Marlot Kuiper

235 control, as clinicians feel constrained by a ‘bureaucratic system’ that only allows them to proceed when boxes are ticked-off. Interestingly, those who still work with “old fashioned paper”, consider digitalization as a step forward and even apologize for the unprofessional paper. The findings suggest that appreciation of a checklist (ostensive) might change when professionals actually start working with artefacts. 7.6.3 Artefacts (are used to) create and overcome boundaries The few studies that put artefacts central in analysing routines (D’Adderio 2008; 2011) focus on representations of the rule as intermediaries for routines. This study contributes by showing that rule-embedded artefacts only matter in relation to other artefacts in an arrangement, but moreover, that other artefacts are crucial to consider when one wants to understand how rule-embedded artefacts (can) affect routines. The findings show that (1) artefacts can create boundaries (2) artefacts can be used to create or strengthen boundaries and (3) artefacts can be used to overcome boundaries. Firstly, other artefacts can create boundaries to use the checklist-artefact. Various devices such as sterile tables, lamps, surgical drapes and doors showed pivotal in understanding patterns of action. A poster may afford to ‘look at’, but other artefacts might keep it out of sight. A paper checklist may indicate responsibilities and demand an anaesthesiologist to ‘walk in’, but a system counting door openings might keep him from doing so. Secondly, artefacts might be used to create boundaries. That artefacts are politicized rather than pragmatic, ‘neutral’ entities, also becomes visible through the boundary work of different professional groups. The concept of boundary work was first raised by Gieryn (1983) who analysed how scientists attempted to distinguish their ‘scientific’ activities from ‘non-scientific’ activities as a means to defend their status and privileges. The results from this chapter show how surgeons show similar strategies in maintaining their dominant position in the team. By explicitly refusing the whiteboards, they demonstrate that this ‘extra’ registration is not part of their surgical activities. Surgeons reclaim the boundaries of their profession by increasing member awareness of boundaries; “This is not something we as surgeons do.” Faraj and Yan (2009) referred to this strategy as ‘boundary reinforcement’. Thirdly, artefacts might be used to overcome boundaries. Interestingly, nurses use the exact same artefact to strengthen their position in the team to ultimately 7