Discourse research that intervenes in the quality and safety of care practices

Discourse & Communication http://dcm.sagepub.com/

Discourse research that intervenes in the quality and safety of care practices Rick Iedema and Katherine Carroll DISCOURSE & COMMUNICATION 2010 4: 68 DOI: 10.1177/1750481309351210 The online version of this article can be found at: http://dcm.sagepub.com/content/4/1/68

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Article

Discourse research that intervenes in the quality and safety of care practices

Discourse & Communication 4(1) 68–86 © The Author(s) 2010 Reprints and permission: http://www. sagepub.co.uk/journalsPermission.nav DOI: 10.1177/1750481309351210 http://dcm.sagepub.com

Rick Iedema and Katherine Carroll University of Technology Sydney, Australia

Abstract Drawing on work done in the area of health services research, this article outlines a view of discourse analysis (DA) that approaches discourse as a co-accomplished process involving researcher and research-participant. Without losing sight of the analytical-critical-reflexive moments that have typified discourse analytical endeavours, this article explores a form of DA that moves from discourse as object to be collected and processed away from where it is practised, towards discourse as dynamically emerging reality shared by (clinical) practitionerparticipants and researchers, and as flexible means to intervene in the quality and safety of care practices. The article begins with highlighting the productive potential of discourse research in health. The ethics informing this mode of DA, the article goes on to explain, is interested and trustful ‘entanglement’ with those who populate this field of practice and structure it with discourse. Elsewhere referred to as ‘experience-based enquiry’, the initiative to reframe discourse research as a mode of intervention involves keeping practitioners’ interpretations and analysts’ questions, critiques and conclusions in tension. The article argues that this approach capitalizes on the intrinsically reflexive, dialogic and emergent nature of discourse. To illustrate these issues, the article presents two case studies drawn from recent projects that have manifested these researcher and practitioner-participant dynamics. The article concludes that, as emergent practice, the analysis of discourse benefits from entanglement with the people and the contexts where discourse is produced. Here, analysis vacillates between a feedback device that enables both research participants and researchers to re-appraise their and each other’s practices, and a knowledge production device that generalizes about these practices and the changes to these practices that result from the research.

Keywords emergence, entanglement, feedback, reflexivity, video ethnography Corresponding author: Rick Iedema, Centre for Health Communication, University of Technology Sydney, Broadway, NSW 2007,  Australia. Email: [email protected]

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Introduction This article provides an overview of an application of discourse analysis that seeks to intervene in the way hospital services are provided. It is important to engage with hospital services because clinical work is becoming more complex thanks to the technologization of care, the rising turnover of clinical staff, the mobility of patients and the difficulty of establishing clinical histories, and the slowing growth in resource investment per patient across most industrialized countries (Sorensen and Iedema, 2008). These factors create risks in hospital care as is evident from reports that analyse the rates and frequencies of ‘iatrogenic’ (hospital/clinician-caused) errors (Baker and Norton, 2004; UK Department of Health, 2000; US Institute of Medicine, 1999) and which publish the results of enquiries into clinical failures (Hindle et al., 2005). In general, research that addresses these matters in health care is concerned with mapping types of errors and the attitudes and beliefs that may be associated with unsafe practice (Runciman et al., 2007; Vincent, 2006). Underpinned by approaches derived from epidemiology, this research operates on the (‘gold standard’) principles that measurement and analysis can and need to be standardized, and that accuracy of research findings can be increased by raising sample size (Timmermans and Berg, 2003). The importation of these ‘gold standard’ principles into health services research has meant that research outcomes in this area are often statistical-numerical generalizations derived from the measurement of incident rates, compliance with guidelines, or beliefs and attitudes about safety. When it comes to studying the developments sketched in the previous paragraph and how they impact on the safety of clinical practice, the approaches that are informed by these research principles render in situ complexities difficult to discern, however (Berwick, 2008). Yet if the aim is to address the safety of health care, we do need to engage with local, in situ complexity. This is because safety is realized in everyday practice, not in the dissemination of generalized knowledge repackaged as safety guidelines or practice regulations (Gherardi, 2007). To engage with everyday practice, there is a growing role for research that creates a space for critical analysis, reflexivity and participative engagement. An important premise of such work is that what people do and say is not objectively out there, but ‘citational’ (Butler, 1997); that is, instantiating and perturbing more or less settled social practices. In everyday work, the citational aspect of practice tends to be overshadowed by the taken-as-given naturalness and apparent necessity of practice. Critical social analyses of this problem have revealed that actors are caught in between resource-poor contexts and (health) professional traditions that prevent revisiting and revising the logics informing clinical practice (Degeling et al., 2003). Seeking to go beyond this research, the question that the present article poses is, what kind of research engages with the problem of actors leaving unquestioned the taken-as-given dimensions of their own practices, thereby insufficiently engaging with the (un)safety of their practices? The present article contends that discourse theory harbours a principle that is central to responding to the question just posed. Discourse theory is grounded in the principle of relativization. That is, a practice, meaning or feeling has a relational dimension in that it becomes meaningful by distinguishing itself from what it is not, relative to other practices, meanings and feelings. Once a previously unrecognized aspect of what is enacted,

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meant or felt, is allowed to come into view, the original practice, meaning and feeling may lose their natural and necessary status and may reveal their local and historical contingency (Iedema, 2007). The research presented in this article evokes this contingency for research participants by using video ethnography and video reflexivity. In video ethnography, we are confronted with the moving image as it interrupts our sense of who we are and what we do (Iedema et al., 2007). By being videoed (ethnographically) and then invited to observe their own practices, meanings and feelings (using ‘video reflexivity’), people’s ‘citations’ become available for exploration and experimentation. This is because the moving image embodies a dynamic and therefore ‘othering’ visualization of what we say and do. Indeed, moving vision effects ‘a continuous displacement of the subject, the object and their general relation . . . it is an opening onto a space of transformation’ (Massumi, 2002: 51). Engaging with ourselves through moving vision therefore harbours the possibility of transformation; an effect that we will describe as the emergence of ‘a new structure of attention’ (Iedema et al., 2009; Thrift, 2004). The focal concern of the present article is how such a new structure of attention may result from practitioners’ engagement in video-ethnographic research. To address this concern, the article sets out an approach that borrows from discourse theory, ethnography, design science and participatory research. By way of background, the article first explores developments evident in the area of discourse analysis that resonate with the work presented here. The article then moves on to describe specific instances of in situ enquiry to put some empirical flesh on the argument put forward. The article concludes with a statement on the implications of these developments for the future of discourse research as theorybased endeavour and its role in social analysis. In doing so, emphasis is placed on pursuing the practical implications of social critique through entanglement between discourse researchers interested in broadening their engagement with an increasingly complex social world and practitioners involved in rapidly changing sites and practices.

Existing modalities of discourse analytical research praxis On the whole, discourse research can be said to encompass two overarching strands of enquiry. The first is one that emerged from linguistics some time ago (Harris, 1952) and which edged up from the sentence analysis towards analysis of ‘the whole text’ (Coulthard, 1977; De Beaugrande and Dressler, 1981; Stubbs, 1983; Van Dijk, 1977), including spoken exchanges (Berry, 1981). This strand is focused on understanding patterns of language use in different forms of linguistic and textual practice. Enquiry here centres on developing generalizations about text patterns and types, sentence constructions and registerial phenomena (see Martin, 1992 for an overview). This strand can also be said to encompass work initiated during the 1970s by a group of UK researchers called ‘critical linguists’ (Fowler et al., 1979). These critical linguists fused linguistic analysis and critical theory. The purpose was to link language patterns to political ideologies (Hodge and Kress, [1979] 1993). This strand was bolstered when it began to cross-fertilize with the lexico-grammatical analyses developed by Michael Halliday ([1985] 1994), producing a rich vein of politically motivated discourse analysis (Martin, 1985). When in the late 1980s Norman Fairclough expounded the theoretical bases of a critical approach to discourse analysis (published as Fairclough, 1995), seeds were

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sewn for an influential paradigm that capitalized on the combined strengths of analytical and critical enquiry: critical discourse analysis (Fairclough, 1992). The second main strand of discourse research centres on exploring the socio-political aspects of contemporary social practices. Placing less emphasis on the analyses of specific empirical objects, this research regards broad social domains as discursive phenomena (Foucault, 1972; Laclau, 2005). The aim here is to denaturalize the principles and assumptions that underpin social practices in general (Thrift, 1997), rather than target language as the re-manifestation of social practices, as is the norm in critical discourse analysis. On the other hand, what unites these two strands of discourse enquiry is interest in the socially constructed and therefore potentially changeable nature of social life (Phillips and Hardy, 2002). In that sense, discourse acts as a banner for work that seeks to challenge takenas-given practices and associated understandings about, and perspectives on, the real. But while both strands of discourse theory conduct critical analysis in the interest of social change, limited evidence exists of researchers engaging with the institutions and practices sought out for critique. This observation becomes acute in light of the ‘liquid’ (Bauman, 2000) or ‘foamy’ ontology of contemporary post-industrial societies (Sloterdijk, 2004, 2005). The rapidly shifting knowledge base of late-modern social life, and the increasingly complex and multi-faceted nature of power and control, both in organizations (Clegg et al., 2006) and in society generally (Sloterdijk, 2005) is certain to affect discourse however defined, raising questions about the durability of discourse theoretical frameworks and discourse analytical generalizations. It is not insignificant in this regard that prominent social theorists like Nigel Thrift and Nikolas Rose, for whom ‘discourse’ represented an important theoretical tool in the 1990s (Rose, 1996; Thrift, 1997), are now actively pursuing prediscursive concerns focusing on the neurological and affective dimensions of social and organizational phenomena (e.g. Rose, 2004; Thrift, 2004). Besides their interest in the non-representational dimensions of being, these writings bear out sensitivity to the tentative nature of knowledge and the inherent changeability of practice. Of further interest is a recent redefinition of discourse enquiry that makes explicit the practical outcomes of such enquiry. In a broad-ranging overview of discourse research, Sarangi provides a typology that distinguishes pure and applied enquiry from consultancy and consultative research approaches (Sarangi, 2005). Having constructed this typology, Sarangi points to the ‘pretence’ that we can isolate a problem from in situ practice and then presume our analyses are relevant to those we write about.1 Sarangi goes on to specify consultancy as targeted problem-solving, or as the roll-out of expertise to address practitioner-defined dilemmas. Here, research is at once subjugated to the needs of practitioners, and conducted with reference to theoretically well-established principles and strategies. In Sarangi’s definition, this modality of research offers limited interaction between researchers and researched other than around specific and potentially quite isolated problems. The fourth component of Sarangi’s typology, consultation, differs from consultancy as follows: . . . the consultative model is more of a collaborative exploration of the nuances of professional practice, where the applied linguist/discourse analyst has not only to justify and problematise what constitutes the object and objective of research but also to rely heavily on the insights of the professional practitioner in making sense of the phenomena under study. (Sarangi, 2005: 373–4)

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In this fourth paradigm, the discourse analyst is not positioned as the expert who arrives with theoretical knowledge in hand to offer advice on how to resolve or minimize communication difficulties. Instead, consultation relies on the researchers and the researched collaboratively addressing problems: ‘a consultative research network is premised upon collaborative partnership, mutual respect and trust’ (Sarangi, 2005: 374). Consultation involves the practitioner as ‘co-researcher in a consultative, reflexive mode’ (Sarangi, 2005: 374). To some extent, consultation is an option more characteristic of participatory and appreciative action research (Cooperrider and Whitney, 1999; Reason, 1999) than discourse analysis, engaging researchers and researched in closely connected research partnerships. But Sarangi insists on a ‘sense of commitment mediated through a situated understanding of participants and their life-world’ as becoming ‘a necessary attribute . . . orienting to the practitioner’s insights as a way of enriching our interpretive practice’ (Sarangi, 2005: 376). Sarangi identifies this research stance as one of ‘thick participation’: Thick participation constitutes a form of socialization and it should not be equated with becoming a professional expert. There is more to expertise than a familiarization with experience from the periphery. What I have in mind here is more of an acquisition of professional/organizational literacy that would provide a threshold for interpretive understanding. (Sarangi, 2005: 377)

For Sarangi, the line between interactional expertise (knowing how to talk to practitioners about their work) and contributory expertise (knowing how to do practitioners’ work) (Collins and Evans, 2002) remains fluid: ‘thick participation is not an either/or matter and . . . there are degrees of participation at stake’ (Sarangi, 2005: 377). Making thick participation possible requires more than traditional discourse analytical methods: ‘Understanding and interpreting others’ practices are dependent on such a participatory stance, which amounts to a reconfigured fusion of ethnomethodology, praxiology and ethnography . . . we have to opt for joint problematisation and provision of ‘‘hot’’ feedback’ (Sarangi, 2005: 389). What is envisaged here is a paradigm of research praxis that puts the critical brief of discursive analysis in tension with the here-and-now relevance of practitioners’ dilemmas and interpretations of those dilemmas. Inevitably, this involves putting discourse theoretical expertise at risk, potentially leading to questions about the usefulness of discourse analytical research for those about whom it speaks. Sarangi’s thinking here echoes Luke’s point: that if we are to take the axiom of ‘what is to be done’ seriously in current conditions, critical discourse studies must turn towards a reconstructive agenda, one designed towards redress, reconciliation and the rebuilding of social structure, institutional lives and identities. (Luke, 2004: 151)

Luke’s call for ‘a flexible analytical toolkit’ (Luke, 2004: 151) mirrors Sarangi’s conceptualization of a hybrid critical-reconstructive praxis that involves the researcher and the research participant in shared sense-making about practice. Sense-making, if read in the context of Weick’s work whence the term derives theoretical currency (Weick, 1993, 1995), is a practice that is not just retrospective, but also prospective and creative, leading to: inquiry in which participants and researchers co-generate knowledge through collaborative communicative processes in which all participants’ contributions are taken seriously. The

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meanings constructed in the inquiry process lead to social action, or these reflections on action lead to the construction of new meanings. (Greenwood and Levin, 2000: 96)

Against this background, the remainder of the article will outline an instance of discourse research that privileges two principles. First, discourse analysts locate themselves in the midst of constantly emerging organizational discourses and practices. This involves confronting the dilemma that the contemporary complexity and fluidity of social and organizational structures require a strategic and flexible stance. Second, discourse analysts are not just suppliers of theoretical and methodological expertise, but people who exploit their ability to recognize the relativity in situated practice, including their own, to move into new roles, cross professional-organizational boundaries, and become co-productive of new professional-organizational realities. To exemplify what such stance looks like in practice, the article now moves on to present two empirical case studies where these principles were realized. What will become evident here is that our concern is not to analyse ‘found practices’ using standard discourse analytical techniques. Rather, we seek to make sense of what is going on alongside practitioners, and, through this feedback and dialogue, co-produce new practices and meanings.

Discourse research as collaborative enquiry The empirical material presented here underpins a form of discourse research that privileges co-accomplished sense-making of practice involving researcher and researched, or, if you like, research participant (Karnieli-Miller et al., 2009). Without losing sight of the analytical-critical moments that have thus far driven discourse analytical endeavours, we will use this empirical description to explore what it means to move from discourse analysis as the deployment of a pre-designed analytical framework and critical objectives towards a stance that creates ‘sites of engagement’ (Latour, 2004) where researcher and research participant partake in the co-construction of discourse as a dynamically emerging practical reality. For the purpose of the present article, the empirical material encompasses two project case studies. The first case study is sited in an out-patients spinal clinic in a local metropolitan teaching hospital. Here, we will consider how the researcher’s interpretation of who they are and what they understand about spinal care is affected by the spinal clinicians’ appropriation of her visual data for reconceptualizing cross-infection in their unit. The second case study is sited in an Intensive Care Unit at a regional hospital, where the negotiation over what to film, what to screen back and how to interpret the footage harboured unanticipated risks, intensities and outcomes for both the researcher and the clinicians.

Case study 1:  the spinal clinic The spinal clinical team participated in a three-year study2 that centred on filming the team doing their everyday work. The filming was done to understand how staff come to embody and enact the increasingly complex processes that are typical of contemporary health care provision. Central to the project was to film clinical practices and show these back to clinicians to learn together (researchers and clinicians) about what was going on, a process referred to as ‘video reflexivity’. As noted above, such learning is crucial for clinicians and consumers due to the rising complexity of contemporary health care. In spinal care in

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particular, this rise in complexity results to an important extent from medical technologies enabling clinicians to do much more for patients now than they could 20 or even 10 years ago (Brown and Webster, 2004).3 This further means that the provision of health services is creating a growing population of chronically ill patients who are, in different ways, dependent on sophisticated kinds of expert medical care, but also on increasingly specialized nursing care, allied health care and community care. Further adding to this complexity, patients themselves are increasingly called upon to ‘co-produce’ the treatment of their own precarious health through self-care, requiring them to be knowledgeable about their condition, treatment, pharmaceutical dependencies and biophysiological needs (Iedema et al., 2008). As far as the spinal clinic is concerned, complexity is inherent in spinal patients’ frequently developing pressure sores from lying still over extended periods of time. These sores often get infected with multi-resistant organisms (MROs) that are transmitted by clinicians who carry them on their clothes and hands. Indeed, cross-infection in hospitals counts among the most serious and costly kinds of clinician-caused incidents (Duerden, 2005; Pittet, 2005), with the cost of in-hospital acquired infections estimated at US$17– 29 billion yearly in the US and at £1billion in the UK (Pittet, 2005). Invasive infections with MROs such as ‘methicillin resistant staphylococcus aureus’ or MRSA are associated with high levels of preventable morbidity and mortality (McLaws and Taylor, 2003). For that reason, the accelerating spread of these hospital-acquired infections (Whitby et al., 2001) calls for intensified ‘surveillance’ of clinicians’ practices to minimize crossinfection. Alongside intensive care units and emergency departments, spinal units are cross-infection hotspots (Vidal, 1991). The screen back of footage showing everyday practice at the spinal unit led to two unexpected developments. First, an infection control nurse who happened to see the footage at a feedback meeting realized that the visual data harboured information that she had not noticed when surveilling people’s practices ‘live’ on the ward. Although hospital-caused cross-infection was not a pre-determined focus of our study, we began working with this nurse to draw out the implications of the infection risks that were evident in the footage (Iedema and Rhodes, in press). The infection control nurse requested to see more footage of clinicians dealing with patients who had infected wounds, enabling her to identify numerous previously unrecognized cross-infection vectors. Where before she had to spend hours on the ward with a clipboard to rate clinician compliance with rigid personal-protective equipment and hand-washing rules, she was now able to identify (for herself and for us) how infections can travel across bodies (from one wound to another on the same body), tools (through handling of mobile phones, referral letters) and spaces (from beds across consult rooms into corridors). Second, the infection control nurse insisted on using this video data to engage the spinal clinicians in discussions about infection control risks. During the bi-monthly video reflexivity meetings the clinical team thus became involved in focusing on cross-infection risks affecting their practices. Footage was shown of clinicians examining patients’ wounds and then leaning on the bed rail, transferring potentially infectious material to a place where other people could pick it up and carry it further again (Figure 1). Other footage alerted the clinicians to the risk of overflowing bins – items that had not been noticed before because they had become taken-as-given and no-longer-noticed elements of the ward environment (Figure 2).

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Figure 1.  Clinician leaning on handrail

Figure 2.  Bin overflowing with potentially infectious material

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Upon viewing the footage, one of the clinicians comments as follows (I = infection control nurse; D = doctor): Extract 1: Reflexive feedback meeting (15/2/05) 8:204 I. it’s really exciting, it’s great 8:25 D. I think it will give us an idea as to whether or not we’re bringing the multi-resistant bugs into the ward from clinic, and whether or not those bugs are evolving and getting more and more resistant as [name patient] comes into contact with other patients. I think they’re the sorts of things we want to know, as objective outcomes, but I guess the other thing is the behaviour that may be contributing to that, and what that is.

This exchange foregrounds two issues of interest. First, it evidences the video footage’s capacity to produce new ways of seeing, and that this new way of seeing in turn creates interest among those present (Iedema et al., 2007): ‘it’s really exciting’ (8.20) and ‘they’re the sorts of things we want to know’ (8.25). Second, it shows the clinicians engaging with the problems highlighted in the footage and thinking through what these insights mean for their practice: ‘it will give us an idea as to whether or not we’re bringing the multi-resistant bugs into the ward from clinic’ (8.25). To us, the researchers, the clinicians’ involvement in exploring practical implications of what they had seen was an unpredetermined outcome of a complex process of negotiation. That is, the reflexive session was contextualized by a range of dynamic positionings on the part of the researchers and the clinicians: the researcher negotiating with clinicians what to film and what to screen back; the infection-control nurse picking out specific footage and requesting that more comparable footage be identified; the clinical team being comfortable with the infection-control nurse driving a particular set of interpretations of the footage;5 and the researchers enabling the clinicians to ‘take over’ when it comes to determining the implications of what is shown for practice. In the extract below (extract 2), taken from the same meeting transcript as extract 1, the researcher who led the reflexive sessions admits to having ‘crossed boundaries’, and points to how important crossing boundaries is to enabling specific issues dropping out from the video reflexive meetings to be pursued by all involved. The point of the discussion replicated in extract 2 is that both researchers and clinicians should be able to let go of their conventional professional expectation of autonomy so they can begin to engage with the implications of reflexive practice. For the researcher, this means allowing the research participant to co-determine what is important and why (Karnieli-Miller et al., 2009). For the clinicians, this means acknowledging that there are patient safety risks that may not be visible to them when they are ‘in the thick of things’, caught up in the ‘hurly-burly’ of everyday practice. Extract 2: Reflexive feedback meeting (researcher speaking to clinicians; 15/2/05) 4:33 We had a meeting with the infection control people, and I wasn’t completely aware of what we were doing, and I feel a little bit nervous about crossing boundaries and working both outside my area of expertise and in what I’m supposed to do, and I’m very

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Figure 3. Video-reflexive feedback meeting in the spinal unit

excited by the opportunities that the infection control stuff is creating for us . . . And we went down there and [name doctor] said “[name researcher] do you want to chair this”, and I immediately went “I don’t know what I’m doing” . . . And it was a confidence issue – it was me being very, very nervous about not wanting to overstep my boundaries, and having an enormous amount of faith in [name doctor]’s ability, more confidence in [name doctor]’s ability to handle the situation than mine, so yeah, I’m not pointing fingers at anything I haven’t done myself. But I think it is something, that if [name doctor] genuinely wants to devolve responsibility, and if the rest of the team genuinely feel that that is an important thing for the clinic – and if you don’t maybe that’s a conversation that needs to be had, but if you do, then strategies for both the passing over and the receiving [of responsibility] are probably worthwhile discussing.

Crossing boundaries enables the researchers to be told what is important in the data that was captured and why. For the clinicians, boundary crossing makes clinical practice visible ‘from under a different aspect’ (Wittgenstein, 1953), entraining new sensibilities and responsibilities with regard to heretofore invisible problems, errors and infection risks. Put in these terms, viewing the real ‘from under a different aspect’, the discourse analytical move par excellence is enabled by the tactic of boundary-crossing, and this tactic is crucial to patients’ safety: new ways of seeing engender a new inter-professional communicative space where material-clinical risks become visible and discussable.6

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Case study 2:  the Intensive Care Unit The second case study was conducted in a regional Intensive Care Unit (ICU) as part of the same project that funded the spinal unit work discussed above. This part of the study involved working with clinicians on their ICU communication practices. Through discussing with them what they saw as issues of concern, one of the things we agreed to pay attention to was their medical information hand-over sessions or ‘ward rounds’ (Carroll et al., 2008). To make aspects of this practice visible, a 15-minute DVD was edited from the many hours of footage collected and this DVD was shown at a reflexive session (Figure 4). As with the spinal clinicians discussed above, viewing the DVD enabled the ICU doctors to see aspects of their own work they had not seen before, despite, or perhaps thanks to, being deeply embedded in ICU practice. But this seeing is not automatic. It is contingent on a complex process of negotiation between the researcher and the clinicians preparing both for sometimes quite confronting insights: I . . . realised there was quite a complex flow of information going on as there were several contributors about each patient but there was talking at different levels about different things, there were fragments of things that people needed to say and then the big picture about this, and then suddenly a small detail issue . . . and they leapt from one to the other and then back to the big picture. There is no build up . . . they just get thrown in as fragments from one to the other. (Intensivist, 26 October 2005)

Besides commenting on the organizational complexities embedded in ward round hand­ overs, this intensivist also focuses on the interpersonal challenges: The things that I was noticing . . . was this is quite daunting for the junior doctors. I realized there was a semi circle of people standing in front of them . . . it looked quite an intimidating situation . . . they were forced to try and create and maintain people’s attention . . . they had to put on an act to try and get people not to be bored . . . other people were struggling to maintain interest by bed 14 . . . not only is it a daunting role but to have to put on a show to try and get people to listen to them . . . I hadn’t realized it was an acting skill as much as a communication skill. (Intensivist, 26 October 2005)

As the researcher who initiated this process explains, deciding what to show back to clinicians is not unproblematic, because inevitably interpersonal issues arise alongside organizational ones. Clinicians’ responses to such range of issues are therefore not necessarily predictable: In the process of video reflexivity the researcher and her video ethnographic gaze is exposed to the experts of the field, resulting in the researcher not only looking alongside clinicians as they interpret the visual footage but also being available for both direct criticism and praise in this creative research space. (Carroll, 2009a: 103)

The video reflexive moment takes place in an uncertain, and potentially creative space where the researcher’s tentative portrayal of clinical practice seeks to dialogue with

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Figure 4.  Negotiating handover practices in ICU

clinicians’ understandings, priorities and concerns. To the extent that clinical work itself is unpredictable and ‘messy’, and clinicians’ interpretations of what is ‘good care’ often diverge (Iedema et al., 2006a), the visual portrayal of clinical work is complex. Such portrayal runs the risk of privileging one particular perspective over others, erasing from the reflexive discussion others’ interpretations and concerns because they missed out on being screened (Carroll, 2009b; Iedema et al., 2006b). On the other hand, video footage is rich in what it captures, and, as with the infection control nurse seen above, its impact cannot easily be predetermined. Hence, screening back visual data situates the researcher in a space of uncertainty and risk: Although this is the more difficult research route, accepting the uncertainty and the ‘mess’ that comes with this creative space also means facilitating the side-benefit of creativity and innovation for clinician-participants. (Carroll, 2009a: 108)

For those willing to negotiate over what to film, what footage to screen back, how to see the footage and what conclusions to draw from it can create a new vitality; that is, a ‘new potential for interaction’ (Massumi, 1995: 96).7 This new potential for interaction emerges from putting at risk that which to date was allowed to appear natural, necessary and ‘automatic’. As with the first case study, the risks inherent in boundary-crossing are therefore not principally sacrificing theoretical and methodological integrity, but, by having one’s

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assumptions and starting points challenged through seeing them ‘from under a different aspect’, having to co-negotiate new communicative spaces and discursive opportunities.

Discussion The discussion above has sought to demonstrate how research can deploy data and methods to perturb taken-as-given practices and spaces, including its own. The negotiation over what to visualize, how to read the footage, and where to take these reflections made it possible for the researchers and clinicians to enter a not-yet-experienced communicative space. In this space, researchers and clinicians created a new potential for interaction, and they risked engaging with a vitality whose orientation and effect were unpredictable and uncharted. In negotiating over what to film, what footage to show and how to respond to it, researchers and clinicians confronted what had until then been natural and necessary, part of everyday business. In doing so, both parties came to apprehend themselves as at once self and other; as practitioners whose academic and clinical routines were now no longer unquestionable. Central here of course is the visualization of practice in that it de-objectifies objects (bringing newly to the fore handrails, bins, ward rounds and other props that populate everyday clinical work) and de-subjectifies subjects (denaturalizing the roles, functions and status of spinal specialists, infection control nurses, ward round leaders, researchers). Put differently, visualization makes questions possible about how subjects have come to act as they do, and about how objects have come to be used the way they are, and about how all this has been allowed to appear natural and necessary by being framed and rendered stable discursively. As Massumi explains, viewing ourselves on the screen effects a complex transformation of how we relate to what we normally take as given. Being shown on a video screen, ‘a de-objectified movement fuses with a de-subjectified observer’ (Massumi, 2002: 50–1). On this basis, visual footage or ‘movement-vision’ affords transformation in that the screen distances the viewer from herself while at the same time unhinging what is shown from the natural and necessary flow of life. It [‘movement vision’] is an opening onto a space of transformation in which a de-objectified movement fuses with a de-subjectified observer . . . The elementary unit of the space of movementvision is . . . a fractured movement-in-itself: change. (Massumi, 2002: 50–1)

Critical to the central argument of this article, the transformations accomplished in both case studies are the discursive analytical move par excellence (Iedema, 2007): the reframing of what appears to be essential to everyday practice into contingence, or ‘discourse’. The notion discourse does not function here as a label for particular objects (language, visuals, spaces of meaning making, and so on) that can be collected, analysed according to a schema, and judged against standardized criteria (power, emancipation, practice improvement). Rather, discourse is a way of seeing, a stance vis-a-vis the practices, meanings and feelings that populate lives, and whose experience (thanks to that stance) is amenable to being de-automatized, and thereby revitalized. To be sure, the recent emphasis on the pre-discursive, affective and neurological dimensions of co-existence (Thrift, 2004) is to acknowledge that practice and discourse

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are hostage to a multiplicity of automatized phenomena such as biophysiological processes anchored in bodily proprioception and exterioception – processes that we have little to no conscious control over (Damasio, 1994; Ledoux, 1996). ‘The fact that emotions, attitudes, goals, and the like are activated automatically (without any conscious effort) means that their presence in the mind and their influence on thoughts and behaviour are not questioned’ (Ledoux, 1996: 63). One way for discourse research to work with rather than ignore the limits of conscious analysis of, reasoning about, and intervention in practice, is by confronting and crossing socially and organizationally sanctioned boundaries, such as those that are inscribed into theoretical frameworks, methodological routines and organizational spaces. Specifically, then, by de-automatizing the conducts that commonly define discourse research as ‘discipline’, researchers may enter discursive praxis. This praxis acknowledges rather than erases the prepersonal dimensions of the research relationship, allowing unpredictability and messiness into the research process, and affording indeterminate outcomes rather than theoretically and methodologically predetermined ones. In this, the visual representation of practice plays the role of catalyst. As discourse that is able to place the taken for granted ‘under a different aspect’, visualization helps perturb what is taken as given. The argument developed above does not involve suggesting that we discard approaches to discourse research that involve data collection and analysis to realize particular descriptive or critical objectives. What the argument does imply is that we begin to ask questions about discourse theory and analytical frameworks; questions that discourse research in general and critical discourse research in particular have to date not adequately addressed (Chouliaraki and Fairclough, 1999; Martin and Rose, 2004). For example, how confident can we be in reading the meaning(s) of social practice off from discursive objects when we know that these objects themselves are becoming increasingly unstable (Iedema, 2007)? Put in different terms, what relevance do generalizing theoretical and analytical frameworks have for engaging with social practices that are becoming increasingly dynamic thanks to intensifying modes of feedback and rising rates of change and innovation (Sloterdijk, 2005)? Indeed, the turnover of repertoires of (discourse) practice is now so fast-paced that some have begun to speak about a ‘permanent emergency’ that forces people to adopt a ‘hair-trigger responsiveness to adapt to the expectedly unexpected’ (Thrift, 1999: 674).8 Can it be then that theoretical frameworks and disciplinary approaches, beyond mapping what is, constrain what could be? Could it be time to take stock of that which has come to define discourse research, and engage with challenging viewpoints, such as Luke’s preference for a ‘reconstructive agenda’, to revitalize taken-as-given assumptions and practices?

Conclusion This article has presented two examples of research that consisted of the construction of a local praxis involving the research participant, that is, the producer of what is at interest for the discourse researcher. This approach to discourse research pursues the emergence of social phenomena and relationships in the first instance, de-emphasizing methodological routines and analytical conclusions in the interest of acknowledging that, when placed ‘under a different aspect’, practices, meanings and feelings may

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emerge in unexpected ways and appear very different. This approach research treats its resources and principles as springboards for initiating and exploring relationships, rather than as analytical-critical courses of action that pre-determine outcomes and effects. Framing itself as emergent practice, we contend that the study of discourse benefits from entanglement with the people and the contexts where discourse is produced. Here, the production of discourse does not reference the object of meaning or feeling which the analyst proceeds to invest knowledge in, but the realization that what was once assumed to be natural and necessary is now discourse, moveable, reconceivable and changeable. Here, analysis vacillates between a feedback device that enables both research participants and researchers to re-appraise their and each other’s practices, and a knowledge recording device that captures these practices and the changes to these practices that result from the research. No doubt, the paradigm presented here challenges discourse analytical conventions as much as it upsets social scientific expectations about appropriate methodologies, authoritative findings and generalizable outcomes. But if discourse analysis is to have relevance in the contemporary world, it will only do so if it can capitalize on its most significant achievements: the relativization and historization of practices, identities, knowledges and values, and the building of solidary relationships through transformation. Notes 1. The pure/applied research distinction has been challenged in rather more critical terms elsewhere: ‘The terms pure research and applied research imply that a division of labour can exist between the pure and the applied, a division which we believe makes social research impossible’ (Greenwood and Levin, 2000: 94). See below. 2. Australian Research Council Discovery Project 0450773. This project had ethics approval from the University of NSW, the University of Technology Sydney, and from the health departments where the research was done. 3. Up until 20 years ago, most patients with spinal fractures simply died. 4. These figures refer to transcript number and place in the transcript. 5. We report on other outcomes from this project elsewhere (Iedema and Rhodes, in press; Iedema et al., 2006b, 2007). 6. There is widespread evidence that clinicians refuse to report problems to or errors made by colleagues. Medicine places a high premium on ‘medical autonomy . . . and has a historical lack of inter-professional cooperation and effective communication’ (US Institute of Medicine, 1999: 142). Consequently, ‘even when problems are noticed . . . such as the disturbingly high yet stable incidence of nosocomial [hospital-induced] infections . . . remedial actions such as hand washing occur with modest frequency’ (Weick, 2004: 189). 7. This second case study led to the clinicians initiating three practice changes (Carroll et al., 2008): they agreed to split the handover process into two separate groups operating at either end of the ICU, alleviating the burden of communicating details and absorbing clinical information for all involved; time was set aside for medical staff to assess patients in greater detail immediately after the ward round, creating more time for discussion between junior and senior medical staff, and a daily worksheet was adopted which helped clinicians in structuring the different kinds of handover information, and in making sure that everything was covered. 8. In health care, this ‘hair-trigger awareness’ manifests not just in ‘emergency’ (rather than ‘casualty’) now being the principal entry point to contemporary medical practice, but also in ‘constant vigilance’ being advocated to limit the spread and rise of clinical failures and errors (Reason, 2004).

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Rick Iedema is a Research Professor in Organizational Communication and Director at the Centre for Health Communication, Faculty of Arts and Social Sciences at the University of Technology, Sydney. His work addresses how the organization and communication of  clinical work impact on patients’ safety and well-being. In addition to Discourses of Post-Bureaucratic Organization (Benjamins, 2003), he has published The Discourse of Hospital Communication (Palgrave, 2007, editor), Identity Trouble (coedited with Carmen Caldas-Coulthard, Palgrave, 2008) and Managing Clinical Processes in Health (co-edited with Ros Sorensen, Elsevier, 2008). Katherine Carroll is a medical sociologist whose research explores the in situ complexities of health service delivery in Australia. Her methodological interests centre on participatory video-based methods and feminist approaches to research design. Using complexity theory, her PhD examined how clinicians in intensive care construct certainty in a highly unpredictable environment. [email: [email protected]]

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