The purpose of the glossary is to set the terms used within the context of this book and the resultant theory. Some of the terms defined are interpreted differently in certain strands of academic study and even everyday use. Hence, the goal is consistency within the approach described rather than offering a universal definition of each term.

Action Research

The two key features of Action Research, as presented here, are:

Refinement of an intervention through iteration of activity;
Activity by individuals directly involved and impacted by the intervention.

The outcome of this iterative activity is a community of practice that integrates learning and understanding of the needs of the practitioners in care delivery with the developers of the technology that facilitates new practice.

Appreciative Inquiry

Is an approach that seeks to engage stakeholders in self-determined change. Rather than make assumptions of the questions that should drive discussion of an intervention, for instance. The approach uses collective inquiry into the best of what is, in order to imagine what could be, followed by collective design of a desired future state that is compelling and thus, does not require the use of incentives, coercion or persuasion for planned change to occur. This is aligned with the ideas of discussing Intent and focusing on the Outcomes sought.

Bottom-up Design

In terms of the approach to context described in the Intervention Space and the Far Environment, Bottom-up Design starts with the intervention at the most local level. In our contextual model this is context level 4 (C4) and builds up to context level 1 (C1). Context level 0 impacts on the intervention but is not under the control of any of the Gateholders.

Complexity Challenges

The four Complexity Challenges identified in the empirical framework originate in the interplay between the Far Environment, the local context and the needs of the practitioners. There may be more than four Complexity Challenges, but the ones identified (hubris, collaboration, sustainability and context) represent recurrent themes experienced in the development of sociotechnical platforms.

Complex Theory of Action

In Developmental Programme Theory for Sociotechnical Platforms (DPT4STP) a parallel is drawn with purposeful programme theory where the programme is a combination of a theory of action and a theory of change. However, in DPT4STP both the theory of action and the theory of change have complexity built in to the approach. This is in the form of the complex spaces represented by the Intervention Space and the integrated approach to the four Complexity Challenges. The Complex Theory of Action defines the “what” of the interaction of new practice with technology.

Complex Theory of Change

In Developmental Programme Theory for Sociotechnical Platforms (DPT4STP) a parallel is drawn with purposeful programme theory where the programme is a combination of a theory of action and a theory of change. However, in DPT4STP both the theory of action and the theory of change have complexity built in to the approach. This is in the form of the complex spaces represented by the Intervention Space and the integrated approach to the four Complexity Challenges. The Complex Theory of Change defines the “how” of the interaction of new practice with technology. The development of the Complex Theory of Change arrives at the Change Space through a sensemaking process that considers behaviour change for all of the Gateholders in a Theory of Constraints type approach.

Challenge of Collaboration

One of the four Complexity Challenges. The Challenge of Collaboration recognises that the technology must be evolved in collaboration with practice with clear understanding of the outcomes sought by all of those impacted as well as the evidence they require to engage in behaviour change. The challenge is overcome through engagement with the POTE (Practice, Outcomes, Technology and Evidence) model of technology development in collaboration with practice and the development of Hypotheses of Outcomes Delivery.

Challenge of Context

One of the four Complexity Challenges. The Challenge of Context recognises that the environment within which the intervention must develop is influenced by many factors. Firstly, the success of the intervention is dependent upon behaviour change across a range of Gateholders. Gateholders being anyone who has an impact upon or is impacted by the intervention. Gateholders exist at many levels in the context. The near context is defined by the ability to influence what happens within it. The far context introduces factors that there are less and less control over. Ultimately the Macro Environment is beyond influence and provides continual disruption. The challenge is overcome by focusing all consideration of the intervention through the lens of the Intervention Space. This separates out Gateholders at different context levels and considers their motivations for change.

Challenge of Hubris

One of the four Complexity Challenges. The Challenge of Hubris recognises that, due to the context and the need to develop practice in collaboration with the technology, there is not a direct connection between the proposed hypotheses of action and the Change Space as arrived at through the sensemaking process of the Complex Theory of Change. The intervention must arise through collaboration, iteration and be accepting of emergence. The challenge is overcome by a sociotechnical platform based on Action Research, Developmental Evaluation, bottom-up and Top-Down Design.

Challenge of Sustainability

One of the four Complexity Challenges. The Challenge of Sustainability recognises that technology that supports a particular process or pathway in a certain context is inherently brittle and can be broken by many circumstances such as disruption from the Far and Macro Environment. The challenge is overcome by a sociotechnical platform that is a combination of practice and technology developed to be resilient and adaptable and developed iteratively through collaboration.

Change Space

The culmination of the sensemaking activity as part of the Complex Theory of Change is the Intervention Space populated by understanding of where each Gateholder group at each level of context are in terms of adopting the intervention. It represents that latest knowledge, using the Theory of Constraints, about what needs to change for the intervention to be adopted.

Communities of Practice

Recognise that the primary unit of analysis is neither individual nor social institutions but the “Communities of Practice” that people form as they pursue shared enterprises over time. This puts social participation at the centre of learning. This is reflected in the DPT4STP approach and can be found in the approach to Gateholders and the SECI-Ba approach to workshops.

Complex Adaptive Systems

The understanding of Complex Adaptive Systems underlies the complexity addressed in DPT4STP. Care is a network of independently acting and motivated agents that interact with each other. The resultant properties of the system are non-deterministic and exhibit emergence. Hence, any attempt to disrupt the system causes the system to adapt and produce outcomes and behaviour that were unforeseen. It is only by iterating solutions and observing how the complex system adapts that solutions can be converged upon.

Complex POTE Space

The simple POTE model shows how Practice, Outcomes, Technology and Evidence are iterated through User-centred Design workshops to generate Hypotheses of Outcome Delivery. By introducing the Intervention Space to each of the POTE dimensions it becomes clear which Gateholders and what context levels need to be considered in the workshops. In this way the POTE dimensions engage with the complexity of context and generate the Complex POTE Space.

Context

Context is used synonymously with environment. Any intervention sits within a context or environment that provides enablers and challenges. DPT4STP introduces levels of context and recognises Gateholders’ motivations for behaviour change within these levels. In this way the Intervention Space is produced as a map of the complex context which supports the idea of Context Mapping for behaviour change.

Context Mapping

The activity that generates and refines the Intervention Space. The two-dimensional mapping occurs such that Gateholders and context levels closest to the intervention are represented in the top-left corner. As the mapping moves out to include Gateholders further from the front-line and to include the Far Environment it populates the Intervention Space towards the bottom-right. In this way Intervention Space mappings become easier to compare between contexts. The Context Mapped Intervention Space then facilitates the application of different models to aid in sensemaking.

Contextual-Learning

As interventions are developed in different contexts it becomes possible to distinguish between aspects of the Sociotechnical Platform that are context sensitive and context insensitive. The context sensitive learning is called Contextual-Learning. Contextual-Learning begins in the first deployment but only allows differentiation from Meta-Learning as the number of deployments increase.

Developmental Evaluation

Developmental Evaluation recognises the full complexity of the context that any intervention is developed within. The Four Pillars call for iteration of the intervention within the complex context. The POTE model recognises the intimate link between outcomes and evidence as hypotheses are developed and tested. Within this approach Developmental Evaluation must be used as it not only recognises the impact of the context but also the differing points of view with regards to outcomes and evidence. As the intervention evolves trough iteration the approach to evaluation must develop.

Differential Contextual-Learning

As the number of deployments increase and the range of contexts grows it becomes possible to distinguish between context-sensitive and context-insensitive aspects of the Sociotechnical Platform. This leads to Contextual-Learning and Meta-Learning about the Sociotechnical Platform respectively. It also begins to inform understanding about how the negotiation with the context occurs for different deployments. This is called Differential Contextual-Learning.

Evidence Space

One of the complex spaces that form the POTE model of practice and technology development. The Evidence Space captures the perspectives within the Intervention Space of what is required for various Gateholders at different context levels to change behaviour. It provides the link in the Developmental Evaluation between the outcomes sought and the evidence that supports them for each Gateholder.

Far Environment

In our development of context in DPT4STP we introduced the idea of the environment within which an intervention sits as being complex and as having different levels. The Near Environment is subject to some level of influence. The further you get into the Far Environment the less influence you have over factors that can impact upon your intervention. Ultimately in the Macro Environment there are the STEEPLE factors that impact upon your intervention but over which you have no control.

Feature Inflation

The tendency, with any software or hardware development, to get excited about the possibilities and start to innovate beyond what is required to meet the identified needs. This concern underlies the inclusion of Outcomes and Evidence dimensions in the POTE model. It is also a key part of the Intent and User-centred Design Workshops.

Gateholders

In the description of stakeholders below it is explained why we depart from the term early in the empirical framework. The fragmentation, artificial competition and outsourcing that characterises care delivery moves the focus away from organisations. They become part of the challenging context within which an intervention sits. For this reason, when considering an intervention, it is necessary to consider concerns that cross organisational boundaries.

Hypotheses of Outcome Delivery

Theories linking use of technology in practice that delivers outcomes sought.

Hypothesis of Outcome Delivery

A theory linking use of technology in practice that delivers outcomes sought.

Initiate Stage

The first phase of the DPT4STP approach. Through an Intent Workshop the intervention is explored and the following mapped:

The outcomes sought;
The Hypotheses of Outcomes Delivery and the
Intervention Space.

Instrumenting the Platform

The inclusion, in the sociotechnical platform, of automated, granular data collection about all aspects of system usage and functioning. The more data that is generated automatically the better the sensemaking can be supported. This is separate from user entered data or separately obtained evaluation data as it represents the automated data only.

Intent Workshop

The Intent Workshop is a key activity in both the Initiate and Iterate Stages. The goals of an Intent Workshop are:

A better understanding by the technologists of the daily challenges faced by practitioners and their modes of working;
A better understanding by the practitioners of what might be possible using technology in practice.

In the Initiate Stage the Intent Workshop is essential in exploring the intent of the intervention. The outcomes are:

The outcomes being sought;
The Hypotheses of Outcome Delivery and
Context Mapping of the Intervention Space.

In the Iterate Stage the Intent Workshop updates these aspects of the intent through sensemaking from the Develop, Deploy, Use activity. This update includes:

An iterated Intervention Space;
Emergent hypotheses of action;
Refined hypotheses of action and
Inclusion of changes in the Near, Far and Macro Environment.

These feed into the next iteration of the Complex Theory of Action. Any change to the Intervention Space also impacts on all of the spaces in the sensemaking process.

Intervention

The Intervention is the overarching term that refers to the combination of the Complex Theory of Action in cooperation with the Complex Theory of Change that results in the realisation of the Hypotheses of Outcome Delivery.

Intervention Space

The Intervention Space is the two-dimensional space that represents all of the impacted Gateholders at all levels of the complex context. It forms the basis of Context Mapping and probing the requirements for behaviour change that leads to the Change Space.

Iterate Stage

The second phase of the DPT4STP approach. This links the Complex Theory of Action to the Complex Theory of Change via the Develop, Deploy, Use and Interpretation parts of the cycle. Through repetition various hypotheses are tested and this feeds the Learn phase.

Learn Stage

The third phase of the DPT4STP approach. The First Order Learning considers what is being surfaced about the interaction between the intervention and the context. As more contexts are encountered it allows core aspects of the intervention that are context insensitive (Meta-Learning) to be differentiated from aspects of the intervention that are context dependent (Contextual-Learning). As many contexts are explored and Meta-Learning increases facets of the variation of context and their impact on the intervention can be differentiated and this is called Differential Context. Second Order Learning considers the operation of DPT4STP and its ability to deliver services and to extract the learning and understanding from the experience.

Macro Environment

The Far Environment is characterised by factors that influence the context of a development but cannot be directly influenced. In other words, the factors are disruptors that cannot be controlled for. We call this the Macro Environment. In the STEEPLE model they are: Social, Technical, Economic, Ethical, Environmental, Political, Legal and Environmental (STEEPLE) factors in the Macro Environment.

Meta-Learning

As interventions are developed in different contexts it becomes possible to distinguish between aspects of the Sociotechnical Platform that are context sensitive and context insensitive. The context insensitive learning provides an understanding of what is core to the sociotechnical platform and is called Meta-Learning.

Near Environment

In our development of context in DPT4STP we introduced the idea of the environment within which an intervention sits as being complex and as having different levels. The Near Environment is subject to some level of influence. The further you get from the Near Environment the less influence you have over factors that can impact upon your intervention. Ultimately in the Macro Environment there are the STEEPLE factors that impact upon your intervention but over which you have no control.

Outcome Space

One of the complex spaces that form the POTE model of practice and technology development. The Outcome Space captures the perspectives within the Intervention Space of what is required for various Gateholders at different context levels to change behaviour. The outcomes are specified in the Hypotheses of Outcome Delivery.

Peeling the Onion

A metaphor for the Theory of Constraints in that removing one set of constraints serves to reveal the next set - as when peeling an onion reveals the next layer below. This is fundamental to the need for an Action Research approach as it means that all enablers and challenges cannot be known up front. They must be revealed through a process of engagement and iteration.

Platforms

Platforms appear in many industries and represent an assembly of technologies and capabilities that, when used together, provide a reusable resource that can be applied to many varied scenarios. They are distinguished from highly targeted solutions in that they are:

Modular in being built of independently functioning components;
Utilise these components in various combinations to achieve specific outcomes;
Provide appropriate interfaces between components to ensure interoperability;
Are rapidly reconfigurable to address newly encountered requirements.

For example, researchers in the biological sciences platform at Sunnybrook Research Institute (SRI) in the U.S. aim to understand the functions and interconnections of molecules, cells, organs and systems. Scientists working in biological sciences use a range of experimental approaches and techniques to understand the mechanisms of healthy and diseased physiology. By understanding these mechanisms, they improve diagnosis and prognosis; and make treatment more specific, selective and personalized, and thus more effective and safer. The reason this department is referred to as a platform is related to the points above.

In IT, platforms are manifested as combinations of software and hardware that provide a service to a population. The underlying technology may involve:

Server technology;
Operating systems;
Communications standards;
Browser technology and
Various technology to access the service at the edge of the system.

A regularly overlooked aspect of all platforms is that they are generally sociotechnical platforms in that they are a combination of human capabilities interacting with the technology to generate outcomes.

POTE – Practice, Outcomes, Technology, Evidence

This model forms the engine of the Complex Theory of Action development. The development of Hypotheses of Outcome Delivery arises out of consideration of how Practice can be supported by Technology in support of Outcomes supported by appropriate Evidence. This is achieved in User-centred Design workshops (UCD) where the needs of all Gateholders are considered and the impact on the technology discussed. The mapping of the requirements for behaviour change for all Gateholders at all levels of context occurs using the Intervention Space. This leads to the Complex POTE model where each of the dimensions is mapped onto the Intervention Space.

Practice Space

One of the complex spaces that form the POTE model of practice and technology development. The Practice Space captures the perspectives within the Intervention Space of what is required for various Gateholders at different context levels to engage with the technology in pursuit of the Hypotheses of Outcome Delivery. The outcomes are specified in the Hypotheses of Outcome Delivery.

Problem Space

The use of the term “space” is indicative of the context within which a problem exists. It acts as a reminder that no problem exists exclusive of its context.

Realistic Evaluation

The word evaluation is often taken in the narrowest sense to mean the analysis of outcomes for a given project upon completion. Often the result is a pass/fail type summation of the outcomes compared to what was predicted at the start. This kind of summative evaluation makes many assumptions about the intervention and assumes that everything proceeds according to plan. It does not address context but attempts to control for it removing its impact on the intervention. The first step on the road to addressing the real world is to introduce context into the evaluation instead of trying to control for its consequences. This step leads to Realistic Evaluation. Here, context is included in the analysis and an attempt to understand how context impacts on the intervention is undertaken. This means that the role of the evaluator shifts from an impartial arbiter of the final result to a collaborator on the co-development of the intervention in the prevailing context. This is known as formative evaluation. This shift away from impartial observer to collaborator on the project is sometimes perceived as problematic as evaluation is often seen as an independent implementation of a set of established tools. This is not applicable in a real-world situation where challenges are being overcome and the fit between the intervention and its context is being negotiated.

Red Queen Hypothesis

The name originates in Lewis Carroll’s “Through the Looking-Glass” published in 1871. The Red Queen makes a statement to Alice in her explanation of Looking-Glass land:

“Now, here, you see, it takes all the running you can do, to keep in the same place.”

The term Red Queen Hypothesis was adopted in evolutionary biology to explain that organisms must constantly adapt, evolve, and proliferate not merely to gain reproductive advantage, but also simply to survive while pitted against ever-evolving opposing organisms in a constantly changing environment. This continual test of “fitness” in a continually changing environment applies equally to digital interventions in care. Not only are the demands on care evolving and changing but the means to supply that care are equally changing. Any digital intervention cannot be thought of as a point innovation such as a scalpel or bandage but must be seen as something that can adapt, absorb new technologies and fight back against the changing environment. This requires a resilient, adaptive sociotechnical platform.

Resilient Adaptive Sociotechnical Platform (RASP)

In overcoming the Challenge of Sustainability and addressing the Red Queen Hypothesis it is clear that a technological intervention that is context sensitive and rooted in a particular technological solution will fail quickly. It can be argued that you cannot test such interventions because, by the time you have evaluated them, the context including available technologies has moved on. The whole point of DPT4STP is to provide an approach to developing technology in collaboration with practice in such a way that it is sustainable against a continually changing environment including the fast-paced development of new technologies. At the technological heart of the approach, as with eCommerce and social media, is a resilient, adaptive, sociotechnical platform. These terms characterise the following features:

Resilient – robust, fault tolerant, self-monitoring, self-managing technology;
Adaptive – modular, reusable, repurposeable components that appear, at the user, through appropriate, easy to use interfaces;
Sociotechnical – focused on the interaction between practice and technology rather than either in isolation. Recognition that this is a Sociotechnical System.
Platform – a combination of the above that facilitates evolution of services, rapid prototyping, hypothesis testing and long-term learning and understanding.

SECI-Ba

It is difficult to describe the User-centred Design and the Intent Workshops as processes. This is due to the fact that they are more akin to the knowledge creation model of the SECI-Ba approach (Nonaka and Takeuchi, 1995). Here knowledge creation is seen as a spiral where knowledge is exchanged between tacit and explicit domains. The spiral is characterised by four actions: Socialisation, Externalisation, Combination and Internalisation (SECI). This happens in an environment or “Ba” that provides time and space to explore the exchange from tacit to explicit forms of knowledge.

Socialisation surfaces aspects of tacit knowledge that are hard to codify and are rooted in experiential learning with the goal of sharing these between participants. An example of this can be thought of as the technologists gaining sympathy for the unwritten aspects of the practitioner’s work. This sharing of tacit understanding is related to what happens in apprenticeships and emphasises why the technologists and practitioners must collaborate in close proximity.
Externalisation captures aspects of the tacit knowledge in conceptual form. This may be in terms of models related to the tacit understanding. This may manifest in requirements for technology that supports the real-world frontline activity. This moves from tacit to explicit knowledge by attempting to codify and capture what is understood in socialisation.
Combination then takes the knowledge generated from the externalisation activity and combines it with the broader, codified and explicit statements about the goals being sought. This domain engages with the levels of context about policy and local guidance. This forms systemic knowledge about how the far context relates to the near and what really happens on the font-line. This activity synthesises deeper and more complete explicit knowledge of the intervention and the context.
Internalisation then takes the resultant combined knowledge and moves it from the explicit domain back into the tacit domain by generating new practice and operational knowledge.

The approach attempts to develop understanding related to both tacit and explicit forms of knowledge and to share this between participants that inhabit different Communities of Practice. The spiral nature of the approach again refers back to the Action Research basis of the theory.

Seeing Through the Swiss Cheese

This is another metaphor linked to the Theory of Constraints. Peeling the Onion relates to revealing the enablers and challenges over time as the intervention is developed. Seeing Through the Swiss Cheese is the lining up of the behaviour of all Gateholders to enable change. This is aggregated into the Change Space and represents the total understanding developed in the sensemaking process through viewing the Intervention Space using different models of behaviour change.

Selling Certainty

A feature of our current culture where uncertainty or imperfect knowledge is perceived as risky or somehow a weakness. This serves to undervalue learning and exacerbate the issues of “presumed wisdom.” It incentivises a range of unhelpful behaviours including overuse of template approaches and reductionism.

Sociotechnical System

The definition used here is as follows:

“An approach to work design that appreciates the interaction between practice and technology as a system that is impacted by the Near, Far and Macro Environment and is subject to evolution and emergence.”

This is different from other definitions in that it is not organisationally focused. This is in recognition that, certainly in the case of care, the fragmentation, artificial competition and outsourcing of aspects of care delivery mean that the focus is no longer any one organisation. Furthermore, the focus cannot be the care system because there isn’t one. There are many competing organisations with overlapping responsibilities and blind spots. Thus, the sociotechnical approach we have adopted here treats the competing organisations as part of the context within which the intervention sits. They become Gateholders in the Intervention Space rather than owners of the intervention.

Space

The term “space” is used repeatedly in this book to reinforce the concept of a context or setting. The recurring theme of the book, that everything is contextual, relies on the use of space to remind us of this.

Stakeholder

We depart from using the term stakeholder early in the empirical framework because the focus moves away from organisations to the intervention itself. Stakeholders are so called because they have a stake in the organisation they represent. This becomes troublesome in our view of Sociotechnical Systems because the competing organisations that impact an intervention become part of the Intervention Space. This is described above in our view of Sociotechnical Systems. This is the reason we move from stakeholders to Gateholders in our analysis and sensemaking.

Technology Space

One of the complex spaces that form the POTE model of practice and technology development. The Technology Space captures the perspectives within the Intervention Space of what is required for various Gateholders at different context levels to change behaviour and engage with the technology in their practice. The outcomes are specified in the Hypotheses of Outcome Delivery.

Test and Learn

An approach to experimentation particularly applicable to sociotechnical platforms. By having a resilient, adaptive sociotechnical platform, new Hypotheses of Outcome Delivery can be rapidly prototyped and tested. The success or failure provides useful feedback about the context and the needs of practitioners and the cared for.

The Four Pillars

In the Challenge of Hubris, we identified that, in a complex context, the assumption that the shape of the intervention that will embed can be known up-front is deeply flawed. In order to overcome the Challenge of Hubris we identified four underlying tenets that support the development of the intervention in such a way that the most Gateholders aspirations can be met. These four tenets are called The Four Pillars and consist of Action Research, Developmental Evaluation, Bottom-up Design and Top-down Design.

Theory of Constraints

A theory relating to understanding what is constraining an intervention or system. It is based on the idea that the chain is as strong as its weakest link. Once that link fails the next weakest link defines the strength. Understanding of the ability of a system to resist change undergoes these transitions as the constraints are revealed one-by-one. The theory underpins the “Peeling the Onion” and “Seeing Through the Swiss Cheese” metaphors.

User-centred Design (UCD)

In DPT4STP User-centred Design is an approach to engaging with different Gateholders and surfacing their concerns and needs with regard to the use of technology in practice. The use of the word surfacing contains the following goals:

To make explicit some of the tacit knowledge that practitioners, patients, carers and care providers have about what outcomes are being sought and how this might be achieved. This includes: checking that the service currently received is what people really want, understanding the motivators and concerns of the care providers, understand how things are currently done.
To interact with the technology, in its current form, and discuss how it fails to meet expectations, how it can be improved, what new ideas it generates and how it can impact on the end-users in positive ways.
To educate the technologists about the world of practitioners, carers and the cared for. To educate the practitioners, carers and the cared for about what is technological possible. To create a community of practice that breaks down language barriers and facilitates the sharing of ideas.
To develop a roadmap of technological functionality that reflects a series of Hypotheses of Outcome Delivery. This means that the focus is not on the technology but on the outcomes facilitated.