Copyright is owned by the Author of the thesis. Permission is given for a copy to be downloaded by an individual for the purpose of research and private study only. The thesis may not be reproduced elsewhere without the permission of the Author. Where we are and how we got here: An institutional ethnography of the Nurse Safe Staffing Project in New Zealand In fulfilment of the requirements for Doctor of Philosophy Massey University, School of Nursing, College of Health Manawatu, New Zealand Rhonda McKelvie 2019 Abstract ii Abstract Frontline nurses in New Zealand hospitals still work on short-staffed shifts 18 years after they began to express concerns about unsafe staffing and threats to patient safety. The Nurse Safe Staffing Project and its strategies (Escalation planning and the Care Capacity Demand Management Programme) were designed to address the incidence and risks of short-staffing. After a decade, these strategies are yet to yield tangible improvements to frontline nursing numbers. Using institutional ethnography, I have charted a detailed description and analysis of how aspects of the strategies of the Nurse Safe Staffing Project actually work in everyday hospital settings. Competing institutional knowledge and priorities organise what is happening on short-staffed shifts, and nurses are caught in the crossfire. The central argument throughout this thesis is that nurses’ vital situated knowledge and work are being organised by and overridden in this competitive institutional milieu. I show how what actually happens is consequential for nurses, patient care, and staffing strategies. This analytical exploration contributes knowledge about nurses’ situated and intelligent compensatory work on short-staffed shifts, how this knowledge is displaced by abstracted institutional knowledge, and the competing social relations present in environments where nurse- staffing strategies are negotiated. Acknowledgements iii Acknowledgements First, I wish to express my thanks to and gratitude for my family and whanau because they have supported the most and suffered the most over the course of this thesis. You know who you are, and I really could not have done this without you. To the frontline nurses who provided data, but also to all frontline nurses who show up every day out of a commitment to patients and the profession. THANK YOU! If it was easy, everyone could do it. Thank you to all the research participants. Collectively we have created something no single one of us alone could know, and that will always be significant. Thank you for your contribution. To my supervisors, Professor Jenny Carryer, Dr Kerri-Ann Hughes, and Dr Janet Rankin, I am incredibly thankful for your guidance, critique, support, and wisdom. I also thank the online institutional ethnography club. I have been so grateful to ‘talk institutional ethnography’ every month with a group made up of both novice and skilled researchers. I am also grateful for the opportunity to attend the workshop in Canada and meet Dorothy Smith and hear her brilliant mind in action. My thanks also to Pip, Jane and Rachel for being practice readers and identifying inconsistencies, misspellings, flow issues and troubles with apostrophes. I am grateful for your time and feedback. Notes for the reader iv Notes for the reader To assist the reading of this thesis, I offer these notes o I use the term ‘Nurse Safe Staffing Project’ to describe the entirety of efforts directed at resolving nurse-staffing shortages in NZ. The Nurse Safe Staffing Project includes the collection of campaigns, enterprise bargaining agreements, industrial action, the safe staffing healthy workplaces committee of inquiry, the safe staffing healthy workplaces unit and nurse staffing strategies designed to reduce the incidence and risks of short- staffing o After the introduction to each chapter (except chapters 2 & 9), a glossary will detail the terminology and abbreviations relevant to that chapter. Chapter 2 constitutes an in- depth explanation of institutional ethnography that precludes the need for a glossary. In chapter 4, the glossary appears immediately ahead of part II – the Nurse Safe Staffing Project. All images of the Care Capacity Demand Management (CCDM) Programme tools, (except those I have created for this research report) are under copyright owned by the New Zealand Ministry of Health, 2017 and were provided by the Safe Staffing Healthy Workplaces Unit and used with permission, or from the public CCDM website. o o There are two patient acuity systems in use in NZ hospitals (Onestaff and TrendCare). None of the participants used Onestaff, therefore most references are to Trendare. All references to TrendCare are based on peoples’ personal and individual knowledge and experience of learning, implementing, and using the system in NZ hospitals. The exception is the reference to the copyrighted TrendCare Gold Standards provided by TrendCare CEO Cherrie Lowe and used with permission. All references to Smith pertain to Dorothy Smith unless the presence of initials indicates otherwise. Contents v Contents Abstract ii Acknowledgements iii Notes for the reader iv Contents v Figures xii Tables xii Chapter 1 Introduction Introduction 1 Glossary for chapter 1 1 The problem 2 Background to the problem 3 The literature 3 The NZ context 4 A disquieting catalyst for the research 7 Gaps in existing knowledge 8 The significance, rationale, and purpose of the study 9 Research questions 10 Researcher credibility and location 10 Introducing institutional ethnography 11 Social and ruling relations 12 Standpoint as the starting point 13 Texts as social mediators 15 Thesis structure – chapter summaries 15 Conclusion 18 Chapter 2 An approach to inquiry Introduction 19 Why institutional ethnography and not a different approach? 19 Contents vi Sources of knowledge 20 Beginnings - development of an alternative sociology 21 Institutional ethnography – an approach to inquiry 25 Social and ruling relations 25 Ideology 27 Institutions 28 Materiality 28 Discourse 29 People 32 Texts 34 Work 37 Disjunctures and the problematic 39 Mapping 41 Conclusion 42 Chapter 3 The research process Introduction 44 Glossary for chapter 3 44 Recruitment of participants 44 Standpoint participants 45 Extra-local participants 46 Data collection 47 Interviews – accessing experience 47 Texts as data 49 Analysis 50 Indexing 51 Constructing accounts 52 Mapping 53 Selecting texts for analysis 58 The problematic as an analytic device 59 Contents vii Research validity and warrantability 59 Ethical considerations 61 Ethical approval for the study 61 Strategies for ethical conduct 62 Reflexivity 63 Conclusion 65 Chapter 4 Context for this investigation Introduction 66 Approach to the literature 66 Search strategy 67 Scope 69 The social construction of nurse staffing knowledge 69 Healthcare reforms (New Public Management, NPM) 70 Global nursing shortage 72 Global patient safety movement 73 The nurse staffing literature 76 Key debates 77 Key author 78 Nurse staffing strategies 80 Glossary for chapter 4 part ii 82 How nurse staffing research has been taken up in NZ 83 A timeline of the Nurse Safe Staffing Project 84 The decision to collaborate 86 The Safe Staffing Healthy Workplaces Committee of Inquiry & report 87 The Safe Staffing Healthy Workplaces Governance Group 89 The Safe Staffing Healthy Workplaces Unit 91 Escalation planning 91 The Care Capacity Demand Management Programme (CCDM) 95 National nurses strike, 2018 99 Conclusion 101 Contents viii Chapter 5 Knowledge in action: Trouble staffing and staffing troubles Introduction 102 Glossary to chapter 5 102 A short-staffed shift begins 103 How nurses know a shift is short-staffed 106 Staffing for current nursing work 106 Staffing for anticipated nursing work 108 Staffing for unexpected nursing work 112 Communicating the short-staffed shift 113 Updating screens 113 Calling for help 118 The Reportable Event Form (REF) 121 Local strategies to repair the shift 124 The bed meeting 126 Organisational responses to short-staffing 130 Nurses’ work of reorganising, rejigging, and juggling 131 The project problematic 134 Conclusion 135 Chapter 6 Knowledge in translation: Translating nurses’ knowledge into hours, colours, and REF reports Introduction 137 Glossary for chapter 6 137 Summary of national implementation of textual processing tools 138 Generating hours – abstract stand-ins for patient care needs and nursing work 140 How nurses are taught to take up the ideas and practices of generating hours 142 Nurses’ concerns 144 Generating colours – abstract representations of the supply and safety of the care environment 146 How nurses are taught to take up the traffic light colours 149 Nurses’ concerns 151 Contents ix Generating ‘safe staffing’ events – the Reportable Events Form (REFs) 152 How nurses are taught to take up the REF 154 Nurses’ concerns 156 Analysis 157 Knowledge translation for measurement, standardisation and control 157 Documentary realities 159 Conclusion 160 Chapter 7 Knowledge in abstraction: Symbols and virtual realities for staffing on the day of care Introduction 161 Glossary for chapter 7 162 Integrated operations 162 Features of the capacity-at-a-glance screen 163 The integrated operations meeting as a site of institutional reading 166 Orange and red circles – the ED6 170 Red triangles – patient length of stay and elective surgery targets 172 Analysis 174 Capacity-at-a-glance: Virtual realties for institutional decision-making 174 How frontline nurses experiences are put together 176 Moving ‘hours’ around- bits and pieces of nursing care 177 Being sent to work elsewhere 180 Patient flow – a moment of divided consciousness 182 A patient flow coordinator 183 Patient flow on short-staffed shifts and the consequences for patient care 187 Nurses’ work to organise patients for patient flow 189 Conclusion 190 Contents x Chapter 8 Knowledge in aggregation: Aggregated stand-ins and annual budgeting for nurses Introduction 192 Glossary for chapter 8 192 Aggregation of frontline stand-ins 193 The (CCDM) council 195 The calculation of nursing FTE past and present 196 The FTE calculation process and report 199 “Well that can’t be right” – a reading of an FTE report 200 “There must be something wrong with the data” 202 “Hiding behind the data and slowing down FTE responses” 203 Taking a staged approach to budgeting for and employing extra nurses 205 “No fat in the system” 206 “If you want to have more nurses, you will have to stop doing something else” 207 “Look at whether they need to improve their practice” 207 Analysis 208 The council’s text reader conversation with the CCDM FTE report 209 Textual chains and institutional circles 209 How decisions in the integrated operations meeting organise frontline nurses’ work 210 Monitoring and correcting nurses 210 Making sure all the accounts line up 213 The effects of staged FTE increases and the ceaseless quest for efficiency 215 “Their elastic’s been stretched and it’s not going back” 215 “Letting patients down” 217 “Their expectations are so low” 218 Conclusion 219 Contents xi Chapter 9 Knowledge in competition: Competing institutional relations organise frontlines nurses experiences Introduction 221 The problem, research questions, and project problematic 221 Substantive findings and critical arguments 223 Textual mediation of frontline nurses’ knowledge and work 225 Competing institutional relations orchestrating frontline experiences 230 Situating the findings in a conversation with the literature 231 Implications of the findings 233 Possibilities and opportunities to change the status quo 237 How nurses could support change from below 237 How organisations could support change 239 How research could support change 240 Study evaluation 242 Reflection on the research approach taken 242 Study limitations 243 Conclusion 244 References 246 Appendices 285 Figures Figure 1 Smith’s (2006) Small hero concept 14 Figure 2 Example of indexing work with frontline participant transcript 51 Figure 3 Portion of text-act-text sequence map 56 Figure 4 Close detail view of text-act-text sequence map 57 Figure 5 The next generation of health care reforms – OECD 2017 71 Figure 6 World Health Organisation (WHO) statistics associated with patient safety 74 Figure 7 Graph of the total nursing hours to 1000 patient days 84 Figure 8 Timeline detailing texts and milestones of the Safe Staffing Project 85 Contents xii Figure 9 Text sample from the right care in the right place at the right time: The Safe Staffing Healthy Workplaces Unit: 2007-2014 87 Figure 10 Text sample Kai Tiaki Nursing New Zealand Feb 2005 88 Figure 11 Bipartite structure from governance to frontline 91 Figure 12 Images of reports examined and employed during the 3D initiative 94 Figure 13 The components of the Care Capacity Demand Management Programme 98 Figure 14 Section of the capacity-at-a-glance screen showing emergency department 109 Figure 15 Section of the capacity-at-a-glance screen showing medical patients identified as outliers on two surgical wards 110 Figure 16 Example traffic light screen 115 Figure 17 Example of traffic light colour display on the capacity-at-a-glance screen 117 Figure 18 Text-act-text sequence in frontline nurses’ work of trying to activate staffing responses 129 Figure 19 CCDM Programme components with detail of VRM intervention 139 Figure 20 Example traffic light screen 148 Figure 21 Example capacity-at-a-glance screen 164 Figure 22 Detail of the capacity-at-a-glance screen showing wait times in ED and ED waiting room 170 Figure 23 CCDM Programme components detail of bipartite governance and council 195 Figure 24 Example marketing and enlisting text from CCDM website 212 Figure 25 Textual mediation of frontline nurses experiences 226 Figure 26 Competing institutional relations organising frontline nurses experiences on short-staffed shifts in NZ hospitals 229 Contents xiii Tables Table 1 Glossary for chapter 1 1 Table 2 Influences on Smith’s thinking 23 Table 3 Glossary chapter 3 44 Table 4 Investigative focus of the nurse staffing literature 76 Table 5 Glossary for chapter 4 part ii 82 Table 6 Glossary for chapter 5 102 Table 7 Glossary for chapter 6 137 Table 8 Glossary for chapter 7 162 Table 9 Glossary for chapter 8 192 Chapter 1 Introduction 1 Chapter 1 – Introducing the study Introduction Extensive primary research studies, meta-analyses, and syntheses have investigated why globally shifts are short of nurses (Thungjaroenkul, Cummings, & Embleton, 2007; Weinberg, 2003; Willis, Carryer, Harvey, Pearson, & Henderson, 2017), what happens for patients when there are not enough nurses, (Ausserhofer, Shubert, Desmedt, Blegen,De Geest, & Schwendimann, 2012; Ball, Murrells, Rafferty, Morrow, & Griffiths, 2014; Cho, Ketefian, Barkauskas, & Smith, 2003; Kalisch, Tschannen, & Hyunwha, 2011; Jones, Hamilton, & Murry, 2015), and what happens for nurses when there are not enough nurses (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Gallagher, 2010; Rathert, May, & Chung, 2016). However, despite this extensive effort, there is little definitive evidence on the ‘right’ number of nurses to guarantee patient safety and comfort through the completion of all nursing work within the hours of every shift. This lack of definitive numbers has not precluded the development of a variety of nurse staffing strategies. In New Zealand (NZ), a decade has been devoted to the development and implementation of nurse staffing strategies, and it is these, and what they have and have not achieved, that is the focus of this research. In this chapter, I introduce the problem this research investigates. I provide a background to the problem in the form of an overview of the literature, a summary of the NZ context, and the disquieting experiences providing the catalyst for the investigation. I identify gaps in existing knowledge, the significance of this research and the purpose of this inquiry. The research questions, the scope of the inquiry, and investigative approach are all detailed, followed by a summary of the chapters that structure the thesis. Table 1 Glossary for chapter 1 Short-staffed shift A shift with an inadequate number of nurses, experience or skills for patients’ needs, and to meet the other needs of the ward, staff, and organisation District Health Board (DHB) Healthcare purchaser and provider organisation responsible for delivering healthcare services to the community within their jurisdiction. There are 20 DHBs in NZ Chapter 1 Introduction 2 Nurse staffing strategies Globally includes nurse-patient ratios, local and national guidelines committees. In NZ nurse staffing strategies include Escalation planning and the Care Capacity Demand Management Programme (abbreviated to CCDM or the programme) The Safe Staffing Healthy Workplaces Unit A national unit established to implement the COI report (see next row). Staffed by nurses and a social worker (allied health) abbreviated to the unit Safe Staffing Healthy Workplaces Committee of Inquiry and report (2006) Report of the Safe Staffing Healthy Workplaces Committee of Inquiry (SSHWCOI) – made up of union, DHB, Ministry of Health, and independent representatives. Tasked with producing a report on requirements to achieve safe staffing and healthy workplaces in NZ healthcare settings. Abbreviated to the COI report New Zealand Nurses Organisation (NZNO) Professional and industrial organisation for nurses, some midwives, and health care assistants in NZ. Enterprise bargaining and Multi-Employer Collective Agreement (MECA) Enterprise bargaining occurs every three years when numerous items are negotiated between the employers (DHBs) and the unions for each professional group. The MECA text enshrines the agreements of negotiations for the current term, e.g. the current MECA agreement is dated June 4, 2018, to July 31 2020 (abbreviated to the MECA) TrendCare An electronic patient acuity system. Currently licensed in 16 of the 20 DHBs in NZ (at the time of writing). Frontline nurses enter data into the TrendCare system on each patient at least twice on each shift Organisation for Economic Cooperation and Development (OECD) An intergovernmental economic organisation with multiple member countries, founded in 1961 to stimulate global economic progress and world trade The problem this research investigates Frontline nurses in New Zealand (NZ) hospitals still work on short-staffed shifts 18 years after they began to express concerns about staffing shortages, threats to patient safety, and unmanageable workloads1. Industrial campaigning and enterprise bargaining on these (and other) issues has resulted in a collaboration between employers (DHBs) and the nursing union (New Zealand Nurses Organisation, NZNO)2 to develop and implement several staffing strategies across NZ. Investment in the development and 1 The same is true of other settings where nurses work but this study focuses on NZ’s public hospitals. 2 As well as other unions subsequent to the original collaboration in 2004. Chapter 1 Introduction 3 implementation of these strategies has consumed extensive resources; costs associated with personnel, the design and dissemination of strategy resources, the purchase, design and dissemination of hardware and software and so on. This investment is yet to yield tangible results that mitigate frontline nurses’ concerns. This situation is both puzzling and problematic. Why, after a decade of development and implementation has the evidence-based nationally agreed Nurse Safe Staffing Project and its strategies not resolved short-staffed shifts and nurses’ concerns in NZ hospitals? Background to the problem The background to the problem this research investigates, incorporates the extensive nurse staffing literature, some of the unique developments in NZ, and my own disquieting experiences as a frontline nurse and staffing strategy designer. It is impossible to separate my experiences and knowledge about nurse staffing strategy design and implementation gained before undertaking this research, and the approach of institutional ethnography supports the contribution of the researcher’s experience and observations to the project. However, I take care to differentiate my experience and observations from data arising from participants and texts associated with this research. The literature More than 30 years of extensive and compelling research literature examines connections between nurse staffing (numbers, skill, education, and experience) and patient experience, safety, mortality, and outcomes (Aiken, et al., 2014; Blegen, Goode, & Reed, 1998; Bruyneel, et al., 2015; Butler et al., 2011; Duffield, Diers, O'Brien-Pallas, Aisbett, Roche, King, & Aisbett, 2011; Dunton, Gajewski, Klaus, & Pierson, 2007; Fagerström, Engberg, & Eriksson, 1998). Assumptions about such connections seem logical (Aiken, Clarke & Sloane, 2001), but few have proven to be empirically causal (Griffiths et al., 2016). One exception being Aiken, Clarke, Sloane, Sochalski and Silber’s (2002) research on the relationship between high numbers of patients in nurses’ allocations (8 or more) and an increased risk (7%) of each patient dying in hospital (failure to rescue), or immediately after discharge (30-day mortality). Nurse staffing research is framed within contemporary healthcare where business management and modelling, patient safety and global nursing shortages Chapter 1 Introduction 4 dominate thinking, policy, and practice (Attree, Flinkman, Howley, Lakanmaa, Lima- Basto, & Uhrenfeldt, 2011). Globally, under the neo-liberal regimes of most western societies, healthcare services of Organisation for Economic and Development (OECD) countries are organised and controlled by marketplace modelling and factory thinking (known as New Public Management, NPM) (Buchan, O'May, & Dussalt, 2013; Buchan, Duffield, & Jordan, 2015; Church, Gerlock, & Smith, 2018; Dent, Chandler & Barry, 2004). Since NPM swept across OECD countries in the 1980s fiscal constraint, practitioner and organisational performance, and outcome measurement have dominated and inexorably altered the contours of the professional workforce landscape (Dent & Barry, 2004; Simonet, 2015). In healthcare settings, the ideas and practices of NPM contend with the global and professional focus on patient safety, often with catastrophic results for patients (see Church, Gerlock, & Smith, 2018, and the report of the Mid Staffordshire public inquiry, The Francis Report, 2013). New Public Management is also implicated in the construction of a global nursing shortage (ICN, 2016; OECD, 2005). Causes of nursing shortage include scenarios in which many countries (such as NZ) cannot supply their national demand for nurses internally (Ministry of Health, 2016; New Zealand Immigration, n.d; OECD, 2016). The nurse staffing research and the complexities of contemporary healthcare settings provide the backdrop to nurse staffing strategies, including the unique approach taken in NZ. The NZ context There are approximately 52,700 registered nurses in New Zealand as of February 2018 (Cassie, 2018; Nursing Council of New Zealand, 2018). Along with the right to vote for women in 1893, New Zealand was the first country to appoint a Chief Nurse and to formally register nurses in 1901 (Cassie, 2009). Registered nurses are regulated by the Nursing Council of New Zealand, and are assessed under the regulatory framework of practice competencies as fit to practice and hold an Annual Practising Certificate (Health Practitioners Competence Assurance Act, 2003; Nursing Council of New Zealand, 2007). Several of these competencies3 make nurses specifically and explicitly accountable for 3 Nursing Competencies 1.2, 2.4, and 2.5. Chapter 1 Introduction 5 patient safety, and the provision of a safe environment for care (see detail in chapter 4). Nurses are trying to accomplish these professional accountabilities for patient and environmental safety under complex and constrained conditions. New Public Management reforms, including healthcare reforms, were embraced and implemented more aggressively in NZ than in any other OECD country (Gauld, 2009 Schick, 1996; Trailblazers, 2017). Among the changes wrought, control over nursing numbers and care environment resourcing were shifted away from frontline nursing managers, reducing clinical nursing’s jurisdiction over these critical aspects of direct patient care. During one of the most significant declines in nurse staffing numbers precipitated by healthcare reforms (see Carryer, Diers, McClosky & Wilson, 2010, and chapter 4), nurses expressed concerns about nursing numbers at the bedside, threats to patient safety, and unmanageable workloads (COI report, 2006). In 2004, nurses’ concerns were a major feature of the enterprise bargaining round (COI report, 2006; Lawless, 2014), and contributed to an agreement between DHB providers and NZNO to work in partnership on an agenda to improve safe staffing and provide healthy workplaces (Kai Tiaki New Zealand, 2005; Lawless, 2014). This collaboration resulted in a committee, a national review, a report, an operational unit, and two nurse safe staffing strategies (I overview these next and provide significant detail in chapter 4). The two nurse safe staffing strategies – Escalation planning and the Care Capacity Demand Management (CCDM) Programme - have necessitated significant changes in thinking and practices from the frontline to national-level governance. For example, most hospital frontline nurses in the DHBs implementing CCDM must now enter data into a patient acuity system (predominantly TrendCare in the majority of NZ hospitals) every shift, for every patient, as this data is vital to the operation of CCDM. Myriads of new technologies, data gathering and reporting processes, software systems, hardware systems, meeting structures, and bipartisan decision-making groups have been formed to operate both strategies. The investment has been immense. However, in July of 2018 NZ nurses undertook a nationwide strike, the first in nearly 30 years, protesting wages, working conditions and the lack of widespread substantive gains on safe staffing. Chapter 1 Introduction 6 The following account of a recent shift from a frontline nurse4, which occurred immediately before the July 2018 nurses strike, illustrates the ongoing travails of frontline staff. Grace, a senior nurse on a casual contract works in an acute planning unit with a high turnover of patients on each shift; she recounts her experience; “As soon as I got there I was handed the pager5. I was told there was no resource nurse6 on, so no backup. I had a student nurse on the shift with me, and two new graduate nurses. That was it. I asked the shift coordinator going off shift what the new graduate nurses knew - were they going to be any use to me in an emergency? I told the Duty Nurse Manager that I would fax my details down to the bed meeting. The meeting is held in an office miles away from the unit, and there is no way that I could go off the ward for 30 minutes with this staffing. It wouldn’t be safe” (Grace). Grace completed the required ‘paperwork’ (an electronic tick-box list, and patient acuity data entry) she has learned are the requirements for assessing and reporting staffing needs. Once data entry was completed, Grace received a system-generated assessment that there were sufficient nurses (in hours of nursing care) on the shift. However, for Grace, there was no option to state that the staff on the shift were made up of herself, two new graduates, and a student. In Grace’s professional judgement, the shift remained short-staffed; short of skills, experience, and back-up for the routine work of the shift, as well as for an emergency. This account points to a gap between what the Nurse Safe Staffing Project strategies are intended to accomplish, and what is actually happening on frontline nursing shifts. Grace’s experience is not an isolated incident, and I heard many such stories while travelling the country, promoting and supporting the implementation of CCDM. I began to experience some disquiet. 4 Working in a DHB more than five years into implementation of Escalation planning and CCDM. 5 Carried by the coordinator of the shift so that they can be notified of patients needing to be admitted to the unit. 6 An experienced senior nurse able to provide additional skills, knowledge, and support to the nurses rostered on the shift. Chapter 1 Introduction 7 A disquieting catalyst for the investigation In 2009, I joined the Safe Staffing Healthy Workplaces Unit to contribute to the design and implementation of a nurse staffing strategy for NZ nurses7. Escalation planning was well established as a process (though not without problems, as subsequent chapters will show). I was employed to work on the strategy that ultimately became known as CCDM (or the programme). Several years into designing and implementing the programme, I began to hear stories from nurses that contradicted the newsletter and reports I was writing about the success of CCDM. In 2014, I was visiting DHBs as a CCDM Consultant, an invited expert on the programme, and had the opportunity to talk with people located in a variety of positions across these organisations, as well as with nursing union representatives. These meetings were characterised by talk of ongoing troubles with staffing, the complexity and challenges of meeting the requirements of CCDM, and the limitations of the environment in which the programme was being implemented. In these meetings, I heard stories of how frontline nurses were redeployed (floated), more often than previously, to solve staffing problems in other wards, including nurses from maternity and paediatric services being sent to work in acute mental health. I heard from managers that the data for calculating nursing FTE was not accurate enough to trust, and that little could be done about this as there was no resourcing to invest in someone to improve this data. I heard that the television and computers screens designed to help create a whole of hospital view of staffing and patients were not purchased because this would require significant financial investment, as well as investment in time getting nurses (and others) ‘up-to-speed’ with these tools. I saw aggregated data from several electronic systems that showed the incidence of short- staffed shifts remained high, and that there were consistently high levels of a discrepancy between how many nurses were needed for a shift, and how many were actually available (sometimes too many and sometimes too few). I heard that the gaps in nursing FTE8, identified by the programme’s software, could not be employed because the ward’s 7 This was ultimately to be extended to other care settings and professional groups such as allied health. 8 Full Time Equivalent. Chapter 1 Introduction 8 budget was insufficient. In other words, few of the people in these meetings were talking about the success of Escalation planning and CCDM, and the problems they had solved. People appeared to have different knowledge depending on where they worked and how they interacted with these two strategies. I knew that some DHBs were taking up the tools, putting up screens, teaching staff about the ideas and tools of the system and the new language that went with them (more about this in chapters 5,6,7,8). As a CCDM consultant, this uptake of the programme’s requirements equated to the success I wrote about in newsletters and reports. Managers knew that data emerging from the tools of the strategies were to be the basis for decision-making, and while some welcomed this while others had concerns about the volume and accuracy of this data. Frontline nurses knew that sometimes when they completed the screens and changed the numbers and colours on them, they got a staffing response, and sometimes they did not. These discrepancies, tensions, and contradictions between knowledge and experience were the catalyst for this study. I wanted to know what was actually going on9. Gaps in existing knowledge In preparation for this research, I began to investigate where there was contested knowledge, and where there were gaps in knowledge, particularly concerning the operation of staffing strategies. The primary nurse staffing research is dominated by quantitative methodologies, particularly retrospective observational studies of patient outcomes, system, and staffing data. Although some of these studies involve millions of points of data, incorporate numerous countries, and are published in high ranking journals (such as Aiken et al., 2014) little of this knowledge is easily or directly translatable into operational strategies (Griffiths et al., 2016). This disconnection between the research and its application to practice represents the first gap in knowledge. Why is the substantive and powerful research not sufficient for practical interventional design? In addition, there are few if any primary research studies that occur before, simultaneously, and following the implementation of a nurse staffing intervention. Rather, these studies, employing both quantitative and qualitative approaches, assess 9 I provide a detailed context to this study in chapter 4. Chapter 1 Introduction 9 nurse reported changes during or following the intervention, but this is often not matched with the contemporaneous collection of system, patient outcome, or staffing knowledge10. The points of experience, knowledge, and data are not occurring in real- time with each other. There is a gap in knowledge about how interventions are actually taken up and operated in the everyday work of organisations. In NZ, the nurse staffing strategies, Escalation planning and CCDM, are soundly evidence-based. These tools build on the extensive research literature, and the knowledge gathered by the Safe Staffing Healthy Workplaces Committee of Inquiry (SSCOI)11, and specific to NZ hospitals. An evaluative study of the implementation of the programme (Hendry, Alione, & Kyle, 2015) identified both gains and potential improvements. Objective reviews of discrete aspects of CCDM validate the accuracy and value of these elements, and yet, frontline nurses are not consistently materially better off after a decade of development and implementation. There appears to be a gap in knowledge between how Escalation planning and CCDM are imagined and how they are done. I set out to investigate what was actually happening in NZ to contribute to closing these gaps in knowledge. The significance, rationale, and purpose of this research This study is significant because among the extensive nurse staffing research there is a dearth of ethnographic investigations of how nurse staffing knowledge and interventions are actually operated by people in their everyday work; day after day, month after month, year after year. Between the research participants and myself, this study incorporates close to 10 years of observational and experiential real-time operation of NZ’s two nurse-staffing strategies. Therefore, the findings of this research have the potential to contribute new knowledge to closing these identified existing gaps. The rationale for this research stems from the acknowledgement that in NZ nurse-staffing strategies are being developed and deployed, but are yet to make a significant difference to frontline nursing numbers and workloads, nor address nurses’ 10 The exception being Twigg et al., (2011) whose primary research study addressed approaches for ascertaining requisite nursing levels for effective staffing across the team skill mix (registered nurses, health care assistant and so on). 11 See the glossary at the start of this chapter. Chapter 1 Introduction 10 concerns about patient safety. Substantial commitment, effort, intelligence, and resources have been directed into these strategies as ‘staffing solutions’. In NZ, the Nurse Safe Staffing Project has required and precipitated significant changes in thinking and practice without comparable material improvements being achieved for frontline nurses. In short, the problems, as frontline nurses experience them (sometimes frequently) are not being resolved. Even DHBs implementing these strategies for close to a decade still have several short-staffed shifts on each day of care, and little recourse to resolve them. The purpose of this research is to produce a detailed investigation, analysis and explanation of how the Nurse Safe Staffing Project actually happens in the everyday settings of NZ hospitals. Four research questions guide this inquiry. Research questions 1. What are the material conditions under which short-staffed shifts occur? 2. What do nurses actually know and do on short-staffed shifts? 3. What accounts of their staffing related knowledge and work do nurses produce for others? 4. What influences the nurse staffing decisions made on the day of care, and in annual budgeting rounds? Any research endeavour must consider scope. There is a great deal more to creating and maintaining safe staffing and healthy workplaces than simply increasing the number of skilled nurses at the bedside. I acknowledge that the scale and complexities of the nurse staffing landscape are vast with multi-layered, social, historical, cultural, political, and gendered features. However, in this project, as a necessity of scope, I am holding a magnifying glass over the territory of frontline nurses as ‘the place to start’, and bringing initial focus to the knowledge, skill and practices nurses employ there to try to make things work on short-staffed shifts. Researcher credibility and location as a committed insider I know the experience of being a frontline nurse and of being a frontline nurse on a short-staffed shift. I worked many short-staffed shifts in 18 years as a clinical children’s nurse. I also know the experience of being part of a team of committed nurses Chapter 1 Introduction 11 working on staffing strategies for frontline nurses. I identify myself as a ‘committed insider’ (Brinkman, 2012), to this research based on my experience and knowledge, as well as my passionate interest in understanding what is actually happening with the operation of the Nurse Safe Staffing Project. My interest, to quote G. W. Smith, is “practical and political, rather than theoretical and speculative” (2014, p. 22). I am not intending to produce a theory about what is occurring, nor to seek consensus among the proponents and critics of the programme, or critique its elements or implementation. Nor is the endeavour to seek scapegoats or cast blame. The objective of this investigation is to discover, interrogate, and provide a detailed explanation of what is actually occurring in the everyday operation of the Nurse Safe Staffing Project. I intend to map out and detail actual goings-on and how these are organised to occur as they do. To accomplish this intention, I am employing a method of inquiry called institutional ethnography. Introducing institutional ethnography Institutional ethnography is a method of inquiry developed over several decades by feminist and activist Dorothy Smith. Smith (1996, 1999, 2003) contends that knowledge is socially constructed and that how knowledge organises and (sometimes) controls peoples’ everyday lives is discoverable in their everyday activities and the contexts of their lives. Rankin and Campbell, state that “[t]he distinctive contribution of institutional ethnography is in making links empirically – not theoretically - between everyday life and its specific social organization” (2009, page number not supplied). This empirical linking is accomplished by focusing on the actual material things people can be seen doing, on the words they use and on the texts (documents, screens, presentations) they interact with (Campbell & Gregor, 2004; Smith, 2006). Institutional ethnography is a densely theoretical and conceptual approach to investigating the real and tangible things going on in a given research setting. Observation, interviews, researcher experience, and textual analysis are the techniques employed to access the real and tangible aspects of research participants’ experiences Chapter 1 Introduction 12 and contexts (Campbell, 2006). The endeavour is to discover, describe and explicate12 the political, social, historical, gendered and economic contours of people’s experiences (Campbell & Gregor, 2004; Bisaillon, 2012b). A standpoint (explained shortly on page 13) is employed to anchor the inquiry and to focus and orientate the course of the investigation amid the vast social landscape of the topic (Smith, 2006). Institutional ethnographers commonly invoke the metaphor of a map to describe how they discover connections between research participants, the work they do, their talk (discourse), the documents and technologies they employ and so on (Smith, 2003, 2014; Turner, 2014). These organising connections (termed social and ruling relations, overviewed shortly and explained in detail in the next chapter) are how the social organisation of participants’ knowledge and experiences, in different times and various places, can be uncovered, illuminated and explicated. Explicating these connections, and the social organisation they bring into view, is the analytic work and product of an institutional ethnography (Campbell, 1984; Rankin, 2017b; Smith, 1999, 2003). (I detail institutional ethnography further in chapter 2). Social and ruling relations The social relations of our lives organise what actually goes on for us (Campbell & Gregor, 2004), but we take much of this organisation for granted. In their primer on institutional ethnography, Campbell and Gregor (2004) offer the example of university students boarding a bus in a Canadian city. What is observable is that each student shows a card to the bus driver as they board the bus, which he acknowledges with a nod (Campbell & Gregor, 2004). What cannot be seen in this exchange is the work the student has done to obtain the card, have a picture taken, learn the bus schedule and the campus layout in order to arrive at class on time. Also invisible in this exchange is the work of the campus officials who authorise the student card process, and how the bus driver is organised to expect to see and check each card as authorised access to the bus. This social organisation goes on in the background, and people enter into its courses of action on the taken for granted assumption that this is how things are done. 12 A term commonly used in institutional ethnography that goes beyond explanation to clarification, illumination, and exposition. Chapter 1 Introduction 13 Ruling relations, as Smith (1996) conceives them, are social relations but differ in that they accomplish the insertion of institutional interests and priorities into people’s activities. In their book, Rankin and Campbell (2006) describe nurse Linda and nurse Janet’s activities associated with the routine discharge of a patient from a surgical unit. The patient is discharged nauseated, in pain, having been advised to buy over the counter analgesia and anti-nausea medication on the way home and handed a cardboard receptacle in case she vomited in the car (Rankin & Campbell, 2006). In the example, the authors acknowledge that the discharge of this patient does not appear to reflect professional expectations and documented standards for nursing care, but do not give this example to criticise the nurses involved. Rather, they identify that what is organising nurse Linda’s priorities is her knowledge that all patients are to be discharged by 11 am. The professional ethos and practice of each nurse, and the specific needs of this particular patient, are overridden by the hospital priority of a timed discharge. This project intends to be able to provide these types of explanations, like the two above, of the social and ruling relations organising the operation of the Nurse Safe Staffing Project in NZ hospitals. The starting point for this investigation is the everyday experiences of frontline nurses in direct patient care and shift coordination roles. Standpoint as the starting point As the researcher, I adopt a standpoint alongside frontline nurses and pay attention to how they know and talk about their everyday day work and the context in which it occurs. I burrow down into the detail of their actual work as only they can know and speak of it. Talking to them about short-staffed shifts, I pay attention to the problems, contradictions and frustrations they experience. These problems and contradictions often indicate chafe points, instances where their knowledge and work comes into tension with priorities that arise from outside the context and urgencies of the short-staffed shift. I am also interested in the texts that nurses are reading, writing, and acting on (more on texts shortly). Standpoint participants are what Smith (2006) calls the small heroes at the bottom of a vast complex of socially organised knowledge. The illustration below (adapted from Smith’s version) has a frontline nurse standing beneath a mosaic of Chapter 1 Introduction 14 overlapping empty boxes. These boxes represent the social and ruling (governing) relations that organise frontline nurses’ experiences of and on short-staffed shifts. An example of what might populate these boxes is the assessment and regulation of nursing knowledge and practice by the nursing competencies of the New Zealand Nursing Council13. The competencies (a text) organise the issuing of an annual practising certificate (a text), as proof of competence to practice. Nurses enter this textual process because they must have an annual practising certificate to be employed and to work as a nurse. What nurses may not know is that behind this regulatory process is the State’s interest in protecting the public from nurses, and the regulation and control of the profession (social and ruling relations). Figure 1 Smith’s (2006) small hero concept In chapter 9, this image in figure 1 will appear again with the boxes populated with the social and ruling relations discovered in the course of the investigation. 13 Body regulating the knowledge and practice competence of nurses and Health Care Assistants, HCAs, in New Zealand. Chapter 1 Introduction 15 Texts as social mediators Smith (2005) asserts that social and ruling relations are omnipresent, taken for granted and often invisibly acting in institutions. They manifest themselves in standardised and replicable texts which move from place to place and person to person (Campbell & Gregor, 2004; Smith, 2006); such as the competency assessment and annual practising certificate process described on the previous page. In this project, I focus on the texts (documents, screens, data entry) nurses produce to communicate their knowledge and experiences on short-staffed shifts to people located elsewhere in the organisation. I will follow the trail of these texts into other settings and examine what the people there do with them. The objective is to trace texts in a documentary chain as far as possible to establish how they organise multiple people, in multiple settings to talk, think and act in similar ways. As the investigation proceeds, the conditions that establish short-staffed shifts and the troubles with resolving them will be examined. I will trace and interrogate how the texts of the Nurse Safe Staffing Project are taken up in frontline settings, and elsewhere. Using the concept of a map, a commonly employed device in institutional ethnography, I will chart and trace the locations associated with textual processes. What happens to the texts in each setting will be examined, as well as the actions that are taken as the text moves from place to place. This charting practice brings into view social organisation in action (Smith, 1999, 2003). Structure of the thesis-chapter summaries Chapter 1, see the conclusion to this chapter. Chapter 2 introduces institutional ethnography as the approach to this inquiry. Placement of this chapter was deliberate as employing institutional ethnography requires an ontological shift in the thinking and practice of the researcher before engaging with the literature, framing the study, and entering the field. In chapter 2, the rich and dense theories and concepts of the approach are unpacked and described. This approach exemplifies how I have learned about the features of the method, and will aid the reader to see how these have framed the investigation. The explanations and Chapter 1 Introduction 16 examples in this chapter will also help the reader make sense of the dense work of analysis and the findings of the research. Chapter 3 describes the structural and procedural approaches to the research. Ethical considerations, data collection methods, analytic approaches, and issues of research validity and warrantability are carefully considered. The fundamental importance of reflexivity in institutional ethnography and how reflexive practice has been woven throughout this investigation is presented. Chapter 4 locates this investigation in relation to existing research knowledge and to the Nurse Safe Staffing Project in NZ. The literature is summarised, highlighting investigative focuses, key debates and identifying the research (and researchers) considered the ‘authority’ on nurse staffing. I trace how these authorised ideas in the research have been taken up and incorporated into the development and implementation of nurse staffing strategies in NZ. I map a chronological development of the Nurse Safe Staffing Project, highlighting specific milestones and considering their impact on the trajectory, organisation and impacts of the project. Chapter 5, the first of the findings chapters, is an ethnographic journey through a short-staffed shift told by multiple frontline nurses as standpoint participants. This journey illuminates some of the knowledge, work, processes, troubles and tensions of nurses’ experience of short-staffed shifts. Several puzzling contradictions come into view from nurses’ experiences. First-level analysis of these contradictions leads to the formulation of a problematic puzzle to guide subsequent data collection and frame the analytic arguments of the thesis. Chapter 6 provides context to the texts frontline nurses described in chapter five, which they produce as textual accounts (textual versions) of the short-staffed shift. Three of these texts are explained in detail including their (conceptual) purpose, a short history of how they come to be a feature of frontline nurses’ work and how nurses take up these textual tools. Nurses’ concerns about where these texts go, who looks at them and what they accomplish are detailed. This chapter focuses on the work nurses do to translate their knowledge, decision-making and skilled nursing work into textual forms. I argue that these textual forms are poor representations of what is actually occurring because Chapter 1 Introduction 17 they are partial and conceptual. I also argue that these textual accounts reconstitute actual people and their experience into abstract stand-ins such as numbers and colours. I show how these standardised abstractions can be consequential for nurses and patients. Chapter 7 follows the textual accounts, introduced in the previous chapter, as they leave the short-staffed shift and enter into staffing decision-making processes elsewhere in the hospital on the day of care. Nurses’ knowledge about staffing and the risks to patients is located, contextual, immediate and specific. Decision-making managers in meetings outside the short-staffed shift base their decisions on the textual accounts (the stand-ins of numbers and colours) nurses have produced. How these managers know patients’ needs, nurse staffing, risks, and nursing workload, based on these textual stand-ins, is materially different from how nurses know these things. In this chapter, I argue that this disparate knowledge has tangible, discoverable and consequential effects on the organisation of frontline nursing work and the safety of patients on the day of care. Chapter 8 follows aggregated versions of the textual stand-ins into annual cycles of calculating and budgeting for nursing staff (FTE14). Here, research participants who are managers and union members are involved in decision-making meetings and receive aggregated versions of numerous shifts, patients and staffing patterns from the previous 12 months. I describe the people, conversations, readings and decisions of these meetings to illustrate socially organised knowledge in action in this setting. I show how decisions made in these meetings are accountable to different requirements and priorities than those of frontline nurses. I argue that location-specific knowledge has differing power and authority, and show how one organises the other in ways that displace situated professional expertise and reorganise frontline nurses’ work, knowledge and ideas about professional accountability. In chapter 9, I close the analytic loop of the investigation by revisiting the questions and problematic of the project and summarise the substantive findings and arguments made. I identify that the findings of this research have generated a narrative 14 Full Time Equivalent Chapter 1 Introduction 18 that runs counter to the authorised view of the Nurse Safe Staffing Project, and CCDM in particular, as an ‘agreed solution’ to nurse staffing issues. I offer material and empirical findings of what is actually happening to create short-staffed shifts, as well as what is happening on and because of them. I explicate the social and ruling relations organising the experiences of frontline nurses as the small heroes of Smith’s (2006) diagram. I consider the implications of the study in relation to existing knowledge in the research literature and the implementation of nurse staffing strategies in NZ and elsewhere. Opportunities to change the status quo are offered. The study is evaluated by reflecting on the approach used and project limitations and includes a summary of investigative paths not followed. Conclusion Chapter 1 introduces the study, the problem being researched and touches on the background to the problem, providing context to this investigation. I identify gaps in existing knowledge and the potential contribution this study makes towards reducing these gaps in NZ and elsewhere. The purpose of this research is identified, along with the research questions and scope of the inquiry and the introduction of institutional ethnography as the investigative approach. I identify my location in relation to the research terrain as a committed insider and my credibility as a researcher based both on knowledge and experience of short-staffed frontline nursing work and on my in-depth knowledge of the nurse staffing strategies being employed in NZ. A single research endeavour cannot substantively map the vast, dense and complex terrain of the entire Nurse Safe Staffing Project. Instead, this research offers a sample, mapping a portion of the whole, charting some of the social and ruling relations that are orchestrating the current state. The next chapter takes a deep dive into institutional ethnography as a research strategy, making available some of the conceptual and theoretical ideas of the approach that frame this inquiry. Chapter 2 Approach to the inquiry 19 Chapter 2 –Approach to the inquiry Institutional Ethnography as a research strategy Introduction The purpose of this chapter is to introduce the research strategy of this inquiry – institutional ethnography. I describe the philosophical, formal, and tacit alignment of institutional ethnography with the intent of the research and my stance as a researcher. A short history of the methodology leads into a description of the dense conceptual and theoretical lineaments that frame the structure, approach, and analytic work of an institutional ethnography. Why institutional ethnography and not a different approach? Numerous considerations are factored into selection of a research methodology, including the research question being asked, the type of investigation to be produced, how well the methodology aligns with the formal theories of the researchers’ discipline, as well as with the tacit beliefs and stance of the researcher (Badenhorst, 2018; Denzin & Lincoln, 2003). The research problem this project investigates is why short-staffed shifts, leading to threats to patient safety and unmanageable workloads, are still occurring ten years after work began on resolving them. The ‘solutions’ (staffing strategies) developed have, in theory, the potential to resolve short-staffing, but have not done so. The research questions and approach of this investigation seek to uncover how short-staffed shifts occur and continue to occur, and how it is that the nurse staffing strategies have not delivered promised resolutions. In order to investigate the research problem, I sought a critical approach. I wanted a way to interrogate the operation of the nurse staffing strategies that would see behind taken for granted assumptions about them, including my own. As part of my consideration of possible frameworks, I examined the 'big three' qualitative approaches ethnography, phenomenology, and grounded theory, (Korstjens & Moser 2017), which have been popular approaches employed for decades in nursing research. In addition to these and other approaches commonly employed in nursing research, such as discourse analysis, I examined less familiar techniques such as social constructivism, critical realism, Chapter 2 Approach to the inquiry 20 human geography and actor-network theory (Brinkman, 2012; Fouberg, Murphy & de Blij, 2015; McHoul & Grace, 1993; Stanley & Wise, 1990). I was looking for an approach that would access what was actually happening behind what people say and do. With this approach in mind, and because I was an insider in the chaotic environment in which I was conducting the research, I narrowed my exploration to ethnographic approaches. With roots in both sociology and anthropology, there are many different types of ethnography arising in grounded theory (Glazer & Strauss, 1967), symbolic interactionism (Prus, 1994), and anthropological ethnography (Fetterman, 1998). These approaches employ procedures such as generalising or conceptualising the data, and some set out to prove/disprove an existing theory, or triangulate data to ‘validate’ findings (see Bisaillon, 2012b and Campbell and Gregor, 2004 for a summary of distinguishing characteristics and key authors). Following a lead from one of my supervisors, I investigated institutional ethnography, as an emerging approach to critical feminist nursing research in NZ (Adams, Carryer & Wilkinson, 2015). Although feminist epistemologies15 vary, they tend to share a focus on how peoples knowledge and experience are ‘particular and concrete’ rather than conceptual and abstract (Encyclopaedia of Philosophy, n.d). They also take seriously the ways in which people are entangled in the social orchestration and control of their lives and work (Mann & Kelley, 1997; Olesen, 2003; Schumann, 2016). This epistemological focus, coupled with the emancipatory and consciousness-raising foundation of institutional ethnography was congruent with my worldview and researcher stance. They were also congruent with my research intention to investigate, for nurses, what is actually going on in the operation of the Nurse Safe Staffing Project and its strategies. I set out to gain a greater understanding of the theory and application of institutional ethnography. Sources of knowledge on institutional ethnography To gain a comprehensive understanding of institutional ethnography, I read closely and carefully a number of Dorothy Smith’s publications (Smith, 1974, 1983, 1987, 15 Epistemology - The theory of knowledge especially in regards to its method, validity, and scope Chapter 2 Approach to the inquiry 21 1988, 1990a, 1990b, 1996, 1999, 2001, 2002, 2004, 2005, 2006, 2007, 2014). In addition, I read numerous edited compilations of institutional ethnography projects (Griffith & Smith, 2014; Smith 2006, Smith & Turner, 2014), and a small number of explanatory and critical texts written by others (Campbell, 2010; Campbell & Gregor; 2004; Carroll, 2010; Norstedt, & Breimo, 2016; Stanley, 2018; Walby, 2007). I was also fortunate to attend an institutional ethnography workshop with Dorothy Smith and Susan Turner (one of Smith’s early students) in during the first year of my study, which was instrumental in clarifying some of the complex conceptual ideas of the approach, some of which I detail shortly. Several other sources of knowledge were also employed. I read widely, other institutional ethnography projects by Masters and Doctoral students, and their publications, paying particular attention to studies involving frontline nurses (Adams, 2017; Campbell, 1984; Melon, 2012; Melon, White & Rankin, 2013; Rankin, 2004; Rankin & Campbell, 2006). I am also a member of a monthly online institutional ethnography group who reviewed newly released institutional ethnography publications and projects and discussed particular concepts of the approach, and how to conduct and write up analysis. The online group members also discussed discrete aspects of their own studies in depth, which was an effective way to explore the application of the approach to different social contexts. The remainder of this chapter summarises what I have learned from these many sources. Beginnings – development of an alternative sociology Already a feminist and activist, Smith’s work on her alternative sociology began in earnest during the second wave of feminism in Canada, where she found herself experiencing two different socially constructed realities simultaneously (Smith, 2006). One, in which she was a mother engaged in the everyday work of parenting, checking homework, reading stories, shopping for food, cooking, cleaning and so on, and the other, as a teacher of traditional Sociology in a university department (Smith, 1987, 2003). Positivist sociology, as Smith was experiencing it, followed the model of Auguste Compte, the ‘father’ of traditional sociology, who believed that the natural sciences with rigid, linear, and methodical empirical scientific methods (such as experiments and Chapter 2 Approach to the inquiry 22 statistics) could provide valid data on how society operates (Crossman, 2018; Gottfried, 2019). The key characteristics of the traditional sociological approach were to objectify what was being studied or subject who was being studied and to maintain researcher objectivity to keep the science ‘pure’ (Crossman, 2018). Of the traditional approach, Smith states “sociology created and creates a construct of society that is specifically discontinuous with the world known, lived, experienced and acted in” (1990b, p. 2). Such a construct, according to Smith, creates an objectifying break whereby the particular people and the material of the actual experience disappear into a pre-conceptualised account of the occurrence (Smith, 1990b, 1999). Smith’s experience aligned with the feminist discovery of the time, which was that women “had been living in an intellectual, cultural, and political world, from whose making we had been almost entirely excluded” (1987, p. 1). Campbell states, of Smith’s ‘bifurcated’ experience, of being a mother and a traditional sociologist, that the “[w]ays of knowing that were relevant there [at home], even essential to giving and supporting life, were not recognised as a legitimate basis for knowing in the other world” [academic sociology] (2003, p. 13). Smith’s difficulty was with the way sociology constructed mothering in abstract and conceptual terms from which individual mothers and children, and their unique knowledge and experiences, were absent (Smith, 1987, 2006). In her quest to develop an alternative to traditional sociology, Smith began exploring her own experiences, and those of the women conventional sociology excluded (Smith, 1996; Stanley, 2018). Campbell states (of Smith’s development of the alternative sociology), “she didn’t want to accept the limitations of a technique that separated out for analysis an event, a conversation, or some other practice from its place nested in the lived world of the subject” (2003, p. 12). Beginning her project to develop an alternative sociology (for women) Smith met Erving Goffman, who supervised her doctorate, and, at the time, was writing The presentation of self in everyday life (1959). Along with Goffman’s thinking, Smith says she ‘unashamedly borrowed’ and took up ideas from various other thinkers and writers, examining, reinterpreting, and extending many of the ideas as she developed the Chapter 2 Approach to the inquiry 23 alternative sociology (Carroll, 2010). Table 2 below contains a list of some of these contributing thinkers and some of their influential ideas and writing. Table 2 Influences on Smith’s development of an alternative sociology Contributing thinkers Influential ideas Influential publications Erving Goffman Looking at what people actually do The presentation of self in everyday life (1959) George Herbert Mead The conceptualisation of language as coordinators of individuals consciousness and actions Mind, self and society from the perspective of the behaviourist (1962) Karl Marx & Friedrich Engels Materialism, ideology, and the political economy The German Ideology, Marx & Engels (translation 1976). Michel Foucault Knowledge, power and discourse The order of things: An archaeology of the human sciences (1970) The archaeology of knowledge: And the discourse on language (1972). Harold Garfinkel Critique of the generalising and abstracting formulations of sociology Ethnomethodology Studies in ethnomethodology (1967) Valentin Volosinov The conceptualisation of language as coordinators of individuals consciousness and actions Marxism and the philosophy of language (1973) Mikhail Bakhtin Primary and secondary speech genres, utterances, discursive chains The dialogic imagination: Four essays (1981), and Speech genres and other late essays (1986) (Table constructed from Bisaillon & Rankin, 2013; Campbell, 2003, Campbell & Gregor, 2004; Carroll, 2010; DeVault, 2014; Smith, 1999, 2006; Smith & Turner, 2014). For more on the points of congruence of these concepts/theories with Smith’s development of Chapter 2 Approach to the inquiry 24 institutional ethnography, as well as points of departure, see Smith, (1987, 1990a, 1990b, 2005), Carroll (2010), and Stanley (2018). The overarching ontology of Smith’s sociology is that knowledge is socially constructed and that people’s everyday lives and work are socially organised by this knowledge (Campbell & Gregor, 2004; Smith, 1990a, 1999, 2005). Smith resists the positivist view that decontextualised knowledge can be constructed from an objective Archimedian point located outside the social settings and conditions of people’s lives (Smith, 2006). Speaking of research located in everyday life Brinkman states, “we need to desacralize knowledge and admit that if knowing is a human activity it is always already situated somewhere” (2012, p. 32). The social knowledge constructed by people and coordinating their lives is local, contextual, specific, historical, embodied, personal, cultural, interactive, discursive, authoritative, institutional, gendered, and so on (Brinkman, 2012; Darville, 1995; Smith, 1999). Smith (2006) says that the socially constructed knowledge to be discovered is perpetually there but also perpetually in motion, active among actual people and the activities in everyday life. In order to be able to access and investigate socially constructed knowledge in action, Smith developed a method of inquiry - institutional ethnography. In the following section, I examine some of the concepts/theories and methodological devices of institutional ethnography. By breaking down the complex method and understanding its conceptual pieces, as other institutional ethnographers have done, (see Benjamin & Rankin, 2014, Bisaillon, 2012b; Deveau, 2008; Rankin, 2017a, 2017b), I was able to interpret and employ them in the framing and analytic work of the investigation. Therefore, while acknowledging that an institutional ethnography inquiry is informed by a complex set of intrinsically intertwined concepts and theories, I believe this somewhat artificial separation aids the reading of the analysis chapters and helps make sense of study findings. Chapter 2 Approach to the inquiry 25 Institutional ethnography – an approach to inquiry There have been a variety of approaches taken to explaining the lineaments of institutional ethnography (see Benjamin & Rankin, 2014; Bisaillon, 2012b; Campbell, 2003; Deveau, 2008; Rankin, 2017a, 2017b; Smith, 2002, Stanley, 2018; Walby, 2007). There is no simple linear progression through the ideas of the method because they both organise how an institutional ethnographer thinks about the research, as well as how they are employed directly as interrogative and analytic techniques. I begin with some of the larger overarching concepts - social and ruling relations, ideology, institutions, materiality, and discourse. I then offer descriptions of methodological ideas associated with ‘people’ and with ‘texts’, as these are central to accessing the material of socially constructed knowledge, before moving to aspects associated with the field and analysis – work, disjunctures/problematics, and mapping. For a number of the elements, I begin with theory, incorporate explanation by proponents and critics of the approach, and provide examples from various completed institutional ethnography projects. Social and ruling relations McCoy provides a relatable example of social relations, she states “you get out of bed, turn on the tap, make coffee, read the newspaper you collected from your front step – and you are participating in [social] relations (municipal water systems, international trade, the mass media)” (2006, p. 111). These are the taken for granted and seemingly mundane practices of everyday life that we expect with almost no detailed knowledge of what is involved in the production of drinking water, coffee, and newspapers. The work of producing these commodities is invisible to us, and so are the material conditions and experiences of the people who undertake this work; unknowingly we may be hooked up into drinking coffee that is harvested and processed by an exploited workforce. Discovering and explicating what is actually going on for people in a particular research setting must be connected, by Smith’s (1990, 1999) conception of social relations, to what is going on for others located elsewhere. Institutional ethnography’s fundamental focus is on accessing and explicating these social relations, from numerous Chapter 2 Approach to the inquiry 26 different social locations, and from the texts in documentary chains (Bakhtin, 1981; Turner, 2014). Imagine each participant and text as pins on a map of the research terrain. The work of the investigation is to trace, map, and explicate the social relations between pins that connect and coordinate people in their various locations. However, as Dobson qualifies, a social relation “is an organum; it is an instrument used to explicate organization rather than something to be looked for” (2001 p.148). Using people’s experiences, knowledge, talk, texts, and work, the social relations can be traced and mapped to piece together how organisation is actually occurring; social organisation in action (Campbell & Gregor, 2004; Carroll, 2010; Smith, 2006). Ruling relations differ from social relations. Ruling relations are not neutral; they privilege authoritative and ideological forms of knowledge, which displace people’s local knowledge and experience, and serve to regulate and even control society (Bisaillon, 2012b; Campbell & Gregor, 2004). Wright defines ruling relations as “the textual venues (such as legislation, governing boards, program planners, management and administration) where power is perpetuated in society across multiple sites” (2003, p. 244). de Montigny states, For women, working people, immigrants, racialized and cultural minorities practices of knowledge production are not neutral, nor are they of mere academic interest. Existing practices of knowledge production are experienced to be central for the reproduction of marginalization, stigmatization, exploitation, and oppression of people (2017, p. 358). The intention of an institutional ethnography is to make visible how ruling knowledge excludes local experiential knowledge subsuming what is actually happening, and inserting authoritative interests into the knowledge and work of people in multiple different locations (Campbell & Gregor, 2004; McCoy, 2006; Smith, 1990a, 1996). Reading institutional ethnographies and publications that bring into view socially organised knowledge and the orchestration of everyday experience has been critical to learning how to apply these concepts to this project. Campbell (1984) and Rankin’s, Chapter 2 Approach to the inquiry 27 (2004) projects explicated ruling relations orchestrating nursing knowledge, talk, and work to accomplish accountability practices, and meet organisational priorities and interests over those of nurses and patients. In de Montigny’s chapter (in Smith & Turner, 2014) professional and authoritative training “take over from the sensory responses” (2014, p. 173) in a child protection case exemplifying how we are all active (consciously and unconsciously) in the orchestration and perpetuation of our own and others experiences. Webster (2009) explicating evidence-based best practice for stroke, and Eastwood, (2014) explicating forest preservation policy documents in the United Nations, both bring forward the machinery, discourse and encoding of governing ideological knowledge that can be traced into the actual practices of actual people in actual places. Ideology Smith takes ideology from Marx and Engels (trans, 1976), not in the political sense, but in the sense that the ruling regime produces knowledge in forms that perpetuate and sanction the social relations of ruling (Deveau, 2008; Smith, 1999). Smith states, I view the ideas, images, and symbols in which our experience is given social form not as that neutral floating thing called culture but as what is actually produced by specialists and by people who are part of the apparatus by which the ruling class maintains control over society (1987, p. 54). From the position of dominance, ideologically produced institutional knowledge (including that in discourse and texts) becomes legitimised (Bisaillon, 2012a), and pushes out and excludes other ways of knowing. An example of legitimate knowledge that overrules others was provided (in the previous chapter) from Rankin & Campbell’s (2006) example of the discharge of an unwell patient to meet the 11 am discharge target. The organisational ideology of every discharging patient being fit for departure by 11 am is not substantiated by nurses’ actual knowledge of individual patients and their specific needs. Chapter 2 Approach to the inquiry 28 Institutions How institutional ethnography investigations conceive of and treat institutions as a fundamental concern of the research are important concepts for the neophyte ethnographer to grasp. Smith (1990b, 1999, 2006) defines institutions as the apparatuses of administration, management, education, healthcare and professional authority. According to Smith, the social relations, knowledge, and practices of these institutions “organize, regulate, lead and direct contemporary capitalist societies” (1990b, p. 2). The work of an institutional ethnography project requires the researcher to keep the institution in view and trace accurately and tangibly how its discourses, texts, and courses of action constitute the conditions of the research setting, and the experiences of the people there (McCoy, 2006). The analytic effort targets the identification of texts and discourses that carry the standpoint of the institution (Hamilton & Campbell, 2011), which privileges ruling interests over those of locally situated frontline workers and which organise the material conditions of their everyday experiences. Materiality In order to trace, map, and explicate the social and ruling relations, one must first access them. Smith (1987) says that institutional ethnography relies on a method of thinking that starts in the same world as the one in which we live. To this end Smith takes up Marx and Engel’s (1976) materialist formulation that begins among individuals, that looks at what they are doing and the material conditions under which they undertake their activities in their everyday lives and work (Smith, 1987). The focus and emphasis of the investigation, Smith states, is on the “world that actually happens and can be observed, spoken of, and returned to…” (1987, p. 123). In an institutional ethnography project, attention to the material conditions focuses on what people are actually doing, as well as the standardised, replicable texts people are using as part of their everyday activities (Campbell 2014; Smith, 1999). In the research setting of this project, nurses can be seen sitting at computer stations entering data, writing in patients’ notes and updating whiteboard lists. These material and observable actions that incorporate texts provide the access point to social organisation. Excavating behind these material actions begins the process of learning how nurses Chapter 2 Approach to the inquiry 29 know to perform this work, as well as charting how the knowledge and actions of these nurses are connected to those of nurses in other settings and to organisational processes and priorities. It is vital to remember; however, that texts do not construct or speak for themselves; they are without agency (Dobson, 2001). Instead, texts are constructed, updated, adapted and activated by people using socially constructed technical, professional, social and context-specific knowledge and discourses. It is not possible to separate people’s activities, discourses and texts because it is their work with and on behalf of discursively organised texts that brings social organisation into being (Smith, 2006). Discourse – words, utterances, and texts During the development of a sociology for women (which later was reframed as a sociology for people) Smith had to work with ideas about discourse (and sociology) constructed solely by men, that produced, reinforced and reified concepts that made sense in the world constructed by men (Campbell, 2003). Many such ideas and concepts were used as if they were self-evident (Campbell, 2003). In order to get behind and underneath the use of these abstract concepts, Smith’s thinking and formulations over time focused on the role of situated discourse and discursively organised texts as the material means to interrogate taken for granted practices of knowing that arose from the hegemony of men’s sociology and society (Campbell, 2003; Smith, 1983, 1990a, 1990b). These interrogative techniques remain intrinsic to institutional ethnography’s focus on digging through taken for granted language to the actual work of individuals that these conceptual discourses obscure. Smith’s reformulation of the ideas of several philosophers and writers (Mead, Volosinov and Bakhtin) on discourse, included concepts such as the coordination of consciousness, connections between peoples situated discourse and institutional discourse, abstraction and power (Campbell, 2003, Carroll, 2010; Turner, 2014). Words, utterances and spoken and textual discourse connect peoples’ consciousness and coordinate their activities across multiple settings, expressing the social organisation in Chapter 2 Approach to the inquiry 30 which they are enmeshed (Campbell & Gregor, 2004; Dobson, 2001; Smith, 1999). Smith states that, In what people say or write, hear or read, we can find at least one important dimension of social organization as a local accomplishment. I am interested in how people are putting our worlds in common together in the ongoing of our everyday lives (2018, conference presentation abstract). Campbell states that Smith took up Bahktin’s (1981,1986) ideas about speech genres, utterances and discourses as local accomplishments in her thinking and focus, describing “discourse-driven dialogue” (2003, p. 121). The social comes into being through language (Smith, 1999), through people’s talk16 of the material conditions, activities and experiences of their everyday lives. Campbell and Gregor state this represents a central tenant of institutional ethnography, that “trans-local and discursively-organised relations permeate informants’ understandings, talk and activities” (2004 p. 90). Campbell (2003) describes the ideas of Wittgenstein (1953), and Smith’s graduate education with George Herbert Mead as influential on Smith’s thinking about abstraction as an accomplishment of discourse and discursive concepts. In tracing the organisation accomplished by discourse, Smith sought to identify how to bring things back from the conceptual and abstract to the complex, problematic and actual ways in which people talk about their material realities (Campbell, 2003), in order to see what is obfuscated by these taken for granted and authorised ideas. Conceptual and technical discourse carries traces of social and institutional organisation that the institutional ethnographer must listen for in the talk of participants. Here is the opportunity to burrow down into what participants are actually doing and saying, and what is actually happening in individual situated experiences. This type of obfuscation and the resulting production of differently organised knowledge can be seen in an example from Rankin and Campbell’s (2006) book, Managing to nurse. Managerial concepts of discharge and length of stay and abstract 16 Which Bakhtin conceived as the primary speech genre made up of utterances in a discursive chain. Chapter 2 Approach to the inquiry 31 health data associated with costs become the basis for a manager to re-categorise shoulder-repair surgery patients to a day of care ambulatory pathway (Rankin & Campbell, 2006). The nurses Rankin observed and spoke with during her fieldwork on the ward had different knowledge and experience of how well these patients fared on the day of surgery. In their example, Nurse Linda’s knowledge of Ms Shoulder’s actual needs (unmanaged pain, uncontrolled nausea) is overridden by the need to discharge Ms Shoulder on time (Rankin & Campbell, 2006). Nurse Linda’s actual work (providing an emesis basin, an antacid and advising Ms Shoulder to purchase an over the counter antiemetic), intended to (try to) compensate Ms Shoulder for what could be perceived as incomplete and substandard care, does not appear in the official account of the discharge. The abstract measure that matters, in this case, is the time of discharge. Nurse Linda’s knowledge and the manager’s knowledge are not valued equally; one pushes the other aside, identifying a discursively organised power imbalance. Uncovering asymmetries of social power (Bisaillon, 2012b) in discursive coordination is part of tracing and mapping social organisation and is another focus of Smith’s thinking on discourse in which she takes up some of Michel Foucault’s (1970, 1972) ideas about power. Campbell states that in Smith’s sociology “no setting is an isolated unit, but is part of an organized whole. This underpins strategy for identifying how power is inserted into (enacted in, actually) the experiential setting, often in silent and mysterious ways” (2003, p. 13). Listening to peoples talk enables the researcher to see social construction and organisation in motion (Campbell, 2010). The social power of the organisation is illuminated and uncovers people’s participation in the construction and organisation of their discourse and experiences (Bisaillon, 2012a). Discursively organised experiences and texts are central to institutional ethnography. Campbell claims “a socially constructed world is one in which control, like all other aspects of an organisation, is a practical accomplishment of real and potentially identifiable people” (1984, p. 22). It is people that accomplish the production of knowledge, that activate knowledge into social processes such as workplace procedures, that read, write and act on behalf of socially constructed documents. In her thesis, Campbell identifies that texts are not only information about organisation “they are integral to how organization is brought into being” (1984, p. 17). Chapter 2 Approach to the inquiry 32 In the following section, I detail the institutional ethnography concepts/theories associated with people’s material and discursively organised experiences/activities and texts. I begin with people. People - situated expert knowers, standpoint, experience as data, local and extra-local participants Following on from the materialist focus on what is actually happening the people observed and interviewed as part of an institutional ethnography are positioned as situated knowers; experts in their own everyday lives as they live and experience them (Campbell, 2014). It is from within people’s situated expertise that social processes can be opened up for examination to understand how society works (Brinkman, 2012; Denzin & Lincoln, 2003). People’s experience as only they can know and speak of it (Campbell, 1998; Smith, 2006), grants access to traces of socially organised knowledge that coordinate their consciousness and orchestrate their experiences (Bisaillon & Rankin, 2013). In other words, what people know and can tell of their experiences carries traces of how their consciousness and activities are operated by society. Part of institutional ethnography’s theory of knowing recognises that the conduct of the research enters the researcher and the situated expert knower participants into a social relation with each other, a relation in which power is a factor (Campbell & Gregor, 2004, for more on this see Walby, 2007). Mitigating this power imbalance is accomplished by the researcher positioning themselves alongside a group of the expert knower participants, not only to collectively explore and explicate how knowing in the research setting is organised, but to also ensure that it is for these participants that the research speaks (Campbell & Gregor, 2004; Smith, 1999, 2006). In this way, the research is for participants, rather than about them. Positioning oneself alongside these participants is known in institutional ethnography as adopting a standpoint. Adopting a standpoint position from which to begin is a central commitment to and the starting point of most projects using institutional ethnography (Bisaillon, 2012a; Campbell & Gregor, 2004). Smith (1999, 2005) says that taking a standpoint enables the inquiry to proceed without reproducing institutional discourses and organisation, and Chapter 2 Approach to the inquiry 33 reifying ruling relations. Rankin states that the institutional ethnographer “must stay grounded in descriptions of things happening—and the observed tensions and contradictions that arise there for those people (who occupy the standpoint)” (2017a, p. 2). Positioning myself alongside the standpoint participants (in this case frontline nurses and shift coordinators) I must learn the research setting as they know it and talk about it, and then learn to see how it is organised and controlled from elsewhere (Campbell & Gregor, 2004). Positioning the researcher alongside the standpoint must be accomplished without her/him being swayed or, to use an institutional ethnography term, captured by authoritative institutional discourses and texts, which carry the standpoint of the institution (Hamilton & Campbell, 2011). Within the current neo-liberal frame, we are both consciously and unconsciously orientated to authoritative discourses and logic, and it is not uncommon for an institutional ethnography analysis to be pulled off track because the researcher is captured by powerful institutional ideas (Campbell, 1984; Rankin, 2017a). The challenge is to produce an analysis anchored in the experiences of standpoint participants, to treat their experience as data, but not to make the analysis solely about participant experiences (Deveau, 2008; Rankin, 2017b). Whether experience constitutes knowledge/evidence is contested (see Deveau, 2008; Hesford & Deidrich, 2014; Murray, Holmes & Rail, 2008; Scott, 1991, for detail on this debate). Deveau states that institutional ethnography’s “stance on experience is that it is real and anchored in material conditions” (2008, p. 14). Campbell (2003) says that Smith was focused on learning how to think from inside experience (what was actually happening), rather than looking in on it from outside. Although Smith (2005) supports Scott’s (1991) assertion that experience does not directly translate to fact, she maintains it is a legitimate place to begin a discovery of how experience is socially organised; beginning where people are in their socially organised material actualities. While acknowledging the ongoing debate regarding feminist researchers’ use of experience as knowledge, Campbell (1998, 2006) identifies that institutional ethnography uses experience as the ground zero of analysis to substantiate two arguments. The first argument is methodological, contending that experience grants access to the social relations under investigation. The second argument is substantive. Chapter 2 Approach to the inquiry 34 Campbell (1998, 2006) using examples from her own and Rankin’s (2004) work, brings into view how a substantive argument is built on the ways a particular relation, (such as workload measurement and healthcare reform) alters how nurses talk about, think about and conduct the nursing work of caring for patients (Campbell, 1998, 2006). Experiential data is generally gathered from participants in two locations, locally and extra-locally. The local setting (in this case hospital wards, and short-stay acute care units) is where standpoint participants are located. It is the experience, actualities and material conditions of standpoint participants in their local settings that anchors and orientates the investigation. de Montigny states that “[a] core insight of Dorothy Smith’s IE is that people in local settings, through situated production and reading of texts, whether policy manuals, assessments, reports, and so forth, practically connect their local practices to extra-local and institutionalized forms of organization“ (2017, p. 341). Extra-local participants are often (but not always) located in a different social setting and timeframe to the immediacy of what is unfolding for local standpoint participants. A further distinguishing difference is that extra-local participants receive standardised and objectified accounts17 of standpoint participants’ experiences (Campbell & Gregor, 2004; Bisaillon, 2012a). Reliance on standardised and objectified accounts subsumes local happenings and results in extra-local participants holding different knowledge to standpoint participants about what is actually occurring (Bisaillon & Rankin, 2013; Darville, 1995). Such textual accounts mediate local and extra-local settings, trailing the social relations with them. Smith states that the inquiry “follows the trail of the relation in order to find out how a form of organization is accomplished” (1996, p. 116). Standardised, replicable, objectifying texts are the breadcrumbs of the trail. Texts - textual realities, textual mediation, text-work-text sequences, text-reader conversations, and textual hierarchy What people are actually doing with and on behalf of texts is fundamental to an institutional ethnography (Bisaillon & Rankin, 2013). Texts mediate and accomplish social organisation across local and extra-local settings (known as trans-local organisation in 17 Usually written texts, or electronic texts that produce a standardised record of goings on that can override and speak for differing individual localised experiences (Smith, 1987). Chapter 2 Approach to the inquiry 35 institutional ethnography), inserting institutional interests into local thinking and practice (Rankin & Campbell 2006; Smith, 1990b). Institutional texts are defined as abstract, standardised and replicable texts that people read, write, enter data into, listen to, view or otherwise generate or interact with, as part of their everyday work (Campbell & Gregor, 2004). This widespread replicability is key to the organisation of multiple different local settings in which people unknown to each other are organised to think, talk and act in similar ways (Turner, 2014). Smith’s alternative sociology asserts that texts mediate the knowledge, discourse, and actions of people, by inserting ruling ideas and institutionally sanctioned actions into the consciousness of readers (Campbell, 2003; Smith, 2014). Smith’s interest has been in the construction of documentary realities that sever knowledge from its material ground in experience, recrafting it into abstract, objectified, conceptual textual accounts which play a part in the constitution of ‘authority and power’, (Campbell, 2003, Smith 1974, 1990a, 1996, 2006). Authoritative texts stand in for actualities (what is actually happening in an actual setting for actual people) and organise which version of knowledge is valued over others. Accessing and explicating textual realities, mediation, trans-local organisation and the construction of authorised knowledge is accomplished by paying attention to textual sequences, text-reader conversations and textual hierarchies (Turner, 2014). Tracing texts within local settings and as they move from place to place across extra- local settings brings into view long text-act-text sequences, many of which are predetermined by institutional processes. The researcher pays attention to how the text is received, read, updated, and sent on to the next location, as well as to the actions people undertake on behalf of the text. de Montigny states that these “[i]nstances of textual work connect particular and local occasions to seemingly transcendent institutional order” (2017, p. 342). This institutional order or framing organises how a reader interacts with a particular text; a concept described as a text-reader conversation. Text-reader c