2.2. Work practice
This section explicates and illustrates what I mean by the everyday work practice that I have chosen as the most essential starting point for this study.
Work practice in this thesis accounts for the concrete and mundane activities of practitioners as they are encountered by the members of work communities in the everyday settings. The interest is particularly in the processes of interaction between practitioners and their use of the material media and tools as well as technological environment in the collaborative activities of producing intelligibility and interpreting meanings to be able to carry out their everyday work.
My interest in everyday work practice is different from the social theories that also deal with practices and use them as a starting point for social structuring and theory building (e.g. Giddens 1984, Smith 1988) as I do not extend my analysis to social theorising but rather remain on the level of theories of technology and work research. Research with similar interests in work practice has been carried out in studies that intertwine work practice and system design, especially within the field of CSCW (e.g. Suchman et al. 1999, Suchman & Trigg 1991, Goodwin & Goodwin 1997, Hughes et al. 1992), and can also be found in collections such as Greenbaum & Kyng (1991), Chaiklin & Lave (1993), Button (1993), Engeström & Middleton (1996) and Resnick et al. (1997).
The example below concretises my take on work practice by presenting an instance of everyday work in one of the radiology departments in OUH that was observed early on in the fieldwork. The extracts[1] outline and illustrate work activities as concrete and situated, which means that work activities occur in particular places in actual organisations and at particular times. Work practice is further characterised by describing the complex social organisation, technological mediation, knowledge and meaning as socially constructed, and the intertwined nature of the unfolding activities in which all these aspects are joined.
Airi, a radiologist, has performed a CT-examination on a patient who has had a persistent pulmonary problem. She has asked a more senior radiologist, Eeva-Liisa, to join her for the image interpretation. The consultation takes place in front of an alternator which Asta, a developer[2], has prepared for the image interpretation session. She has mounted some films on the light panels, organised the patient materials in the patient examination folder (PEF) accompanied by the patient’s film file (see Table 1, Picture A, p. 27).
The session starts with the radiologists reading through the request to find out the specific question formulated by the admitting clinician (Picture B and Transcript B, p. 27). They then search for some additional images of previous X-ray examinations in the patient’s film file. As they find the appropriate films they mount them on the light panels (Picture C and Transcript C, p. 28).
With the films of previous X-ray examinations displayed Airi and Eeva-Liisa position themselves side-by-side in front of the light panels with their bodies aligned towards the mounted films. Eeva-Liisa orientates by finger pointing Airi’s attention to the images she’s reading and describes verbally the considerations that are substantial for diagnosis. They establish an understanding of how the patient’s pleural fluid has developed over a period of time and clarify what they should be looking for (Picture D and Transcript D, p. 28).
The light panels are changed and Eeva-Liisa continues systematically directing the interpretation through the images of the patient’s previous and current CT-examinations. They agree that there continues to be pleural fluid on both sides. Airi poses a tentative cause for the pleural fluid (“impaired heart functioning”) and as they try to find an explanation for the fluid they go back to some of the images and discuss the diagnosis (Picture E and Transcript E, p. 29).
Elsi, a roentgen-nurse, comes up from a CT-scanner to ask Eeva-Liisa whether the next neurological patient to be examined should be prepared for the injection of contrast medium. Eeva-Liisa concedes as she glances through the request that Elsi holds out for her to read (Picture F and Transcript F, p. 30).
As Elsi withdraws the radiologists quickly conclude the diagnosis and Eeva-Liisa hastens over to the CT-scanner. Airi finishes the case at hand by dictating a report. As she summarises the interpretation she refers to the patient materials on table and the films on the light panels (Picture G and Transcript G, p. 30).
An instance of everyday radiology work practice.
| Picture A. Asta, a film developer, mounts films on light panels for the radiologists’ image interpretation session. |
| Picture B. Two radiologists, Eeva-Liisa and Airi, read the request. |
Transcript B: Eeva-Liisa: Well, what do we have here? Airi: A by-pass has been done … before that has had a stroke, viscous pleurisy on the left and … Eeva-Liisa: Difficulty in breathing … biopsy. Are there any X-ray images? | |
| Picture C. Radiologists search for and mount X-ray images. |
Transcript C: Eeva-Liisa: (Takes a film from the table) Here is an eighteenth of July, what is it like? It is like that. (Takes another film). This has been taken the twenty-first of July.… let’s mount this on the light panel (rises and mounts the film). Airi: (Takes a film from the film file) Here is another, a fifth of August. Eeva-Liisa: (turns to Airi) Is there? Airi: Yeah, but it’s a side view. | |
| Picture D. Radiologists interpret X-ray images. |
Transcript D: Eeva-Liisa: And there it’s been like that (points along arrow 1 and taps on the image) and then in that (shifts to point along arrow 2, then withdraws her arm) side view it’s been about the same, so there’s not much difference, maybe it has diminished a bit from there. Airi: Yeah (nods). And a couple of utterances later: Eeva-Liisa: Well, this (points along arrow 3) may be what they want us to look at. | |
| Picture E. Radiologists interpret CT images. |
Transcript E: Eeva-Liisa: There it’s done with contrast medium (points at a film depicted by arrow 4) in 21.7.94 when there has been pleural fluid on both sides, and not much else. Airi: Hmm (looks at the images displayed on the upper light panel and nods). And a couple of utterances later: Eeva-Liisa: And then today this has been done without contrast medium. Here’s probably the same finding (points at film depicted by arrow 5. Airi looks at the same film and glances at the film depicted by arrow 6, then returns to look at film pointed at by Eeva-Liisa). Has the pleural fluid diminished? It has diminished from here (points at film depicted by arrow 6. Airi looks at it again). Maybe it has diminished here, but I think there is more here (Eeva-Liisa points at a film depicted by arrow 7). Airi: Yhmmmm (nods). Eeva-Liisa: Don’t you think (continues to point at film depicted by arrow 7)? Airi: Yeah. There’s more on the left (shifts her gaze a couple of times between the films depicted by arrows 6 and 7 and nods). Eeva-Liisa: On the left. It has increased there but, but, (points at film depicted by arrow 8 and continues gesturing at four images on the last two rows of the film. Airi follows Eeva-Liisa’s gestures and looks at the images). Well, no lumps have appeared there or anything like that. Airi: Yeah (looking around the films). A while later: Airi: Has this been caused by impaired heart function (….) Eeva-Liisa: Well… no. (Both keep looking at the films). At least it doesn’t really look like being so (…) the heart is big though, but I don’t think this plethora is in any way (points at a film depicted by arrow 7) very prominent, well there may be something messy there but not so very much. There’s been some fluid here too at that time (points at a film depicted by arrow 6) as you can see in those CT images but… Airi: Yeah. Eeva-Liisa: I mean the parenchyma certainly looks somewhat messy so it’s not quite normal, but whether it was caused solely by a heart condition or not it’s hard to say. Airi: Hum… Eeva-Liisa: Surely it’s partly possible. | |
| Picture F. A nurse steps in to ask a question. |
Transcript F: Eeva-Liisa: ... there are no tumor alterations ... Elsi: A back examination ... should we inject this one beforehand? Eeva-Liisa: I suppose you could have a venous cannula prepared. | |
| Picture G. Airi dictates a report. |
Transcript G: Airi: Dictating, dictating, Airi [surname];, of [patient’s name and social security number];, pulmonary HRCT and CT, colon, pleural fluid found on both sides, comma, on the right side pleural fluid has diminished in comparison to previous… | |
2.2.1. Social organisation
Here the analysis of work practice as complexly socially organised begins from the point of view of the social actors acting in a work environment. By analysing human interactions with others and with the material environment the purpose is to elucidate what counts as competent practice that encompasses the work. Competent work practice becomes manifest in behaviour and activities that rely on a foundation of purposeful and mutually intelligible interaction. The everyday intelligibility of social organisation can be achieved by identifying and describing aspects of practice in terms that are relevant and meaningful to practitioners. As particular behaviors and activities have to be understood in relation to how they are embedded in the social and historical fabric of everyday work, discerning them as aspects of social organisation may require a thorough familiarisation with the work practice.
In this example Airi has consulted Eeva-Liisa who has more experience in viscero-CT examinations. As they sit down Eeva-Liisa says “what do we have here” to commence the session (Transcript B, p. 27). They collaboratively read through the request, occasionally uttering aloud some keywords. Eeva-Liisa leads the way in interpreting images (Pictures and Transcripts D and E, pp. 28-29). She continually directs Airi’s attention to the image she is reading and brings up what is worth noting. Airi occasionally nods or utters something to express that she is attentively following. At times they engage in a dialogue to clarify something or to establish an agreement. They form a descriptive diagnosis for the patient’s condition as nothing conclusive could be found.
In the clinic of radiology collaborative image interpretation sessions are a regular part of everyday radiology work practice, specialists with residents, peers with different specialities, and specialists consulting subspecialists for second opinions etc. Not only are the collaborative sessions to ensure the best available expertise for each case but they also offer possibilities for learning and passing on the interpretive expertise and lived-experience of seniors. In this particular case Airi learns more about diagnosing this particular kind of examinations through an apprenticeship with Eeva-Liisa.
Another interesting example of complex social organisation of radiology work is the subtle intervention by the roentgen nurse to ask a question from Eeva-Liisa (Picture and Transcript F, p. 30). The instance makes visible the occupational division of tasks and responsibilities in the clinic. Elsi comes over to ask about the next patient’s examination because radiologists make the decisions on how the patients are examined as interpretive diagnostics is exclusively their field of expertise. Elsi needs to know the type of examination as it is her duty to prepare the patient and the equipment for the CT-scanner to be able to assist the radiologist during the examination.
However, what might be even more interesting to note here is how the practitioners collaboratively organise their action to get the job done (cf. ‘working division of labour’, in which “the separation, individuation and combination of activities is accomplished in an accountable way through a collectively developed, negotiated and evolving knowledge and practice” (Hughes et al. 1992, p. 117). By coming over and asking about the injection the nurse also informs Eeva-Liisa, who is to perform the next examination but currently engaged in the interpretation of another case, that the next patient is almost ready, except for the possibly needed venous cannula. Elsi implicitly negotiates the schedule with Eeva-Liisa and allocates various resources, e.g. optimal use of the CT-scanner, care for the patient not to have to wait for too long and radiologist’s expertise. As Elsi withdraws the radiologists quickly finish the interpretation and Eeva-Liisa hurries over to the CT-scanner to give the injection and begin the examination.
2.2.2. Technological mediation
Seeing work practice as technologically mediated presupposes that work is materially organised. By material mediation I refer to the ubiquitous use of paper and paper-based mundane artifacts in human activities, or as in radiology work practice the use of film and film-based artifacts, which then also become the material for the everyday organisation of work. There is a handful of workplace studies that have taken a special analytic interest in the material mediation in studying particular mundane artifacts from the point of view of system design (Harper & Sellen 1995, Sellen & Harper 1997, Heath & Luff 1996, Hughes & King 1996, Luff et al. 1992, Yates 1989, Suchman & Trigg 1991, Trigg et al. 1999, Berg et al. 1997, Berg 1998 and Engeström et al. 1988)[3].
The study of work practice as materially mediated recognises the intimate relation between work and technology, i.e. that available technologies as well as the material mediation on which they are based afford certain resources and constraints on how the work gets done. Not only is it important to locate the mundane artifacts and more elaborate technologies within the work sites, but also to investigate how they are used, i.e. how they become integrated into work through practitioners’ actions (cf. Suchman & Trigg 1991, Suchman et al. 1999, Goodwin 1994b).
The above instance of radiology work takes place on the alternator that is used for the interpretation of viscero-CT examinations. Alternators, which are devices that are used for the display and short time storage of films, allow the radiologists a relatively undisturbed workspace in which they can focus on the images and concentrate on the diagnostic interpretation but, should the occasion arise as it did in the above example, they can also be easily approached due to their proximal location to the examination and imaging devices. The large area of light panels affords for an overall view of images, for a rapid exchange of light panels from the alternator magazine used for temporary storage of mounted films if they cannot be fitted on one pair of light panels, and for continuous juxtaposition of images for simultaneous reading and comparison between images during interpretation, though individual images may also be read carefully by moving closer to them. The alternator environment affords side-by-side peripheral awareness during collaborative image interpretation, i.e. the radiologists can have unhindered access to the numerous images arranged on the light panels and stay aware of each other’s orientation. As the collaborative process is based on joint seeing, the radiologists meticulously keep a mutual focus of attention during interpretation. Airi and Eeva-Liisa take advantage of orientation of the body, movements of the head and direction of the gaze, as well as pointing and gesturing which intimately intertwine with their deictic talk (Pictures and Transcripts D and E, pp. 28-29). Radiologists’ interaction is intimately mediated through the films they interpret.
In image interpretation sessions radiologists need to examine and bring together a multitude of patient documents. Radiological images are examined in reference to other patient representations which may be other images or medical records. During the interpretation process radiologists form spatial associations between the images as they have to be ‘connected’ to have meaningful relationships. In a previous article we have called this ‘shared interpretation of a space of representations’ (Kuutti & Karasti 1995). These spatial associations establish effective cues for recall, allowing the radiologists to return to appropriate images as the need arises.
Another example of the technological mediation of radiology work practice that becomes visible in the above instance is an artifact which is pervasive in all roentgen departments but so mundane and taken-for-granted that it has no name. I have named it patient examination folder (PEF) as it is formed for each patient to be examined by collecting her/his patient materials into a plastic folder and made use of throughout the entire examination trajectory (cf. Strauss et al. 1985). The PEF starts out with at least the request in it, more materials are added as the examination progresses, in the end it is dismantled and the films are returned to the film archives. The PEF affords for flexible use of the patient materials in each situated instance of usage. In the above example the film developer prepared the PEF by checking that all materials were in order and by inserting a small number tag to notify on which light panels the patient’s films were mounted as she organised the alternator for the radiologists’ image interpretation session. The radiologists consulted the PEF in the beginning of the session to check for the right light panels and to read the request (Picture B, p. 27). During interpretation they returned to the PEF to reread some segments of the patient’s roentgen history and patient record. The nurse used a PEF of another patient when she came over (Picture and Transcript F, p. 30). She had stripped off all other materials but the ones that the radiologist would need in making the decision about whether the examination was with or without contrast medium.
These two examples illustrate how the mundane artifacts and technologies are used and gain their significance in everyday radiology work practice. Image interpretation is intimately mediated through the material used in imaging. Furthermore, plenty of ‘film work’ is carried out to ensure the availability of films along the patient examination trajectories.
2.2.3. Socially constructed knowledge and meaning
Research that focuses on work practice requires a radical conceptual switch “to seeing knowledge and meaning as socially constructed within ongoing communities of practice” (Jordan 1996a). This necessitates analysis of everyday work practice from the point of view of practitioners achieving competent practice through activities that rely on a foundation of purposeful and mutually intelligible interaction. The everyday intelligibility becomes manifest, for example, in the analysis of work practice where the practitioners can relate the observable activities and events with their own experience of what counts as accountable practice, and thus identify and articulate meanings of work as they are called in this thesis.
Furthermore, studying knowledge and meaning as socially constructed necessitates, instead of distinguishing between expert and routine work, an investigation of all work with regard to the judgement and reasoning required in its accomplishment[4]. This requires exploring the dimension of knowledge that is often labelled ‘invisible’, i.e. tacit, implicit, and not easily articulated. “Most of tacit knowledge is not really tacit, but rather codified in local practices and communication. As such, it is subject to negotiation, revision, and argument. If we think of it as out of the control or conscious attention of scientists, we mystify it and black box it out of our own reach.” (Star 1995, p. 109.) To make the invisible visible, to tease out the implicit, complex workplaces need to be investigated for the practical task-oriented activities and the competencies in which practitioners co-construct knowledge and skill by drawing on the social and material resources available to them.
This calls for close observation of everyday work settings rather than interviewing practitioners about their work as their accounts may differ from how the work is actually carried out. It means finding intriguing and captivating such mundane practices that the members of a work community may disregard as taken-for-granted. For instance, with regard to the instance above, the radiologists explained to us that the session was uninteresting because there were so few findings in the case. Furthermore, the practitioners may experience difficulties in trying to articulate the mundane and tacit aspects of their work. For example, radiologists’ descriptions of image interpretation characteristically omit the detailed texture of the activities involved. As they have learned the practice through several years of apprenticeship, by sitting side-by-side and seeing together, they are unable to put into words the complex embodied practice and their experience, i.e. experiential knowledge that is gathered in and through everyday activities.
By and large the radiologists’ joint image interpretation is a good example of the co-construction of knowledge and meaning in work because it is exactly the essence of cooperative interpretative diagnostics. The work activity is based on an intimate sequential examination of relevant radiological images where “everything has to be read” followed by a more focussed scrutiny of selected images, such as the ones suspected of pathology. In the unfolding process of image interpretation the radiologists draw on their knowledge and expertise. Airi knows initially more about this particular patient case as she has familiarised herself with the patient records and met with the patient during examination whereas Eeva-Liisa has more experience in CT-viscero diagnostics in general. Airi offers her initial formulation of the suspect cause for the problem (impaired heart function) and Eeva-Liisa considers it but does not find enough evidence for it in the patient images. Consensually they arrive at a statement noting the pleural fluid but no specific pleural or pulmonary reason for it.
The session also gave us fieldworkers an early insight of the tacit knowledge which film developers employ in their work of ensuring a well-organised material environment for radiologists’ image interpretation sessions. It became visible, though indirectly, because the radiologists had to do a part of the film developer’s work in midst of image interpretation activities. The film developer in duty had not been able to mount all images on light panels as usual because the film printer had been out of working order now and then during that day. Therefore, the radiologists had to engage in selecting and mounting relevant X-ray images by going through the patient’s film file and roentgen history (Picture and Transcript C, p. 28). The laborious way in which the radiologists went through the films of previous examinations and negotiated their relevance to the interpretation at hand made us realise that the work of ‘hanging images’ requires plenty of local knowledge, i.e. knowing within a worker’s horizon of relevance additional matters not formally available (COMIC Deliverable 2.4 1995) which film developers have acquired during years of lived work practice. Ensuring a well-organised material environment requires for example knowledge of the images as radiological representations, of their relevance to the specific patient case and of the common ways and traditions in everyday image interpretation.
2.2.4. The intertwined character of unfolding activities
The last point about work practice brings together the above three aspects of everyday work with the endogenous course of activities in what is here called the intertwined character of unfolding work activities[5]. It requires attention to the details of how work is put together as a gradually disclosing real-time phenomenon and in relation to the complex social setting. Under examination is how the complex, ongoing interaction of people with each other as well as the use of specific material and technological environment become intertwined in the unfolding activities of those practitioners who engage in constructing knowledge and meaning as an integral part of their everyday work (Suchman & Trigg 1991). The analysis of unfolding work activities thus allows for the scrutiny of regular procedure, artful behavior, customary trouble, unique problem solving and skillful reorganisation of action.
The above instance on the diagnostic interpretation of the pulmonary patient describes on a rather crude level how the specific social, material and technological circumstances come together in the unfolding process of preparing and interpreting patient representations, and producing a diagnostic statement in form of a roentgen report. The material and technological infrastructure (Star & Bowker 1995, Star & Ruhleder 1996) of film-based radiology work practice that has evolved over a hundred years provides for the concrete environment. Drawing on her local knowledge the film developer prepares the materials in the alternator for the radiologists’ interpretation session (Picture A, p. 27). The radiologists embark on a collaborative image interpretation process in order to reach an answer to the question posed by the clinician. They employ their professional expertise of human internal anatomy, physiology and pathology as well as their practical experience in clinical interpretive diagnostics on reading and analysing the unique set of patient materials. They adapt their activities to the unfolding course of contingencies, for instance, when they find out that all necessary films are not mounted they first hang them (Picture and Transcript C, p. 28), and as the nurse approaches them they interrupt the interpretation (Picture and Transcript F, p. 30) and only as she leaves they resume interpretation to draw it quickly to an end. In order to live up to the need for optimal use of the resources which they all know in common, Pirkko hurries over to the CT scanner and Airi finishes the case alone (Picture and Transcript G, p. 30).
Starting with this initial characterisation of work practice I continue to discuss and explore the notion of work practice in the context of system design throughout the thesis. My aim is to reconsider the notion as an attempt to integrate the ideas of ethnographic studies of work with the needs of system design and to reconstruct it so that the sensitivity of everyday work practice in system design is increased.