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
4 Acting in Anaesthesia
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.
Understanding Anaesthesia 5
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
6 Acting in Anaesthesia
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).
Understanding Anaesthesia 7
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
8 Acting in Anaesthesia
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
Understanding Anaesthesia 9
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
10 Acting in Anaesthesia
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
Understanding Anaesthesia 11
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.
12 Acting in Anaesthesia
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
Understanding Anaesthesia 13
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
14 Acting in Anaesthesia
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
Understanding Anaesthesia 15
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
16 Acting in Anaesthesia
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).
Understanding Anaesthesia 17
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
18 Acting in Anaesthesia
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.
Understanding Anaesthesia 19
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.
20 Acting in Anaesthesia
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
Understanding Anaesthesia 21
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,
22 Acting in Anaesthesia
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
Understanding Anaesthesia 23
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
24 Acting in Anaesthesia
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
Understanding Anaesthesia 25
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
26 Acting in Anaesthesia
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
Understanding Anaesthesia 27
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.
28 Acting in Anaesthesia
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
Understanding Anaesthesia 29
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,
30 Acting in Anaesthesia
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
Understanding Anaesthesia 31
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.
32 Acting in Anaesthesia
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.
34 Acting in Anaesthesia
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
36 Acting in Anaesthesia
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
38 Acting in Anaesthesia
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