Practising knowing in emergency departments : tracing the disciplinary and institutional complexities of working, learning and knowing in modern emergency departments

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In this thesis I examine ‘knowing in practice’ (Gherardi 2006) in emergency departments (EDs) and present a new conceptualisation of how knowing in practice is done. In particular, I examine how nurses and doctors draw on recognised disciplinary practices and adapt these in the institutional setting of the ED to reconstitute what they need to know to enact safe practice. I situate their practices in a meta-disciplinary and institutional practice framework, as collective enactments of ED work that are proximal, prefigured participatory, pre-emptive, and protocol or rule-governed. Through analyses of the study’s ethnographic and linguistic ethnographic data, collected in five Australian EDs over four years, I explore how nurses and doctors work, learn and know in the ED. Drawing on practice theorisations of organisational work (Gherardi 2008; Orlikowski 2002; Schatzki 2001a; Yamauchi 2006), I examine how their working, learning and knowing in practice respond to disciplinary and institutional structurings of care that afford particular opportunities for action. In doing this, ‘prominence and explanatory power’ are given to ‘materiality, spaces, time, the body, affectivity, interests, and preoccupations [in the ED]’ (Nicolini 2011, p. 617). Findings show that as nurses and doctors interact with patients, others, the material arrangements of the ED and its objects, they engage in collective and individual activities and actions to resource, reconstitute and (re)produce ED knowledge. Knowledge is proposed as knowing: it is situated, embodied, teleological and relational, enacted in the activity of everyday practice(s). This view challenges the way knowledge is conventionally understood in healthcare, i.e. as an ‘epistemology of possession’ (Cook & Brown 1999, p. 383; Nicolini et al. 2008). A focus on knowing rather than cognitive understandings of knowledge, shifts attention away from nurses and doctors as individual knowers/doers/communicators, towards a systemic, institutional and disciplinary framing: one that underpins the extra-individuality (Kemmis 2009) and teleological aspects of nurses’ and doctors’ professional practices (Schatzki 2009) and how these are enacted in the organisational setting of the ED. The thesis findings contribute to a deeper understanding of the complexity of knowing in practice in the ED and reframe conventional approaches to addressing teamwork, interprofessional communication and the current model of care in EDs.
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