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Maintaining optimal infection prevention and control (IPC) in a busy, clinical environment is challenging. Video-reflexive ethnography (VRE) is a collaborative, interventionist approach to practice improvement. We hypothesised that giving clinicians opportunities to view and reflect on video footage of everyday ward activities would raise awareness of, and suggest strategies to reduce, pathogen transmission risks. We undertook a VRE project, between March and September 2013, in two tertiary hospital surgical wards, with persistently high methicillin resistant Staphylococcus aureus(MRSA) endemicity, despite previous IPC interventions.

Healthcare systems redesign and service improvement approaches are adopting participatory tools, techniques and mindsets. Participatory methods increasingly used in healthcare improvement coalesce around the concept of coproduction, and related practices of cocreation, codesign and coinnovation. These participatory methods have become the new Zeitgeist—the spirit of our times in quality improvement. The rationale for this new spirit of participation relates to voice and engagement (those with lived experience should be engaged in processes of development, redesign and improvements), empowerment (engagement in codesign and coproduction has positive individual and societal benefits) and advancement (quality of life and other health outcomes and experiences of services for everyone involved should improve as a result). This paper introduces Mental Health Experience Co-design (MH ECO), a peer designed and led adapted form of Experience-based Co-design (EBCD) developed in Australia. MH ECO is said to facilitate empowerment, foster trust, develop autonomy, self-determination and choice for people living with mental illnesses and their carers, including staff at mental health services. Little information exists about the underlying mechanisms of change; the entities, processes and structures that underpin MH ECO and similar EBCD studies. To address this, we identified eight possible mechanisms from an assessment of the activities and outcomes of MH ECO and a review of existing published evaluations. The eight mechanisms, recognition, dialogue, cooperation, accountability, mobilisation, enactment, creativity and attainment, are discussed within an ‘explanatory theoretical model of change’ that details these and ideal relational transitions that might be observed or not with MH ECO or other EBCD studies. We critically appraise the sociocultural and political movement in coproduction and draw on interdisciplinary theories from the humanities—narrative theory, dialogical ethics, cooperative and empowerment theory. The model advances theoretical thinking in coproduction beyond motivations and towards identifying underlying processes and entities that might impact on process and outcome.Trial registration numberThe Australian and New Zealand Clinical Trials Registry, ACTRN12614000457640 (results).

Substantial evidence-practice gaps exist in the management of acute coronary syndromes (ACS) in China. Clinical pathways are tools for improving ACS quality of care but have not been rigorously evaluated.

Organizational and wider health system factors influence the implementation and success of interventions. Clinical Pathways in Acute Coronary Syndromes 2 is a cluster randomized trial of a clinical pathway–based intervention to improve acute coronary syndrome care in hospitals in China. We performed a qualitative evaluation to examine the system-level barriers to implementing clinical pathways in the dynamic healthcare environment of China.

While much contemporary organizational research has highlighted how surveillance and self-surveillance are dominant modes of attempting subjective control in organizations, in this article we consider whether ‘being seen’ harbours the potential to also engender an ethics that motivates care for self and other. This ethics resides in an ‘undecided space’— one where individual conduct and subjectivity are not decided by surveillance-based discipline but performed by active subjects in interaction with each other in relation to that discipline. We draw on fieldwork conducted in the spinal unit of a major hospital to explore and demonstrate the instability of the association between discipline and surveillance in organizational life. The article provides an account of how a video-based intervention in the hospital led to alternative conducts and outcomes. We consider examples of in situ practice that show clinicians being dynamically attuned to one another in response to the video study. The contribution of the article is to demonstrate and illustrate how emergent subjectivity and interaction can result from such video ‘surveillance’. We conclude that ‘being seen’ can intensify mutual attentiveness to the point where interaction affords an ethic of care for self and other.

This article analyses the emotional and generic dimensions of critical incident reports. These incident reports have been selected from the specialty of retrieval medicine; that is, a specialized service that transports patients from distant accident sites to hospitals. With its focus on emergencies in distant locations, this area of medicine and the care it provides is a hothouse for procedural difficulties, medical complications and, therefore, emotive language. The analysis demonstrates, firstly, that these reports can contain a range of evaluative expressions, including personal and depersonalized affect, interpersonal and normative udgements, and assessments of the functionality of objects. Secondly, these evaluations frequently harbour a tension between informal (private, emotional, self-oriented) and formal (public, depersonalized, formalized) discourse. Thirdly, the overall structure of incident reports is such as to effect a complex discursive transformation from personal sentiments into organizational assessments and solutions. The article concludes that incident reporting is an important postbureaucratic technique, in that it creates a space where clinicians are invited to link experiential dilemmas to service redesign strategies, and display their commitment to the ethos and practices of organizational improvement.

This essay considers the ways that organizational discourse studies have deployed the concept `discourse'. A review of the literature reveals conceptual ambiguities in the definition of `discourse', as well as pre-analytical distinctions that are imposed between discourse, action and text, and between discourse, beliefs and material practices. The paper suggests that such a priori analytical categories risk tying the researcher to an inflexible research agenda, ruling out engaging with organizational specifics and emergent aspects of practice. The essay argues for an alternative view of discourse that centres on the following three arguments: discourse is not limited to language but also includes image, design, technology and other modes of meaning making; discourse and materiality co-emerge; and discourse manifests a specific, historically situated form of life.

Central to the critical study of contemporary management practice has been an understanding of the possibilities for worker subjugation framed in terms of the disciplinary practices of surveillance and responses to it in terms of compliance and resistance. In this paper, we explore how the volatility of everyday interaction also leads to a different response — one we call ‘observance’. We introduce this term to refer to the process of identity diversification at work, and to create an analytical-conceptual space that is not fully circumscribed by compliance and resistance. To give the concept of observance empirical flesh, we present an account of team meetings held as part of a quality improvement programme in a manufacturing workplace in Sydney, Australia. We use this account to show how the interpersonal dynamics among team workers led to ‘emergent’ subject positions and conducts. Capturing the effects of the volatility of everyday workplace interaction, the concept of observance is shown to account for such emergent positioning and reflexivity. Observance enables us to highlight this and also how people exceed the parameters of surveillance, compliance and resistance, especially in relation to participativecommunicative or ‘immaterial’ forms of work.

Abstract: Within the context of structural theories this paper examines what health professionals say about their clinical service structures. We firstly trace various conceptual perspectives on clinical service structures, discussing multiple theoretical axes. These theories question whether clinical service structures represent either superficial or more profound changes in hospitals. We secondly explore which view is supported though a content analysis of the free text responses of 111 health professionals (44 doctors, 45 nurses and 22 allied health practitioners) about their clinical service structures in a questionnaire survey in two large hospitals that had implemented clinical service structures three years previously. Commentaries unfavourable toward clinical service structures were made by 47.7% of staff, favourable by 24.3%, mixed (both favourable and unfavourable) by 17.1% and non-evaluative statements were made by 10.8%. The most frequent criticisms were inefficient organisation of change (27%), poor management (24.3%), lack of cooperation between staff (15.9%) and failure to empower health practitioners (13.5%). All professions made more negative than positive evaluations of their clinical service structures but the ratio was highest for doctors and lowest for allied health. Ranking of nurses' and allied health staffs' specific evaluations were similar but both differed significantly from doctors.' Unfavourable or negative comments predominated, and change appears more superficial and less profound than advocates of structural contributions hope. Four types of belief systems about clinical service structures are apparent. Some study participants are disposed toward the status quo; others toward restructuring; yet others are team oriented; and a final group is tribally oriented. The implication of this paper for managers is that more work is needed if clinical service structures are to realise the promise of more multi-disciplinarity and less fragmentation across professional groups. For scholars, the implication is that marrying different theoretical frames with empirical data can serve to produce fresh perspectives and perhaps new insights.

Electronic ordering systems provide many potential benefits for improving the efficiency and effectiveness of healthcare delivery. They also have major implications for organisational and communication processes within hospitals. We undertook a qualitative study using focus groups and interviews with doctors, nurses, IT managers, and pathology laboratory managers to investigate the impact of the system on their work processes and relations within a major teaching hospital. This study revealed that the new electronic ordering system involved major alterations to the information management processes within the hospital, which in turn affected communication processes and work relations.

In this paper we provide an overview of research into organizational discourse, making a tentative distinction between organizational discourse studies (emerging from organization and management theory) and organizational discourse analysis (emerging from more linguistic-oriented research). Our primary aim is to focus on organizational discourse studies in a fashion that complements, rather than replicates, previous overviews of the field. In so doing, we suggest that organizational discourse research is too complex and multivariate to be pigeonholed on the basis of academic discipline or research method. Further, abstracting the multiplicity of organizational discourse research endeavors into just two single dimensions as do Alvesson and Kärreman (2000), for example, runs the risk of losing some of this richness. We aim to provide insight into the complexity of organizational discourse and the philosophical and methodological richness that it embodies by highlighting that commentators often straddle dierent positions. To this end, we propose five dimensions by which to map this rich domain of research. Our concluding argument is that organizational discourse studies (ODS) and organizational discourse analysis (ODA) would do well to combine the former's normative and the latter's analytical prerogatives with attention to practitioner-situated problematics and struggles.

The aim of this article is to outline in discursive-linguistic terms how doctor-managers (or ‘physician-executives’ as they are termed in the USA) manage the incommensurate dimensions of their boundary position between profession and organization. In order to achieve this we undertook a discourse analytical study of both recorded, situated talk and open interview data focusing on one doctor-manager navigating between profession and organization. The doctor-manager at the centre of this study locates himself on the boundary of at least three discourses which, in many respects, are incommensurate. These are the profession-specific discourse of clinical medicine, the resource-efficiency and systematization discourse of management, and an interpersonalizing discourse devoted to hedging and mitigating contradictions. While this multi-vocality in itself is not surprising, data show that the doctor-manager positions himself acrossthese discourses and manages their inherent incommensurabilities before a heterogeneous audience and on occasions even within the one utterance. In this particular case, boundary management is achieved by weaving incommensurable positions together into the social and linguistic dynamics of a single, heteroglossic stream of talk. This highly complex and dialogic strategy enables the doctor-manager to dissimulate the disjunction between his reluctance to impose organizational rules on his medical colleagues and his perception that such rules, in the future (to some extent at least), will be the appropriate means for managing the clinical work, and through that the organization.

This paper analyzes different manifestations of the medical record in order to demonstrate how and why some discourse creates greater organizational reach. In doing so, the paper presents four arguments. First, that types of discourse research that analyze organization from the perspective of regularized practices on the one hand, and those which frame organization as narrative and story-telling unfoldings on the other, are to be complemented with discourse research that considers the inherent characteristics of discourse and its relationship to and relevance for organizational process. Second, that organizing discourse is discourse that mediates between specifying and dedifferentiating moments of representation, by interposing standardizing categories, inscriptions and material appearances; only in this way is discourse able to connect the specific and the personalized with the general, abstract, and depersonalized. Third, the paper argues that the paperbased medical record largely absolves clinicians from 'organizing' clinical care as it is defined in this paper: its discourse (content, visual appearance, rules governing authorship) remains 'un-organizing'. Finally, it is argued that the electronic PCIS is being framed in discourse that standardizes how clinical care is informated, and potentially even intervenes in the substance of that care; and while at greater risk of bringing about 'bad records' (Garfinkel 1967), such 'organizing discourse' ultimately achieves 'lines of force' across and beyond the clinic.

There are many complicated and seemingly intractable problems in the health care sector. Past ways to address them have involved political responses, economic restructuring, biomedical and scientific studies, and managerialist or business-oriented tools. Few methods have enabled us to develop a systematic response to problems. Our version of softsystems methodology, SSM+, seems to improve problem solving processes by providing an iterative, staged framework that emphasises collaborative learning and systems redesign involving both technical and cultural fixes.

Australia is fortunate to have medical clinicians with the scientific rigour, ethical drive, and enthusiasmexemplified by Stephen Bolsin. This said, we are not comfortable that these attributes are enough to ensure thecultural resistance to progress is overcome as rapidly as we would want it to be. This commentary will outlinethe main reasons for our discomfort.

This paper considers the tension which develops among participants present at a health planning meeting, and describes the ‘ymbolic violence’ Bourdieu 1991) committed by two speakers on another. The focus will be on the contradiction that arises between bureaucratic discourse which is oriented towards ‘ue process’ and the interpersonalising trend of the talk towards conflict. The paper presents an analysis of around ninety turns of talk, with the purpose of showing two things. First, because the talk is enacted in a formal context and through the bureaucratic register,it is constrained in terms of the ways in which the interpersonal politics can be acted out. Second, the divergence between the speakers’ interactive styles is shown to gradually exacerbate. To be able to bring out this interactive dynamic, the paper provides a ‘ogogenetic’ analysis of the interaction, maintaining an analytical dialectic among levels of language and context. Logogenesis here refers to an analytical perspective which regards the unfolding of meaning in both a systemic (meanings mobilising specific domains of language and not others) and a text-historicising way (meanings ‘evolve’ rom one another in the course of interaction and reinforce or stand in tension with one another).

Health information permeates healthcare delivery from point-of-care, across the continuum of care and throughout the healthcare system’s policy, population health, research, planning and funding arenas. Health information managers (HIMs) expertly manage that information. This commentary theorises the health information management profession for the first time. Its purpose is to identify and contextualise, via a historiographical account, the societal and political drivers that have shaped contemporary Australian health information management and HIMs’ scientific work. It seeks to build our knowledge of the socio-political influences on the profession’s emergence and development, and the projected drivers of its future. Eight critical, socio-political drivers were identified and are addressed in temporaneous order. Scientific medicinehas reflected the influences on medicine in the past century and a half of the medical record and other technologies, laboratory-based sciences, evidence-based medicine and evidence-based health. Standardisationhas underpinned and guided the profession’s practice. The hegemony of non-medical healthcare managersand resource- and performance-related accountabilities emerged in the 1960s, as did the efficiencies of bureaucratisationin healthcare and post-bureaucratic shifts to textualisation and technogovernance. Technologisationhas driven constant change in health information management, as have the forces of the fast-paced risk society. Since the 1980s, the health consumer movementhas propelled regulatory mechanisms that accord patients’ access rights to their medical records and mandate information privacy protections. Finally, a nascent commodification of health informationhas emerged. These forces exert ongoing impacts on the profession. They will, we conclude, singularly and collectively continue to shape its discourses and direction.

This paper addresses the increasingly sophisticated means by which teachers get students to do things. First, it discusses the resources available for realising should-ness, or modulation. In Halliday's (1985:336) interpretation, modulation can be realised subjectively (e.g. 'You should go') or objectively ('You are required to go'). The semantic continuum ranging from subjective realisations via objective realisations to demodalised realisations like 'The requirement is that... ' proposed in the Write it Right industry research monograph Vol. III (Iedema, 1996) is briefly presented. This framework is then applied to seven teacher talk extracts. It is shown that early primary teacher talk tends to make use of mostly subjective kinds of modulation, while late primary teacher talk makes use of both highly objectified and ideationalised as well as highly 'interiorised' forms of control. Thinking of the school as 'an expert system of civic governance' (Hunter, 1994: xx), I argue that students' induction into bureaucratic-pastoral self-discipline and self-determination is enabled by their exposure to and eventual control over linguistic modes of modulation. These modes both increasingly background the sources of should-ness and thus its interpersonal negotiability, and increasingly interiorise the ultimate source of compliance. I also argue for explicit classroom attention to these technologies of positioning and social control.

Politics of the Media Ian Ward, Macmillan Melbourne 1995Art & Social Structure Robert W Witkin, Polity Press Cambridge 1995On Meaning-Making: Essays in Semiotics Mieke Bal, Polebridge Press Sonoma California 1994