Professor Roderick Iedema

Iedema, R.A. 2003, The Discourses of Post-Bureaucratic Organization, 1, John Benjamins, Amsterdam, Philadelphia.
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This book considers the discourses that come into play in organizational change. The book outlines the tensions that arise for people having to enact change, and analyzes the ways in which they position themselves in changing organizational environments. The book takes a social semiotic perspective on discourse, organization and change. Here, discourse encompasses not only the multi-modal resources that people mobilize in organizational (inter)action, but also the practices and transformative dynamics afforded by those resources. The organizational changes highlighted in the book revolve around three dimensions of work that are increasingly coming to the fore: participation, boundary-spanning and knowledging.

Caldas-Coulthard, C.R. & Iedema, R.A. 2008, Identity trouble: Critical discourse and contested identities, Palgrave-Macmillan, Houndmills Basingstoke.
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Edited book

Sorensen, R. & Iedema, R.A. 2008, Managing clinical processes in health services, Elsevier, Sydney.

Iedema, R.A. 2007, The Discourse of Hospital Communication: Tracing complexities in contemporary health care organizations, Palgrave-Macmillan, UK.

Iedema, R.A., Long, D. & Carroll, K.E. 2010, 'Corridor communication, spatial design and patient safety: Enacting and managing complexities' in van Marrewijk, A.; Yanow, D. (eds), Organizational Spaces, Edward Elgar, United Kingdom, pp. 41-57.
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This chapter describes how a mUlti-diSciplinary clinical team occupies its clinical space and, in particular, its corridor. When we started to observe the practices of this clinical team in a metropolitan teaching hospital in Sydney in 2004, I the character of the work conversations that clinicians enacted there signalled to us that the corridor performed an important role. These conversations became possible in this corridor space, we suggest, because the team capitalized on what they probably perceived to be a 'liminal' space' that is a space that does not embody strong indications for staff about what' is to take place within it.

Grant, D., Iedema, R.A. & Oswick, C. 2009, 'Discourse and Critical Management Studies' in Alvesson, M., Bridgman, T., Willmott, H. (eds), The Oxford Handbook of Critical Management Studies, Oxford University Press, Oxford, UK, pp. 213-231.
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This chapter discusses several prominent critical manangement studies (CMS) approaches to discourse analysis that are embedded in critical traditions. It also considers the limitations of these prevaling forms of engagement and presents a way of enhancing and progressing a discursively informaed CMS agenda.

Iedema, R.A. & Scheeres, H.B. 2009, 'Organisational discourse analysis' in Bargiela-Chiappini, Francesca (eds), The Handbook of Business Discourse, Edinburgh University Press, Edinburgh, pp. 80-91.
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This chapter provides an overview of the changes and innovations that we see in contemporary business organisations and their implications for employees. These changes and innovations involve new technologies, restructured product lines or services, and new managerial, professional and occupational tasks and responsibilities. What the research that is reviewed in this chapter suggests is that these developments manifest most dramatically in how employees relate to one another, what they say to one another, how much they say to one another, and how frequently they (have to) communicate with each other (Adler 2001; Child and McGrath 2001). For that reason, the focus ofthe chapter is on how changes within business organisations impact on employees in those organisations - not on the discourses of how people do business with one another across organisations.

Iedema, R.A., Sorensen, R., Jorm, C. & Piper, D.A. 2008, 'Co-producing care' in R. Sorensen & R. Iedema (eds), Managing clinical processes in health services, Elsevier, Sydney, Australia, pp. 105-121.
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Iedema, R.A., Ainsworth, S. & Grant, D. 2008, 'Embodying the contemporary 'clinician-manager': entrepreneurialising middle management?' in Carmen Caldas Coulthard & Rick Iedema (eds), Identity Trouble, Palgrave Macmillan, Houndmills Basingstoke, UK, pp. 273-291.
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Iedema, R.A., Degeling, P.J. & White, L. 2008, 'Professionalism and Organisational Change' in R. Wodak and C. Ludwig (eds), Challenges in a Changing World - Issues in Critical Discourse Analysis, Passagen Verlag, Vienna, pp. 127-155.
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Rhodes, C.H., Scheeres, H.B. & Iedema, R.A. 2008, 'Triple Trouble: Undecidability, Identity and Organisational Change' in Coulthard & Iedema (eds), Identity Trouble, Palgrave Macmillan, Houndmills Basingstoke, UK, pp. 229-249.
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Sorensen, R. & Iedema, R.A. 2008, 'Implications for practice' in R. Sorensen & R. Iedema (eds), Managing clinical processes in health services, Elsevier, Sydney, Australia, pp. 225-242.
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Sorensen, R. & Iedema, R.A. 2008, 'Managing clinical processes: objectives, evidence and context' in R. Sorensen & R. Iedema (eds), Managing clinical processes in health services, Elsevier, Sydney, Australia, pp. 3-20.
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Iedema, R.A. 2007, 'Communicating Hospital Work' in Rick Iedema (ed), The Discourse of Hospital Communication, Palgrave Macmillan, New York, USA, pp. 1-17.
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The focus of this volume is on hospital communication and interaction. our interests in what goes on in the hospitals reflects a general rise in public scrutiny of the enactment and organisation of hospital work.

Iedema, R.A. 2007, 'Corridor Conversations: Clinical Communication in Casual Spaces' in Rick Iedema (ed), The Discourse of Hospital Communication, Palgrave Macmillan, New York, USA, pp. 182-200.
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Iedema, R.A. 2007, 'Why Do Doctors Not Engage with the System?' in Rick Iedema (ed), The Discourse of Hospital Communication, Palgrave Macmillan, New York, USA, pp. 222-243.
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Rhodes, C.H., Iedema, R.A. & Scheeres, H.B. 2007, 'Identity, Surveillance and Resistance' in Alison Pullen, Nic Beech and David Sims (eds), Exploring Identity: Concepts and Methods, Palgrave Macmillan, Houndmills, pp. 83-99.
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Iedema, R.A. 2006, '(Post-)bureaucratizing Medicine: Health Reform and the Reconfiguration of Contemporary Clinical Work' in Advances in medical discourse analysis: Oral and written contexts, Peter Lang, Gottingen, pp. 111-131.
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Iedema, R.A. 2005, 'Clinical Governance: Complexities and Promises' in Stanton, Pauline; Willis, Eileen and Young, Suzanne (eds), Workplace Reform in the Healthcare Industry, Palgrave Macmillan, London, UK, pp. 253-278.
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Degeling, P.J., Maxwell, S. & Iedema, R.A. 2004, 'Restructuring Clinical Governance to Maximise its Developmental Potential' in Gray, Andrew & Harrison, Stephen (eds), Governing Medicine: Theory and Practice, Open University Press, Maidenhead, pp. 163-179.
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Degeling, P.J., Iedema, R.A., Winters, M.E., Maxwell, S., Coyle, B., Kennedy, J. & Hunter, D.J. 2003, 'Leadership in the Context of Health Reform: An Australian Case Study' in Dopson, Sue and Mark, Annabelle (eds), Leading Health Care Organizations, Palgrave MacMillan, UK, pp. 113-133.
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Iedema, R.A. 2003, 'Putting Schegloff's principles and practices in context' in Prevignano, Carlo L. & Thibault, Paul J. (eds), Discussing Conversation Analysis: The Work of Emanuel A. Schegloff, John Benjamins B.V., Amsterdam, pp. 65-90.
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Iedema, R.A. 2001, 'Analysing film and television: a social semiotic account of 'Hospital: an Unhealthy Business'' in Leeuwen, Theo van & Jewitt, Carey (eds), Handbook of Visual Analysis, Sage Publications Ltd., London, pp. 183-206.
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Iedema, R.A. 2001, 'How to Analyse Visual Images: A Guide for TESOL Teachers' in Burns, Anne & Coffin, Caroline (eds), Analysing English in a Global Context: A Reader, Routledge, London, pp. 194-210.
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Iedema, R.A. 2000, 'Bureacratic Planning and Resemiotisation' in Ventola, Eija (eds), Discourse and Community: Doing Functional Linguistics, Gunter Narr Verlag Tubingen, Tubingen, pp. 47-70.

Iedema, R.A. & Eggins, S. 1997, 'Difference Without Diversity: Semantic Orientation and Ideology in Competing Women's Magazines' in Wodak, Ruth (eds), Gender and Discourse, Sage Publications Ltd., London, pp. 165-196.

Iedema, R.A. 1997, 'The Language of Administration: organizing human activity in formal institutions' in Christie, Frances & Martin, J. R. (eds), Genre and Institutions, Cassell, London, pp. 73-100.

Yates, C., Lewis, J. & Iedema, R.A. 2012, 'Quality and Safety in the Context of the Australian Health Care System' in Willis E., Reynolds L., Keleher H (eds), Understanding the Australian Health Care System, Elsevier, Australian, pp. 205-215.

Caddas-Coulthard, C.R. & Iedema, R.A. 2008, 'Identity trouble: Critical discourse and contested identities' in Carmen Caldas Coulthard & Rick Iedema (eds), Identity Trouble, Palgrave Macmillan, Houndmills Basingstoke, UK, pp. 1-14.

Iedema, R.A. 2008, 'Hospital sector organizational restructuring - evidence for its futility' in Organizing and Reorganising: Power and change in health care organisations, Palgrave Macmillan, London.

Iedema, R.A. 2008, 'Medicine and Health, Inter- and Intraprofessional Communication' in Brown, Keith (eds), Encyclopedia of language and Linguistics: 2nd Edition, Elsevier, Ansterdam & New York, pp. 745-751.

Iedema, R.A. 2007, 'Discourse Analysis' in Clegg, S. and Balley, J. (eds), International encyclopedia of organization studies, Sage publications, UK, pp. 389-393.

Iedema, R.A. 2005, 'Communication in Institutions' in Ammon, Ulrich (eds), Sociolinguistics: An International Handbook of the Science of Society, Walter de Gruyter, Berlin, pp. 1602-1615.

Iedema, R.A. 2005, 'Halliday, multi-modality and organizational (discourse) analysis' in Continuing Discourse on Language: A Functional Perspective, Equinox Publishing Ltd, London, pp. 170-172.
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Breitschwerdt, R., Iedema, R.A., Robert, S., Bosse, A. & Thomas, O. 2012, 'MOBILE IT SOLUTIONS FOR HOME HEALTH CARE', Advances in Health Care Management, vol. 12, pp. 171-187.

Iedema, R.A., Ball, C., Daly, B., Young, J., Green, T., Middleton, P., Foster-curry, C., Jones, M., Hoy, S. & Comerford, D. 2012, 'Design And Trial Of A New Ambulance-to-emergency Department Handover Protocol: 'IMIST-AMBO'', BMJ Quality & Safety, vol. 21, no. 8, pp. 627-633.
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Background: Information communicated by ambulance paramedics to Emergency Department (ED) staff during handover of patients has been found to be inconsistent and incomplete, and yet has major implications for patients' subsequent hospital treatment and t

Iedema, R.A., Allen, S., Britton, K.L. & Gallagher, T. 2012, 'What Do Patients And Relatives Know About Problems And Failures In Care?', BMJ Quality & Safety, vol. 21, no. 3, pp. 198-205.
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Objective: To understand what patients and family members know about problems and failures in healthcare. Design: Qualitative, semistructured open-ended interviews were conducted with 39 patients and 80 family members about their experiences of incidents

Iedema, R.A. & Allen, S. 2012, 'Anatomy of an Incident Disclosure: The Importance of Dialogue', Joint Commission Journal on Quality and Patient Safety, vol. 38, no. 10, pp. 435-442.

Mitchison, D., Butow, P., Sze, M., Aldridge, L.P., Hui, R., Vardy, J., Eisenbruch, M., Iedema, R.A. & Goldstein, D. 2012, 'Prognostic Communication Preferences Of Migrant Patients And Their Relatives', Psycho-Oncology, vol. 21, no. 5, pp. 496-504.
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Objectives: Migrant patients comprise a significant proportion of Western oncologists' clientele. Although previous research has found that barriers exist in the communication between ethnically diverse patients and health professionals, little is known

Piper, D.A., Iedema, R.A., Gray, J., Verma, R., Holmes, L. & Manning, N. 2012, 'Utilizing experience-based co-design to improve the experience of patients accessing emergency departments in New South Wales public hospitals: an evaluation study', Health Services Management Research, vol. 25, no. 4, pp. 162-172.

Butow, P., Bell, M., Goldstein, D., Sze, M., Aldridge, L., Abdo, S., Mikhail, M., Dong, S., Iedema, R.A., Ashgari, R., Hui, R. & Eisenbruch, M. 2011, 'Grappling With Cultural Differences; Communication Between Oncologists And Immigrant Cancer Patients With And Without Interpreters', Patient Education And Counselling, vol. 84, no. 3, pp. 398-405.
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Objective: Immigrants report challenges communicating with their health team. This study compared oncology consultations of immigrants with and without interpreters vs Anglo-Australian patients. Methods: Patients with newly diagnosed incurable cancer who had immigrated from Arabic, Chinese or Greek speaking countries or were Anglo-Australian, and family members, were recruited from 10 medical oncologists in 9 hospitals. Two consultations from each patient were audio-taped, transcribed, translated into English and coded. Results: Seventy-eight patients (47 immigrant and 31 Anglo-Australian) and 115 family members (77 immigrant and 38 Anglo Australian) participated in 141 audio-taped consultations. Doctors spoke less to immigrants with interpreters than to Anglo-Australians (1443 vs. 2246 words, p = 0.0001), spent proportionally less time on cancer related issues (p = 0.005) and summarising and informing (p <= 0.003) and more time on other medical issues (p = 0.0008) and directly advising (p = 0.0008). Immigrants with interpreters gave more high intensity cues (10.4 vs 7.4). Twenty percent of cues were not interpreted. Doctors tended to delay responses to or ignore more immigrant than Anglo-Australian cues (13% vs 5%, p = 0.06). Conclusions: Immigrant cancer patients with interpreters experience different interactions with their doctors than Anglo-Australians, which may compromise their well-being and decisions. Practice implications: Guidelines and proven training programmes are needed to improve communication with immigrant patients, particularly those with interpreters.

Butow, P., Goldstein, D., Bell, M., Sze, M., Aldridge, L.P., Abdo, S., Tanious, M., Dong, S., Iedema, R.A., Vardy, J., Ashgari, R., Hui, R. & Eisenbruch, M. 2011, 'Interpretation In Consultations With Immigrant Patients With Cancer: How Accurate Is It?', Journal Of Clinical Oncology, vol. 29, no. 20, pp. 2801-2807.
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Purpose Immigrants with cancer often have professional and/or family interpreters to overcome challenges communicating with their health team. This study explored the rate and consequences of nonequivalent interpretation in medical oncology consultations.

Iedema, R.A. 2011, 'Creating Safety By Strengthening Clinicians' Capacity For Reflexivity', BMJ Quality & Safety, vol. 20, no. Suppl 1, pp. I83-I86.
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This commentary explores the nature of creating safety in the here-and-now. Creating safety encompasses two dimensions: revisiting specific behaviours by focusing on substandard performance (reflection), and a more broad-ranging attention to everyday beh

Iedema, R.A., Allen, S., Britton, K.L., Piper, D.A., Baker, A.C., Grbich, C., Allan, A., Jones, L., Tuckett, A., Williams, A., Manias, E. & Gallagher, T. 2011, 'Patients' And Family Members' Views On How Clinicians Enact And How They Should Enact Incident Disclosure: The '100 Patient Stories' Qualitative Study', British Medical Journal, vol. 343, no. NA, pp. 0-0.
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To investigate patients' and family members' perceptions and experiences of disclosure of healthcare incidents and to derive principles of effective disclosure. Retrospective qualitative study based on 100 semi-structured, in depth interviews with patien

Iedema, R.A. & Carroll, K.E. 2011, 'The 'clinalyst': Institutionalizing Reflexive Space To Realize Safety And Flexible Systematization In Health Care', Journal of Organizational Change Management, vol. 24, no. 2, pp. 175-190.
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Purpose: This paper aims to present evidence for regarding reflexive practice as the crux of patient safety in tertiary hospitals. Reflexive practice buttresses safety because it is the precondition for flexible systematization - that is, the process tha

Iedema, R.A., Allen, S., Sorensen, R. & Gallagher, T. 2011, 'What Prevents Incident Disclosure, and What Can Be Done to Promote It?', Joint Commission Journal on Quality and Patient Safety, vol. 37, no. 9, pp. 409-417.
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Background: Adverse-event incident disclosure is gaining international attention as being central to incident management, practice improvement, and public engagement, but those charged with its execution are experiencing barriers. Findings have emerged from two large studies: an evaluation of the 2006-2008 Australian Open Disclosure Pilot, and a 2009-2010 study of patientsÔ++ and relatives' views on actual disclosures. Clinicians and patients interviewed in depth suggest that open disclosure communication has been prevented by a range of uncertainties, fears, and doubts.

Richmond, C., Merrick, E.T., Green, T., Dinh, M. & Iedema, R.A. 2011, 'Bedside Review Of Patient Care In An Emergency Department: The Cow Round', Emergency Medicine Australasia, vol. 23, no. 5, pp. 600-605.
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Objective: Clinical handover is a critical point in medical care in the ED, which can contribute to adverse effects for patient care and staff workloads. Over a 4 and a half months in a tertiary referral hospital ED, a centralized whiteboard handover was

Sorensen, R. & Iedema, R.A. 2011, 'End-Of-Life Care In An Acute Care Hospital: Linking Policy And Practice', Death Studies, vol. 35, no. 6, pp. 481-503.
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The care of people who die in hospitals is often suboptimal. Involving patients in decisions about their care is seen as one way to improve care outcomes. Federal and state government policymakers in Australia are promoting shared decision making in acut

Forsyth, R., Maddock, C., Iedema, R.A. & Lassere, M. 2010, 'Patient Perceptions Of Carrying Their Own Health Information: Approaches Towards Responsibility And Playing An Active Role In Their Own Health - Implications For A Patient-Held Health File', Health Expectations, vol. 13, no. 4, pp. 416-426.
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Objective To elicit patients' views on whether they could contribute to improvements in their care by carrying their own health information to clinician encounters; and to consider the implications for the development of a patient-held health file (PHF).

Foureur, M., Davis, D.L., Fenwick, J.H., Leap, N., Iedema, R.A., Forbes, I. & Homer, C.S. 2010, 'The Relationship Between Birth Unit Design And Safe, Satisfying Birth: Developing A Hypothetical Model', Midwifery, vol. 26, no. 5, pp. 520-525.
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Recent advances in cross-disciplinary studies linking architecture and neuroscience have revealed that much of the built environment for health-care delivery may actually impair rather than improve health outcomes by disrupting effective communication an

Hor, S., Iedema, R.A., Williams, K., White, L., Kennedy, P. & Day, A. 2010, 'Multiple Accountabilities in Incident Reporting and Management', Qualitative Health Research, vol. 20, no. 8, pp. 1091-1100.
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In this article, we examine the current and increasing emphasis on accountability and patient safety in health care, focusing on practices of incident reporting and management in New South Wales, Australia. We describe the frames of accountability associated with an incident reporting system, and explore how this system manifests in practice. In contrast to literature that situates incident reporting and local practices as oppositional, we used ethnographic methods to observe the incident management practices of clinical staff in a hospital, and found evidence to characterize this relationship differently. We found that accountability has multiple conceptualizations, and we present three findings that demonstrate how the reporting system and incident management policy are interwoven with local enactments of accountability. We suggest that systematic efforts toward improvement cannot be divorced from the local context, and emphasize the importance of local ecologies of practice in facilitating the meaningful utilization of such incident reporting systems.

Iedema, R.A., Brownhill, S., Haines, M., Lancashire, B., Shaw, T. & Street, J. 2010, ''Hands On, Hands Off': A Model Of Clinical Supervision That Recognises Trainees' Need For Support And Independence', Australian Health Reveiw, vol. 34, no. 3, pp. 286-291.
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Rationale. This article presents a study of junior doctor supervision at a rural hospital. The objective of the present study was to gain insight into the types of supervision events experienced, the quality of supervisory relationships, the frequencies

Iedema, R.A., Merrick, E.T., Piper, D.A., Britton, K.L., Gray, J.S., Verma, R. & Manning, N. 2010, 'Codesigning As A Discursive Practice In Emergency Health Services: The Architecture Of Deliberation', The Journal of Applied Behavioral Science, vol. 46, no. 1, pp. 73-91.
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This article addresses the issue of how government agencies are increasingly attempting to involve users in the design of public services. The article examines codesign as a method for fostering new and purposeful interaction among service-delivery staff

Iedema, R.A. & Carroll, K.E. 2010, 'Discourse Research That Intervenes In The Quality And Safety Of Care Practices', Discourse and Communication, vol. 4, no. 1, pp. 68-86.
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Drawing on work done in the area of health services research, this article outlines a view of discourse analysis (DA) that approaches discourse as a co-accomplished process involving researcher and research-participant. Without losing sight of the analyt

Iedema, R.A. & Rhodes, C.H. 2010, 'The Undecided Space Of Ethics In Organizational Surveillance', Organization Studies, vol. 31, no. 2, pp. 199-217.
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While much contemporary organizational research has highlighted how surveillance and self-surveillance are dominant modes of attempting subjective control in organizations, in this article we consider whether 'being seen' harbours the potential to also e

Perrott, B. & Iedema, R.A. 2010, 'Knowledge management in healthcare settings', Asia Pacific Journal of Health Management, vol. 4, no. 1, pp. 27-33.
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Strong forces of competition and globalisation have created awareness and an urgency to focus on how an organisation controls and nurtures its intellectual capital. The knowledge concept and its management have gained currency and momentum as technology has enabled thoughts and ideas to be more easily generated and distributed. The knowledge management has relevance for all stakeholders involved in healthcare. As a contribution to this debate, this paper describes various knowledge domains at the different levels of healthcare organisations. The paper uses Polanyi+s knowledge framework to identify issues that need to be considered to ensure knowledge can be progressively applied to the continuous improvement of health services whilst safeguarding the rights of individuals.

Sorensen, R. & Iedema, R.A. 2010, 'Accounting for healthcare outcomes: implications for ICU practice and performance', Health Services Management Research, vol. 23, no. 3, pp. 97-102.
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The aim of this study was to understand the environment of health care, and how clinicians and managers respond in terms of performance accountability. A qualitative method was used in a tertiary metropolitan teaching intensive care unit (ICU) in Sydney, Australia, including interviews with 15 clinical managers and focus groups with 29 nurses of differing experience. The study found that a managerial focus on abstract goals, such as budgets detracted from managing the core business of clinical work. Fractures were evident within clinical units, between clinical units and between clinical and managerial domains. These fractures reinforced the status quo where seemingly unconnected patient care activities were undertaken by loosely connected individual clinicians with personalized concepts of accountability. Managers must conceptualize health services as an interconnected entity within which self-directed teams negotiate and agree objectives, collect and review performance data and define collective practice. Organically developing regimens of care within and across specialist clinical units, such as in ICUs, directly impact upon health service performance and accountability.

Studdert, D., Piper, D.A. & Iedema, R.A. 2010, 'Legal Aspects Of Open Disclosure Ii: Attitudes Of Health Professionals - Findings From A National Survey', Medical Journal of Australia, vol. 193, no. 6, pp. 351-355.
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Objective: To assess the attitudes of health care professionals engaged in open disclosure (OD) to the legal risks and protections that surround this activity Design and participants: National cross-sectional survey of 51 experienced OD practitioners con

Ainsworth, S., Grant, D. & Iedema, R.A. 2009, ''Keeping things moving': space and the construction of middle management identity in a post-NPM organization', Discourse and Communication, vol. 3, no. 1, pp. 5-25.
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Reforms associated with New Public Management (NPM) have led to changes in the management of work and organization that challenge the stability, durability and linearity of the managerial hierarchy in contemporary public sector workplaces. Against this background, this article considers the ways in which two clinician-managers who work in a large metropolitan teaching hospital speak about their organizational roles. Reflecting the complexity of their part of the organization, the emergency department, the interviewees position themselves as operating at the interstice between the competing and contradictory spatial logics of locality and mobility. With their identities strongly anchored in emergency as locality, the clinician-managers intervene in the flows of meanings and resources that affect its processes in ways that require intra- and inter-organizational mobility and which are incommensurate with traditional perceptions of middle managers. In regarding the interviews as `practical authoring' (Shotter and Cunliffe, 2003), we note our own spatial ambiguity as academic researchers interested in organizations other than our own and suggest that our insider-outsider positionings are reflected in the interviews' complex spatialities. We conclude that the interviewees' boundary-spanning and cross-spatial self-positionings are indicative of the hybrid roles that workers under NPM increasingly embody and are in contrast to traditional perceptions of how the provision and management of public service work is carried out.

Iedema, R.A., Jorm, C., Wakefield, J., Ryan, C. & Sorensen, R. 2009, 'A New Structure of Attention? Open Disclosure of Adverse Events to Patients and Their Families', Journal of Language and Social Psychology, vol. 28, no. 2, pp. 139-157.
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This article presents an inquiry into how clinicians realize a health policy reform initiative called Open Disclosure. Open Disclosure mandates that discussions with patients/family and team staff about "adverse events" are now no longer ad hoc, individualized, and without consequences for how the work is done, but planned, collaborative, and leading to systems change. The article presents an empirical analysis of a corpus of interviews about the impact of Open Disclosure on clinicians' practices. It situates Open Disclosure in the context of arguments that health care workers are increasingly expected to do "emotional labor" with patients and their families, in that staff are advised to practise "reflexive listening" as a means of managing patients' and family members' emotions in response to incidents. The analysis suggests that thanks to the intensity of Open Disclosure interactions, clinicians may be introduced to an affective-interactive space that they were hitherto unaware of and unable to enter or attain what Nigel Thrift calls "a new structure of attention."

Iedema, R.A., Jorm, C. & Lum, M.E. 2009, 'Affect Is Central To Patient Safety: The Horror Stories Of Young Anaesthetists', Social Science & Medicine, vol. 69, no. 12, pp. 1750-1756.
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This paper analyses talk produced by twenty-four newly qualified anaesthetists. Data were collected from round table discussions at the Young Fellows Conference of the Australia and New Zealand College of Anaesthetists 2006. The talk consisted to an impo

Iedema, R.A. 2009, 'New Approaches To Researching Patient Safety', Social Science & Medicine, vol. 69, no. 12, pp. 1701-1704.
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This article presents an overview of contemporary research into patient safety. The article suggests that patient safety research to date has tended to privilege the formal and structural dimensions of safety at the expense of the social and affective di

Iedema, R.A., Jorm, C.M., Wakefield, J., Ryan, C. & Dunn, S. 2009, 'Practising Open Disclosure: clinical incident communication and systems improvement', Sociology of Health and Illness, vol. 31, no. 2, pp. 262-277.
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This article explores the way that professionals are being inducted into articulating apologies to consumers of their services, in this case clinicians apologising to patients. The article focuses on the policy of Open Disclosure that is being adopted by health care organisations in the US, Canada, the UK and Australia and other nations. Open Disclosure policy mandates 'open discussion of clinical incidents' with patient victims. In Australia, Open Disclosure policy implementation is currently being complemented by intensive staff training, involving simulation of apology scenarios with actor-patients. The article presents an analysis of data collected from such training sessions. The analysis shows how simulated apologising engages frontline staff in evaluating the efficacy of their disclosures, and how staff may thereby be inducted into reconciling their affective and reflexive sensibilities with their organisational and professional responsibilities, and thereby produce the required organisational apology. The article concludes that Open Disclosure, besides potentially relaxing tensions between clinicians and consumers, may also affect how staff experience and enact their role in the overall system of health care organisation.

Iedema, R.A., Merrick, E.T., Kerridge, R.K., Herkes, R., Lee, B.B., Anscombe, M., Rajbhandari, D., Lucey, M. & White, L. 2009, 'Handover - Enabling Learning in Communication for Safety (HELiCS): a report on achievements at two hospital sites', The Medical Journal of Australia, vol. 190, no. 11, pp. S133-S136.
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The provision of health care is becoming increasingly complex and fragmented.1,2 As a result, to ensure continuity of care, the handover of clinical tasks is becoming more frequent and important. However, the general lack of clinical handover planning and training in handover communication creates unacceptable risks for patients.1 Not surprisingly, clinical handover has been identified as a major international policy and research priority.

Sorensen, R., Iedema, R.A., Piper, D.A., Manias, E., Williams, A. & Tuckett, A. 2009, 'Disclosing Clinical Adverse Events To Patients: Can Practice Inform Policy?', Health Expectations, vol. 13, no. 2, pp. 148-159.
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Objectives To understand patients' and health professionals' experience of Open Disclosure and how practice can inform policy. Background Open Disclosure procedures are being implemented in health services worldwide yet empirical evidence on which to bas

Sorensen, R. & Iedema, R.A. 2009, 'Emotional labour: clinicians' attitudes to death and dying', Journal of Health Organization and Management, vol. 23, no. 1, pp. 5-22.
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Purpose This paper aims to understand the impact of emotional labour in specific health care settings and its potential effect on patient care. Design/methodology/approach + Multi-method qualitative ethnographic study undertaken in a large ICU in Sydney, Australia using observations from patient case studies, ward rounds and family conferences, open ended interviews with medical and nursing clinicians and managers and focus groups with nurses. Findings + Clinician attitudes to death and dying and clinicians' capacity to engage with the human needs of patients influenced how emotional labour was experienced. Negative effects were not formally acknowledged in clinical workplaces and institutional mechanisms to support clinicians did not exist. Research limitations/implications + The potential effects of clinician attitudes on performance are hypothesised from clinician-reported data; no evaluation was undertaken of patient care. Practical implications + Health service providers must openly acknowledge the effect of emotional labour on the care of dying people. By sharing their experiences, multidisciplinary clinicians become aware of the personal, professional and organisational impact of emotional labour as a core element of health care so as to explicitly and practically respond to it. Originality/value + The effect of care on clinicians, particularly care of dying people, not only affects the wellbeing of clinicians themselves, but also the quality of care that patients receive. The affective aspect of clinical work must be factored in as an essential element of quality and quality improvement.

Carroll, K.E., Iedema, R.A. & Kerridge, R.K. 2008, 'Reshaping ICU Ward Round Practices Using Video-Reflexive Ethnography', Qualitative Health Research, vol. 18, no. 3, pp. 380-390.
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Hunter, C., Spence, K., McKenna, K. & Iedema, R.A. 2008, 'Learning how we learn: an ethnographic study in a neonatal intensive care unit', Journal Of Advanced Nursing, vol. 62, no. 6, pp. 657-664.
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Aim. This paper is a report of a study to identify how nurse clinicians learn with and from each other in the workplace. Background. Clinicians+ everyday practices and interactions with each other have recently been targeted as areas of research, because it is there that quality of care and patient safety are achieved. Orientation of new nurses and doctors into a specialty unit often results in stress. Method. An ethnographic approach was used, including a 12-month period of fieldwork observations involving participation and in-depth interviews with nurse, doctor and allied health clinicians in their workplace. The data were collected in 2005+2006 in a paediatric teaching hospital in Australia. Findings. The findings were grouped into four dimensions: orientation of nurses, orientation of medical registrars, preceptoring and decision-making. The orientation of new staff (nursing and medical) is a complex and multi-layered process which accommodates multiple kinds of learning, in addition to formal learning. Workplace learning also can be informal, incidental, interpersonal and interactive. Interactive and interpersonal learning and the transfer of knowledge include codified and tacit knowledge as well as intuitive understandings of `how we do things here+. Conclusion. Research into how nurses learn is crucial for illuminating learning that is non-formal and less recognized than more formal kinds. To provide a safe practice environment built on a foundation of knowledge and best practice, there needs to be an allocation of time in the busy workday for learning and reflection.

Iedema, R.A., Jorm, C. & Braithwaite, J. 2008, 'Managing the Scope and Impact of Root Cause Analysis Recommendations', Journal Of Health Organization And Management, vol. 22, no. 6, pp. 569-585.
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Increased public awareness of clinical failure and rising levels of litigation are spurring health policy makers in industrialized countries to mandate that clinicians report and investigate clinical errors and near misses. This paper seeks to understand the value of root cause analysis (RCA) recommendations for practice improvement purposes. The paper presents an analysis of interviews with nine senior health managers who were asked about their views on RCA as practice improvement method. Interview data were collected as part of a multi-method evaluation consultancy project investigating a local Health Safety Improvement Program. The interview data were discourse analysed and arranged into over-arching themes. The analysis reveals rather negative views of the improvement potential of RCA: RCA is subject to too many constraints to be able to produce valuable recommendations; RCA recommendations: are perceived to be of "variable quality"; generate considerable extra work for senior management to do with vetting RCA recommendations; are experienced as contributing in only a limited way to organizational and practice improvement. This study focuses on nine interviewees only and presents an analysis of single (not multiple) interviews. However, these nine interviewees fulfil crucial roles in implementing clinical practice improvement initiatives in their respective geographic areas. The findings suggest that RCA requires much time and negotiation, and that the recommendations produced may not live up to the philosophy of clinical practice improvement's expectations. It may be necessary to reorient the expectations of the power of RCA, or accept that RCA produces communication about clinical processes that would otherwise not have taken place, and whose effects may not be registering for some time to come.

Iedema, R.A., Sorensen, R., Manias, E., Tuckett, A., Piper, D.A., Mallock, N.A., Williams, A. & Jorm, C.M. 2008, 'Patients' and family members' experiences of open disclosure following adverse events', International Journal for Quality in Health Care, vol. 20, no. 6, pp. 421-432.
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Objective To explore patients' and family members' perceptions of Open Disclosure of adverse events that occurred during their health care. Design We interviewed 23 people involved in adverse events and incident disclosure using a semi-structured, open-ended guide. We analyzed transcripts using thematic discourse analysis. Setting Four States in Australia: New South Wales, Victoria, Queensland and South Australia. Study participants Twenty-three participants were recruited as part of an evaluation of the Australian Open Disclosure pilot commissioned by the Australian Commission on Safety and Quality in Health Care. Results All participants (except one) appreciated the opportunity to meet with staff and have the adverse event explained to them. Their accounts also reveal a number of concerns about how Open Disclosure is enacted: disclosure not occurring promptly or too informally; disclosure not being adequately followed up with tangible support or change in practice; staff not offering an apology, and disclosure not providing opportunities for consumers to meet with the staff originally involved in the adverse event. Analysis of participants' accounts suggests that a combination of formal Open Disclosure, a full apology, and an offer of tangible support has a higher chance of gaining consumer satisfaction than if one or more of these components is absent.

Iedema, R.A., Mallock, N.A., Sorensen, R., Manias, E., Tuckett, A., Perrott, B., Brownhill, S., Piper, D.A., Hor, S., Hegney, D., Scheeres, H.B. & Jorm, C.M. 2008, 'The National Open Disclosure Pilot: Evaluation of a policy implementation initiative', The Medical Journal of Australia, vol. 188, no. 7, pp. 397-400.
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Objective: To determine which aspects of open disclosure +work+ for patients and health care staff, based on an evaluation of the National Open Disclosure Pilot. Design, setting and participants: Qualitative analysis of semi-structured and open-ended interviews conducted between March and October 2007 with 131 clinical staff and 23 patients and family members who had participated in one or more open disclosure meetings. 21 of 40 pilot hospital sites, in New South Wales, South Australia, Victoria and Queensland, were included in the evaluation. Participating health care staff comprised 49 doctors, 20 nurses, and 62 managerial and support staff. In-depth qualitative data analysis involved mapping of discursive themes and subthemes across the interview transcripts. Results: Interviewees broadly supported open disclosure; they expressed uncertainty about its deployment and consequences, and made detailed suggestions of ways to optimise the experience, including careful pre-planning, participation by senior medical staff, and attentiveness to consumers+ experience of the adverse event. Conclusion: Despite some uncertainties, the national evaluation indicates strong support for open disclosure from both health care staff and consumers, as well as a need to resource this new practice.

Iedema, R.A., Forsyth, R., Georgiou, A., Braithwaite, J. & Westbrook, J.I. 2008, 'Video research in health: Visibilising the effects of computerising clinical care', Qualitative Research, vol. 6, no. 2, pp. 15-30.
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This paper discusses video ethnography as part of a multimethod study of the introduction of information technology to streamline pathology test order entry in hospitals and its effect on the work of pathology laboratory scientists. The paper opens with an overview of video research in health care settings. After acknowledging the limitations inherent in video data, the paper offers a description of how video footage served to enhance insight in three ways. First, the footage enhanced the researchers' own appreciation of the significance of particular facets of the data, which led them to reassess information collected through interviewing, focus groups and research field notes. Second, the footage enhanced the pathology laboratory scientists' appreciation of the problems they experienced when incorporating the new information technology into their daily work practice, by enabling them to articulate these problems to outside researchers.

Slade, D.M., Scheeres, H.B., Manidis, M., Iedema, R.A., Dunston, R., Stein-Parbury, M.J., Matthiessen, C., Herkes, G. & McGregor, J. 2008, 'Emergency Communication: the discursive challenges facing emergency clinicians and patients in emergency departments', Discourse and Communication, vol. 2, no. 3, pp. 271-298.
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Effective communication and interpersonal skills have long been recognized as fundamental to the delivery of quality health care. However, there is mounting evidence that the pressures of communication in high stress work areas such as hospital emergency departments (EDs) present particular challenges to the delivery of quality care. A recent report on incident management in the Australian health care system (NSW Health, 2005a) cites the main cause of critical incidents (that is, adverse events such as an incorrect procedure leading to patient harm), as being poor and inadequate communication between clinicians and patients. This article presents research that describes and analyses spoken interactions between health care practitioners and patients in one ED of a large, public teaching hospital in Sydney, Australia. The research aimed to address the challenges and critical incidents caused by breakdowns in communication that occur between health practitioners and patients and by refining and extending knowledge of discourse structures, to identify ways in which health care practitioners can enhance their communicative practices thereby improving the quality of the patient journey through the ED. The research used a qualitative ethnographic approach combined with discourse analysis of audio-recorded interactions. Some key findings from the analysis of data are outlined including how the absence of information about processes, the pressure of time within the ED, divergent goals of clinicians and patients, the delivery of diagnoses and professional roles impact on patient experiences. Finally, the article presents an in-depth linguistic analysis on interpersonal and experiential patterns in the discursive practices of patients, nurses and doctors.

Sorensen, R., Iedema, R.A. & Severinsson, E. 2008, 'Beyond profession: Nursing leadership in contemporary healthcare', Journal of Nursing Management, vol. 16, no. 5, pp. 535-544.
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to examine nursing leadership in contemporary health care and its potential contribution to health service organisation and management

Sorensen, R., Iedema, R.A., Piper, D.A., Manias, E., wilson, A. & Tuckett, A. 2008, 'Disclosing clinical adverse events to patients: can practice inform policy?', Health Expectations, vol. 13, no. 2, pp. 148-159.
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Abstract Objectives: To understand patients and health professionals experience of open disclosure and to consider how open disclosure practice can inform policy. Background: Open disclosure procedures are being implemented in health services worldwide yet empirical evidence on which to base patient-clinician communication and policy development is scant. Design, setting and participants: A qualitative methodology was used. Semi-structured open-ended interviews were conducted with 154 respondents (20 nursing, 49 medical, 59 clinical/administrative managerial, 3 policy coordinators, 15 patients and 8 family members) in 21 hospitals and health services in four Australian states. Results: Both patients and health professionals were positive about open disclosure. We found that five major elements underlie their experience of open disclosing error namely: initiating open disclosure, apologizing for the error, taking the patientÔ++s perspective, communicating the adverse event and being culturally aware. Patients and health professionals differed on their assessments of practice effectiveness. Conclusions: Health services that evaluate the impact of policies such as open disclosure can collectively refine their delivery processes and develop an evidence base to inform future policy development. Health services can use specific properties relating to each of the five open disclosure elements as standards for training purposes and to assess the progress of policy implementation.

Sorensen, R., Iedema, R.A., Piper, D.A., Manias, E., Williams, A. & Tuckett, A. 2008, 'Health Care Professionals' Views of Implementing a Policy of Open Disclosure of Errors', Journal of Health Services Research and Policy, vol. 13, no. 4, pp. 227-232.
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Objectives: To understand the views of doctors, nurses, allied health professionals and health managers of open disclosure of medical errors. Methods: Semi-structured interviews were conducted with 131 health professionals to understand their experiences of implementing open disclosure in 21 providers in Australia. Results: Health professionals are positive about open disclosure and are applying the model to patient+ clinician communication encounters more generally. Workforce and systems competencies enable clinicians and health service managers to implement open disclosure principles and practices, although a propensity to hide errors, wavering commitment and to exacerbate the problem inhibits implementation as policy intends. The gap between policy objectives and their implementation limits the benefits to health professionals. Conclusion: Health services must develop organizing capabilities if open disclosure is to be implemented as intended. Activities should identify and address factors that impede implementation and enable workforce and system competencies to develop. These activities will allow health services to adapt central open disclosure policy to local conditions and to embed its principles and practices organization-wide.

Sorensen, R. & Iedema, R.A. 2008, 'Redefining accountability in health care: managing the plurality of medical interests', Health: an interdisciplinary journal for the social study of health, illness and medicine, vol. 12, no. 1, pp. 87-106.
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Conflict in health service delivery is common. It is often attributed to disputes between clinicians and patients or their families about treatment decisions and is particularly common in intensive care units (ICUs), in the form of `futility disputes' between families and medical clinicians about decisions to terminate the active treatment of a dying family member. More common, but less prominent in the literature, is conflict within the medical profession about patient care goals and treatment. We contend that managing the plurality of medical interests is essential in achieving a more managed and positive experience for patients and families of the care they receive, and for achieving standards of quality and resource use. From an ethnographic study undertaken in a large ICU in Sydney, Australia, we found that the knowledge and practice differences of multiple medical decision-makers generated conflict, inconsistency of practice and subjectivity of decision-making that impeded coherent clinical decision-making and integrated patient care planning, coordination and care review. Improving patients' and families' experience of care requires medical clinicians and medical managers to accept responsibility for institutionalizing effective communication and decision-making processes within clinical networks and between clinical and managerial domains. Thus, strategies to improve patient care will need to extend beyond the medical profession to incorporate administrative management. We conclude that restructuring communication and decision-making processes is imperative to achieve clinical accountability in the workplace and systems accountability in the organization.

Braithwaite, J., Westbrook, M., Travaglia, J., Iedema, R.A., Mallock, N.A., Long, D., Negus, P., Forsyth, R., Jorm, C. & Pawsey, M. 2007, 'Are health systems changing in support of patient safety? A multi-methods evaluation of education, attitudes and practice.', International Journal of Health Care Quality Assurance, vol. 20, no. 7, pp. 585-601.
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Purpose - The purpose of this study is to evaluate the effects of a health system-wide safety improvement program (SIP) three to four years after initial implementation. Design/methodology/approach - The study employs multi-methods studies involving questionnaire surveys, focus groups, in-depth interviews, observational work, ethnographic studies, documentary analysis and literature reviews with regard to the state of New South Wales, Australia, where 90,000 health professionals, under the auspices of the Health Department, provide healthcare to a seven-million population. After enrolling many participants from various groups, the measurements included: numbers of staff trained and training quality; support for SIP; clinicians' reports of safety skills acquired, work practices changed and barriers to progress; RCAs undertaken; observation of functioning of teams; committees initiated and staff appointed to deal with adverse events; documentation and computer records of reports; and peak-level responses to adverse events. Findings - A cohort of 4 per cent of the state's health professionals has been trained and now applies safety skills and conducts RCAs. These and other senior professionals strongly support SIP, though many think further culture change is required if its benefits are to be more fully achieved and sustained. Improved information-handling systems have been adopted. Systems for reporting adverse incidents and conducting RCAs have been instituted, which are co-ordinated by NSW Health. When the appropriate structures, educational activities and systems are made available in the form of an SIP, measurable systems change might be introduced, as suggested by observations of the attitudes and behaviours of health practitioners and the increased reporting of, and action about, adverse events. Originality/value - Few studies into health systems change employ wide-ranging research methods and metrics. This study helps to fill this gap.

Braithwaite, J., Iedema, R.A. & Jorm, C. 2007, 'Trust, Communication, theory of mind and the social brain hypothesis: deep explanations for what goes wrong in health care', journal of health organization and management, vol. 21, no. 4/5, pp. 353-367.
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The purpose of the paper is to examine the deep conceptual underpinnings of trust and communication breakdowns via selected health inquiries into things that go wrong using evolutionary psychology

Georgiou, A., Westbrook, J.I., Braithwaite, J., Iedema, R.A., Ray, S., Forsyth, R., Dimos, A. & Germanos, T. 2007, 'When requests become orders-A formative investigation into the impact of a computerized physician order entry system on a pathology laboratory service', International Journal Of Medical Informatics, vol. 76, no. 8, pp. 583-591.
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Purpose The purpose of this study was to identify the key implications of the implementation of a computerized physician order entry (CPOE) system on pathology laboratory services. Methods An in-depth qualitative study using observation, focus groups and

Iedema, R.A. 2007, 'On the multi-modality, materiality and contingency of organizational discourse', Organization Studies, vol. 28, no. 6, pp. 931-946.
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This essay considers the ways that organizational discourse studies have deployed the concept 'discourse'. A review of the literature reveals conceptual ambiguities in the definition of 'discourse', as well as pre-analytical distinctions that are imposed

Iedema, R.A. 2007, 'Critical incident reporting and the discursive reconfiguration of feeling and positioning', Journal of Applied Linguistics, vol. 2, no. 3, pp. 343-364.
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This article analyses the emotional and generic dimensions of critical incident reports.

Lee, B.B., Iedema, R.A., Jones, S., Marial, O., Braithwaite, J. & Long, D. 2007, 'Recognising and Enabling Clinician-led Quality Improvement Initiatives: the Spinal Pressure Pressure Care Clinic', Asia Pacific Journal of Health Management, vol. 2, no. 2, pp. 1-8.
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Riley, R., Forsyth, R., Manias, E. & Iedema, R.A. 2007, 'Whiteboards: Mediating professional tensions in clinical practice', Communication and Medicine, vol. 4, no. 2, pp. 165-175.
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This paper draws together data from two studies to report om the use and impact of whiteboards as a persuasive and yet under-reported mechanism of communication in clinical practice.

Sorensen, R. & Iedema, R.A. 2007, 'Advocacy At End-of-life Research Design: An Ethnographic Study Of An ICU', International Journal Of Nursing Studies, vol. 44, no. 8, pp. 1343-1353.
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Background: Clinicians worldwide are being called upon to reconcile accountability for patient outcomes with the resources they consume. In the case of intensive care, contradictory pressures can arise in decisions about continuing treatment where benefi

Westbrook, J.I., Braithwaite, J., Georgiou, A., Ampt, A., Creswick, N., Coiera, E.W. & Iedema, R.A. 2007, 'Multimethod Evaluation Of Information And Communication Technologies In Health In The Context Of Wicked Problems And Sociotechnical Theory', Journal Of The American Medical Informatics Association, vol. 14, no. 6, pp. 746-755.
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Objective: Few research designs look at the deep structure of complex social systems. We report the design and implementation of a multimethod evaluation model to assess the impact of computerized order entry systems on both the technical and social syst

Westbrook, M., Braithwaite, J., Travaglia, J., Jorm, C., Long, D. & Iedema, R.A. 2007, 'Promoting Safety: longer term responses of three health care professional groups to a safety improvement programme', International Journal of Health Care Quality Assurance, vol. 20, no. 7, pp. 555-571.
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Purpose - Patient safety has been addressed since 2002 in the health system of New South Wales, Australia via a Safety Improvement Programme (SIP), which took a system-wide approach. The programme involved two-day courses to educate healthcare professionals to monitor and report incidents and analyse adverse events by conducting root cause analysis (RCA). This paper aims to predict that all professions would favour SIP but that their work and educational histories would result in doctors holding the least and nurses the most positive attitudes. Alternative hypotheses were that doctors' relative power and other professions' team-working skills would advantage the respective groups when conducting RCAs. Design/methodology/approach - Responses to a 2005 follow-up questionnaire survey of doctors (n=53), nurses (209) and allied health staff (59), who had participated in SIP courses, were analysed to compare: their attitudes toward the course; safety skills acquired and applied; perceived benefits of SIP and RCAs; and their experiences conducting RCAs. Findings - Significant differences existed between professions' responses with nurses being the most and doctors the least affirming. Allied health responses resembled those of nurses more than those of doctors. The professions' experiences conducting RCAs (number conducted, leadership, barriers encountered, findings implemented) were similar. Research limitations/implications - Observational studies are needed to determine possible professional differences in the conduct of RCAs and any ensuing culture change that this may be eliciting. Practical implications - There is strong professional support for SIPs but less endorsement from doctors, who tend not to prefer the knowledge content and multidisciplinary teaching environment considered optimal for safety improvement education. This is a dilemma that needs to be addressed.

Braithwaite, J., Westbrook, J.I., Pawsey, M., Greenfield, D., Naylor, J., Iedema, R.A., Runciman, B., Redman, S., Jorm, C., Robinson, M., Nathan, S. & Gibberd, R. 2006, 'A prospective, multi-method, multi-disciplinary, multi-level, collaborative, social-organisational design for researching health sector accreditation [LP0560737]', BMC Health Services Research, vol. 6, pp. 1-10.
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Background: Accreditation has become ubiquitous across the international health care landscape. Award of full accreditation status in health care is viewed, as it is in other sectors, as a valid indicator of high quality organisational performance. Howev

Braithwaite, J., Westbrook, M., Hindle, D., Iedema, R.A. & Black, D.A. 2006, 'Does restructuring hospitals result in greater efficiency? An empirical test using diachronic data.', Health Services Management Research, vol. 19, no. 1, pp. 1-12.
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Hospitals are being restructured more frequently. Increased cost efficiency is the usual justification given for such changes. All 20 major teaching hospitals in Australia's two most populous states were investigated by classifying each over a 5-6 year period in terms of their cost efficiency (average cost per case weighted by Australian diagnosis-related group [AN-DRG] data and adjusted for inflation) and structure, categorized as traditional-professional (TP), clinical-divisional (CD), or clinical-institute (CI). In all, 12 hospitals changed structure during the study period. There was slight evidence that CD structures were more efficient than TP structures but this was not supported by other evidence. There were no significant differences in efficiency in the first or second years following changes from either TP to CD or TP to CI structures. All four hospitals changing from CD to CI structure became significantly less efficient. This may be due to frequency rather than type of change as they were the only hospitals that implemented two structural changes. Hospitals that changed or did not change structure were similar in efficiency at the beginning and at the end of the study period, in overall efficiency during the period, and in trends toward efficiency over time. The findings challenge those who advocate restructuring hospitals on the grounds of improving cost efficiency.

Braithwaite, J., Westbrook, M., Mallock, N.A., Travaglia, J. & Iedema, R.A. 2006, 'Experiences of health professionals who conducted root cause analysis after undergoing a safety improvement program', Quality and Safety in Health Care, vol. 15, no. 6, pp. 393-399.
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Objective: To study a cohort of health professionals who conducted RCAs after completing the NSW Safety Improvement Program (SIP). Hypothesis: Participants in RCAs would: (1) differ in demographic profile from non-participants, (2) encounter problems conducting RCAs as a result of insufficient system support, (3) encounter more problems if they had conducted fewer RCAs and (4) have positive attitudes regarding RCA and safety. Design, setting and participants: Anonymous questionnaire survey of 252 health professionals, drawn from a larger sample, who attended 2-day SIP courses across New South Wales, Australia. Outcome measures: Demographic variables, experiences conducting RCAs, attitudes and safety skills acquired. Results: No demographic variables differentiated RCA participants from non-participants. The difficulties experienced while conducting RCAs were lack of time (75.0%), resources (45.0%) and feedback (38.3%), and difficulties with colleagues (44.5%), RCA teams (34.2%), other professions (26.9%) and management (16.7%). Respondents reported benefits from RCAs, including improved patient safety (87.9%) and communication about patient care (79.8%). SIP courses had given participants skills to conduct RCAs (92.8%) and improve their safety practices (79.6%). Benefits from the SIP were thought to justify the investment by New South Wales Health (74.6%) and committing staff resources (72.6%). Most (84.8%) of the participants wanted additional RCA training. Conclusions: RCA participants reported improved skills and commitment to safety, but greater support from the workplace and health system are necessary to maintain momentum.

Georgiou, A., Westbrook, J.I., Braithwaite, J. & Iedema, R.A. 2006, 'Multiple perspectives on the impact of electronic ordering on hospital organization and communication.', Health Information Management Journal 2005, vol. 34, no. 4, pp. 214-219.
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Electronic ordering systems provide many potential benefits for improving the efficiency and effectiveness of healthcare delivery. They also have major implications for organisational and communication processes within hospitals. We undertook a qualitative study using focus groups and interviews with doctors, nurses, IT managers, and pathology laboratory managers to investigate the impact of the system on their work processes and relations within a major teaching hospital. This study revealed that the new electronic ordering system involved major alterations to the information management processes within the hospital, which in turn affected communication processes and work relations.

Iedema, R.A., Jorm, C., Braithwaite, J., Travaglia, J. & Lum, M.E. 2006, 'A Root Cause Analysis of clinical error: Confronting the disjunction between formal rules and situated practice.', Social Science and Medicine, vol. 63, no. 5, pp. 1201-1212.
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This paper presents evidence from a root cause analysis (RCA) team meeting that was recently conducted in a Sydney Metropolitan Teaching Hospital to investigate an iatrogenic morphine overdose. Analysis of the meeting transcript reveals on three levels that clinical members of the team struggle with framing the uncertain and contradictory details of situated clinical activity and translating these first into `root causes+, and then into recommendations for practice change. This analysis puts two challenges into special relief. First, RCA team members find themselves in the unusual position of having to derive organizational+managerial generalizations from the specifics of in situ activity. Second, they are constrained by the expectation inscribed into RCA that their recommendations result in `systems improvements+ assumed to flow forth from an extension of formal rules and spread of procedures. We argue that this perspective misrecognizes the importance of RCA as a means to engender solutions that leave the procedural detail of clinical processes unspecified, and produce cross-hospital discussions about the organizational dimensions of care.

Iedema, R.A., Flabouris, A., Grant, S. & Jorm, C. 2006, 'Narrativizing errors of care: critical incident reporting in clinical care', Social Science and Medicine, vol. 62, no. 1, pp. 134-144.
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This paper considers the rise across acute care settings in the industrialized world of techniques that encourage clinicians to record their experiences about adverse events they are personally involved in; that is, to share narratives about errors, mishaps or `critical incidents+. The paper proposes that critical incident reporting and the `root cause+ investigations it affords, are both central to the effort to involve clinicians in managing and organizing their work, and a departure from established methods and approaches to achieve clinicians+ involvement in these non-clinical domains of health care. We argue that critical incident narratives render visible details of the clinical work that have thus far only been discussed in closed, paperless meetings, and that, as narratives, they incite individuals to share personal experiences with parties previously excluded from knowledge about failure. Drawing on a study of 124 medical retrieval incident reports, the paper provides illustrations and interpretations of both the narrative and the meta-discursive dimensions of critical incident reporting. We suggest that, as a new and complex genre, critical incident reporting achieves three important objectives. First, it provides clinicians with a channel for dealing with incidents in a way that brings problems to light in a non-blaming way and that might therefore be morally satisfying and perhaps even therapeutic. Second, these narrations make available new spaces for the apprehension, identification and performance of self.

Iedema, R.A., Rhodes, C.H. & Scheeres, H.B. 2006, 'Surveillance, resistance, observance Exploring the teleo-affective volatility of workplace interaction', Organization Studies, vol. 27, no. 8, pp. 1111-1130.
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Central to the critical study of contemporary management practice has been an understanding of the possibilities for worker subjugation framed in terms of the disciplinary practices of surveillance and responses to it in terms of compliance and resistanc

Iedema, R.A., Jorm, C., Long, D., Braithwaite, J., Travaglia, J. & Westbrook, M. 2006, 'Turning the Medical Gaze in upon Itself: Root Cause Analysis and the Investigation of Clinical Error', Social Science and Medicine, vol. 62, no. 7, pp. 1605-1615.
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n this paper, we discuss how a technique borrowed from defense and manufacturing is being deployed in hospitals across the industrialized world to investigate clinical errors. We open with a discussion of the levers used by policy makers to mandate that clinicians not just report errors, but also gather to investigate those errors using root cause analysis (RCA). We focus on the tensions created for clinicians as they are expected to formulate `systems solutions+ that go beyond blame. In addressing these matters, we present a discourse analysis of data derived during an evaluation of the NSW Health Safety Improvement Program. Data include transcripts of RCA meetings which were recorded in a local metropolitan teaching hospital. From this analysis we move back to the argument that RCA involves clinicians in `immaterial labour+, or the production of communication and information, and that this new labour realizes two important developments. First, because RCA is anchored in the principle of health care practitioners not just scrutinizing each other, but scrutinizing each others+ errors, RCA is a challenging task. Second, thanks to turning the clinical gaze in on the clinical observer, RCA engenders a new level of reflexivity of clinical self and of clinical practice. We conclude with asking whether this reflexivity will lock the clinical gaze into a micro-sociology of error, or whether it will enable this gaze to influence matters superordinate to the specifics of practice and the design of clinical treatments; that is, the over-arching governance and structuring of hospital care.

Iedema, R.A., Long, D., Forsyth, R. & Lee, B.B. 2006, 'Visibilising clinical work: Video ethnography in the contemporary hospital', Health Sociology Review, vol. 15, no. 2, pp. 156-168.
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This paper discusses the role of video-based research methods in social research. The paper situates these methods in the context of rising levels of visibility of professionals in government-funded organisations. The paper argues that while visual research may appear to play an ambiguous role in these organisations, it can also enable practitioners to confront the encroaching demands of post-bureaucratic work. To ground its argument, the paper presents an account of a video- ethnographic project currently underway in a local metropolitan hospital. This project focuses on negotiating understandings about existing care practices among a team of multidisciplinary clinicians. Visual data gathered as part of that project are presented to specify issues which have thus far arisen during the project. Against this empirical background, the paper turns to considering the ambiguous potential of video-based research. The argument developed here is that, besides potentially exacerbating the pressure already imposed on clinicians - thanks to audit, surveillance and risk minimisation - video-based research may provide staff with new resources and opportunities for shaping their increasingly public and visible work practices.

Long, D., Forsyth, R., Iedema, R.A. & Carroll, K.E. 2006, 'The (Im)possibilities of clinical democracy', Health Sociology Review, vol. 15, no. 5, pp. 506-519.
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In this article, we argue that homogenising discussions of medical dominance on the meta-level of professions do not fully capture the complexity that characterises current clinical care in multidisciplinary health care teams. We illustrate this through an empirical study of a multidisciplinary team attempting to enact their work in a clinically democratic way. The challenges that arose in putting this into practice highlight the depth and complexity of enculturated medical dominance in Australian hospital practice. Our study shows that effective facilitation of clinician reflexivity has the potential to challenge and change deeply embedded structures and behaviours.

Sorensen, R. & Iedema, R.A. 2006, 'Integrating patients' nonmedical status in end-of-life decision making: Structuring communication through 'conferencing'', Communication and Medicine, vol. 3, no. 2, pp. 185-196.
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This paper considers the nonmedical status of patients in end-of-life decisions. Considering nonmedical factors is not yet routine, particularly in decisions to withhold or withdraw treatment. The paper advocates that non-medical factors+the capacity and willingness to withstand continuing treatment+are essential to ensure that decisions taken are in the patient's best interest. We argue that including this dimension of patient care not commonly considered gives balance to decisions about continuing treatment where its benefit is diminishing. Drawing on a qualitative study of intensive care nursing in a large public hospital in Sydney, Australia, the paper exemplifies and interprets the tendency of some clinicians to not disclose the medical and nonmedical status to conscious patients, and the environment of mistrust and conflict that can result. We propose a process of `conferencing++a regular, inclusive, ongoing, and dynamic process of communication begun early in the patient's admission+to allow multidisciplinary clinicians to manage their differences, agree on patient-care goals, and prepare the patient and their family for the experience of dying. By integrating both medical and nonmedical factors, conferencing becomes the means of enacting and embedding a multidisciplinary, multidimensional approach to end-of-life care.

Braithwaite, J., Westbrook, M., Iedema, R.A., Mallock, N.A., Forsyth, R. & Zhang, K. 2005, 'A tale of two hospitals: assessing cultural landscapes and compositions', Social Science and Medicine, vol. 60, no. 5, pp. 1149-1162.
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Clinical directorate service structures (CDs) have been widely implemented in acute settings in the belief that they will enhance efficiency and patient care by bringing teams together and involving clinicians in management. We argue that the achievement of such goals depends not only on changing its formalised structural arrangements but also the culture of the organisation concerned. We conducted comparative observational studies and questionnaire surveys of two large Australian teaching hospitals similar in size, role and CD structure. Martin's conceptualisation of culture in terms of integration, differentiation and fragmentation was applied in the analysis of the data. The ethnographic work revealed that compared to Metropolitan Hospital, Royal Hospital was better supported and more favourably viewed by its staff across six categories identified in both settings: leadership, structure, communication, change, finance and human resource management. Royal staff were more optimistic about their organisation's ability to meet future challenges. The surveys revealed that both staff groups preferred CD to traditional structures and shared some favourable and critical views of them. However Royal staff were significantly more positive, reporting many more benefits from CDs e.g. improved working relations, greater accountability and efficiency, better cost management, more devolvement of management to clinicians and a hospital more strategically placed and patient focused. Metropolitan staff were more likely to claim that CDs failed to solve problems and created a range of others including disunity and poor working relationships.

Braithwaite, J., Westbrook, M. & Iedema, R.A. 2005, 'Giving voice to health care professionals' attitudes about their clinical service structures in Theoretical Context', Health Care Analysis, vol. 13, no. 4, pp. 315-335.
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Within the context of structural theories this paper examines what health professionals say about their clinical service structures. We firstly trace various conceptual perspectives on clinical service structures, discussing multiple theoretical axes. These theories question whether clinical service structures represent either superficial or more profound changes in hospitals. We secondly explore which view is supported though a content analysis of the free text responses of 111 health professionals (44 doctors, 45 nurses and 22 allied health practitioners) about their clinical service structures in a questionnaire survey in two large hospitals that had implemented clinical service structures three years previously. Commentaries unfavourable toward clinical service structures were made by 47.7% of staff, favourable by 24.3%, mixed (both favourable and unfavourable) by 17.1% and non-evaluative statements were made by 10.8%. The most frequent criticisms were inefficient organisation of change (27%), poor management (24.3%), lack of cooperation between staff (15.9%) and failure to empower health practitioners (13.5%). All professions made more negative than positive evaluations of their clinical service structures but the ratio was highest for doctors and lowest for allied health. Ranking of nurses' and allied health staffs' specific evaluations were similar but both differed significantly from doctors.'

Grant, D. & Iedema, R.A. 2005, 'Discourse Analysis and the Study of Organisations', Text, vol. 25, no. 1, pp. 37-66.
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In this paper we provide an overview of research into organizational discourse, making a tentative distinction between organizational discourse studies (emerging from organization and management theory) and organizational discourse analysis (emerging from more linguistic-oriented research). Our primary aim is to focus on organizational discourse studies in a fashion that complements, rather than replicates, previous overviews of the field. In so doing, we suggest that organizational discourse research is too complex and multivariate to be pigeonholed on the basis of academic discipline or research method. Further, abstracting the multiplicity of organizational discourse research endeavors into just two single dimensions as do Alvesson and Kõrreman (2000), for example, runs the risk of losing some of this richness. We aim to provide insight into the complexity of organizational discourse and the philosophical and methodological richness that it embodies by highlighting that commentators often straddle dierent positions. To this end, we propose five dimensions by which to map this rich domain of research. Our concluding argument is that organizational discourse studies (ODS) and organizational discourse analysis (ODA) would do well to combine the former's normative and the latter's analytical prerogatives with attention to practitioner-situated problematics and struggles.

Iedema, R.A., Sorensen, R., Braithwaite, J., Flabouris, A. & Turnbull, L. 2005, 'The teleo-affective limits of end-of-life care in the intensive care unit', Social Science & Medicine, vol. 60, no. 4, pp. 845-857.
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This paper explores the relevance of a specific kind of sensed connectedness or 'teleo-affectivity' to the organisation and enactment of end-of-life care. Referred to as heedful inter-relating, this teleo-affective connectedness has been found to occur a

Iedema, R.A., Meyerkort, S. & White, L. 2005, 'Emergent Modes of Work and Communities of Practice', Health Services Management Research, vol. 18, no. 1, pp. 13-24.
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This paper argues that the recent emphasis on teams in the health services research literature tends to be attributed to our rising recognition that flexible and self-organizing teams are in the best position to handle the increasing complexity and fragmentation of health services. With a brief review of two papers on health-care teams as its point of departure, this paper argues that the concern with teams harbours a realization that the organizational-managerial point of gravity of most clinical work lies with those who do the work. In the context of health reforms sweeping across most countries in the industrialized world, this means that teams are to embody dynamic self-organization as do 'communities of practice (CoPs)', and be the origin of the managerial and documentary realities that describe, define and validate them. Following through on this last point, the paper reflects on some of the constitutive facets of teams as CoPs, and proposes that in the context of health reform such emergent teamness encompass participating, knowledging and boundary spanning. Fusing contextual, attributional and processual dimensions of team conduct, these notions are elaborated to show how descriptions of teamness can be rendered sensitive to the prerogatives of health reform. The paper concludes with outlining some of the implications of this proposal for how we reconceptualize health services management.

Iedema, R.A., Rhodes, C.H. & Scheeres, H.B. 2005, 'Presencing identity: organizational change and immaterial labor', Journal of Organizational Change Management, vol. 18, no. 4, pp. 327-337.
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Purpose - To examine Hardt and Negri's discussions of immaterial labor in relation to personal identity and sociality at work in a context of the postmodernization of the global economy. Design/methodology/approach - Hardt and Negri's discussions of imma

Turnbull, L., Flabouris, A. & Iedema, R.A. 2005, 'An outside perspective of the lifeworld of ICU', Australian Critical Care, vol. 18, no. 2, pp. 71-75.
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This paper has been reconstructed from the field notes of the principal author on this paper. Selected sections may enable those for whom intensive care encompasses a taken-as-given world, to share with an outsider some thoughts on its everyday workings, common assumptions, and remarkable characteristics. The orientation of the paper is ethnographic as well as 'phenomenological'; that is, the descriptions are informed as much by the ethnographer's private sentiments as by what is objectively 'there'. This creates a quite 'personal' narrative. The description centralises ethnography as much as that which is commented on. The sentiments expressed may be of interest, we believe, because they are likely to reflect those experienced by patients and their families upon entering the intensive care unit for the first time

Degeling, P.J., Maxwell, S., Iedema, R.A. & Hunter, D.J. 2004, 'Making clinical governance work', British Medical Journal, vol. 329, no. 18, pp. 679-681.
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Clinical governance has been described as "by far the most high-profile vehicle for securing culture change in the new NHS."1 However, the government's past preoccupation with delivery and top down performance management has undermined its developmental potential.2 To be effective, clinical governance should reach every level of a healthcare organisation. It requires structures and processes that integrate financial control, service performance, and clinical quality in ways that will engage clinicians and generate service improvements.3 We strongly endorse this view. Because clinicians are at the core of clinical work, they must be at the heart of clinical governance. Recognition of this fact by clinicians, managers, and policy makers is central to re-establishing "responsible autonomy" as a foundation principle in the performance and organisation of clinical work. We look at problems with the prevailing model of clinical governance and describe an alternative approach.

Delaney, G., Jacobs, S., Iedema, R.A., Winters, M.E. & Barton, M.B. 2004, 'Comparison of face-to-face and videoconferenced multidisciplinary clinical meetings', Australasian Radiology, vol. 48, no. 4, pp. 487-492.
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A trial of videoconferencing of multidisciplinary breast cancer clinical meetings between three public hospitals was conducted in an attempt to increase attendance by medical staff at the meetings, and thus facilitate multidisciplinary care for breast cancer patients. The videoconferences were compared with the previously existing face-to-face clinical meetings through questionnaires, attendance, number of cases discussed and anthropological analysis. Although more people attended the videoconferences than the face-to-face meetings, most of the participants in the trial preferred the face-to-face meetings to the videoconferences. The mean number of cases discussed at the videoconferences was significantly less than the mean number of cases presented at the face-to-face clinical meetings. The face-to-face meetings were informal, spontaneous and conducive to open discussion. In contrast, the videoconferences were formal and regimented. Multidisciplinary case discussion can be facilitated by videoconferencing. Some of the negative experiences we encountered could be overcome with changes in meeting format. Our experience may help others in setting up a successful multidisciplinary team via videoconference.

Iedema, R.A., Degeling, P.J., Braithwaite, J. & White, L. 2004, ''It's an Interesting Conversation I'm Hearing': The Doctor as Manager', Organization Studies, vol. 25, no. 1, pp. 15-33.
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The aim of this article is to outline in discursive-linguistic terms how doctor-managers (or `physician-executives+ as they are termed in the USA) manage the incommensurate dimensions of their boundary position between profession and organization. In order to achieve this we undertook a discourse analytical study of both recorded, situated talk and open interview data focusing on one doctor-manager navigating between profession and organization. The doctor-manager at the centre of this study locates himself on the boundary of at least three discourses which, in many respects, are incommensurate. These are the profession-specific discourse of clinical medicine, the resource-efficiency and systematization discourse of management, and an interpersonalizing discourse devoted to hedging and mitigating contradictions. While this multi-vocality in itself is not surprising, data show that the doctor-manager positions himself across these discourses and manages their inherent incommensurabilities before a heterogeneous audience and on occasions even within the one utterance. In this particular case, boundary management is achieved by weaving incommensurable positions together into the social and linguistic dynamics of a single, heteroglossic stream of talk. This highly complex and dialogic strategy enables the doctor-manager to dissimulate the disjunction between his reluctance to impose organizational rules on his medical colleagues and his perception that such rules, in the future (to some extent at least), will be the appropriate means for managing the clinical work, and through that the organization.

Iedema, R.A., Degeling, P.J., White, L. & Braithwaite, J. 2004, 'Analysing discourse practices in organisations', Qualitative Research Journal, vol. 4, no. 1, pp. 5-25.
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This paper addresses the issues that arise when ethnographic discourse analysis is used to describe and analyse hospital interaction among medical and non-medical staff in a metropolitan hospital, and when research analyses are reintroduced into the workplace environment. The paper considers the challenges that result from doing intervention-oriented research. The research involves analyses of discourse and talk and a related set of theoretical tools, including transcripts of talk used as data and as evidence in formal accounts, and ethnographic and discourse-analytical claims about hospital interaction that are to be shared with staff for the purpose of communication intervention and workplace change. The paper addresses the salient criticisms that were levelled at our research by senior clinician-managers of the hospital, and reasons about the divergences between sociological (ethnographic-discourse analytic) and medical+practical understandings of research method and of hospital work. Finally, the paper attempts to reposition both our own social-scientific account and clinical staff+s understandings of their work in relation to one another, in the interest of a continued dialogue. Such repositioning is central, we suggest, to maintaining not only the validity of our research but also the momentum of clinicians, and especially doctors, in their move towards hospital reform. Discourse research, we argue, is a unique device for engendering reflexivity on the part of researchers and the researched.

Iedema, R.A., Degeling, P.J., Braithwaite, J. & Chan, D.K. 2004, 'Medical Education and Curriculum Reform: Putting Reform Proposals in Context', Medical Education Online: an electronic journal, vol. 9, no. 17, pp. 1-11.
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The purpose of this paper is to elaborate criteria by which the principles of curriculum reform can be judged. To this end, the paper presents an overview of standard critiques of medical education and examines the ways medical curriculum reforms have responded to these critiques. The paper then sets out our assessment of these curriculum reforms along three parameters: pedagogy, educational context, and knowledge status. Following on from this evaluation of recent curriculum reforms, the paper puts forward four criteria with which to gauge the adequacy medical curriculum reform. These criteria enable us to question the extent to which new curricula incorporate methods and approaches for ensuring that its substance: overcomes the traditional opposition between clinical and resource dimensions of care; emphasizes that the clinical work needs to be systematized in so far as that it feasible; promotes multi-disciplinary team work, and balances clinical autonomy with accountability to non-clinical stakeholders.

Iedema, R.A., Sorensen, R., Braithwaite, J. & Turnbull, L. 2004, 'Speaking about Dying in the Intensive Care Unit, and its Implications for Multi-Disciplinary End-of-Life Care', Communication and Medicine, vol. 1, no. 1, pp. 85-96.
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This article addresses how professionals working in an intensive care unit in Australia speak about dying, with particular reference to the contradictions and complexities that characterize their work in this setting. The article reflects on the incommensurabilities in these clinicians' talk, and the consequences of this for how different professionals work together and care for extremely ill patients. Examples are drawn from talk recorded during ward rounds and focus groups. The article argues that intensive care units are settings where being reflexive about one's work and assumptions is especially difficult because it involves negotiating decisions and taking moral responsibility for decisions affecting very sick patients. These decisions and responsibilities put into sharp relief the 'wicked problems and tragic choices' of end-of-life existence and of intensive care in specific. This article shows some of the complex ways in which specific clinicians' discourse absorbs and manifests these tensions and responsibilities. The article concludes that these kinds of complexities are unlikely to be resolved with reference to formal knowledge or in-principle conviction, and that a new interactive basis needs to be found where clinicians can rehearse alternative ways of speaking with which to approach each other, the dying, and their families.

Chan, D.K., Ong, B.S., Zhang, K., Li, R., Liu, J.G., Iedema, R.A. & Braithwaite, J. 2003, 'Hospitalisation, care plans and not-for-resuscitation orders in older people in the last year of life in Australia', Age and Ageing, vol. 32, no. 4, pp. 445-449.
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Background: over 60% of older people have at least one admission to hospital in their last year of life, with the majority of people having multiple admissions. In Bankstown, New South Wales, Australia, we have a diverse ethnic and cultural population. We were interested in bed utilisation, documentation, and follow through of Ô++care plansÔ++ as well as Ô++not for resuscitationÔ++ orders in the last year of life of the older people in our area.

Iedema, R.A. & Scheeres, H.B. 2003, 'From doing work to talking work: Renegotiating knowing, doing, and identity', Applied Linguistics, vol. 24, no. 3, pp. 316-337.
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Iedema, R.A. 2003, 'Multimodality, resemiotization: Extending the Analysis of Discourse as Multi-Semiotic Practice', Visual Communication, vol. 2, no. 1, pp. 29-57.
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This article has the following two overarching aims. First, it traces the development of multimodal discourse analysis and sets out its main descriptive and analytical parameters; in doing so, the article highlights the specific advantages which the multimodal approach has to offer and exemplifies its application. The article also argues that the hierarchical arrangement of different semiotics (in the way common sense construes this) should not be lost from sight. Second, and related to this last point, the article will advance a complementary perspective to that of multimodality: resemiotization. Resemiotization is meant to provide the analytical means for (1) tracing how semiotics are translated from one into the other as social processes unfold, as well as for (2) asking why these semiotics (rather than others) are mobilized to do certain things at certain times. The article draws on a variety of empirical data to exemplify these two perspectives on visual communication and analysis.

Iedema, R.A. 2003, 'The Medical Record As Organising Discourse', Document Design: journal of research and problem solving in organizational communication, vol. 4, no. 1, pp. 64-84.
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This paper analyzes different manifestations of the medical record in order to demonstrate how and why some discourse creates greater organizational reach. In doing so, the paper presents four arguments. First, that types of discourse research that analyze organization from the perspective of regularized practices on the one hand, and those which frame organization as narrative and story-telling unfoldings on the other, are to be complemented with discourse research that considers the inherent characteristics of discourse and its relationship to and relevance for organizational process. Second, that organizing discourse is discourse that mediates between specifying and dedifferentiating moments of representation, by interposing standardizing categories, inscriptions and material appearances; only in this way is discourse able to connect the specific and the personalized with the general, abstract, and depersonalized. Third, the paper argues that the paperbased medical record largely absolves clinicians from Ô++organizingÔ++ clinical care as it is defined in this paper: its discourse (content, visual appearance, rules governing authorship) remains Ô++un-organizingÔ++. Finally, it is argued that the electronic PCIS is being framed in discourse that standardizes how clinical care is informated, and potentially even intervenes in the substance of that care; and while at greater risk of bringing about Ô++bad recordsÔ++ (Garfinkel 1967), such Ô++organizing discourseÔ++ ultimately achieves Ô++lines of forceÔ++ across and beyond the clinic.

Braithwaite, J., Hindle, D., Iedema, R.A. & Westbrook, J.I. 2002, 'Introducing soft systems methodology plus (SSM+): why we need it and what it can contribute', Australian Health Review, vol. 25, no. 2, pp. 191-198.
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There are many complicated and seemingly intractable problems in the health care sector. Past ways to address them have involved political responses, economic restructuring, biomedical and scientific studies, and managerialist or business-oriented tools. Few methods have enabled us to develop a systematic response to problems. Our version of soft systems methodology, SSM+, seems to improve problem solving processes by providing an iterative, staged framework that emphasises collaborative learning and systems redesign involving both technical and cultural fixes.

Scheeres, H.B. & Iedema, R.A. 2002, 'Organizing and businessing identity: rethinking/reframing pedagogies', Teaching English for International Business, vol. 1, no. 2, pp. 36-49.
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Iedema, R.A. & Degeling, P.J. 2001, 'From difference to divergence: The logogenesis of interactive tension', Functions of Language, vol. 8, no. 1, pp. 41-78.
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This paper considers the tension which develops among participants present at a health planning meeting, and describes the `ymbolic violence+ Bourdieu 1991) committed by two speakers on another. The focus will be on the contradiction that arises between bureaucratic discourse which is oriented towards `ue process+ and the interpersonalising trend of the talk towards conflict. The paper presents an analysis of around ninety turns of talk, with the purpose of showing two things. First, because the talk is enacted in a formal context and through the bureaucratic register,it is constrained in terms of the ways in which the interpersonal politics can be acted out. Second, the divergence between the speakers+ interactive styles is shown to gradually exacerbate. To be able to bring out this interactive dynamic, the paper provides a `ogogenetic+ analysis of the interaction, maintaining an analytical dialectic among levels of language and context. Logogenesis here refers to an analytical perspective which regards the unfolding of meaning in both a systemic (meanings mobilising specific domains of language and not others) and a text-historicising way (meanings `evolve+ rom one another in the course of interaction and reinforce or stand in tension with one another).

Iedema, R.A. 2001, 'Resemiotization', Semiotica: journal of the international association for semiotic studies, vol. 137, no. 1/4, pp. 23-39.
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Consider the following scenario: The New South Wales Department of Health has made a budget available for the renovation and expansion of a mental hospital. An architect-planner is hired to produce the project's planning report for the local health authority. His report is to set out how available funds can be best used to do the work. After five meetings with health officials, engineers, architects, and future users of the building, and after three drafts of the report and of its tenta-tive two-dimensional drawings, everybody present at the last meeting signs o. on the planning report. During the next stage of the project, the report's two-dimensional drawings are used to produce three- dimensional computer-generated designs. These designs are plotted onto special sheets, which become the basis from which the builders proceed with their construction of the building. Apart from producing a newly renovated mental hospital, what does this `stream of events'/'flow of objects' mean?

Iedema, R.A. 1999, 'Formalizing organizational meaning', Discourse & Society, vol. 10, no. 1, pp. 49-65.
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Formality indexes interactional closure: it limits the possibilities for the renegotiation of agreements and decisions. In this article the focus is on how formality is constructed in organizational settings. The article proposes that organizational formalization is achieved on the strength of the recontextualization of meaning from one discourse or practice to another. Importantly, organizational processes of recontextualization tend to increasingly technologize meanings with respect to both what they signify and their materialization. This means that discursive practices will mobilize, aside from human or embodied modes of meaning making, increasingly disembodied or exosomatic modes of meaning making, such as electronic kinds of communication, as well as other kinds of inscription of meaning (infrastructure, architecture, and so on).

Iedema, R.A. & Wodak, R. 1999, 'Introduction: Organizational Discourses and Practices', Discourse & Society, vol. 10, no. 1, pp. 5-20.
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This article provides a brief introduction to the other articles in this Special Issue, and sets out some of the traditions in linguistics and discourse analysis which have engaged in organizational research. The article then addresses some of the issues that define organizationality, such as impersonalization, power, and (re)production. The latter of these three is focused on in greater detail and is linked to current concerns with what is now termed the `recontextualization' of professional and organizational phenomena (Bernstein, 1990; Iedema, 1997a; Linell and Sarangi, 1998). Here, recontextualization is proposed to be at the heart of organizationality itself; that is, organizationality is seen as constituted in (re)productive processes which apply discipline/scientific technologies to human/exosomatic resources, producing lasting effects. These effects include both specialized practices and alternative social and material realities. Relatedly, we argue that organizational meaning making practices are to be considered as `multimodal' chains of recontextualization, with alternative semiotics such as design and built construction forming equally important links as does language in the chains of organizational processes.

Iedema, R.A. 1998, 'Institutional Responsibility And Hidden Meanings', Discourse & Society, vol. 9, no. 4, pp. 481-500.
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This article aims to show how bureaucratic discourses encode and construe the complicity and reciprocal power relations which theorists like Giddens and Bourdieu see as underpinning and maintaining institutional and hierarchical power. It will address th

Iedema, R.A. 1997, 'The Structure of the Accident News Story', Australian Review of Applied Linguistics, vol. 20, no. 2, pp. 95-118.
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This paper presents an overview of 150 years of accident news writing as presented in the Sydney Morning Herald, with the aim of uncovering the genesis of the 'hard' news story, and locating the practice of news writing in its historical context This oveIView will serve as a grounding for a discussion of current news writing practices in general. Parallels will be suggested between the nature of accident stories on the one hand, and the role and concerns of the print media in modern industrial society on the other. The paper concludes that 'hard' news writing is concerned with the recontextualization ofsocially <destabilizing' events (Iedema, Feez and White-1995), as well as with the rendering relevant of these recontextualizations to a diffuse and generalised media audience.

Iedema, R.A. 1996, ''Save the Talk for After the Listening': The Realisation of Regulative Discourse in Teacher Talk', Language and Education, vol. 10, no. 2 & 3, pp. 82-102.
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This paper addresses the increasingly sophisticated means by which teachers get students to do things. First, it discusses the resources available for realising should-ness, or modulation. In Halliday's (1985:336) interpretation, modulation can be realised subjectively (e.g. 'You should go') or objectively ('You are required to go'). The semantic continuum ranging from subjective realisations via objective realisations to demodalised realisations like 'The requirement is that ... ' proposed in the Write it Right industry research monograph Vol. III (Iedema, 1996) is briefly presented. This framework is then applied to seven teacher talk extracts. It is shown that early primary teacher talk tends to make use of mostly subjective kinds of modulation, while late primary teacher talk makes use of both highly objectified and ideationalised as well as highly 'interiorised' forms of control. Thinking of the school as 'an expert system of civic governance' (Hunter, 1994: xx), I argue that students' induction into bureaucratic-pastoral self-discipline and self-determination is enabled by their exposure to and eventual control over linguistic modes of modulation. These modes both increasingly background the sources of should-ness and thus its interpersonal negotiability, and increasingly interiorise the ultimate source of compliance. I also argue for explicit classroom attention to these technologies of positioning and social control.

Iedema, R.A. 1995, 'Legal Ideology: the Role of Language in Common Law Appellate Judgements', International Journal for the Semiotics of Law, vol. 8, no. 1, pp. 21-36.
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This article presents an analysis of two judgments delivered in Dugan v. Mirror Newspapers Ltd. 1 The analysis is based on the systemic- functional model proposed by Halliday 2 and the discourse semantic approach outlined in Martin 1992.3 It is argued that legal ideology and linguistic realisation "redound, "4 and that the negotiation of legal meaning involves competing discourses, aiming to consolidate or realign the socio-political positionings of the social actors involved; that legal discourse, in other words, is primarily a "social discourse, "5 not merely a disciplined/disciplinary manipulation ofspecialised meanings.

Iedema, R.A. 1993, 'Legal English: Subject Specific Literacy and Genre Theory', Australian Review of Applied Linguistics, vol. 16, no. 2, pp. 86-122.
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In this paper student Case Notes are analysed to exemplify the degrees oflinguistic intricacy that come into play within the context of legal discourse - the 'target discourse'- and to demonstrate that apprenticeship into this particular academic discourse community involves more than familiarisation with content specific material on the one hand and the control of common English structural conventions on the other. The discussion sets out to show that the intricate and often 'hidden' (as in 'not made explicit') linguistic demands academic discourses impose on NESB students need to be brought out into the open to highlight andcIarify the association between specific lexicogrammatical realisations and generic meanings in the discourse. The paper concludes by emphasising the need for linguistically infonned assistance for NESB learners at the tertiary level

Iedema, R.A. 2008, 'Training healthcare staff in root cause analysis - results from national programme evaluations in the UK and Australia', The Healthcare Risk Resource, vol. 8, no. 1, pp. 15-19.

Braithwaite, J., Westbrook, J.I. & Iedema, R.A. 2007, 'Health Care Participants Dualism Are New Sub-species Evolving?', Journal Of The Royal Society Of Medicine, vol. 100, no. 2, pp. 78-80.
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NA

Iedema, R.A. 2006, '"Producing Patient Information: How to develop and produce effective information resources" by Mark Duman', Information Design Journal, vol. 14, no. 2, pp. 186-187.

Braithwaite, J., Westbrook, J.I. & Iedema, R.A. 2005, 'Restructuring as gratification', Journal of the Royal Society of Medicine., vol. 98, no. 12, pp. 542-544.
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Iedema, R.A. 2004, 'Critical Discourse Analysis and Cognitive Linguistics, by Kieran OÔ++Halloran', Linguistics and Education, vol. 15, no. 4, pp. 413-423.

Sharrock, P. & Iedema, R.A. 2004, 'Ideology, Philosophy, Modernity and Health Promotion: Discourse analysis of eight reviews from the Reviews of Health Promotion and Education Online', Reviews of Health Promotion and Education Online, vol. 13.

Wodak, R. & Iedema, R.A. 2004, 'Constructing boundaries without being seen: The case of Jorg Haider, politician', Revista Canaria de Estudios Ingleses, vol. 49, pp. 157-178.

Iedema, R.A., Braithwaite, J. & Sorensen, R. 2003, 'The reification of numbers: Statistics and the distance between self, work and others', British Medical Journal, vol. 326, no. 7392, pp. 771-771.
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We have been presenting papers at healthcare and medical conferences, workshops, and symposiums for many years, and have noticed an interesting phenomenon. Health professionals, particularly doctors, are acutely heedful of data in the form of tables and charts and less so of words and models. We have not seen this described before and we seek to label it "numerical supremacy syndrome."

Iedema, R.A. & Degeling, P.J. 2001, 'Quality of care, clinical governance, and pathways', Australian Health Review, vol. 24, no. 3, pp. 12-15.

Iedema, R.A. 1995, 'Review of Ian Ward's "Politics of the Media"', Social Semiotics, vol. 5, no. 2, pp. 309-313.

Iedema, R.A. 2008, 'The challenges of clinical governance: 'informationalising' as socio-technical literacy', Health Information Management Journal, vol. 33, no. 4.

Iedema, R.A. 2005, 'The Tension Between Professional and Institutional Discourse: Applied Linguitics, 21st Century Health Care and the Contemporary Hospital', Journal of Applied Linguistics, vol. 3, no. 2.

Chen, Y., Bongers, A.J. & Iedema, R.A. 2009, 'Visual Melodies - Interactive Installation for Creating a Relaxing Environment in a Healthcare Setting', Australian Computer Human Interaction Conference, Melbourne, November 2009 in Proceedings of the OZCHI 2009, ed Kjeldskov, J., Paay, J. and Viller, S., ACM CHISIG, Melbourne, pp. 361-364.
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Overview of research and design of the Visual Melodies installation for hospital waiting rooms.

Carroll, K.E., Bridgeford, S. & Iedema, R.A. 2007, 'Rostered Labour and Intensive Work Places: The Organisational and Industrial Relations Complexities of providing 24 hour care', Our Work...Our Lives Conference, Adelaide, Australia, September 2007 in Our Work...Our Lives: National Conference on Women and Industrial Relations, ed Dann, S; Franzway, S; Masterman-Smith, H, Hawke Research Institute, University of South Australia, Adelaide, Australia, pp. 24-34.
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Carroll, K.E. & Iedema, R.A. 2006, 'Incorporating Complexity Theory and Feminism into Video Ethnography', Australian Consortium for Social and Political Research Incorporated, Sydney, Australia, December 2006 in Australian Consortium for Social and Political Research Incoporated - ACSPRI Social Science Methodology Conference Online Proceedings, ed NA, ACSPRI, Sydney, Australia, pp. 1-13.
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This research uses video firstly as a tool for data collection, and secondly as a method for reflexive sessions that engage both the researcher and clinicians in reflexive viewing of organisational aspects of clinical work. By focusing on empirical data from videoethnographic research in an intensive care unit (ICU) in New South Wales (NSW)1 this paper broadly demonstrates the compatible intertwining of complexity theory, feminist research principles and video-reflexivity.

Rhodes, C.H., Iedema, R.A. & Scheeres, H.B. 2005, 'Being at work: Immaterial labor, affectualization and the presencing of identity', EURAM Conference, Munich, Germany, May 2005 in Responsible Management in an Uncertain World - EURAM 2005 Conference, ed -, European Academy of Management, Munich, Germany, pp. 1-21.
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Westbrook, J.I., Braithwaite, J., Iedema, R.A. & Coiera, E.W. 2004, 'Evaluating the impact of information communication technologies on complex organizational systems: a multi-disciplinary, multi-method framework', World Congress on Medical Informatics, San Fransisco, USA, September 2004 in Proceedings of the 11th World Congress on Medical Informatics, ed M. Fieschi, E. Coiera and Yu-Chan, IOS, Washington, USA, pp. 1323-1327.
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The health informatics research community has been undertaking work at the organization-technology intersection for some time now. However there is no one place in the literature which presents a rigorously-defined evaluation framework for use by practitioners and researchers seeking to assess the impact of information and communication technologies on organizational processes and outcomes. There are two main challenges. One is to conceptualize the design features of such an evaluation framework. The second is to specify what data will be gathered and how. This paper aims to address each of these problems.

Rhodes, C.H. & Iedema, R.A. 2007, 'Beyond the Gaze: Ethics and Care in Organizational Surveillance', European Academy of Management 2007 Conference, Paris, France, May 2007 in European Academy of Management 2007 Conference, ed Thomas Durand, Rodolphe Durand, Pierre Dussauge and Maurizio Zollo, EURAM, Paris, pp. 1-20.

Braithwaite, J., Iedema, R.A. & Westbrook, M. 2006, 'Health sector organisational restructuring: Evidence for its futility', Organisational Behaviour in Health Care Conference, Aberdeen, Scotland, April 2006 in Prooceedings of the Organisational Behaviour in Health Care Conference, University of Aberdeen, Aberdeen.

Braithwaite, J., Westbrook, M., Westbrook, J.I. & Iedema, R.A. 2006, 'On the problem of continuous organisational restructuring: risks and solutions', A measure of hospital health: The Biennial Health Conference, UNSW, Sydney, Australia, November 2006.

Iedema, R.A., Long, D., Carroll, K.E., Stenglin, M. & Braithwaite, J. 2006, 'Corridor work: how 'liminal' space can be a focal resource for handling complexities of multi-disciplinary health care', Melbourne, Australia, December 2005 in Proceedings of the 11th International Colloquium of the Asia-Pacific Researchers in Organization Studies (APROS), ed Muetzelfeld, M., APROS, Melbourne, Australia, pp. 238-247.
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This paper presents an analysis of video-ethnographic data of a corridor in an Australian metropolitan teaching hospital. As the video data will illustrate, the corridor connects spaces (wards, consulting rooms) and practices (clinicians consulting each other about shared patients and co-organizing their work). The paper describes how the complexities of multi-disciplinary practice and disease trajectory; the dynamic circulation of bodies and materials, and the material-phenomenological intentionalities embedded in space converge in the corridor, and how this helps transmute 'marginal' space into a site of intense productivity. It is here that the interstices among clinical knowledges, processes, problems and purposes are dynamically negotiated and worked out. The corridor, perceived as liminal space, becomes the place par excellence for the negotiation and resolution of an array of complexities inherent in how multi-disciplinary care intersects with the uncertain trajectories of disease and access to hospital resources. In our conceptualization, the corridor is a space whose perceived liminality becomes a crucial resource: this is a unique site where final decisions can be held in abeyance and where uncertainties and provisional decisions can co-exist; a space where the fixities of hierarchy and specialization can be attenuated if not suspended, and a space where people can agree to work around rules and regulations; in short, a space where tasks and positionings become sufficiently provisional, flexible and negotiable to enable clinicians to weave the complexity of emerging facets of clinical practice into a workable and productive unfolding.

Forsyth, R. & Iedema, R.A. 2005, 'Video ethnography as research tool: Unique challenges and insights', AQR conference, La Trobe University, Bundoora Campus, Melbourne, July 2005.

Forsyth, R. & Iedema, R.A. 2004, 'Video Ethnography as a Method for Studying Professional Communication in Health Care', Revioning Institutions: Change in the 21st Century, Latrobe University, Beechworth Campus, Australia, December 2004 in TASA Conference 2004: Conference Handbook and Programme, ed Richmond Katy, TASA, Melbourne, Australia, pp. 77-77.

Iedema, R.A., Rhodes, C.H. & Scheeres, H.B. 2004, 'Observance and Surveillance: The ethics and aesthetics of identity (at) work', 6th International Conference on Organizational Discourse, Amsterdam, Holland, July 2004 in Organizational discourse: Artefacts, Archetypes and Architexts, ed Combes, C. ; Grant, D. ; Keenoy, T. ; Oswick, C., Kings College, London, London, UK.

Turnbull, L., Iedema, R.A., Degeling, P.J., Hillman, K. & Flabouris, A. 2002, 'Improving End-of-Life Care in the Intensive Care Unit - A case study presentation as part of the first phases of an action research process', Critical Care Conference, Liverpool Hospital, NSW, Australia, June 2007.

Turnbull, L., Iedema, R.A., Degeling, P.J., Hillman, K., Flabouris, A. 2002, 'Making Meaning in a Liminal Space: Improving the Care of the Dying in the Intensive Care Unit', The Social Context of Death Dying and Disposal Conference, York, September 2002.