acting in anaesthesia (lb. englezĂ).pdf

Acting in Anaesthesia: Ethnographic Encounters withPatients, Practitioners and Medical Technologies

In recent years, evidence-based medicine (EBM), clinical governance

and professional accountability have become increasingly significant

in shaping the organization and delivery of health care. However,

these notions all build upon and exemplify the idea of human-

centred, individual action. In this book, Dawn Goodwin suggests

that such models of practice exaggerate the extent to which

practitioners are able to predict and control the circumstances and

contingencies of health care. Drawing on ethnographic material,

Goodwin explores the way that action unfolds in a series of

empirical cases of anaesthetic and intensive care practice. Anaesthesia

configures a relationship between humans, machines and devices that

transforms and redistributes capacities for action and thereby

challenges the figure of a rational, intentional acting individual.

This book elucidates the ways in which various entities (machines,

tools, devices and unconscious patients, as well as health care

practitioners) participate, and how actions become legitimate and

accountable.

Dawn Goodwin is a social science lecturer in medical education and

director of problem-based learning. She teaches courses on various

aspects of science, technology andmedicine to bothmedical and social

science students. Her current research interests focus on the

development of embodied knowledge, its place in clinical practice,

and the processes of learning involved. Her doctoral and postdoctoral

research centred on the notions of participation and accountability in

health care practice. Along with colleagues Dr Buscher and

Dr Mesman, Dawn Goodwin is currently editing a book of

ethnographic studies of diagnostic work drawn from a range of

disciplines.

Acting in Anaesthesia

Ethnographic Encounters with Patients,

Practitioners and Medical Technologies

DAWN GOODWIN

Lancaster University

Contents

Series Foreword page ixAcknowledgements xi

1 Understanding Anaesthesia: Theory and Practice 1

2 Refashioning Bodies, Reshaping Agency 33

3 Accounting for Incoherent Bodies 61

4 Teamwork, Participation and Boundaries 105

5 Embodied Knowledge: Coordinating Spaces, Bodiesand Tools 139

6 Recognising Agency, Legitimating Participationand Acting Accountably in Anaesthesia 167

References 177Index 185

vii

Series Foreword

This series for Cambridge University Press is widely known as

an international forum for studies of situated learning and

cognition.

Innovative contributions are being made by anthropology; by

cognitive, developmental, and cultural psychology; by computer

science; by education; and by social theory. These contributions

are providing the basis for new ways of understanding the social,

historical, and contextual nature of learning, thinking, and

practice that emerges from human activity. The empirical

settings of these research inquiries range from the classroom

to the workplace, to the high-technology office, and to learning

in the streets and in other communities of practice. The situated

nature of learning and remembering through activity is a central

fact. It may appear obvious that human minds develop in social

situations and extend their sphere of activity and communicative

competencies. But cognitive theories of knowledge representa-

tion and learning alone have not provided sufficient insight into

these relationships.

This series was born of the conviction that new and exciting

interdisciplinary syntheses are underway as scholars and

practitioners from diverse fields seek to develop theory and

empirical investigations adequate for characterizing the com-

plex relations of social and mental life, and for understanding

ix

successful learning wherever it occurs. The series invites

contributions that advance our understanding of these seminal

issues.

Roy Pea

Christian Heath

Lucy Suchman

x Series Foreword

Acknowledgements

I would like to express my sincere thanks to all the people who

have both made this book possible and helped me through it: to

all the participants patients and staff of the expertise project;

to the NHS North West R&D Fund (grant number RDO/28/3/

05) for funding the expertise project and for contributing

towards the finance of my doctoral studies; to the ESRC/MRC

for funding my postdoctoral work (grant number PTA-037-27-

0050). I also owe a debt of gratitude to Andrew Smith for having

such confidence in me; to Catherine Pope for her unfailing

encouragement and guidance and most especially to Maggie

Mort, who is responsible for initiating my interest in STS, whose

enthusiastic and critical commentary helped to shape this work,

and whose kindness, understanding and friendship have

extended beyond the realms of a supervisor. This work has

also benefited from being presented to and discussed with the

Lancaster STS community. In particular, I would like to thank

Lucy Suchman and Maureen McNeil for being such sources of

inspiration and without whose encouragement and critical

insight this work would be far poorer.

xi

Acting in Anaesthesia: Ethnographic Encounters withPatients, Practitioners and Medical Technologies

1 Understanding Anaesthesia: Theory

and Practice

After changing into my theatre blues I walk down the corridor

and check the work allocation Theatre 1, General Surgery.

I begin by checking the anaesthetic machines, both in the anaes-

thetic room and in theatre. I turn the gases on and disconnect the

pipeline supply the alarms sound. Turn on the cylinders to check

the back-up supply turn them off and reconnect the pipelines.

Next, the breathing circuit and ventilator: Any leaks? Leave it

functioning but disconnected and wait for the low-pressure alarm,

occlude the end and listen for the high-pressure alarm. Check the

suction clean, connected and working? Finally, top up the vol-

atile agents. This work is quiet, constant and regular; there is no

need to talk, the familiar routine is comforting first thing in the

morning, and the solid and tangible machines are a reassuring

presence.

These are some of the general checks. I then need to think about

the specifics: Which surgeon, which anaesthetist and what proce-

dures are on the operating list? Mindful of their preferences,

I begin to set up for the first case. Patients are always talked about

like this in operating theatres, as cases or procedures such as a

mastectomy or a hip replacement. It might also be depersona-

lising, but for me, its utility is as a specific way to think about the

mornings workload, to anticipate the likely requirements of the

morning. First on the list is a right hemicolectomy; an ET tube

will be needed to secure the patients airway, size 8.5 for a male, a

1

size 5 face mask, a size 14 or 16 naso-gastric tube, intravenous

cannula a large grey one, 16 gauge, intravenous fluids and a fluid

warmer, the warming blanket to go over the patients upper half

during surgery, flowtron leggings to prevent deep vein thromboses

and a diathermy plate to earth the electrical current used to cau-

terise bleeding vessels. Provided that the anaesthetist doesnt want

to do anything fancy, he or she will require a combination of

drugs: an induction agent, propofol is now almost ubiquitous, but

it could be thiopentone if the anaesthetist is conscious of the drug

budget; a muscle relaxant, usually atracurium; opiate analgesics,

probably fentanyl and morphine; may be a sedative, a little mid-

azolam; and some intravenous antibiotics. If the anticipated sur-

gery is going to be quite extensive, they may also want to do an

epidural; I get the kit together just in case.

The anaesthetic room is over-run with a kit such as this

drugs, syringes, needles, cannulae, tubes and connective devices,

all in five or six different sizes. Working as a nurse in anaesthetics,

you develop an affinity for these devices. There is something sat-

isfying about being able to lay your hand on just the right device

for almost every eventuality, and at being adept at assembling the

intricate constructions required for invasive monitoring, for

example. You develop personal routines, the efficiency of which

rely on having the relevant item strategically placed for use.

Working so closely with the anaesthetists is interesting; it is

fascinating to learn about management of an unconscious patient

both holistically and in terms of the articulated systems of the

body: for example, learning how to take care of a patients airways

and respiratory system, understanding the precise combination

and volume of gases the respiratory system needs at a given point

during anaesthesia and how to provide for this, appreciating the

concatenated effects this has on the rest of the body, and fol-

lowing how control for this system passes back and forth between

the patient, anaesthetic machine and anaesthetist. Engaging in

2 Acting in Anaesthesia

these dynamics in knowing, doing, acting and intervening can be

totally absorbing.

It is intriguing how so much can be gleaned from a reading

and a trace on the monitor. As a patient exhales, he or she will

expire carbon dioxide; therefore, when controlling a persons

respiratory system measuring the carbon dioxide levels becomes

crucial. First of all, do you have a reading? If the monitor is

connected and is functioning correctly and there isnt a carbon

dioxide reading, then either the patient isnt breathing or the

breathing tube (the endotracheal tube) is in the wrong place the

oesophagus rather than the trachea. Then there is the reading to

consider: the normal range of measurements, for an adult, is

between 4.5 and 6. For measurements outside this range, it is

possible to read into those figures an array of potential meanings;

for example, is the patient being underventilated (in which case

the respiratory rate and volume of gases supplied is insufficient to

adequately ventilate the patient)? Is the patient developing sep-

ticaemia? The increased metabolic rate which results from the

patient becoming overwhelmed by an infection means that an

elevated level of carbon dioxide is produced. Or is the reading

significant in indicating malignant hyperthermia (a rare inherited

metabolic disorder triggered by anaesthetics)? Again, in this, the

excessive level of carbon dioxide relates to an increased metabolic

rate. Further interpretations can be garnered from the shape of

the trace. As the patient exhales, the measurements are displayed

on the monitor in the form of a line graph. If the line rises only

gradually as the patient exhales, one possible interpretation is

that the patient has chronic lung disease, the gradual climb of

the carbon dioxide reading corresponding to the rigid non-

compliant cells irregular release of carbon dioxide. In this sense,

physical manifestations of an individuals life testify to the spec-

ificity of unconscious bodies. The persons habits, preferences,

perhaps even occupational history connect an unconscious body,

Understanding Anaesthesia 3

here and now in the operating theatre, to a life and history

elsewhere.

Patients play a curious role in the operating theatres; they arrive

as relatively independent individuals, and I meet the person briefly

before he or she is anaesthetised. Patients are then rapidly trans-

formed, connected to electronic monitoring, attached to drips and

infusions and rendered unconscious, and responsibility for this

vulnerable body is redistributed amongst doctors, nurses, techni-

cians, auxiliaries, computerised technology and mundane artefacts.

Once anaesthetised, however, patients do not become passive and

homogeneous; they continue to exert their particularity in their

bodily condition and the interventions he or she requires. A simple

example of this is how an extremely nervous patient may require

significantly more anaesthetic to induce unconsciousness; more

complex examples come in the form of lengthy and intricate

medical histories of chronic disease inmultiple systems, requiring a

vast range of adjuncts and specifications to routine care.

Following surgery, patients gradually reclaim their indepen-

dence on a piecemeal basis, first breathing, then consciousness,

speech and so on; this process may continue long after the patient

has been discharged from hospital. As a nurse in Recovery, one can

witness this initial re-emergence of the person. For me, working in

Recovery also has the advantage of greater autonomy, by working

closely with the anaesthetists but not under their direct supervi-

sion. The patient is in a state of intense transition, reclaiming their

ability to breathe unaided, regaining their protective reflexes,

moving quickly from unconsciousness to consciousness, having

been cardiovascularly destabilised by surgery and their awareness

of pain changing rapidly with their level of consciousness. This

short period of instability requires concentrated nursing support:

the Recovery nurse must ensure that the patients blood loss has

been controlled and compensated for, their level of consciousness

is adequate and not overly affected by the sedative effects of


pain-relieving drugs and indeed that the measures taken for pain

relief are adequate. Then there are the specific complications

related to every surgical procedure for which the recovery nurse

must be aware and vigilant; vascular surgery, for example, carries

an elevated risk of dislodging a fat embolism and incurring a

stroke. However, by taking primary responsibility for a patient in

this brief period of time, the nurse is in a position to specify the

interventions required an ability denied to the anaesthetic nurse

because the anaesthetist is virtually always present and assumes

principal responsibility. So in Recovery I can act, I can say this

patient requires more pain relief, I can obtain a prescription and

administer it, if I think the prescribed drug inappropriate I can

request a different one. In anaesthesia, the anaesthetist decides and

administers I can only assist and suggest, but this rarely causes a

problem.

I find it interesting how the distribution of roles and

responsibilities has developed in theatres; how the boundaries of

ones practice are formed, maintained, challenged, extended and

yet remain both relatively constant and always susceptible to

change. How is it that the anaesthetic nurse, in addition to

assisting the anaesthetist, also takes responsibility for the dia-

thermy, operating table attachments, the operating lights, pressure-

relieving devices, warming aids and additional surgical devices

such as insufflators, cameras and screens used during laparo-

scopic surgery? At least in the hospital where I worked, scrub

nurses relinquished all claim to these duties. Instead, in addition

to their core duty of preparing and accounting for the surgical

instruments, they complete the operating theatre register, coor-

dinate the pace of the operating list by sending for the patients

and undertake the majority of the theatre cleaning. Sometimes

these roles overlap, and there is certainly scope for much greater

fluidity here, yet these role divisions, whilst they rarely receive

explicit attention, seem curiously constant.


My work as an anaesthetic and recovery nurse left me won-

dering about the relationships between these elements I mention:

the patients, the anaesthetic machines and the monitoring, the kit

and equipment, the team of practitioners and the ways in which

work is distributed amongst them. How do these elements inter-

sect with knowledge and with action? How is knowledge gener-

ated, by whom and how does this shape actions? And, conversely,

what are the limits, the restrictions, those factors that inhibit

knowledge production and action? How do these questions relate

to such descriptions of practice contained with the prescriptions of

evidence-based medicine (EBM)?

An opportunity to pursue and develop these questions came in

the form of an invitation to join a team of researchers concerned

with understanding the learning processes involved in an anaes-

thetists development of expertise.1 Briefly, the motivation for the

research project stemmed from the increasing emphasis, in the

training of anaesthetists, on formalised learning on tutorials,

the recall of theories and techniques of anaesthesia and on the

demonstration of observable and measurable competencies.

This emphasis, however, served to undermine the value of the

traditional apprenticeship form of learning. How exactly

learning in practice learning in doing contributed to the

development of anaesthetic expertise remained unarticulated,

and its significance continued to be implicitly and practically

diminished by policy changes that reduced junior doctors

working hours and the service-delivery elements of their work.2

1 The research project was entitled The problem of expertise in anaesthesia. It wasfinanced by the NHS North West R & D Fund (project grant number RDO/28/3/05). My colleagues in this project were Dr Andrew Smith, a consultant anaesthetist,Dr Maggie Mort and Dr Catherine Pope, both social scientists.

2 The New Deal for Junior Doctors restricted the amount of time trainees spent inhospital, therefore reducing both the training and the service delivery elements oftheir work (Simpson, 2004). The implementation of the European Working TimeDirective, which introduced a 58-hour working week for all hospital employees inAugust 2004 (http://www.dh.gov.uk, 2004), further reduced the working hours of


Fieldwork Identities and Local Knowledge

The study adopted an ethnographic approach grounded in

detailed real-time observation along with a series of in-depth

interviews. The emphasis of the observation was to capture the

details, particularities and demands of anaesthetic work that tend

to be missed in textbook accounts of anaesthesia for example,

the ways in which anaesthetists develop personal routines and

practices, and their particular ways of performing a certain

technique. The interviews were similarly focussed on practice

sometimes being quite general and exploratory in nature, and

sometimes being focussed on a recent period of practice or a

specific critical incident. With a remit to observe anaesthetic

practice in its various forms and environments, and to discuss the

processes by which anaesthetists have developed their styles, it

was my responsibility to organise and engage in the fieldwork.

The first hurdle was to secure access to the clinical environ-

ment primarily, the operating theatres. Formal approaches were

made to the Department of Anaesthesia, the hospital ethics com-

mittee and the theatre management and staff. These formal access

negotiations were eased significantly by Dr Smith, a consultant

anaesthetist and member of both the department of anaesthesia

and the research team. The anaesthetists we approached were

unaccustomed to, and sceptical of, the research methods we pro-

posed. Therefore, having a consultant anaesthetist initiate and

support both the aims and methods of the research assuaged some

fears and countered some scepticism.

However, in spite of having attained departmental and hos-

pital clearance, there was also a more subtle, ongoing process of

junior doctors. In addition, the structure of anaesthetic training programmes movedaway from the traditional apprenticeship-style training that incorporates a servicedelivery element (Ellis, 1995), and became focussed around observable and mea-surable competencies (Royal College of Anaesthetists, 2000).


negotiating access, on an individual level. Each time I observed in

the clinical areas, I had to secure the consent of the individuals

concerned. I began with those anaesthetists who looked favour-

ably on the project and who were enthusiastic to share their

knowledge and expertise. These tended to be practitioners with

whom I had enjoyed working as a nurse, with whom I had an easy

rapport, and who were less likely to be concerned by my pres-

ence. After a while I began to receive invitations to observe from

some anaesthetists who were initially less forthcoming. By this

time, the novelty of the project had worn off slightly and the

suspected ominous presence of the observer in the anaesthetic

room had never materialised, tempered by my familiarity with the

environment. It seemed almost as though these anaesthetists

were a little affronted they hadnt attracted my research attention

through which the banal and ordinary activities of the working

day are transformed into the mysterious and correspondingly

interesting (Suchman, 2000a: 2).

The clinical side of anaesthesia, that is, life in the operating

theatres, was familiar to me; it was my territory. I had a natives

knowledge of the environment; I could move about the hospital

and its departments relatively unquestioned, unchallenged in my

right to be there. What was unfamiliar to me, hidden from view,

was the work required of anaesthetists once the operating lists

were finished and they left the theatre department. To demystify

this aspect of anaesthesia, I negotiated office space in the depart-

ment of anaesthesia to use as my working base. Office space in the

department was enormously beneficial in that I could observe how

the department of anaesthesia functioned as a body within the

hospital, and how individuals managers, consultants, secretaries,

clinical nurse specialists, anaesthetic trainees functioned within

this. I was able to follow how managerial, bureaucratic and

organisational decisions were made, inscribed into documents and

presented to the department, and also the clinical ramifications of


these decisions. I was able to observe how the department orga-

nises, maintains and polices itself, and how personal narratives of

clinical practice were brought back to the department, discussed

informally, infused with theories, contrasted with anecdotes and

solidified into learning experiences.

Therefore, all these issues shaped the boundaries of my

empirical field: the growth of the project from concerns about

the training of anaesthetists, the relative ease of access, my

familiarity with the operating theatres and the strangeness of the

anaesthetic department. These early influences and factors gave

the study certain characteristics, which I did not wholly

appreciate at the time, characteristics that in some ways are

contrary to my personal understanding of anaesthetic practice.

By locating myself in the anaesthetic department, my focus was

both broadened and narrowed. It was broadened in that I became

aware of how the practice of anaesthesia was not solely a clinical

endeavour; I was introduced to the professional, political,

bureaucratic and educational duties that also constitute the work

of anaesthesia. It was narrowed in that my focus centred on

anaesthesia as the work of anaesthetists. This is somewhat at

odds with my experience of anaesthesia as something that is

produced in practice by an array of actors such as nurses, oper-

ating department practitioners, medical devices and technologies

and local routines, and includes but is not reducible to the

activities of anaesthetists.

My identity and its legacy, therefore, brought some very

particular qualities to the research, and as Peshkin (1985)

observes, these qualities will be simultaneously enabling and

disabling, opening some research possibilities whilst closing

others. One such aspect is my local knowledge of the setting. The

merits of this are uncertain and have a long history of debate

within methodological literatures. As Garfinkel (1972) points

out, for background expectancies to become visible, one must


either be a stranger to the life as usual character of everyday

scenes or become estranged from them. Potentially, then, my

familiarity with anaesthetic practice may blind me to the signif-

icance of members knowledge. Given that one of the interests of

the team project was the development of tacit knowledge, this

served as a useful heuristic for thinking about my own. When

typing up and elaborating upon my field notes, therefore, I was

conscious to include detailed descriptions of the physical settings

(even though the layout of the anaesthetic rooms and what each

cupboard contained was as familiar to me as my kitchen cup-

boards at home), and although I would use the nomenclature of

anaesthesia in my field note transcripts, I was mindful to add a

translation, and where I added my own interpretation of an event

I would take care to explain what had informed my interpreta-

tion. There was also a practical need for this level of specificity in

the transcripts, in that they were to be shared amongst the

research team, two members of which were social scientists. In

addition to the attention granted to making my local knowledge

visible, we also conducted seven joint observation sessions, in

which I was accompanied by one of the two social scientists.

Perhaps, not surprisingly, these accounts were different, but only

insofar as the level of detail I was able to incorporate. Hess (2001:

239) sees this level of near-native competence as a marker of

good ethnography:

the standard of near-native competence means that good ethno-graphers are able to understand the content and language of the field its terminology, theories, findings, methods, and controversies andthey are able to analyse the content competently with respect to socialrelations, power structures, cultural meanings and history of the field.

This criteria laid out by Hess placed me at an advantage, and in

terms of writing field notes and asking questions, I certainly

found my familiarity with the abbreviations, terminology,

abundance of conditions, drugs and technological devices a


useful resource. During the fieldwork, then, I sought to utilise

and advance my knowledge of anaesthesia, and stepping out of

my role as a nurse, being relieved of the need to act as a nurse,

afforded the opportunity to note and examine that which is taken

for granted.

Watching Anaesthetic Work

Guided by the expertise study design, the clinical observation was

organised around the aim of appreciating the variation encom-

passed in anaesthetic work and exploring how experience of these

different settings informs an anaesthetists development. I

observed anaesthetic practice approximately once a week over a

12-month period, joining a morning or afternoon operating list,

evening or weekend on-call period. This observation covered each

of the surgical specialties, particularly those that necessitate spe-

cific anaesthetic techniques, and the various environments in

which anaesthesia is practiced, in order to gain insights into how

different theatre layouts and equipment might affect the practice

of anaesthesia. I also chose operating lists to which a combination

of anaesthetists were assigned, such as a lone consultant, a con-

sultant and trainee, experienced trainee and novice anaesthetist, a

lone trainee. This not only captured some of the variation of

anaesthetic practice but also rendered visible some of the differ-

ences between anaesthetists at varying stages of experience. The

sessions with two anaesthetists were particularly illuminating, as

the need for anaesthetists to articulate their actions to a greater

degree resulted in their practice being more amenable to scrutiny.

In these observation periods I took running field notes; my

mandate was to record as much detail as possible, not only of what

was said but also of actions, features of the environment and the

role of anaesthetic technology. I attended to those taken-for-

granted practices, the body of assumptions and conventions on


which everyday anaesthetic practice proceeds. And, as I suggested

earlier, my knowledge of the setting in some ways facilitated this

process; in describing a scene, I could quickly focus on its signif-

icance for a practitioner, the object of a practitioners attention or

recognise an unusual or novel circumstance. And, in working from

the anaesthetic department when transcribing these field notes,

I was able to elaborate and clarify my understandings, discussing

issues with, for example, the anaesthetist at the next desk.

Supporting and informing this body of clinical field notes are

my notes of what I alluded to above as the non-clinical side of

anaesthesia. In using the anaesthetic department as my working

base, I was initiated into the busy informal networks of anaesthetic

learning, where difficult cases were talked about in an opportu-

nistic manner, over a sandwich at lunch, viva practice and tutorials

for the trainees were carried out, journal clubs took place, and

where the departmental meetings occurred in which policies are

discussed and anaesthetists are invited to share their recent criti-

cal experiences. Again, wherever possible, I would take overt field

notes, which for the examination and viva practice and the

departmental meetings was straightforward but it was more diffi-

cult for the opportunistic occasions. These unprompted, sponta-

neous conversations in which experiences and concerns were

shared with colleagues would occur unexpectedly around

me, often the significance of which I would only appreciate in

retrospect.

However, I realised that in noting these conversations my

fieldwork had inadvertently developed a duplicitous quality. I was

concerned about whether I might be abusing my position in the

department, exploiting the relationships I had established before

the research began. I was most concerned about this with my key

informants. These were the individuals I found it particularly

fruitful to talk to and question, although these relationships

stemmed from friendships and alliances I developed as a nurse.


Paradoxically, then, where rapport was at its best, and my identity

most enabling, was also the point at which it was most disabling.

Whilst this may be a familiar scenario when using observa-

tional methods (see, for example, Dingwall, 1980), it nevertheless

enhanced my awareness of the ethical implications of under-

taking research in a familiar environment with familiar people.

Hence, I was charged with practically resolving this issue in such

a way that allowed me to capitalise on the insights I gained

through working from the department but without this under-

current of duplicity. My response was to reiterate my identity as a

researcher regularly and to negotiate consent every time I for-

mally observed anaesthetists. Incidents and issues that came to

my attention informally I would try to follow up during the

formal data collection where the ambiguous status of the data,

whether on or off the record, was clarified. For example, over

lunch, a conversation developed between three consultant

anaesthetists in which they chatted about their opinions of the

clinical abilities of some new trainees the ones they knew would

be all right and the ones about whom they had concerns. When

I subsequently formally observed one of the consultant anaes-

thetists involved in this conversation, I brought up the subject of

trainee assessment and how he personally approached this topic.

Feeding the informal data through these formal channels both

enhanced the candour of the fieldwork and improved the quality

of the data.

In the paper Ethics and Ethnography: An Experiential

Account (Goodwin et al., 2003), I explore the ethical implica-

tions of my position in more depth. In discussing this and other

situations in which the ethics of observation concerned me,

I came to appreciate, first-hand, that although I might try to

alleviate the duplicitous quality of my fieldwork, I alone could not

control the situations I was included in and excluded from and

the information that participants revealed or withheld. The


participants also exert their agency and in doing so contribute to

the shape and character of the data.

Talking Common Sense

My remit to ascertain and elucidate the tacit aspects of practice,

what counts as common sense for anaesthetic practitioners

proved challenging to attain when it came to the interviews. The

difficulty was that my interest lay in the mundane routines of

everyday practices the things that people had become so

accomplished at that it no longer took a great deal of concerted

effort; how then to encourage people to articulate the deeply

embedded practices they no longer have to think about? I found

that the most successful approach was to anchor the discussion to

personal practice, how their practice developed, how it came to

look the way it does. I also asked respondents to take me through

their last clinical session and any problems or issues it raised, or

we might discuss a specific critical incident they had recently

experienced. Towards the end of my fieldwork, the opportunity

for a different kind of interview a debrief arose. I had been

observing in intensive care, following a routine ward round when,

in the process of modifying a patients treatment, the patients

condition deteriorated and became critical. After several hours of

intense work, the patients condition was stabilised. The anaes-

thetist suggested that he would find it valuable to look at a copy of

my observation transcript, as a form of self-assessment. I readily

agreed and proposed we debrief afterwards: to use the transcript

as a resource to guide reflection. The subsequent interview lasted

more than 2 hours and was replete with detail: the anaesthetist

was able to contribute features that I had missed or to which I did

not have access; for example, what he had seen down the bron-

choscope or the pressure he had felt when ventilating the patient.

He also talked of the interactions between the different members


of staff and the role that X-rays, ventilators and chest drains

played in this situation.

This technique has much to offer both analytically and meth-

odologically. In terms of the quality and depth of the primary

data the transcript of the field notes a debrief provides the

opportunity to compare accounts, to clarify misunderstandings, to

elaborate the description. It also presents an interesting analytical

position, a layering of researchers and participants experiences,

accounts and reflections. On this occasion, debriefing offered

benefits for both participant and researcher; however, this process

was extremely time-consuming for the practitioner. Despite the

potential of this technique, the demands it places on the practi-

tioner, coupled with the impending conclusion of the fieldwork,

meant that it was only possible to debrief, in this way, on one

further occasion.

Standardising Health Care Work and Accounting for Practice:Knowledges Made Visible and Invisible

This book utilises the fieldwork I undertook for the expertise

study, and whilst it draws on our collective theorising in the team

project, it is primarily a development of those personal curiosities

I acquired working as a nurse, presented in the opening account of

my work in anaesthesia. The point to note is that, being funded by

theNational Health Service (NHS), the team research project had,

at the end of 2 years, to produce policy-relevant findings and

recommendations that could feed into the debates around the

training of anaesthetists (see, for example, Smith et al., 2003a,

2003b, 2006a, 2006b; Pope et al., 2003), whereas this book pre-

sents a broader, and yet more personal, reworking of the learning

in doing topic.

My involvement in the expertise study taught me about how

knowledge changes in content and form as it passes from person


to person, gets embedded into personal and local routines, is

written into research papers or books, becomes incorporated in

the design of machines or devices or is formalised as a standard,

guideline or protocol. I came to understand how knowledge is

thoroughly embodied and situated in practices; a particular tech-

nique performed by one anaesthetist may yield entirely different

results as the same technique in the hands of another anaesthetist.

And I began to appreciate how knowledge and expertise can be

seen as an effect of a particular configuration of persons, routines,

environments, machines, tools and devices.

However, for me, questions remained around learning,

knowing and doing: Which participants act, in that they con-

tribute to shaping the trajectory of anaesthetic care? How do they

do so and how do they learn about doing so? How are these

actions recognised and rendered accountable? These are ques-

tions of increasing significance in the light of growing efforts in

the United Kingdom in recent years to regulate and standardise

medical practices. EBM, patient safety initiatives, clinical gov-

ernance and professional accountability have all become pro-

gressively more important in shaping the organisation and

delivery of health care around standardised practices. McDonald

and colleagues identify how the use of clinical guidelines aims to

reduce the opportunity for individuals to apply their own jud-

gements about what constitutes best and safe practice, thus

limiting the variability of clinical work and increasing overall

quality of care (McDonald et al., 2006). May et al. (2006) propose

that, collectively, EBM, clinical guidelines, protocols and

decision-making tools, along with new practices and technolo-

gies that distribute accountability beyond the clinical encounter,

bring into play a new form of governance. Technogovernance

refers to the way that informatics interventions discipline

and frame the individual subjectivities of both patient and

doctor (for example, as EBM divorces patient experience from


knowledge about the effectiveness of treatments) and have

embedded in them means of adjudicating and reporting on those

decisions to others. Such surveillance, May et al. argue, intro-

duces a much wider network of accountabilities.

As McDonald et al. point out, these movements in health care

all utilise the notion of standardisation as an inherent good, one

that limits the potential for error and results in safer practice.

Standards, it seems, are so ubiquitous that they frequently

become invisible (Bowker and Star, 2000). They are often

deployed in the aim of making things work together, frequently

need to be legally or professionally enforced and, once estab-

lished, have an inertia that renders them exceedingly resistant to

change (Bowker and Star, 2000). Indeed, standards are pervasive

in health care; from the size of the connections that enable

syringes to be attached to intravenous cannulae, to the dosages of

drug administration, to the policies and guidelines that set out

the practices of health care practitioners, standards coordinate,

orchestrate and regulate the practice of health care. Bowker and

Star (2000) point out that in forming boundaries around objects

and activities, standards impose a classification system and

furthermore, that:

Classifications are powerful technologies. Embedded in workinginfrastructures, they become relatively invisible without losing any ofthat power. Classifications should be recognized as the significant siteof political and ethical work that they are. (Bowker and Star, 2000: 147)

EBM is emblematic of such a standardising logic: it is the

principle that the selection of health care interventions be based

on research findings that testify as to their effectiveness; a prin-

ciple that is now endorsed in NHS policy (Harrison, 1998). It

builds on a classification system known as a hierarchy of evi-

dence that ranks evidence according to the reliability and validity

of the study design, from randomised controlled trials at the top to

expert opinion and case studies at the bottom (Lambert, 2006).


The political and ethical dimensions of this classification system

relate to the evidence it valorises and that which it renders invis-

ible, and accordingly unimportant; here, epidemiological research

evidence is strongly promoted as the most reasonable, rational

basis for making decisions about health care interventions, whereas

factors such as the patients wishes (drawing on their knowledge

about what is preferable, practical and manageable in their par-

ticular lives), the availability and accessibility of treatments (given

that some treatments may only be accessed by travelling consid-

erable distance to centralised facilities), the experiential knowledge

of the practitioner (what practices work best in their hands), the

knowledge embedded in local routines (that can accommodate the

demands of some interventions and not others) and situational

knowledge (ideas about what would work best in this instance,

rather than a universal best) are all eradicated from the decision-

making framework.

At least in the United Kingdom, Western Europe and the

United States, basing medical practices on proven diagnostic and

therapeutic knowledge has meant an attempt to standardise

medical practices through the increasing use of clinical practice

guidelines:

Under the recently emerged banner of evidence-based medicine,guidelines have become the tool of choice to weed out unwarrantedvariation in diagnostic or therapeutic practice and to enhance the sci-entific nature of the medical care delivered. (Berg et al., 2000: 766)

However, Berg (1997a) notes that guidelines do not confine

themselves to carrying rational knowledge; rather, the con-

struction process will interweave a wide, heterogeneous range of

elements. Take, for example, a National Institute for Clinical

Excellence (NICE) technology appraisal: in line with EBM these

guidelines rely heavily on the RCT as the preferred source of

evidence for the critical review. However, in tackling somewhat

less than glamorous subjects such as wound care, which


command less publicity, and research interest and funding than

perhaps new surgical techniques or new drugs, NICE are com-

pelled to work with other forms of evidence, those lower down,

or even off the bottom of, the hierarchy. In the case of difficult to

heal surgical wounds there exists no RCT evidence to support

any particular debriding agent (products that breakdown and

absorb dead tissue). In the absence of such evidence, NICE advise

that the choice of debriding agent should be based on comfort,

odour control and other aspects relevant to patient acceptability;

type and location of wound; and total costs (NICE, 2002: 128).

The way these tools are presented, however, largely hides these

negotiations from view (Berg, 1997b).

Moreover, the interweaving of many different logics, rational-

ities, evidences and knowledges that characterises the construction

process of clinical practice guidelines continues when the tool

becomes part of the local work routines. Berg identifies how, for

example, nurses tinker with the tools prescriptions so that blood

tests can be done on time whilst, seemingly simultaneously, the

patient is wheeled to the X-ray department. However, Berg

insists:

This is not a deplorable and preventable outcome of the corruptingprocesses of getting a tool to work: it is the only way for the tools towork in the first place. Delegating the task of producing the toolsdemands in real time to medical personnel requires leaving them theleeway to digress from the tools prescribed steps, to skip or skew input,or to sometimes just avoid the tool completely. . . . It requires allowingmedical personnel to adjust the tool to their ongoing work. It requiresthat the tools become part and parcel of local work routines. Itrequires, thus, a further localisation of the tool: a moving away from itsideal-typed universality and uniformity. (Berg, 1997a: 152, originalemphasis)

Accordingly, EBM and clinical guidelines are just one of the

elements that gets worked into clinical practice alongside the

other, perhaps less visible but no less relevant, elements.


In this sense, Timmermans and Berg (1997) argue that uni-

versality is always local universality. Only when studying how a

guideline works in practice does it become clear what is not

explicitly mentioned, how the guideline both relies upon and

changes pre-existing practices and routines, and the knowledge

and expertise of practitioners. Somewhat paradoxically, then,

allowing the practitioners some discretion in how they articulate

the demands of the guideline seems to be the only way to achieve

standardisation:

Tinkering, having the leeway to adjust the protocol to unforeseen eventsand repair unworkable prescriptions is a prerequisite for the protocolsfunctioning: in these practices, the overall stability of the network is atthe same time challenged and dependent upon the instabilities within itsconfiguration. (Timmermans and Berg, 2007: 293)3

Suchman (2007: 200) elaborates this point in respect of the

general nature of plans: it is the inherent underspecification of

the formal plan that affords the space of action needed for its

realization. Standards, plans and guidelines work, therefore, by

presupposing a vast array of unspecified knowledges and prac-

tices, and incorporating a discretionary space for the accom-

plishment of these contingent labours.

Consequently, and in contrast to the well-articulated fear that

EBM and guidelines stifle decision making, denigrate medical

expertise and deplete skills, Timmermans and Berg propose that

these tools transform and redistribute existing knowledge,

responsibilities and expertise, making some skills obsolete and

requiring others. These new competencies involve not only

bringing together new and old ways of doing the work, but also

creatively accounting for the work (Suchman, 2007: 204) so that

it both accords with the demands of the guideline whilst pro-

viding a reasonably accurate description of events.

3 This insight follows from the work of Vicky Singleton on the instabilities of theCervical Screening Programme.


Suchmans observation about creative accounting draws

attention to the implications of tinkering and rearticulating the

guidelines prescriptions. Although the tools functioning may

depend on this, often tinkering will require health care practi-

tioners (nurses in particular) to operate outside their official

responsibilities and, if interpreted literally, to contravene the

formal prescriptions which, in turn, renders them vulnerable to

disciplinary action. In sum, technologies of coordination and

control (Suchman, 2007: 277), such as procedural instructions

and guidelines, prescribe courses of action designed to be reliably

reproduced, and serve as a measure for comparative assessment.

The problem, as pointed out earlier, is that these tools rely on a

discretionary space a space for judgement and action. So rather

than guidelines limiting the scope for the application of indi-

vidual judgement, as is their aim (McDonald et al., 2006), it is

more that the need for individual judgement is obscured. So my

concern echoes that of Bowker and Star: it is a concern for the

political and ethical implications of what is rendered visible and

invisible. Guidelines underscore the scientific basis of the pro-

posed treatments and interventions, whereas the necessity for the

subtle use of judgement in the deployment of guidelines is erased.

The implementation of clinical governance is a further way

in which the standardisation of practice and the accountability of

health care practitioners are being prioritised in the United

Kingdom. Clinical governance is a framework through which

NHS organisations are accountable for continually improving

the quality of their services and safeguarding high standards of

care (Department of Health, 1998: para 3.2). By harnessing

movements such as EBM and tools already in use, such as

guidelines, audit and incident reporting, clinical governance aims

to create a systematic set of mechanisms to specify quality stan-

dards and to guide and monitor the delivery of health care. These

tools of clinical governance all share the aim of clarifying and


documenting clinical practice, which, in conjunction with the

emphasis on regulation and monitoring of performance, results

in a concentration on the explication and reporting of, and

accounting for, health care work. Clinical governance is a means

of performing accountability; it works, not only to specify duties

but also to construct the means through which clinical practice is

judged:

Accountability is more than, indeed systematically different from,responsibility. The latter entails, literally, being liable to answer forduties defined as yours. . . . Accountability, on the other hand, is in itsoperation and scope more total and insistent. Not only are dutiesspecified, but the means of evaluating the level of their performance isalready prescribed, in implicit or explicit norms, standards and targetsof performance; wherefore surveillance over and judgement of per-formance is vastly widened and deepened. (Hoskin, 1996: 265)

So as indicated in this discussion, where practice is formalised,

standardised and prescribed, as in the tools of clinical gover-

nance, it serves as an (idealised) version of practice against which

everyday practice is measured. Moreover, clinical governance has

been seen as a challenge to professional autonomy and medical-

managerial relationships (Gray, 2004), tethering, as it does,

improvements in quality to stronger mechanisms of professional

regulation and requiring that clinicians engage in self-surveillance

(Flynn, 2002): modern professional self-regulation, for example,

will play a fuller part in the early identification of possible lapses

in clinical quality (Department of Health, 1998: para 1.16). The

mechanisms of clinical governance, therefore, multiply and

extend the lines of accountability.

Codes of practice are the primary tool through which pro-

fessional bodies achieve the self-regulation and accountability of

doctors and nurses. Again, these codes are normative descriptions

of professional conduct that set out the standards that practi-

tioners must demonstrate. A major problem with these codes,


however, is the model of practice on which they are based. For

example, doctors must:

Prescribe drugs or treatment, including repeat prescriptions, onlywhere you have adequate knowledge of the patients health and medicalneeds. (General Medical Council, 2001: 3)

This assumes that it is always possible to know the cause of the

patients health problems before acting. However, often doctors

need to perform an activity in order to learn something about the

patients condition. The model of practice embedded in these

statements inverts this cycle of learning, presuming it is always

possible to learn first and then act. Decisions are conceived of as

carefully thought out rationalisations cost/benefit analyses of

known and predictable consequences that can be isolated to

discrete moments of cognition from which actions follow. In this,

medical practice is characterised by clarity and certainty, grossly

underestimating the level of ambiguity and uncertainty that has

long been recognised as a feature of clinical practice (Fox,

1957, 2000).

Furthermore, these codes stress the autonomy of the practi-

tioner:

When working as a member of a team, you remain accountable foryour professional conduct, any care you provide and any omission onyour part. (Nursing and Midwifery Council 2004: 8)

And:

Working in a team does not change your personal accountability foryour professional conduct and the care you provide. (GMC,2001: 12)

These statements reify a model of practice in which practitioners

act individually, with actions and omissions being clearly bounded

entities. Collaboration with other professionals does not detract

from the personal accountability of the nurse. However, it is dif-

ficult to ascertain the degree to which one practitioners actions

are informed by anothers. For example, nurses have considerable


influence over doctors diagnoses and prescriptions, perhaps by

describing a patients condition in such a way that the doctors

response is the one the nurse desired, or by making direct

requests for a specific prescription (Hughes, 1988; Prowse and

Allen, 2002).

For the GMC, good teamworking specifically depends on the

clarity of roles and responsibilities between participants. Doctors

must:

Make sure that your patients and colleagues understand your profes-sional status and specialty, your role and responsibilities in the team andwho is responsible for each aspect of patients care. (GMC, 2001: 12)

Here, the composition of teams is implicitly taken to be regular

and deliberate. However, often team members might be rather

more ad hoc, their responsibilities being less distinct and over-

lapping. An operating team, for example, will include a surgeon, a

scrub nurse, a circulating nurse, an anaesthetist and an anaes-

thetic assistant either a nurse or operating department practi-

tioner. In addition, the surgeon may have an assistant, there may

be more than one anaesthetist, more than one circulating nurse,

the recovery nurse may attend and there may be all manner of

learners and students present. Whilst practitioners will have their

own specified duties, they will also share tasks that need to be

shared, fill in for one another where necessary, and generally

participate flexibly as their skill, knowledge and experience

allows. Codes of practice focus on the individual within a team

rather than reflecting how collaborative work is achieved.

The codes emphasise the accounting for actions:

Whatever decisions or judgements registrants make, they must be ableto justify their actions. (NMC, 2006: 1)

And doctors must:

Keep clear, accurate, legible and contemporaneous patient recordswhich report the relevant clinical findings, the decisions made, the


information given to patients and any drugs or other treatment pre-scribed. (GMC, 2001: 3)

Practitioners must be able to give an adequate account of their

actions, but as Hoskin points out, the terms of accounting are

already specified implicitly and explicitly. An adequate account is

necessarily one that draws on the same notions of practice as the

codes: an autonomously acting individual that consciously eval-

uates the likely outcomes of a proposed intervention and then acts

accordingly. As Suchman (2007) identifies, this leaves practi-

tioners to reconcile the differences between the way they practice

and the way these codes insist they should practice.

To summarise, these codes build upon and exemplify the idea

of human-centred, individual action; professional conduct is

premised upon an individual, cognitive mode of decision making

and activity that negates the collaborative nature of health care

work, and in which the contingent and distributed nature of

decision making is completely absent. Decisions are supposed to

be made prospectively, on the basis of knowns and certainties,

and actions follow. In these documents, professional account-

abilities crystallise on certain actions and particular actors, they

exaggerate the authority and autonomy of practitioners and the

degree to which they can predict and control the circumstances

and contingencies of health care.

An alternative view of practice is developed in this book, one

in which clinicians and patients act in concert with each other and

various medical technologies, machines and devices. Activity,

decisions and participation are fluid, relational, and collaborative.

I explore the way that action unfolds in a series of empirical

cases of anaesthetic and intensive care practice. I follow how

capacities for action are produced in the interactions of practi-

tioners and patients together with technologies, machines and

devices and address the tensions that arise for practitioners in

attempting to reconcile the differences between the way practice


unfolds and the way that formal descriptions of practice insist it

should happen. Anaesthesia provides a particularly interesting

position from which to interrogate the relationships between

evidence or other formalisms such as policies and guidelines,

with patients, machines and practitioners and the capacities for

action these relationships produce. By inducing unconsciousness,

disabling speech and intervening in the ability of the body to

autonomously regulate itself, anaesthesia plays with the char-

acteristics usually assigned to an actor. Anaesthesia configures a

relationship among humans, machines and devices that trans-

forms and redistributes knowledge and agency, and stands in

contrast to the figure of a rational, intentional agent. This jux-

taposition enables one to question the assumptions a rational

position invokes and to scrutinise the conditions necessary for

action. This relational nature of agency, however, escapes formal

methods of allocating accountability, and in codes of professional

conduct, individual clinicians become responsible and account-

able for actions authored by many participants, both human and

non-human.

Unfolding Anaesthetic Work

In the next chapter I begin this examination of acting in anaes-

thesia by exploring the role of the patient and the anaesthetic

machines. I begin here because the patient, being unconscious

and rendered speechless, can easily be overlooked, or considered

absent, construed as the object of knowledge rather than an active

participant in events. For example, Atkinson (2002) analyses the

relationship between medical technologies and patients bodies,

conceptualising the machines as technologies of inspection,

interrogating the body and disaggregating it into signs and

representations to be read by competent observers. Whilst this

usefully elucidates how technology mediates knowledge of the


body, in this configuration, the patient as a unique individual is

almost deleted, rendered passive, and stripped of agency. In some

cases it may be that this construction of the patient as a passive

object actually enables certain health care practices. Hogle (1999)

has argued that organ transplantation practices mandate

mechanisms that change the conception of the patient, that

depersonalise the patient. She suggests that in attending to the

medical technology a donor requires in intensive care, person-

hood and identity are progressively filtered out. In anaesthetic

practice, however, I contend that the patient as an individual is

very present, and a very active agent in the unfolding perfor-

mance of anaesthesia. In this chapter I grapple with how to

conceptualise and articulate the contribution to anaesthetic

practice the patient makes.

The interface between human and non-human agencies pro-

vides an interesting vantage point from which to investigate

actors differentiated capacity for action. And given that here, the

unconscious patient is conceptualised as a vigorously acting

entity, albeit acting in some rather ambiguous ways, how the

anaesthetist is seen to plan, prescribe and execute a course of

anaesthetic care is a process that requires some elaboration.

Frequently, in medical practice, there will be multiple,

incompatible explanations of a patients condition, prompting

numerous and different possible courses of action. Chapter 3

focuses on the work of the anaesthetist in constructing a situated

and dynamic account of a clinical situation that renders the sit-

uation intelligible and in doing so indicates an appropriate course

of action. Decision making, in these circumstances, has been

analysed as a process of alignment by bringing together various

sources of knowledge a coherent narrative that explains the

majority of the patients signs, symptoms readings, and mea-

surements is produced, a narrative that also organises prospective

actions by indicating an appropriate response on the part of the


practitioner. More recently in Science and Technology Studies

(STS), attention has turned from looking at methods of closure

how, of all the paths that might possibly be taken, options are

reduced and a single path emerges to exploring the multiplicities,

disunities and incoherences of bodies, objects and knowledges (see,

for example, Berg and Mol, 1998, and Mol, 2002). Here, analyses

have highlighted how, despite there being tensions, differences are

not necessarily resolved, they endure. However, in health care

settings the notion of professional accountability has become

increasingly significant, consequently, the existence of unre-

solved differences can sometimes be deeply problematic. Health

care practitioners work in a culture in which certainty of

knowledge, diagnoses and actions is highly valued and, on one

level, enacted as a prerequisite for interventions, and yet on

another level, it is frequently, if implicitly, enacted as an unat-

tainable ideal. In this chapter, I explore how accountability can be

achieved both in circumstances where a coherent narrative may

be drawn and where, despite concerted efforts at alignment, the

disunity of the patients body persists.

The activities of nurses and operating department practi-

tioners (ODPs)4 also contribute to the particular shape and

quality of anaesthetic care. The distribution of work between

4 ODPs and nurses work in the United Kingdom is now reasonably interchangeablewith the exception of a few professional and historical distinctions: First, as there is nomandatory register for ODPs, only qualified nurses are supposed to hold the keys forthe controlled drug cupboards. Second and historically, nurses tended to perform thescrub role (which seemed to be held in greater esteem) whilst technicians oroperating department assistants (as they used to be known) assisted the anaesthetist.This distinction is still discernable with the majority of scrub practitioners beingnurses and the majority of anaesthetic assistants being ODPs, however, as anaesthesiaas a specialty has developed so has the role of the assistant, ODAs have become ODPsnow with a 3-year diploma/degree course, and it is largely impractical for the keys tobe held by anyone other than the anaesthetic assistant, as it is the anaesthetist, ratherthan the operating surgeon, who administers the controlled drugs. In the hospital atwhich I worked, a local policy was devised that acknowledged that the keys could beheld by the anaesthetic assistant, regardless of their professional background.


anaesthetist and nurse or ODP, the level of energy these practi-

tioners exert in shaping the course of anaesthesia varies from

person to person, and the way professional boundaries of practice

are enacted also affects the unfolding course of anaesthesia.

Chapter 4 concentrates largely on challenges to these boundaries

so as to elucidate the consequences they have for the generation

and distribution of anaesthetic knowledge, and how the form and

character of knowledge a practitioner develops affords particular

levels of involvement. The continual negotiation of the distri-

bution of work and knowledge between doctors and nurses means

that the issue of professional boundaries has remained a current

and controversial subject for sociological analysis. I discuss some

of the ways these boundaries have been theorised: as ecologies of

knowledge in which the character of knowledge each profes-

sional group develops and utilises is a consequence of their daily

work experiences (Anspach, 1987), as a negotiated order

(Svensson, 1996) in which nurses are in a unique position with

knowledge that doctors depend on, and as the boundary-

spanning activities that nurses perform, making decisions using

doctors tools, coordinating the movement and activities of doc-

tors, and engaging in activity that resembles medical diagnosis

(Tjora, 2000).

This discussion outlines how the knowledge and practices of

nurses are shaped and defined by disputes and constraints on

practice, and tacit arrangements as to the boundaries of their

responsibilities. I explore this theme using Lave and Wengers

(1991) concepts of legitimate peripheral participation in com-

munities of practice. One of the most important learning

resources that Lave and Wenger identify is the legitimacy of the

learner to participate, and they suggest that the level of legitimacy

conferred is strongly related to the degree to which the different

identities are forged. This draws attention to the integral role

access plays in the generation of knowledge. This chapter


addresses the tensions that develop when practitioners stray

outside accepted boundaries, and the consequences for practi-

tioners learning, the resources they have for influencing the care

of a patient and the accountability of their actions.

As I indicated earlier, work as an anaesthetic nurse involves

developing an intimate knowledge and awareness of the kit: the

specific features, characteristics, purposes, possible uses, techni-

ques of handling and availability of the devices used in anaes-

thesia. The availability of a piece of equipment, and the skill of

the user, could radically change the path an anaesthetic trajectory

might follow. The possibilities for action afforded by artefacts

and devices, therefore, also have a bearing on how anaesthetic

practice unfolds. In Chapter 5, I examine the spatial dimensions

of the workplace, the arrangement of material resources and the

development of embodied knowledge. I explore how the

accomplishment of anaesthetic techniques depends on the precise

alignment of practitioners bodies, tools and the patients body.

Developing an awareness of the specificities of anaesthetic

practice, an anaesthetist cultivates a body of normal appearances

(Sacks, 1972). I discuss how the form, position and configuration

of both humans and devices are significant elements in consti-

tuting this body of expectations. Moreover, set against this body

of expectations, any departures from the normal are more

immediately visible; in becoming accustomed to the normal

appearance of a given situation one can recognise more readily

the abnormal or missing. By following disruptions to customary

configurations of teamwork, I explore the utility of these

arrangements and how disruptions function as learning oppor-

tunities vital to the development of expertise.

It is this intersection of humans, technology and devices, with

learning, knowing and doing that interests me, and it is how

these relationships are enacted that I examine in this book. In this

study of the relationships between patients, machines, devices,


teams of practitioners and the hospital environment, along with

formalisations such as policies, procedures and the prescriptions

of EBM, this book draws heavily on the field of STS and eth-

nomethodology but also brings the fields of medical sociology

and medical anthropology to bear on these topics. The impor-

tance of this study of agencies comes into focus when posing the

question of how situated actions, with their variously recognised

actors and agencies, relate to the configurations of actors and

agencies implicit in professional codes of conduct. Such codes

tend to tether accountability to discrete and precise actions, and

to particular practitioners, which means that specific participants

are held to be responsible for events authored by multiple actors.

This, in turn, indicates certain tensions between practice and

accounts of practice.

Showing how practice in anaesthesia unfolds, that it is not

only made up of the contributions of practitioners, but also of

machines, unconscious patients, as well as tools, devices and

organisational routines disrupts the deterministic sense in which

medicine has been practiced and interpreted. Within the medical

profession itself, the concept of an autonomously acting clinician

is highly valued, and the need to control diagnosis, treatment and

the evaluation of care strongly informs professional ideology

(Harrison, 2004). Importantly, the dominance of medicine, in

terms of the ability of doctors to determine a patients state of

health and command compliance with treatment regimes, has

itself come under scrutiny by medical sociology and by feminist

studies of medicine. These critiques have raised awareness of the

manifold ways in which patients participation in decision making

has been systematically diminished, patients are thus constructed as

passive objects of medical treatment rather than as active agents in

the healing of their bodies. Indeed, Cussins (1998: 169) observes

that we have become accustomed to thinking of patients as

disciplined subjects par excellence.Without denying the dominance


of medicine, however, this book will delineate the limits of this

critique by highlighting the obstacles and difficulties individual

practitioners face when trying to determine the course of events,

for example, it will show how patients participate in shaping the

course of their anaesthetic even when unconscious. Conse-

quently, this book traces the tensions individual practitioners

work with when held accountable for actions that are distributed

amongst many participants, especially those assumed not to act.

Following Suchmans (1987, 2007) analyses of human-

machine relations, this book argues for the primacy of the

immediate context of action in understanding how trajectories of

care are shaped. Most particularly, the analysis of the interactions

between the patient, the anaesthetic technologies and the

anaesthetist demonstrates the intractably contingent character of

action, elucidating the ways in which entities that lack the tra-

ditional characteristics of an agent (machines, tools, devices and

unconscious patients) can and do act. The conclusion discusses

the consequences that erasure of these actors incurs for pro-

fessionals when they have to account for their actions, and how

the emphasis on specifying and formalising the delivery of care

works to undermine the grounds on which action is based; it

diminishes the legitimacy of the patients and situational contin-

gencies to inform treatment decisions and obscures the exper-

tise and knowledges that have contributed to such decisions.


2 Refashioning Bodies, Reshaping Agency*

The purpose of anaesthesia is to temporarily insulate a patients

senses from the trauma of surgery. This necessitates a reconfigu-

ration of bodily boundaries and a redistribution of bodily func-

tions. Anaesthetic machines are called upon to assume some of

these responsibilities, for example, frequently patients are para-

lysed in the process of anaesthesia thus disabling their capacity to

breathe, and the anaesthetic machine, once programmed, will then

assume this responsibility. Furthermore, in rendering the patient

unconscious, anaesthesia incurs a silencing of the patient. Here,

anaesthetic machines are again enrolled to provide an alternative

route of expression with monitoring devices displaying readings,

diagrammatic traces andmeasurements. An anaesthetised patient,

therefore, is heavily reliant on the relationship that is forged with

the anaesthetic machine. Indeed, the patient is technologically

extended and augmented through this relationship. In a very

practical and material sense, the patient becomes a mix of organic

and technological components, in other words, a cyborg.

Cyborgs: Fact, Fiction and Social Reality

The word cyborg was coined in 1960 by Clynes and Kline,

as short for cybernetic organism. It referred to a living

* This work was first published as Goodwin, D (2008) Refashioning bodies, reshapingagency. Science, Technology and Human Values, 33:3 (34563).

33

creature enhanced by computer-controlled bio-feedback systems,

developed in the aim of liberating the human from environmental

constraints:

The Cyborg deliberately incorporates exogenous componentsextending the self-regulatory control function of the organism in orderto adapt it to new environments. (Clynes and Kline, [1960] 1995: 31)

Space travel, according to Clynes and Kline, would be better

facilitated by modifying the body in partial adaptation to space

conditions rather than persisting in carrying the earths envi-

ronment into space. Importantly, the technological components

of the cyborg should function unconsciously, to prevent the

space traveller from becoming a slave to the machine:

The purpose of the Cyborg, as well as his own homeostatic systems, isto provide an organizational system in which such robot-like pro-blems are taken care of automatically and unconsciously, leaving manfree to explore, to create, to think, and to feel. (Clynes and Kline,[1960] 1995: 31)

The technological components of the cyborg, therefore, are

necessary only insofar as they support the vitality, ingenuity and

imagination of the human.

This idea that humans need not be tethered to their environ-

ment but may be technologically augmented so as to enable super

new capabilities is an enticing imaginative resource. Cyborgs have

proliferated in fiction; they have become a projection of our fan-

tasies about ourselves (Hacking, 1998: 211). And, in doing so, the

definition has loosened, the emphasis centring more on new

capabilities than on bio-feedback systems:

(science fiction) cyborgs tend to be big, sort of mechanical but also sortof organic; there is seldom the organic being upon which or in which abio-feedback mechanism has been implanted. They are, however,correctly described as alive, living. (Hacking, 1998: 212)

Again, the defining feature of the cyborg is his/her vigour and

liveliness.


The cyborgs of fiction have increased in imaginary complexity

from humans who, when adorning a special suit, are endowed

with special powers to humans whose bodies have been perma-

nently modified to take advantage of the latest technological

innovations that engender such new capacities as incredible

strength, speed and intelligence. And, latterly, cyborgs have taken

the form of mutants whose altered genetic code allows them to

spontaneously change their shape and biological structure as

circumstances require (Oehlert, 1995). These heroes increas-

ingly demonstrate an ambiguous and uneasy double-edge: they

deal with violence by violence, their powers may be used for good

or evil and the interventions that gave them their powers may also

destroy them (Oehlert, 1995). The unease with such imaginary

cyborgs seems to revolve not around the question of whether the

machine will take over the human but around what the human

chooses to make of his/her new abilities (Oehlert, 1995).

Haraway reminds us that the cyborg is also a creature of

social reality as well as a creature of fiction (1991: 149). The

cyborg, she suggests, takes a material form in ones lived social

relations, and particularly those of modern medicine (Haraway,

1991: 150). Medicine excels at creating cyborgs; Gray, Mentor

and Figueroa-Sarriera (1995: 2) argue that there are many

actual cyborgs among us in society and those they cite are the

products of medical interventions persons with artificial

organs, limbs or supplements (such as a pacemaker), immunized

persons reprogrammed to resist disease and those pharmaco-

logically reordered to behave differently. These cyborgs are not

necessarily augmented with homeostatic feedback mechanisms,

but they are humans supplemented with technological innova-

tions designed to support, and perhaps transform, their capaci-

ties, vitality and their life. Lock (2002) argues that advances in

medical science have brought about a confusion of body

boundaries and mingling of body parts never before possible

Refashioning Bodies, Reshaping Agency 35

(Lock, 2002: 1406).Medical sociologists, Nettleton andGustafsson

(2002: 13) explain:

As we develop our knowledge, expertise, technologies and activitiesassociated with the body, the more uncertain we become as to what thebody actually is. The boundaries between the biological, social andtechnological become less clear. Boundaries, such as the distinctionbetween life and death, that once appeared immutable, are no longerclear-cut.

Distinctions that had previously been made with confidence and

clarity, including that of human/machine, are now clouded and

uncertain. In this sense, cyborgs epitomise the mix of techno-

logical and organic necessary to extend and enhance life, and to

generate new capacities, but they also represent a powerful

blurring of boundaries, they are provocative in their subversion

of easy distinctions, and in conveying a sense of unpredictability

they invite caution and wariness. This is instructive when

thinking about both medical and technological innovations and

existing practices. Natural boundaries are transgressed, new

entities with different capacities are created, requiring recon-

sideration of existing responsibilities and accountabilities. It is as

Haraway (1991: 150) argues: for pleasure in the confusion of

boundaries and for responsibility in their construction.

The Cyborg: An Analytical Resource for Thinkingabout Agency

The confusion of bodily boundaries and the evermore intimate

connections and relationships forged between bodies and tech-

nologies have encouraged, and are deeply implicated in, debates

about the forms and locations of agency. Such debates have

figured prominently in STS, which, through symmetrical anal-

yses of humans, technologies and materials, sought to recover

the agency of things. The product of this body of work is

frequently summarised by the proposition that humans and


artefacts are mutually constituted (Suchman, 2007). However,

as Suchman (2007: 269) points out: mutualities . . . are not

necessarily symmetries and within assemblages or networks of

humans, machines and materials, there are important questions

of difference in terms of the forms of agency to which different

actors have access. Nevertheless, Gray, Mentor and Figueroa-

Sarriera (1995) note that the traditional allocation of agency,

which casts humans as intentional agents and machines, tech-

nologies and materials as inert, is tenacious. Callon and Law

(1995: 490) identify the characteristics usually attributed to an

agent:

agents are those entities able to choose, to attribute significance to theirchoices, to rank or otherwise attribute preference to those choices;(. . .) agents are able to intervene to act in order to (re)create linksbetween their goals and the actions that they cover.

The analysis of cyborg relationships in anaesthesia offers a

particularly focussed opportunity to reconsider this traditional

view of agency as it allows me to analyse the capacity and

character of agency that can be demonstrated when both patient

and machine elements lack intentionality. Taken together with

the other cases discussed in this book, this project is an attempt

to acknowledge the agency of things and to study the asymme-

tries between things and humans without falling back to the

default position that Gray et al. indicate. Delineating some of

the different forms and locations of agency found in the dense

sociotechnical arrangements that make up much of contempo-

rary health care, and how these agencies intersect and are

effected in interactions, is urgently required in order to better

understand, and allocate, appropriate accountabilities. Cur-

rently, codes of professional conduct attribute agencies and their

associated accountabilities much as Gray et al. describe with

practitioners (note: not humans as that would include patients)

being the intentional agents, and all other elements of health

Refashioning Bodies, Reshaping Agency 37

care practice as inert. Analysing the union between an uncon-

scious patient and anaesthetic machine as a cyborg a living,

vital, communicating entity opens a window on the constraints

and elements shaping practitioners actions, sensitivity to which

is almost completely absent in current attributions of account-

abilities.

In keeping with the desire to recognise the agency of things,

Latour (1999) suggests that we must learn to redistribute actions

among many more agents, a suggestion that prompts the ques-

tion of where to draw the boundaries of anaesthesias cyborgs; is

the anaesthetist part of the cyborg? What of the nurses and

ODPs? Where should the dispersement of agency end? My

response to these questions is to reiterate that the patient-

anaesthetic machine cyborg is an analytical unit, purposely

chosen to elucidate the form agency might take when both

human and technological components lack intentionality. To

add conscious, intentional actors into this unit would only serve

to cloud this analysis. The cyborg figure focuses attention on the

intense human-machine interdependencies necessary for current

anaesthetic practice, an emphasis that the term anaesthetised

patient does not convey. It is not a natural bounded category,

on the contrary, the cyborg invokes ideas about the disruption

of seemingly natural bodily boundaries, and the redistribution of

some bodily functions necessary for life, in a way that other

analytical terms, such as hybrid, does not. Hence, my aim is not

to delineate what capacities for action belong to the human or

the machine, but to explore what agencies this dynamic rela-

tionship demonstrates.

Haraway (1991) has argued that those human-machine rela-

tionships that are forged, and the boundaries that are drawn

within, around and between entities are issues that matter. She

contends that the cyborg figure can be used to question the

political and ethical effects related to which human-machine


acting in anaesthesia (lb. englezĂ).pdf

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