Visibilising clinical work: Video ethnography in the contemporary hospital.

ABSTRACT

This paper discusses the role of video-based research methods in social research. The paper situates these methods in the context of rising levels of visibility of professionals in government-funded organisations. The paper argues that while visual research may appear to play an ambiguous role in these organisations, it can also enable practitioners to confront the encroaching demands of post-bureaucratic work. To ground its argument, the paper presents an account of a video-ethnographic project currently underway in a local metropolitan hospital. This project focuses on negotiating understandings about existing care practices among a team of multi-disciplinary clinicians. Visual data gathered as part of that project are presented to specify issues which have thus far arisen during the project. Against this empirical background, the paper turns to considering the ambiguous potential of video-based research. The argument developed here is that, besides potentially exacerbating the pressure already imposed on clinicians--thanks to audit, surveillance and risk minimisation--video-based research may provide staff with new resources and opportunities for shaping their increasingly public and visible work practices.

KEY WORDS

Video ethnography; post-bureaucracy; spinal care; reflexivity; health care; sociology

Introduction

Decades ago, Strauss and colleagues noted that 'no one knows what the hospital "is" on any given day unless he [sic] has a comprehensive grasp of what combination of rules and policies, along with agreements, understandings, pacts, contracts, and other working arrangements, currently obtains' (Strauss et al 1963:163). As we move into the 21st century, hospital work is unlikely to become any simpler. On the contrary, medical technological change (Gosling et al 2003), demands for organisational accountability (Degeling et al 2004), organisational restructuring, health reform and care improvement initiatives (Berwick and Nolan 1998), increased stakeholder representation in health care decision-making (Gattellaria et al 2001), and the growing instability of professional and occupational boundaries (US Institute of Medicine 2001), are factors which suggest hospitals are significantly more complex now than they were in Strauss' time.

Most prominent among these developments is that hospitals, like most other large organisations, are under increased pressure to account for what they do and ensure hospital-internal processes are 'transparent'. Starting in the 1970s, transparency was first sought by clarifying the kinds of medical work in hospitals which attract particular kinds of resource expenditure. Thus, economists began to appropriate medicine's categorisation of its treatments, referred to as Disease Related Groups (DRG), and use these to devise DRG-cost maps for hospitals. These maps charted the variety of medical treatments doctors provide in a particular organisation, and made it possible to produce 'casemix' statements, which, in turn, enabled managers and policymakers to build a picture of the relationship (and potential divergence) between a particular hospital's resource utilisation, its medical treatment categories, and specific costs (Degeling 1994).