the installed technology, which shows that the inscriptions in the installation of the technology were not absolute. The installed equipment may be appropriated for different interests. For example the technicians might use the camera to monitor who was present in the operating theatre. Especially if one of the technicians was on the way to the operating theatre to correct something, the camera might be directed towards the door to see when he entered. Then the control room technician may phone or speak through the loudspeaker to communicate with him. At some instances the cameras would also be focused on cables and connections to try to detect the source of lacking images or other problems. Sometimes when there were no transmissions or guests, the audio lines would be used for transmitting music from the video room to the team working in the operating theatre. Separate cables were present for connecting the movable imaging equipment to the network. When unused, these connection cables were sometimes used for other purposes, like connecting an unused monitor to the laparoscopy monitor to provide also the anaesthesia team with the image from the internal laparoscopy camera. The team is usually located at the patient s head end of the operation table, and previously they had to move a bit in order to watch this image on one of the surgeons monitors. The continuous availability of image on the extra monitor provided them with a general awareness of the progress and allowed them to assess the amount of bleeding (which may impact the patient s vital functions) directly without having to ask the surgeon.

10 From these examples we see that definite inscriptions are present in the seemingly neutral and obvious design of the communication facility. These inscriptions reflect more or less explicit organisational values, and they are more or less chosen or intended. These inscriptions are not located in particular artefacts or actors, but are rather a result of the particular way the actor-network is configured. We see, however, that as the network configuration changes (e.g. with different use areas) the effect of these inscriptions vary. In some instances it seems possible to appropriate and capitalise on the present inscriptions, in other instances the inscriptions seems to constitute limitations that must be circumvented for example by enrolling other artefacts. The central role of usage, or the intentions and rationale behind actions, is evident. This points one more time to the delegated role as crucial when it comes to agency. The technology s delegated role gets changed when a different kind of usage is attempted, and consequently the technology s performance in this new role may not necessarily be the same as before. We may envision different demands to parameters like image quality, or as it seems to be the case here, a too inflexible location requires an alternative sub-network to be established (including the mobile camera). Agency is thus dynamic, not static and given once for all by an artefact s attributes and its location. What is a powerful location in one configuration of the actor-network, may be a disadvantaged position in another Expanding the network The presence of the local transmission facility spurred a continuous process of designing, testing and adjusting network configurations to achieve a well-working (aligned) network. When external transmissions were performed, either across the ISDN or the ATM network, some fundamentally new challenges and changes were introduced. The old translations and inscriptions were insufficient, and new alignment activities were necessary. These changes also reverberated backwards into the previously aligned network, and changed the established and tested configurations Even more changes in work practice becomes necessary Locally the expansion of the network required enrolling more technical artefacts (more equipment), and a more complex material infrastructure emerged. Audio mixers, several loudspeakers and headsets were purchased to be able to monitor and adjust sound to and from the different participants, and more cameras and monitors also became necessary to manage more image sources and destinations. In addition several video recorders were included in the set-up, to be able to record transmissions. The result was a considerable increase in complexity, which led to more dependence on technicians. Earlier the departments medical doctors had been able to go into the video room and initiate a local transmission for their guests, or an ordinary ISDN conference. With the new complex set-up they became dependent on the assistance of the technicians in order to do this. The support work changed in content, character and importance, and the technicians acquired a more intermeshed and crucial role in the network. In addition to managing the local equipment, new tasks for the support technicians included establishing the ATM (or ISDN) connection to the other side, verifying proper image transfer both ways and doing sound checking (which in its nature is very interactive). Then the internal network had to be activated and connected to the external (telemedicine) network, with corresponding image and sound checks (typically between nurses and technicians). The required images from the operating

11 theatre had to be selected, the sound quality adjusted, and the transmission monitored during its whole extent. Planning and coordination work, both internal (with local participants/the work team) and external (with the other site s technicians or receivers) became a larger part of the technicians work than before. (See (Johansen et al., 1999) for further elaboration on the character of the support work). The change of the technicians position is also reflected by the fact that the external room started to be called the control room instead of the video room or video studio as before, at least among the persons involved with the telemedical transmissions. Although not mentioned here, other use areas outside the operating theatre (e.g. transmission of lectures and meetings, off-line video recording and editing) were important experiences, as it provided the technicians with opportunities to learn to handle the technology and exploit possibilities. See (Aanestad and Hanseth, 2000) on the process of learning through gradual expansion of use areas. Here we see the new demands from the technology met by the work practice through translating them into definite work tasks performed by the technicians. The process is similar to the experiences with the local facility, but the network technology introduces new kinds of demands that have to be met through a new round of alignment. We thus see that sustaining an aligned network is a continuous process, and that a given stability is only temporal and local. When changes or expansion occur, the alignment needs to be performed anew Problematic configurations The possibility to transmit sound and images from a surgical procedure in real-time to remote receivers introduced novel possibilities. At the same time some limitations were introduced, e.g. by the fact that transmission of sound and images was a narrower channel for communication than real co-presence. This could be problematic as is illustrated by the following example. A surgeon s main focus during a laparoscopic procedure is on the video image from the inside of the abdomen. However, during some procedures also other image sources are used. This may be ultrasound images, or X-ray images. Sometimes the surgeon switches focus between these different sources frequently and rapidly. This dynamic image use is not a problem when students are present in the operating theatre, as the surgeon s direction of vision and other small bodily or verbal cues are easily detected. However, it turned out to be difficult for the technicians in the control room to detect or interpret the surgeon s change of focus and consequently switch to the correct image source to transmit. This demanded constant and close attention to the verbal interaction and all the available images from the operating theatre (on the 16 small 10x10 cm, black and white monitors in the control room), a task that the technicians felt tiring and demanding. They also lacked the medical knowledge necessary to determine which image was in focus at which time. To secure that the transmission would be successful, the surgeon had to comment explicitly on the image use, a task that was not necessary when the students were present in the room. At one instance, a students facilitator was present with the operating surgeon, explaining and commenting on the procedure. The explicit comments on image use greatly helped the technicians to decide and switch images correctly. In other words, a new work task needed to be performed by the surgeon, or a new role as a medical producer may be called for. Other alternatives where the other actants is delegated this role may be envisioned. The technology may perform this task, e.g. via intelligent image switching, based on automatic detection of surgeon s direction of view. Or the task could be delegated to the receivers if all available images were transmitted and displayed at the same time, so they could choose for themselves which image to watch.

12 The particular configuration with the technicians central role is not unproblematic. This need for reconfiguration became evident through real use, and it was a general feature of the process that these kinds of problem were unexpected. We see the possibility of several ways to attempt alignment, the choice depending on contingencies. This emphasises the essentially unplannable and inherently non-deterministic character of the process. Which network configuration that will work is an empirical question. We also here see illustrated that the technology s agency (its capacity to act according to delegated role) is dependent upon the surrounding network. The technology requires quite a lot of facilitation and support work from the other actors The technology shaping the communication A given surgical procedure became more of a demonstration and a performance than it used to be (even with spectators like students or visitors present in the room). Teaching students, no matter whether co-present or distant, requires explanations and demonstrations, but the form of these explanations and demonstrations may become changed when they are mediated through a communication technology. The co-present students will have to be directed and positioned in the operating theatre, in order to provide them with an adequate view of the activity. For teaching the distant students the important task became more related to providing them with the adequate view in the virtual space. It became important to ensure that the receivers see the correct image, might have to request certain camera views from the technicians or to pause action and minimise movements of instruments in order for the transmitted image quality to be optimal. The technology is delegated the role of being the receivers eyes and ears, and the surgeons consequently has to relate to the camera. The discussions about surveillance issues in the early phases reflect the loss, or rather shifting or distribution of control over the communication situation that occurs when the technology s is given this role. The initial attempts to regain control (enrolling a control key and red light) were mainly successful in the local context. The guests present in the external room were often expected and known in advance, or they were presented to the staff in the operating theatre. When the external transmissions started, these measures were not sufficient to keep this expanded network stable or aligned. During the first test transmissions some receivers (at the other side) would come and go according to their local duties. The operation team did not know how many or exactly who the receivers were, or whether they where present or not at any given moment. If there had been quiet time periods (without interaction), the operating surgeon might ask explicitly who were watching. In fact, as the technology provided a two-way audio- and video-connection, an image was actually transmitted also from the receivers site, but this image was (in the beginning of the project) only being displayed in the control room, where the technicians were located. Later this image signal was forwarded also into the operating theatre and displayed on a monitor. Then the whole team could see who the receivers were. It would however, still be possible for a receiver to position oneself outside the camera view and thus be an invisible viewer. This would amount to avoiding the program of action that was intended to provide the required reciprocity. If the surgeon wanted to address the audience before the surgical procedure started, he/she needed to know which camera (e.g. the roof- or the wall-mounted room camera) that was currently active in order to simulate eye contact with the audience. Also in other situations the surgeon or the team might want to know which camera view was transmitted, how close it zoomed, or which of the other available image sources was transmitted. In other words

13 feedback was wanted in order to manage and control the self-presentation. Some transmissions were performed where not only images from the operating theatre, but also images from other rooms as well as PowerPoint presentations and videos were transmitted. Then the operating theatre was not on air all the time. Even though the images were constantly transmitted to the control room, they were not transmitted any further. At these instances, the operating theatre team was provided with the outgoing image (the image sent to the receivers), and they could then relax when they knew that they were not being watched. This image was displayed at the same monitor as mentioned before, and consequently they were not able to see a picture of the receivers. This was not felt to be interesting, as long as one knew that there would be a lot of people watching anyhow. This shows the dynamic character of the work practice s demands to feedback and reciprocity, according to different contexts. The two different genres of communication required different configuration of the network elements, and the chosen configuration was closely related to the human actors wishes and goals. External transmissions also implied less control over receivers values and norms, and potential secondary use of information. The issue of sensitive patient data was resolved by not transmitting any identifiable information (no images of face, patient data on x-ray images were removed). Another issue that had been discussed before, but became intensified when external transmissions started were the routines for informing the patient and obtaining patient consent. As the patient often was pre-medicated at the arrival at the department, consent obtained by the receiving nurses would not be legally valid. The surgeon would have to include this task in his/her previous talk with the patient. Apart from the legal considerations, discussions also arose over general protection of patient s rights and dignity. After some instances of discussions and disagreement, the nurses and the technicians agreed on some rules (i.e. inscriptions of patients interests): usually no recording or transmission during the early phases of the procedure, where the patient was anaesthetised and naked. After the patient s body was covered, and only the area of interest to the surgeon was exposed, the camera system was turned on. Focusing on the patient s facial features was avoided. The intensified feeling of less control also led to increased efforts to create a shared awareness in the department through a couple of organisational inscriptions. Planned transmissions and off-line video recordings were included as a note on the weekly work schedule (which listed all the patients with their planned procedures, time and location, as well as the participating staff). It was also requested that information about content and purpose of planned transmissions should be given at weekly meetings between all staff. The technology s attributes were the initial reason for their inclusion into the network, but we see that they also may introduce unwanted effects (loss of control of operation team). The changes introduced arose from a wish to adjust the particular configuration of the network to achieve a desirable distribution of power and control for the operation team or the surgeon. This counter-acting of problematic effects, as well as the encouragement and strengthening of wanted changes demands a lot of what could be called configuration work or alignment work. 4. Configuring networks The myriad of mundane, even trivial, details recounted above are some of the traces of an alignment process. The work practice has adapted to the technology s demands for new knowledge and skills, for incorporating material artefacts, and for adjustments of the work

14 practice (new tasks, changed procedures, new roles, new personnel groups). We do also see changes and expansions of the technology itself: additional technical artefacts have been enrolled (red light, additional camera etc.) and the technology has been used in unintended ways to circumvent the limitations. Some of the tasks necessary for achieving and sustaining the alignment have been delegated to artefacts (representation of the receivers, warning of transmissions), and other tasks have been delegated to humans (providing input to the technology and producing the context relevant to the receivers). In fact the achievement of alignment is not that easy to pinpoint and allocate to specific actors, it is rather a network effect, where the humans plus the artefacts is achieving the result. For example, in order for the monitor in the operating theatre to represent the receivers, several other human and non-human actants needed to act accordingly. A camera had to be adequately placed at the receivers site, turned on and connected, and the receivers had to position themselves in front of the camera. The transmitted image had to be transmitted further to the operating theatre, a task that required technicians, additional cables, an unused monitor, somebody to turn it on etc. Correspondingly, in order for the human actants to provide the technology with the required input, they had to enrol microphones and cameras, as well as cables. There is a network of human and non-human actants around or behind each actant; nobody can act in isolation. From the analysis of the empirical data we may see that: Successful alignment is a collectively achieved result, a network effect dependent on the properties and characteristics of the whole collective ensemble (the heterogeneous network). The alignment of the network is a performed stability, which is achieved through a continuous and dynamic process of dynamically defining and implementing adequate translations and inscriptions of all the involved actants needs and interests. This process can also be viewed as a process of configuration of the network. This requires attention to all kind of details, dedication and care (Ciborra, 1996). The work of alignment, support, or facilitation is crucial in the testing and redesigning of adequate and well-working network configurations. This also means that the process is costly and resource demanding. To keep a network aligned requires attention, dedication and continuous work, as expressed by the phrase every day is a working day (Latour, 1996; p.86). The process is continuous and never-ending. The apparent stability in the case study is a local and temporal stability. In a limited context, in certain time periods, or around defined use areas a relatively stable network of artefacts, routines, and work practice may emerge, but any change or expansion will destabilise this network, requiring new translations to align the network (Aanestad and Hanseth, 2000). When a new artefact or a new feature is introduced or when a new use area is included, the network will encounter new networks, new actants, new interests and demands that it needs to merge with and align. As more actants are involved, the translation and alignment process may be harder to accomplish. The realisation of influences from multiple sources helps us realise that alignment is fragile in the sense that a lot of actants are necessary in order to hold the network together (aligned, in function). The scale of the network contributes to this fragility (more links increased risk for one weak link). But also the increased complexity and inter-dependence between actants means increased risk for collapse, as it introduces higher possibility for unintended dependencies and side effects.

15 The process of integration is inherently non-deterministic and open-ended; at the same time we can predict that it will involve displacement (relative to the initial plans). Displacement can be understood as the direction the collective takes once its shape, extent, and composition have been altered by the enrolment and mobilization of new actants (Latour, 1999; p.194). The network elements agency is crucial in achieving and sustaining alignment. But their agency is relationally defined, which also implies that it is dynamic and changing, depending on the particular network configuration. Thus it is not feasible to allocate agency to objects as such, it may however be possible to identify effects of agency at the network level Displacement and agency In this case, incorporating the technology into the work practice definitely effected change and displacements. These changes may be attributed to the introduction of the technology and thus be an expression of its agency. This is not an expression of the technology s pre-given and static agency in any deterministic sense, but is the agency that emerges in this particular network configuration (or set of configurations). We may see at least two features of this displacement: Increase in complexity, power, and dependence We see the displacement towards a more complex and enmeshed hybrid of human and nonhuman actants. The new work practice, understood as both carrying out (as before) and transmitting a given surgical procedure to external viewers, constitutes a new network of both human and non-human actors that are inseparably intermingled. By this increase in complexity the network has become more powerful and far-reaching, as it can extend itself and communicate with distant receivers. This was the intended and wanted change. At the same time and as a consequence of these changes, control and power was shifted and became distributed rather than located to specific actants. The dependency of the actants on each other was increased. Paradoxically enough, this also reduced power, in the sense that there was less control, and less predictability than before. We may say that the agency of network technologies has manifested itself in the introduction of network dependencies. The implications of this for the development of telemedicine (or other network technologies) are profound, but to expand on this issue is not within the scope of this paper. We ll therefore turn to another effect of the displacement From procedures to performances A shift or displacement of the work practice towards a performance in front of an audience is evident. The patient was the one most immediately affected, by having images from the inside of the body transmitted to the outside world. Most of the time the patient s interests were represented by the nurses and the surgeons, and the interests have been translated into new rules for patient information and consent, as well as restricting the camera s view (defining rules for when it was OK to record or transmit). This amounts to defining and managing the patient s role in the performance. The operation team encountered a new work situation, and the discussions around the surveillance issues as well as the wishes for feedback and reciprocity in the communication situation were signs the shift towards performance aspects of the work. These discussions and issues can clearly be attributed to the impact of the technology. As one of the central persons in the work team the surgeon was affected by being in front of the