Responsive Routines

The nature of (medical) professional work is changing rapidly. Because of increased knowledge and better technologies, patients live longer but cases become more complex. This complexity requires multiple, diverging team compositions. Current literature reports poor teamwork as main cause of failures in critical care. Several standards to organize professional work have been introduced; they are mainly clinical and patient oriented. Studies demonstrate that these standards are not well incorporated in daily work processes. The fact that they are evidence-based and arise from within the occupation, makes it more puzzling that usage remains limited.

Our understanding of how and why new procedures get institutionalized or not is still limited. We argue that new standards must be ‘woven into’ technical and social taken-for-granted ways of working. Therefore, we look at professional routines, which connect individual behaviour and system action, but also link assumptions, artefacts and practices. We see standards as artefacts. This in line with scholarly work on organizational routines.

The paper presents an ethnographic analysis of how professionals in the critical care department of an academic hospital in the Netherlands use artefacts in multiple workflows. We question how new forms of more organized professionalism are being embedded in existing professional routines (or not). In order to advance our understanding of complex medical processes, we shadowed professionals from different occupational groups (e.g. anesthesiologists, surgeons).

Formal standards contrast sharply with real life practices of professional work, we show. It is a matter of treating multiple cases simultaneously, instead of treating individuals. Clinicians therefore have to decide on the spot, and constantly adapt practices. Unpredictable and equivocal conditions require routines that enable interpretation. Our findings demonstrate that using standards in critical care is a matter of joint reflexivity. Using standards is not so much about ‘compliance’ but about responding to high-paced workflows.