Writing Samples 1: Ethnomethodological Work

Lift me up before you go : an ethnomethodological account of a simple organizational matter. [1]

Russell Kelly[2]

University of Central Lancashire

This demonstration involves a simple, everyday organizational problem. Five people are needed to lift a patient in an intensive care unit. More than five people are available, from time to time, throughout a shift, but not all of them can be included. In this instance, the organising of these five people to do this lift is the most talked about, referred to task in this particular eight-hour shift. A lot of working time and effort, that is, much of the talking is about this problem and trying to get it solved. It is the most important matter for the nurses engaged in this shift given that each nurse is otherwise responsible for the particular needs and care of one seriously-ill, ventilated patient.

Looking from the outside, it would seem that these nurses first and primary concern is, and should be, the needs of and care of their patients. Managerially, organizationally - in any formal account of what is or ought to be going on - patient care should be what most of the nurses spend most of their time in an eight-hour shift doing. What is interesting is that organization occurs in and through their talk, management occurs, leadership, authority all key concepts in Sociology occur but not as sociological theory would expect. Methodological questions arise about these important concepts as the data are interrogated because these important phenomena dont seem to occur as they should. Or, at least, as sociologists think they should.

· Key Words: Ethnomethodology, ICU, Lifting, Sociology, Leadership, Organisation, Management, Legitimation.

Ethnomethodologists have identified a host of features of conversation or talk, particularly around the idea that social order in work settings is an accomplishment, is achieved and maintained in interaction, through talk. (Garfinkel, 2001) The qualifying criterion for inclusion in the corpus of ethnomethodological work is that the work seeks to identify members methods for understanding the World and for being-in-the-World. That means that knowledge is not produced by researchers in questionnaires, in interviews, nor in ethnographic studies. Such work is members-as-sociologists doing sociological work for sociological reasons. Ethnomethodology focuses on members doing members work-in-the-World - that is, getting by, working a shift, being ill, nursing on a ward, managing stuff. (Kelly, 1998)

1. Researchers and theorists of any kind tend to treat members as cultural dopes, as dummies, unable to understand, to comprehend or to communicate how it is they manage to exist-in-the-World, as they choose or decide to know how to. The stance most criticised in this regard is that of the anthropologist or ethnographer who interprets the World of other people and informs them of what their World is like. Some might regard that stance as academic arrogance, as racism, as patronising, as colonialism - for ethnomethodology, it is simply not the way to do it.

2. What is known, what can be known - in this sense, the knowledge of place, situation, setting, culture, life world, lebensanschaung - is what we need to know to get by. To do what has or needs to done, here and now. The epistemology rests on an Ontology of the Present.

3. It is Phenomenological - it has its origins as an epistemology - a way of knowing the World - in the philosophies of Kant, Schopenhauer, Husserl, Heidegger and the Sociologies of Georg Simmel and Alfred Schutz.

4. Out of modern Ethnomethodology come questions about the relationship between mind, language and knowledge. There are ongoing discussions about the relationship of the policy for studies with the philosophy of Wittgenstein, of Ryle and of the American Pragmatists, Dewey and James.

5. The main concern is with primacy, or quiddity and haeccity - the just-thisness or just-thatness of members methods. That which a member does, or says, is just that. It has indexicality - it is the description of the situation, of what is going on, of the solving of the problems that any situation poses for members currently engaging, there, without respite, with no time-outs.

This demonstration, rooted in these ideas, involves the presentation and exploration of a set of data. The data is organizational in that it goes on within an organization, within an organization - an Intensive Care unit - within a general hospital. It is about an organizational problem. A patient needs to be lifted vertically in order that an inspection can be made of the patients back and buttocks, for evidence of pressure sores or other areas of damage or discomfort. This requires four nurses, trained in lifting patients, to gather around the bed to lift the patient while a fifth nurse inspects the patients back. The problem, then, is to bring five people together in the same place, to act in concert, to achieve a goal, to lift this patient. What is going on is seeking the solution to this organizational problem. Members, the nurses involved, will as a matter of everyday, ordinary routine to accomplish this task. They will use what methods are necessary for analysing the task such that it can be accomplished and will not note this occurrence as other than a commonplace, everyday activity. Should this task be noticeably or accountably special in any sense, then an account of it as special will be offered and understood by the nurses in the ways that nurses do this sort of thing. (Garfinkel, 1967)

Equally if any theory lies within these actions, these accomplishments of the nurses, that theory and any process of theorising should be indexed in the actions of those same nurses. The data for discovering theorising is their actions, their talk, as they go about working this shift. This is where Glaser and Strauss also directed attention: to the discovery of theory from data. (Glaser and Strauss, 1968, p. 1)

So, How do members do things? Not, How do sociologists, management scientists, or others, describe, count, account, research, explain and expound about their versions of what members do? The data is tape recordings made during a shift where this organizational problem was identified by them as their problem for that shift.

The Problem

This demonstration involves a simple, everyday organizational problem. Five people are needed to lift this patient and inspect for possible wounds. More than five people are available, from time to time, throughout this shift but not all of them can be included. One piece of the work, then, involves categorising who is, or is not, an appropriate members for inclusion in the category, Can help us in doing this lift. In this instance, the organising of these five people to do this lift is the most talked about, referred to task. A lot of working time and effort, that is, a lot of the talking, is about this problem and trying to get it solved. It is, therefore, for them, an important matter given that each nurse is otherwise responsible for the particular needs and care of one seriously ill patient. Other routine matters also need attending to like going for a break, having something to eat, sneaking out for a cigarette, going off somewhere, up the rotas (examining future shift allocation), collecting medication or supplies from the pharmacy or stores, being there to support doctors who do rounds or come to do tests, take measurements, put lines in for drips, for feeding and intravenous medication, ventilating or adjusting the ventilation equipment and monitors to which the patient is attached and on which the patient depends - for life support to survive.

Looking from the outside, it would seem that these nurses first and primary concern is and should be the needs of and care of their patient. Managerially, organizationally - in any formal account of what is or ought to be going on, patient care should be what most of the nurses spend most of their time in an eight-hour shift doing. But as we see, here, other managerial and organizational matters are indexed as relevant and important by these nurses on this shift. The matter is first raised early in an exchange:

Here is where the problem first arises. Martina (Nurse C) asks Pam (Nurse D) to come and look at the bed. What is interesting, here, to the outsider is what is not said, what can apparently be taken for granted. That Martina addresses the request for doing looking to Pam and, despite the use of first names, indicates that Pam has some kind of authority, expertise, superior skill, courage and confidence that warrants the request being put to her.

Sacks (1966) talks about NCDs, or Nominal Categorisation Devices, which he later expands to a discussion of the means of categorisation. In more general sociology, any discussion of status or organization design will tend to begin with some kind of hierarchical diagram of offices or officers. Perhaps it will begin with listing the names used to describe the ranks to be referred to, Sister, Staff Nurse, Charge Nurse. What is noticeable in these two lines is how hierarchy, authority, status, and position are accomplished by these nurses. Martina knows without any reference to title, position, rank (e.g. Sister, Boss, Chief) that Pam is the appropriate person to approach to seek the assistance she requires to lift her patient. The referencing of the request to look at the bed does all the necessary work in indexing rank and relative status. Nothing more than that is required, here, now.

Schegloff, Sacks and Jefferson (1974) write of the simplest form of social organization, turn-taking in conversation. The request phrased by Martina to Pam is just that, the simplest organized and ordered feature of everyday activities - the request when phrased requires a response, that the second turn be taken.

Can it not wait? would be one response. In this case, the inclusion of the categorisation device in Can it not wait, Martina? is doing extra work. What extra work, other than replying does the Martina do? This is a response to the previous Pam, the categorisation device appropriate to this context, at this time, involving these nurses. It is a response to the demand for an authoritative decision regarding the bed (i.e. organising the lift). The response is not a simple reply, or request for further information. Because of the repetition of the categorisation style, Pam-Martina - it assumes the form of a command, Not now - but later..

Nurse A is named elsewhere as Joanna. Joanna addresses Pam while Martina is attending by the bed. The we exchanges in first two lines of this segment are interestingly different from the categorisation devices used in the previous one. If Martina-Pam is taken as a subordinate-superordinate exchange, then the we that characterises the exchange between Joanna and Pam indexes a shared rather then unequal status.

The indexicality of this exchange is a consequence, a reference back, to the previous exchange. For clarification, it is worth noting that all these exchanges take place within one space and will generally be addressed fairly loudly into the space to overwhelm the background sounds of monitors and ventilation equipment. The previous exchange between Martina and Pam would have been available to Joanna who was attending one of several patients in adjacent beds.

In this case, it is probable that that is how Sisters talk to each other and how Staff Nurses address Sisters and how Sisters respond. The Do we?-Yeah exchange, however, conveys a sense of reference-to and deference-towards the one taking charge and thus introducing a further distinction of rank. Pam maybe a Senior Sister or Nurse Manager, Joanna the Junior or Second Sister for this shift. Or the ranking is Sister, E Grade Staff Nurse with Martina as D Grade Nurse. But, then, would a D Grade Staff Nurse have addressed a Senior Sister as in the earlier exchange? Whereas, an E Grade might so address a Senior Sister. Working this out for outsiders is difficult, yet is poses no problem to the participants who manage interactions between ranks with consummate ease. All that can be said, is that the locating of relative status, the categorising of rank, is done, accounted, for sustained and maintained in sentence exchanges juts like these.

Theres nobody out here is stating a logical nonsense. The Nobody is the embodiment issuing this answer. But this demonstrates that rules of logic, of rationality, of counting, fact and precision, are not necessary to the everyday understanding of members Worlds. Not one of the individuals responds to the un-factual statement because they understand that the counting associated with such a response is, in fact, that present are Nobody+1, a quite sophisticated form of natural mathematics. It is sophisticated because it is their accounting system to which they are all party and which suffices for them to organise their World. Managerially, Nobody+1 = Nobody would be a catastrophe, especially when multiplied through all the ICUs, hospitals, etc. because it would require the application of a different mathematics in managerial accounting practices where 2 = 1 or, at least, 1+Nobody! This is one clear point where doing organization in commonsense ways gets the job done while managerial theory and practice rests on some fundamentally divergent ways of understanding the world of the organization. This probably accounts for why applications of managerial theorizing to organisational settings has rarely been either reproducible or successful.

It is interesting that those missing for doing the lift, Jack, Graham and Liam are carrying mens names and are male nurses, an instance that would perpetuate the often repeated myth that male nurses are never around when you need them, or are never there when there is work to be done. It appears to be legitimate for Graham to be at the library. Liam being up the rotas makes Liam available for the lift. The ignoring of Jack would seem to disqualify him from being in the lifting team. Is this how teams are selected? Is this how team work is done? It seems to resemble kids picking two sides in a game on the park. The logic of team construction, the most efficient at goal attainment in the group (Parsons, Bales and Shils, 1953), seems to have gone in favour of Whos around? or Hell do. Hes up the rotas.

There are naturally occurring ways of knowing who is the kind of person it is best to have, from those available, when lifting a patient is the task. Again, what makes this noticeable is that no challenge or confirmation is offered to Pams apparent selection - or is this how managerial decisions are made and conveyed, but unsaid?

The key to remember is that we, the observers, the theorizers, the experts in organization matters, cannot make these decisions. The next statements, exchanges, members actions will tells us somewhere, somehow, whether we would have fitted in or not, with them, in their World. What we are trying to learn in Ethnomethodology is the methods that members have found for doing these sorts of things effectively, without pause, without reflection, as successful accomplishments.

Note that now there are enough people around for the lift to become a possibility, something that Martina and Joanna have been working to organise since the beginning of the shift. The arrangement is however potentially unstable as other things can, might and have to be done. Note the tentativeness in Line 123 as Joanna (A) tries to begin. In Line 128, Martina (C) tries to initiate the action by drawing Joannas attention to the problem of organisation.

Line 130 reformulates the problem as a new problem. Up to this point, needing five has not been posed as a question, or questioned. It was not previously presented as any kind of problem. That Martina and Joanna somehow needed three others to do this lift was not questioned and can be taken to have been something accepted as within their competence, abilities and knowledge and that they could reliably, justifiably, and without question have the right to decide.

What becomes interesting in Line 130-132, is that now the doing of this lift has become possible, this is the point at which the doing of it can be questioned as a necessary thing to be done. Martine and Joanna must not justify that the doable, needs to be done. Two forms of justification are offered. Just in case I have to change the sheets would justify lifting the patient. There is a job to be done and in the doing of it another job might arise. First, the nurses have to look to see if there are wounds, sores, whatever they might routinely expect to find when they lift the patient up. These things are known to nurses. There is an encyclopaedia of what to expect which is not written, is not taught, but comes to be known when youve done that sort of thing a few times. Incidentally, in this case, if the nurses find what they might reasonably expect to find, then this is likely to occasion, change the sheets which, presumably, can only be done with the patient lifted.

Now that the lift can be justified because something has to be done or might expectably need to be done, the account is understood to be not complete, Five? and What for? have not been sufficiently answered. Changing the sheets is understood by Joanna not to be a sufficient justification to the understood managerial challenge which she anticipates. Leadership or managerial authority depend here not so much on the traits or characteristics of the leader or manager since it is not necessarily clear who is doing the managing. Martina was earlier shown to be subordinate with Pam and Joanna as equals but probably superiors to Martina. But, here, it is Joanna who is anticipating that her response to Martinas questioning will need further explication. Martina, the subordinate, somehow seems to have the authority to challenge Joannas need to do this, here, now. Joanna proceeds to anticipate the need for further justification by offering Four have to lift, to lift him up straight. Lines 134 to 138 are a continued challenge which is only resolved with the proper justification For the pelvis which Martina acknowledges as a proper justification for needing five people to do this straight lift of a patient with a possible pelvic injury with, Oh. Right.

While any observer or organizational theorist might speculate wildly about how Martina might have the authority over Joanna who appears from the outset to be acknowledged as the organizational superior (Sister), doing the-authority-to-require-formal-justification-for-an-action occurs as a routine, expected, natural thing to do and to respond to.

In opening the matter for challenge, by anticipating Martinas questioning of the need for five, Joanna offers a turn which produces a further challenge from Nurse E whose significance, or otherwise, to this team effort is indexed somehow by not using her forename.

It may be worth noting at this point that there can be up to 14 working nurses doing their work in this space at any one time. It would not be unusual in the nature of their mutual working for one nurse to turn away for a few moments from the current patients bedside to assist a colleague as Nurse E does here. Nurse E offers the information that two nurses lifted that patient yesterday. That this is a matter of some importance rests in its repetition in Line 142. Joanna, then, recognises the challenge as knowledge that is known, Yeah, I know. and introduces a new a further justification that the action be done in this way Line 143:

Now, Joanna recognises that this process of challenge, anticipated challenge and further challenge, needs some kind of authoritative rebuttal. the orthopaedic does this work. Orthopaedics can obviously do forbidding in ways that senior nurses on a shift cannot.

Again a possible team is assembled as Pam (D established earlier as a Senior Sister) offers one of the male nurses a challenging question with an implicit command that completes the necessary complement to do this lift.

But this occasions a repeat of the ultimate authority to justify the lift team as Joanna anticipates the challenge for the male nurse. It is interesting to that Joanna and Martina have progressively, with other team members, worked up, constructed a sufficient justification for doing this lift in this way. The reasoning process now only requires the repetition of the last and sufficient authority for the male nurse to join the team to do the work. Because there is no further challenge or justification offered, the male nurse appears to take it for granted that this reasoning process has occurred and has reached this sufficient point of justification. Now the work starts:

In Lines 163, as the work begins, Martina identifies an emergent problem (Taylor and Van Every, 2000), the need of the fifth. Joanna extends the reasoning further to include the need for the fifth one has to look under because we cant see when we lift. It is now impossible (Line 165).

Pam, Pam, the Senior Sister now moves off to attend to something else. As well as nurses, other people are justifiably present on the Unit. Some are relatives who have to be attended to. Pam wants the relatives to move out of the immediate space to out here, where she is currently which again has a kind of nonsense logic. Here is where I am but it is also not here, because it is out. The expectedly correct phrasing would be out there but since I am there presently, it must be here so out here is routinely and ordinarily correct and is understood by all those present in that nobody challenges or seeks further clarification.

Joanna now proposes to defer the lift as Jack has agreed to come later, for five oclock. Joanna proposes to wait until, then, from now, so long as the generic authority, her understands that it has to be done. Again the her is hearably a reference to someone or some authority which the hearers understand with challenge or comment. Martina proposes to continue as the organization of the team is nearly complete, we just need Sarah, now.

The lift gets done. But the job is not complete. The team has to be held together as Nurse E moves off and the patient it is so heavy.

Comment

This has been an examination in some detail. It could have been in even greater detail but with this audience, I know I can take for granted an enormous amount and still get through the presentation without significant challenge. The data have been addressed looking for the kinds of things we might expect to see. Organization, management and sociological theorists would have directed our attention to obvious matters, leadership, authority, power, control, legitimation The list could be considerably longer. In so far as these concepts are applicable to the solution of this simple organizational problem, then we ought to be able to find the concepts readily in the data. One thing is for certain from this data, members, that is the nurses, do not use or make reference directly to any of the concepts that are likely to be found in textbooks about these matters. At best we might use the reference to the orthopaedic as some kind of reference to professional dominance (Freidson, 1970 and still prevalent in Freidson, 1994). We might use the ways of referring to the missing male nurses as gender issues but there is no obvious indication that the men are more powerful or have greater authority, that patriarchy is rampant.

Power, authority, legitimation and similar kinds of concepts need some serious reworking to match the data presented here. The lift and its organization need some justification in the setting but to whom and by whom is never clear, nor are those who assume the right to challenge or to question necessarily those with the position, the responsibility or the organizational authority to do so. If management or leadership occur then they emerge as features of the job getting done. They are descriptors of doing the job which members, that is, the nurses might recognise afterwards if we, the sociologists, drew their attention to them as matters of interest to us.

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[1] The first version of this paper was presented to the Society for the Study of Symbolic Interactionism at the American Sociological Association 96^th Annual Meeting, Anaheim, 18-21 August, 2001

[2] E-mail to RSKelly@uclan.ac.uk or RSKelly@tiscali.co.uk


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