How Activity Theory Applies to

Healthcare Software and

Documentation Design
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Table of Contents
Table of Contents.............................................................................................2

Introduction......................................................................................................3

Activity Theory Properties and Hierarchical Structure......................................3

How Activity Theory is Applied to Computer-based System Design.................7

Task Analysis in Computer-based System Design............................................9

Can Activity theory Framework Be Applied to Medical Software

Documentation?.............................................................................................11

Conclusion......................................................................................................18

REFERENCES ................................................................................................. 19
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Introduction
One of the cornerstones of any intelligent being is to understand
how occurrences in the surrounding world influence their
behavior. In reading an article for class, the term activity theory
stood out, which made me want to explore further the meaning of
the term. In reading many research articles this week, I came
upon a multitude of authors who defined activity theory in a
similar way. Activity theory is a body of thought that is not only
relevant to education and psychology, but also understanding
how organizations work. Activity theory is a descriptive tool to
help understand the unity of consciousness and activity. (Kofod-
Petersen and Cassens 2006). It is a framework for understanding
human activities that offers an alternative method to that of
human information-processing as to how people learn and society
evolves, from a materialistic perspective, based on the concept of
human activity as the fundamental unit of analysis (Bannon
1997). The focus is on the individual and group work practices.
An activity is made up of a subject, an object, and a mediating
artifact or tool. A subject is a person or a group of people who are
doing the activity. The object is held by the subject who has a
goal that they want to achieve and giving the activity specific
direction. “The basic definition of an activity is a form of doing
directed at an object. One activity is differentiated from another
activity by its object, and transforming the object to the outcome
is the motive for the existence of an activity. Objects can be
material things or something intangible, such as a plan or an
idea, as long as it can be shared for manipulation” (Cluts 2003,
146). The reason for my paper is to explore the possibilities of
applying activity theory to documentation – medical software
documentation to be precise.

Activity Theory Properties and Hierarchical Structure

Kofod-Petersen and Cassens 2006 list some basic properties of
activity theory, they are:
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• “Hierarchical structure of activity: Activities are composed

of goal-directed actions. These actions are performed
consciously. Actions, however, consist of non-conscious
operations.”

• “Object-orientedness: Objective and socially or culturally

defined properties. Our way of doing work is grounded in a
praxis, which shared by our co-workers and determined by
tradition. The way artifact is used and the division of labor
influences the design."

• “Mediation: Human activity is mediated by tools and

language. The artifacts as such are not the object of our
activities, but appear as socio-cultural entities.”

• “Continuous Development: Both the tools used and the

activity itself are constantly reshaped.”

• “Distinction between internal and external activities.

Traditional cognitive psychology focuses on what is denoted
internal activities in Activity theory, but it is emphasized
that these mental processes cannot be properly understood
when separate from external activities, that is the
interaction with the outside world.”

Activity theory excels at examining and pulling apart the

complexities of an activity, especially the tensions among the
components of that activity. That might have implications for how
we write documentation, what we document, and what media,
style, and tone we choose. It also may lead toward packaging
complex decision making (e.g. forms, database fields), using
different technologies to deliver information (e.g. PDAs, tablets),
or thinking about how to deliver information where people need it
(e.g. telemedicine).

Kofod-Petersen and Cassens (2006) then explain the hierarchical

structure of activity, which has the following levels:

• Activity: “Composed of different actions that are related to

each other by belonging to the same activity.” For example,
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an individual activity could be traveling to a conference.

Individual activities can also be a part of collective
activities, such as attending a meeting with co-workers.

• Actions: Are composed of different operations that can be

defined as automatic tasks. For example, a person would
present a confirmation at the front desk upon checking in to
the hotel.

• Operations: Actions that are performed non-consciously,

such as writing your name on a sign in sheet, or taking out
your keys to start a car.

Marlin M. Cluts (2003) said that activities are influenced by

motives while actions are influenced by goals and operations by
conditions. This hierarchy becomes useful in analyzing people’s
behavior. What is interesting is that people become frustrated
depending on whether goals or motives change. Activity theory
allows for dynamic expansion and contradictions arise in the form
of problems, breakdowns, and misfits. The expanded model of
activity theory shows that humans do their work in a social and
cultural environment. This adds the community component and
mediators such as rules and the division of labor as depicted in
the chart below (Kofod-Petersen and Cassens 2006).
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What we should know about activity theory is that we should

study the whole system not just the artifacts. However, it is
important to recognize the three type of artifacts associated with
activity theory such as tools (mediate the relationship between
subject and object), rules (mediate the relationship between
subject and community), and division of labor (mediates the
relationship between community and object) (Cluts 2003). Let us
look at an example and see how all three artifacts play an
important role in software development. I will use my company as
an example. My company develops nursing software. We have
three programmers on our team. They can be labeled as subjects
in the development process. They form a community together
with the stakeholders or in our case the counties who use our
software. We also have a Training and Implementation team who
works with programmers by providing software documentation
and conducting training for the client. Therefore, we work
together in a division of labor as we have different duties and
responsibilities. The recently added billing feature that was
integrated into the software is considered the object. The
programmers agreed to follow a set of rules provided by upper
management to comply with the software standards. The rules
are to code the billing portion so that it is compatible with the
State regulations. Our developers are using tools (or mediating
artifacts) for design, programming tools such as Ruby on Rails (an
open source programming app), and documentation that I write
for the software.

Activity theory also includes changing contexts in breakdown

situations. Numerous times, I heard our programmer say that the
Ruby on Rails application stopped working and is generating
errors while in the middle of compiling the code. It is now a
priority to get the compiler working again in order to continue
programming the software. The programmer’s focus has been
shifted from development to troubleshooting of the compiler. Our
technical support team had to jump in and help troubleshoot the
issue, which then becomes a community activity, or a change in
the community. “The ability of activity theory to identify
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breakdown situations makes it possible for the system designer

to identify these possible shifts in situation and model the
anticipated behavior of the system” (Kofod-Petersen and Cassens
2006, 11).

How Activity Theory is Applied to Computer-based

System Design
Now that we have grasped the concept and looked at the
definition of activity theory, I would like to move on and look at
how activity theory is applied in computer-based system designs.
According to J.E. Bardram (2009), people organize and think of
their work in terms of activities that are carried out in pursuit of
some overall objective, often in collaboration with others. Once a
person moves away from desktop and into a non-office like
environment such as a hospital, it becomes challenging to
manage their activities because they are now multitasking which
is combined with mobility, collaboration, and urgency. Bardram
(2009) defines mobility as having clinicians moving constantly
between physical and social environments and using different
computational devices to perform their tasks. The clinicians are
using a shared PC instead of their own personal computers to
enter patient information. The term collaboration “refers to the
fact that clinicians need to remain aware of others’ work and be
able to coordinate and communicate easily with colleagues” (p.
10:2). Finally, urgency of clinical work “means that the overheads
involved in accessing medical information, including manual
reconfiguration due to interruptions, mobility, or collaboration,
must be kept to an absolute minimum, since delays may have a
direct impact on the well-being of a patient” (p. 10:2).

The clinician’s main objective is to collaborate and problem-solve

to achieve the overall objective and that is to provide the best
care and treatment for patients. After talking to a few registered
nurses (RNs), it’s apparent that they relate their work in terms of
specific work activities, each with a specific objective in mind.
This objective relates to the treatment of patients, but can also
relate to teaching and research. It is important to note that
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activity theory does not view an activity as tied to one specific

individual (Bardram 2009). Human activity is always collective
and oriented towards an objective that exists outside the
individual (Bardram 2009). Such collaboration is achieved by
distributing the actions within a given activity among different
actors (Bardram 2009).

There is a wide range of computer systems and applications that

support the activities of patient treatment. While these systems
offer support for various clinical work, clinicians still complain
about the lack of integration. The system may support a set of
particular tasks that are carried out by the staff, but it is difficult
to support them with the overall activities in treating their
patients. For this kind of integration to happen, the servers and
databases need to be incorporated using a middleware approach.
“The aim of activity-based computing is to help users manage the
complex set of actions, tools, materials, resources, and people
involved in an activity by introducing an explicit representation of
the activity into the computer system” (Bardram 2009, 10:8). The
author defines activity-based computing as “a computing
infrastructure, which supports users to create, save, manage,
suspend, resume, move, share, and discover computational
activities” (p. 10:10). He has identified five core principles for
activity-based computing:

• Activity-Centered Resource Aggregation: This simply means

that activity-based computing needs to support relevant
resources and services and all materials related to
treatment of patients. For example, accessing patient
electronic records, lab results, and medical images (e.g. x-
rays). “These services and resources may come from many
different sources but all are part of a single activity.”

• Activity Suspension and Resumption: Clinicians perform a

multitude of tasks and constantly switch from one activity
to another. In addition, because of the nature of their work,
they are constantly interrupted (e.g. someone calls them,
pages them). The clinicians are involved in more than one
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activity at a time and are responsible for different actions

within each of the activities. Once the activity is suspended,
its state is saved. Once the clinician resumes they are able
to resume their activity and pick up where they left off.

• Activity Roaming: This refers to transferring activities from

one computing environment such as a desktop PC or a
laptop to a Tablet PC or another hand-held device. This
allows the clinician to pause their activity on one device and
resume it on another. “The system must therefore be able
to automatically bring up all the applications and resources
associated with the activity, thereby relieving users from
manually restoring all the resources and views associated
with the on-going activity.”

• Activity Sharing: “An activity is seen as inherently shared

by a set of participants, who can resume and suspend the
activity—asynchronously as well as synchronously—and
work “inside it”.”

• Activity Awareness: “Denotes the principle that the

computer system maintains information about the users’
real-world activities. This awareness is used to give the user
easy access to appropriate resources and tools.”

Task Analysis in Computer-based System Design

When building new software, there are a few things that
designers must keep in mind. The first thing they need to do is
task analysis, that is, how they see the system would be used.
Let’s say that my company decided to create new nursing
software called XYZ1. There are a few criteria that designers
should consider (1) Potential uses of XYZ1 (2) Expected benefits
(3) User interface requirements of XYZ1, and (4) Data interface
requirements of XYZ1.

1. Potential uses of XYZ1: The programmers will need to first

come up with ways that the nurses and doctors will use the
application. Will the software allow them to input patient
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data? Will it store images such as x-rays, or will it help with

billing and coding?

2. Expected benefits of XYZ1: How will the clinicians benefit

from having this type of application? They will input patient
records into the computer instead of using paper, and will
be able to chart the information easily. This will prevent the
current method of paper-based records in getting lost or
being misread.

3. User interface requirements of XYZ1: What do the clinicians

expect to see in the interface of the software? Should the
software interface be similar to other programs such as
Microsoft Word, Internet Explorer, so that users are familiar
with the layout? Should the buttons be located at the top of
the screen or at the bottom?

4. Data interface requirement of XYZ1: They can look at

different ways to integrate email, or excel spreadsheets into
the software. Also, look at portability across different
operating systems and platforms.

Some of the questions that they would look at would be:

• Does XYZ1 facilitate the achievement of user goals?

• How well does XYZ1 fit into the present work environment
of the users?

• What training demands are made by XYZ1?

• How does XYZ1 affect development of an organization?

In order to achieve the best design, my company would need to

collaborate with clinicians and have their input and participation
in the design process. There was a case study done by Kyhlbäck
and Sutter 2004 on who is involved in the human-computer
interaction design. The case study was about the development of
a digital wound care documentation computer system. In the late
nineties, a few nurses attended a university distance course on
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wound care treatment. One of the nurses brought her experience

into the hospital and shared her knowledge with the rest of the
staff. Her colleagues were better-educated thanks to her
instruction. A result of the nurses’ work was the design of a three-
page wound documentation form. The form was soon adopted by
the municipal elder care. “Influenced by the successful work of
the hospital nurse, the municipal nurses adopted her specific
three-page paper form. At a low technology level the nurses
themselves design their own artifacts in choosing what have
proved to be useful for them” (Kyhlbäck and Sutter 2004). Over
time, rules on wound cleaning and treatment have changed
which in turn would change the artifacts in use. In 2003, several
municipal nurses participated in the design of a computer
system, “a process that resulted in a software prototype.” They
worked with a team of software designers and developers, and
together they designed a digital wound care documentation
system named Helar.

The software design has become much more than just a list of
functional specs, it has to be worked in a way where practitioners
and designers interact. “The cultural-historical activity theory
bridges the gap between the problem and the way to design an
appropriate computer/software solution. If the practitioners’
general design work is recognized, the artifacts in the present
domain will be utilized in the software process as an essential
resource for transforming initial ideas into a future product”
(Kyhlback and Sutter 2004, 78).

Can Activity theory Framework Be Applied to Medical

Software Documentation?
Perhaps the greatest research that was done on activity theory
and how it relates to the real world is how it’s being used for
computer-based system design. The articles that I found all deal
with bridging a gap between the application design and the user.
The main question that arises is can activity theory framework be
applied to documentation design? Should we include our users’
opinions when designing documentation?
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In the last year, I have spent a lot of time designing and crafting
software documentation for my company. Coming up with
document design is my favorite thing to do. Designing the format,
the colors, coming up with the best typography – the most
interesting for me. But of course I need to keep in mind the
usefulness of the document as well. The content needs to have
an easy flow, clear language, and no grammatical errors. When I
write, I think of the user. What would users click on first, what will
they click on next when performing a typical task at their job. For
Kenneth Burke as we read in class, rhetoric is all about
identification. My role as a technical communicator is to establish
a level of understanding with my audience. In Kari Kuutti’s article
on Framework for HCI Research, he quotes L.J. Bannon, who said
“computer users need to make some modifications to the system
in various ways, tailoring the system before it is truly usable. So
in very real sense users are designers as well” (29). So would
that be the same for software documentation? Wouldn’t a
technical communicator want the user to have a say in
documentation design and structure because essentially they will
be the ones using it? Kari Kuutti’s broad definition of activity
theory is that it’s “a philosophical and cross-disciplinary
framework for studying different forms of human practices as
development processes, with both individual and social levels
interlinked at the same time” (25).

So let’s take a nurse for example, who works at a medical facility.

She is using the software that my company designed and her
main activity is to run reports in the system. Reports are
somewhat of a new feature in our software so the nurse might
not have had a chance to use it yet. In this activity of running
reports, the artifact is the user guide that I created called
Creating Reports. The documentation in this example has a
mediating role. “Relations between elements of an activity are
not direct by mediated” (Kuutti 1996, 26). The user guide
document that I created was the first version of documentation
that could be used by printing out a hard copy, or on the screen
as online help. Thus, this artifact I call a user guide has been
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transformed during development of the activity. If the nurse were

to move on to her next task, which is to use a user guide for
entering patient’s billing information into our application, her
activity would change, and we would say that she is entering
billing information now because “activities are distinguished from
each other according to their objects. Transforming the object
into an outcome motivates the existence of an activity” (Kuutti,
1996, 27). For the nurse to become more skilled in running
reports or entering billing information, operations must be
developed so that her actions of performing these tasks become
more fluid. At first, the nurse will use the documentation to follow
a step-by-step procedure of executing her task of running reports
for example, but after a while, this conscious action transforms
into an operation. She will no longer need to plan her actions, her
actions will become automatic. As the nurse continues to run
reports in the system, she will start to come up with her own
ways of doing it. She will find a way to do shortcuts, or figure out
an easier way to change the fields to be included on the reports.
She might also find a way to not only run the reports but to
export them and archive them on the computer – a new
operation is formed as the nurse’s skills increase. It is important
to remember that activities are always changing and developing.

As Kari Kutti said, “because activities are not isolated units but
are more like nodes in crossing hierarchies and networks, they
are influenced by other activities and other changes in their
environment” (34). Meaning, external influences change the
activity causing an imbalance called contradictions. This is where
the elements of the activity is broken down, or problem and
misfits arise. Even though that might have a negative
connotation to it, it is actually not a bad thing. This allows for
further development, in our case making our software
documentation better for the clinicians. When the online help for
our nursing application was not enough, my team decided to
create user guides in addition to the online help. When nurses
were unable to print step-by-step instructions using the
embedded online help, they were aggravated. So my team
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decided that it was time to give the clinicians additional

resources and thus the user guides were created.

A lot of research articles concentrate on explaining how to use

activity theory framework to create computer-based system
designs. What I would like to see is how the same framework can
be used for documentation design, specifically for medical
software documentation. We can think of activity theory as a way
of getting a system-level view of an activity so that we can map
out the points at which information is blocked – and specifically
the innovations people have put together to get the information
unblocked. Once we map out the system, we can begin to design
the best interventions – in our case, the best documentation,
delivered to the right people in the right form at the right time.

Marlin M. Cluts (2003) lists a few research questions that apply

towards the use and evolution of artifacts in the design of
computer systems. But how about using the same questions for
documentation design? Some of the questions we might ask
would be:

1. How are artifacts shared? – How will the nurses use our
documentation to perform tasks, and how will they share
them with other nurses and doctors who are in their medical
community.

2. How is the perceived use or credibility of artifacts

determined? – What makes the clinicians trust that our
documentation is accurate? Do they trust it because they
see others using it?

3. How are the relationships among workers affected by the

use of the artifacts? – Are nurses/doctors reluctant to ask
their co-workers questions even though they are following
our documentation, or do they share their concerns with
their team?

So the next question arises, is there set of methods that we can

use to apply activity theory to create a research study for
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medical documentation design? In his book Tracing genres

through organizations: a sociocultural approach to information
design Clay Spinuzzi talks about “fieldwork-to-
formalization”method. Which include examples of contextual
design, application design, client-led design, and user-centered
information design. The “fieldwork-to-formalization methods are
meant to guide system design through the stages of gathering
data from customers, modeling and interpreting that information,
and designing and implementing system based on that
information” (Spinuzzi 2003, 11). These are the methods that
Spinuzzi talks about in his book.

• Gathering Field Data – this is where a facilitator would visit

the site and talk with individual workers or a group, looking
for the type of artifacts used at the location, and obsering
people work (informally). In my case, I would visit a state
county (or an agency as we call them at my job) to speak
with the registered nurses on staff and ask them what their
business objectives are, do they want to be more
productive, do they want to improve customer satisfaction,
etc. I would also look for any distractions or problems that
might potentially disrupt their work flow.

• Building Formalizations – “After the fieldwork comes the

formalizations—the models, categorical descriptions, and
sequential descriptions—that can be used to communicate
findings to software developers and to describe and design
future system” (Spinuzzi 2003, 17). Our goal is to
concentrate on the specific aspects of the work the nurses
perform that can potentially affect the documentation
redesign. We want an overall summary of the
formalizations so that we can find a pattern on the issues of
the work structure.

“Certainly these methods sometimes entail examining user

innovations, collecting feedback, and even collaborating with
users to redesign artifacts. But in the end, the goal is to
transform a messy set of ad hoc, unofficial solutions into a single,
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neat, coherent, officlal—and—static generalized solutions”

(Spinuzzi 2003, 22).

Another concept that Spinuzzi introduced in the book is genre

tracing. Genre tracing “provides a way to highlight users’
experiences with official and unofficial genres and to compare
them across communities or workplaces” (Spinuzzi 2003, 22).
Through genre tracing, we examine how people inteact with
communities and solve problems. Genre tracing examines how
workers figure out a way to workaround an issue themselves by
developing unofficial genres and innovations. Genre tracing is
time-consuming just as ethnographic research,
ehtnomethodological research, and fieldwork-to-formalization
methods can be. Thus, it’s recommended to use genre tracing in
either a major design or a redesign of a project. Genre tracing
involves three levels of scope: (1) the macroscopic level of
activity also called a “contextual” layer, that show the big picture
and investigates the meaning of the activity, (2) the mesoscopic
level of action “is that of goal-directed action—the tasks in which
people are consciously egaged” (33), in other words it’s how
individuals perform routine tasks with specific tools, and (3) the
microscopic level of operation or moment by moment operations
that respond to conditions. Spinuzzi says that often information
designers focus on one of the levels while ignoring the other two.

“Genre tracing attempts to integrate levels of scope by tracing a

sociocultural unit of analysis—genre—across the three levels”
(Spinuzzi 2003, 51). Spinuzzi lists the following data collection
and data analysis methods.

• Data collection – the data collection is approached through

an integrated-scope examination of genres. It’s a way of
searching for destabilization at each level of activity and
seeing how it affects other levels.

• Macroscopic Data Collection – involves collecting data to

show the big picture.
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• Mesoscopic Data Collection – looks at how users’ actions

help accomplish bigger activities. The goal-directed actions
are usually executed within minutes or hours.

At the end of the book, Spinuzzi talks about and gives examples
of "open systems" approach to information design. "The point is
not to rescue workers with a better designed system," as some
practitioners of user-centered design would emphasize, "but to
provide a base for workers to build on" (204). Open systems allow
workers to “modify, extend, and customize a centrally designed
core in ways they deem important; their innovations become
important parts of the system" (211). “Spinuzzi implies that
technical communicators need to see how various forms of
information fit within a
sphere of activity, and observes that we should carefully examine
how genres—however they are identified or defined—affect each
other and are shaped by human activity” (Willerton 2004, 559).
 Page 18 of 21

Conclusion
In activity theory, it is important to theorize reflection,
imagination, and intention as the center of human cognitive
processes; whether we use the activity theory framework to
design a top of the line computer program or create software
manuals and user guides. Activity theory helps us better
understand how people act with technology. They are able to
commit certain acts with certain technologies, whether it is email
to communicate with their families or an iPod for listening to
music. Activity theory lets us distinguish between things and
people, which allow us to further discuss human intentions. When
we write documentation, we need to know who will use it, and if it
will be used in conjunction with other resources be it another tool
or a person. One of the things in Plato’s theory that we should
think about is his emphasis on knowing the person to whom you
are speaking and the approach that will work to convey truth to
that individual. This fits well with documentation design, you
have to know who your audience is, and if possible get your users
involved in the process of documentation design. Ultimately, they
are the ones who will use your documentation. The most difficult
part for technical communicators is figuring out what our
audience/users needs to know or do. In my example, the nurse
needs to know how to print reports and add patient information
into the system. We also need to enable the users (or in our case
nurses) to do so, usually in a mediated fashion by including
motivation, knowledge, and the need to accomplish a task,
whether a simple or a complex one.
 Page 19 of 21

REFERENCES

Bannon, L.J. Activity theory. 1997.

http://www.irit.fr/ACTIVITES/GRIC/cotcos/pjs/TheoreticalApproaches/Act
vity/ActivitypaperBannon.htm (accessed 4 20, 2010).

Bardram, Jakob E. "Activity-based computing for medical work in

hospitals." ACM Transactions on Computer-Human Interaction (TOCHI)
(ACM) 16, no. 2 (2009).

Cluts, Marlin M. "The evolution of artifacts in cooperative work:

constructing meaning through activity." Proceedings of the 2003
international ACM SIGGROUP conference on Supporting group work.
Sanibel Island: ACM, 2003. 144-152.

Fjeld, Morten, Martin Morf, and Helmut Krueger. 2004. "Activity theory
and the practice of design: evaluation of a collaborative tangible user
interface." International Journal of Human Resource Development &
Management 4, no. 1: 94-116.

Freitas, Maria Rosali de, and Byrne Elaine. "Activity theory as an

analytical tool: a case study of IS development for an anti-retroviral
treatment clinic in South Africa." Proceedings of the 2006 annual
research conference of the South African institute of computer
scientists and information technologists on IT research in developing
countries. Somerset West: South African Institute for Computer
Scientists and Information Technologists, 2006. 90-99.

Kaptelinin, Victor, and Bonnie A Nardi. "Activity theory: basic concepts

and applications." Conference on Human Factors in Computing
Systems . Atlanta: ACM, 1997. 158-159.

Kofod-Petersen, Anders, and Jorg Cassens. "Using activity theory to

model context awareness." Computer Science (Springer) 3946 (2006):
1-17.

Kuutti, Kari, and Tuula Arvonen. "Identifying potential CSCW

applications by means of activity theory concepts: a case example."
 Page 20 of 21

Proceedings of the 1992 ACM conference on Computer-supported

cooperative work. Toronto: ACM, 1992. 233-240.

Kuutti, Kari. “Activity theory as a Potential Framework for Human-

Computer Interaction Research.” Context and Consciousness: Activity
theory and Human-Computer Interaction, 1996. 17-44.

Kyhlbäck, Hans, and Berthel Sutter. "Who is involved in HCI design?: an

activity theoretical perspective." Proceedings of the third Nordic
conference on Human-computer interaction . Tampere: ACM, 2004. 71-
79.

Miller, Carolyn R. "BOOK REVIEW: Tracing Genres Through

Organizations: A Sociocultural Approach to Information Clay Spinuzzi.
Cambridge, MA: MIT Press, 2003. 246 pp." Technical Communication
Quarterly 16, no. 4: 476-480.

Mirel, Barbara. "General hospital: modeling complex problem solving in

complex work system." Proceedings of the 21st annual international
conference on Documentation . San Francisco: ACM, 2003. 60-67.

Spinuzzi, Clay. "Grappling with distributed usability: a cultural-historical

examination of documentation genres over four decades." Proceedings
of the 17th annual international conference on Computer
documentation . New Orleans: ACM, 1999. 16-21.

Spinuzzi, Clay. Tracing genres through organizations : a sociocultural

approach to information design. Cambridge: MIT Press, 2003.

Tuikka, Tuomo. "Remote concept design from an activity theory

perspective." Proceedings of the 2002 ACM conference on Computer
supported cooperative work. Louisiana: ACM, 2002. 186 - 195.

Turner, Phil, Susan Turner, and Julie Horton. "From description to

requirements: an activity theoretic perspective." Proceedings of the
international ACM SIGGROUP conference on Supporting grou (Willerton
n.d.)p work . Phoenix: ACM, 1999. 286-295.

Willerton, Russell. "Tracing Genres Through Organizations: A

Sociocultural Approach to Information Design." Technical
Communications 51, no. 4: 558-559.
Page 21 of 21