Wayne Martin Mellinger "Negotiated Orders: The Negotiation of Directives in Paramedic-Nurse Interaction"
Negotiated Orders: The Negotiation of Directives in Paramedic-Nurse Interaction
Wayne Martin Mellinger
University of California-Berkeley
Whereas the "negotiated order approach" emphasizes the importance of communicative events in the constitution of organizational settings, there has been little attempt to formally describe the properties of talk that occur in these settings. This article demonstrates that detailed examination of the temporal unfolding of negotiative processes contributes to our understanding of the bundle of tasks which comprise organizational settings. Through close analysis of the negotiation of directives in paramedic calls for emergency field orders, I demonstrate that negotiation is more than a metaphor for describing organizational order: real-world negotiations are complex interactional processes which can be described in their rich detail.
In a provocative paper originally presented at the annual meeting of the American Sociological Association in 1985, Stinchcombe provides a memorable call for students of work to return to ethnographic observation of work practices. As he persuasively argued, "there is now very little ethnography of any kind about social interaction at work" (Stinchcombe 1990, p. 114). The claim that there is little attention paid to social interaction at work might seem to oversight symbolic interactionist research, given the flowering of the "negotiated order approach" in the last two decades. As its name implies, the negotiated order approach stresses the importance of negotiations in institutional settings. As Strauss, Fugerhaugh, Suczek, and Wiener state, "Negotiation enters into how work is defined, as well as how to do it, how much of it to do, who is to do it, how to evaluate it, how and when to reassess it" (Strauss et al. 1985, p. 267). Further, "negotiation is a necessary cement for organizational action" (p. 267).
By attending to the negotiated order of organizational and occupational settings, interactionist studies have opened new topics for research and have provided fresh insight into the relationship between the interaction order of these settings and the structural context in which those interactions exist. Extensive and extremely valuable work has been done concerning how organizational actors' perceptions of, and expectations for, negotiation affect negotiation processes and outcomes. For example, Wallace (1990), in a recent study of a residental hotel, found that actors' theories of structural constraints and of negotiation contexts, and actors' understanding of desired outcomes, affected the negotiation process and outcomes. Other aspects of negotiation processes that have been explicated include the conditions which encourage or discourage negotiation (Hall and Spencer-Hall 1982), how structural conditions affect the nature of negotiations and where these processes may occur (Busch 1980), as well as how conflicting theories of negotiation can lead to prolonged debates on who will negotiate, what will be negotiated, and how the negotiation will occur (Kleinman 1982).
These are impressive achievements. Yet, whereas organizational actors' conceptions and understandings of negotiation have been increasingly examined, little attention has been addressed to the structure of real-world negotiations. Few interactionist researchers employ audio/video recordings and detailed transcriptions of naturally occuring activity as primary data, and most have employed research-mediated materials such as in-depth interviews and fieldnotes, which are designed to capture the worker's point of view or definition of the situation. I am not arguing that interactionists should abandon their study of worker's perceptions of negotiation; I am arguing that examining the detailed organization of in situ negotiative processes can augment our understanding of negotiation in organizational life. Moreover, I am arguing that this type of fine-grained analysis is only available with the use of modern recording technologies and is unlikely to emerge from even the most observant ethnographer's fieldnotes.
Whereas interactionist studies of work and organizations have recognized the centrality of communicative acts, they have not found a method to deal with everyday talk-in-interaction, or other forms of discourse. Researchers in this tradition have treated language use as a taken-for-granted feature of organizational settings that need not be explicated (cf. Atkinson 1985). Negotiated order research has only been concerned with talk as a "resource" for understanding actors' theories and has not examined talk as a topic in its own right (cf. Zimmerman and Pollner 1970). Interactionist researchers often examine the interaction of workers as a source of information, or an expression of job attitudes or feelings, or a statement of naive theories. In short, they employ talk as a means of providing access to the worker's point of view or definition of the situation. What they have not done is address the details of interaction as topics in their own right, treating social interaction as orderly activity which is an integral feature of any workplace.
In this article, I demonstrate that examination of the precise and patterned processes workers employ to achieve negotiation in real-time instances of occupational activity reveals a level of social order rich in complexity and subtle in its effects. My data are drawn from the occupational world of emergency medicine. Specifically, I examine the negotiation of directives in radio calls between paramedics at the scene of a medical emergency and emergency department (MICU) nurses. After discussing my methods of research, I turn to my data.
Ethnomethodological Studies of Work
While the sociology of work is replete with studies "about" work and workers, studies "of" work are rare. We do not know what occupational activities consist of, nor how workers manage their tasks (Heritage 1984). Social scientists have been unresponsive to what Garfinkel often refers to as "Shils's Complaint:"
"In 1954, Fred Strodtbeck was hired by the University of Chicago Law School to analyze tape recordings of jury deliberations obtained from a bugged jury room. Edwards Shils was on the committee that hired him. When Strodtbeck proposed to a law school faculty to administer Bales Interaction Process Analysis categories, Shils responded: 'By using Bales Interaction Process Analysis, I'm sure we'll learn what about a jury's deliberations makes them a small group. But we want to know what about their deliberations makes them a jury'" (Garfinkel, Lynch, and Livingston 1981, p. 133).
This story is worth repeating to make the point that an overriding concern in ethnomethodological studies of work is to discover just what it is that makes a work activity what it is. Work activities are analyzed for how they exhibit the accountably competent practices of the workers in the local production of the work. Whereas a growing body of research helps to define ethnographic studies of work as a separate stream of research in the ethnomethodological program (Garfinkel et al. 1981; Lynch, Livingston, and Garfinkel 1983; Sharrock and Anderson 1987; Harper 1987), these studies can be regarded as extensions of earlier ethnomethodological themes. Many of Garfinkel's early research projects deal specifically with the contingencies of occupational practices-for example, the study of the work activities of a suicide prevention center (Garfinkel 1967, pp. 11-18) and the study of clinic records (Garfinkel 1967, pp. 186-207). In addition, the research of many of Garfinkel's early students and associates deal with uncovering the orderly world of occupational life (e.g., Zimmerman 1969).
Ethnomethodology has emerged into two somewhat distinct research enterprises: (1) ethnomethodologically informed ethnographies of naturally occurring settings, and (2) conversation analytic studies. The former has paid ample attention to the role of language use in everyday settings; the latter has made that topic a rigorous science. Researchers in conversation analysis have subjected everyday talk to detailed examination, creating a body of research attesting to the orderly features of social interaction. A central goal of this form of analysis is to describe the practices and procedures speakers use to produce actions and to recognize the actions of others in talk-in-interaction. Specifically, there is a focus on the sequential structuring of everyday talk and the local production of social order.
The goal of conversation analysis is "to explore the possibility of achieving a naturalistic discipline that could deal with the details of social actions, rigorously, empirically and formally" (Schegloff and Sacks 1973, p. 239). To gain access to the practices and procedures conversationalists employ in social interaction, analysts work with audio and/or video recordings of naturally occurring activity. Through repeated hearing or observation, a detailed transcript is produced, allowing the analyst to specify the regularities across a range of interactions and participants. (A full description of the transcription conventions is found in the Appendix.)
Talk as Work: Paramedics-in-Action
The data to be examined in this study derive from a corpus of radio calls between paramedics and emergency department (MICU) nurses-admittedly, one small slice of occupational life. When a paramedic arrives on the scene of an emergency, a radio call is routinely made to the nearest emergency department to describe the victim's symptoms and to receive orders for medical action from the emergency department nurse. Our concern here is with negotiations which occurred between paramedics and ER nurses concerning these medical directives.
Elsewhere (Mellinger 1990, 1992a), I have described the organization of these paramedic calls for emergency field orders, which I shall briefly review here to present the sequential context in which these negotiations occur. There are five major components which characterize these calls:
- Opening
- The Paramedic's Assessment
- Question/Answer Sequence
- The Nurse's Medical Directive/Paramedic's Receipt
- Closing
The following call exhibits the outline of this structure:
Call #46b
00 P: Saint Mary's rescue thirty five howd'ya copy
01 N: I copy loud an clear go ahead
02 P: Saint Mary's from rescue thirty five we've been called
03 to uh store (.) tuh take care of uh male patient (.) seventy
04 three years old=weighs about uh hundred an eighty pounds
05 .hh who witnesses describe thuh patient as having uh
06 syncopal episode .hh 'pon our arrival thuh patient was
07 alert an oriented sitting in uh chair .hh states that he
08 still feels just uh little bit weak. (.) Urn: at that
09 time he had uh blood pressure of nine eight (.) over six
10 zero .h with uh pulse rate of sixty four, (.) respiratory
11 rate of eighteen, lung sounds are (.) .hh clear no
12 shortness of breath, alert an oriented, uh slightly pale
13 but (he's) dry tuh thuh touch (.) an warm. We've laid
14 thuh patient down .hh have had him in a supine position
15 for approximately three minutes he now has uh blood
16 pressure of one three zero over eight six. Pulse rate is
17 one hundred an regular, no ectopy (.) and restoration
18 all other signs remain unchanged. Patient has uh
19 history of high blood pressure=he takes
20 hydrocholorothiazide (.) as well as potassium, takes no
21 other medications and has no known allergies. Patient has
22 sustained no injuries as uh result of his syncopal
23 episode by the way .hhh he has no allergies=we have him
24 on oh two of four liters per nasual cannula (13) an our
25 closest facility is your facility with an ee tee ay of two
26 tuh three minutes. I understand that you're closed tuh
27 criticals=if=you cannot accept then Providence would be our
28 second closest with uh three minute ee tee ay .hh your
29 incident number is two seventy seven over
30 N: Saint Mary's tuh city rescue thirty five=that's uh roger
31 I copy .hhh um (1.6) go ahead an- an continue your oh
32 two at four liters by nasual cannula .h urn s: start an
33 eye vee of normal saline to keep open
34 at this time ((sniff)) prior to that I'd like ya
35 tuh draw um (2.4) one tiger top an one purple top (.) an
36 durn: (1.1) I'm sorry I didn't copy whether or not you had
37 your patient hooked up to an ee kay- ee kay gee monitor
38 if so what are you seeing and can you send me uh lead two
39 over
40 P: Saint Mary's from rescue thirty five I copy continue thee oh
41 two draw bloods establish an eye vee .hh of normal saline tee
42 kay oh rate .hh we do have him on thuh monitor at this
43 time=we're showing border=line sinus=tachycardia .hh
44 no ectopy=l'll send you thuh lead two
45 here=in=just=uh=second there we have uh lot of baseline
46 artifact as uh result of thuh ((ambil'nsydling)) so (.)
47 you won't have uh very good baseline (.) by=thuh=way thuh
48 pupils are pearl:, he's in mild distress=here's your lead
49 two
50 ((LONG BEEP))
51 N: Saint Mary's tuh city rescue thirty five .hh u:m I'm
52 really sorry=but I'm not copying anything except uh lot of
53 artifact over
54 P: Saint Mary's thirty five roger we're showing borderline sinus
55 tack at uh rate of uh hundred over
56 N: Saint Mary's tuh city rescue thirty five that's uh roger
57 urn: I'll go ahead with that .hh um:: we're gonna send
58 your pa:y- patient tuh Providence over
59 P: Saint Mary's thirty five roger that's what we anticipated.
60 N: Saint Mary's tuh city rescue thirty five once your eye
61 vee's established um : whydoncha go ahead an get me: one
62 more blood pressure=an meanwhile 1'11- I'll (.) notify
63 Providence over
64 P: Thirty five roger.The call's temporal organization is comprised of five components: (1) paramedic and emergency department nurse accomplish an opening (lines 00-01) in which their respective identities are aligned and the interactional availability of the ER nurse is established; (2) the paramedic presents an extended Assessment summarizing the patient's condition (lines 02-30); (3) if more information is needed, a series of questions and answers may follow, initiated by the nurse (lines 30-49); (4) the nurse delivers medical directives regarding a course of treatment for the patient (lines 31-39, 60-62) and the paramedic displays receipt of those directives (lines 40-49, 64); and (5) finally, a closing section tailored to the specifics of the call must be mutually achieved (lines 63-64). Note that the third and fourth components are intertwined in this call, as is common in most of these calls.
Considering the above example in more detail, observe that the opening sequence begins with a "request for the go ahead" (Mellinger 1992a, pp. 84-86) by the paramedic (line 00). This turn at talk contains a term of address for the emergency department nurse ("Saint Mary's), a categorical self-identification by paramedic ("rescue thirty five"), and a question concerning the quality of the radio transmission ("how d'ya copy"). One function of this utterance is as a summons (Schegloff 1968), and thus is the first part in a two-part turn couplet or adjacency pair-the summons/response sequence (Schegloff and Sacks 1973). The nurse's "Go Ahead" (line 01) functions as the response in this sequence. The nurse answers the paramedic's question about the quality of the radio transmission ("I copy loud an clear") and then gives the "go ahead." When this occurs, the mutual availability of both parties has been determined and the call can continue.
As can be seen in the above example, the paramedic's Assessment is a lengthy utterance, composed of many separate components, including: a reiterated term of address and categorical self-identification (line 02, "Saint Mary's from rescue thirty five"); the patient's age, sex, and approximate weight (03-04); the patient's chief complaint (05-06: "uh syncopal episode"); and the patient's medical status, including his mental state ("alert and oriented"), blood pressure (09), pulse (10), respiratory rate (10-11), lung sounds (11), tidal volume (11-12 "no shortness of breath"), and skin vitals (12-13). The paramedic describes the changes in the medical status that have occurred since their arrival on the scene (13-18). The paramedic continues with the patient's medical history (18-19), current medications (19-21), allergies to medications (21), the preliminary medical treatments already undertaken before the call was made (23-24), a list of the two closest emergency departments, the estimated time of arrival to each (24-28), and the run's incident number (29).
Following paramedics' Assessments, nurses' next turns at talk are routinely concerned with a multitude of tasks. In the above example, the nurse displays reciept of the paramedic's information (30-31: "that's uh roger I copy"), gives medical directives to the paramedic (31-36), and requests additional information (36-38). The paramedic's next turn at talk (lines 40-49) is also concerned with a multitude of tasks: displaying receipt of the nurse's directives (40-42); answering the question concerning the EKG (42-47), providing the requested information (47-48). After the electrocardiogram (or "lead two") is sent (line 50), the nurse states that she is having trouble reading the signal, "I'm really sorry=l'm not copying anything except uh lot of artifact over" (51-53). Distortion of the ECG signal is known as "artifact" or "noise" and can result from a variety of sources, including transmission beyond the range of the transmitter. The paramedic gives the nurse his interpretation of the electrocardiogram on their monitor. "Borderline sinus tach" (or sinus tachycardia) is a form of cardiac dysrhythmia, in part marked by heart rates of 100 beats per minute or more. Notice that the paramedic's interpretation of the EKG is repeated from the prior Assessment in which he also projected the problem of artifact.
In her subsequent turn, the nurse states the acceptability of the paramedic's interpretation, "1'11 go ahead with that," and announces the hospital that will be their destination (lines 57-58). The announcement of the run's destination is one of several possible closing-relevant tasks which routinely lead to the call's termination (Mellinger 1992a). The paramedic displays receipt of this information in the following turn (line 59, "roger that's what we anticipated"). Two separate tasks are performed in the nurse's final turn. First, the nurse informs the paramedic of her intention to "notify Providence," that is, to check if that hospital will take this patient. Since this task requires that the nurse "break" communication with the paramedic, at least momentarily, announcement of it can be seen as an initiation of a closing sequence. The second task that the nurse performs here is to request an update on the blood pressure, "once your eye vee's established." The paramedic's "roger" in the final turn is doubly an acceptance of the closing initiation begun by the nurse, and of the request for an updated blood pressure.
This interactionally achieved and situationally contingent structural organization is prototypical and is found throughout this corpus of radio calls. These electronic encounters represent a specialization and adaptation of the interactional mechanisms found in mundane telephone conversation (cf. Heritage 1984). These modifications are sensitive to a variety of contextual factors, including the tasks being accomplished, the "channel" of communication, and the institutional roles of the participants. The stable and recurrent features of these calls arise from situated practices which are responsive to the contingencies of these urgent interactions (Mellinger 1992a). Detailed examination of these situated practices provides a useful window through which to observe the emergent and contingent properties of any work setting.
Negotiating Directives
As can be seen in the above call fragment, medical directives in these calls are typically achieved through two-part sequences in which (1) the nurse proposes some medical treatment, and (2) the paramedic displays receipt of these directives in a subsequent turn. Both the nurse's proposal for treatment and the paramedic's acknowledgment of that proposal routinely occur in multiunit utterances, turns in which a multitude of tasks and speech acts are performed.
Elsewhere (Mellinger 1992a, pp. 92-95) I have described the mitigated character of the nurse's directives. That is, as opposed to our commonsense notion of "orders" as verbal commands that one conversationalist gives to another, the medical directives in this corpus of paramedic calls are syntactically shaped to display the nurse's indirectness. Mitigated directives, such as proposals and suggestions, allow speakers to avoid offending another by formulating their wishes in downgraded ways (Labov and Fanshell977, pp. 84-85; Goodwin 1990, pp. 67-70; West 1990). The "whydoncha go ahead and do X" format found above (lines 61-63) downgrades the directive to the status of a suggestion and deemphasizes the status difference between nurse and paramedic.
In most calls, the directive-response sequence is limited to this two-part format. Only rarely does explicit negotiation concerning medical treatment occur. The four following instances of negotiation of directives between paramedics and nurses involve the nurse withdrawing a prior directive and replacing it with another, after a problem arises with the original directive. In that "we know very little about basic patterns of negotiation as constructed through participant's actual talk" (Maynard 1984, p. 165), these efforts to describe the order of negotiation are necessarily exploratory.
Example One: Local Versus Remote Negotiation
One situation in which a change in the directives is necessary is when the original directives are unable to be fulfilled. The process of negotiation concerning the nurse's directives can be either immediate-achieved in the turn immediately following the directive, or remote-dealt with at a later point in the interaction. If the paramedic knows of a problem with the nurse's directive when it is presented, the negotiation is likely to be immediate. If a problem arises while the paramedics are attempting to implement the directive, the negotiation will be remote. Consider the following call fragment which illustrates remote negotiation:
Call #19
01 A: Rescue thirty five from Saint Mary's (.) continue with thee
02 oh two at four liters (.) you can go ahead with an eye vee
03 of normal saline=jus' run it tee kay oh (.) draw me some
04 bloods if your able to (.) an I'd like ((uh lead two))
05 when ever you can please over
06 C: Rescue thirty five roger we copy an eye vee normal saline
07 an: stan' by one for lead two
08 ((long beeps of the lead two))
09 C: Saint Mary's rescue thirty five
10 A: Thirty five go ahead
11 C: Saint Mary's rescue thirty five, uh thuh patient (.) uh
12 has (.) no veins that we're able to access (.) uh we feel
13 comfortable transporting her without an eye vee (.) if
14 you do an:: what would our destination be
15 A: Rescue thirty five that's fine transport her as is an
16 you'll be transporting to our facility over
17 C: Rescue thirty five roger: uh if you feel comfortable we can
18 go ahead an break down: .hh an we'll see you in about five
19 minutes ...In the above call fragment the nurse presents a series of directives-continue with the oxygen, set up an intravenous solution of saline, draw some blood samples, and send a "lead two," the telemetric electrocardiogram transmission (line 01-05). Note that the nurse projects trouble with the IV in how she tags this directive with "if your able to" (04). She is able to infer trouble with this based on her interpretation of the prior Assessment of the patient by the paramedics The paramedic's display of receipt (06-07) only mentions that they "copied" establishing an intravenous line. The paramedic informs the nurse that the lead two is about to be transmitted. After the lengthy EKG signal is sent, the paramedic informs the nurse of their trouble with one of the directives, "thuh patient (.) uh has (.) no veins that we're able to access" (lines 11-12). An alternative course of action is proposed by the paramedic, "we feel comfortable transporting her without an eye vee" (lines 12-13). The paramedic tags this counterproposal with "if you do," which I take to be an implicit request for the nurse's point of view on the matter. The paramedic's utterance ends with a request for the run's destination. In the next turn, the nurse accepts the paramedic's counterproposal, "that's fine transport her as is" and gives the name of the designated hospital. In the next turn (lines 17-19), the paramedic initiates a closing sequence.
Sequentially, the above negotiation begins with the issuing of directives by the nurse. In response, the paramedic displays receipt of these directives in the next turn. A series of other activities, primarily the sending of the lead two, ensue before the directives are dealt with again. The paramedic subsequently reports a problem with the nurse's directive, offers an alternative course of action, and implicitly requests the nurse's point of view. In response to the paramedic's utterance, the nurse agrees with the paramedic's counterproposal. Remote negotiations occur when problems with the directives arise after they have been presented. All of the other instances of negotiation examined here are immediate negotiations, in which problems with the directives arise immediately following their presentation.
Example Two: Nurse Counterproposes
In the above call fragment, it is the paramedic who offers a counterproposal after a trouble with the nurse's directive has been stated. This is not always the case. There are a range of sequential paths which may be navigated by paramedic and nurse to negotiate a medical course of action. Consider now an instance of negotiation over medical directives in which the nurse formulates a counterproposal:
Call 891
01 N: Rescue twenty seven from Saint Mary's=l copy (.) uh I would
02 like you tuh establish an eye vee of normal saline (.) tuh
03 keep open at this time, (.) uh- if you could (.) draw bloods
04 prior to: red and lavender top=and what's- once your eye vee's
05 established I'd like you to administer dee fifty fifty
06 (( )) eye vee push (.) um and I'd like her on some oh two
07 at five liters nasual cannula (.) uh: while you're doing that
08 let me call Eastside to see if they can accept thuh patient
09 over
10 (3.2)
11 P: Saint Mary's rescue twenty seven roger uh we: informed her
12 that we're gonna have tuh start an eye vee on her and she
13 adamantly refused=she says that nobody is sticking her with
14 anything .hhh uh we explained to her that it is a necessity
15 but she uh is holding on to both of her arms and she won't let
16 us (.) have either arm? I understand that you'll go ahead and
17 contact Eastside and see what they say. ((click))
18 N: That's roger rescue (.) uhm:=if she won't allow that could you
19 give her one milligram of glucagon uh do you think you might
20 be able to manage that=would she allow that over
21 P: Saint Mary's rescue twenty seven we'll give it uh shot=however
22 she's (.)r-r- she's uh quite upset when we mention anything
23 about needles or shots and she doesn't seem to go for that .hh
24 however we will try tuh (.) go with the glucagon one milligram
25 N: That's uh roger 1'11 be uh: (.) on thee other phone for uh
26 moment.The call fragment seen above comes after the paramedic's lengthy Assessment of the patient. After displaying receipt of information given by the paramedic in the prior turn, "I copy" (line 01), the nurse begins a list of medical directives-to establish an intravenous line, to "draw bloods," to set up a "red and lavender top," and to administer some dextrose and oxygen. The nurse informs the paramedic that she will call "Eastside," while they are "doing that," to confirm an available space at that hospital (lines 7-9). A problem with the nurse's directives arises in the paramedic's next turn. The patient "adamantly refused" (line 13) to allow the paramedics to establish an intravenous line. The paramedic quotes the patient, "she says that nobody is sticking her with anything" (lines 13-14) and reports their unsuccessful efforts to convince the patient to comply, "we explained to her that it is a necessity but she uh is holding on to both of her arms and she won't let us (.) have either arm." Finally, the paramedic displays receipt of the nurse's informing about her calling Eastside, (lines 16-17).
The nurse next formulates a counterproposal, crafted as an if-then conditional, "if she won't allow that could you give her one milligram of glucagon." Her utterance ends with two questions tagged to the counterproposaL(1) "do you think you might be able to manage that," and (2) "would she allow that," which both request the paramedic's assessment of the situation. In the next turn, the paramedic twice states their willingness to comply with the nurse's counterproposal, "we'll give it uh shot" (line 21) and "we will try" (line 24). The discourse connective "however," also employed twice in this utterance, marks the upcoming unit as contrasting with a prior unit (Schiffrin 1987). The contrast is drawn between their willingness to comply and the patient unwillingness to "go for" needles or shots. The nurse displays receipt of this turn, "That's uh roger," and states that she will be "on thee other phone for uh moment" (line 25-26).
The above instance of negotiation shows that either participant can proffer a substitute course of medical treatment once the trouble with the original directive is mutually known. Moreover, we see that there are different types of "problems" which arise with medical directives. In example 1, the problem with the nurse's directive concerned the physical possibility of carrying out the proposed treatment (patient has "no veins that we're able to access"); in example 2, the problem involved the patient's refusal to allow the treatment.
Example Three: New Information
Another type of problem with a proposed course of treatment may occur if the paramedic presents new information after the nurse has already formulated a medical course of action. If additional information on the patient is presented by the paramedic after the nurse has proposed a line of treatment, the original directives might need to be adjusted in light of the new knowledge. Consider the following call fragment:
Call #48
01 N: Saint Mary's to urn rescue eighty two put her on some oh two
02 at six liters uh nasual cannula .hh start an eye vee of normal
03 saline=jus run that tuh keep open right now. Draw some bloods
04 an we'll follow that with uh point eight of Narcan an fifty
05 cee cees of dee fifty .hh did I copy that her skin vitals are
06 all normal?
07 P: Saint Mary's city rescue eighty two. Uh that's affirmative
08 (.) also patient is on uh methadone program=she didn't go
09 t'day (.) as far as her family knows
10 N: Mary's tuh eighty two hold on tuh that narkan=f'r jus uh
11 minute' 'n give her fifty cee cees of dee fifty an duh: what
12 's your destination an ee tee ayAfter dealing with identity issues, the nurse in the above call fragment delivers four directives to the paramedic (lines 01-05), all decidedly in the form of explicit commands ("put," "start," "draw"). The nurse terminates the utterance with a question verifying the "skin vitals." After addressing identity issues, the paramedic responds "that's affirmative" in response to the question about the skin vital signs, and then briefly pauses. At this point the paramedic adds several new bits of information-particularly, that the patient receives regular methadone treatments, and that she might not have received that treatment on this day (lines 07-09). Interestingly, the paramedic does not display receipt of the nurse's prior directives, which could indicate an understanding that crucial information was omitted from the Assessment which would influence the nurse's choice of a course of treatments.
In the next turn, the nurse instructs the paramedics to stop the injection of the narcotic-antagonist drug naloxone (tradename = Narcan), "hold on tuh that narcan=f'r jus uh minute" (lines 10-11), and repeats the order for 50 cc. dextrose solution, "give her fifty cee cees of dee fifty." The nurse requests the name of the closest emergency department and their estimated time of arrival (ETA) to that location. Several turns later the nurse proposes to give the naloxone:
20 N: Mary's tuh eighty two uh we're gonna be sending you on tuh
21 Oaks with this lady. When you have your eye vee established
22 uh we- we'll go ahead an give thuh Narcan point eight. An uh
23 what are you seeing on your lead two.While the motive for the nurse's withdrawl of her directive is unclear, the warranted inference can be made that the nurse changed the medical directive due to the information provided by the paramedic in the prior turn.
Example Four: Assessment-Trading in Medical Work
One aspect of the emergency medical subculture which is articulated within these negotiations is the overwhelming concern among paramedics and emergency department nurses with what they refer to as "assessment-trading." Throughout this corpus of calls, both nurses and paramedics routinely request the other's point of view regarding a course of medical action. This sensitivity to another's "comfortability" with a course of action in part arises because the highly trained emergency nurse must give orders to lesser-trained professionals, who might know how best to treat the patient's problem because they are present at the scene. Consider the following call fragment which displays this concern for assessment-trading.
Call #17
01 A: U:h that's uh roger uh Woodview one seventy
02 one (.) um (.) I think maybe: we better (.) you
03 can do this en route (.) uh maybe we better go
04 with thuh mast suit an uh attempt thuh eye vee en
05 route an (.) uh once your eye vee's established go
06 ahead an give her two hundred cee cees fluid
07 challenge if in fact you are able to establish
08 that while you're (.) en route over
09 B: Saint Mary's ((this is)) one seventy one ten
10 four we copy go ahead with thuh mast suit an duh
11 inflate all three chambers an duh then go ahead
12 an du:h (.) u:h ra- attempt tuh reestablish an
13 eye vee while en route an if successful go two
14 hundred cee cees fluid challenge=or would you only
15 like thuh legs inflated on thuh mast suit
16 A: uh rescue huh: Woodview one seventy one .hh
17 no you can go with all three chambers: that will
18 be fine an if you need to you can recontact me if
19 you run into any problems while your en route to
20 uh Hilltop uh- are you comfortable with that=over?
21 (2.11
22 B: Saint Mary's from Woodview one seventy one
23 uh: we'r:e (.) uh little uncomfortable with going
24 with uh thuh abdominal chamber=jus because thuh
25 patient's breathing so fast we're afraid that we may
26 uh uh (.) make kuh diaphrenatic movement uh little
27 bit tough on thee patient she's so small an frail uh
28 but if you'd like tuh go ahead with thuh legs
29 A: That's uh roger rescue (.) um Woodview one
30 seventy one go ahead an jus inflate thuh legs
31 bilaterally an you can leave thuh abdomin uh (.)
32 alone an duh (.) are ya comfortable at this time
33 in breaking down? uh an do you have ay: also ay-
34 I need an incident number if possible overThe above call fragment is part of a "call back"-that is, the nurse and paramedic were previously involved in a radio call about the same event, and are now resuming their interaction. In the first call, the paramedic gave an Assessment for a patient whose chief complaint was "shortness of breath." After informing the paramedics to continue with their "oh two at ten liters by mask," and to "give me uh blood pressure," the emergency department nurse states:
"I'll be away from thuh radio for uh moment=l'm gonna discuss with ou:r physican (.) um (.) uh whether thuh patient should be transported tuh Mission with an ee tee ay of ten or to Hilltop .hh uh I'll be back with ya in a moment."
The call fragment I am concerned with here is midway through the "call back" and involves the negotiation which occurs regarding the "mast suit." MAST, or Medical Anti-Shock Trousers, are inflatable garments that surround the legs and torso, and are often used to raise the blood pressure of a patient in shock or trauma. In lines 03-04 the nurse states, "maybe we better go with thuh mast suit." The paramedic receipts this directive in the next turn (lines 10-11), "we copy go ahead with thuh mast suit an duh inflate all three chambers." At the end of that turn, the paramedic asks (line 14-15), "would you only like thuh legs inflated on thuh mast suit." Note that while the nurse has proposed use of the mast suit without mentioning the three chambers, the paramedic's receipt of these directives displays an understanding that the nurse has requested all three chambers to be inflated. The paramedic's question about only inflating the legs can be heard as a 'challenge' to these directives. The nurse responds, "no you can go with all three chambers" (line 171, clearly stating that all of the chambers should be inflated. Later in that turn, the nurse asks the paramedic, "are you comfortable with that=over?" This question by the nurse is an excellent example of assessment-trading. The nurse has issued her medical directives for the patient and yet in a subsequent turn inquires about the paramedic's point of view regarding those orders, in fact, inviting a counterproposal if one is to be had.
Beginning on line 23, the paramedic states that they feel "uh little uncomfortable" with the nurse's order to inflate the abdominal chamber of the mast suit, ''jus because thuh patient's breathing sofast we're afraid that we may uh uh (.) make kuh diaphrenatic movement uh little bit tough on thee patient she so small an frail." The paramedic terminates this turn at talk, "but if you'd like tuh go ahead with thuh legs" (line 28), showing that while he disagrees he is willing to follow her directives. In the next turn, the nurse modifies her previous directive concerning inflating the mast suit, telling the paramedic that they can "jus inflate thuh legs bilaterally an you can leave thuh abdomin uh (.) alone" (lines 30-32).
In the above sequence, the nurse has given medical directives to the paramedic. In the same turn in which the paramedic displays receipt of these instructions (lines 10-11), the paramedic asks a question which can be seen as a challenge to these instructions (lines 14-15). Initially, the nurse holds to her original instructions and then requests the paramedic's point of view regarding this procedure. In response to the nurse's query, the paramedic states their uncomfortability with these orders, which leads to the nurse altering the original directive.
Conclusion
The give-and-take moves which compose the sequential logic of these negotiations constitute an elegant and effective interactional machinery through which the nurse and paramedic collaboratively arrive at a mutually acceptable course of action. The negotiation sequence begins with the nurse's directive for some medical treatment. A second move occurs in the next turn, in which the paramedic typically displays receipt of the nurse's directive. Instead of merely displaying receipt of the directive, the paramedic may state a problem with the directive (example 2), present new information which calls into question the prior directive (example 3), or even counterpropose an alternative line of action (example 4). As we have seen, throughout these sequences there is a deep concern for assessment-trading, and the nurse often requests the paramedic's point of view in problematic cases (examples 1 and 4). A statement of the paramedic's uncomfortability with a directive can lead to a withdrawl of the original directive and its replacement with another directive by the nurse (example 4). These bargaining activities involve a subtle coordination between the participants in which meanings are locally achieved and occupational roles instantiated.
Close analysis of actual negotiations reveals just that coordination of action Hughes and Strauss were so sensitive to, and precisely locates it in the patterned processes of the interaction order. Negotiations are interactional events accomplished through the mechanisms of language-in-action. Included in this repertoire of interactional procedures are artful ways of issuing directives to a co-worker, techniques for stating problems with those directives, and collaborative strategies for arriving at a mutually acceptable compromise. All of these bargaining activities are achieved on a turn-by-turn basis and display recurrent sequential structures. Thus, I am proposing that the negotiated order becomes available for analysis through the detailed examination of naturally occurring social interaction.
My goal in this article has been to illustrate the usefulness of conversation analytic research for symbolic interactionist studies of work and organizations. The negotiated order approach gives analytic centrality to the role of language, meaning and negotiation in its attempt to understand organizational and occupational life. Yet, language tends to be a taken-for-granted feature of these settings that need not be explicated. There has been little attempt to formally describe how the micromoments of the social drama of work unfold in orderly and recurrent patterns. I believe that the use of audio and video recordings of naturally occurring settings as primary data could supplement symbolic interactionist studies. Principally, this would provide a rigorous means to capture the delicate details of real-world, actual activities as they happen. The "bundle of tasks" which compose occupational life have a richness and complexity beyond any notion in Hughes' time. While not perfect, recorded materials capture the in situ accomplishment of occupational activity, so that the moment-by-moment unfolding of any particular phenomenon can be tracked.
Appendix: Transcription Conventions
The transcription conventions employed in these transcripts were developed by Gail Jefferson. The following conventions are most relevant to the present analysis:
- (word) - Parentheses surrounding a word indicate uncertainty about transcription
- (0.5) - Parentheses around a number indicates silences, in seconds and tenths of seconds
- (.) - A period inserted within parentheses indicates a very short (probably one-tenth of a second or less) untimed silence
- ((click)) - Double parentheses are used to enclose a description of some phenomenon with which the transcriptionist does not want to wrestle (e.g. vocalizations and other sounds)
- Stress - Underlining indicates emphasis
- LOUD - Capital letters indicate speech that is much louder than accompanying talk
- °quiet° - Degree signs are used to indicate a passage of talk that is much quieter than the surrounding talk
- Co:lons - Colons mark the prolongation of the preceding sound; the more colons, the greater the prolongation
- hhh .hhh - Audible aspirations (hhh) and inhalations (.hhh) are inserted in the speech where they occur
- . - A period indicates a stopping fall in tone, not necessarily the end of a sentence
- , - A comma indicates a continuing intonation, not necessarily between clauses of sentences
- ? - A question mark indicates a rising inflection, not necessarily a question
- - - A single dash indicates a halting, abrupt cut-off, or, when multiple dashes hyphenate the syllables of words, the stream of talk so marked has a stammering quality
Acknowledgments
This is a revised version of papers presented at the Society for the Study of Symbolic Interaction/Stone Symposium in San Francisco in February 1991 and at the Qualitative Research Conference in Toronto, Canada in May 1990. The author greatly benefitted in preparing this article from discussions with, and often critical comments from, Don Zimmerman, Harvey Molotch, Deirdre Boden, Candace West, Robin Lloyd, Rodney Beaulieu, Joan Weston, Gene Lerner, Angela Garcia, Anselm Strauss, Tomatsu Shibutani, and the students in my classes on conversation analysis at the Santa Cruz and Santa Barbara campuses of the University of California. The author is indebted to the anonymous reviewers of Symbolic Interaction for their guidance and encouragement.
References
[Full reference list as in original]
Originally published in Symbolic Interaction, Vol. 17, No. 2 (Summer 1994), pp. 165-185
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