Theoretical Note. 
Strauss and Corbin 1990. pp. 216-7.


AS/JC 7-22-88 (Telephone)

I posed the issue, long ago observed, that nurses encountered typical problems --- often costly of time and effort and sentiment --- but do not act to change institutional rules or procedures to prevent. Rather they go on with their institutionalized-routine ways of doing work. (Problematic dying patients for instance, or as in pain book). Rather they typify this patient as like one(s) they have had before. But afterward there is no institutional change. These I have thought for a long time are due to the way organizations get work done, their priorities, and perhaps structural strains that precipitate recurrent semicrises. But here is a much better and detailed set of answers.

  1. When work processes break down, then there is a change of procedure.
  2. If they don't change procedures, it's because the work associated with the problem is not of high priority. The nurses are SO BUSY doing the high priority work, that they don't have time and effort to do anything else. They will, in fact, if the problem (like a problem patient) gets bad enough call in specialists-social work- ers, chaplains, psychiatrists-because their own work has to go on. Or they will ignore the patient; perhaps making the problem worse, but...
  3. If the work affected by the breakdown of work process is of high priority (like affect its efficiency or patient's safety), then they have to reflect on how to prevent this from occurring again.
    1. If the change is easily done, then it is done through interactional processes: negotiation, persuasion, even some coercion.
    2. If the change will be difficult organizationally, this essentially means a lot of additional work must be done but it must be done --- that is: figuring out what's to be done, planning decision making, persuading, negotiating, finding new resources, acting to raise motivation, additional supervising when the new rou- tines are instituted, etc. And of course, an additional drain on the total articulation process until everything is acting smoothly again.
  4. So, what we are saying is that THESE ARE THE CONDITIONS FOR AND MECHANISMS THROUGH WHICH ACTION IS INSTITUTED TO REPLACE ROUTINES WITH NEW INSTITUTIONALIZED PROCEDURES. Notice: we have to look more closely at the meaning of routine procedures. At the lowest level, it means how tasks are done. But this can be done by staff agreement as well as by administrative rules.