Marlot Kuiper

256 Connective Routines Secondly and building on this, I found role taking, hierarchy, and connections as important mechanisms that mediate routine dynamics. These are helpful in explaining how some ostensive aspects translate into performances, while others do not, and how performances translate into the ostensive dimension. Firstly, role taking matters. Role taking is important for aligning tasks and structuring interactions in the performance of the checklist, but professionals often stick to their own role rather than anticipating on others and aligning their practices with other participants. Professional judgment and notions of “my patient” hinder consultation of other professionals in the team. Performances then are individual rather than connected. Secondly, hierarchical positions matter. The hierarchical position of individuals in the team enables or constrains opportunities to amend abstract patterns. An anaesthesiologist is more able to amend the abstract pattern of the checklist routine by starting new performances, while for scrub nurses, who have a lower hierarchical position, it is more difficult to start performances that fit their abstract understanding. Different hierarchical positions imply differences in professional agency. Thirdly, connections matter. This chapter has shown that connections do not so much result from standards but are a prerequisite for using standards. They can be better considered as ‘effortful accomplishments’ (also Feldman et al. 2016), rather than ‘automatic outcomes’ of artefacts. There must be some ‘connective potential’ when standards for making connections are used. Surgical teams who frequently interact, such as specialized surgical teams in Plainsboro and general surgery teams in St. Sebastian’s, rely on firmer connections than teams who have less interactions, such as general surgery teams in Plainsboro. Interestingly, these shared understandings (‘knowing’ what to do and how to go about it) might also prelude the ongoing need for coordinated action. In these teams, informally checking safety items is more the routine than systematic use of the checklist. In general surgery teams where team compositions fluctuate, teams are more inclined to use the checklist. Adding to this, high-ranked professionals play important ‘frontrunner’ roles in order to exploit connective potential. When they set the tight tone and stimulate others to collaborate, checklists are used differently, both in terms of ideas and actions. Professionals themselves rather than checklists establish collaboration, but checklists are important devices for actually using such connective potential. Thirdly, hybridity is not yet ‘natural’. The observations did show how professionals are working with broader ‘organisational themes’ like patient safety, also directly linked to accreditation. Nonetheless, in daily practice, they tend to focus on individual case treatment, emphasized with notions of “my patient”, and herewith neglect the overarching organisation of surgical care.