Moral judgements as organizational accomplishments : insights from a focused ethnography in the English healthcare sector

In this chapter, we aim to deepen our understanding of judgments in organizations. Whilst previous studies have underscored the situated nature of individual judgments exercised by e.g. leaders or managers, our research focuses on how judgments emerge as organizational responses to recurrently emerging moral dilemmas. Accordingly, we study a setting—decision practices in the English healthcare sector—where moral puzzles (to fund or not to fund healthcare for apparently atypical patients) demand ongoing attention and systemic handling. We conducted (and present findings of) a focused ethnography of the ways expert decision-making panels in three health authorities confronted, engaged, and coped with morally perplexed situations. The moral perplexity there lay in that panels were called upon to prudently and demonstrably determine whether a particular patient deserved or not exceptional investment; and do so by taking into consideration the healthcare needs and rights of all patients under the same health system. By adopting a practice perspective (Schatzki, 2002), we develop an analytical account of the effortful accomplishments (sociomaterial activities or intertwined “projects” in practice theory terms), which enabled the recurrent collective exercise of judgments in accordance with publicly recognizable moral expectations—namely notions of fairness. Our main contribution lies in conceptualizing the work of rendering moral judgments as organized pursuits possible and meaningful and hence in complementing current “ecological understandings” of individual judgment-making in organizations

Integrating knowledge in the face of epistemic uncertainty : dialogically drawing distinctions

In this article, we contribute to a processual understanding of knowledge integration in interdisciplinary collaboration by foregrounding the role of dialogue in dealing with epistemic uncertainty. Drawing on an ethnographic study of collaboration among scientists involved in developing a highly novel bioreactor, we suggest that knowledge integration is not a homogeneous process but requires switching between different knowledge integration practices over time. This is particularly notable in the case of ‘epistemic breakdowns’ – deeply unsettling events where hitherto-held understandings of the nature of problems appear unworkable. In such cases, it is not sufficient to deal solely with coordination issues; collaborators need to find ways to address generative knowledge integration processes and to venture, collectively, into the unknown. We demonstrate how this generative quest of knowledge integration is achieved through a dialogical process of drawing and testing new distinctions that allows actors to gradually handle the epistemic uncertainty they face

Knowledge sharing and health-care coordination : the role of creation and use brokers

This paper arises from research that examined a health-care coordination improvement initiative that was focused on increasing knowledge sharing among a network of health-care workers involved in the care of children with complex medical needs. Part of this initiative involved a summary medical note (the Single Point of Care (SPOC)) that was paper-based and carried by parents between the specialists involved in their child’s care. The SPOC’s effectiveness is discussed through a knowledge-as-practice perspective, which focuses on the role of mediators (both material and human). Our analysis demonstrates that the SPOC’s effectiveness can be understood by looking at the combined roles of boundary objects and human brokers. We identify two distinct broker roles: creation brokers and use brokers. In discussing our case, we extend our analysis to suggest how these broker roles may also be useful in thinking about how to improve the effectiveness of (electronic) health record systems more generally – for researchers as well as for practitioners

Recovering the performative role of innovations in the Global Travel of Healthcare Practices : is there a ghost in the machine?

This chapter discusses the global travel of a specific approach to incident investigation (Root Cause Analysis or RCA for short). We assess how knowledge of the technique was mobilized, from the United States to Australia, the United Kingdom and beyond. We argue that the globalization and world spanning circulation of this set of practices was sustained and facilitated by the construction of an “anxiety-reassurance” package. This package raised public and professional anxiety about patient safety and created reassurance by proposing a new management solution to solve this problem. Playing together these two seemingly opposite discourses, the innovation generated a wave of interest and urgency that it then rode and that allowed rapid globalization. We suggest that a focus on the innovation as a well-oiled piece of discursive machinery helps us to understand the active role of innovations in fuelling their own translation without reverting to the old idea that innovations are “diffused.

Finding your sea-legs : exploring newcomer embodied learning in an extreme context

Embodied learning involves developing not only socio-technical know-how but also the bodily capacity to execute practices competently. In extreme contexts, newcomers encounter threatening experiences that may incapacitate their ability to participate. How newcomers develop the bodily capacity to participate in such situations is a research area that requires further attention. Using ethnographic data from a study of novices working in the risky context of seafaring, we show that newcomers encounter threat experiences (imagined, immediate, and attenuated) that trigger them to engage in three types of body work: priming, battling, and enduring, from which they develop the capacity to participate. Our analysis suggests a model of newcomer embodied learning in practices in an extreme context and contributes to embodied learning literature by showing: (1) body work directed at capacity to participate, (2) the mutually constitutive relationship between body work and threat experiences, and (3) the temporal complexity of embodied learning anchored in the body work and threat experiences

Evidence-based commissioning in the English NHS : who uses which sources of evidence? A survey 2010/2011

Objectives: To investigate types of evidence used by healthcare commissioners when making decisions and whether decisions were influenced by commissioners’ experience, personal characteristics or role at work. Design: Cross-sectional survey of 345 National Health Service (NHS) staff members. Setting: The study was conducted across 11 English Primary Care Trusts between 2010 and 2011. Participants: A total of 440 staff involved in commissioning decisions and employed at NHS band 7 or above were invited to participate in the study. Of those, 345 (78%) completed all or a part of the survey. Main outcome measures: Participants were asked to rate how important different sources of evidence (empirical or practical) were in a recent decision that had been made. Backwards stepwise logistic regression analyses were undertaken to assess the contributions of age, gender and professional background, as well as the years of experience in NHS commissioning, pay grade and work role. Results: The extent to which empirical evidence was used for commissioning decisions in the NHS varied according to the professional background. Only 50% of respondents stated that clinical guidelines and cost-effectiveness evidence were important for healthcare decisions. Respondents were more likely to report use of empirical evidence if they worked in Public Health in comparison to other departments (p<0.0005, commissioning and contracts OR 0.32, 95%CI 0.18 to 0.57, finance OR 0.19, 95%CI 0.05 to 0.78, other departments OR 0.35, 95%CI 0.17 to 0.71) or if they were female (OR 1.8 95% CI 1.01 to 3.1) rather than male. Respondents were more likely to report use of practical evidence if they were more senior within the organisation (pay grade 8b or higher OR 2.7, 95%CI 1.4 to 5.3, p=0.004 in comparison to lower pay grades). Conclusions: Those trained in Public Health appeared more likely to use external empirical evidence while those at higher pay scales were more likely to use practical evidence when making commissioning decisions. Clearly, National Institute for Clinical Excellence (NICE) guidance and government publications (eg, National Service Frameworks) are important for decision-making, but practical sources of evidence such as local intelligence, benchmarking data and expert advice are also influential

Improving the capabilities of NHS organisations to use evidence : a qualitative study of redesign projects in Clinical Commissioning Groups

Background Innovation driven by authoritative evidence is critical to the survival of England’s NHS. Clinical Commissioning Groups (CCGs) are central in NHS efforts to do more with less. Although decisions should be based on the ‘best available evidence’, this is often problematic, with frequent mismatches between the evidence ‘pushed’ by producers and that used in management work. Our concern, then, is to understand practices and conditions (which we term ‘capabilities’) that enable evidence use in commissioning work. We consider how research gets into CCGs (‘push’), how CCGs use evidence (‘pull’) and how this can be supported (toolkit development). We aim to contribute to evidence-based NHS innovation, and, more generally, to improved health-care service provision. Method Supported by the National Institute for Health Research (NIHR), we conducted semistructured ethnographic interviews in eight CCGs. We also conducted observations of redesign meetings in two of the CCGs. We used inductive and deductive coding to identify evidence used and capabilities for use from the qualitative data. We then compared across cases to understand variations in outcomes as a function of capabilities. To help improvements in commissioning, we collated our findings into a toolkit for use by stakeholders. We also conducted a small-scale case study of the production of evidence-based guidance to understand evidence ‘push’. Results Fieldwork indicated that different evidences inform CCG decision-making, which we categorise as ‘universal’, ‘local’, ‘expertise-based’ and ‘trans-local’. Fieldwork also indicated that certain practices and conditions (‘capabilities’) enable evidence use, including ‘sourcing and evaluating evidence’, ‘engaging experts’, ‘effective framing’, ‘managing roles and expectations’ and ‘managing expert collaboration’. Importantly, cases in which fewer capabilities were recorded tended to report more problems, relative to cases in which needed capabilities were applied. These latter cases were more likely to effectively use evidence, achieve objectives and maintain stakeholder satisfaction. We also found that various understandings of end-users are inscribed into products by evidence producers, which seems to reflect the evolving landscape of the production of authoritative evidence. Conclusions This was exploratory research on evidence use capabilities in commissioning decisions. The findings suggest that commissioning stakeholders need support to identify, understand and apply evidence. Support to develop capabilities for evidence may be one means of ensuring effective, evidence-based innovations in commissioning. Our work with evidence producers also shows variation in their perceptions of end users, which may inform the ‘push’/’pull’ gap between research and practice. There were also some limitations to our project, including a smaller than expected sample size and a time frame that did not allow us to capture full redesign projects in all CCGs. Future work With these findings in mind, future work may look more closely at how information comes to be treated as evidence and at the relationships of capabilities to project outcomes. Going forward, knowledge, especially that related to generalisability, may be built by means of a longer time and the study of redesign projects in different settings

Navigating turbulent waters : crafting learning trajectories in a changing work context

How do newcomers gain access to learning opportunities when they are denied opportunities to practice? Changes in the nature of work, such as labour outsourcing and technological advancements, have created challenges for newcomers to learn. They may be more easily relegated to low-level repetitive tasks, such as scutwork. In these situations, newcomers’ ambiguous position as learners can limit access to participation in practices needed to progress their learning trajectories. Using field-study data, we explore the situated learning of merchant-navy cadets. We show that, when newcomers are not permitted access to participation, the structural arrangements of practice – temporal structures, spatial territories and hierarchical arrangements – hinder learning opportunities. We show, further, that some newcomers leverage these same structural arrangements surreptitiously as resources to access participation, which we conceptualise as stealth work. Consequently, we unveil the soft forms of power at play in crafting access to learning trajectories, making three contributions. First, we show how structural arrangements of a practice can be leveraged to enable learning. Second, we show that gaining access stealthily, requires both normative and counter-normative performances. Third, we show the importance of access in crafting learning trajectories and unpack how such access is navigated by newcomers