ABSTRACT
Background and Purpose: The purpose of this investigation was to gain insights into the experience of adoption and integration of an electronic tool in physiotherapy. Case Description: The research data was generated through close observation of eight clinical encounters in primary health care, where the electronic tool was used, and then the physiotherapists were interviewed in-depth on the experience of adopting and using it. Outcomes: The analysis, inspired by post-phenomenological theory and research, reveals how physiotherapists deploy their clinical reasoning skills in an active, critical appropriation of the eTool. Despite an ambiguous attitude toward the tool, they develop an ownership to the eTool that enables them to balance and combine two modes of practice; that of collecting data for research purposes and that of treating the patient. Discussion: It seems that this ownership development is crucial to stimulate continued use of the eTool.
Introduction
The objective of this study is to provide insights into the adoption and use of an eTool that is under development. During our research, we sought to identify and conceptualize what seemed to be vital elements in some physiotherapists’ way of integrating a novel digital element into their practice.
A key assumption of eHealth, currently the subject of considerable research and commercial development (Kamel Boulos et al., Citation2009), seems to be that digital solutions will “upgrade the organization of health-care work” (Olesen, Citation2006). Multiple examples of the benefits of eHealth have been cited (Li et al., Citation2013). Yet sustainable solutions seem difficult to identify and adopt and the tantalizing vision of health services permeated by electronic supportive devices remains unrealized (Kellermann and Jones, Citation2013).
Li et al. (Citation2013) argued that part of the explanation for this lies in the complex contextual dynamics of health care settings. Their review indicated that multiple complex factors influence health care providers’ acceptance of eHealth applications. On the basis of a systematic literature review, they identified seven clusters of factors: 1) health care provider characteristics; 2) medical practice characteristics; 3) voluntariness of use; 4) performance expectations; 5) effort expectations; 6) social influence; and 7) facilitating or inhibiting conditions.
A growing body of research supplementing the established tradition of health technology assessment is highlighting the interaction between humans and technologies, where technologies, technological systems, devices and artifacts are acknowledged as active agents within the relationship.
Ethnographic studies such as Mol’s (Citation2002) seminal work on atherosclerosis shed light on how context shapes the meanings ascribed to, and associated with, diagnosis. Using a method similar to that of Mol (Citation2002); Bødker (Citation2019) illustrated how health workers in a reablement program reproduced stereotypes of home dwelling elderly people largely because of the way the program is designed. These two studies investigate ‘technology’ in broad terms, including the analysis of networks and technological set-ups.
Other studies have addressed technologies in a more explicit manner. Investigating radiologists’ use of systematics when reading electronic images, Friis (Citation2017) found that, contrary to the theoretical perspectives of radiology training, practitioners did not rely exclusively on systematics; instead they made implicit use of interpretation at every stage. Kiran and Nakrem (Citation2017) refer to an interview-based study that revealed how patients could feel left alone and bearing too much responsibility for taking prescribed medicines correctly when their nurse was replaced by an electronic pillbox. In many cases, patients’ spouses ended up administering the medication, rather than the actual users.
Rosenberger’s (Citation2007) analysis of the experience of a slowly loading webpage illustrates a familiar situation; the way technologies disappear from our attention when they are working as they should, only to tip us into exasperation when they stop working. Forss (Citation2012) elaborated on how practitioners interact with the microscope and how they use bodily interpretive skills to determine the character of the cells they are scrutinizing. Her analysis demonstrated that ‘confounding objectivity’, which tends to be frowned upon by laboratory workers, in fact constitutes a vital part of a practitioner’s way of describing samples.
What these and related empirical studies have in common is the intimacy and finesse with which they explore the complexities of human-technology interaction. They suggest that using technology toward such goals as ‘independence’ and ‘efficiency’ is far from straightforward. It is not a simple matter of ‘just doing it’; much more detailed knowledge is required, especially given the fact that new technologies can have unanticipated side effects or other consequences.
In this article we present findings from an investigation that leans upon a methodology that scrutinizes human-technology interaction by ‘letting things talk’. The research question we address is: How do our participant physiotherapists experience using an eTool in the clinical context?
Within physiotherapy, there is an urgent need to investigate what it is like for the clinician to use digital technologies. The experience of using hand-held digital devices in physiotherapy has yet to be comprehensively investigated. Regarding studies of technology use in health care in general, Olesen (Citation2006) noted that a “key concern will be to study the non-neutral, or transformative effects of technological artifacts.”
We refer to the digital device in question as the eTool. It is an App for tablets, originally developed to convert, display and store standardized questionnaires electronically to reduce the quantity of paper records piling up in physiotherapy clinics. In Norway, a consortium of researchers and clinicians (Lillehagen, Vøllestad, Heggen, and Engebretsen, Citation2013) participated in a project to develop the App into a clinical tool which physiotherapists could use in their day-to-day work with patients. This project is managed through the Research Program for Physiotherapy in Primary Health Care, the FYSIOPRIM.
The eTool is still under development, with the therapists contributing to data generation on a voluntary basis. The questionnaires already integrated into the eTool have been selected toward the primary goal of developing a database to facilitate research on patient characteristics, treatment courses and prognostic factors in primary health care in Norway (Evensen et al., Citation2018).
In this article, we refer to the eTool as ‘the FYSIOPRIM’, a name coined by one of our informants. gives an outline of the questions and questionnaires included in the FYSIOPRIM. Most of these items have not been designed or developed to support clinicians in face-to-face encounters with patients. Despite this, efforts are under way to transform this eTool into a device that offers clinical support. Clinicians are active collaborators both in data generation and in conveying feedback to the consortium.
Table 1. Outline of elements in «The FYSIOPRIM»
Theoretical perspectives
We understand the practice of physiotherapy as an inter-personal practice where the perceiving body – whether that of clinician or patient – is the resource and access to meaning-making, always in relation to someone and something. We view practice as situated and contextual (Svenaeus and Bornemark, Citation2009). In this particular case, the ‘something’ to which we direct our interest is an eTool.
Our vantage point for the investigation as well as for the analysis is the conceptual framework of post-phenomenology. An expanding group of scholars has developed this framework to describe the “variability and context-dependency of human-technology relations” (Rosenberger and Verbeek, Citation2015). Rooted in classical phenomenology, this framework seeks to develop the insights of that tradition in a nuanced way, while critiquing certain positions on human-technology relations taken by earlier proponents. Adhering to a post-phenomenological framework enables us to investigate physiotherapy practice from a perspective that is neither utopian nor dystopian regarding human-technology relations.
In his analysis of the skilled handling of equipment, Heidegger (Citation2010) argued that using equipment tends to restrict our experience of things as they are. He introduced the notion of experiencing equipment as ready-to-hand, which is intended to suggest that the use of the equipment is embodied. Here, the action by which the equipment is used can be performed without noticing the equipment. In contrast, when the equipment breaks down or becomes “unhandy”, Heidegger conceptualizes the experience as one in which equipment becomes present-at-hand; suddenly we start noticing it, and the situation becomes awkward.
For Ihde (Citation1990), technology neither diverts nor monopolizes our attention. Ihde’s position differs from that of Heidegger, remaining closer to Merleau-Ponty’s (Citation1962) analysis of “the phenomenology of things.” Merleau-Ponty described how things in our world “offer themselves as poles of action”; they “delimit a certain situation, an open situation moreover, which calls for a certain kind of work”. Merleau-Ponty (Citation1962) speaks here of what we in this article, in a post-phenomenological continuation, explore as technological intentionality, or technological mediation, in a clinical context.
Ihde (Citation1990) imagines a continuum or spectrum of ways of experiencing through technology and has identified and developed some possible human-technology configurations. In the present study, our data analysis explores embodiment relations and alterity relations in patient-therapist-eTool configurations. These two configurations illustrate two distinct if related ways of characterizing physiotherapists’ experience of relating to the eTool and the patient. In an embodiment relation one experiences through the technology; the technology can be almost forgotten or unnoticed while in use. However, for those experiencing an alterity relation while using a specific technology, it is as if the technology becomes another while in use. The notion of technological ‘transparency’, a running thread of this article, refers to “the degree to which a device recedes into the background of a user’s awareness as it is used” (Rosenberger and Verbeek, Citation2015).
Another concept we utilize to make sense of our empirical material is that of “field of awareness” (Rosenberger and Verbeek, Citation2015). This has been developed to help analyze the experience of using hand-held devices of the sort with which we have become increasingly familiar. The concept involves an expansion of the transparency aspect that Ihde (Citation1999) referred to when elaborating on the various configurations of human-technology relations. ‘Field of awareness’ can help us understand what happens when two parallel fields of attention occur. It helps articulate how a technology reorganizes a user’s field of awareness or can split our intentional directedness.
In this article, we understand clinical reasoning as one of many variant elements in therapists’ interaction and relationship with the eTool and their patient. For analytical purposes, we consider clinical reasoning a ‘sense’. Here, we are inspired by Øberg, Normann, and Gallagher (Citation2015), who depicted clinical reasoning as “embodied cognition”. In their model, different sources of experience, expression and knowledge are integrated in a sense-making process where co-construction is the key. We draw on this model, and have integrated the eTool into it.
Method
The physiotherapists who participated in our study comprise a convenience sample. At the start of the recruitment process therapists were still undergoing training in the use of the eTool while also participating in data collection for the cohort study. As participation in both the cohort study and our qualitative investigation would make demands on therapists’ daily schedule, we felt it prudent to keep the invitation open.
The recruitment and data generation period lasted from April to December 2016. An e-mail was sent to roughly 60 physiotherapists working as private practitioners; all were registered users of the eTool and associates of the FYSIOPRIM at the time. Consent forms were attached to the e-mails. In addition, an ‘informant rally’ was held at a meeting for municipally employed physiotherapists in one municipality. Altogether, six physiotherapists working as private practitioners and two municipally employed physiotherapists volunteered and participated in the study.
All the participating physiotherapists had gone through the same formal training in the use of the eTool, and had access to user support. All were experienced clinicians who had developed considerable professional knowledge, along with various manual skills, during their careers. While six participants had been involved in the eTool project for several years, two had only recently started using the eTool. All eight participants were still in the process of learning to use the eTool; they were gradually getting acquainted with its various questionnaires and still learning how to integrate it into their habitual practice.
The first author visited the private practitioners at their clinics and accompanied the municipally employed physiotherapists to sessions in patients’ homes. In each case she observed a session where the eTool was used, and then interviewed both the physiotherapist and the patient. The data presented in this paper comes from the interviews with the therapists.
The decision to interview therapists was made in order to get a detailed account of their experience of using the eTool. Conducting the interviews directly after she had observed a therapy session enabled the first author to steer the conversation toward discussion of anything of interest she had noted during her observation.
Analysis was guided by a hermeneutic approach (Gadamer, Citation2010; van Manen, Citation2014) and a phenomenological mode of interpreting text. Throughout, efforts were made to acknowledge, and actively engage, the preconceptions and prejudgments brought by the interpreters to the analysis. The first author in particular sought to explore multiple perspectives and possible meanings (Spence, Citation2016) from what she had identified as the salient parts of interviews: those parts which shed particular light on the research question.
In a constantly evolving process, new questions arose and were incorporated into a reflexive diary. Following the transcription of interviews, sections that stood out as relevant to the research question were identified and ‘questioned’, along the lines suggested by Spence (Citation2016). The authors scrutinized and revised themes in collaboration.
In the Findings section below, we present a crafted story, guided by van Manen (Citation1990, Citation2014, Citation2017) and in line with Crowther, Ironside, Spence, and Smythe (Citation2017). Based on our interviews with the eight physiotherapists, we have used “the method of examples” (van Manen, Citation2017) to put our argment across.
Although the themes we present in this article are not particularly sensitive or unsettling as such, we honor our commitment to protect our informants’ anonymity. Recruited from a small sample within a small country, they are easily identifiable by colleagues and members of the research consortium. For that reason, we present our findings in terms of one composite story: that of Alex, a fictional physiotherapist who shares some key traits with our eight participating professionals.
We have chosen the name Alex (the short form of both Alexandra and Alexander) to reflect the fact that both male and female therapists participated in our study. The story told by the composite figure of Alex addresses some salient, shared elements in the physiotherapists’ accounts, as identified by the first author.
Thematically, these elements were united by a sense of ambivalence. This was conveyed to the first author in a variety of forms: clear statements, predicaments, reluctance, doubts, jokes, questions and self-contradictions. The first author explored this recurrent theme of ambivalence across and within interviews through her own reflection and writing, and through discussions with the coauthors. She concluded that the theme was a significant one, worthy to highlight and report on.
While Alex’s story relates certain particular experiences of a physiotherapist attempting to integrate an eTool into everyday work with patients, it does not attempt to include every experience narrated by our participants. As van Manen (Citation1997) observed, “the experiences of others are the possible experiences of oneself. Phenomenology always addresses any phenomenon as a possible human experience. It is in this sense that phenomenological descriptions have a universal (intersubjective) character.”
The intention behind Alex’s crafted story is to provoke the reader into a questioning frame of mind. The purpose is “to reveal that which lies in, between, and beyond the words while staying close to the phenomenon of interest. As researchers, attuning our thinking to this purpose is essential as we begin our interpretive work with verbatim data” (Crowther, Ironside, Spence, and Smythe, Citation2017).
Findings
“Some of these questions I would never ask a patient”
Alex experiences the eTool as a research aid rather than something to be used in clinical practice:
In the sales pitch to patients I emphasize the research element of the eTool (…) I must admit that I think of it as something that’s still under development, that’s for research. It doesn’t have a clinical foundation, and it would never have entered my clinic had it not been for its research aspect.
The need to “pitch” the eTool suggests that Alex is attempting to prepare the ground for its use. Despite claiming that “it would never have entered my clinic,” Alex is actually taking steps to adopt it. The data collecting, research-relevant part of the eTool script is what seems to motivate Alex to continue using it. This emphasis on the tool’s potential research value is what encourages Alex to persuade patients to participate in the project; it is as if Alex needs to define the value of the tool primarily in these terms.
For the research project, Alex and other participating physiotherapists are asked to do a baseline registration, preferably before they meet a patient for the first time. However, Alex prefers to wait until the end of the first session to do this, and only if there is enough time. Often patients are asked to enter their data into the FYSIOPRIM only during their second appointment with Alex, who explains this in the following way:
Most of the time, I start with my standard assessment, conversation, and only afterwards move on to ‘the FYSIOPRIM’. Because then we have already talked about many of the topics the FYSIOPRIM questionnaires address, and that helps speed up the answering part. (…) It’s a way of making contact with the patient. If you go straight to registration, the conversation gets very unnatural. During a conversation one often sidetracks, but that’s not really possible when one’s sticking to a fixed schema: ‘Okay, now we have to stick to THIS particular question.’ So if I have my own conversation to start things off, it’s easier to make contact and to cover many things.
For Alex, establishing trust involves an open conversation geared to revealing a patient’s particular concerns and needs, expressed in their own words. During first appointments with patients, Alex does not feel comfortable asking questions in the fixed, structured way typical of questionnaires. As Alex notes, “It’s ‘questionnaire-language’. Nobody talks like that, really.”
Alex also seeks to distance him/herself from the generic way questions are framed in the standardized questionnaires included in the eTool:
Some of these questions I would never ask a patient. But they are part of a questionnaire, so patients have to answer all of them. So before we start the registration process I tell patients that some of the questions might not seem relevant, while others are quite important to cover. In that way I prepare them a bit for what is to come. I hope to take away the ’edge’ of the most awkward questions.
Alex’s ambiguous relationship with the eTool is further underscored:
It is a selection. Other people [the researchers] have picked out the questionnaires and put them together in this [eTool]. But my patient group is diverse. (…) Not all the questions are appropriate to ask!
Alex seems concerned that the topics covered by the questionnaires fail to accommodate the uniqueness of each patient’s situation. Someone else has decided beforehand what is important, what counts as relevant information about the patient. Although aware that questions and questionnaires have been selected primarily to generate a database for epidemiological research purposes, Alex finds it difficult to keep these two ‘modes’ of practice separate. It is as if s/he has to somehow meld these two modes in the encounter with the patient. Temporarily this constrains the space within the particular encounter between patient and therapist, a space which Alex sees them as creating together.
Viewed through a post-phenomenological lens, the eTool and its constituent questionnaires become things-for-Alex. They present as elements that do not fit into the situation. As a result, they become something that is ‘in-between’ Alex and the patient when Alex introduces them. This perceived ‘in-betweenness’ becomes an obstacle to the creation of a therapeutic ambience.
It is as if Alex’s intentionality is split. When introducing the eTool, Alex must focus on two things at once: on the patient, to whom s/he is attempting to sell something, and also on maintaining a certain distance from the eTool. Both demand close attention. This is an instance of how technology reorganizes a user’s field of awareness and splits their intentional directedness. In order to be trustworthy enough to convince the patient, Alex must negotiate between promoting the eTool and keeping some distance from it. Alex tries to avoid being blamed for the parts of the eTool that are neither appropriate nor relevant to that particular moment with that particular patient. At the same time Alex tries to smooth things over to prevent patients being offended by what might seem inappropriate or overly numerous questions. The experience becomes an awkward one for Alex, for whom the eTool has become present-at-hand.
On the basis of the above descriptions and interpretation, we can imagine the eTool becoming a significant source of distraction for Alex. Drawing on the concept of ‘transparency’, we can surmise that the eTool does not fit smoothly into Alex’s habitual practice; the objectiveness of the eTool makes it an awkward, out-of-place artifact. Alex also seems concerned that the eTool may give the patient a wrong impression of the physiotherapist’s competence. In his/her habitual practice, Alex feels competent and safely within his/her comfort zone. When introducing the eTool, however, Alex’s intentions become object, other, not-mine. Alex tries to reduce this uneasiness by separating his/her own identity as a practitioner from the eTool. Alex does not want patients to read this artifact, or these questionnaires, as “the therapist asking.” Instead, Alex reverts to his/her normal routine:
It [the eTool] has so many questions unrelated to the individual patient, so I choose to have my own introduction … I’ve tried starting off with the registering, but I think in the long run I will stick to my ordinary routine, doing things as I’ve always done.
Letting the eTool address the potentially difficult topics
At the same time, Alex seeks ways to incorporate the eTool into his/her regular practice by tinkering with the FYSIOPRIM script. There is ambiguity here. On the one hand, Alex takes precautions by removing the ‘edge’ of certain questions and distancing him/herself from the eTool. On the other hand, Alex explores ways of making the eTool fit into and become part of ordinary routine. For Alex, the research element of the tool compensates for its limited clinical relevance.
Interestingly, Alex has found that the eTool can act as a support for both patient and physiotherapist by posing questions that could be awkward or difficult to ask. Alex is not comfortable asking patients about “psychoanalytical stuff”. But since starting to use the eTool, s/he has found a way to let the eTool ask the difficult questions:
For example, the patient that was here yesterday. I kind of sensed that he was worried. I asked a bit about it, naturally, but the questionnaires have a different angle. Maybe answering questions via the tablet is a bit less intimidating for patients at the beginning. Then later on I can perhaps ask more focused questions relating to their concerns.
This passage suggests that Alex uses the eTool as a digital assistant to gain access to the patient in a new way. The tool enables Alex to complete the patient history and make the treatment plan based on a broader selection of data sources than before. As an assistant, the tool can be a way of putting sufficient space between Alex’s own physiotherapy approach and the notion of electronic registering for research purposes. The eTool-as-assistant can be experienced as an extension and enhancement of the physiotherapist self in clinical work. It can become a digitally augmented physiotherapist, in invisible contact with the electronic answers given by the patient.
Alex has started exploring how the eTool, with its extensive range of questions and questionnaires, could potentially enrich the initial phase of recording the patient’s history:
The way I see it, getting that ‘quality conversation’ at the beginning is like a quality assurance. Because I’ve always emphasized the importance of getting a thorough patient history. There are a lot of words in that history that I don’t need for the rest of the course, for outcome measures. As treatment continues, it’s still important to know who this person is.
As Alex reflects on how the ‘in-betweenness’ shapes the experience in a more embodied fashion, perhaps s/he is experiencing an augmented co-constitution. Instead of positioning itself between Alex and the patient, the eTool now acts beside Alex. There is an increase in the eTool’s transparency; it provides flow while enabling Alex to feel the quality of the experience as a totality. Alex is able to distinguish a difference between outcome measures (‘hard facts’) that can be used for documentation, and ‘words’ that help describe this unique patient. Both categories contribute to Alex’s ability to integrate the patient into his/her clinical approach and style.
While the outcome of treatment is measured by ‘hard facts’, words that might be considered surplus or redundant shed light on the complementary question: ‘who is this person?’ Alex sees this as beneficial not only at the start of treatment but also throughout its course. Both kinds of knowledge are seen as significant and meaningful within Alex’s physiotherapy practice.
Use of the eTool also encourages patients to think afresh. As Alex notes,
My patients seem to be reflecting more on things they would not have reflected on were it not for this [the eTool]. The questions they are asked make them start to think.
As patients engage with the eTool, their responses provide Alex with useful entry points to further discussion during their treatment course. The experience of the eTool as augmenting Alex’ already acquired physiotherapy skills seems to provide extra motivation to keep up the work of adopting the eTool, despite its limitations and flawed performance in many areas. The new entry points revealed by the eTool seem to encourage Alex to put in the time and effort needed for their exploration. Alex can cope with the embarrassment generated by its potentially provocative ‘research-related’ features as long as there is a promise of some ‘clinic-related’ features as well.
Reflections and discussion
Our findings suggest that physiotherapists attempting to adopt an eTool confront several challenges. One is that of striking a balance between ‘pitching’ the eTool and maintaining a certain distance from it (i.e. avoiding being identified with everything the eTool asks the patient about). Physiotherapists can find themselves in a predicament here: while wishing to encourage patients to complete the eTool’s questionnaires, they also seek to dissociate themselves from the questions posed. The risk is that the patient will lose confidence in the therapist.
At the same time, the eTool has the potential to become a digital assistant, perhaps even an augmented physiotherapist. One positive outcome of registering this amount of data is that it can sometimes ‘make people think’. Therapists are inclined to explore this possibility, with its potential benefits for the therapeutic relationship and the patient’s treatment outcome.
It appears that when incorporating this particular solution into their practice, physiotherapists deploy their own embodied cognition as a ‘sense’. They use their own intricate ways to prepare the ground for adopting this novel element, constantly negotiating the ‘when’ and the ‘how’. Øberg, Normann and Gallagher’s (Citation2015) model offers one way of interpreting this process. Here, different sources of experience, expression and knowledge are integrated in a sense-making process where co-construction is the key.
To shed light on the explicitly active co-construction by both human and non-human within this structure, we draw on some key post-phenomenological concepts. For Verbeek (Citation2005), human contact with the world is always mediated, with technological mediation one possible form of this. We have shown how the mediating artifact, the eTool, can be present in different ways. When therapists enter into an active embodied engagement and co-constitution with the patient, keeping the eTool temporarily in the background, they gain an opportunity to give full attention to the unique aspects of the patient and their situation at that moment. When therapists ‘invite’ the eTool into the encounter, however, this results in an active embodied engagement and co-existence with both the patient and the eTool. New relational platforms emerge for the interaction of therapist and patient.
As our analysis reveals, the eTool technology reorganizes the physiotherapist’s field of awareness. The inter-relation between patient, physiotherapist and eTool involves a split in the physiotherapist’s intentional directedness in the actual situation. The humans and the eTool become three collaborative agents who create, transform, and perform their part in an ongoing therapy session. The subject (the human) and the object (the technology) are not separated; rather, they constitute a dynamic unity. When the clinician lets the eTool ask the difficult questions, this suggests an engagement in an alterity relation (Ihde, Citation1990) with the eTool. The object becomes an ‘other’: something close to an ‘avatar physiotherapist’ upon which the clinician can lean and rely, and perhaps with which they may even develop an embodied relation (Ihde, Citation1990). The eTool potentially enhances the therapist’s skills and thereby augments the physiotherapy self. Letting the eTool ask the difficult questions, and be slightly provocative by asking many questions, provides therapists with entry points to different information and clinically relevant topics that might otherwise have remained unthematized. In such situations, we consider the eTool’s presence as enabling.
At the same time, the technology has its limitations. While amplifying some themes, the eTool might also let others pass beneath the radar. Physiotherapists may experience the eTool’s ‘irrelevancy’ as particularly jarring. They may find the ‘objectness’ of the eTool becoming the focus of their relationship with the patient, perhaps undermining the multiple levels of trust required. The risk of becoming identified with a technology that is both irrelevant and offensive can be experienced as too much to handle. Physiotherapists do not wish to be perceived as an eTool’s ‘marionettes’. It seems that maintaining their professional identity can collide with the responsibility they have taken on concerning data collection for the database. They develop an ownership of the eTool that enables them to balance these two modes of practice. This ownership development appears crucial for ongoing use of the eTool.
The two-sided mediation suggested by the findings of our study resonates with other research into the qualitative impact of technology use. This two-sidedness appears closely related to the ‘affordance’ (Kiran, Citation2015) of the artifact in question. While the praxes and interpretations made possible by the eTool are doubtless limited, the technology could offer clinics a new trajectory. By incorporating the eTool as an ‘augmented physiotherapy self’, practitioners could potentially enhance their skills. In tandem with the eTool, the therapist could develop into an ‘ePhysiotherapist’ of sorts, free of negative ‘marionette’ associations. In such situations, eTool devices may have the potential to “fulfill the technological promise of liberation and enrichment” Verbeek (Citation2005).
Physiotherapists’ ambiguous relationship with the eTool, and their desire for a balanced relationship with both patient and eTool, conform with the post-phenomenological notion of the non-neutrality of any artifact (Forss, Citation2012; Hasse, Citation2008; Verbeek, Citation2008).
Viewing our findings through the lens of technological transparency or mediation (Ihde, Citation1990), we argue that physiotherapist, patient and eTool relate to one another in ways which are both limited and open. We identify the potentiality of the technology, which we characterize as ‘present-at-hand’ in situations where the degree of transparency is reduced. Within the clinical encounter, we see the eTool operating within limits while remaining capable of a variety of actions, in line with the post-phenomenological perspective (Ihde, Citation1990; Kiran, Citation2015).
We emphasize that the moment a ‘thing’ (i.e. an artifact, a technology) is introduced into practice, changes will happen. Things do things; they interact; they are never simply there as something inert or ‘dead’. However, technologies do not control processes of mediation all by themselves. Their ‘demand’ for attention results in interaction; their presence stimulates certain ways of questioning, certain forms of communication and dialogue. As Wiltse (Citation2014) pointed out, “When digital technologies make activities visible (…) it is some part of the world being ‘caught in the act’ by technologies that have been designed to do the catching in particular ways.”
In our study, participant physiotherapists found the most sensible way to adopt the eTool was by tinkering with it and deviating from the ‘script’. This suggests a need for close investigation and constant scrutiny as digital health practices develop and expand. Our inquiry also highlights the creative ways in which users respond to the challenge of new technology. Over time they develop a sense of the potentiality of specific devices. This too merits more attention and further research.
We chose to create a composite physiotherapist to put across some of the experiences of our eight participants. While this methodological approach remains relatively untried, it is worth noting that Grimsbø and Engelsrud (Citation2005) also created a composite figure in order to clarify the presentation of a particular theme. Kincheloe and McLaren (Citation2005) stated that qualitative researchers have the responsibility to present their findings as clearly as possible, using all available means toward that goal. As researchers working within a “post” tradition, we interpret this as favorable to our decision to craft the story of “Alex”. However, the approach has its limitations. One is the possibility that its very novelty risks making it a distraction for the reader. It has also been a challenge to tell Alex’ story in a way that does not imply that it was the only story told in the study, or that it speaks for all physiotherapists. Ultimately, our reservations were overridden by our commitment to keep the identities of our informants anonymous and safe.
Conclusion
Already a feature of clinical life, new technologies and artifacts are likely to proliferate in years to come. In the case of physiotherapy, we have sought to shed light on how a new device becomes incorporated into professional practice, including habitual forms of bodily action and perception. The adaptation process requires courage on the part of physiotherapists, who must trust the patient, the technology and themselves as they engage in an active, critical appropriation of the technology in question.
Given the exploratory nature of our study, we do not regard its findings as generalizable to all fields in which eHealth is being applied. However, we believe our research has valuable insights to contribute to the growing body of empirical research on the ‘soft impacts’ of technologies. Swierstra (Citation2015) described these as “orphan impacts” whose prediction, investigation and results are as yet to be underpinned by methodology.
Our inquiry has revealed one promising approach, involving the active, critical appropriation of novel technologies. Here, the clinician is given the liberty and responsibility to explore any potential use within the scope of their practice. We conceptualize the clinical decision-making skills involved as ‘embodied cognition’. Here, dynamic, sensitive and explorative engagement with new technology, involving both clinician and patient, can harvest meaningful knowledge and new insights.
The process of integrating such new knowledge into professional practice involves moving beyond isolated actions by individual clinicians. Liaison is required between researchers, developers, and users (both clinicians and patients). The need is to develop sustainable technological solutions which clinics can readily and routinely use. Health technology assessment protocols and models for developing health technologies would benefit from theoretical foundations that acknowledge the non-neutrality of technologies and address the two-sidedness of technologies and tools.
Declaration of Interest
The authors report no conflict of interest.
Acknowledgments
Financial support from The Norwegian Fund for Post-Graduate Training in Physiotherapy through the FYSIOPRIM project is gratefully acknowledged. We are grateful for the help given by Sylvi Sand. We thank Ingebrigt Meisingset and Kari Anne I. Evensen for developing the original table of variables in the FYSIOPRIM database (Evensen et al., Citation2018). We acknowledge the participants and thank them for letting the first author into their already packed schedules.
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