Protocols, practice, and power
I recently got accepted to a workshop on practice theory and power in Lancaster, the heart of contemporary practice theory. This must be one of those moments every new PhD has, the reality re-adjustment of meeting the people you’ve been citing for months in person for the first time. It was a strange and proud moment when I realized the person accepting my abstract was Stanley Blue — the same guy whose paper was a part of my recruitment process into this PhD, the first ever practice theory paper I ever read. (It’s this one btw Reducing Demand for Energy in Hospitals: Opportunities for and Limits to Temporal Coordination)
In writing the required 3000-4000 word paper as my written contribution to the workshop this week, I advanced quite a few interesting thoughts and got to think of my work almost indulgently theoretically.
(On the thought of indulging:
I usually prefer to look at my work in the light of its societal aims, always aware of the environmental implications of how (not) circular hospitals are. This creates urgency and in a way does create clarity on what in the unfathomably complex web of things, thoughts and people in a hospital one should focus on. So far I’ve not experienced the common PhD pain of “does my work even matter”, and doubt I will. But that kind of clarity doesn’t go much deeper than the immediate things and phenomena around me. As much as I was hired to advance academic understanding as well as real-world impact, the academic part can feel frivolous in comparison to the societal challenges at hand, or when people from consortium partners to research interviewees ask about what has already changed, what should people do, what impact has or will be created. So being given explicit permission to go theoretical for a moment was pretty great. )
What I submitted was a little think piece on hospital protocols and power, exploring some interesting questions rather than giving answers quite yet. Rather than going into the whole question of what power is and how it fits into theories of practice, I took my empirical case and started looking for the fingerprints of power in protocols and the hospital life around them. Here are some of the main points I made and developed:
Protocols are not neutral checklists. Even when developed based on existing practice, protocols don’t just describe, but actively label ways of doing work as legitimate or illegitimate, prescribing certain combinations of instruments, competences, and bodily actions, etc.
Not all protocols are the same. There is a whole ecology to Dutch hospital protocols, and lines of influence go up, down, sideways, and loops probably. All of these also have their own processes of protocol development and adjustment, making these lines of influence from one protocol to another different in their effects and nature
Protocol power comes from two main sources. On the one hand, they act as carriers of practice elements, transporting the accepted way of doing things from one place to another. On the other they are issued by authoritative organizations whose stamp of approval gives them weight, even legal significance.
Still, protocols are not all-powerful. They depend on practice for their relevance: if they are unworkable, practitioners can ignore, bend, or adapt a “bad” protocol and develop “shadow protocols” of their own. Over time, these can feed back into formal revisions, creating a feedback loop of practice to protocol to practice again.
Co-creation processes matter. In some departments, protocols are revised collectively through structured discussion and consensus; in others, senior professionals could technically even adjust them individually, although in practice, a reasonable medical professional knows to seek inter-disciplinary input on changes. This brings in the perspective of practitioners having power over protocols.
Protocols can entrench or enable change. A protocol can lock in (until revised) unsustainable habits by prescribing single-use products as the default, but they can also become levers for transformation if rewritten to validate sustainable alternatives. One of my interviewees recently had an interesting take on this: a good protocol doesn’t give people options on what to do, how to do things greener if they want, etc. Rather, if greenness is an institutional priority, that must be written into the protocols by only prescribing the greennest options — not adding to the cognitive load of professional by asking them to make (green) choices.
These thoughts will continue to develop from here on; in Lancaster in September with the people skating on the cutting edge of practice theory and for the next year or so as I incorporate observational field work and protocol analysis into the picture. Stay tuned!
