A conceptual framework for investigating documentary practices in prehospital emergency care

Introduction

The complexity of work practices in prehospital emergency settings – at scenes of accidents, in peoples’ homes, and in ambulances – is this far understudied. This setting contains a multitude of reoccurring actions and interactions, which involve the use and production of various documents; for example, performing assessments and tests, establishing diagnoses, using protocols and checklists for treatment decisions, interacting with patients, relatives and/or bystanders, and producing accurate and reliable documentation (Andersson Hagiwara et al., 2019). The aim of this study is to outline a conceptual framework suitable for empirical studies of documentary practices in complex mobile, unpredictable and time critical contexts, and thereby, in extension, contribute to increased knowledge about the role of documents and documentation in such settings.

The notion of documentary practices comprises a wide range of activities pertaining to documents including both the production and the use of documents in different formats, e.g. recording, distributing/sharing/transferring, sorting, and reading. Documents in this setting may be bodies (the own as well as others’), clothing, notecards/-pads, preprinted forms, digital record systemergency medical services, system specific outputs, notice/white -boards, and other material objects that allow for inscriptions. Altogether these constitute a complex, hybrid information infrastructure: a chain of various documents and documentary practices onto which the overall work of the emergency medical services (EMS) staff is hinged. This infrastructure also serves as a multifaceted representation of the various ways in which the work is instantiated, with documents of different sorts functioning as boundary objects and reference points in this process. Hence, by mapping and interpreting the infrastructure as a more or less coherent process, novel insights into the configuration of work can be gained.

The following overarching research question has guided the research process: how can connections between, on the one hand, documents and documentary practices in prehospital emergency care and, on the other hand, other work practices enacted by emergency clinicians be described and understood? The question is based in the assumption that there is a linkage between documents (and the production of these) and social organization in the shape of, as in our case, work as it unfolds in and around the ambulance and patient (cf. Smith, 1974; 1984).

As a site for research, the prehospital setting is challenging in terms of following and observing work practices: there might be issues with access, safety and other practical matters; unpredictability in both call volume and types of situations; and concerns regarding integrity, ethics and consent among patients and emergency medical services clinicians alike (Söderholm et al, 2019). By studying both documents such as medical records and the practices through which they are used and produced, but also the traces of practices that are visible in the documents that remain after the work is finished, we gain insights into the role of documents in practice. This dual perspective provides additional insight into the configuration of work and its organization, and into the multiple, potentially normative and idealized, sometimes colliding narratives that tend to pervade work.

Background

There is a fairly generous amount of theoretically sophisticated studies concerning documentation and records management, located to the empirical setting of health care, in research areas such as information systemergency medical services (e.g. Jones, 2014), organization research (e.g. Nicolini, Powell & Korica, 2014), sociology (e.g. Berg & Bowker, 1997), and medical informatics (e.g. Berg & Goorman, 1999). Some of these indeed contribute with theoretical, empirically grounded research specifically on documents and documentary practices (e.g. Østerlund, 2008). However, despite the rich tradition of studies of documents and documentary practices in library and information science (e.g. Buckland, 1997; Trace, 2011; Sundberg and Kjellman, 2018) there is a clear lack of theoretically grounded studies on documentary practices within the empirical area of emergency health care, and in particular ambulance care. The strand of research that has investigated emergency-health care in and in the vicinity of ambulances seemergency medical services to be mostly oriented towards either specific treatments and health conditions or IT-based decision support-system solutions (e.g. Ho et al., 2017). This research is often conducted within a paradigm characterized by hypothesis testing and quantitative methods. However, a general observation in the previous research is that documentary practices and overall work organization are intrinsically intertwined; when new systemergency medical services for recording and monitoring events are introduced, there are implications for the work that the systemergency medical services are supposed to enable and support (e.g. Jones, 2014; Söderholm, 2013). On a similar note, it has furthermore been suggested that documents and documentary practices that are supposed to function as enablers of work practices are equally likely to bring with them unforeseen constraints (e.g. Smith & Schryer, 2008; Prior, 2003), requiring re-interpretations, negotiations and workarounds of both practices and documents.

Documents in practice

We anchor our theoretical reasoning in a set of empirical observations from previous studies of prehospital emergency care. Based in an overall practice perspective (e.g. Schatzki et al., 2001), the study to a great extent draws on “critical document theory” (Lund, 2009, p. 15) in the way it has been proposed and practiced by, e.g., Dorothy Smith (2005) and John Seely Brown and Paul Duguid (e.g. 1996). According to such stance, focus in documentary studies is shifted from content analysis to the role of documents as coordinators and constrainers of the social.

A practice theoretical perspective on the study of documents

The framework for studying documentary practices that we suggest primarily draws on critical document theory, but is overall firmly grounded in practice theory. In the following, we briefly outline our take on practice theory and how it is employed in this framework. Building on our previous work, we contend that a practice can be conceived as “a set of interrelated, routinized actions (including linguistic statements); more or less established and shared ways of understanding the world; more or less pronounced rules (one must…), norms (one should…) and conventions (one usually…); as well as the material objects people interact with, including the places they are located in” (Pilerot and Lindberg, 2018, p. 256). The work conducted by the emergency medical services staff is thus analytically perceived as organized by the constituents highlighted in the above description of a practice. The people and things involved form a recognizable constellation of embodied activities grounded in time and space, which contributes to the (re)production of the socio-material. Through conceptualizing and connecting practices as constellations that form bundles (Schatzki, 2002: 246) we furthermore enable analysis of documentation as a practice intertwined with other, related work practices in the bundle of practices. According to this approach, what is going on in and around the ambulance can be understood as a complex fabric of practices that in various ways are entangled with other activities.

Moreover, the bundle of practices that constitutes the work of the emergency medical services staff can, on an analytical level, be sorted into integrative and dispersed practices (Schatzki, 1996). Integrative practices are “the more complex practices found in and constitutive of particular domains of social life” (p. 98) such as, for example, pre-hospital care. Examples of integrative practices in pre-hospital care include e.g. driving an ambulance appropriately according to level of urgency and with considerations regarding the care that is going on during transport, operating monitoring equipment such as ECG; and managing specific conditions e.g. bleeding, cardiac arrest or mental health issues. Dispersed practices are more general in character and can be discerned in “different sectors of social life” (Schatzki, 1996, p. 91). They appear in all sorts of bundles and can be exemplified with practices such as documenting – i.e. the practice of prime interest in this paper – but also observing, explaining, describing, examining, controlling, etc. The specific meaning assigned to disperse practices depends on where they are enacted. They are, for instance, given certain meaning when they are performed in the practice bundle of pre-hospital care, whereas integrative practices carry specific meaning in themergency medical serviceselves. The key reason for making this analytical distinction between integrative and dispersed practices is that it helps us understand how certain practices are assigned meaning depending on the context in which they are enacted.

Practices can, however, be studied by employing different focus points depending on the research questions addressed. Regarding the study of documents and documentation, we specifically highlight material dimensions of practice. This is reflected in our assumption that documents should be seen as carrying a certain agency, which brings us closer to the basic ideas underpinning critical document theory, an approach where tangible, material features of the study object constitute the passage point that leads into the knowledge aimed at.

Critical document theory

We conceive of a document as “any artifact that includes substantial references to the social processes through which it was produced and reproduced” (Shankar, Hakken & Østerlund, 2016, p. 59). However, documents provide evidence, not only through their content but also through the ways in which they are handled, referred to and contributing to structure the activities in which they are produced and used. This is in line with Frohmann’s (2004, p. 405) suggestion that “[a]ttention to practices with documents reveals how it is that particular documents, at particular times and places and in particular areas of social and cultural terrain, become informative”. In order to further emphasize the document’s role in the shaping and structuring of the organization of professional practice, Brown and Duguid’s (1996) notion of “the social life of documents” is useful. They convincingly argue that communities are held together and structured by their circulation and use of documents, and thus claim that “[w]e need to see the way documents have served not simply to write, but also to underwrite social interactions; not simply to communicate, but also to coordinate social practices” (Brown & Duguid, 1996, no pag.). The document can accordingly be said to “carry institutional structures and point to both past and future activities [and thereby] open a window to larger organizational practices” (Øesterlund, Snyder, Sawyer, Sharma & Willis, 2016, p. 391).

The scientific focus on documents and documentary practices fits well with the notion of a documentary society (Smith and Schryer, 2008), which strongly embraces the idea that documents contribute to the coordination of work practices. It is a society permeated by a multitude of all sorts of documents, documentary practices, and technologies for documenting, and where not least work practices increasingly are mediated through standardized and standardizing genres (Smith, 2001, p. 173). In the context of pre-hospital care, rules and regulations, guidelines, instructions etc. incessantly play a central part and contribute to shape activities, thereby reflecting a documentary society.

As pointed out by Smith and Schryer (2008), in a documentary society there is also an impending risk that actors get caught in what the authors refer to as documentary governance, which is a situation where documentation is perceived as prescribed and where people feel obliged to pay attention to specific documents, which in turn can result in imposed documentary practices that exercise authority and control in such a way that other work practices are hampered.

Another basic assumption on which this study rests is that documents produced in professional practice cannot only be seen as representations of that which they document, as texts that putatively aspire to be read as accounts of “‘what actually happened’” (Smith, 1974, p. 260). The preordered structure of documents, be they digital or paper-based, with their specific fields and sections, boxes to be ticked and more or less limited, predestined areas that enable or constrain what can be documented, including their inscribed axes of time and place, is shaped by, but also contributes to shape, the work conducted in the realm of documentary practices. By studying documents such as medical records and the practices through which they are produced we can learn about how documents produced in caring and medical practices are “interwoven with the structure of medical work in fundamental ways, and that different medical record systemergency medical services embody different notions of how work is organized” (Berg and Bowker, 1997, p. 532). In this capacity, the document can be seen to constitute “both a complex object and a fascinating and crucial focus for sociological research” (Ibid). It is, however, not only the actual empirical sites where we conduct our research that are elucidated through the study of documents. This sort of study also has the potential to open up a wider perspective where we can see how different sites, separated by both time and space, tend to be orchestrated through documents.

This ruling relation is what Dorothy Smith is aiming at when she asserts that the document and “its transformations coordinate people’s action; each move initiates a new action on its arrival at someone’s work site; the [document] is then passed on, transformed or not, to the next site, where it again initiates an action” (Smith, 2005, p. 173). That is, by following the documents through the work processes, as integral to work, we are able to see how documents contribute to regulate and coordinate practices. Such a focus on documents is in itself a focus on the connections (or relations) between documentary practices and other work practices. Since documentary practices of emergency medical services staff to a great extent is regulated by not only more or less stretchable guidelines and directives but also by strict legislation, the whole bundle of practices (documentary and others) can to some extent be seen as coordinated, in this case, by the Swedish Health and Medical Services Act. In this process, we discern how the local is connected to the extra-local.

From emergency call to handover – a hybrid information infrastructure

This section of the paper fills two functions. Based on one of the author’s observations and experiences from empirical work with emergency medical services clinicians (e.g. Andersson Hagiwara et al., 2019), it presents the setting of the study. The section can also be seen as comprising the method we employ since the framework we suggest is formed through theorising about a set of empirical examples, including the emergency medical services writing on rubber gloves, mashing up guidelines and directives, and paying attention to medicine cabinets and waste baskets. These examples are elaborated on at the end of the section.

The sequence of events between when emergency medical services receive a call and the final handover of the patient to the hospital is never exactly the same, but there are some features that are reoccurring. In the following account, we are highlighting these features and relate them to various information and documentary practices (Cf. Fig. 1).

When an emergency medical services team receives a call, they confirm the call, enters the ambulance, and initially establish the best route to the patient. Based on the information provided by the dispatch center, they seek to assess safety. This assessment can include questions such as if the address is located in a known area, if there are reasons to expect drug-related activities, violence or if the area in any other way can constitute a hazardous environment, or, everyday information that is crucial in this context, e.g. if anyone will meet up, if there is a door code, or which floor in a multi-level building the patient is located on. This initial stage in immediate connection to the call can also include seeking for additional information from the dispatch center or through calling the patient or relatives. At this juncture, the team also makes plans for the mission by trying to imagine a possible scenario, deciding who in the team is responsible for what and which equipment that should be brought from the ambulance to the scene. Examples of documents featuring in this stage would be treatment guidelines and, when available, the patient’s chart and medical history.

On the basis of visual (and sometimes olfactory) information, the emergency medical services team, when arriving at the scene, assess possible risks by paying attention to weather and light conditions as well as to the social conditions characterizing the site. First impression of the patient is established by talking to the patient, looking at the body position and the body’s constitution, attending to skin colour and the patient’s breathing and body movement. Apart from “reading” the surroundings including the body, a prominent documentary practice in connection to this stage is note-taking about first impressions. The on-scene activities includes a first survey through which Airway, Breathing Circulation, Disability and Exposure (ABCDE) are assessed and, if needed, treated. A second survey includes triaging and a check of vital parameters as well as focus on the patient history. Clinical decisions regarding level of urgency, care and potential further treatments are also made; in connection hereto interventions in the form of on-scene treatment can be made. Depending on the type of case, and the context, sometime during the on-scene time, emergency medical services clinicians make the decision to move the patient to the ambulance and continue the care there. This stage of the process involves continuous documentation and recording of assessment results. Guidelines to perform surveys and assessments, as well as treatment and process protocols, are consulted.

In connection to leaving the scene, decisions need to be made about whether leaving the patient at home with self-care advice, or transport to either primary care, the nearest local hospital or to a specialist hospital with e.g. stroke facility or advanced trauma centre. Furthermore, decisions are required concerning best technique for transport to the ambulance. At this stage, the hospital (or other designated care-giving units) needs to be notified, which ideally includes sending records of field assessments. Both this stage and the subsequent one, which takes place in the ambulance, also include re-evaluation and re-assessment through consulting the previously mentioned guidelines and protocols. En-route to the decided care unit, assessment and treatment continue while communicating with the receiving unit by phone.

At the arrival, the patient is prepared and then handed over to the hospital staff, followed by a structured hand-over report and the events that have taken place are – if there is time – documented according to local routines, either on paper, in digital format(s) or both. The end of the call-out may very well constitute the start of a new one. In that case, the assumed final documentation has to be postponed until the emergency medical services team is back either at the hospital or the emergency medical services centre. Otherwise, the end of the process is approached when the ambulance has been cleaned and used equipment been replaced. It is an understatement to say that the process described is contingent in character. There is plenty of room for unforeseen events, and the ambulance and it’s immediate surroundings is enmeshed in a wider context constituted of the general (local, regional and national) care-system with its structures, including administration, politics and practices. What is going on in the ambulance can thus not be sharply disconnected from this overall setting.

What is apparent from the above description of the process from call to handover is that the hybrid information infrastructure becomes visible, and that it reflects the document society that the emergency medical services’ work practices are a part of. It includes several instances in connection to which the emergency medical services is informed in various ways and is supposed to document their work to provide others with information. In the subsequent account, however, we are focusing on a selection of instances comprising documentary practices that for various reasons take place outside of or in between these “required” and more or less foreseeable documentary “sessions”, a set of documentary practices “in the wild” which can be described as taking place in alignment with, but still between or outside of, the anticipated stretches of more or less formalized documentation. At least partly, they take place in the wild since work tends to unfold in an unpredicted manner. The following examples do also include highlighting of the prime constituents of the suggested framework.

Writing on rubber gloves

emergency medical services staff are often pressed for time and repeatedly called out without breaks in between one call and another. Therefore, the expected, required documentation which is supposed to be conducted and result in the structured hand-over report needs to be gradually produced and maintained in a more flexible manner. This is where the emergency medical services clinicians’ rubber gloves come handy. The gloves are a required part of the basic equipment. They weigh little and are easy to carry. Taking quick notes on a rubber gloved hand is an available and easy way to document events compared to the handling of paper forms or digital interfaces that are too obtrusive in many critical care situations. Once notes have been taken on a glove, the glove can be exchanged with a new one and the inscribed glove can be saved in a pocket, often together with previous gloves used for note taking, and made use of later for when it is time to produce the formal hand-over report. Even though this is a makeshift solution for the intended documentary practice, it has turned out to be a way to support the recording of the most crucial information to manage the required documentation in stressful situations. This instance can be seen as an example of when a break with the prevailing documentary governance is called for. The established routines for documenting does not fit with the overall work practice and a workaround is required. The system in place – be it digital or paper based – thus becomes more or less invalid, time does not allow for the anticipated documentary practice, which may result in important information about the handling of the patient getting lost since the information compiled from the makeshift document – a set of rubber gloves – does not necessarily include an accurate description of the sequence of events; or, there might be several sets of notes from different calls (“rubber gloves in both pockets” is one way of dealing with this); or, information might be missing if one glove was suddenly contaminated or soiled and needed to be discarded.

Mash-up of guidelines and directives

Documents in the form of checklists, guidelines and directives, for example regarding how to conduct treatment and assessment, where to call for specialized support, and alternatives of where to transport under different circumstances, contain regulatory – and by all means plausibly helpful – requirements and instructions that dictate how emergency medical services are supposed to perform. Since the setting in which the emergency medical services staff, the documents and other actors, are at play is unpredictable, the staff sometimes work around and reinterpret the assumed integrative practices of, as in this case, adherence to protocols and guidelines. A very concrete example of how such a reinterpretation is performed was noted in a not yet reported clinical study of using video technology in ambulances. When researchers were trying to understand the current way of working and asked for the checklists and treatment protocols that emergency medical services service currently were using for suspected stroke cases, they were presented with official documents as well as a sort of mash-up of different sets of guidelines, directives, phone numbers and recommendations that were created by a local emergency medical services clinician. By making use of her experience from a multitude of previous call outs, this particular staff member explained that she had put together and prepared, by actually cutting different bits from various documents and putting them together, physically through the use of glue and sticky plastic, a set of itemergency medical services in a customized list that consists of parts from different, previous documents, in order to accomplish a list that is easier to handle but still deemed sufficient for the anticipated work tasks. The mash-up was deemed better at actually reflecting the relation between documentary and other work practices, and was found a better match with the workflow in situ. The clash that underscores this production of a customized mash-up is between different perceptions regarding what constitute and what does not constitute an integrative practice in emergency health care. As a result of the documentary governance, which sometimes is prevailing in the work, the dispersed (general) practice of rule-following does not become the intended integrative (specific) practice of adhering to specific protocols and guidelines unique for this particular kind of work. It is not perceived by the staff, and therefore does not become, an integrative practice until the mash-up is produced. At least for this member of staff, the ruling relation between the original, un-cut, version (including its producers) and the ways in which work unfolds in and around the ambulance, causes her to take a documentary practice detour. Concerning the agency of documents (and other material objects), this example shows how documents that are not really in use, apart from being the building blocks for the mash-up, contribute to shape the activities of the staff.

Medicine cabinets and waste baskets

The previous example, concerning the mash-up, was an instance of how documents sometimes are modified in order to better suit the overall work in the ambulance both with respect to content and format. The following example illustrates the use of informative objects that are not necessarily by all staff, or work guidelines, perceived as documents. We have already pointed at the act of “reading” that the emergency medical services staff engages in when arriving on-scene, e.g. how the body functions as a document, as something “that includes substantial references to the social processes through which it was produced” (Shankar, Hakken & Østerlund, 2016, p. 59); in this case the patient refers to, among other things, the accident or the causes of the body being in a critical state. By taking sight on documents, the framework allows us to see, describe and understand how work in and around the ambulance and patient unfolds. Relations between things that for an outsider or inexperienced emergency medical services clinician might not be perceived as important for the work, can be identified. In this way peripheral components in the home of a patient, for example their medicine cabinet, the waste basked in the kitchen, the things placed on their coffee or bedside table, provide clues for clinicians’ understanding of both the physical and mental state of the patient. By looking at and reading the labels of the packages in the cabinet or found in the kitchen waste together with other trash, and looking at the state of the home environment, the emergency medical services can be informed about prevailing medical conditions of the patient, what and if they might have eaten, or other issues such as addiction or dementia. The consultation of this documentary source constitutes an opportunity that is contingent in character, but still useful in understanding the patient and their situation. Being an experienced and skilled emergency medical services clinician includes having the readiness for paying attention also to those documents that are not necessarily formally required to consult. In this specific setting, these can function as informative documents that have the capacity to support the patient care practices.

Concluding discussion

In order to reach the aim of the study, a framework suitable for empirical studies of documentary practices in complex mobile, unpredictable and time critical contexts, the question concerning how connections between documents and documentary practices and other work practices can be described and understood has been addressed. Our empirical examples illustrate that documents and practices pertaining to these must be seen as integral with, and in some cases inseparable from, the overall bundle of practices that constitute the work of the emergency medical services staff. By applying our proposed framework to empirical examples, we have shown the integrality of the documentary practices, and also allowed for the framework in itself to emerge. In order to further explicate the construction of the framework, we have identified its key constituents and their prime functions (see table 1). By application on data produced, for example, through medical records generated at different points in the work process (e.g. paper-based ambulance record, digital hospital record), notes, interviews, observations, by asking study participants to walk through their workplace specifically in search for documents in order to elicit data in the shape of photographs, field notes and transcribed interviews, the overall purpose of the framework is to make visible and enable analysis of the research object.

By conceptualizing that which is going on in the empirical setting as practices and bundle of practices, we have demonstrated how documentation is incorporated in context, as a mutually shaping part of a certain arrangement. Through the application of the pair integrative and dispersed documentary practices, we have separated such practices that are perceived by practitioners as integral and suited for a certain bundle of practices (customized based on experience) from those that are perceived as generic and imposed (general rule-following). Furthermore, we have shown how documentary governance, in the shape of poorly fitted formats, gives rise to innovative documentary practices including rubber-gloves. Of fundamental importance for the framework suggested here is the assertion that documents must be understood as situated in actual time and place, as agents in practice that form an integral part of a course of action, and that there is an interplay going on between one or several people and the document(s) (Cf. Smith, 2005, p. 168). We have shown how documents are active, also when they are not in immediate interaction with their users. A prime aspect of documents conveying texts and images, which we have captured in the term ruling relations, is that they are replicable, which means that they are capable of coordinating activities in a similar manner in more than one site, locally and translocally. In this way, as pointed out by Smith (2005, p. 166), documents are “essential to the standardizing of work activities of all kinds across time and translocally”. Nevertheless, despite being structured by the “same” documents, practices unfold in different ways in different places due to a range of other factors; a phenomenon which we have termed documentary practices in the wild. This phenomenon can also, at least partly, be seen as documentation in opposition to prevailing documentary governance.

The novelty in our study, apart from being a theoretical, yet empirically informed, contribution to the under-researched area of documentary practices in emergency health care, is the innovative combination of practice theory and critical document theory. This implies a number of questions that could be addressed by the application of the suggested framework, including, but by far not limited to, the interplays along a multidimensional trajectory of manual – digital; personal – institutional; and informal – formalized documentary practices. How do these complement each other (if they do)? What are the ways and strategies for fusing them? How do temporal aspects – documenting in a hurry under stressing circumstances – play out? What are the implications of the mobile – documents travelling between different physical locations and/or digital systemergency medical services – characteristics?

About the authors

Dr. Ola Pilerot is associate professor in Library and information science, at the Swedish School of Library and Information Science, University of Borås. Ola’s research is centered on the big issue concerning people and their relationship to information. How and why individuals and groups of people find and make use of information, but also the consequences and outcomes of their information practices, is thus an overarching and reoccurring question in most of his research projects. He can be contacted at ola.pilerot@hb.se.
Dr. Hanna Maurin Söderholm's research interests concern (future) technologies for collaboration and information sharing (computer-supported cooperative work, CSCW). She is particularly interested in visual technologies and challenging use contexts such as pre-hospital care, and use situations where people deal with many different types of information (tactile, visual, textual). She can be contacted at hanna.maurin@hb.se .

How to cite this paper