High technology medicine in practice : the organisation of work in intensive care

The aim of this thesis is to develop a grounded understanding of the practice of high technology clinical work and how it is organised. It combines systematic empirical analysis of the clinical locale of intensive care with scholarly work in medical sociology and the related fields of health services research, medicine, nursing and social studies of science and technology. The empirical data were obtained through fieldwork on three intensive care units (ICUs). The methods comprised periods of detailed observation, informal conversational interviews in the field and tape-recorded semi-structured interviews. The substantive contribution of the thesis is an analysis of contemporary and traditional themes in medical sociology: medical uncertainty; clinical knowledge in practice; inter- occupational relationships; the material and social character of medical and nursing work; and the organisational 'reality' of one clinical site within the modem hospital. In particular, the thesis demonstrates the utility of 'craft' as a metaphor for understanding medical work in ICU; provides a critical empirical review and reformulation of nursing theory as it has been applied to ICU; and proposes a new conception of the relationship between medicine and nursing in the grounded situation of clinical work. Two subsidiary contributions are also made: one methodological and one theoretical. In terms of methodology, I provide concrete examples of how ethnographic analysis can explain findings which have been derived from other health services research methods and thereby inform the future direction of such research. In terms of theory, I illuminate current debates at the interface of medical sociology and social studies of science and technology about the appropriateness of a post-structural style of analysis. In conclusion, I specify in what ways our understanding of health care work is - and is not - enhanced by the adoption of Actor-Network Theory.