Institutions as objects of inquiry

In short, the overall project of institutional ethnography is to explore the social relations organising institutions as people participate in them. Institutions, in Smith’s view, are vast complexes embedded in ‘ruling relations’ that are organised around a distinctive function, such as healthcare. Institutional ethnography aims to go beyond and behind the individual’s doings, knowledge or experience to discover how what they are doing is connected with the doings of others. The idea is to map the institutional aspects of ‘ruling relations’ that refer to distinctive authoritative forms of social organisation and social relations – mediated by texts of many different kinds. (Smith 2005, 225, 227; 1987, 160, 166–67.)

Dorothy E. Smith has a background in feminist sociology, and is probably best known for her work on methodology and her accounts of institutional ethnography (Smith 1987;

2005; 2006). She has also done empirical work on educational systems and psychiatric practices (e.g. Griffith & Smith 2004; Smith & David 1975). Her institutional ethnographic research material has varied from different kinds of documentary/text material to interviews and observational material. According to Smith, institutional ethnography should involve looking for sequences of action that implicate other people, other experiences, other work and texts in institutional processes, and courses of action.

That is, the ethnographer should search for indications of connections to social organisation and relations. To put this in simplified and more technical terms, this means exploring conceptualisations and sequencing as social relations in organisational action or work (linguistic or otherwise) (Smith 1987; 2005; 2006).

Social organisation is present in the language people use in their everyday lives. That is, they use terms and concepts that organise activities in which they participate. Furthermore, these terms coordinate activities in accordance with each term’s meaning in a given setting (Smith 2005, 132–135; 1987, 156–157). Emphasising the sequences of action directs our attention to the fact that terms, language, experiential accounts, work activities and so on are embedded in institutional process(es) that establish different positions in social relations enacted at the level of everyday work, for example, at maternity healthcare clinics (e.g. Smith 2005, 158).

The textuality or text-based organisation of (care) work is of extreme importance in Smith’s theory of institutions. According to her, it is the existence of technology that enables the replication of texts and gives contemporary institutions their particular character. Replication makes it possible for texts to be viewed in particular local and observable settings, and at the same time enables those texts to engage the individual’s consciousness in relations that are to a certain degree independent of the local setting.

Furthermore, the replication of texts independent of time and place produces the stability and replicability of the organisation and hence the institution: texts have a standardising (‘generalising’ in the original) effect. This is crucial to the recognisability of institutional (inter)action as such, regardless of local context. This is something Smith calls

‘translocal’.⁹ (Smith 1991, 209–225; 2005, 165–198; 1987, 212, 136–41.) This is how both the nurses and the pregnant women are involved in text-based work – complementarily – to produce institutional subjectivity and agency inside and outside the clinics.

The notion of text is used in institutional ethnography to refer to ‘words, images, or sounds that are set into a material form of some kind from which they can be read, seen, heard,

9 ‘Extralocal’ in Smith 1987, 47.

watched, and so on’ (Smith 2006, 66). Smith notes that unlike some theories of ‘text’, her work uses the term ‘strictly to identify texts as material in a replicable form (paper, print, film etc.)’ (Smith 2005, 228). However, it should be noted that texts in action in everyday institutional work do not have to be materially present in forms, handouts or textbooks, for example, at a given moment. A peculiar ‘agency’ of texts in action, textual regulation – which may appear nowhere in the observed situation as such – may be identified from characteristic uses of argumentation or concepts, i.e. interpretive frames or discourses (Smith 2005, 118, 165–182; 1991, 120–159).

Finally, according to Smith, texts should be understood as occurrences embedded in what is going on. This suggests that they are not to be analysed separately from the ways in which they enter into and coordinate sequences of action (Smith 2005, 118, 165–182;

2006). For instance, Finnish maternity healthcare texts, such as case files or the casebook system, are a product of, and make accountable the coordination of the work of public health nurses in relation to clients or patients (pregnant women) and administrative standards. Public health nurses are made accountable to the municipal healthcare administration, and they are expected to follow the guidelines by reporting through a computerised casebook system during or after every individual appointment. This information implies that, even when not observable, these texts are still integral to the courses of action, and organise work at given moments.

Socio-material practices in institutional activities

I will start this section with a snapshot from my ethnographic data. In it I will contrast two ways of attributing qualities to the unborn as I have come to understand them during my fieldwork at three different maternity healthcare clinics¹⁰ in one large city in Finland.

Often before the screening the public health nurses choose to inform pregnant women and their partners about screenings in accordance with the brochures handed out at the clinics. This seems to be in accordance with the local policy linked up with the will of the individual: women need to make

10 Additionally, video-recordings of special ‘welfare assessment interviews’ were obtained from a fourth clinic.

a choice between attending or not attending the screenings. Furthermore, the nurses use rather clinical and medical terms when referring to the unborn, and try to keep to ‘the facts’. This is done on purpose: nurses tell me that they intentionally use the term ‘foetus’ and try not to personalise it in other ways before the screenings, so as to ease the anxieties some women might have concerning the screenings. However, nurses offer these ‘facts’ in various ways that are embedded in advice-giving on how to think positively, and in encouragement and affirmation. They may, for instance, tell stories of their own pregnancies and give the pregnant woman a warm hug. When discussing the screenings afterwards, mostly in the cases where there are no abnormalities, the nurses go back to talking about babies or ‘womblings’ (kohtulainen) that ‘do’ things and are new members of the family in many ways. These womblings may have a nose that looks like their father’s on the ultrasound screen, or they may show temperament if they kick a lot in the womb. It seems that these associations and positive feelings towards the baby-to-be are provoked by the nurses.

It is not really surprising that health workers hold back and stick to giving ‘neutral’

information like this about screening for somatic abnormalities when it comes to making decisions about diagnostic tools or treatment. The highly valued Western ideal of patient (informed) choice or autonomy in all its varieties obviously shapes daily care at the maternity healthcare clinics. It is even taken as a self-evident ‘good’ within a medical ethical repertoire of care that works in alliance with biomedical knowledge about the natural order of things. Most often care is also organized in terms of citizen’s/social rights of some kind. (e.g. Helen 1997; Pulkkinen 2003, 135–157; Mol 2008a, 29–41; Duden 1993.)

When patients (or clients) are put in this decision-making position, it is usually either by means of the market or by means of the civil society. In the former case, patients become customers who need to make value choices between different ‘goods’ of healthcare i.e.

care acts and interventions. In the latter, on the other hand, interventions are chosen not as

‘goods’ but as policy measures. Patients act first and foremost as citizens who are granted jurisdiction and representation over interventions, but they must argue civically. (Mol 2002, 166–167; 2008a, 14–42; Harbers & Mol & Stollmeyer 2002, 217–219.)

Yet this is not the end of the story. For a few decades now, many feminist accounts of reproductive matters have been amending the way ‘will’ or ‘choice’ is understood in

Western theoretical, popular philosophical and socio-political thought (e.g. Whitbeck 1984; Petchecky 1985; Morgan 1996; Addelson 1999; Harouni 1999). Indeed, the critique of Kantian, utilitarian and liberal conceptions of the autonomous subject that makes rational choices was the starting point of the ethics of care (e.g. Held 2006, 3–4; Baier 1994), and such conceptions were even deemed absurd in relation to pregnancy in some feminist accounts (e.g. Duden 1993). This has meant a shift from the universal principle of doing ‘good’ to practical deliberations on the various available courses of action inspecific situations, and a shift from autonomous (human) subjects to relational (human) subjects.

With this shift scholars have tried to grasp the fact that power differences alter the possibilities of doing (good) care. (Harbers & Mol & Stollmeyer 2002, 218; Mol 2008a;

Held 2006.)

However, so far the majority of studies on healthcare have been dominated by a humanist orientation to practices: human beings are the relevant actors in these conceptualisations (Harbers & Mol & Stollmeyer 2002, 218). It has been noted that, in order to understand clinical practice, it is not only the concept of will or choice that needs to be altered, but also our understandings of the workings of nature and technology, the materialities and technicalities of practices (ibid., Mol 2008a, 1–8). This has only recently been attended to, mostly by science and technology studies (STS) scholars such as Annemarie Mol (2002;

2008a), Hans Harbers and Alice Stollmeyer (in Harbers & Mol & Stollmeyer 2002).

In the specific case of screenings this means that the ‘natural course’ of foetal development or pregnancy is in some sense left unexamined. If natural fate is invoked, what is left unaddressed is the fact that people experience and deal with foetal abnormalities and uncertainty in different ways. Some women’s anxieties may be assuaged by offering support – advice, encouragement and affirmation – while others’ may not. It does make a differencehow doubt – which is just as characteristic of healthcare practices as certainty – is lived with. For instance, shifting the repertoire from unborns with social relations and identities to unborns that are more like mere bodies in a biologically natural process (‘the foetuses’) can be understood as a way of accommodating the unpredictability of screening results. A mere concept of nature holds little explanatory power in relation to the question

of ‘how to give shape’ to the course of pregnancy (cf. Mol 2008a; Harbers & Mol &

Stollmeyer 2002, 218).

How, then, can (good) shape be given to the course of pregnancy, if pregnancy matters and the unborn are not one but multiple in this way, and if healthcare practice attends to this multiplicity and uncertainty? Activities at the clinics do not depend on what is ‘real’ in any singular and straightforward way, and professionals orient themselves towards ideal standards, such as ‘patient autonomy’, ‘health’ and ‘the good life’, in many different ways;

but this does not mean that we cannot seek positive interventions (Harbers & Mol &

Stollmeyer 2002, 219). This is where ethnography as a methodology of inquiry comes to the fore.

Engaging in an ethnography of the practicalities and materialities of daily care allows us to attend to the ‘goodness’ of care differently than, for example, the medical professional or ethical approaches. It sets out to enquire into the modes and styles of setting standards in care work practices, and to study the giving of ‘good’ and avoidance of ‘bad’ care (Mol 2008a). Thus the focus is on knowledge practices – not so much on finding ‘the truth’ but on how objects such as pregnancy matters are handled in practices. Since they are not same from site to site or moment to moment, this ethnography also asks how the coordination between such objects proceeds (Mol 2002, 5–6). Answering these questions involves paying attention to the specific issues that are at stake in practices. Furthermore, since this approach claims that making a judgement in a single difficult moment of deciding about a course of action tells us little about the ‘goodness’ of care, it also calls for an ethnographic time frame. A long period of fieldwork is required to attend to the entire trajectory of care for patients/clients. Overall, because the issue is to explore the modes of care given at specific places such as clinics and the dynamics of a collective that insists on the socio-materiality of practices, ethnography offers a suitable toolkit. (Mol 2008a;

Harbers & Mol & Stollmeyer 2002; see also Beaulieu & Scharnhorst & Wouters 2007;

Hine 2007; Clifford & Marcus 1986.)

To address the materialities, technicalities, practicalities and ‘goods’ that organise institutional activities, then, my theoretical and methodological orientation draws on insights from writers associated with traditions of science and technology studies on material practices¹¹ (e.g. Mol 2002; 2008a; Harbers, Mol & Stollmeyer 2002; Haraway 1991a; 1997; Berg & Mol 1998) and applies them to a Smithian project of institutional ethnography. These writers have also been characterised as engaging in (feminist) studies of technoscience (FT). Especially, my PhD project has been influenced by Annemarie Mol’s (e.g. 2002; 2008a) and Donna Haraway’s (e.g. 1991a; 1997) work.¹²

Combining elements of these two traditions of thought is not an easy task. It is not that ethnographic methods per se conflict with the FT approaches I aim to apply. Rather, it is a question of fitting together their respective ontological presumptions. Thus, combining elements from FT to IE involves altering my conceptual framework as such.

I want to emphasise here that I am not trying to formulate a theoreticalfusion of any kind, because that would require a PhD study of its own, and in any case I remain sceptical that such a fusion would even be possible. There would always be traces of irreducible differences, and there would not be any smooth compromises: at best a hybrid text, in which both theoretical repertoires would coexist but ‘not [always] at once’, could be achieved (cf. Mol & Messman 1996, 437). I want to take the term ‘hybrid’ in this sense of not being ‘at once’, and to conceptualise IE and FT as two modes of ordering ‘in the form of theoretical repertoires’ (Mol & Messman 1996, 437) which relate to each other in many ways but cannot and need not be neatly reduced to or conflated with each other to apply them both. In my analyses there might remain simultaneous narratives from both orderings that ultimately will be coordinated: they will hang together, but not as one. Overall, I will only apply some insights from particular writers, namely on the enacted/performed character of (natural) objects/subjects, to widen my analytical IE perspective, particularly on agency.

11 that often involves health and illness/disease.

12 Mol’s and Haraway’s work differ from each other is some respects, especially in relation to conceptualising power and normativity. This will be elaborated on later on in this chapter.

In what follows, I will elaborate on my working through of these (seeming) differences in ontological commitments. First, I will revisit Smith’s key methodological concepts by bringing in elements from socio-material (or as it is also called, material-semiotic) ways of thinking methodology. I will simultaneously consider the possibilities and benefits of doing such combining work. Then I will orient my key concepts of agency and subjectivity to both FT and IE lines of thinking.

Institutional ethnography and feminist studies of technoscience

Smith’s conceptual ‘design for ethnography’ works for me as a broad frame for conceptualising how institutions exist as objects of inquiry (Smith 1987; 2005). The overall project of institutional ethnography is to explore the social relations organising institutions as people participate in them, from the perspective of specific groups within such institutions. My particular focus is on pregnant women’s partial and shared agency and embodiment. In other words, the actualities of pregnant women’s lives and accounts of their experiences work as an entry point (standpoint) that organises my analysis. It is from this partial and particular perspective that the analysis proceeds to account for the ‘ruling relations’ coordinating the work and workings of all the actors involved at different levels (and sites) of institutional activities as they stand today.

As I understand it, Smith’s key methodological concepts in her studies of institutions include standpoint, experience, ruling relations and work (knowledges). Smith’s view of standpoint cannot be equated or identified with certain social standpoints which usually originate from subjugated experience (e.g. Rich 1976; Chodorow 1978; Harding 1986;

Hartsock 1975). That is, it cannot be simply equated with what have been termed the

‘feminist standpoint theories’, usually associated with the 1970s and 1980s. Smith herself explicitly takes issue with the theoretical challenge to the notion of standpoint made in terms of its alleged essentialism (in regard to the category ‘woman’, especially Harding 1988). Smith (2005, 10) writes that

[t]he version of standpoint that I have worked with […] does not identify a socially determined position or category of position in society [… ] Rather, my notion of women’s

(rather than feminist) standpoint is integral to the design of what I originally called ‘a sociology for women’ [1987, RH], which has necessarily been transformed into ‘a sociology for people’. It does not identify a position or category of position, gender, class, or race within the society, but it does establish as a subject position for institutional ethnography as a method of inquiry, a site for the knower that is open to anyone.

Standpoint, then, is a methodological starting point in the local particularities of bodily existence and people’s everyday lives. It is designed to be an alternative to the objectified subject of knowledge of social-scientific discourse in ways that do not return it to the universalised subject or empiricist truth claims on the basis of any unified experience as an authority to speak truly (Smith 2005, 7–25; 1987, 78–88). It is in this way that Smith’s (later) work on standpoint can be described as a model or method that attempts to answer the criticisms usually ascribed to postmodern feminism. Although Smith does not use the terms ‘partiality’ or ‘multiple’ (subjectivities) as, for example, Donna Haraway (1991a;

1997) and her contemporaries do, I see no reason to think that their views on subjectivity or knowing are incompatible. Rather, these conceptualisations offer material to build upon some of Smith’s notions.

The term ‘experience’ in Smith’s formulations refers to what people come to know (knowledge), and it originates in everyday bodily being and action and cannot be reduced to the givens of institutional discourse. It emerges for the ethnographer in dialogue with particular people at particular times and sites. Hence experience is not some a priori feeling between the body and the world, or something that is subsequently evoked in conversation (Smith 2005, 123–143). To refer to that kind of a priori being, Smith uses the term ‘lived experience’. This is probably the point where material-semiotic views at a first glance seem to be in greatest contradiction with the theoretical presumptions of institutional ethnography. Experience, perception and similar concepts are tangential to science and technology studies in general, and STS on health in particular, because such concepts imply a separation between the caregivers and the cared-for, and between interpretations and physicalities (e.g. Mol 2002, 10–13). The associations between the social and the physical/material are the main focus of STS/FT theory and research.

This is where Donna Haraway’s (1991a; 1997) unique approach proves useful. Her work on ‘situated knowledges’, which refers to the partiality of knowledge, addresses what Smith calls ‘the standpoint’ (achieved via dialogically produced experience-based knowledge). For Haraway, situated knowledges are a reflection of the ‘particular and specific embodiment’ (1991a, 191) of the knower, which in turn is telling of her position in social networks (1991, 190; Campbell 2004, 170). While Smith is a little vague, in my

This is where Donna Haraway’s (1991a; 1997) unique approach proves useful. Her work on ‘situated knowledges’, which refers to the partiality of knowledge, addresses what Smith calls ‘the standpoint’ (achieved via dialogically produced experience-based knowledge). For Haraway, situated knowledges are a reflection of the ‘particular and specific embodiment’ (1991a, 191) of the knower, which in turn is telling of her position in social networks (1991, 190; Campbell 2004, 170). While Smith is a little vague, in my