The Academic Life in Emergency Medicine (ALiEM) Faculty Incubator was hard at work during the pandemic to bring you the fifth volume of the Education Theory Made Practical series. This series strives to make theory accessible to educators by distilling the background and key literature of each theory and grounding them in practical education scenarios.
The Faculty Incubator is a year-long professional development course for medical educators centered around a virtual community of practice (a concept we have all started to appreciate during quarantine). Teams of 2-3 participants from around the world authored primers on education theories and different teams offered a first round of peer review on each post. As in prior years, they will be serialized on the ICE Blog for review and comment. You can learn more here.
They have published three e-book compendiums of this blog series (Volume 1, Volume 2, Volume 3) and you can find the Volume 4 posts here (the e-book is in progress!) As with the previous iterations, final versions of each primer will be complied into a free eBook to be shared with the health professions education community.
Your Mission if you Choose to Accept it:
We would like to invite the ICE Blog community to peer review each post. Your comments will be used to refine each primer prior to publication in the final ebook. No suggestion is too big or small – we want to know what has been missed, misrepresented, or misconstrued. Comments as small as grammatical errors all the way to new scenarios for practical applications or new citations are welcome. (Note: The blog posts themselves will remain unchanged.)
This is the sixth post of Volume 5! You can find the previous posts here: Banking Theory; Constructive Alignment; IDEO’s Design Thinking Framework; R2C2 Feedback Model and, Feminist Theory.
Authors: Fawziah Alsalmi (@FoozFlower), Lorne Costello, Kristine Prince
EDITOR: Sara M. Krzyzaniak (@SMKrzyz)
Main Authors or Originators: tWanda Orlikowski, Susan Scott
Other important authors or works: Barad: agential realism; Leonardi: imbrications; Martine and Cooren: materiality and relationality
Part 1: The Hook
Ms. Smith, an 87 year old with a past medical history of untreated hypertension, called the ambulance when she began having significant chest pain. On arrival, she informed Shannon, one of the paramedics, that the severe, tearing pain began suddenly about one hour prior and radiated into her left arm and back. As per her medical directive, Shannon began transporting the patient and consulted with an emergency physician, Dr. Lee, via a telemedicine link.
During transport, the telemedicine platform had connection issues and kept cutting in and out, much to the frustration of Shannon and Dr. Lee. As a result, Shannon was unable to relay much of the patient’s history or her vital signs, so Dr. Lee asked that she just send the ECG. He planned to review it to determine appropriate triage prior to the patient’s arrival. His review of the ECG showed ST elevation in the inferior leads (II, III, and aVF), and he interpreted this as consistent with an inferior ST-elevation myocardial infarction (STEMI). The concerned emergency physician informed the paramedics to bypass the emergency department and transport her directly to the cardiac catheterization suite for primary coronary intervention (PCI). He requested that the paramedics give aspirin and sublingual nitroglycerin. As Shannon started to express her concern about the patient’s atypical sounding chest pain, Dr. Lee was called overhead to attend to another sick patient. He apologized and ended the telemedicine call.
On arrival at the cardiac catheterization suite, the patient had received the requested medications. The patient was now short of breath and hypotensive. As the paramedics handed over the patient to the interventional cardiology team, Dr. Sam, the cardiologist, performed a bedside echocardiogram. The bedside echo demonstrated hypokinesis of the inferior wall with moderate aortic regurgitation, and a large pericardial effusion. Dr. Sam raised the concern for an aortic dissection, which is what Shannon had been concerned about all along.
Shannon and her partner transported the patient down to the emergency department while Dr. Sam called for an emergent cardiac surgery consult. As the paramedics bring the patient into the emergency department, Shannon hears a familiar voice; standing before her is the now shocked emergency physician, Dr. Lee.
Part 2: The Meat
The term “social”, defined as “relating to society or its organization,” dates back to the 17th century and is derived from the Latin word Socialis. “Material” is defined as “denoting or consisting of physical objects rather than the mind or spirit” or “important; essential; relevant.” In the literal sense, sociomaterialism is a noun of the blending of the terms ‘social’ and ‘material’ first postulated by Wanda Orlikowski as a conceptual framework for the theory sociomateriality.3 Rather than treating the social and material environments as two different entities, Orlikowski argues that the two are intertwined with one being no more important than the other, a concept known as as “constitutive entanglement.” Derived from previous work of relational theorists, it is this constitutive entanglement that blurs the overlap of technology, work, people, and organization.
Sociomateriality consists of five central ideas identified in the literature: materiality, inseparability, relationality, performativity, and practice.
● Materiality can differ among professions and areas of studies, but in general refers to how something is used.
● Inseparability describes the close interrelatedness of humanity (in sociality) and materiality.
● Relationality is the inseparability of humanity and materiality in that each entity depends on one another.
● Performativity is the notion that the “boundaries between humans and technologies are enacted in practice.”
● Practice relates to the development of a lens to improve one’s knowledge base and understanding.
In its resurgence since 2007, sociomateriality has been described as an umbrella theory containing a number of sub-theories. These sub-theories exist within the aforementioned central ideas to aid in formatting the framework of sociomaterialism.
The core tenant of sociomateriality is the effect technology has on human interaction, personal and professional lives, and sociality. This framework concurrently describes effects of people on the design of, use of, and dependence on technology in the modern world. Commonly cited examples in the literature include internet search engines and smartphones. Sociomaterial, is a concept that has been circulating in the fields of sociology and economics since the 1950s. Since, there has been a relatively slow evolution of the topic up until 2007, a key point-in-time for sociomaterialism and advances in related research and application. In 2007, Orlikowski built upon her work from 1995 and sparked a renewed interest in sociomaterial through the development of sociomaterialism and the concept of entanglement.3 As previously discussed, constitutive entanglement is the intertwining of social and material as a singular concept. Subsequently, several authors have debated the soundness of Orlikowski’s constitutive entanglement and theorists have created several branching theories under sociomaterialism including artefact, apparatus, affordance, constrain, object, entity, and actor-network-theory.[5,6]
Additional viewpoints on the conceptual framework of sociomaterialism have been created including agential realism by Barad, imbrications by Leonardi, and materiality and relationality by Martine and Cooren. Barad’s agential realism states that there is no absolute distinction between social or material and that the concept is purely sociomaterial as one singular concept. Leonardi’s imbrications, or critical realism, states that social and material are separate and only “imbricates,” or overlaps, becoming sociomaterial as people create the link between the two.7 Martine and Cooren’s materiality and relationality was developed to help clarify the confusion created by constitutive entanglement’s language, suggesting that the two concepts can be singular or joint depending on the situation in which the concept(s) is/are needed.
Modern takes or advances
Despite its 2007 resurgence, sociomateriality has had few modern advances apart from the aforementioned viewpoints, notions, and debates. Regardless, its value is increasingly recognized in the impact of technology in the modern world and is now be utilized in many fields of study after years of being used primarily in organization and information systems literature. The constitutive entanglement described by Orlikowski is evident more than ever with humanity’s dependence on technology in nearly all aspects of everyday life. There are myriad benefits to the advances of technology in the modern world including but not limited to worldwide connection, rapid communication and dissemination, ease of access to information, improved productivity and efficiency of industries, and increased lifespan. However, there is a darker side to technology including vulnerability, risks of breaches of sensitive personal information, diminished need for human rote memory and knowledge, and human job loss as processes become automated. More significant concerns include pandemics due to synthetic biology, climate change with geoengineering, production of weapons of mass destruction via distributed manufacturing, and unpredictable artificial intelligence systems. While the hope of technology benefits outweighing the risks, individuals and organizations must be cognizant of these risks to mitigate adverse outcomes. Sociomaterialism is the conceptual framework surrounding these issues.
With the rapidly changing face of technology and its impact on humanity, sociomaterialism and sociomateriality are among the most commonly discussed and debated conceptual framework and theory applications in increasing numbers of fields of study and organizations. Applications of sociomaterialism were also evident within the COVID-19 pandemic with mitigation measures, rapid transition from face-to-face interaction to digital platforms, use of technology in continuing patient care without in-person interaction, as well as significant educational responses in light of COVID-19. 
Other examples of where this theory might apply in both the classroom & clinical setting
With technology’s far-reaching impact in many aspects of the modern world, the classroom and clinical settings are prime locations for application of sociomaterialism as technology intersects these arenas. Within the classroom, sociomaterialism is rooted within use of advanced technology (e.g. computers, smartboards and projectors), online teaching practices or mobile learning, simulations, use of social media to disseminate information or provide educational opportunities, open educational resources via the Internet, and access to unlimited digital resources that benefit both the educator and learner.[11,12,13,14]
Within the clinical setting, there is a plethora of medical literature applying sociomaterialism and sociomateriality in both medical education and practice. Examples of application include multidisciplinary approaches to patient care, medical technology, distributed medical education (e.g. distance education, web conferencing, video conferencing, online educational platforms and online communities), use of social media to disseminate evidence-based practices and free open access medical education (FOAMEd), electronic medical records, use of smartphones and tablets, simulation-based learning, and digital resources.[15,16,4,17,18,19]
Annotated Bibliography of Key Papers
Bavdaz A. Past and recent conceptualisations of sociomateriality and its features: Review. Athens J Soc Sci. 2017;5(1):51-78. doi:10.30958/ajss.5-1-3 
Aleksandra Bavdaz dives into the topic of sociomaterialism in an extensive review. The review covers a number of topics including the evolution of definitions of material and social, as well as technology, descriptions of varying viewpoints on sociomaterialism, a discussion of research junctures and associated metatheories, studies of the features of the conceptual framework, reviews examples of real world applications, and highlights points for further research.
Jones M. A matter of life and death: Exploring conceputalizations of sociomateriality in the context of critical care. MIS Q. 2014;38(3):895-925.
This paper provides a detailed background on sociomateriality including historical perspective and key features/notions of the conceptual framework including materiality, inseparability, relationality, performativity, and practice. Jones also provides a comprehensive literature review surrounding sociomaterialism from 2007-2013 having found 146 papers that are outlined in table format. After reviewing sociomaterialism, Jones then goes on to apply the conceptual framework to the “implementation of a computer-based clinical information system in a 25-bed critical care unit” and describes how each of sociomatieralism’s core ideas play a role in the case example. The article concludes with a discussion of sociomaterialism’s influence in the information systems world and dives deeper into the conceptual framework’s importance of the principle of the interaction of technology and humans.
Leonardi PM. Theoretical foundations for the study of sociomateriality. Inf Organ. 2013;23(2):59-76. doi:10.1016/j.infoandorg.2013.02.002 
Paul Leonardi highlights two theoretical foundations of sociomateriality: agential realism and critical realism. For agential realism, the paper discusses the foundation of the theory and reviews shifting definitions. The paper then reviews challenges of agential realism and describes how these lead to the development of critical realism as a solution to these problems. The paper also provides graphical descriptions of the structural approach of technologies from 1986 to 2000 and key differences between agential realism and critical realism. The paper concludes with comparing and contrasting the two theories.
MacLeod, A. and Ajjawi, R., 2019. Thinking sociomaterially: Why matter matters in medical education. Academic Medicine. DOI: 10.1097/ACM.0000000000003143 
This primer introduces sociomaterialism and its role in health professions education and scholarship. It begins with a coherent and readable overview of the ontological, epistemological, axiological, and methodological foundations of sociomateriality. The authors then put these ideas into action by emphasizing the foundations of sociomaterialism in a sample medical error case involving a resident trainee. This case helps the reader to better understand the practical side of sociomaterialism and how it can play a role in everyday healthcare and education.
Limitations to sociomaterialism depend on the field of study or area to which the conceptual framework is being applied. However, common limitations noted in the literature include the lack of addressing of problems in social inequality, strong versus weak versions of sociomaterialism, confusing language of the framework itself, and ruminating design.
- Social Inequality: sociomaterialism and sociomateriality assumes equal access to technology among all individuals and organizations. This limitation is highlighted in work using sociomaterialism within the fields of education and literacy. This limitation is also seen in healthcare applications, for example the use of a computerized algorithm that assumes equal access to care
- Strong versus weak versions: weak sociomaterialism denotes separateness of social and material while strong sociomaterialism does not.
- Language and descriptors can be very difficult to understand.This, combined with multiple definitions and overlapping theories, lends to significant confusion.
- Ruminating design: authors repeatedly debate the soundness of the foundation rather than focusing on the establishment of the framework and its application to individuals, relationships, and organizations.
Part 3: The Denouement
After Ms. Smith is quickly stabilized in the emergency department and transferred to the operating room, Shannon asks Dr. Lee if they can discuss the case since she feels uneasy about what has happened. Dr. Lee agrees and they go to a quiet room next door.
Shannon expresses that she feels guilty for not speaking up sooner and is frustrated that there were technology issues that prevented clear communication. Furthermore, she feels that she was dismissed by Dr. Lee who rushed her off the phone. Dr. Lee understands and states that he feels also guilty for missing the correct diagnosis, leading to a delay in care. He apologizes to Shannon for dismissing her earlier and reiterates that there was a sick patient and he was faced with competing urgent issues that needed attention. They agree on the importance of better communication in this and decide to file a safety report with their respective leadership teams to help mitigate the risk of a similar incident in the future.
Within their meeting, Shannon and Dr. Lee unknowingly identified key issues applicable to sociomaterialism. The lack of working technology prevented both parties from doing their job correctly and led to frustration. Shannon was unable to communicate her concerns and Dr. Lee, with minimal information, switched to another material (ECG) to decide how he would act next. Furthermore, this technology glitch changed the way that both the physician and paramedic interacted. Similarly, the environments that they both were in also influenced their behaviours and interaction. For example, Dr. Lee was paged overhead to attend to another sick patient, despite being within eyesight of the patient’s room and available to immediately help.
Beyond this conversation, there are other factors at play in this constitutive entanglement. The medical directive acted as a forced mechanism that led to an action (i.e. the paramedic calling the emergency physician) and the introduction of another material, ultrasound, that when used by the cardiologist led to the patient’s correct diagnosis and shifted the patient’s care and disposition. Similarly, the location of the patient also guided what needed to be done next (e.g. transfer to the emergency department and then the operating room) and one could also consider the power dynamics between professions as they interacted (e.g. the paramedic being ordered to give aspirin and nitroglycerin despite her concerns).
So, there you have it, a practical example of the complexities that involve materials and social in everyday learning and practice. Sociomaterialism supports that medical practice is a collective sociomaterial enactment and not a question solely of an individual’s skills. It decenters the human as the focus to allow for a deeper exploration of the complex, messy and non-linear relationships between materials and social practices.20 Furthermore, the goal of sociomaterialism is not to prescribe what should be but rather to have a better understanding of what emerges.15 Sociomaterialists believe the world—people, things, practices—is constituted through assemblages (e.g. heterogeneous entanglements of human and nonhuman elements).21 By using this theory, readers will better understand how clinicians and learners change their interactions and behaviors based on the world around them.
Don’t miss the seventh post in the series, coming out Tuesday, September 7, 2021!
PLEASE ADD YOUR PEER REVIEW IN THE COMMENTS SECTION BELOW
1.Lexico. “Social.” Published 2020. Accessed August 5, 2020. https://www.lexico.com/en/definition/social
2. Lexico. “Material.” Published 2020. Accessed August 5, 2020. https://www.lexico.com/en/definition/material
3. Orlikowski WJ. Sociomaterial practices: Exploring technology at work. Organ Stud. 2007;28(9):1435-1448. doi:10.1177/0170840607081138
4. Jones M. A matter of life and death: Exploring conceputalizations of sociomateriality in the context of critical care. MIS Q. 2014;38(3):895-925. DOI:10.25300/MISQ/2014/38.3.12
5. Bavdaz A. Past and recent conceptualisations of sociomateriality and its features: Review. Athens J Soc Sci. 2017;5(1):51-78. doi:10.30958/ajss.5-1-3
7. Leonardi PM. Theoretical foundations for the study of sociomateriality. Inf Organ. 2013;23(2):59-76. doi:10.1016/j.infoandorg.2013.02.002
8. Hultin L. On becoming a sociomaterial researcher: Exploring epistemological practices grounded in a relational, performative ontology. Inf Organ. 2019;29(2):91-104. doi:10.1016/j.infoandorg.2019.04.004
9. Global Priorities Project, Future of Humanity Institute University of Oxford, Oxford Martin School, University of Oxford, Centre for the Study of Existential Risk University of Cambridge. Unprecedented Technological Risks.; 2014. doi:10.1007/978-3-642-56958-6_12
10. Cleland J, Tan ECP, Tham KY, Low-Beer N. How Covid-19 opened up questions of sociomateriality in healthcare education. Adv Heal Sci Educ. 2020;25(2):479-482. doi:10.1007/s10459-020-09968-9
11. Bolldén K. The emergence of online teaching practices: A socio-material analysis. Learn Media Technol. 2016;41(3):444-462. doi:10.1080/17439884.2015.1044536
12. Mifsud L. Mobile learning and the socio-materiality of classroom practices. Learn Media Technol. 2014;39(1):142-149. doi:10.1080/17439884.2013.817420
13. Hopwood N, Rooney D, Boud D, Kelly M./ Simulation in higher education: A sociomaterial view. Educ Philos Theory. 2016;48(2):165-178. doi:10.1080/00131857.2014.971403
14. United States Department of Education. Use of technology in teaching and learning.
15. Fenwick T. Sociomateriality in medical practice and learning: Attuning to what matters. Med Educ. 2014;48(1):44-52. doi:10.1111/medu.12295
16. MacLeod A, Kits O, Whelan E, et al. Sociomateriality: A theoretical framework for studying distributed medical education. 2016;44(0):0-19. doi :10.1097/ACM.0000000000000708
17. Abrandt Dahlgren M. Perspectives on co-learning: Practices as sociomaterial entanglements.
18. McMurtry A. Reframing interdisciplinary and interprofessional collaboration through the lens of collective and sociomaterial theories of learning. Issues Interdiscip Stud. 2013;98(31):75-98.
19. Barrett M, Oborn E, Orlikowski W. Creating value in online communities: The sociomaterial configuring of strategy, platform, and stakeholder engagement. Inst Oper Res Manag Sci. 2016;27(4). doi:10.1287/isre.2016.0648
20. Goldszmidt M. When I say… sociomateriality. Medical education. 2017 May;51(5):465-6. https://doi.org/10.1111/medu.13149
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