The Cloak of Visibility Accommodating transparency and opacity in a nursing home

Master’s thesis in Culture, Organization and Management Daniëlle Bovenberg 2558348 Supervisor: Dr. Sierk Ybema Second reader: Dr. Ida Sabelis August 2015

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Contents

ABSTRACT ........................................................................................................................... 3

INTRODUCTION .................................................................................................................. 4

CHAPTER 1. LITERATURE REVIEW ...................................................................................... 8

CHAPTER 2. SETTING AND APPROACH ............................................................................ 17

CHAPTER 3. MORE THAN A STOREROOM ....................................................................... 22

CHAPTER 4. THE CQ INDEX: CONTEXT, PURPOSE AND VISIBILITY MANAGEMENT....... 30

CHAPTER 5. THE CLOSEST THING TO TRANSPARENCY ................................................... 41

CONCLUSION. ADVANCES IN NEGATIVE KNOWLEDGE .................................................. 48

LITERATURE ...................................................................................................................... 54

Abstract The creation and spread of information figure prominently in policymaking and media talk surrounding Dutch nursing homes. Many calls for "transparency" demand clear measurement and high visibility as the way to prevent abuse and malpractice, and to capture the quality of complex healthcare products. The question remains, however: does information exclusively add to our knowledge? Whereas both proponents of transparency and many of its critics tend to see transparency and opacity as opposite (or at least separate) states of being for organizations, the ethnographic research presented in this master’s thesis presents processes of “making known” as accompanying, rather than supplanting ignorance. The paper describes three settings where the known and the unknown are jointly produced: nurses’ reporting practices, a client satisfaction survey, and the daily, deliberate attempts at knowing the resident through measurement and description. Drawing on critical knowledge theorists, each chapter suggests ways in which information about a process or person functions as a cloak for effort, purpose, and political choice. By suggesting, through story and theory, where the promise of transparency falls short, this thesis offers a critical reflection on a strong societal discourse that posits visibility as exclusively benign. Its theoretical contribution lies in its attempt to present an organization as characterized by inseparable knowledge and ignorance, suggesting future explorations on the role of the unknown or unknowable in organizational life.

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Introduction Are we more than the information that is collected about us? In a society where more and more of our lives is measured and stored, this question is a relevant one (Haggerty and Ericson, 2000). The extent to which a data-aggregate of activity can be seen (and acted upon) as a representation of its source is of practical and theoretical importance. The ways in which this question applies to one organization are central in this thesis, which is an ethnographic report and reflection on the production of information, visibility and transparency at Cloverhill1, a nursing home in the Amsterdam area of the Netherlands.

During the period of my fieldwork, care for the elderly had become a topic of public discussion in the Netherlands, with stories of abuse and neglect in residential institutions making the news regularly (Brenninkmeijer, 2012; De Telegraaf, 2014; De Volkskrant, 2014; Landeweer, 2014). These narratives were often couched in highly visual metaphors, such as “uncovering” abuse, or “bringing” malpractice “into the open”. The solutions that such narratives suggest, in order to protect patients and to control managers, are formulated in similar language: enhanced visibility and more detailed information. Policy discourse of the Dutch Minister of Public Health placed “transparency” center stage for the year 2015, a word around which to mobilize the sector into publishing more, and clearer, information about the “quality of care” that health care providers deliver (Schippers, 2015a). In short, transparency through information was looked to with expectancy as a cure for an ailing sector, particularly as a way to improve and control nursing homes.

Recently, scholars have been pointing out the limits of what information and transparency can do, and the unintended consequences of a one-sided pursuit of the “measurement of everything” (Power, 2004: 767). These philosophically and critically informed scholars point out that what is called ‘information’ captures only a small part of reality: that part which can be codified, or expressed. However, much of society is fueled by the assumption that information does capture phenomena completely, or at least adequately. As a consequence, such a single-minded pursuit, an attitude of “information reductionism” (Tsoukas, 1997: 830) means that other types of knowledge, the people that hold them, and the phenomena that are known by them, are neglected and become invisible to this way of seeing (Birchall, 2011). When applied to the person, it means that the human body becomes fragmented and standardized, to the extent that that which cannot be registered or captured—arguably that which sets people apart—is not valued (Haggerty and Ericson, 2000). Underlying these critiques is the observation that before we can count, we must categorize. Far from neutral, measurement implies a decision that some things or people are similar in some way and worthy of note (Townley, 1993). Consequently, regimes of measurement are regimes of

1 Cloverhill is a pseudonym. I have further adapted the names, and sometimes other defining characteristics of people featured in this thesis.

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performance and of value, and in the act of rendering some arenas visible, they cloak others.

When applied to organizations, a focus on measurable outcomes runs the risk of reorienting the organization towards proxies, rather than the phenomenon they were designed to represent (Hansen and Flyverbom, 2014). Taking this line of argument, many scholars have criticized the idea of ‘transparency’ (Arellano-Gault and Lepore, 2011; Hansen and Flyverbom, 2014; Heald, 2006; Neyland, 2007; O’Neill, 2006; Roberts, 2006). Based on observations in the fields of education and politics, such scholars write how transparency does not “involve straightforwardly opening a window on organizational activity” (Neyland, 2007: 504), but rather “can distort organizational performance, and impose new forms of closure, self-censorship and anxiety” (Hansen and Flyverbom, 2014: 4), and hence “transparency can easily become part of the problem it was intended to solve, producing concerns with distortion, concealment and collusion.” (Hansen and Flyverbom, 2014: 2) A simple, but I think too simple, conclusion to draw from such observations, is that ‘transparency’ is an illusion, a farce, that the organization is opaque instead. Much thinking on organizational transparency is ruled by questions such as, Is this organization transparent or opaque? Can the organization be transparent or not? This is akin to asking, Is this organization unified or divided? Is there consensus or dissensus? By phrasing the question in such terms, we set ourselves up for a particular style of answer—one that picks transparency or opacity, unity or conflict as being the sole characteristic of the organizational setting. In being guided by these questions, scholars assume that for transparency (or consensus) to be present, opacity (or dissensus) must be absent. In the case of consensus and dissensus, Ybema (1996) argues that this assumption is illusory. Illustrating how the two phenomena go together in a range of settings, he argues for an perspective that accommodates both. I take a similar approach in my thesis. By drawing on my ethnographic fieldwork, I give examples of how transparency and opacity, information and ignorance, visibility and invisibility do—and indeed, must—accompany one another in one organization. These pairs are often presented as separate processes (or states of being) in organizations. In this thesis, I present them as concomitant.

To my mind, performing this exercise means choosing one of two inroads. Based on the way that policy-makers on the one hand, and critical scholars on the other, tend to answer the question can an organization be transparent? I could either start at the ‘no’-side of the argument and argue towards ‘well, actually, also yes…’, or start at the ‘yes’-side and move in the opposite direction. I have chosen the second path. Accordingly, I take the following question as guiding for my argument: what do information, visibility, and transparency cloak at Cloverhill? Consequently, the largest effort in this thesis is in questioning the assumed completeness of information, the purifying effects of visibility and the straightforward insights given by transparency. The greater argument sketched above should be kept in mind, however: pointing out what looks like invisibility does not drive out the possibility of simultaneous visibility.

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I approach my question by taking instances of organizational life at Cloverhill, that are commonly regarded as moments when information is transferred, visibility is created or transparency is enacted. Then, I draw out the strands of organizational life that critical theorists point out as generally overlooked: the goals that people have with their communication, the context that they operate in, and the active, rather than passive, role that the organization has in managing visibility. In this way, I aim to illustrate the ‘blind spots’ of ‘information’, and illustrate the shortcomings of an approach that takes it as a representation of organizational life. By suggesting where the promise of information, visibility and transparency fall short, I aim to inject a critical note into discussions surrounding the monitoring of nursing homes in the Netherlands. As my observations indicate, visibility is not a straightforward precursor to insight, and neither is information to knowledge. An overreliance on either can have unintended consequences that are undesirable both for the people living in nursing homes, and the people supporting them through their days.

The structure of my thesis is as follows. Chapter one gives a brief overview of scholarship on information and transparency, focusing on four points of critique that critical scholars bring to bear on the “information society” (Tsoukas, 1997). This chapter serves to set up the theoretical concepts that I will be referring to in the empirical chapters that follow. In chapter two, I briefly introduce the organization and present my research narrative. In detailing my ethnographic fieldwork, I present it as a process made out of elements thoroughly intertwined: nearness and distance, observation and theorizing, painful impressions and exhilarating discoveries. Chapters three and four are my main empirical chapters. They fulfill the purpose described above: taking moments where information is transferred, and pointing out what we miss. In chapter three, which is about the practice of rapportage, I suggest these blind spots to be the goals that nurses use information to reach and the different media they have at their disposal to do so. In chapter four, I take a biennial client satisfaction survey, the CQ survey, and do my ethnographic best to evoke one ambiguous, power-laden backdrop to it: client-Cloverhill relations. I show how the purposiveness of actors, far from being a theoretical side note, lies at the heart of the organization’s struggles with the imminent survey.

Chapter five is a reflection on what living in the “information society” (Tsoukas, 1997) can mean for residents of Cloverhill. This chapter is an exercise in ethnographic imagination and impressionist writing (Van Maanen, 1988: 120). The sense that I got from my time in the field was that the unintended consequences of a style of life that values information as the dominant form of knowledge came down hardest on the residents themselves, who, unlike nurses and management, were unable to resist visibility and measurement. There is a discomforting side to this ‘transparency’ ideal and ‘information’ approach, where much of the resident’s body and actions are laid bare, but the core is left unseen. In this context, the question that I started this introductory chapter with takes on immediate importance. In Chapter five I also struggle with my own attempts at ‘making known’ people and places within the constraints of writing, being a creator of information myself. Chapter six summarizes and concludes my thesis, offering suggestions for future research.

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In this thesis, I take information, visibility and transparency to be instances of a similar way of thinking, and to a large extent as interchangeable terms. All three tend to see communication as linear, and assume that there is one position from which to view the organization; one point of view from which the organization looks a certain way. To a large extent, I use these terms interchangeably. But for reading ease, I will from now on use them one at a time, mostly resorting to ‘information’ to refer to codified representations of events, processes or people.

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Chapter 1. Literature review

Basketball and ‘information’ This chapter serves to introduce ways that scholars have thought about the word ‘information.’ To introduce the theoretical questions and concepts that I will be engaging in this thesis, I make use of a metaphor drawn from sports. I want you to imagine a basketball game. Take a moment to place yourself in the stadium, where two rival teams are playing against each other. Imagine the smell, the sounds, the pulse of the crowd that you, as a spectator, are part of.

Having this picture in your mind, I want you to think of the aspects that you can write down or record about the match—the things you could tell me about the game. You might think of the score, and some other statistics. You might want to list the names of the starting players, or write a summary of the game. You could film the game with a recording device and show it to me. In a second scenario, say you would not go to the match, but instead you received all this information, compiled. What would you be missing? This is a question that philosophers and social scientists, among others, have thought about a great deal, and it is central to the material in this chapter. These scholars ask, what does it add to your knowledge, to be present at the match? And, how important is this added ‘something’? For a third and final scenario, I want you to imagine that you are the newly-appointed coach of one of the teams. However, you are not allowed to attend their matches. You have not met the players in person. Instead, you are handed any information you want, and ways of communicating with your team at a distance. How well would you be able to coach your team? And, an equally important question, was this why you became a coach—that is, are you enjoying yourself?

If society is like a basketball match, and people who want to understand and govern society are like the coach in the third scenario, then, broadly speaking, a great deal of effort and thought has been put into refining the statistics of the game, and transporting them to the physically absent coaches. As technologies of measurement and storage have become more powerful, more information has become available to decision-makers in society who are often distant from where the information originates. For example, indexes exist to measure concepts such as happiness, corruption, and quality of care (Helliwell, Layard and Sachs, 2015; Transparency International, 2014; Schippers, 2015a). Increasingly, however, scholars have been indicating the limits of this enterprise of measurement and long-distance control, pointing out the unintended consequences of what is known under various names, including “the measurement of everything” (Power, 2004: 767), “the information society” (Tsoukas, 1997), and “the surveillant assemblage” (Haggerty and Ericson, 2000). Paradoxically, these scholars point out that the pursuit of ‘information’ removes parts of life from view. They give clues as to what that “something” might be—those parts of the game that you miss when viewing (or coaching) at a distance. These clues form the tools that I will use in my

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empirical chapters to address the question, what do information, visibility, and transparency cloak at Cloverhill?

After briefly giving an impression of the pervasiveness of “the information society” (Tsoukas, 1997), and how it is connected to a way of thinking that scholars have called the “epistemology of possession” (Cook and Brown, 1999: 383), this chapter serves to detail the critiques leveled at the popular and powerful paradigm that equates information with knowledge (Tsoukas, 1997). I distinguish four areas of critique. Where I think it helps, I refer back to the basketball image introduced above. Where applicable, I add illustrations from Dutch health care discourse. I end this chapter by situating my own thesis project in light of the literature in two ways. First, as a critical reflection on a strong societal discourse surrounding Dutch nursing homes that highly values information, visibility and their amalgam, transparency. Second, as an attempt to present organizational life as made up out of information and ignorance rather than forcing a choice between them.

To have and have not: the epistemology of possession Much scholarship looks at the spread of knowledge in society and in organizations specifically (see e.g. Anil, Gupta and Govindarajan, 2000; Spender and Scherer 2007; Szulanski, 1996). Like in our example, this branch of science works at refining and managing the representable aspects of the basketball match, such as its statistics. In doing so, these scholars take knowledge to be very similar to, or even synonymous with information: bits of text and image, separable from context, to be exchanged between people. These scholars take such information as given, and focus on, for example, studying ways to better communicate it, studying barriers to information transfer (Brown and Duguid, 2001). Cook and Brown (1999: 384) describe this perspective on knowledge as follows: “that knowledge, particularly anything that might pass as rigorous knowledge, is something that is held in the head of an individual and is acquired, modeled, and expressed most accurately in the most objective and explicit terms possible.” This leads the authors to refer to this perspective as the “epistemology of possession” (1999: 383), implying that knowledge is seen as something that can be held and transferred, separate from its source.

It is within this paradigm that scholars use the term “information asymmetry”; namely the situation in which one side of the transaction has more information about the quality of a product (or other aspects relevant to the transaction) than the other side (Akerlof, 1970; Dranove and Satterthwaite, 1992). A similar term is “information problems.” The implication is that to solve these problems, information needs to be transferred to relevant decision makers. This is a powerful rationale, especially within mainstream economics.

Information asymmetry as a term has frequently been applied to (health) insurance and health care markets—and is considered, in fact, to be one of the core characteristics of these markets (see e.g. Akerlof, 1970; Arrow, 1963; Blomqvist, 1991; Halbersma, 2008; Rochaix, 1989). In the context of a market for health care, one ‘information problem’ is that it is hard to measure ‘quality of care’. This makes determining a correct price difficult. Having identified this problem,

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practitioners and theorists inspired by this way of thinking look to the creation and publication of information about quality as a way to alleviate it. Exemplary in this discourse are the writings of Halbersma (2008), who writes about the Dutch system of health care:

“Public quality-information has a strong influence on the behavior of consumers and care providers. […] In markets where, next to information about price, information about quality is also available, the price-quality-ratio will, consequently, be better. Empirically, publicizing quality-information has been shown to lead to a shift of patients to providers with better quality. Additionally, relatively weaker providers have been shown in practice to show strong improvement after the publication of quality-information. Both effects lead to an improvement of the average level of quality.” (Halbersma, 2008: 26)

Here “quality-information” (“kwaliteitsgegevens”) is conceptualized as something that, adequately representing “quality of care”, can be transferred and made available to the public. Making information available is expected to improve decision-making, product quality, and hence the functioning of the market.

This rationale of the creation and publication of information in order to improve market functioning, through “better choices” is paralleled by the Dutch Minister of Public Health in a recent policy document. In a letter to the House of Representatives in March of 2015, she fated 2015 to be the “Year of Transparency”. In the letter, she starts out by drawing a parallel between health care markets and other markets in society, where “information about the price and quality of products and services is available with the click of a mouse.” (Schippers, 2015a: 1) Designating the absence of such knowledge as a source of problems in the current health care system, she then proceeds to introduce a series of policy measures aimed at creating and organizing information related to health care. She speaks about a shared ambition to improve the clarity of “already existing data” and “the development of new information.” (2015a: 2) The writings of the minister point to an ambition to capture and condense “quality” and to transport this information to the people who make choices.

Assuming that “quality” is a phenomenon that can be captured, the problem then becomes how to capture this information accurately, transport it well and present it clearly to decision-makers. This perspective sees knowledge as something to be possessed, managed, and passed on. From this paradigm, problems arise in the absence of knowledge (Spender and Scherer, 2007: 11). Once information is created, it is relayed to “centers of calculation” (Hansen and Flyverbom, 2014: 13), ensuring that decisions can be made at a distance.

The blind spots of information: critical scholars Tsoukas (1997) argues that we have come to see society predominantly in the way that the coach in the example at the start of this chapter sees the game, and coaches her team: as a collection of information packages that represent people and processes. We have become used to hearing information about distant places

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and then thinking that we know what we need to know about those places and the people there. Information can convey a very detailed picture. The enhanced detail of information-pictures, or “data doubles” (Haggerty and Ericson, 2000: 606) in society can make us think that the world is comprised solely of such sums of information ‘out there’, waiting for someone to pick them up, scoop them up, or gather them. However, scholars point out, information is only one type of knowledge, namely that which can be put into words (or numbers) and transported (Cook and Brown, 1999; Tsoukas, 1997). They point out that in contemporary society, we have come to favor information so highly as to see it as the only form of relevant knowledge (Tsoukas, 1997: 829). According to theorists working from this paradigm, a single-minded focus on information leaves out key aspects of life, and can have undesirable consequences.

Why does this matter? We will see that the manner by which a situation, process or person ‘becomes’ information is a process by which human aspects such as purpose, effort and political choice are obscured by a cloak of presumed impersonality and objectivity (Hansen and Flyverbom, 2014). Scholars point to four unintended consequences of a single-minded focus on information: a blindness to the power-structures that underlie measurement schemes, the devaluation of other types of knowledge and the subsequent invisibility of the things that cannot be measured, a blindness to the communicative purposes of people, and a reorientation of the organization towards proxies rather than the phenomena that they are designed to represent.

Critique A. Blindness to categorization as a political choice Measurement systems are generally presented as neutral ways to capture the world, as if they are merely counting what is already ‘out there.’ (Hansen and Flyverbom, 2014) However, critical scholars remind us that before we can count, we need to classify. We need to choose which objects are similar to each other, and which among them we consider important. Because of how backgrounded these choices are once measuring tools are in place, we tend to forget that they were ever made: that someone chose what the important thing to measure was—and what was not. As Michel Foucault pointed out, this process of “making known” through creating distinctions is not a neutral territory, either in terms of value or power (Foucault, as interpreted by Townley, 1993: 525). Power (2004: 772) calls this process “first-order measurement.” First-order measurement refers to the capturing of objects, practices and people in metrics; second-order measurement deals with the handling of these metrics once they are created. In the course of the latter process we often forget the human action and choice involved in the former. Critique B. Devaluation of other types of knowledge and what is seen by them In a wider sense, questionnaires, forms, and other types of information gathering devices embody assumptions about what counts as knowledge, and what type of event is worth observing (Hansen and Flyverbom, 2014: 3). Taking information as the only trusted source of certainty implies a hierarchy of what trustworthy knowledge is, and a “denigration of other forms of disclosure” (Hansen and Flyverbom, 2014: 2; Birchall, 2011). What about the aspects of a process that

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cannot be measured with the chosen tool? They run the risk of becoming invisible. As Power (2004: 775) puts it, “data that cannot be readily quantified are marginalized and rendered invisible, and proxy measures end up representing the thing itself.”

‘To know’ gets a narrow definition in an information society; it means only possessing certain information (Tsoukas, 1997: 831). But do you ‘know’ the same about a basketball match from the statistics as you do from being there? Does the experience of being at the game add nothing to your ‘knowledge’ of the event? As helpful as information can be, there is the danger that “[i]nformation becomes a surrogate for the world—what is actually going on tends to be equated with what the relevant indicators (or images) say is going on.” (Tsoukas, 1997: 833) In other words, seeing the world solely in terms of ‘information’ means that you see only the parts of the world that can be written down or otherwise codified, at the expense of a blindness to what cannot be captured thus.

An extreme case of what Tsoukas (1997: 830) calls “information reductionism” would be if we took the scores of the basketball team that you are coaching in two different basketball games and compared them, and noting that one score is higher than the other, concluding that your team had played a better game. But as one of your players might interject, perhaps your team’s defense was better in the lower-scoring game, and the opponent was a tougher one. Perhaps you were missing one of your best players. What’s more, by taking mediated data to represent the game, you miss things that cannot by their very nature be transformed into numbers or words. Perhaps your players just felt that your team was playing a better game, a judgment honed by years of experience in playing basketball.

Parallel this with the idea of measuring ‘quality of care’ in health care organizations. Like ‘good play’ it is not visible, it is not ‘out there’. It has to be deduced from the traces that it leaves. Quality measures capture those traces. The consequence of a single-minded pursuit of information as a proxy for ‘quality’ might be that in practice, whatever cannot be measured, does not matter. This is an unsettling idea, when we consider that it is exactly the important stuff in life that resists measurement: a good basketball match, having been cared for well, a good life (Haggerty and Ericson, 2000; Hansen and Flyverbom, 2014).

One especially ‘uncapturable’ entity is the human person. As Haggerty and Ericson (2000: 606) point out, a focus on the measurable parts of the human body means “abstracting human bodies from their territorial settings, and separating them into a series of discrete flows. These flows are then reassembled in different locations as discrete and virtual “data doubles” which can be scrutinized and targeted for intervention.” A focus and reliance on ‘information’ brings with it the unintended consequence that the human body becomes fragmented and standardized (Tsoukas, 1997: 830). Haggerty and Ericson (2000: 613) point out how what they call the “surveillant assemblage” is concerned with “transforming the body into pure information, such that it can be rendered more mobile and comparable.”

What are other types of knowledge? Theorists have long pointed out the importance of different ways in which people hold knowledge, such as “tacit” knowledge (see e.g. Polanyi, 1962, 1966; Nonaka and Takeuchi, 1995; Tsoukas,

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2003). Knowledge has no existence apart from action, these philosophically-informed scholars argue. Other studies seek to go beyond ‘information’ by conceptualizing the idea of group knowledge as something other and more than the sum of its parts (Cook and Yanow, 1996; Orr, 1996). Cook and Brown (1999: 383) combine these tacit-explicit and group-individual dimensions in a 2x2 matrix, in order to illustrate how an “epistemology of possession” only accounts for knowledge that is individually held and that can be made explicit. According to these writers, Western thought after the Enlightenment has privileged knowledge that can be fit into a person’s head to the neglect of other ways of knowing. In sum, a deeper critique of the “information society” would say that even if you had the most sophisticated image-capture technology, there are specific parts of life to which you remain blind.

This, then, is the second critique of the “information society”: with a single-minded focus and reliance on information, we run the risk of ignoring and devaluing other types of knowledge and the people that hold them. As a consequence, the unmeasurable aspects of life are not seen or valued. It is problematic that these unmeasurable phenomena are generally the most important ones to human flourishing. Critique C. Ignoring communicative purpose and context Besides cloaking the political choice involved in categorization, information obscures the fact that people who convey information have purposes with such communication—a fundamental characteristic of communication (Tsoukas, 1997: 830). One often needs to infer the goal behind a piece of information, because it is not in the words, numbers or images themselves. An advertisement telling us that a product is favorable to all others does not persuade us as a newspaper article displaying the same message might, although they feature the same information. We make this distinction because we suspect the motives of the authors to be different. But sometimes this distinction between sources is not so clear. The bits of data that arrive in databases outside an organization may have served a communicative purpose within the organization; say, more along the lines of ‘advertisement’ than ‘article’. Assuming there was no such purpose, means treating all data in a database as equivalent, regardless of why they are there in the first place. Purpose and context are tied together; by investigating the goals that people have, you are considering the local realities that they are referring to. By ignoring purpose, you also ignore the local realities that people tie into their choices. Purpose is cloaked by an aura of impersonality and neutrality once a piece of knowledge reaches the status of ‘information.’ Critique D. Reorienting the organization A final critique of “the information society” points out the organizational consequences that a preoccupation with the measurable aspects of organizational life can have. Power (2004: 776-777) points out how “pressure […] for more complete contracts, with more measurable ex ante definitions of performance” can lead to the “elevation of new measures to targets.” Because performance is conceived in terms of measured realities, the organization is reoriented towards the

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traces that phenomena leave rather than the phenomena themselves. Several scholars of transparency point to the “complex effects” that efforts at relieving ignorance may have (Heald, 2006; Roberts, 2006) as people incorporate heightened visibility into their working lives. Empirical studies illustrate how governments and higher education institutions adapt to transparency rules (Arellano-Gault and Lepore, 2011; Neyland, 2007; Roberts, 2006), and how such measures may end up concealing more than they reveal.

Scholars argue that organizations become better at managing visibility (Gabriel, 2005). An example of this is how an “audit culture” (Power, 2004) can lead not to heightened visibility, but to stronger boundaries as to which areas of organizational life are for auditors, and which are not. In an information society, organizations become simultaneous “glass cages” and “glass palaces” (Gabriel, 2005), where the awareness that people are watching determines the organization’s priorities—and is accompanied by feelings of both anxiety and exhilaration. As managing image has become an organizational priority, non-palatable operations are moved to areas outside the “audit universe” (Neyland, 2007) or perimeters of sight (Pachirat, 2011).

The fourth critique of the “information society” is founded on empirical examples. A focus on the informational representations of performance can, in organizational practice, turn measures into goals, creating different types of opacity, while suggesting transparency.

Conclusion Traditionally, much scholarship has looked at refining measures for intangible constructs and transporting these to centers of power. Working under an “epistemology of possession” (Cook and Brown, 1999: 383), that focusses on the transfer of knowledge, this group of scholars can be seen as those working on making the ‘basketball match’ of society viewable (and manageable) at a distance. They take information and knowledge to be equivalent. In the context of health care in the Netherlands, such scholars position ‘information asymmetry’ as a core problem. A solution, they argue, is to create more and better information and make it public to those who must make decisions (Halbersma, 2008; Schippers, 2015a).

Recently, however, theorists have pointed out the parts of events, processes, and people that such a paradigm overlooks, and the unintended consequences that a focus on information as the sole way of knowing can have. According to these writers, information is only one way of knowing among many. In this chapter, I described four areas of critique from their writings. They argue that a fixation on information makes us blind in some ways. These ‘blind spots’ include: the power-structures that underlie measurement schemes, the existence and value of different types of knowledge, and the parts of events, processes and people that cannot be measured. Information also does not convey the purpose that people have in communicating. A fourth critique pertains to the ways that a pursuit of transparency may have the opposite effect, instead reorienting the organization towards image and proxies and more clearly defining the boundaries between what is visible and what is not.

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In this thesis, I use the critiques of Power (2004), Tsoukas (1997), Birchall

(2011) and Haggerty and Ericson (2000) to look at information transfer at Cloverhill. Chapters three and four draw especially on critiques C and D. In these chapters, I suggest what purpose and context might look like, and I emphasize the work done in the organization to manage visibility. To explore these aspects, my chosen method of ethnographic fieldwork was a good fit. The chance to walk around with, talk with, listen to nurses and managers, was ideally suited to hear and observe the consequences and audiences that they connected their actions to. In chapter five I use the critiques A and B to reflect on ways in which residents are simultaneously known and not known, seen and not seen. In the context of health care in the Netherlands, information, visibility and transparency are generally described as exclusively good. They are mentioned with reference to their positive attributes. “Oversight” and “inspection” are oft-cited remedies to malpractice (De Volkskrant, 2014a; NOS, 2014; NRC Handelsblad, 2014) One might say that at the time of this writing, Dutch nursing homes are “super-visible” (Brighenti, 2007: 330) in Dutch media. Media and policy narratives rely heavily on metaphors of sight. Given the visual metaphors in which elderly care is couched, and the choice of the minister of health to focus on ‘transparency’ in 2015, I think that critical reflections on the returns on visibility and transparency are called for. I think that the critical theorists introduced in this chapter propose helpful ways of doing so.

At the same time, it is important to note the reasons why such policies of sight were implemented in the first place. Visibility goes a fair way in reducing the “countless, daily opportunities for the strong to injure the weak, for the smart to cheat the simple” (Power, 2004: 770). In perceiving instances of what looks like opacity as presented by critical scholars, it is tempting to dismiss efforts at visibility all together. Enthused embracing of transparency as well as its quick dismissal rely on the same assumption: that for transparency to be present, secrecy and opacity must be absent.

I argue for entertaining and exploring the idea that both transparency and opacity appear together in organizations. They are two sides to the same coin (Gabriel, 2005). Elevating transparency to an “intrinsic value” (Heald, 2006) and an undisputable good—as dominant discourse in Dutch health care tends to do—neglects the ways that committing to a way of seeing results in areas of not seeing. Statistics can help coaches see things that they would not otherwise see. But, as scholars remind us, a basketball match, like society and the people in it, is known by different people in different ways—and comes to us through a series of political choices. Just as the study of organizations benefits from entertaining that both unity and disunity, harmony and conflict can exist in the same organization (Ybema, 1996), so our approach might prove more sensitive to the intricacies of organizational life when we welcome the idea that both knowledge and ignorance, transparency and opacity play their part. Far from being mutually exclusive, they make their appearance together. In light of the literature presented in this chapter, a fruitless question would be, Is Cloverhill a transparent organization? Much more interesting is, How do people at Cloverhill use transparency and opacity to do their work? The

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ways in which opacity and transparency accompany each other in one organization, tied to the practices of the people working there, is what this thesis is about.

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Chapter 2. Setting and approach

Introduction In this chapter, I give an account of the research project I undertook. First I provide a storyline detailing access. After outlining my general approach in doing fieldwork, describing the attitude I tried to take, I provide an impression of how my research questions evolved throughout. I hope to give a sense of how the process of ethnography as I experienced it as one made up of elements thoroughly interwoven: observation and theorizing, nearness and distance, painful impressions and exhilarating discoveries.

Setting I conducted empirical research over a five-month period from December 2014 to April 2015 at Cloverhill, a residential elderly care facility in the Amsterdam area. People live there while receiving heavy physical or mental care. Funding comes partly from the Dutch government for each patient, depending on their “heaviness of care indication” and partly from residents themselves or their families. Cloverhill houses only people with the heaviest of these indications. These are people who, for example, suffer from advanced Parkinson’s or Alzheimer’s disease, or who are partially paralyzed. They require assistance for aspects of daily life such as getting out of bed, washing, eating, drinking and using the restroom as well as medical assistance in the management of their illnesses. Cloverhill has three main buildings, each with its own focus on rehabilitation, dementia, or somatic care. The building that I studied, Cirrus, has five floors, of which C2 and C3 deliver somatic care (meaning that it is where people live and receive care primarily for their bodies over their minds). Each floor houses up to twenty residents. C4 houses the management: the manager of Cloverhill, the Head of Care of Cirrus and a team of employees working in areas such as “policy” and “human resources”. Starting in December 2014 I engaged in ethnographic fieldwork on C2 and C3, where I joined the staff of caregivers in their shifts, observing their tasks and interactions. Starting in February, I attended meetings on C4.

Approximately eighty people work on C0-C3, under the supervision of the Head of Care. The Dutch system of nursing education knows several levels or “niveaus”. Nurses will say, “I am niveau x”. For the most part, with an eye on ease of reading as well as in the interest of protecting the identities of those people kind enough to have me accompany them, I will refer to all of them as “nurses” in this thesis. By far the largest part of the employees was 3 or 3IG, or “verzorgende”.

Approach As a regular volunteer at Cloverhill, I had developed a pleasant relationship with the ladies who worked at the activities center. I enjoyed spending time with the residents at Cirrus every other week. With my Master’s thesis in mind, I contacted the center’s manager by e-mail and met with him in November. After consulting his superiors on my behalf, he granted permission for my presence as a researcher. In late November, I met with the Head of Care of Cirrus. She showed me around

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the building that day, and told me that I was quite welcome, that I should consider this a “24-hour company” in which I could come by anytime if I wanted to.

My approach in fieldwork was roughly to “learn by going” (Geertz, 1995: 133, quoted by Bate, 1997: 1152). I started in December by joining nurses on the third floor for their morning shifts. Rather than investing in preliminary desk-research, I chose to be present and, through interaction and observation, to see which categories and distinctions mattered to my companions. When, during a shift, I would hear the name of an institution or person being dropped a few times I would ask what or who it was, or make a note to ask later. When I would hear about a meeting or an event, I would ask to attend it. One-on-one and group conversations were helpful in introducing me to the different interests and emotions that were involved in the work of these people. Gradually I started to identify topics that I wanted discuss with particular nurses privately and at length. This resulted in the nine interviews that I held near the end of my fieldwork period, which I used to check my impressions and furnish them with detail.

Working in this way, I got to join biannual department staff meetings by February, and started attending the weekly meetings between the head nurses and the Head of Care. I joined events such as a graduation ceremony and the New Year’s reception. I continued to join shifts where I could in the mornings and evenings, now on the second floor, and volunteered occasionally. In March, my questions led to the balance of my presence being shifted to the management level. I attended two meetings between the Heads of Care and others in the “management team” and two meetings between the “client council” and representatives of management. In addition to this, I spent time at the computer exploring the company’s “intranet” system and reading reports about residents. I studied the content of audit reports and gathered other bits of documentation that an organization produces: annual reports, brochures, websites, and weekly newsletters to the staff.

Besides presence and note-taking, “fieldwork” relied heavily on absence. On Friday afternoons, far from Cloverhill, I would take out a sheet of paper and my fieldnotes. I would do the following: (1) write down what I considered significant events or people, (2) take stock of the strongest sensations that I had felt in the field and (3) note any themes that I was recognizing in caregivers’ speech and acts. For example, one week’s reflections could include the following: (1) salient points from the “family meeting” between caregivers, residents and their families, (2) jotted down words like, “irritation” and “affection”, as well as (3) notes on instances that nurses had referred to the way that their work was affecting their bodies, tied to a theme, “work and the body.” I would then jot down, on the same sheet of paper, what else I wanted to know, and make plans to find it out. In my experience, this back-and-forth of fieldwork and reflection, “closeness and distance” (Ybema and Kamsteeg, 2009) could not be separated. One gave rise to the other, and vice versa. Together, for me, they constituted “fieldwork”. In an average week, I would spend two days on fieldwork, at least one afternoon reflecting on the fieldwork, and one day a week exploring literature of theoretical interest.

In considering how fieldwork, review of fieldnotes and reading of theory worked together, I wholeheartedly agree with Bate (1997) that “the place to find

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the “right question” is not in a textbook but out in the field, by following your nose.” ( 1152) I would supplement this with the point that one of my lecturers, Ida Sabelis, made in class, that “there is never only one question.” Accordingly, my research question and focus evolved. In December I had just written a paper about Evidence-based Medicine for one of my Master’s courses, which had sensitized me to the different types of knowledge that nurses and management seemed to possess. Hence, during initial fieldwork I focused on observing the ways that information was documented and written down, as well as overt moments of information transfer, such as those taking place at the start and end of every shift. My mind was focused on observing instances of knowing and not-knowing, my position as ethnographer facilitating the sometimes disempowering feeling of ignorance. Later, my emphasis would come to lie specifically on the use of knowledge, and as I became more familiar with the organization, I could combine my broad theoretical questions with concrete organizational realities. Towards the end of my fieldwork, my research question had evolved into, how do the people that work and live at Cloverhill regard and respond to requests for information? This question evolved further when I did the bulk of my theorizing after leaving the field. Interpretive Research There are many ways to look at, and write about, nursing homes. The perspective I am taking here sees people as working on assumptions of shared meaning attached to objects, acts and talk. My assumption is that actors’ social realities are not ‘out there’, independent of them, but constructed through interactions with other people and institutions. This does not make these realities less ‘real’, in the sense of physically present, as the nature of work and life in an elderly care home brings painfully close. Rather, this perspective denies the existence of one place from which to view reality and places center stage the ways in which people arrive at these meanings, how they differ from person to person, from group to group in surprising ways. The strength of this perspective is that it shows the variety in human experience, as well as the unintended consequences of well-intentioned structures. Taking as a goal to understand these local meanings that actors work under, this research paradigm calls for an engagement with a society for some duration, in which the ethnographer interacts with the people that she finds there, observes how they act, asks them questions like, “what does this mean?” and “what do you use that for?” (Spradley, 1979). It is, then, an effort to “converse” with a group of people bound together by place (Geertz, 1973: 24).

In other words, my general approach consisted in wanting to come as close as I could to understanding this piece of the world in the terms that the nurses themselves used. I wrote my fieldnotes in English, reserving Dutch for the recording of “native terms” (Spradley, 1979). The first months were especially helpful in getting a sense of the way that nurses organized their world; for example, the considerations that went into designating a day as “busy”, or which tools were used by the nurses and which were left untouched, and the enormous role that training and credentialing took in their day-to-day talk.

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Connected to this approach, I discovered, is a recognition of the non-linearity and messiness of ethnographic research. Not all days of fieldwork are created equal. Whereas the first month was spent getting used to the research setting, and I found it hard to stay throughout a whole shift, January and February were particularly ‘productive’ months in terms of fieldnotes, attention, insight, and contact with nurses and other employees. Some days were clear, and incredibly useful, while others were uneventful (in my eyes). At times, theory and observations would meet in a fruitful way. Again, I’m not sure where fieldwork ended—since I would spend the following days of the week reading what I had written earlier. Insight was also drawn from strange places: poems, books, nature documentaries. In this way, I think a tentative case could be made for time spent inside the focal organization being only a vague indicator of the quality of observations, and of nearly as much value as time spent outside the field.

Drawing a neat distinction between fieldwork and non-fieldwork is one way to ‘sanitize’ my account of research, something I do not wish to do unnecessarily. It is relevant to note that there were days, according to my field notes, at the end of which my heart felt unbearably heavy. While I was discovering this new world, the organization and all its realities were making their impressions on me, in the way I viewed aspects of daily living—my body, my character and my surroundings. There were the mornings that I helped myself out of bed with the thought that “the sooner I go, the sooner I get to leave again.” Second, the role of “professional stranger” (Agar, 1980) was tiring at times. There were plenty of times that my courage failed. The experience reminds me a bit of starting to do abdominal exercises, but nobody has told you that your back will start hurting too. You didn’t know your back needed strengthening as well. Similarly, different parts of me started hurting, or straining, when I started this ethnography project. At times I was left with the question, “am I doing this right?”

Still, alongside, and oddly intermingled, were moments of connection with my informants, and glimpses of beauty in the attitudes of caregivers and residents in what could sometimes be a sad, sterile place. There were moments in the evening shift when a private, closed, almost conspiratory atmosphere would settle over the department. At these times I felt in-the-know and just a bit of an insider. There was also the exhilaration of “getting” more and more of what was being said and done in the organization. I was learning to “converse”, as Geertz (1973: 24) put it, with the caregivers, and I was discovering (at least some of) the right questions to ask in this context, and I was getting some remarkable answers. Fieldwork became for me this non-linear, generative mix of nearness and distance, painful weight and surprising beauty and inspiration. It was helped along by showing up, help from others and luck. Deskwork During fieldwork I would spend a day a week reading theory, but the bulk of my theorizing would come after I left Cloverhill entirely in the months of April, May, June and July. Van Maanen (1988: 4) calls this stage “deskwork”. Form me, three elements came together in this period. Coming out of fieldwork in mid-April, my priority was to become familiar again with my empirical material: the fieldnotes,

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transcripts, recordings and the documents that I had gathered. Meanwhile, readings in organizational epistemology had led me to paradigms that helped me ‘see’ my data better. Reading what others had written about knowledge use and visibility in organizations cast the data in a different light. So I re-read the data and compared it to theory again. I focused on trying to describe what I had seen as well as I could, using these ideas. A third strand of thought was borne out of the frustration, ache and sadness that I felt in the field, which took shape in freer, more impressionistic writing. You will encounter these different writing styles throughout this thesis.

June and July were spent considering the common elements in these three strands of thought. I sensed that, to a certain extent, they arose from frustration from one source in particular: our inability to know people but our acting like we can, and the illusion of completeness that visibility gives us, myself included. This puzzlement fueled the greatest efforts in putting this project together. In closing, I would suggest reading this thesis as you might look at a painting (Hatch and Yanow, 2008). I have made choices in terms of style, emphasis and representation that highlight what I think is worthy of note in a particular place. They include the variety of reasons and considerations that nurses gave for reporting events, the hot-and-cold relationship between Cloverhill and residents’ family, and finally, the jarring feeling of being an observer of Cloverhill’s residents, who were in no position to avoid my gaze or return it, as at least the other participants in my research had. I have chosen a perspective, and have not avoided writing myself into the descriptions in this thesis. At the same time, a painter must work at technique, and some representational choices are due to a simple lack of skill. They, too, will become clear at times in terms both of execution and the writing up of my research. Rather than dwelling on these points here and speculating on their precise location and role in my narrative, I would rather weave my reflections into my narratives as they arise. This next chapter starts with one such narrative.

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Chapter 3. More than a storeroom

“the reporting system and reporter’s self-reporting activities are integral features of the clinic’s usual ways of getting each day’s work done—ways that for clinic persons are right ways.” –Harold Garfinkel (1967: 191)

“PEG sonde” “I have someone with me, Esther,” the nurse says loudly, “she'll be watching. Is that all right?” The lady looks up from her wheelchair, nods her head and gives a soft “yes.” Everything this lady says is said softly. Her voice sounds like it is emitted from an old transistor radio, faint and crackly, but nearby. I greet her with a big grin and a “good afternoon”. From where I stand, notebook in hand, I have a view of the length of her bed. Joan, the nurse who had introduced me, explains, “she likes to be called by her first name, isn't that right, Esther?” Another feeble “yes” comes from her bowed head, with her grey hair gathered in a spindly bun high on top.

As Joan helps Mrs. F. out of her wheelchair and into bed, I consider the words used to speak of the procedure about to be performed. Joan had spoken of “replacing the PEG sonde”: a procedure, or “handeling” that she had been “made proficient at”, or “bekwaam gemaakt” by one of her colleagues. Since this was her first time performing it independently, she still had to have her senior colleague Greg present as she worked. He is standing at the foot of the bed. Joan asks him, “since you are supervising me, shall I describe what I am doing?” He answers, “officially, yes...” with an apologetic smile that suggests to me his awareness of his being in the position to supervise a colleague twice his age. “No problem,” she says, and my impression is that she really doesn't think it's a problem. The sense I'm getting from her is one of excitement, of realization that a chance like this, to perform this procedure, doesn't present itself every day. The anticipation also shows itself in sentences like, “I've watched lots of YouTube clips online about this,” directed with a smile to Greg as she tests out the PEG sonde: a clear plastic

Abstract In this chapter I look at CR, a database for information about clients, and challenge an information-centric approach by lifting out the goals that nurses spoke about in creating their reports and the “genre repertoire” (Orlikowski and Yates, 1992) that they spoke of using. The empirical material I present, drawn from observations and interviews, evokes a picture of CR fulfilling many purposes beyond ‘storeroom’: a stage upon which nurses show that they are doing their work well, but also a place where they “cover” themselves, correct colleagues, and instruct professionals of other disciplines. I join Garfinkel (1967: 192) in saying that “the least interesting thing one can say about [client files] is that they are “carelessly” kept. The crux of the phenomenon lies elsewhere, namely in the ties between records and the social systems that services and is serviced by these records”. Exactly what these social systems might look like, and what such ties could be, is what this chapter explores.

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tubing system with a small balloon at one end and assorted colored openings on the other.

She is meant, I gather, to first test how much liquid the balloon can hold. It is meant to hold 15cc. From the other end, she injects water from a syringe into the clear tube, and I see the little balloon fill up and then expand. “That's ten,” she says, “shall I try five more?” Greg nods, grins, and says, “that's always exciting, to see if it holds...” Joan sucks up five more with her syringe and positions its nozzle to one of the colored openings. She says, “well, it says it's made to take fifteen” and she injects it. She twirls the taught balloon between the fingertips and thumb of her blue-glove-clad left hand, squeezing it lightly, regarding it approvingly. She sets it down and draws the water back out with the syringe and the balloon deflates.

I assume the same type of object is inside Mrs. F., since colored plastic openings at the end of a tube are protruding from her stomach as well. Mrs. F. is holding up her shirt with both hands, her elbows tucked into her sides. The tube coming out of her stomach isn't clear, though. I mean, I cannot see through it like I could with the one they just tested out. My vision is obscured by an opaque yellowness inside the tube that runs from her stomach. I learn that the balloon inside her likewise holds “fifteen”. Joan takes cotton balls soaked in liquid and swabs the area surrounding the place where the tube exits. “I'm just cleaning it, Esther”, she says loudly to Mrs. F., who answers with a soft “yes.”

The next time that I hear Esther speak, she is saying, “Ah. That hurts terribly.” She enunciates this slowly. Joan is attempting to remove the tubing by lightly tugging it. She has been counting, the last two minutes or so, the amount of liquid removed from the balloon inside of Mrs. F. “Ten” went easily, using the syringe. Joan squirted it out into the waste bin. Then, “three”, barely. There doesn't seem to be more, Joan concludes after attempting another withdrawal. Greg agrees. She attempts a removal. The balloon doesn't come out, and Mrs. F. states her pain with her radio voice. Another attempt is made at emptying the internal balloon. “One” or less of liquid is drawn out this time.

At this point I have found a spot on the surface of the floor to fix my eyes on, unable to observe any longer. The cycle of drawing out the stubborn liquid and attempting removal of the tubing is repeated, and at another “It hurts too much” from Mrs. F., I feel my legs weaken, and my stomach clench. After some split-second mental attempts at steadying myself, I utter a feeble “I'm just gonna...” and I stumble out of the room. I struggle to find my footing, but I arrive at the restroom at the end of the hallway without falling. After closing the door behind me, I crouch down close to the floor and close my eyes. I lean on the palms of my hands. Through the balls of my feet it feels like the ground beneath me oscillates. Left-right-left-right. A minute later, I stand up, and meet a very pale me in the mirror. I feel ashamed. I never faint. After a few more minutes, I walk to the living room and take a seat. Ten minutes later, Joan comes in, wheeling Mrs. F. before her. She places her by the window, in her usual spot.

Later that day, I accompany Joan to the last part of her shift: reporting the happenings of that day, rapportage. She swiftly maneuvers within CR, the reporting system on her computer screen, to find each resident, typing in relevant data about them. We arrive at Mrs. F. With deliberation, Joan types in the empty field, PEG

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sonde was replaced this afternoon at 12:00 with good result. Please take care of the opening. My stomach drops. She turns to me and says, “That it went with difficulty, I don't need to write down. I will tell the doctor that; because otherwise they will ask, 'what did you do?' and things like that... When the doctor comes, I will talk about it with her.”

Introduction Is an adequate description of Joan’s activity in rapportage “information transfer”? From the perspective of the “epistemology of possession” (Cook and Brown, 1999: 383) as introduced in chapter one, it might be. From this perspective, databases like CR are like storerooms of impersonal bits of data that people can draw from at any time and for any purpose; information is treated as equivalent regardless of why it is there in the first place. In his study of clinical records, Garfinkel (1967: 200) called this information-centered perspective an “actuarial reading” of these records. He had been attempting to draw data from clinic files for a different research project, and found the files to be consistently poor. The reason for his troubles, he would later write, was that he had been trying to separate the information from its source: a system that had its own rationale. His project departed “in theoretical or practical import from organizationally relevant purposes and routines under the auspices of which the contents of the files are routinely assembled in the first place.” (1967: 191). This means that, rather than simply calling the record-keepers “careless”, he tied the “poor clinical records” to the organizational system of the clinic—reasoning instead that the record-keepers must have good reason to keep the records the way they had been doing: this way of record-keeping was helping the employees do their jobs well.

This chapter takes a similar perspective, aiming to place CR and the practice of rapportage in context. In line with Garfinkel, I argue that information itself does not reveal the purposes of the speaker. Rather, one must know the speaker’s purpose in order to understand the information. This reminds us of one of the shortcomings of an information-centric approach, according to critical scholars. Indeed, purposiveness and context are two of the things they point out that are missing from information (Hansen and Flyverbom, 2014; Power, 2004; Tsoukas, 1997). This chapter is thus a first illustration of these aspects of their critique.

I operationalize purposiveness and context in two ways. First, as Tsoukas (1997) suggests, I describe the goals that nurses related their rapportage to as they spoke of them to me. A second tool for describing context and purpose is the presence of other “communicative genres” (Yates and Orlikowski, 1992) at Cloverhill. In other words, making sense of Joan’s rapportage involves looking at the consequences she associates with her writing, and at the other communication avenues that she has at her disposal. As Garfinkel (1967: 197) suggests, “to think of such troubles as a managerial problem of bringing record-keeping performances under greater or more consistent control, overlooks a critical and perhaps unalterable feature of medical records as an element of institutionalized practices.” Starting with quotes that support an “actuarial” reading of reports, I use purpose and genre repertoire to open up our perspective to other ways of seeing CR.

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Storeroom narratives The continual and compartimentalized nature of nursing work entail that no one person can know all that is necessary about each client. Because work takes place 24 hours a day and in separate rooms, care of one client is shared by the whole department. The activity of rapportage involves typing information about each resident into CR, a software database. Besides keeping track of daily values for various bodily functions, nurses are required to file a descriptive report after observing an out-of-the-ordinary event, or “bijzonderheid”. The electronic database was introduced in 2009. It is expected of nurses to write down something at the end of every shift. CR thus serves as a container for information about each client: quantitative measurements (such as blood pressure) as well as descriptions of their behavior by caregivers. In this context, to the nurses I interviewed, CR serves the purpose of sharing the information relevant for one’s colleagues to work well with the client in question. As my respondents articulated,

“For example, my job is to keep track of residents’ stools. I can tell a colleague in the hallway, “Mrs. B. had a bowel movement,” but that’s just one person that I’m telling. So the rest of my colleagues won’t know. So they might think, “is Mrs. B. constipated; hasn’t she had a bowel movement in a while?” So, you see, such things need to be reported in CR.” (Mary, interview) “For example, yesterday I had a meeting with a resident’s family. Well, no one else was there either. But I can write it into CR, and then everyone else can read how it went.” (Mary, interview) “You report for your colleagues too. Otherwise no one saw it. Then no one will know.” (Daisy, interview)

The role that CR had in informing action was echoed by the receiving side as well. When I asked nurses what they would need to do before starting work again after a hypothetical two-week absence, all of them answered first that they would read the rapportages of the past week. Some nurses added something like, “not more than one week, there’s no use—you won’t remember it anyway.” These observations still fit inside an “actuarial reading” (Garfinkel, 1967: 200), since CR is conceptualized as a place to draw information from.

Further goals, other genres As mentioned in chapter one, one aspect of organizational life that ‘information’ does not convey, is the purpose of the person who created it. Tsoukas (1997: 830) notes, “to reduce something to allegedly objective information and then treat that information as if it was an adequate description of the phenomenon at hand, is to obscure the purpose behind the information, a purpose that is not made explicit in the information as such.” (emphasis in original) Although informing their colleagues was a goal that nurses spoke of, they mentioned purposes beyond this.

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Below I suggest four such goals: activating other disciplines, signaling quality to family members, shifting responsibility and voicing disagreements. One purpose in rapportage is to activate other disciplines. One nurse I spoke to likened herself and her colleagues to “an extension of the resident”. To her, this meant communicating with other professionals involved in the medical enterprise, taking action on behalf of the resident. Within CR, this means giving one’s report a “destination”—that is, linking a professional (group) to the report. This use of CR was echoed by other nurses as well, although they spoke of using a combination of avenues of communication to reach their goal.

“After reporting for a few days, then I really want to see some action on it. Then I e-mail the doctor about it, and I give the rapportage the destination SOC [Specialist Old-age Care], or the dietician, if I see that someone has lost weight. The doctor should look through all the reports each day.” (Daisy, interview)

Residents’ family members, even when physically absent, are present within the reasoning and talk of nurses. Signaling quality to them appears to be a second key purpose of rapportage. The family's access to the CR reports is taken into account when events are recorded. This is a second goal of rapportage: creating a favorable impression towards clients.

“Um, in principle you should report everything. Whether someone has poop or pee, or if the pee is dark or whatever. Everything that’s special. And if someone’s been showered, on their shower day, then we often write it in the box for washing and dressing: “Madame has been showered.” That way, colleagues can also see. And when family comes with a comment, like, “as far as I can tell, my mother is never showered,” then you can look back and then say, “Oh yes, have a look, she was showered on that day.” So actually we report a lot and also elaborately. Interviewer: “I can imagine, that for some people it’s a bit…” Nurse: “A bit more important, because their family members are trickier. There is that difference.” (Grace, interview) “Sometimes you have ‘tricky’ family, who prefer to know everything. In that case, I write down everything. Then I even report showering people.” (Daisy, interview)

With family members in mind, this means that nurses are instructed to use “neat” language, to avoid jargon, and to avoid naming other residents by name. They are also instructed to report “as objectively as possible.” One nurse added to this, as she was showing me, not without pride, the careful wording of one of her reports: “tactical, isn’t it?” Having relatives as an audience suggests that, in the case of “difficult” relatives, that nurses report more extensively than in other cases. Too extensively, according to one nurse I interviewed: “some people report too much. What do I care, when I’m starting my evening shift, whether someone was showered in the morning?”

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A third purpose of rapportage involves the shifting of responsibility. In an interview, one nurse mentioned how she uses CR, together with e-mail, to “cover” herself. I asked her, “Is that something you learn with time?” “Yes, yes,” she answered,

“When, for example, a resident complains about a headache, then you report it. Say I then meet you, a doctor, in the hallway and I tell you this information, and you say, “ah, give her a paracetamol”—well, maybe that resident gets a brain hemorrhage that night. So, if you’ve e-mailed that earlier, then at least you’ve covered yourself. You can show, “I’ve done everything I could.” Sometimes it’s not urgent to write a rapportage in that moment, but it becomes important later on, that the person was like this for a few days, with these symptoms.” (Daisy, interview)

Fourth, rapportage can also be a way to voice one’s preference on matters relating to treatment of patients to co-workers that one doesn’t see face-to-face. One nurse recalls,

“I do know that sometimes there’s a discussion in CR between two staff members. Like, one person thinks that Madame should sleep without socks at night, and then someone else will respond to that rapportage with, “well, Madame…” or “I think Madame should wear her socks,” for example. I’ve spoken with my supervisor about this. We should pay attention to these things, so that they don’t happen. That’s not the idea, of course. It should be about the client, and not about what you think, or what your opinion is.” Interviewer: “How interesting. Perhaps it’s better, indeed, to speak face-to-face in such a case” Nurse: “Yes, indeed, if you can’t agree. Or send an e-mail, if needs be—but not over CR, where everyone can read it.” (Mary, interview)

The quote above also indicates a key point to keep in mind when thinking about rapportage: it is not the only way that nurses communicate. Throughout nurses’ narratives are sprinkled references to other media that they use. With reference to the vignette that started this chapter, we might ask, does the presence of other “genres”—the possibility, for example, to talk to the doctor face-to-face—affect what is written in reports? I use the term genre because it emphasizes the meanings attached to media—inviting us to think about how the same medium can carry different meanings. In the study of literature, a genre provides readers with background information that helps in interpreting the content of a text (Cook and Brown, 1999). In organizations, too, people write and read various bits of differently shaped information. The totality of these media, and the meanings that actors attach to these forms, make up an organization’s “genre repertoire” (Orlikowski and Yates, 1994). 2 Different genres are tied to different goals and audiences. It is important to keep in mind that “[m]embers of a community rarely

2 That is not to say that there is complete agreement over the genre repertoire, that it is static, or that there exists only one. Rather, we do well to hear in mind that combinations of consensus and dissensus exist alongside each other, as in other aspects of organizational culture (Ybema, 1996).

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depend on a single genre for their communication. Rather, they tend to use multiple, different, and interacting genres over time.” (Orlikowski and Yates, 1994: 542)

As can be read in the excerpts above, nurses often spoke of a combination of genres used in accomplishing a goal. Joan uses CR to communicate certain facets of what happened that afternoon. For example, the time of the procedure, and the fact that it took place, that the sonde was indeed switched (by her) and instructions for its continued care. However, it also becomes clear from her speech to me at the end of the day, that there is some information that she would rather not include in the rapportage. She deems a different genre, “telling the doctor when she comes” more appropriate for communicating “that it went with difficulty.” Other genres nurses spoke of in relation to doctors included, “sending the doctor an e-mail”, “giving her a call”, “writing it on a scrap of paper” or a combination of these. When nurses spoke about rapportage, they always mentioned it in combination with other genres that were necessary to either convey something fully or to get the full picture themselves.

Conclusion We see, then, that CR and the practice of rapportage perform several roles in the working life of nurses. “To inform” seems an inadequate descriptor of their purposes. Rather, words come to mind like activate, assuage, cover, or critique. These action-verbs show how embedded CR is in organizational life at Cloverhill. Again, I am reminded of Garfinkel’s (1967: 200-201) observation that “folder documents are very much like utterances in a conversation with an unknown audience which, because it already knows what might be talked about, is capable of reading hints.” Nurses have goals that they want to reach, with reference to local actors and local institutions. They have a repertoire of genres with which to reach them. Rapportage is only one of these. It has its unique, context-specific configuration of audiences, standards and limits. Therefore, this genre is used to pursue certain goals whereas other goals find their fulfilment in other genres.

In this chapter I presented two pieces of organizational life that critical scholars argue that an information-centric approach misses: actors’ purposiveness and their context. In doing so, I started out by presenting CR, the client database, as a simple storeroom. Then, drawing from nurses’ narratives about their goals and the way they used organizational genres, I contextualized CR and the practice of rapportage. This answers calls made by scholars for studying knowledge as tied to social context (Cook and Brown, 1999; Nag, Corley and Gioia, 2007) rather than as a neutral substance independent of human action. Taking only ‘information’ as an indicator of a situation, means that you do not allow for a mixed-genre approach like the one nurses described. Divorcing knowledge and context means that we might be left reading advertisements as if they are newspaper articles. Or—in this context—reading a rapportage as if it is a nurse’s full account of events.

Garfinkel (1967: 192) argued for the interconnectedness of records and the “social system that services and is serviced by these records.” This way of looking at things pulls observations about incomplete records out of considerations such as “laziness” or “incompetence” and points us to more structural reasons for

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“poor clinical records”. That is, as attributable to the expectation that the organization has of its employees, the tasks that employees must complete, the repercussions (and rewards) they imagine, and the ways they think they can reach their goals. The next chapter takes up the concepts of purpose and context again, this time linked to an information production exercise for audiences outside the organization.

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Chapter 4. The CQ Index: context, purpose and visibility management

“The Battlefield” One afternoon in February I am talking with Susan, the Head of Care of Cirrus, in her office. We are just wrapping up our conversation, when we hear a knock on the door. Marjorie, the management assistant, pops her head in. She asks Susan, “Excuse me—just a quick word, for the e-mail. The family meetings tomorrow, Cirrus 2 and 3. Where is the battlefield?” Susan answers, “The living rooms of each floor; I will shuttle between them.” Marjorie nods and closes the door. Susan turns back to me, smiles, and asks, “Now, where were we?”

The next day I show up to join this meeting—how could I resist? It was so evocatively described the day before. These “family meetings” take place every six months, and have the declared aim to keep clients and their families informed of any organizational changes, and to collect feedback from clients. Today Paul, the head nurse of C2 is leading the meeting. So at three thirty in the afternoon, I join seven residents, five family members and Paul, in the living room of the second floor. I recognize some of the family members as ‘regulars’, and others I have not seen before. Today we are all gathered in this spacious room. A wintery light, bright and cool, streams in through the large windows and is seemingly magnified by the bright linoleum floor, making it hard for me to see any shadows on the

Abstract The overall aim of this chapter is to propose four reasons why a single-minded focus on transparency and visibility (as separate from opacity and invisibility) through the gathering of information is unhelpful and unrealistic in the context of Cloverhill. To this aim, I take the biennial CQ survey— a client satisfaction questionnaire commissioned by the Dutch government1— as focal point. This chapter is built up out of two parts. First, I give an ethnographic description of “public” and “hidden” (Scott, 1990) transcripts of a client-staff interaction, by painting a picture of this interaction as characterized by pockets of power, where both parties feel powerless at times. Second, this painting then serves as a backdrop for a discussion of the organization’s response to the CQ survey. Guided by critical scholars, I reflect on the CQ-survey as an instance of “control at a distance” (Tsoukas, 1997: 831). This is where the argument comes in. Gathering and transporting data means that context, purposiveness, and the organization’s ability to manage its visibility are removed from view (Hansen and Flyverbom, 2014; Heald, 2006; Hood, 2006; Power, 2004; Tsoukas, 1997). I further reflect on the ways that visibility gets in the way of other aspects of nurses’ work, showing how a transparent organization can be both a palace and a cage (Gabriel, 2005). The first part of this chapter is concerned with painting a picture. The second part reflects on this picture, with the theory described earlier in this thesis. And although I use the following story to make a point, I want to leave room in my style of writing and thinking for ambiguity, silence, and patches of darkness. It is not “what happened”; it is what I saw.

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floor. The space is open at several sides: two doors open into the hallway, and one end of the room leads straight into a second, identical living room. This is where most of the residents eat and spend much of their days. After offering everyone a cup of tea, Paul invites us to form a half-circle around him. Paul takes his place in its center. He is wearing his nursing uniform, which is a white, short sleeve shirt with snaps up to his neck, with lilac accents that pick up the color of his loose-fitting trousers that bunch at his heavily-profiled sneakers. Holding his own copy of the agenda before him, he says, “Shall we begin?” The man sitting directly to my left, the only resident not wheelchair-bound, gives a gruff, “What did you say?”, followed by a “perhaps you could speak a little louder?” from his daughter. “IS THIS BETTER?” Paul says at an elevated pitch. He has our attention and the meeting is underway.

After discussing a number of items on the agenda, mostly logistical matters, Paul arrives at the point described as atmosphere in the department. He clears his throat and continues, “Department atmosphere. Yes, of course things do go wrong sometimes – and it’s good that you tell us about those. But things go wrong at home too sometimes. I can report, promise, commit it a thousand times, and on the days that I am here myself I get the sense that things go the way that they should. But I can’t always prevent things going wrong. So, ehm, I hope for your understanding in this.” Here, Paul shifts his weight, takes a deep breath and continues, “But— keep telling us. Keep letting us know, because if we don’t get feedback, we think that things are going well, while we hear a different story in the hallways.” As he says this, his eyes take on a tired look. The lady sitting to my right, with one arm around her father, interjects a warm “You’re a star, Paul!” He answers, “Well, I’m trying.”

After an hour or so of Paul informing the clients and welcoming their responses, Susan ‘shuttles’ into the room, coming from a meeting from the floor above. The door that she enters through is placed so that she enters the center of the semi-circle almost at once. “Well!” she exclaims with a broad smile contradicting the look in her eyes, “A circle! Gosh, I’m taken aback. Upstairs they’ve got a table that they’re all sitting around” Paul says, “Oh, I thought I’d make a cozy circle…” Susan smiles, moves her hair out of her face with her hand, sets a few steps forward, into the circle and leans back onto a countertop behind her. She seems to recover her usual, bold appearance. After another “What did you say?” from the man to my left, and general elevation in volume, Susan introduces her intention to “inform” us about “a few policy matters.”

Her last point involves introducing a biennial Client Quality Questionnaire. At this, I pay particular attention, because I know (from previous management meetings) that there has been debate on the best way to “inform” clients about the survey and its purposes, without “influencing” them. About the survey, she explains that it is aimed to ascertain client satisfaction, because the government needs to know it. The results will serve other audiences as well, she says: for example, insurance companies. Insurance companies together are responsible for allocating funds among care facilities in the region, “and if a home does really well, then you’ve got a bigger chance of getting more money than when you do poorly.” She continues, “I am not bribing you here,” and after a short chuckle, “you shouldn’t think that. If you have complaints, you can come to me, to Paul, or to

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anyone here, and we will handle them. And if you are dissatisfied, you should say so on the CQ survey. But I do hope that we will have heard about it first, because then we can work on it.” She then turns to describing the survey procedure: “all somatic residents will be interviewed. They will ask questions like, what do you think of the food; how do you feel the care is here; do you feel that you have enough of a say; do you think there are enough activities?”

This question seems to embolden one family member to bring forward her points of critique. I know Mrs. A. to be one of the ‘regulars’: a near-daily presence in the department. Her husband has been living at Cloverhill for four years now, suffering from advanced Parkinson’s disease. Mr. A. does not speak anymore, and rarely appears to be conscious of the people around him. His wife, however, is observant and articulate. She starts out by saying, “in terms of activities, I feel like there is very little here. I am part of two choirs; but here there is nothing. I think the activities are very, very bad. In another nursing home, they have a performance every two weeks.” Susan tilts her head and answers, “that’s unfortunate. I will pass it on. Do you have a card, and can I call you about this choir?” “Yes, well, we’re called the Sun Choir. And one more thing. When will you organize another flea market?” “There was a flea market not too long ago. I am certain.” Other residents chime in. “Yes, she’s right.” “When? I’ve been walking around here for four years and I haven’t seen one. In the other nursing home, they had one that brought up 1,500 euros.” “Yes, well, we offer individual activities and collective activities. Like a fashion show that we had the other day.” She continues, “Thank you for mentioning these things, and I will pursue them. If you like, I can make an appointment with the activities coordinator for you—” “If I could just say one last thing. A month ago I joined my husband to the bingo. A man won, and his prize was a necklace. He won a second time, and his prize was a jewelry box. Those aren’t prizes, I’m sorry. It used to be that when you won, in the old house… we won a second prize once, and that was a cruise through Amsterdam, for four persons!” “Mrs. A., if I could interrupt you for a second. It’s about the residents, that they have a good time. The prizes, that’s separate from the activity. We could do it without a prize, it’s about the activity. Are there any more questions for me?” Susan lifts her gaze and looks around the room. After a last round of questions, Paul starts to close the meeting by saying, “then I hereby…” when Susan breaks in, “oh, could we take a picture for Facebook?” While she takes out her camera, we arrange ourselves. “Yes, you join too!” she says to the dietary assistant who has since joined our number. Residents, relatives, the dietary assistant, Paul and I, we all sit still and smile as our picture is taken.

Hidden transcripts Was this a battlefield? Do you offer your opponent a cup of tea before a battle? Do you take a picture together afterwards? I was left wondering this to myself after the meeting. There was tension, sure. But in my mind, battle presupposes open

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conflict, and somewhat even show of aggression—both of which I did not see during the meeting. Indeed, Cloverhill staff had invited and accepted feedback. Towards Paul family had been generally deferential and polite. Things appeared to tense up when Susan came, but she too remained open and submissive. With this puzzle in my mind, I headed to the deserted nurses’ station to write out my notes about the meeting. The nurses’ station is a small, quiet room at the end of the hallway. It’s nice and quiet there, I think to myself. I’ve made it through half of a page of fieldnotes when Susan comes in, followed by Paul. At the sight of me and my notebook, Susan pauses for a split-second, but continues through the doorway and closes the door behind her. As she turns to Paul, these words spill out of her mouth. “Ugh, can you believe Mrs. A.? These aren’t the good old days anymore, when we have unlimited money to spend on bingo prizes! Shit.” “Do they know what it’s like to have to bring him to the toilet every five minutes?” Paul is pacing back and forth throughout the room, while Susan plops herself onto a chair near the wall, her torso slumped, knees together but her feet apart. While exchanging words with Paul like this, she intermittently squeezes the contents of a juice pack into her mouth through a straw. “Do they think that the extra cookie we serve with the tea comes from government money? No way! And those activities that Mrs. A. was talking about; they are mostly for her…” The words, “That man is incredibly incontinent!” precede the mouthful of cake that Paul ingests. He pauses his pacing, looks me in the eye, mops his eyebrow and chews his cake. His lips are dry. The pace of his breathing slows. “Of course,” he continues in a tone more closely resembling his usual speech, “this isn’t what the man had imagined his old day to be. Before his disease, I bet he imagined a nice, active retirement, not to be locked up here among these half-lunatics…” “You know what,” Susan adds, “I’ll call that choir that Mrs. A. mentioned. In a way, she’s right, that’s what they’re here for.” And just like that, this second meeting is over, sealed by a knock on the door bringing in a group of nurses just returned from an outing.

I would later make a note in my fieldnotes, that to see Paul and Susan like this was delightfully different form their public selves. It was as if Paul was using shorthand for people: “half-lunatics” instead of the usual, long-drawn formulation used in public spaces. Maybe this was a different kind of battlefield, I thought to myself; a battle without open conflict, but where energy erupts away from ‘the field’. Anthropologist James Scott (1990) employs the phrase “hidden transcript” to describe the words and actions that occur in such a “backstage” area. A “critique of power spoken behind the back of the dominant” (1990: xii), these transcripts are voiced in private moments of ventilation. Hidden transcripts are what the powerless rehearse and repeat among themselves, but dare not to speak to the powerful. Forced by undeniable power structures, an oppressed group reverts to deference and submission in moments when they meet with the more powerful group, and the “public transcript” is played out. Among themselves, however, the members of these groups rehearse a different transcript. Although the hidden transcript might be voiced spontaneously, but its content is the result of rehearsal and group creation, “a collective cultural product” (1990: 9).

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In this case, when Cloverhill employees are in the presence of family members, we might observe a transcript closely resembling that which was played out in the “family meeting” at the start of this chapter. Deference and openness characterize the attitude of Cloverhill employees. Any aggression appears to be uneven. In different spaces, closed spaces, a different transcript is aired. In fact, I had been hearing parts of this transcript for weeks. And in the weeks after, I would have plenty of occasions to hear different versions of the transcript rehearsed, nuanced and applied. These moments of talk among nurses or managers shared a mention of the skewed, inflated or otherwise unrealistic expectations of family members, and reference to the impossibility of meeting these expectations due to poor funding. In some situations, talk included specific complaints about a resident’s continual demands, nearly always accompanied by a nuancing comment like the one that Paul made, softening the clients’ critique somewhat by providing explanations for their malcontent, usually found in the client’s emotional hardship. Such a comment might sound like, “Ah, but the lady comes here every day, only to see her husband’s health get poorer and poorer,” or, “Who can blame her? Her children never come to visit.”

The occasion that I witnessed after the family meeting was exceptional in its force and visceral energy finding an outlet in this sealed space that Paul and Susan had chosen, in which I happened to be present. This pressure was palpable in that small room for those few moments, perhaps three or four minutes in total. This pressure had been leaking out in small bits in my presence on earlier occasions during my fieldwork. But here, doors closed, “unfortunate” became “shit”, “cognitively impaired” became “half-lunatic”. The strength, detail and uniformity of this hidden transcript, and its stark contrast with its public counterpart, leads me to believe nurses and other employees at Cloverhill to hold a strong sense of powerlessness with relation to clients’ family.

Up until now, the picture would be one of Scott’s (1990) descriptions of one-sided domination, were it not that the family members, too, enact a hidden transcript of sorts that suggests their feelings of powerlessness. I do not refer to critique of the organization, but rather to critique of nurses. Public critique, such as that voiced so emphatically by Mrs. A. in the meeting usually centered on the organization as a whole rather than nurses specifically. When speaking of the organization as a whole, transcripts included critique on poor management and organization, a lack of activities scheduled, too few nurses scheduled, or limited food choices. Critique aimed at nurses was a very rare occurrence in my field of vision. When criticizing nurses, family members would complain of poor management skills of some among them, or “I can’t believe the nurses spend so much time behind their computer.” However, critique of nurses was hushed, whenever it would come up in the conversations I had with relatives in the course of fieldwork. Family members are quick to note which nurses their resident takes a liking to, and will often try to exert some influence by asking, is [name] coming in today? These observations, that at least two parties hold a hidden transcript suggestive of powerlessness, suggest a more nuanced and ambiguous picture than a domination-resistance narrative.

Rather, family-Cloverhill relationships are like a patchwork of dependencies. In one meeting, both parties can feel dominated by the other. As

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exemplified in Susan’s speech about the CQ index, Cloverhill depends on the favorable responses of clients in the questionnaire to get “a better chance” at more funding. Client satisfaction is a necessary resource for the ‘client-centered care’ that the organization strives to offer. Relatives, on the other hand, are aware that their family members are in the hands of this organization and its employees, and their goodwill, for the remaining 22 or so hours of every day. In a way, the excerpt from Susan’s talk about the CQ index suggests this mutual dependency: the way that you evaluate our care might affect the care that we can offer your father. The palpable energy in these hidden transcripts point to a relationship heavily laden with power. But rather than a straightforward example of a dominant and subordinate group, the hidden transcripts of these groups suggest that power-relations are ambiguous and shifting.

Three points of critique: what does the CQ survey cloak? In the section that follows, I place the observations above in light of critical scholarship on ‘information’ and ‘transparency.’ Taking the CQ survey as an instance of “governing at a distance” (Hansen and Flyverbom, 2014: 5), I apply three of the critiques that were set forth in chapter one. First, I note how the CQ index overlooks context. Second, I describe how it obscures the purposes with which people respond. Third, I mark how the CQ survey reoriented the organization, raising the question whether it has indeed served to increase ‘transparency’.

The point was raised in chapter one that a main characteristic of ‘information’ as conceived of by critical scholars, is that it is taken out of context. As Power (2004: 772-773) writes, “As second-order measures are normalized, they become cut off from their original imperfect databases, they travel and are mobilized in unqualified form, constituting techniques of long-distant control between remote centres of calculation and the basis for new interventions in organizations.” In our example the complex, ambiguous, tense, shifting structures of power lines described in the vignette above form the backdrop to the CQ survey. And yet, how much of this context will the results reflect? Once ‘gathered’, the information takes on a life of its own among the survey results drawn from other nursing homes, and no one will think of the very human, anxious, uncertain people who sourced it. In the relevant “center of calculation” where this picture is analyzed and compared to others, nothing will be visible of the frenetic efforts of the organization to produce the numbers, to stage the picture. Uncertain, chaotic action is presented as objective, unequivocal actuality.

A second area left unseen by ‘information’ is that of human purpose. Chapter three already made a point of this. A ‘storeroom’ or ‘actuarial’ perspective on rapportage, just like a ‘snapshot’ perspective on the CQ survey, treats all responses as equal, regardless of the reason for them having been communicated in the first place. And, as suggested by Susan in our example, these reasons can be several. In her speech, she mentioned three audiences that would see and act on the CQ survey results. These were the Dutch government, insurance companies, and Cloverhill itself. The Dutch government simply needed to “be informed” of client satisfaction, whereas insurance companies would use the results to determine

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its funding of Cloverhill. Cloverhill itself, Susan emphasized, would rather hear of complaints through different genres of communication. This made sense to me, when I considered the low scores that might result if clients interpreted the CQ survey as an opportunity to communicate their displeasure to management in order to force what looked to them like improvement. Consider, how different would responses to the survey be if instead clients considered the repercussions of their answers for insurance companies? Rather than a theoretical side note, respondents’ purposiveness – which goals they chose to pursue – lies at the very heart of the struggle surrounding the CQ survey. But like the photograph taken for Facebook, this ‘picture’ taken by the survey-takers visiting Cloverhill will gain a certain independence, separate from the goals that generated it. Context and purpose, these are among the things that information cloaks, the “decontextualization” of knowledge and the “purposiveness of actors” that critical scholars write about.

Measures to increase ‘transparency’ are generally presented as an effort on the part of the party gathering the information. The narrative offered in this chapter, and my observations surrounding it suggest the reverse. They underscore the active role that an organization can take in the production of information. In light of the financial consequences of a poor score, preparation for the CQ interviews in the months following the family meeting was a process fraught with anxious activity—scheduling, talking, strategizing and fretting—on the part of the organization, a space in which employees sensed their fragility. Do we staff extra nurses on weekends when the family comes? Do we plan supplementary activities in the period leading up to the questionnaire? These considerations were raised in management meetings. In such a meeting, a management member burst out, “I am incredibly scared that the people will let the uproar of the day weigh more heavily than an entire year’s program.” All around, members of the organization were voicing their discomfort with the vulnerability that seemed to accompany the questionnaire, and were suggesting ways to cope with it.

This active component on the part of the organization has frequently been marked by scholars critical of the supposedly straightforward gains of ‘transparency.’ They argue that an emphasis on measurable targets reorients the organization in undesirable ways, creating new types of opacity and darkness, due to the capacity of organizations to manage their visibility (Arellano-Gault and Lepore, 2011; Hansen and Flyverbom, 2014; Heald, 2006; Neyland, 2007; O’Neill, 2006; Roberts, 2006). These scholars lead us to entertain the idea that anthropologist Timothy Pachirat (2011: 235) suggests, of the “unexpected sympathy between concealment and surveillance”. The third point of critique, then, is that managed transparency means that visibility does not automatically infer transparency. These three suggest that the road towards ‘transparency’ is not a straightforward one reached by creating information.

Below, I add a fourth point to my argument, which argues against seeing visibility as a single process with only benefits, but rather as accompanied by ambiguity and tension.

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A fourth point: palace and cage For sociologist Yiannis Gabriel (2005), visibility, fragility and an emphasis on transparency in contemporary organizations evoke a metaphor of glass as the characteristic building material of organizations. Drawing from scholars of postmodernism, he paints a picture of the contemporary organization to be both a “glass palace” and a “glass cage” to evoke the two-sidedness of visibility: it can mean recognition, but also over-exposure (Brighenti, 2007). The remainder of this chapter uses Gabriel’s metaphor to structure observations and reflections on managed visibility and its two-sided nature. These point to a fourth point of critique of a one-sided pursuit of visibility: the materials used to build a palace are the same ones that can later, or simultaneously, make up the cage.

Cloverhill is rendered ‘visible’ in many ways. Openness and transparency are suggested by architecture, public relations material and discourse by staff. In terms of its architecture, many of the floor plans seem to be made to yield maximum visibility and an equal spread of light. Doors to common spaces are generally left open, and clients can come by at any time to visit their family members. Transparency is also evoked by the pictorial and textual content of its publications towards clients and their families. The picture taken of the group of us at the end of the family meeting is such an artifact of Cloverhill as a “glass palace,” characterized as “a container aimed at highlighting the uniqueness of what it contains” (Gabriel, 2005: 20). In Cloverhill’s monthly newsletter to clients, featuring a half-page image of one of their buildings in broad daylight on its cover, light, photographs and publication of activities showcase how hard the people at Cloverhill are working to create a good environment for resident life, creating the impression that these are the realities you would encounter if you came by. An emphasis on visibility makes the organization look good. However, as Gabriel (2005) writes, the experience of work under visual scrutiny can be a nerve-racking one.

“the glass cage acts as a metaphor for the formidable machinery of contemporary surveillance, one that deploys all kinds of technologies—electronic, spatial, psychological and cultural. Appearances are paramount; image is what people are constantly judged by. […]Exposure, with its thrills, horrors and corresponding desires to protect privacy and create sheltered spaces, is thus the key to the experience in the glass cage… ” (Gabriel, 2005: 18-19)

What might this cage look like? The openness to criticism that is espoused in “family meetings” means that criticism will come. The predictable presence of a number of observant family members means that nurses must sometimes choose between work that looks good and work that must be done. From where I was standing, these are two tensions that nurses and managers at Cloverhill faced regularly.

The interaction between Mrs. A. and Susan at the meeting at the start of this chapter suggests that an open attitude to criticism means being hit by sharp feedback but still having to invite more of it. Throughout the meeting both Paul and Susan repeated that they were “happy with your involvement.” As noted,

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offstage discussion of this topic often went together with strong emotions of frustration and anger. With these “hidden transcripts” (Scott, 1990) in mind, It was a jarring experience to see nurses affected by the blow of a point of “feedback” voiced undiplomatically in the next moment reorienting themselves and telling the clients, “But—keep telling us.”

Visibility to others and its effect of reorienting the organization have often been noted by organizational scholars. As Goffman (1959) points out, all work carries with it a symbolic element that does not quite overlap with the content of the actual work. Doing your work well isn’t the same as making it apparent that you are performing well (Goffman, 1959: 33). Sometimes, one is made to choose between image-work and care-work. In an interview I had with her, one nurse gave the following example:

“Look, when understaffing means that we cannot shower people that day—then, it that day is her ‘shower day’, all sails are set to get her under that shower. Because, well, that husband of hers will be coming this afternoon, and he is offended by it, and it’s the first thing that he asks […] But it shouldn’t be that way, you see? I am here for nineteen people, and it should not be that because that resident happens to have a fiery daughter or a very involved husband who comes at you directly in a nasty way… It shouldn’t be that way, but it happens.” (Samira, interview)

In these two ways, we are left guessing whether we are in a palace or a cage, or whether one part of the organization, by building a palace of visibility, might be assembling a cage for other employees. The palace is evoked by the beautiful, clear pictures and direct feedback policies, which give the organization as a whole a stamp of being ‘transparent’. The cage-like qualities of this contraption thus assembled, become evident when we consider the dilemmas work in a high-visibility (exposed) environment places before nurses. The palace and the cage are each other’s reverse. To expect to have one without the other is unrealistic. This, to me, is another reason to think critically about the merits of ‘transparency’, and the way of thinking that says that more ‘transparency’ ought always to be pursued.

Conclusion When I came home from the “family meeting”, and took a look on Facebook, I saw my smiling self, looking up from the Cloverhill Facebook page under the heading, “Another good and convivial [gezellig] family meeting today!” Much like this photograph, taken for publication on Facebook at the end of the family meeting, the CQ survey results will not convey the context, conditions, power lines, effort that produced them. And much like the photograph, the results give the impression of visibility and of representativeness. This chapter is an illustration, through story and theory, of how modern information-gathering procedures depend on, and yet cloak purposiveness and context. In other words, I tried to show what the critical scholars presented in chapter one seem to be so concerned about when they say stuff like “decontextualization overlooks the purposiveness of human agents.” I attempted to convey context by first presenting Cloverhill-family relations as a shifting patchwork of power and powerlessness,

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where both parties sensed their fragility and power. With a focus on discourse by Cloverhill employees, I explored what their “hidden transcripts” (Scott, 1990) could tell us about the relations of power. Such an approach takes us beyond what is said in open, spacious spaces towards closed, smaller ones beyond the eyes of power. By glimpsing offstage discourse, a sense of mutual dependence, ambiguity and contradictory goals emerged as the backdrop for the CQ survey.

As in chapter three, a second blind spot of this instance of ‘information’ was the purposiveness of actors. The survey was presented to clients as serving several possible audiences. It was felt keenly by managers at Cloverhill that which audience respondents embraced would determine their response. Besides giving the Dutch government a picture of client satisfaction throughout the country, results might also affect the insurance companies in charge of allocating money among institutions. In this context, Cloverhill employees informed respondents of the survey’s different audiences and consequences, thereby encouraging them to consider which goal they wanted to pursue with their responses. Whether a client is directing her responses to Cloverhill’s middle-management, or to insurance companies, is lost in the CQ survey. This is ironic, since purpose seemed to lie at the very heart of Cloverhill staff’s struggles with the CQ survey. This chapter illustrates the analytical merits of tying information to practice; to the goals that people are trying to reach. However, divorcing information from practice is exactly what happens in long-distance governance. Once given the status of ‘information’, survey results gain a type of independence and commensurability to the results drawn from different contexts and produced for different audiences.

An initial conclusion of this chapter is, then, that visibility does not straightforwardly signify transparency. The active stance on the part of the organization makes it more complicated: turning instances such as the CQ survey into an exercise in creating, rather than gathering information. The examples about the client quality questionnaire can be seen as instances of how Cloverhill responds to a request for information, not by simply allowing it, but by anticipating it, changing its conduct for a brief period of time. “Especially with the CQ coming up…” was a commonly heard phrase in several meetings, when matters of practical importance were discussed. The CQ survey becomes an exemplary instance of how information-gathering efforts can contribute to greater opacity rather than transparency, aided by the ability of contemporary organizations to manage their visibility.

This is a point that critical scholars of transparency raise against transparency policies (Arellano-Gault and Lepore, 2011; Hansen and Flyverbom, 2014; Heald, 2006; Neyland, 2007; O’Neill, 2006; Roberts, 2006). As presented in chapter one, these scholars argue that measures aimed at transparency and performance measurement reorient the organization towards proxies, creating ever sharper distinctions between front- and backstage areas. As Neyland (2007: 499) writes, “In this way, internal aspects of organizations are not ‘made available’ but instead are re-oriented toward the production of specific forms of informational output that will externalize (or make available) a particular version of the internal dynamics of the organization.”

Besides these three critiques, this chapter proposes a fourth critique. Visibility brings with it recognition as well as exposure (Brighenti, 2007). This

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fragility coupled with visibility are evoked similarly by Gabriel’s (2005) twin metaphor of “glass palace” and “glass cage”. I used these metaphors to describe how visibility is suggested by Cloverhill’s architectural and discursive arrangements, but also how two tensions accompany this emphasis on visibility. First, an organization-wide commitment to openness places before nurses choices between doing their work well and making it look as though they are doing their work well. Image-work conflicts with other norms and ideals. Second, commitments to transparency, while constructing a glass palace for one part of the organization, might be building a glass cage for another. There are moments when an organization-wide commitment to openness exposes employees to insult. In these two senses, transparency is as much of a cage as a palace for those working at Cloverhill. These four points of critique lead me to conclude that higher visibility is not always better.

Dominant discourse on Dutch nursing homes, as exemplified by government policy and media coverage, sees visibility as an unquestionable road to improvement: the purpose being to “uncover”, “shed light on” and “get a clear picture” of “what goes on” in nursing homes (De Telegraaf, 2015; Effting and Stoffelen 2014a; NOS, 2014). Darkness and ignorance are the problem, light and information the solution. However, critical scholars point out that a one-sided pursuit of visibility at all costs, combined with a stigmatization of secrecy, leads only to situations characterized by a more managed transparency, accompanied by clearer boundaries between the “audit universe” (Neyland, 2007: 511) and the places where the ‘real work’ gets done.

In light of the observations and reflections presented in this chapter, I am tempted to think, in keeping with Birchall (2011) and in the style of Ybema (1996), that it is not a matter of transparency or opacity in organizations, visibility or invisibility. Rather, as Birchall (2011) points out, they exist side-by-side, symbiotically. A more profitable way to look at organizational disclosure practices might be to allow for them both to be present simultaneously. Hence, a key outcome of this essay is a call to engage in the difficult work of navigating those tensions, engaging them rather than forcing a choice between them, analytically and practically. This is a theme that the next chapter takes on.

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Chapter 5. The closest thing to transparency

“If you want to identify me, ask me not where I live, or what I like to eat, or how I comb my hair, but ask me what I am living for, in detail. Ask me what I think is keeping me from living fully for the thing I want to live for.” – Thomas Merton

Introduction Up until now, we have been considering the question, what do information, visibility and transparency cloak? in the context of a nursing home. Taking clues from one set of scholars, we have been looking for actors’ purposes and context in moments of ‘information transfer’, to see what we miss when we take ‘information’ as a sufficient representation of events, people or processes. In this way, the chapters so far have highlighted people’s ability to manage their responses to information requests. In taking this approach, we have mostly been addressing critiques C and D of chapter one. In pointing out these blind spots of context, purpose and visibility management, the previous chapters have focused mainly on the way that human action and choice thwart the societal dream of full visibility.

This current chapter considers a group of people who do not have the capability for evasive action that others at Cloverhill do. In their passivity, they are the closest that one comes to transparency—in the sense of offering an unobstructed view of their person and conduct—at Cloverhill. They are the residents themselves. Despite what might appear to be unmediated accessibility, I will argue in this chapter that here too—and perhaps especially here, in the knowing of people—the limits of information become visible and tangible. We explore the puzzle of how residents are at the same time seen and not seen, known and not known. As in previous chapters, core concepts are information, visibility, and their amalgam, transparency. Here, I argue that residents’ non-action throws into sharp relief the other critiques raised in chapter one. These are the critiques that point to the non-neutrality of measurement systems, and how an emphasis on codified data implies a hierarchy of the senses to the detriment of other ways of knowing. The person has become transparent, and what do we see?

I start by describing ways in which residents at Cloverhill are made visible and made known. To see the blind spots of an approach that does not go beyond information, I then return to the writings of critical scholars. Two arenas emerge where the resident seems visible-yet-invisible. The first arena is Cloverhill itself, where residents are invisible compared to their data proxies that are constructed daily. The second arena is in the domain of policy discourse, where current residents are absent—invisible compared to the future consumer of care. All in all, in this chapter information and ignorance are presented as concurrent phenomena, as bound to one another. In presenting information like this, I explore what it means to view organizational life as routinely bearing combinations of visibility and invisibility. The pressure to choose one over the other seems an unnecessary and unhelpful assumption.

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Information and Visibility Nursing involves striking a balance between responding to individuality and offering structure. In guiding nineteen people through their day, it involves entering the lifelong backstages of people’s lives: the moment between waking up and taking that first look in the mirror, the moment between turning off the shower and taking the towel off the hook. In these backstages, nursing means encountering uniqueness and daily fluctuation. Yet, the work of the modern nurse is also to transform this individuality into comparability.

Through a series of checklists and forms, the resident is divided up and put onto paper. At 7:30, as she opens her eyes, she is a line in the medicine checklist followed by a nurse’s signature atop of the medicine cart. At 8:00 she is her blood pressure measured and noted down on a small piece of paper that the nurse puts in his pocket. At 10:00, while she squeezes a ball in her hand, she is the notes that the physical therapist scribbles down. At 8:30, 11:00, 12:00, 16:00 and 18:00, she is a cup of coffee, a glass of water, half a cup of tea and a glass of juice: the list of liquids she has drunk that day. At 23:00, after she closes her eyes, she takes shape in rapportage, a collection of words and numbers that the nurse finds to describe her day. This information is what the next shift picks up. The resident is every day transposed into a specified set of measures; with measurement tools and doctors’ orders, with a computer into which to enter and store data, the person is rendered on-screen. This second person, a proxy for the first, does not sleep, talk or change, unless by choice of those surveying her. The building of Cloverhill is well-suited to this collection of information. It offers a clear, unobstructed view of those it holds. Windows are large, and rooms are spacious. Residents sit in a space apparently without shadow, visible to a generalized other. To get an idea of what such high visibility and information richness blind us to, we will return briefly to the critical scholars that I presented in chapter one, and an excerpt taken from my fieldnotes.

Ignorance, invisibility Do we not in fact know very little about this resident? The picture that we get of her is detailed, to be sure. But it is one-sided. It is heavy on the ‘measurable’: weight, blood pressure, fluids, and light on the ‘intangibles’: joy, peace, rest. As noted in chapter one, critical scholars argue that we have come to see this information picture as complete, and they offer suggestions as to what information obscures.

Before we can count, we need to classify. We need to assign categories to things. Brighenti (2007: 325) points out how measurement tools extend our capability to sense the world, but that “these extensions are hardly neutral. They contribute to selectively enhance a certain type of sensory perception and establish a ‘ratio’ among the senses, a hierarchical ranking” By prioritizing recordable data, we establish it in relation to other ways of knowing, giving it a higher position in practice and in theory. Thus established as primary, it is what we look out for when we interact with the world, and it is what counts as “real knowledge.” (Hansen & Flyverbom, 2014: 3). You might even say, it is “the stuff that matters.” Inarticulable parts of reality, what scholars call “local, grounded experience” (Brighenti, 2007: 337) are not recorded, and therefore not seen and valued.

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These assumptions of what counts as knowledge carry over in treatment of people in medical settings. Haggerty and Ericson (2000) point out the fragmentation of the body that results from lifting out only the bits that are seen by what Foucault (1973) calls the regard médicale. Brighenti (2007: 327) describes Foucault’s idea as follows: “The individual living body […] presents itself as invisible, both because of its organic depth, its impenetrability to sight, and because of the intricate interweavings of symptoms it exhibits. Accordingly, the task of modern medicine became that of bringing the invisible back to visibility.” (emphasis in original) In this effort, human bodies are abstracted from their place and time and divided “into a series of discrete flows,” which are then the focus of any interventions planned from afar (Haggerty and Ericson, 2000: 605). The individual is replaced by a “dividual”, captured in standardized terms (Brighenti, 2007: 337; Tsoukas, 1997: 830)

These ‘invisible’ parts of life that I allude to are difficult to express in writing. I struggled with this puzzle in the field as well, and devoted a portion of my fieldnotes to describing my frustration. In a small dose, I include a fragment of my fieldnotes below, because I think it is relevant to the topic of this chapter. This piece was written at the end of a week of fieldwork in February. At the time, I had not yet read any of the critical scholars that are central to this thesis. At the end of one day, I took a seat for a few hours in the large foyer of Cloverhill. This foyer has walls made of glass, with sliding doors in four directions, making it a passage way. The ceiling is high, and there are two olive trees in the center of the room. I glanced around me, and noticed tiny gauges stuck into the bases of the potted trees nearby, measuring the amount of water in the ground beneath the knotty olive trees. They stuck with me. To be honest, I was irritated by their presence; that this was being measured too. Is there nothing here that is not measured? I glanced up and saw the straight edges of the buildings across from me in the courtyard. I bet someone knows exactly how high that building is, I thought. I settled into a frame of mind that John van Maanen (1988: 102) would probably call “impressionist”, which he captures with the phrase, “[f]or the most part, then, the images of the impressionist tales are presented as they may have appeared at the time to the fieldworker and not as they became known later.” (1988: 121) What follow are the words that I could find in that moment to describe my puzzlement.

“The plural-ness of life seems so far away in a place like this, where surfaces are paved or otherwise smooth, and the lines of large objects are straight. All straight. All new. And then there’s us humans walking around here. Bits of glory irregular and wobbly. Showing goofy grins, like the one Jenny just gave me on her way out. Giving concerned, uncertain attention, like that given by a wife for her husband, whom she is wheeling in. He is so young to be in the palliative care unit. Or like me, moving with tired eyes and heavy heart, sometimes unsure of whether what I am doing is right, yet choosing to go anyway—to expend energy, move past inertia, back into the field. It’s not that this place isn’t beautiful. It’s just something so much less wild and wobbly and courageous than the human hearts that live and work here.

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Is the frustrating thing that all is measured, or has been measured? That therefore all is… (thought to be) known? Things such as the amount of water those trees in the hallway have (by those annoying little gauges stuck at their root); how tall the buildings are, exactly; how warm it is here; where people may go and where they may not? All those windows, too. We also know: The number of people spending their lives here Whether they have had a bowel movement today How much they weighed this morning How many ccs of water are pumped into their PEG sonde Why, on the basis of his configuration of points two and three, Mr. C. is so silent today. Who knows the weight of his heart today? The color of his memories. What makes hearts sing? People are so much more vast than we get tricked into thinking. Than this place makes me think. Here’s the thing. People’s beauty is masked by the appearance of cleanness, or even of health. I need moments when I can stand back, marvel, and let people be. And yet, I feel like with this research, I am squished into another mode, that of seeing purely with the senses of ‘science.’ By only watching and listening, somehow it is as if my gut is muted, made deaf, by my at times strained effort that goes into obtaining ‘data.’ I don’t quite envision a journal publishing my piece on how my heart aches here, how I have come to simplify people in the course of this project. While I recognize the need for observational data for my thesis, I just – I wish I could have both.”

I consider this a significant moment in my fieldwork, when I first started to articulate what was making me nervous about Cloverhill. This is also the moment when the wish started to take shape, which I would later express as: I want to write about how we get tricked into thinking that we know somebody.

With all the possibilities and mandates for measuring the resident, it is tempting to think of residents as the sum of the information collected about them. An abundance of checklists, forms, reporting systems, light and space suggest that rendering a person knowable is a main goal for this organization. However, it seems to me that the key parts of people are the things that you know but cannot quite—or easily—express, the things that you only find out when you interact with them, and that require creativity, time and effort to put into words. Bakhtin (1984) writes that people are “unfinalizable”—always changing and never fully revealed to the world. I like that idea. The trap is that when we measure something, we tick the box, fill in the number, maybe we note down a few more things, like how well Mrs. C. slept last night, or that she appears cheerful today, that when we gather this information, we think we have her. But do we?

The resident runs the risk of becoming invisible, because of her high visibility in terms of information. The resident’s “data double” (Haggerty and Ericson, 2000: 606), the totality of the lists, forms and rapportage on her, becomes a stand-in for the person. This is the first arena in which the resident can be considered

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unknown as well as known, invisible as well as visible. A second arena is public discourse on the measurement of ‘quality of care.’

A second invisibility In a universe made up of ‘information’ waiting to be gathered, we see that the goal becomes to discover, detach and move this information to the right people (Tsoukas, 1997; Hansen and Flyverbom, 2014; Power, 2004). In this universe a nursing home is transformed into an information-gathering apparatus; the starting point of the conveyor belt of information transfer. As the Dutch minister of Public Health suggests, this conveyor belt leads to the choosing consumer (Schippers, 2015a). But where, exactly, does this conveyor belt begin? Impersonal terms such as ‘quality of care’ tend to obscure this, but oft-cited components to quality such as reporting well, keeping treatment files up-to-date, and keeping track of bedsores, are impossible without information gathered from the resident herself or himself.

As I have come to see it, the “information products” (Schippers, 2015a: 7) that the minister wishes to create are, in a sense, the current patients themselves. Gabriel (2005: 20) speaks of “the holy alliance forged between the manager and the consumer at the expense of the worker or the employee” that is characteristic of contemporary organizations. However, the situation sketched by the policy letter seems to leave another group out: the current patient. An unintended consequence of focusing on the choosing consumer is overlooking the current one. The current resident is notably absent in the discourse at policy-level.

Conclusion In dominant discourse on the governing of nursing homes, information and visibility are presented as uniform, pure processes, separate from ignorance and invisibility (NOS, 2014; NRC Handelsblad, 2014). They are presented as single phenomena, complete in themselves. Taking a different perspective, this chapter treats knowledge/ignorance and visibility/invisibility as inseparable. I tried out this perspective by considering how Cloverhill’s residents are both rendered known and, simultaneously, unknown. Their relative inability to resist measurement and visibility draws our eye to the scholarly critiques that apply to the construction of measures rather than the responses they elicit from organizations (as has been the focal point in the preceding chapters). This chapter looked at residents, the critiques, and offers one exploration of how visibility and invisibility go together in an information-rich and highly visible environment. In this chapter, the resident is presented as both highly visible and invisible—both known in detail and profoundly unknown.

To see how this can be, we considered the critiques outlined in chapter one. The first critique, critique A is that categorization is a political choice, not a neutral one. Regimes of measurement overlap to a large extent with regimes of value. Critique B argued that when information comes to be regarded as the main source of knowledge and the sole base for decision-making, it means that other types of knowledge, those that hold them and the things they describe are devalued. As a consequence, the parts of life that cannot be captured by

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‘information’ become invisible. With an emphasis on information, we create priorities by deciding which parts of residents to spend time on. At Cloverhill, it is tempting to equate residents with the data-proxies that we have of them. It is tempting to think that in order to ‘know’ the resident, only the right amount of information is required. The filling out of forms and the typing up of data communicate knowledge, insight and completeness. But how they invariably bring with them their own opacities and dark spots is not generally mentioned. Ignoring our ignorance and taking our knowledge as complete comes at the expense of the things which I would argue are rather important things when we talk about people. This, then, is the first arena within which the resident is rendered invisible. Compared to her data proxy, she is invisible.

The second arena in which the resident is curiously absent is the arena of dominant policy discourse on ‘quality of care’ and ‘transparency’. This invisibility can be connected to ideas of consumer sovereignty, which seem to drive much of policy discourse on the matter of transparency. Under the model of governance at a distance, one face of the nursing home is an information-gathering machine. It is the starting point of the conveyor belt that moves data from a local place to remote centers of calculation. But within Cloverhill, where does this conveyor belt start? The current consumer, the one already in a nursing home, is invisible—even while it is data drawn from her life that makes up the “information products” (Schippers, 2015a: 7) presented to the future consumer. So, whereas in the first instance of invisibility/visibility, the residents is overlooked in favor of her data double, in the second instance of invisibility/visibility, she is overlooked in favor of the future consumer.

With these observations in mind, I am left with two questions for future thought. The first is: at Cloverhill, transparency seems most attainable in the case of residents. Unmediated, unobstructed access to someone seems be within reach most closely when people do not have means of hiding, moving, or resisting. What does that say about the desirability of this attribute for other people in society? Indeed, previous chapters of this thesis have raised the point repeatedly that organizational actors thwart dreams of transparency by their active role in shaping the information they produce. But seeing what unobstructed access looks like, in the situations of residents, leaves me with a sense of appreciation for actors’ agency—as a sign of health— in the face of mechanisms of surveillance.

Next, thinking about invisibility and ignorance seem to point to one aspect in particular of our culture: the way we deal with not-knowing. In our society, accepted response seems to be to gather (more) data. However, I suspect that other options exist. So, my second question is about these alternative responses to ignorance. What might they be? They might include trusting those people who are grounded in the phenomenon that you wish to control. Although, perhaps information is not the key to better care. Perhaps it is as simple as Samira, a nurse, stating her resolution as, “when I am treating a resident, I expressly try to not talk over her head to a colleague.” I would see nurses do this: look a resident in the eye. Pay attention to and respond to their changing moods, approach them as fresh people every day rather than as their images congealed in information. Perhaps it is a nurse who says, upon looking at the resident’s file, “now for the important stuff”—and then goes to the resident herself. But these are only traces left by an

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attitude and a practice, which remains largely unknown to me. Perhaps it means asking whether the thing which we do not know is unknowable rather than merely unknown, or something that must be navigated moment-by-moment, every day again, rather than at a distance, once-and-for-all. My sense is that much of this attitude cannot be codified, written down, and is woven into the fabric of daily doing. And ‘knowledge’ as a descriptor does not come near it.

In this chapter I did not mean to argue that attempting to ‘know’ the resident is somehow a bad or futile enterprise. Rather, I am suggesting that information is not ‘sold separately’, that is, in an organizational setting it is accompanied by ignorance and blindness. Accordingly, I am pointing out that ‘information’ is just one type of knowledge among many, more complex ways of knowing. An awareness of these possibilities enriches our understanding of organizations.

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Conclusion. Advances in negative knowledge One conclusion of this thesis is that in the case of one nursing home in the Netherlands, more information and higher visibility are not necessarily better. Although frequently presented as the tools of enlightenment and emancipation, they can be the means by which employees are “caged” (Gabriel, 2005) and residents “fragmented” (Haggerty and Ericson, 2000). By drawing from ethnographic fieldwork in Cloverhill, a Dutch nursing home, this thesis shows how an approach that considers only visibility and transparency, and not the concomitant invisibility and opacity, is problematic in practice and unnecessarily limiting in theory. In this chapter, I situate these conclusions in the context of increasing demands for ‘transparency’ in Dutch healthcare, I review the components of my thesis, and suggest one area for future research that I am particularly partial to: the expansion of “negative knowledge” (Knorr-Cetina, 1999) or “known unknowns” (Kerwin, 1993).

The pressure for ‘transparency’ and its critics There is a pressure in Dutch society to make known nursing homes specifically, and health care more generally (NOS, 2014; NRC Handelsblad, 2014). Nursing homes are framed in the media as obscure places in need of light; and information is presented as the instrument that will enlighten us (NOS, 2015). How? By capturing intangible phenomena such as ‘quality’ and ‘satisfaction’ in metrics, information is created to be transported to distant decision makers who can then control them through “inspection” and “oversight” (De Volkskrant, 2014a). At the time of this writing, insurance companies were making demands information upon which to make their pricing decisions (Cats, 2014; Kuiken, 2014; Verbeek, 2004). Consumers, it is argued in a similar vein, are also in need of information for their choices (Halbersma 2008). In the spring of 2015 the minister for Health published a letter to the Dutch House of Representatives in which she announced an effort to mobilize different parties in the Dutch system towards the “Year of Transparency” (Schippers, 2015a). For health care organizations, transparency is presented as an ideal state, “a virtue, the secular version of a born-again cleanliness that few can fail to praise.” (Birchall, 2011: 8) Information is looked to with expectancy for its capacity to bring visibility and transparency, as a remedy for a range of ills attributed to ignorance.

So much emphasis is placed on the capacity of information to enlighten and make us all better off, that I was curious, instead, about what it obscures, and how it might bring with it unexpected consequences. What does information remove from view? To address this question, I drew from one set of critical scholars who problematize ‘information’ (Birchall, 2011; Brighenti, 2007; Haggerty and Ericson, 2000; Hansen and Flyverbom, 2014; Power, 2004; Tsoukas, 1997). Inspired by their work, I defined ‘information’ as a codified representation of an event, process or person and set out to explore what an exclusive emphasis on ‘information’ does in fact cloak at Cloverhill. In this context, the purpose of my thesis was to counter a dominant discourse that sees information as the remedy for grand issues, but overlooks the ignorance that comes with it. The question that guided my fieldwork was, how do the people that work and live at Cloverhill regard and

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respond to requests for information? When I looked at this question in light of theory, I became interested in the idea of ‘information’ as a cloak, a cover, for a host of aspects of organizational life and asked: what do information, visibility, and transparency cloak at Cloverhill?

Overview of chapters In chapter one, I drew from critical scholars for suggestions as to what parts of life information renders invisible. According to these scholars, information cloaks the power inherent in categorization, the purpose and context of communicators and the capacity for people and organizations to manage their visibility. In short, those things that cannot be read from the information itself. Measures are generally presented as politically neutral (Hansen and Flyverbom, 2014; Power, 2004), and epistemologically complete. Placing an emphasis on information as the source of trustworthy knowledge means rendering invisible other types of knowledge, the people that hold it, and the parts of life that are known by them (Haggerty and Ericson, 2000; Tsoukas, 1997; Birchall, 2011). Furthermore, the reasons for creating the information in the first place cannot be read in the information itself, but is yet key to understanding its meaning and role in social life (Tsoukas, 1997). The last point of critique is a well-known organizational phenomenon: the reorientation of the organization towards checklists and audits, rather than the things they are meant to represent. The organization’s capacity to manage its visibility casts doubt on the causal link between visibility and transparency, information and knowledge (Arellano-Gault and Lepore, 2011; Hansen and Flyverbom, 2014; Heald, 2006; Neyland, 2007; O’Neill, 2006; Roberts, 2006).

In light of these critiques, I pointed out the temptation to consider transparency as impossible or nonexistent—but that this temptation should be resisted. Rather than seeing transparency and opacity as mutually exclusive states of being, I stated that I wanted to consider how transparency and opacity accompany each other in organizational life. I set out to apply the critiques outlined in chapter one to what I had seen, heard and felt at Cloverhill.

In chapter two, I gave a storyline of access to, and time spent in ‘the field’. I wrote about the approach I took, which I characterized as to “learn by going” (Geertz, 1995: 133, quoted by Bate, 1997: 1152). My movement around the organization between December 2014 and April 2015 was guided mainly by noting and following up on unknown people, names and terms that I would hear in conversation. Furthermore, I characterized my fieldwork as a mix of presence and absence (Ybema and Kamsteeg, 2009), unpleasant awareness and exciting discoveries, and theory and observation. I needed absence to refocus my efforts in the field, where I collected impressions to fuel my reflections. I did not find ethnographic research to be a linear or ‘clean’ process; insight was sporadic and unpredictable, and time spent at Cloverhill was emotionally trying. Time in the field was only one part of the work that went into this thesis. Another is the “deskwork” (Van Maanen 1988: 4) that represents the molding of field notes and theory into a research narrative. In ethnography, the researcher is the research instrument. It follows that an ethnography – the thing that an ethnographer writes – is a highly personal, individual product. I do not in any way claim to be a passive

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transmission belt of ‘organizational reality’ at Cloverhill. As I described in chapter two, I have chosen to represent what I believe to be worthy of note.

The theoretical tools proposed by critical scholars to consider the ‘blind spots’ of information meshed well with the ethnographer’s purposes and tools. The ethnographer, as presented in methodological literature, aims to “converse” with people in a different culture (Geertz, 1973: 24), to be a “professional stranger” (Agar, 1980) in order to understand a particular place in terms of the meanings that those living there attach to it themselves (Spradley, 1979). Frequently described as getting “the native’s point of view” (Malinowski, 1922: 25), the aim of the ethnographer is not to get a ‘full picture’ of reality. Rather, she takes there to be no one vantage point from which to regard social life, but infinitely many (Hatch and Yanow, 2008).

In chapters three and four, I drew from my period of fieldwork at Cloverhill. In each chapter, I took a piece of information: nurses’ reports and a client satisfaction survey, respectively. Then, I placed these observations in light of critical scholars’ critiques. This brought into focus the things that ‘information’ overlooks: context, communicative purpose and the active, rather than passive, role that actors have to shape their visibility. Both these chapters served to highlight the effort, choice, ambiguity and uncertainty that precede the production of ‘information.’ But once something like a rapportage or CQ survey result reaches the status of ‘information’, its imperfect and very human roots are forgotten, and it is treated as objective and representative.

In chapter three I described the goals that nurses connected to the practice of rapportage: the entering of information into a client database (CR). Rather than reading nurses’ reports as isolated utterances, I argued for a perspective that places them within the social system in which they operate (Garfinkel, 1967). I argued that CR is many things to nurses, and a storeroom is only one of them. Drawing from interviews and observations, I distinguished a number of different goals that nurses pursue when using CR. Nurses use CR to activate other health professionals, to signal quality to inquisitive family members, to relieve themselves of responsibility, and to critique fellow nurses. What’s more, nurses use a combination of “genres” (Yates and Orlikowski, 1992) to reach these purposes. These observations support the idea that an information-centered, or an “actuarial reading” (Garfinkel, 1967: 200) of reports overlooks the purposiveness of actors, while this is a crucial element of understanding the content of the information.

In chapter four, I started out by describing a meeting between residents, their relatives and Cloverhill staff. Initially described as a “battlefield” by two employees, I came to see this relationship as an unorthodox “battle”, where most of the aggressive energy is expended away from “the field”. I used Scott’s (1990) term “hidden transcripts” to describe these moments of offstage aggression by the powerless towards a dominant party, making the point that both family and Cloverhill employees perform these transcripts. I painted this ambiguous and tense relationship as the backdrop to a biennial client satisfaction survey (the CQ survey) commissioned by the Dutch government. Clients were asked by Cloverhill employees to consider the different audiences that the results would reach. Do you direct your responses to the national government, to insurance companies—who might reduce funding based on poor results—or to Cloverhill’s managers? These

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purposes were central in the struggle of the organization with preparing for the survey, but are overlooked by the CQ survey. To these three ‘blind spots’ of context, communicative purpose, and visibility management, I added a fourth critique of organizational visibility. Based on the work of Gabriel (2005), I argued that the same materials that go into producing the “glass palace” of transparency and openness, also contribute to construct a “glass cage”. The rewards that come with visibility are accompanied by anxiety and difficult choices for staff. All in all, chapter four suggested several reasons why a single-minded pursuit of visibility as a goal is undesirable for those working at Cloverhill.

In chapter five, I reflected on the role of measurement and visibility in the lives of the residents of Cloverhill. I presented an “impressionist tale” (Van Maanen, 1988: 120) of an afternoon at Cloverhill to convey the frustration that I felt in the field with omnipresent ‘knowledge’ through information and my own inability to capture what I was seeing and feeling in writing. In this chapter, I experimented most clearly with the idea that information and ignorance go together, as do visibility and invisibility. Residents at Cloverhill are at the same time elaborately known as they are profoundly unseen. Their relative passivity to measurement brings into focus the other critiques of critical scholars: an emphasis on information renders other parts of life invisible; namely those that are captured by other ways of knowing. Compared to their “data doubles” (Haggerty and Ericson, 2000: 606), residents are invisible. A second arena in which residents are rendered invisible in the effort of making them known, is the arena of political discourse. Here, they become invisible compared to the future consumer of care, while the current consumer becomes part of the “information products” (Schippers, 2015a: 6) that will be presented to the future consumer.

All in all, the empirical material in this thesis was aimed at arguing that a focus on ‘information’ does not necessarily deliver clearer sight of organizational realities, that visibility isn’t a precursor to alleviating darkness, and that a pursuit of only information and visibility is not always best for employees and residents. On the contrary, visibility also makes us blind, and information makes us ignorant.

However, theorists are often as quick to dismiss transparency as their

optimistic counterparts are to embrace it. To dismiss transparency entirely seems to rest on the same assumption that the unchecked enthusiasts of transparency seem to be working under: transparency and opacity cannot exist together. This is an unhelpful and unnecessary assumption, which hampers our capacity to describe organizational life in its complexity. Because choosing to see one thing, means that we do not see another, ways of seeing always go together with ways of not seeing. This point of view is expressed eloquently by Kerwin (1993:174-175), who writes, “The metaphor of sorting – separating percepts or concepts into polar bins or knowledge and ignorance – too often falsifies our complex experience. […] Perhaps suffusion is a better metaphor than sorting. The unknown suffuses the known. They are “entwined.” Enmeshed.” Similarly, Birchall (2011: 18) draws attention to how “it is the space, the relation, the tension between transparency and secrecy, rather than each of these terms independently, which is of most interest. It is this space we often inhabit but rarely work through, not least because of the pressure to make a choice between transparency and secrecy.” She would

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rather see opposite terms less as a choice and more as a space in which to work. Seeing transparency not as a linear process that we must all march towards, but as always accompanied by opacity seems to me a more fruitful goal, and one that I would like to pursue in research and practice in the future.

Future research and practice As I mentioned in my conclusion to chapter five, my reflections on work

and life at Cloverhill lead me to consider one aspect of our culture particular: how we cope with not-knowing. If, as this thesis argues, ignorance is as large a part of our attempts to know as knowledge is, then this ignorance – its character, role, and our responses to it—are worthy of study as much as knowledge has traditionally been. Setting such a course means that we enter into what Knorr-Cetina (1999) calls the domain of “negative knowledge”, namely, “knowledge of the limits of knowing, mistakes in attempts to know, things that interfere with knowing, and what people do not want to know” (Smithson, 1989: 210). In a way, we are reversing our color palette: rather than focusing on the role of knowledge (practices) in society, we focus on ignorance (practices). This perspective is what I will touch upon in this discussion, in which I give suggestions for further research.

Traditionally, that which we cannot know has been regarded as lying outside the domain of science. However, ignorance can equally be said to typify situations of which scholars have traditionally deemed knowledge to be characteristic. Such situations (such as market transactions, medical care and surveillance mechanisms) can fruitfully be seen from a perspective of ignorance as well. Smithson (1989) argues that ignorance characterizes some of the largest problems facing humanity, such as how to craft solutions to climate change— where there are no previous examples to draw from for information, and limited possibility of trial and error. This point has been made by scholars of “wicked problems” (Churchman, 1967) and “rude surprises” (LaPorte, 2007). The added value of this thesis has been to point out that not-knowing characterizes the small things too: interactions on a daily scale. When nurses encounter the elderly, what do they see? What does the organization pressure them to see? Do they see residents predominantly as known (represented by data) or as unknown? Can a nurse still be a good nurse when she acknowledges her daily battle with ignorance? And does it have to be a battle?

It is in this context that I would like to see further research take place. For this to occur, such studies require a more sensitive way of talking about ignorance, and must do justice to its socially constructed character: ignorant from whose perspective? (Knorr-Cetina, 1999; Smithson, 1989: 210) How is ignorance constructed in a given context? How do people cope with ignorance? Are certain types of ignorance thought to be more reprehensible than others? What social functions does ignorance serve? How do people negotiate the determination of what is unknowable and what is simply unknown? In short: what would the world look like if we saw social situations not as characterized by great knowledge, but as by great ignorance?

Not only in science is an acknowledgement of “negative knowledge” (Knorr-Cetina, 1999), or “known unknowns” (Kerwin, 1993) of value. A

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realization of what we cannot or do not know— that is, advances in negative knowledge – may serve to inform practice as well. Coming from a perspective that is aware of negative knowledge, we might critically challenge what we expect from organizations and the people in them. Can we engage in the difficult work of navigating ignorance—instead of coming up with more complete contracts and more elaborate measuring tools? That is a shift that I would like to see. And I think theoretical and practical attention to negative knowledge could help us towards such a shift.

In line with the nature of my contribution, I am more interested in the day-to-day navigation, negotiation and coping that surround ignorance, than in policies at a larger scale. Indeed, from a perspective of those governing at a distance, my recommendations probably seem unworkable. But my suspicion is that for those in the field they are workable— more workable, at least, than an assumption that ignorance can be avoided, and that static figures can adequately represent organizations, processes and people. From the field that I have studied, I would like to see accounts of how nurses, managers, family members and residents navigate the space between knowledge and ignorance. At the same time, I am aware of the limits of such a study—since it would mean producing another bit of information about practice, only a small part of which can be caught in words. Yet to do so seems to be the ethnographer’s challenge.

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