According to Walsham (1997, p. 472) ‘actor-network theory addresses the local and contingent, but plays little attention to broader social structures which influence the local’. Walsham (1997, p.472) illustrates this criticism by referencing a citation from Reed (1995, p.332):
‘the theory (ANT) concentrates on how things get done to the virtual exclusion of the various ways in which institutionalised structures shape and modify process of social interaction and the socio-material practices through which it is accomplished’
The micro/macro debate is challenged by Latour (1991, p.118) who states that
‘the macro-structure of society is made of the same stuff as the microstructure, especially in the case of innovations, which originate in a garage and end up in a world that includes all garages’. Latour (1991, p.118) concludes that ‘the scale change from the micro to macro and macro to micro is exactly what we should be able to document’.
Walsham (1997, p.473) states that he shares some of the concerns expressed in the above debate. He suggests that one way in which these deficiencies maybe overcome ‘is to combine the methodological approach of ANT with insights and analyses drawn from theories of social structure’. Walsham (1997) also states that a major criticism of Giddens (1984) structuration theory is that
‘the material world of technology is not treated in any depth’ (Walsham, 1997, p. 473). The deficiencies of both theories could then be potentially overcome by a combination of structuration theory with the ‘methodology and concepts of ANT that would offer more than either one’ (Walsham, 1997, p.473). McClean and Hassard (2004, p.507) disagree with this point and state that ‘the agency/structure dichotomy is ‘antithetical for those adopting an ANT position’,
‘to talk of structure in the same breath as ANT is to confound the approach’.
For these reasons the combination of structuration theory and ANT is deemed
‘unfeasible, unbeneficial and undesirable’ (McClean and Hassard, 2004, p.508).
Conversely Jones and Karsten (2008, p.127) consider the development of hybrid approaches to ‘show a more active engagement with theory, exploring and challenging its limits’. Examples of such a hybrid approach include the combination of ANT with soft systems methodology (Atkinson, 2000) and
structuration theory (Brooks, Atkinson and Wainwright, 2008; Greenhalgh and Stones, 2010).
Brooks, Atkinson and Wainwright, (2008), for example investigate the influence of the EPR and IS on the development of clinical audit within the UK NHS.
This research highlights that although the patient is considered the object of the audit he/she is not put ‘actively at the centre of the process’ (Brooks, Atkinson and Wainwright, 2008, p. 453). In this example, it is initially the clinician who
‘initiates the audit, undertakes it and uses its outcomes to further their clinical practice’ (Brooks, Atkinson and Wainwright, 2008, p. 453). In essence, the clinician’s reaffirm their position as ‘the most powerful class of actors within the medical health system’, while at the same time ‘evoking structures of domination’ and ‘legitimisation’ (Brooks, Atkinson and Wainwright, 2008, p.
458).
Building upon a cumulative programme of research (Atkinson and Brooks, 2003; Atkinson and Brooks, 2005; Waring and Wainwright, 2000; Waring and Wainwright, 2002) this framework termed ‘StructurANTion’ has been developed as ‘a tool for Information System research in order to explore its potential impact on the process of reflexivity and emancipatory clinical practice’ (Brooks, Atkinson and Wainwright, 2008, p. 454).
Clinical audit is viewed here ‘as a formalised and overt form of reflexivity (surfacing and addressing issues) which has served to entrench the clinician and their interests at the centre of healthcare delivery networks along with their clinico-centric ‘structured order’ within care settings’ (Brooks, Atkinson and Wainwright, 2008, p. 456). While it may improve clinical care within this context, clinical audit does not ‘mobilise’ the emancipatory structure to
‘problemise’ and ‘translate’ the healthcare humanchine network’s incumbent structured order’ (Brooks, Atkinson and Wainwright, 2008, p. 456).
The ‘emancipatory’ feature of this work aims to explore ‘an alternative form of healthcare reflexivity: patient centred audit, in which patients have a more central role, leading to better outcomes’ (Brooks, Atkinson and Wainwright, 2008, p. 456). These changes aim to reconfigure the power relationships in the network in terms of conducting the audit, and in affecting change in the network both of which have the patient as the focal actor’ (Brooks, Atkinson and Wainwright, 2008, p. 458). In conclusion, Brooks, Atkinson and Wainwright, (2008, p.459) state that a number of important lessons were learnt from this process. Firstly ‘clinical audits can benefit from involving healthcare professionals and patients’. Secondly patients may ‘disclose more about their experiences to other patients than to healthcare professionals’. The development of this hybrid theory has then extended the theoretical concepts and practical application of both structuration theory and ANT, within a
‘sensitive professionally driven environment, dominated by clinico-centric power structures.
3.5 ‘ANT and after’
Law and Singleton (2005, p.331) state that traditional social science methods are ‘ill adapted for the study of complex and messy objects’ such as alcoholic liver disease (ALD). In order to overcome these deficiencies Law and Singleton (2005, p.334) suggest that an ontological shift is required which moves away from considering ‘multiple interpretations’ of objects to thinking about ‘multiple objects themselves’. From a performative perspective realities are considered to be ‘enacted into being’ and such enactments take place in the practice of getting to know those realities. ALD is thus described as a messy object
because our ‘methods are not geared up to detect or know it’ (Law and Singleton, 2005, p.334).
Working within the framework of ‘ANT and after’ Law and Singleton (2005, p.335) go onto to illustrate three versions of the object ALD, objects as ‘regions or volumes’, ‘networks’ and ‘fluids’ before highlighting a fourth perspective objects as ‘fire’.