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.

“Scissors, Please.” The Practical Accomplishment of Surgical Work in the Operating Theatre.

The focus of this article is on professional activity in the operating theater. We explore how surgeons and nurses organize their activities, how social interaction is used to help structure and define situations, and how differentials in knowledge are constructed and oriented to. We utilize some ideas and concepts from symbolic interactionism, ethnomethodology, and conversation analysis to analyze small clips of audio- and video-recorded interaction. Focusing on how surgeons and nurses request, provide, and apply surgical instruments, the analysis shows how surgical work is accomplished through talk and bodily conduct. We conclude that, examined in detail, the social interaction between surgeons and nurses is analytically inseparable from the “technical” demands of their work.

Read the full article: Bezemer, J., Murtagh, G., Cope., A., Kress, G. and Kneebone, R. (2011). “Scissors, Please” The Practical Accomplishment of Surgical Work in the Operating Theatre. Symbolic Interaction 34, 3, 398-414.

“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.

Learning, Design and Performance: Towards a Semiotic-Ethnographic Account of Surgical Simulation.

In this chapter I develop a semiotic-ethnographic perspective on medical simulation. I attempt to investigate simulation as a social semiotic practice in its own right and move away from the current focus in medical education on validating simulation in terms of ‘replication’ of and ‘transfer of skills’ to the ‘real’ environment. I propose to make a distinction between ‘simulator’ and ‘simulation’. By a simulator I mean a set of resources –objects and/or places –that are made available for simulation; by a simulation I mean the social interaction that unfolds when these objects are used in situ. A simulator can be relatively static when it is made available for a particular occasion and maintains its shape throughout the simulation, such as the simulator I discussed in my examples. A simulator can also be ‘dynamic’, for instance when objects can be made to respond (manually or by computers) to the unfolding activity. A simulation is dynamic by definition as it is shaped in social interaction. Thus, a simulator can have a life span of many years, or for as long as the objects last, whereas a simulation is ephemeral: it ‘exists’ for as long as its users wish to sustain the simulation.

We can also differentiate between two groups of social actors involved in simulation. Designers include those who make simulators. Performers are those who use the simulator and produce the actual simulation. Together designers and performers co-construct simulation. Designers produce and assemble objects and spaces which performers use as resources for simulation. In any study of simulation the distribution of agency among these groups requires careful attention. One social actor can be both designer and performer, for instance when new simulators are tested out, but they are more likely to be different people whose social relation is pedagogic: by designing a simulator designers can structure simulation, i.e., by providing resources they can steer the performers into certain directions and shape their engagement with the world.

Simulators and simulation both involve designers and performers simulating, yet in different ways and for different purposes, drawing different relations with what is simulated: some foreground what is seen to be typical, others foreground what is a-typical. They use different strategies to work out what is and what is not typical, ranging from ‘systematic’, ‘empirical’ research to ‘idiosyncratic’ ‘recollections’. As they simulate they transform, for instance a performer may re-enact certain hand movements; and they transduct; for instance a designer may transduct a three dimensional object to an image on a banner.

The full chapter will appear in: N. Pachler & M. Böck (eds). Multimodality and Social Semiotics: Communication, Meaning-making and Learning in the Work of Gunther Kress. New York: Routledge.

“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.

Assessment of Competence in the Operating Theatre

My colleague, Alexandra Cope, went to the 15th Ottawa Conference to present a joint paper on the assessment of competence in the operating theatre.

Background: Assessment of competence in the operating theatre has not previously been defined. Assessment by a trainer of when a trainee becomes competent is through a process of inference from observing the trainee’s performance during other cases.This study sets out to define what domains are regarded to contribute to general operative competence.

Summary of work: Semi-structured interviews with 10 trainers and 12 trainees in UK hospitals. This was a purposeful sample including doctors from both teaching and district general hospitals. Interviews were audio recorded, transcribed and thematically analysed by a panel of author from different academic backgrounds.

Summary of results: We identified different types of competence required in the operating room – routine technical competence, adaptive competence, motor competence and social competence.

Conclusions: Assessing competence in the operating room environment is complex and requires assessment across several domains to ensure that decisions about whether a trainee is ready to ‘go solo’ are robust. There is a requirement to be able to cope with the unexpected, complications and patient variability as well as routine tasks.

Take-home messages: A taxonomy of curricular items required for competence has been created and should be considered by trainers when assessing whether a trainee is ready to ‘go solo’.

Alexandra Cope, Stella Mavroveli, Jeff Bezemer, George Hanna and Roger Kneebone (2012). Assessment of Competence in the Operating Theatre. Paper presented at the 15th Ottawa Conference, Kuala Lumpur, 11th March 2012.