Partnerships in research: Doing linguistic ethnography with and for practitioners

In this chapter I reflect on linguistic-ethnographic research I conducted in partnership with surgeons. My focus is twofold: I explore how the partnership has shaped my research; and I illustrate how linguistic ethnography can contribute to public and professional debates about health care. Three joint research projects on learning and communication in the operating theatre form the backdrop of the chapter. In each of these projects I worked closely with two surgeons: Roger Kneebone and Alexandra Cope. In the first project, ‘Mapping Educational Activity in the Operating Theatre’, we looked at on-the-job surgical training (funded by the London Deanery, the organisation responsible for postgraduate medical education; and the Royal College of Surgeons of England). In the second project, ‘Digital Technologies in the Operating Theatre’, we explored the role of video technology in surgery (funded by the Economic and Social Research Council (ESRC)). In the third project, ‘Transient Teams in the Operating Theatre’, we investigated communication between surgeons and nurses during operations (funded by the ESRC). The chapter is based on my field notes, email exchanges with my research partners and memos I wrote after field work. The chapter follows different stages in the partnership. First, I discuss the field work I did in a London hospital. Second, I outline the theoretical and methodological perspectives that guided my initial engagement with the data. Third, I present two case studies that illustrate how I built on these perspectives to address the concerns of surgeons, health care professionals and the public more widely, which focus on the pertinent and timely question of how to improve the safety and quality of health care.

Bezemer, J. (in press). Partnerships in research: Doing linguistic ethnography with and for practitioners.
In F. Copland, S. Shaw and J. Snell (eds). Linguistic Ethnography: Interdisciplinary Explorations. Palgrave Advances Series. Read the manuscript.

“Do You Have Another Johan?” Negotiating Meaning in the Operating Theatre.

This paper discusses language use at a workplace in a context of instability and diversity. Its focus is on the operating theatre, where communication is an integral part of complex, collaborative tasks, impacting on patient-safety, staff well-being and overall quality of health care. In the operating theatre health care professionals gather to work on the recurring task of surgical operations, in teams that exist only for the duration or parts of the task. Not only do the members of these unstable teams have different professional backgrounds, such as surgery and nursing, they also draw on different, social, cultural and linguistic resources. The paper shows how this instability and diversity which is so characteristic of contemporary society plays out in the moment-by-moment use of language at the operating table. On the basis of prolonged fieldwork in a London hospital and a unique set of audio- and video-recordings we show how surgeons formulate requests and how nurses and surgical trainees disambiguate these requests on the basis of their prior experiences with surgical instruments and equipment, the surgical procedure, and, crucially, the surgeon’s ‘idiolect’. We analyze instances where this process of disambiguation is highly successful, as well as examples where it is not. We tease out the strategies that nurses and surgeons deploy to deal with this ambiguity and explore ways to deal with instability and diversity in professional communication.

Read the full article:: Bezemer, J., Cope., A., Kress, G. and Kneebone, R. (2011). “Do You Have Another Johan?” Negotiating Meaning in the Operating Theatre. Applied Linguistics Review 2, 313-334.

“Are you happy?” Collaborative decision making in the operating theatre

Decision making has become a key term in the endeavours of health professionals, patients, policy makers and researchers to describe clinical work and explain its outcomes. In this talk for the Social Science Research Forum, Queen Mary University, 27 March 2012, I explore how decisions are made in the operating theatre. I will report the initial findings of a detailed analysis of talk during 12 laparoscopic gall bladder removal operations. The focus will be on who says what to whom prior to the cutting of the cystic duct and the cystic artery. This is a critical moment in the operation as there is a risk of incorrect identification; the structures to be cut look like the main structures from which they branch off and which should not be damaged. Our analysis shows that in this data set the decision to cut the structures thought to be the cystic duct and cystic artery was always made in collaboration, irrespective of whether it was a consultant or a registrar who was operating. By asking, eg, “Are you happy?” the ‘operating’ surgeons sought confirmation from their (senior) colleagues prior to making the cuts. I will discuss the implications of this form of collaborative decision making, and place them in relation to current discourses, in the NHS and in society at large, about participation, sharing, agency, responsibility, and transparency.

“How many lap choles have you done?” A linguistic-ethnographic take on counting surgical experience

Introduction

In this paper we explore a site of work and learning that is rarely investigated ethnographically and to which few applied linguists have gained access: the operating theatre. Taking up the 2011 BAAL Annual Meeting’s theme, ‘The Impact of Applied Linguistics’, we argue that linguistic ethnography, through detailed analysis of situated, embodied interaction (Maybin & Tusting 2011), can and should make an important contribution to research on and improvement of the quality and safety of health care.

Background

Surgical trainees learn to operate through participation in numerous operations. Clinical research has shown that the complication rates of cases performed by trainees under supervision are comparable to those of cases performed by consultants (Acun et al., 2004). However, ‘process variables’, such as the (variation in) the communicative features of the supervision that was provided, have received little attention. Our study was aimed at rendering these features visible and placing them in the wider social-pedagogic context of the operating theatre, highlighting the dynamic, embodied interaction between consultant-supervisors and surgical trainees.

Data and method

Observations were carried out in a major teaching hospital in London by a linguist and a clinical researcher. 35 cases were observed (equivalent to 82 hours of operating time), 10 of which were audio and video recorded (22 hours of operating time). A wireless microphone was worn by one of the surgeons, and in-built video cameras were used to capture the operative field. Field notes of all operations were kept by the researchers. All staff in theatre and all patients involved have given informed consent to collect the data. Ethical approval was granted by the UK National Health Service Research Ethics Committee (ref nr 10/H0712/1). Video clips were transcribed multimodally, detailing use of speech, instruments, and hand, arm and head movements.

Results

Linguistic-ethnographic analysis of interaction at the operating table shows how surgical trainers and trainees coordinate their actions using all communicative resources available to them (see also Svensson et al 2009; Bezemer et al. 2011a, 2011b). These include speech, gesture, gaze and posture, as well as their use of instruments. Each of these resources offer distinctly different potentialities and constraints for instruction. For instance, on one occasion a trainer may use speech to describe to the trainee the operative manoeuvre to perform (cf. “Do you see that white line there? That’s where you need to dissect”); on other occasions the trainer may point to anatomical structures (giving meaning to deictic elements such as ‘here’ and ‘there’), reposition the hands of the trainee, or take over control over the instruments to demonstrate the next action. Trainees display embodied responses to this guidance, and trainers adjust their guidance in accordance with these responses and the unfolding operation. Thus the degree of guidance can vary significantly from moment to moment: some operative manoeuvres may be performed by a trainee without any visible or audible guidance, whereas others are strongly mediated by multimodal instructions.

Discussion

The variation in the degree of guidance given to trainees who ‘perform’ an operation under supervision raises important questions about how operations are recorded, analyzed and assessed in professional surgical discourse. The number of times that surgical trainees have ‘performed’ or ‘done’ a procedure is often taken as a reliable indicator of their surgical experience. For instance, the randomized control study discussed above compares operations ‘performed by’ trainees with operations performed by consultants. Our study shows that such classifications wrongly suggest that trainees classified as ‘(operating’) ‘surgeon’ have had equal control over the operation. Operating surgeons are not necessarily primary ‘agents’ throughout an operation: they don’t always ‘do’ or ‘lead’ the operation; nor are they merely passive ‘recipients’ of instruction. To measure participation in operations adequately more sophisticated categories will need to be used, detailing changes in the degree of guidance.

Our study shows that linguistic ethnography and applied linguistics more generally can contribute to an important research agenda from which it is currently noticeably absent. By rendering visible the moment-by-moment unfolding of surgical operations and the training embedded within it we have drawn attention to the complexities and contingencies of clinical work and patient safety in situ, thus complementing generalized pictures of ‘what works’ (Iedema, 2009) and ‘what is safe’ (as in randomized control trials). These insights are crucially important as linguists, ethnographers, clinical researchers, policy makers and health care professionals work together to improve health care.

Acknowledgements

The paper was part of a colloquium, The Impact of Applied Linguistics: Using Linguistic Ethnography to Study Health Care, organized by the UK Linguistic Ethnography Forum (www.uklef.net). The other speakers were Jamie Murdoch, Deborah Swinglehurst, Sara E Shaw, Celia Roberts (chair) and Rick Iedema (discussant). The research reported in this paper was supported by the Royal College of Surgeons of England, who funded a research fellowship (2009-2010), and the London Deanery, who granted an award under the Simulation and Technology-Enhanced Learning Initiative (2009-2011).

References

Zeki Acun et al. (2004). A Randomized Prospective Study of Complications Between General Surgery Residents and Attending Surgeons in Near-Total Thyroidectomies. Surgery Today 34(12): 997-1001.

Jeff Bezemer, Alexandra Cope, Gunther Kress and Roger Kneebone (2011a). “Do You Have Another Johan?” Negotiating Meaning in the Operating Theatre. Applied Linguistics Review 2: 313-334.

Jeff Bezemer, Ged Murtagh, Alexandra Cope, Gunther Kress and Roger Kneebone (2011b). “Scissors, Please” The Practical Accomplishment of Surgical Work in the Operating Theatre. Symbolic Interaction 34, 3, 398-414.

Rick Iedema (2009). New approaches to researching patient safety. Social Science & Medicine 69(12): 1701-1704.

Janet Maybin and Karin Tusting (2011). Linguistic Ethnography. In: James Simpson (ed), The Routledge Handbook of Applied Linguistics. Routledge, London (pp. 515-528).

Marcus Svensson, Paul Luff and Christian Heath (2009). Embedding instruction in practice: contingency and collaboration during surgical training. Sociology of Health and Illness 31(6): 889-906.

Please refer to this paper as: Bezemer, J., A. Cope, G. Kress, & R. Kneebone (in press). “How many lap choles have you done?” A linguistic-ethnographic take on counting surgical experience. In: The Impact of Applied Linguistics. Proceedings of the 44th Annual Meeting of the British Association of Applied Linguistics. London: Scitsiugnil.