An Empirical Study of Multidisciplinary

An Empirical Study of Multidisciplinary Communication in Healthcare using a Language-Action Perspective Mareike Schoop Department of Computer Science, Informatik V – Information Systems, Aachen University of Technology, Germany

Abstract Good communication is the basis for effective cooperation. An area where cooperation is essential is multidisciplinary healthcare. In this paper we will present a research project that aims at promoting effective multidisciplinary communication in a healthcare environment. We will answer the question of whether empirical modelling of the communication and cooperation patterns can be done based on a Language-Action Perspective and whether a Language-Action Perspective can be the basis for designing computer systems supporting multidisciplinary communication and cooperation in healthcare. An emphasis will be on the discussion of the Language-Action paradigm for the present work in the context of existing critiques.

1 Introduction In recent years there has been a move towards more cooperation in healthcare. A more holistic approach to patient care is now taken. Patient care is no longer solely medical care but involves input from healthcare professionals coming from several disciplines [14]. Today, it is not permitted to discharge a patient from hospital simply on the grounds that his or her medical treatment has finished. Nursing or social needs have also to be met before a patient can be allowed home. As is to be expected, the areas of healthcare that see the greatest changes towards truly shared patient care are the ones where professionals from different disciplines have a large impact on the shared task of improving a patient's state of health. For example, Geriatrics is a highly cooperative area. The different needs of elderly people can only be met by the interaction of professionals from several disciplines. Thus, the cooperation between professionals from many different disciplines is necessary to achieve the task of effective patient care. However, the reality is sometimes different: professionals do not always understand each other and cooperation does not always work. Healthcare professionals have particular interests concerning the patients that are determined by their professional role. For example, a doctor is interested in a patient's present medical complaints whereas a nurse needs to find out the care needs; a physiotherapist is interested in a patient's state of mobility, and an occupational therapist assesses a patient's needs concerning daily living in order to ensure a maximal safe level of independence. According to their different interests and tasks, the professionals will notice different things when looking at the same patient and, therefore, will talk about different aspects of patient care. These differences in viewpoints can make communication between healthcare professionals difficult [16]. If communication problems exist then they often lead to difficulties in cooperation because professionals cannot cooperate if they do not understand each other. Cooperative documentation systems (CDSs) have been developed to support multidisciplinary communication and cooperation in healthcare. CDSs are information systems containing multidisciplinary documents. They aim to support a cooperative plan of care by providing a medium for information exchange between different professional groups such as doctors, nurses, physiotherapists. The whole process from admission to discharge is documented there and a CDS acts, therefore, as a medium of written multidisciplinary communication [17]. The aim of the present work is to improve cooperation between different professional groups in healthcare, especially cooperation between doctors and nurses by means of information technology. As will become clear later, the focus is on improving multidisciplinary communication through CDSs. In order to find out about cooperation and communication patterns and existing communication problems in healthcare, a multidisciplinary healthcare environment was selected and ethnographic studies were conducted there. At the end of the ethnographic studies a list of key issues was elaborated that it was felt should be considered for introducing computer-based systems for supporting cooperative work in such an environment. These key findings will be introduced in section 2. These findings prompted us to look at theories of communication as a theoretical basis for a new and more theoretically rigorous approach to the design of CDSs. The present work is based on the so-called Language-Action Perspective (LAP) which has developed into a new paradigm in the field of information systems. The basic assumptions underlying this paradigm will be introduced in section 3. After classifying common communication problems, the general requirements for a (computer-based) CDS were considered. Section 4 will present a number of conceptual categories that were felt need to be The Language Action Perspective, 1999

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An Empirical Study of Multidisciplinary Communication in Healthcare using a Language-Action Perspective considered for the design of effective CDSs. It will then be described how we accommodated the key findings of the ethnographic studies for the design of better CDSs (section 5). The Language Action Perspective has attracted much interest but also some criticism in the field of information systems. The main criticisms of LAP will be summarised and our answers to these criticisms with respect to the present work will be discussed in section 6. The paper will end with a summary and concluding remarks (section 7).

2 Ethnographic Studies in Multidisciplinary Healthcare To collect the necessary empirical data for the present work, it was decided to conduct ethnographic investigations in a multidisciplinary healthcare setting. The aim of these empirical studies was to find out in general about viewpoints and more specifically about • • • • • • •

work practices information flow and possible obstructions documentation practices cooperation structures the terminology used in each professional group typical communication problems areas where IT could support the work of multidisciplinary teams

In the following section the ethnographic methods used for the present work will be discussed. Section 2.2 will summarise the main issues arising from the qualitative research.

2.1 Overview of ethnographic methods used The first step in any ethnographic investigation is sampling; the location, the participants, and the events to be observed must be selected. The research site was an acute Geriatric ward in a Geriatric hospital in Greater Manchester, UK. Geriatrics is a highly cooperative area which requires input from many different disciplines in order to provide good patient care. The ethnographic investigations concentrated on the groups of nurses and doctors as these are the main contributors to the care process. Consequently, the work began with the routine events of nurses and doctors, i.e. their daily work. As the particular interest of the field work lay in the cooperation between doctors and nurses, the ward rounds and the case conferences were of special interest as the manifestations of multidisciplinary communication and cooperation on the ward [17]. Participant observation was the ethnographic method that was primarily used in the field work. Participant observation involves observing people in a natural setting over a prolonged period of time, and talking and listening to them [5,11]. Once familiar with the field, less time was spent observing and informally talking to the participants and more time was spent carrying out interviews. At first, unstructured interviews were conducted with nurses and doctors about their views on cooperative work, on the shared care process, and on the patients. After learning that the nurses would dislike formal interviews, preferring to explain and discuss, semi-structured interviews were then carried out. In these interviews a set topic and agenda was given while letting the professionals talk without interruption. Document analysis was carried out for three forms of documents. The care plan is the nurses’ main medium of documentation whereas doctors record in the medical notes. Both types of document were analysed. All information concerning more than one discipline is recorded in the so-called MDT (multidisciplinary treatment goals) folder. The MDT is a CDS that was jointly developed by the healthcare professionals working on the ward. The documents in this shared system contain the multidisciplinary goals, the responsible persons, dates etc. During the phase of document analysis, we highlighted possible problems drawing on the experiences with existing communication problems in that environment. The interested reader is referred to [17] for an extensive discussion of the field work conducted during the research project.

2.2 Results of ethnographic studies This section will summarise some of the key issues emerging from the field work that need to be considered for introducing technology support for multidisciplinary cooperation. Many of the issues relate to the use of documentation and will be addressed in section 5 in relation to CDS design.

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An Empirical Study of Multidisciplinary Communication in Healthcare using a Language-Action Perspective 1. Cooperation is important and necessary for effective patient care. It was found that different healthcare professionals need to cooperate to achieve the shared task of maintaining or improving the health of patients. There can be no work in isolation; professionals must work together in the care process. In the interviews both doctors and nurses expressed the view that cooperation must take place because each professional group provides one important part of the "whole picture". Doctors, for example, provide primarily input on the patient’s present medical state whereas nurses talk about nursing and social matters concerning the patient. 2. Doctors and nurses have different tasks and professional interests. Doctors are primarily concerned with the patients’ presenting complaints, their medical histories etc. to give the diagnosis and decide on an appropriate treatment. Nurses, on the other hand, are mainly interested in the patients’ nursing needs as nurses will care for the patients while they are on the ward. The tasks together with the resulting responsibilities and duties form the professional role of each member of staff. 3. Cooperation and communication problems exist between doctors and nurses. Although nurses and doctors feel the need to cooperate, they experience a number of problems. The different professional groups have different viewpoints according to their professional role. Taken together, these views add up to give a holistic picture of the patient. On the other hand, different views make communication more difficult and this can lead to problems in cooperation. According to their different viewpoints, the professionals have different requirements. Doctors often complained that nurses provided a lot of irrelevant information and talked too much. Nurses thought that doctors were symptom-oriented whereas nurses were patient-oriented and had a holistic view on the patient. In the opinion of nurses, doctors often left out too much detail. It was found that one of the most important problems in multidisciplinary healthcare is the breakdown of communication. When professionals entered face-to-face dialogues they were usually able to solve their communication problems. In situations where communication took place via a documentation system, i.e. via a written medium, the problems could not be solved directly through a discussion with the communication partner. Thus, in these "non-co-presence" situations communication problems could become serious obstacles for smooth and effective cooperation and could lead to breakdowns 4. Doctors and nurses have different professional terminologies. Doctors’ and nurses’ terminologies are different which can lead to problems of understanding each other. This is the type of communication problem that occurs most often [15]. Experienced nurses and doctors have learned some of the relevant terms of each other’s terminology but problems still occur. They can be clearly observed when student nurses and house officers communicate. Some of the terminological problems occur on the level of synonyms where a term used by one professional group has a synonym in the other group’s terminology. For example, nurses use the term ‘pyrexial’ whereas doctors would say ‘febrile’. The underlying concept is similar but the terms used are different. Other problems occur when the interpretations of the utterances differ. For example, a nurse might say "The patient is depressed." to indicate that the patient is a little upset. A doctor would interpret the utterance as an expression of clinical depression which is treated by drugs and/or therapy sessions. 5. Doctors and nurses communicate in different modes. There are two types of communication, i.e. face-to-face and written, and three modes of interaction. The type of communication used most often in a multidisciplinary healthcare environment is face-to-face communication of which there are two modes on the ward. Firstly, the ward rounds provide the medium for doctors and nurses to talk about all patients while being able to examining them or talking to them. The second mode of direct communication is interacting in case conferences where all professionals involved in the care process exchange information that concerns more than one discipline. The second type of communication is written communication. Here, the communication partners are usually not co-present and interact via a written medium. On the ward this medium is the cooperative documentation system where all professionals are supposed to enter information that is relevant for other groups.

3 The Theoretical Foundations There are two foundations of the present work. It is based on the Language-Action Perspective in the context of Computer-Supported Cooperative Work. Both areas will be briefly introduced below.

3.1 Computer Supported Cooperative Work As the work reported on in the present paper is about supporting cooperative work by means of information technology, the general domain of the work is Computer Supported Cooperative Work (CSCW). This term was first used in 1984 by Cashman and Greif as the title of a workshop. Today it is used as an umbrella term for a The Language Action Perspective, 1999

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An Empirical Study of Multidisciplinary Communication in Healthcare using a Language-Action Perspective number of different research methods and approaches in different settings. In general, CSCW aims to develop an understanding of work practices and group work in a given setting and, based on these insights, to develop technology that supports and enhances cooperative work. The work processes to be supported can be synchronous or asynchronous, local or distributed; the groups to be supported can be small teams or large organisations. Scrivener and Clark [19] propose the following classification of CSCW systems: • • • •

Synchronous local: These are systems to support a group of people working together at the same location at the same time, e.g. meeting support. Synchronous remote: Such systems provide group support for workers at different locations, e.g. electronic conferencing. Asynchronous local: These systems support a group of people working at the same location but not at the same time. Scrivener and Clark state that this is not often supported and that there exist no CSCW systems specifically for this purpose. Asynchronous remote: These systems support a group of people working at different locations at different times. An example are electronic mail systems where sender and receiver are not at the same place and there can be a considerable time difference between sending the mail and reading it.

The present work is to promote effective written communication between nurses and doctors working on the same ward at different times. Thus, the relevant category for this work according to the above classification would be the support of asynchronous local processes.

3.2 The Language-Action Perspective In section 2 it was discussed that communication problems exist and can be critical for cooperative work. This finding prompted us to look at current theories of communication to determine which theories could be useful in this context. The two theories that influenced the present work are Searle’s Theory of Speech Acts [20,21] and Habermas’ Theory of Communicative Action [10]. The broader context of the present work lies in the so-called Language-Action Perspective (LAP). LAP is based on Searle’s and Habermas’ theories and focuses on communication aspects in information systems which is also the focus of the present work. In LAP it is argued that language is used to coordinate actions, an experience that was made during the ethnographic studies. This section introduces the Language-Action paradigm. LAP was first introduced in the field of information systems in 1980 by Flores and Ludlow [9] who stated that human being are fundamentally linguistic being and act through language. It was argued that language is not only used for exchanging information as in reports or statements but also to perform actions, e.g. promises, orders etc. Winograd and Flores developed the original ideas further [24,25]. The conventional perspective on information systems stresses the contents of messages rather than the way they are exchanged. In contrast, LAP emphasises what people do while communicating and how communication partners use language to provide a common ground and to coordinate their actions. The focus is on the pragmatic aspect of language, i.e. how language is used in particular contexts to achieve practical goals such as agreements or mutual understanding. This new approach argues that as social action is mediated through communication, the main role of an information system should be to support organisational communication. LAP has since developed into a new paradigm for the design of computer systems. There are a number of basic assumptions underlying LAP [13]: • • • • •

The basic unit of communication is a speech act. Natural language sentences correspond to the performance of speech acts. The meaning of sentences can be revealed by specifying the speech acts that have been performed. Speech acts obey socially determined rules. Cooperative work is coordinated by the performance of language actions which are speech acts.

Rather than introducing the relevant concepts of Searle’s Theory of Speech Acts and Habermas’ Theory of Communicative Action which has been done elsewhere [15,18], we will move on to discuss how we used the key findings of the ethnographic studies in the context of the Language-Action Perspective.

4 The Description Language for Cooperative Documentation Systems The aim of the work presented here is to exploit the potential of information technology to create a new generation of (computer-based) cooperative documentation systems that can help to avoid breakdowns in communication and cooperation. The ethnographic studies showed that fundamental communication problems exist between doctors and nurses. Merely presenting data in different ways (e.g. in different interfaces for doctors and nurses in shared computer systems) according to the different viewpoints will not overcome these problems and thus not be a sufficient answer to the key findings. Rather, it is the author’s conviction that the The Language Action Perspective, 1999

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An Empirical Study of Multidisciplinary Communication in Healthcare using a Language-Action Perspective design of computer-based cooperative documentation systems requires a fundamental overhaul, in particular that a rigorous theoretical foundation is required that draws on theories of communication and is anchored in empirical evidence. The qualitative analysis of communication patterns in healthcare showed which particular problems occurred and how they could be explained. These findings together with the theoretical basis provided by the Language-Action Perspective can be seen as indicating those features of multidisciplinary communication an ideal CDS would need to facilitate. To provide a basis for CDS design, a means of defining and articulating communication structures is then required. To specify requirements in these terms, a suitable formal language is needed. Therefore, a transition from the ethnography to an abstraction must take place. The development of such a description language forms the focus for the present section. The language describes the features that need to be considered for the design of CDSs that can help to avoid communication breakdowns. Thus, the description language can be seen as a language for design of future computer-based CDSs. The elements of the description language are shown in table 1. Some of the elements will be introduced in this section. For a complete introduction of the description language the interested reader is referred to [17]. Actors (speakers and hearers) Main task and primary interest of actors Responsibilities and duties of actors Domain specific illocutionary forces Illocutionary forces for speaker-hearer combinations Degree of strength of illocutionary forces Medical knowledge of actors and propositional content Terminological correspondences Propositional content conditions Preconditions Validity claims Commitments of actors Date of speech acts Interactions between speech acts Table 1: Elements of the description language

4.1 Classification of speakers and hearers First of all, the possible speakers and hearers have to be specified. As mentioned before, the present work has concentrated on the professional groups of doctors and nurses as these are the main contributors to patient care. However, there are obviously many different subclasses of these groups and a more refined classification of possible speakers and hearers is necessary in order to be able to specify the speaker and hearer of an utterance in a detailed way. For example, some classes of nurses are: sister, charge nurse, nurse giving IV injections, named nurse, district nurse; some classes of doctors are: consultant, registrar, doctor on call, doctor giving diagnosis doctor prescribing drugs.

4.2 Tasks and interests, duties and responsibilities of actors Two important concepts in the present approach deriving from the field work are the professionals’ main task and the primary interest. Each professional group has a main task, which determines the primary interest. A doctor’s main task is to give the diagnosis and decide upon a treatment plan and, therefore, (s)he is primarily interested in the patients’ presenting complaints, the past medical history, drug history, family history etc. Nurses are primarily concerned with patients’ needs while they are on the ward because their main task is caring for the patients. The main task and primary interest must be considered because they partly determine what the different professional groups will talk about when looking at the same patient, i.e. what can be said in the propositional content of their utterances.


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An Empirical Study of Multidisciplinary Communication in Healthcare using a Language-Action Perspective Closely related to the main task are the responsibilities and duties of each professional group. The professional role indicates which obligations arise for different groups. This is an issue relevant to the set of possible illocutionary forces for each professional group. A nurse, for example, is responsible for administering drugs, assessing the patient’s activities of daily living, referring a patient to speech therapy, and preparing the patient’s discharge; whereas a doctor is responsible for giving the diagnosis, prescribing drugs, assessing the patient’s medical state, ordering blood tests, transferring a patient etc.

4.3 Domain specific illocutionary forces Searle’s five categories of illocutionary forces, i.e. assertives, commissives, directives, expressives, declaratives, are used to classify forces in the present work. However, there are domain-specific illocutionary forces that have to be analysed and classified. These are forces that are used in the area of healthcare as observed during the ethnographic studies. These forces can be classified according to Searle’s general framework as shown in table 2. An explanation of the taxonomy would go beyond the scope of this paper and can be found in [17]. Assertive assess diagnose evaluate identify needs inform observe record

Commissive evaluate investigate review set goal

Directive investigate order refer request prescribe

Expressive query rule out suspect

Declarative admit discharge transfer

Table 2: Classification of illocutionary forces

4.4 Possible forces for speaker-hearer combinations The general classification shown in table 2 does not consider that some of these forces are only used by particular speakers which is determined by their professional roles and associated pragmatics. For example, the "identification of needs" concerns nursing needs only and is therefore specific to the nursing domain whereas "rule out" is only used by doctors. Therefore, the set of all possible forces for each professional group has to be specified. For example, the set of illocutionary forces used by nurses (denoted by IFNurse) and the set of those forces that doctors use (denoted by IFDoctor) can be specified as follows. IFNurse= {assess, evaluate, identify needs, inform, observe, record, investigate, review, set goal, refer, request} IFDoctor= {assess, diagnose, evaluate, inform, observe, record, investigate, review, order, refer, request, prescribe, query, rule out, suspect, admit, discharge, transfer} Furthermore, it must be made explicit which particular forces the professionals use in the context of certain hearers; this is again determined by the professional role. Thus, the possible combinations of forces, speaker, and hearers must be specified. For example, an evaluation carried out by a nurse will only be passed on to a nurse whereas both doctor and nurse can be recipients of a request.

4.5 Medical knowledge and propositional content The professional role of each actor determines what knowledge (s)he has about a certain aspect of the care process. Such medical knowledge is embodied in the propositional content of utterances which in general describes what an utterance is about. Speech act theory and illocutionary logic treat the propositional content as a primitive [21]. However, formalisation of the propositional content is required in order to allow queries to be made about the contents of an utterance (e.g. "Has the patient been seen by the stroke unit" or "What is the patient’s therapy plan") and to enable basic comprehensibility problems to be addressed (see next section). This will also help to clarify questions like "What do nurses really mean when they speak about stroke? What do doctors mean by this term?".

4.6 Terminological correspondences Comprehensibility problems can occur on two levels: that of unknown terms, where the utterance cannot be interpreted by the hearer, or that of misinterpretations where the hearer’s interpretation differs from the speaker’s The Language Action Perspective, 1999

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An Empirical Study of Multidisciplinary Communication in Healthcare using a Language-Action Perspective intended meaning. In routine interaction, comprehensibility problems are usually solved by rephrasing or translating. In written communication there is no possibility to employ these human problem-solving strategies and, therefore, even the most basic comprehensibility problems can lead to total breakdowns in communication and cooperation [16]. In order to address these problems it is clearly vital that a cooperative documentation system must provide mechanisms to support the translation of the propositional content according to each group’s requirements if necessary in order to avoid breakdowns due to incomprehensibility. The need for such translation mechanisms is important given the prevalence of comprehensibility problems recorded by the empirical studies. These mechanisms will provide familiar terms of the hearer’s own professional terminology rather than forcing cooperating participants to understand and use the terminology of their communication partners. The professional terminologies have been developed over time to fit each group’s requirements; they are not necessarily useful for interaction between different professional groups. Therefore, it is argued here that the possibility of a basic translation process will enable the participants to express themselves in the best possible way (in their own terminology) and to understand the communication partner appropriately (by translating unfamiliar terms). The participants will thereby achieve greater autonomy and emancipation. One possible point of criticism is that in reality comprehensibility problems are usually solved and such mechanisms will, therefore, not be necessary. This is true for experienced nurses and doctors who have learned over time to translate automatically when they talk to each other. Student nurses or staff nurses on the one hand and medical students or senior house officers on the other hand experience many comprehensibility problems. Therefore, it is argued that the possibility to translate basic terms or phrases can be helpful; in the end it is the professional who decides whether to use such support or not. If translation is to be integral to a CDS, it is vital that the description language provides appropriate notational features for expressing such correspondences. However, translation between different (medical) terminologies is a major research topic in its own right and beyond the scope of this work. Furthermore, comprehensibility problems concern semantic issues whereas the strategic emphasis of this work is on the metalinguistic and pragmatic level where the validity claims of truth and appropriateness are based. A more limited aim of this work is thus adopted, namely to provide a simple notation for accommodating synonyms and characteristic phrases. Results from other areas will be accommodated as and when this work on translation matures. For example, there has been work on explaining parts of the medical patient record to patients which includes translating from the medical terminology to that of the lay patients [6]. Work within the GALEN project has included using a formal model of clinical terminology as an interlingua between different classification systems [12]. In the present approach, work has been carried out on the level of synonyms and characteristic phrases with different levels of detail where comprehensibility problems can be solved relatively easy. Examples include the following: • • • • •

TIA (doctor) - mild stroke (nurse) fractured neck of femur (doctor) - broken hip (nurse) febrile (doctor) - pyrexial (nurse) reminding to urinate or open bowels (doctor) – prompting (nurse) myopic (doctor) - short-sighted (nurse)

4.7 Validity claims A key idea in the present approach is to incorporate validity claims as introduced by Habermas. They are critical to the success of speech acts. Only if the hearer of a speech act says implicitly "yes" to all the claims raised can the speech act be seen as successful. The consideration of validity claims allows fruitful discursive communication rather than a hierarchically-based issuance of orders and mere obedience of orders. In Habermas' words, communicative action that is oriented towards mutual agreement is enabled rather than concentrating only on strategic action oriented towards personal success. Nevertheless, these two types of action can be distinguished and strategic action can also be dealt with, e.g. in orders issued by doctors to nurses where no discussion is possible. Thus, both communicative and strategic action are supported equivalently. To allow only sensible challenges, the relations between the validity claims and the components of a speech act, i.e. the illocutionary force and the propositional content, need to be considered. An utterance can be incomprehensible because the propositional content is not understood by the hearer. This is a common communication problem. However, it is also possible to challenge the comprehensibility of the illocutionary force used in a speech act. Illocutionary forces are not always specified in communicative interaction which can lead to misunderstandings about which force the speaker meant to use when uttering a sentence. For example, a consultant in a case conference might utter the sentence "We need to make a mental test with the patient." which was meant as a request (i.e. a directive) for the SHO to make the test; whereas the SHO understands the The Language Action Perspective, 1999

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An Empirical Study of Multidisciplinary Communication in Healthcare using a Language-Action Perspective utterance as a mere statement (i.e. an assertive). Therefore, the claim of comprehensibility is related to both the propositional content and the illocutionary force. Questioning the truth of a statement means questioning whether the statement really represents a fact, a common experience etc. It is not possible to challenge the truth of an illocutionary force because questioning whether the speaker’s intentions indicated by the illocutionary force are sincere is questioning the speaker’s truthfulness. Thus, "truth" is related to the propositional content only. The challenge of truthfulness is only related to the illocutionary force since the hearer doubts whether the speaker is really committed to the illocutionary force used when truthfulness is questioned. Here, the ostensible nature of the speech act is questioned, e.g. what seems to be an assertive act is really an attempt to deceive. Both the illocutionary force and the propositional content can be inappropriate. However, a challenge of appropriateness concerns more often the illocutionary force than the propositional content. The hearer challenges the appropriateness of the illocutionary force used by the speaker by questioning whether the speaker is entitled to use this force in this particular context. The speaker could have violated existing power relations, recognised norms, or professional standards. A propositional content can also be inappropriate. Here, the hearer questions whether the sentence fits a given normative context, i.e. whether it is legitimate to say so. To summarise, the validity claim "truth" is related to the propositional content whereas "truthfulness" concerns the illocutionary force only. Both "comprehensibility" and "appropriateness" can be challenged for the illocutionary force as well as for the propositional content. Furthermore, the relations between particular speech acts and the validity claims must be examined [16,17], e.g. a directive speech act can be incomprehensible or inappropriate but not false. Habermas’ classification can be the basis for this examination as it provides a taxonomy of speech acts according to the dominant claim [10]. Habermas does not consider the claim of comprehensibility in his classification of utterances but the power claim which is not a validity claim because it cannot be criticised by the hearer. The relations between validity claims and the five types of speech acts used in this work are shown in table 3 which also includes the relations to the particular component of the speech act as discussed before. Thus, it is possible to state which claims are related to the propositional content (abbreviated by PC) or the illocutionary force (abbreviated by IF) of each class of utterance. Table 3 can be explained as follows. Speech Act

Assertive

Commissive

Directive

Expressive

Declarative

PC IF

PC IF

PC IF

PC IF

PC IF

IF

IF

IF

IF

PC IF

PC IF

PC IF

Validity Claim Comprehensibility Truth

PC

Truthfulness

IF

Appropriateness

PC IF

Table 3: Relations between validity claims and types of speech act Comprehensibility problems can occur in all utterances. Habermas argues that all claims can be criticised for all types of speech act. The author does not agree with this notion as the claim of "truth" is not related to directive, commissive, expressive, and declarative speech act themselves but to their presuppositions. Therefore, the validity claim of truth is taken to be only related to the propositional content of assertive speech acts. The hearer can always challenge the speaker’s sincerity and thereby question the truthfulness of an utterance. A speaker might not believe in the statement (assertive) made, might not really promise (commissive) something, might not want the hearer to carry out the action as directed (directive), might not express real feelings (expressive), or might not be sincere when declaring a new fact (declarative). Thus, "truthfulness" is relevant for the illocutionary force all types of utterances. Appropriateness is related to assertive, directive, expressive, and declarative speech acts. For example, a statement or an expression of feelings can be inappropriate if the utterance in that particular context is against certain social norms. It is argued here that appropriateness is not related to commissive speech acts because a speaker can always commit himself or herself to carry out a certain action. There are certain presuppositions attached to commissive acts. For example, a promise presupposes that the hearer wants the speaker to do as promised. Thus, a hearer can challenge the truth of these presuppositions but this is not a challenge of appropriateness.


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An Empirical Study of Multidisciplinary Communication in Healthcare using a Language-Action Perspective

4.8 Commitments All utterances create commitments for speaker or hearer [20,21]. The most important forms of commitment occur in commissive and directive speech acts. Commissive and directive speech acts commit the speaker or hearer to carry out the action represented by the propositional content. However, the hearer has the possibility to explicitly accept or reject such commitment. Only if the hearer accepts all claims raised in these types of speech act can the related commitment be accepted. The rejection of a commitment is based on a challenge of an underlying validity claim. Therefore, it must be possible within the language to express commitments used in a cooperative documentation system to indicate whether each commitment has been accepted, rejected, or not yet dealt with. If a commitment is rejected then the claim that has been challenged and the component of the utterance concerned (i.e. illocutionary force or propositional content) must be specified. Thus, the CDS must provide mechanisms to deal with commitments in that way. Commitments can be used for several purposes, e.g. as a reminder (the patient has yet to be referred to district nurses), control by the users themselves (which commitments are not fulfilled yet?), discourse (where does the cooperation between ward nurses and district nurses break down, what could be changed?), and for coordination of cooperation (referral to district nurses means that the district nurses have to take up the patient’s care within three days).

5 Towards More Effective Cooperative Documentation Systems Having introduced the description language on a conceptual level we will now revisit the key findings of the ethnographic studies and discuss whether and how they were considered. First of all, we used some of the main concepts of Searle’s and Habermas’ theories for analysing the communication and cooperation structures in the field [16,18]. Thus, it is argued that LAP can be used for empirical modelling in such an environment. It was found that healthcare professionals must cooperate in order to provide effective patient care but that this is not without problems. The main philosophy behind this work is that cooperative documentation is not only important but indeed vital for effective cooperation. However, cooperation does not always work and, therefore, a new approach is necessary. CDSs must provide a medium for expressing communication problems in a structured way. We have proposed to do this on the basis of Habermas’ validity claims (comprehensibility, truth, truthfulness, appropriateness) and Searle’s classification of illocutionary forces (assertive, commissive, directive, expressive, declarative speech acts). Searle’s classification provides a means for grouping different utterances whereas the validity claims can be used to classifying communication problems [16]. Communication problems will be made explicit so that it is clear to all communication partners what kind of problem exists and what part of the utterance is challenged. In contrast to the present practice where communication problems can only be solved when both partners are co-present, a new CDS based on our approach will help to avoid breakdowns in communication. The different tasks and professional interests of doctors and nurses have been included in the present work because they are vital for specifying the organisational communication structures. For example, a doctor will issue diagnoses whereas a nurse is not allowed to do so. On the other hand, nurses evaluate their plan of care once every 24 hours because for them documentation is much more a coordination tool. For doctors, documentation acts more as a memory aid. The different professional terminologies must be considered because they are the cause of many communication problems. Other work in the area of LAP has excluded the validity claim of comprehensibility which we find unacceptable for the present context. If a professional does not understand a certain term used by a professional from a different group then (s)he cannot do anything until (s)he can communicate with the other professional and ask for clarification. There can be no guessing as healthcare is a sensitive area where communication and cooperation is necessary to ensure best patient care. In order to address these problems it is clearly vital that a CDS must provide mechanisms to support the translation of the content of an utterance according to each group’s requirements if necessary in order to avoid breakdowns due to incomprehensibility. This issue has been incorporated in the present work by providing terminological correspondences. The only mode of communication that is supported is written communication. It has been established that information technology is most helpful in these non-co-presence situations. If communication takes place via a written medium, even the most basic communication problems can lead to total breakdowns. In face-toface interactions, problems are usually solved and, therefore, it was felt that these situations would not benefit from computer support.

6 Reconsidering the Language-Action Perspective The Language-Action Perspective has attracted much interest in the field of information systems including a number of critiques. We argue that as our work falls in the context of LAP, we must consider these critiques and The Language Action Perspective, 1999

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An Empirical Study of Multidisciplinary Communication in Healthcare using a Language-Action Perspective find adequate answers. This has not been done very often for newer LAP approaches and we find that this gap must be filled.

6.1 Some critiques of the Language-Action Perspective LAP has been criticised from disciplines such as sociology, ethnography, philosophy, computer science, linguistics. Critiques often specifically concern Searle’s theory but are also related to the more general use of the Language-Action Perspective for organisational communication. John Bowers provides a critical attack on LAP and, more specifically, on the Coordinator from the point of view of a psychologist [3,4]. He begins his critique with a more general attack on the notion of formal representations. He asks whether formalisms have politics. He understands a formalism as "a representational systems of a certain sort. A formalism generates representations through the operation of rules over some vocabulary. ... To formalise is ... to distinguish between the legal and the illegal. ... Systems which support, embody or express formalisms (are) formal systems" [3, p.234]. He refers to the Coordinator as an example of a system in the area of computer-mediated communication which relies heavily on formal representation, for expressing networks of communication structures. Bowers discusses common justifications for developing and using formalisms. It is often claimed that formalisms make a task clearer and more efficient. They can provide some form of emancipation for the user as certain things are made explicit which gives the user control over these things or at least makes him or her aware of them. This is one of the intentions behind the Coordinator. However, it must also be seen that any formalisation includes the possibility of forcing people to behave according to the representation. The aim of the Coordinator is to facilitate and support communication in distributed work environments. The question that Bowers raises is whether there is a central point which can draw all distributed speech acts together to coordinate them. If so, then it is possible to have central power and to use it to influence others. The users that are being represented might not be aware of this fact and might not have access to the representation. Bower calls for formalisms that are decentralised and open to critical assessments for all users. One strategy to achieve this is to use participatory design. One of the most prominent and challenging criticisms of the Language Action Perspective (LAP) comes from Lucy Suchman [23] who refers to some of Bowers’ arguments. She does not talk about formalisms in general but rather concentrates on speech act theory and the Coordinator as an exemplar of LAP applications. Her main argument is that using speech act theory for the development of computer-based communication systems enforces discipline and control and, therefore, oppresses the users. Suchman presents both LAP and especially the Coordinator as aiming to provide frameworks for representing and controlling normal communication practices. Suchman comments that speech act theory proposes strict classifications that do not allow for individuality and creativity of communication partners and suggests that "Alternatively, we might embrace instead ... an appreciation for and an engagement with the specificity, heterogeneity and practicality of organizational life." [23, p.78]. The more concrete points she makes about the Coordinator are that, firstly, it concentrates on pairs of a speaker’s utterance and a hearer’s reaction rather than interactions between the two; secondly, that conversations are often indeterministic in that a speaker does not always know what (s)he means at the beginning of a dialogue but that the meaning and intentions emerge during the interactions with the hearer. This is not considered in the design of the Coordinator and, therefore, an unnatural structure is imposed. The intentions that are often implicit in normal interaction must be made explicit by the speakers in systems like the Coordinator. Suchman argues that the machine can be used to warn of potential breakdowns or to keep track of actions, a mechanism which can be used by organisations for control so that oppressive organisational structures are enforced rather than loosened: "Rather than being a tool for the collaborative production of social action, in other words, THE COORDINATOR ... is a tool for the reproduction of an established social order." [23, p.168]. In [22] Suchman argues that plans are not executable sets of actions but rather that actions are performed depending on circumstances in certain contexts and are only loosely related to any plans. Thus, if the application of speech act theory as in the Coordinator forces the user to act according to predefined plans it is oppressive and against natural behaviour. A critical look at LAP from a linguistic perspective is provided by Allwood [1]. His conceptual criticism of Searle’s and Austin’s theories has many facets. Firstly, he comments that the theories cannot account for the multi-functionality of speech acts. For example, the statement "It is raining." could be a warning or an assertion, depending on the particular context. Furthermore, Allwood argues that common communicative functions such as feedback or turntaking cannot be expressed because there are no related English speech act verbs. This leads to his second point which is that Searle’s classification is based on verbs rather than communicative functions. As a consequence, Searle’s speech act taxonomy is not complete. Furthermore, Allwood argues that Searle’s speech act taxonomy does not consist of mutually exclusive categories. The speech act conditions that Searle proposes do not clearly separate what is general from what is particular for one act. For example, there are some conditions that make general statements about a class of acts while others are valid for a particular act only. Allwood also argues that Searle’s theory relies heavily on literal meaning which is problematic as literal meaning The Language Action Perspective, 1999

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An Empirical Study of Multidisciplinary Communication in Healthcare using a Language-Action Perspective does not really exist; it is dependent on context. Finally, Allwood presents a perspectival criticism. He argues that the context is not sufficiently taken into account, especially any existing non-rational or non-intentional aspects of communication. Habermas does not deal with what he calls defective speech acts and Searle presupposes intentional conversations. Habermas makes no distinction between ethics and rationality which leads to an insufficient treatment of ethics. Allwood calls for some changes to be made to the theories and their use in applications of the Language-Action Perspective. An alternative well-founded classification of utterances with disjoint classes should be developed. Furthermore, ethical issues should be sufficiently taken into account. There has been criticism from within the LAP community concerning the adequacy of Searle’s theory for analysing human communication. As an example, Dietz and Widdershoven [8] recount Habermas’ criticism of Searle’s theory and argue that Habermas’ Theory of Communicative Action is superior. The critical points are illustrated using the Coordinator as an example of a system based solely on speech act theory; it is argued that the Coordinator has severe shortcomings due to the shortcomings of Searle’s theory. The most significant drawback of Searle’s theory is that it does not adequately consider what makes a speech act successful, i.e. Searle neglects validity claims. Consequently, the Coordinator is not able to state the success criteria for speech acts and it is not clear what mechanisms for communication and coordination the system supports. Moreover, since Searle does not consider a speaker’s orientation there is no distinction between directives based on validity claims and those based on power claims. Thus, strategic action cannot be distinguished from communicative action in the Coordinator as both strategic and communicative types of action are classified as directives according to Searle’s theory. Furthermore, speech acts with claims to appropriateness (such as promises) and others with claims to truthfulness (such as intentions) appear in the same category of speech acts. Dietz and Widdershoven then go on to say that these problems can be overcome by using Habermas’ theory as it: • • •

provides the success criteria of speech acts in terms of criticisable validity claims, distinguishes between strategic and communicative action, provides a classification according to the dominant validity claim.

The consequences for the design of communication support systems are then obvious: there must be a facility to negotiate validity claims, to discuss problematic claims, to make it clear for all participants whether they are engaged in strategic or communicative action.

6.2 Critical discussion In the following, we will discuss how we took these critiques into account for a new approach to the design of cooperative documentation systems. Dietz and Widdershoven criticise that applications based on Searle’s theory cannot distinguish between strategic and communicative action. In the present work there is a distinction between these two forms of prediscursive interaction. However, the distinction is not made through the categories of speech act according to Habermas but through the related validity claims. It is argued that there should be a distinction between commissive and directive speech acts that are both called regulative acts in Habermas’ theory. We want to know whether a speaker makes a promise or a request. Therefore, we decided to use Searle’s categories in the present work but to relate the power claim to the act of "order" where no discussion is allowed. It would be possible to use regulatives as a category and then have directives, commissives, and declaratives as subcategories but this does not seem to be an advantage because in the end "regulative" would be used only as a label. The classification of illocutionary forces used in healthcare does not produce a set of distinct classes (see table 2), a fact that Allwood would attribute to the shortcomings of Searle’s five categories. However, we feel that this is not a general problem of Searle’s taxonomy but a specific problem of these forces. An evaluation consists really of two distinct (speech) acts which is why this force is classified in that way. Evaluating patient care and treatment implicitly includes two illocutionary forces, i.e. stating a patient’s current state (assertive) and reviewing the planned interventions and goals and changing them if necessary (commissive). It would perhaps be more effective to divide the force into these two actions and classify each of them. However, it was decided to use the illocutionary forces as they are used in reality. Suchman has criticised the Coordinator for requiring users to make parts of an utterance explicit. She argued that this can be problematic because a speaker does not always know what (s)he means at the beginning of an interaction. We would argue that this might be the case in everyday interaction but this is not very relevant for organisational communication in the case of multidisciplinary conversations in a healthcare setting. It has not been observed that the problems with implicit utterances concerned the speaker’s problems of uttering what (s)he meant; rather the speaker thought the utterance was clear for the hearer who did not understand it as was intended to, e.g. what was meant as a directive was understood as a mere statement. A system based on the present work on the design of CDSs is certainly less rigid compared to systems such as the Coordinator because the present work addresses interactions between two actors rather than being focused on a speaker of an utterance. Furthermore, through the incorporation of validity issues, discussion is encouraged and the hearer is given the possibility to criticise an utterance in a structured way. Finally, by The Language Action Perspective, 1999

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An Empirical Study of Multidisciplinary Communication in Healthcare using a Language-Action Perspective including the possibility of a "free shot" through a charity relation which allows any participant to ask anyone else for a favour without being in a position to issue an authorised request, it is acknowledged that there are situations that cannot or should not be structured but rather left to the actors to decide on an appropriate response. Another point worth mentioning is that this work presupposes the existing social structure in multidisciplinary healthcare. In this sense, the established social order is reproduced and the actors are forced to comply to this structure, a fact that both Suchman and Bowers have been critical about in their works. The author concedes that her goal was not to change the organisational structures but to enhance interactions within them. It is not believed that a system that dissolves the organisational and power structures would succeed in such a highly hierarchical domain as healthcare. However, this work could provide the possibility for social change. We have decided to use a fixed definition of authorised illocutionary forces for each actor in the system. Another possibility would be to give and retract authorisations between communication partners dynamically, i.e. the partners themselves could negotiate these authorisations. This could lead to the establishment of new social structures. For example, nurses could be allowed to prescribe certain drugs, doctors could relinquish their right to order nurses to perform actions etc. Suchman’s criticism that the categories and classifications of organisational behaviour are imposed from the outside rather than coming from the users of systems themselves is clearly avoided here. The classification of communication problems emerged during the ethnographic studies and was further refined using concepts from Searle’s and Habermas’ theories. The aim of ethnography is to present situations from the participants’ own points of view rather than forcing the researcher’s own categories on the data. Contrary to Dietz and Widdershoven, we do not see Searle’s and Habermas’ theories as contradictory. Rather we would argue that they consider different aspects of speech. Searle describes different types of utterances and classifies them. Furthermore, general characteristics of a speech act are established and their different values are discussed for the different types of speech act. Therefore, Searle describes conditions for ideal communication. Habermas, on the other hand, develops a framework for the process of achieving consensus through negotiating validity claims that are imminent in each utterance. He takes into account that communications problems can occur. Habermas implicitly presupposes the satisfaction of preparatory and propositional content introduced by Searle and then introduces further conditions of his own. Therefore, the two theories can be integrated to provide a powerful framework for communication analysis.

7 Conclusion In this paper we introduced work on supporting cooperative work in healthcare by making written communication more effective. To provide the empirical platform for the present work, ethnographic investigations were performed in a multidisciplinary healthcare environment. A number of key findings was introduced as the results of the ethnographic work. It was discussed how these findings together with general issues of the fields of Computer Supported Cooperative Work and the Language-Action Perspective were considered for the design of better cooperative documentation systems. An emphasis of this paper was on the reply to established critiques of the Language-Action Perspective. Empirical studies using the Language-Action Perspective have not frequently been done before. Although there has been much theoretical work in the LAP community, the practical modelling has usually not been based on empirical data. We would argue that by basing the approach on a solid empirical platform, many of the criticisms that have been made of LAP have been reassessed and overcome. The Language-Action Paradigm focuses mainly on the pragmatic and metalinguistic level which means that comprehensibility problems are often ignored. It has been argued in the present approach that comprehensibility problems need to be addressed because they are the most common communication problems in doctor-nurse interactions. Therefore, the possibility of providing translation between different professional terminologies has been proposed. Thereby we aimed at drawing together the semantic level dealt with in the area of translation and the pragmatic level of the Language-Action Perspective. The main contribution of the present work is that it provides a systematic theoretical framework for the design of CDSs (see [15,17]). Further work could be carried out by building a prototype of a computer-based cooperative documentation system based on the present approach to evaluate further how such an operation system would enhance written communication. A decision on candidate architectures would have to be made. For example, the architecture of the CHAOS [2] or the MILANO [7] systems could be taken as the basis for the prototype. To summarise, we have shown the potential of an extended Language-Action approach as the basis for better cooperative documentation systems that promote effective written multidisciplinary communication.


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