1. The relationship between technology and changing professional roles in health care : a case-study in teledermatology Dr. Stephen Timmons, School of Nursing, University of Nottingham Mrs. Sandra Lawton, Consultant Nurse, Dermatology, Queen's Medical Centre, Nottingham

2. Background Huge unmet need for dermatological care Increasing referrals and waiting lists/times Too few dermatologists Difficult physical access to hospital Patients seen by the most appropriate member of the dermatology team An equitable service across the district

3. Geography Nurse led community clinics in primary care supported by teledermatology Nurse led community clinics in primary care supported by teledermatology.

4. Store and Forward Telemedicine Mail Server Telemarque Server Unit Training Data Base NHS Net Remote GPwSI QMC Dermatology Unit Live Remote PCT Clinics

5. Teledermatology Store & Forward Digital CameraDigital Camera Lap TopLap Top EmailEmail

6. Methods Case Study Design Embedded single case designEmbedded single case design Single case – community clinicsSingle case – community clinics Subunits- all those involved in patient journey ( GP, Patient,Nurse, Dermatologist and others)Subunits- all those involved in patient journey ( GP, Patient,Nurse, Dermatologist and others)

7. Patient Journey

8. Sample Purposively selectedPurposively selected 2 patient journeys:2 patient journeys: GP, Patient, Nurse, Dermatologist and others

9. Data Collection Semi-structured interviewsSemi-structured interviews Observation of the nurse / patient consultationObservation of the nurse / patient consultation Data obtained from clinical records and databases.Data obtained from clinical records and databases.

10. Data Analysis The analysis and interpretation of the data was performed manually.The analysis and interpretation of the data was performed manually. Based on an ethnographic approach and influenced by the principles of grounded theoryBased on an ethnographic approach and influenced by the principles of grounded theory Description of the case (How and Why)Description of the case (How and Why) Comparative analysis of the data sets :Comparative analysis of the data sets : ( interviews,observations and records) Analysis of the emerging themesAnalysis of the emerging themes

11. Results/Discussion

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

13. Shifting boundaries : how ? By using teledermatology, individual and organisational practices have been adjusted Nurses collect information But, crucially, decide when & how to refer The nurses’ role now, effectively, includes diagnosis

14. Patients Like the service, and are unconcerned about the profession of the person seeing them GPs value the expertise of the nurses

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

16. An ‘advance’ in nursing practice A contentious point (in nursing) Not just working to protocols (as often happens in ‘nurse-led’ services) Used existing skills and knowledge, and developed new ones.

17. How was it possible ? 1Policy push 2Skills of the nurses 3Agreement & support from the consultant & the GPs 4The technology

18. A bit of theory ANT ? Social construction of technology