Marlot Kuiper

259 Conclusion Building on the findings of chapter 5 the findings of chapter 6 show how the internal routine dynamics can be altered through the interaction of routines. For example, because of a conflict between existing routines and the checklist as an envisioned routine, ostensive aspects of the routine might change from a ‘helpful tool’ into ‘a distraction’ and thereby affect performances. Professionals might see the checklist as a burden, not so much because of the checklist itself, but because it comes on top of other procedures. How professionals value the checklist routine is thus not so much about the checklist itself, but about its (mis) fit with existing routines. “How do artefacts affect how standards work in medical teams?” (chapter 7) In the third and final empirical chapter of this dissertation, my analytical focus was on artefacts as models for routines. In this chapter, I drew four main conclusions. Firstly, “the artefact” does not exist. The starting point of this chapter were the representations of the checklist, and how these affect routine dynamics. At the two research sites, different artefacts were employed to model the routine. Building on the argument that ‘the checklist’ (as a guiding principle) does not exist; so doesn’t ‘the artefact’ representing the checklist. I introduced the concept of an ‘artefactual arrangement’ in which different artefacts that model the same routine. Drawing from Gibson’s (1977;1979) notion of affordances, I illustrated how different artefacts afford different actions, which makes them inherently relational. Perceived and actual possibilities for action not always align; paper is often portrayed as ‘old fashioned’ but affords a firm connection between the artefact and the routine, whereas ‘modern’ software systems allows for bureaucratic control, and not storage of clinical data. Secondly, creating workable artefacts in performance-oriented contexts is political. Rather than pragmatic, static entities, artefacts should be considered dynamic and political entities. Those who have the power the amend artefactual arrangements, for instance by introducing additional artefacts or by embedding responsibilities in software systems to make themmore persistent, aim to force control over professional work. Thirdly, artefacts (are used to) create and overcome boundaries. Professionals use artefacts to (re)negotiate roles and responsibilities, for example by refusing 8