Geoffrey C. Bowker
Graduate School of Library and Information Science
University of Illinois at Urbana-Champaign
Introduction - Well do I remember...
"I remember that I had a typical English grammar school education from ages 11-14, after which time the family emigrated to Australia". This is a kind of reminiscence we can all relate to, but it is clearly problematic, in my case, with respect to the issue of the truth about the past. It is a memory laden with my present understanding of the category `English education', which feeds partly at least off the film If about English private schooling, and so which `should' not be relevant. Furthermore, I saw the film some years after I left England and school both. So the framework that contains, in some sense, my memories of what it was like in those years could not possibly have existed at the time that I experienced them. It may still be a valid and useful framework; however it almost certainly helps me to remember some parts of my life (which make me like Malcolm MacDowell in the film) and forget others (less heroic and less nihilistic).
Recall is in general a problematic concept, even when we can assume that people are trying to tell the truth about the past. Studies of people's intensely remembered `flashbulb memories' (what were you doing at the time that Kennedy was assassinated) have proved them to be often false (Brown and Kulik, 1982). John Dean claimed fairly total recall at the time of Watergate - but as Ulric Neisser points out through analysis of the tapes made in the Oval Office he remembered neither conversations, nor even gists of conversations - but rather an ideal set of possible conversations which encoded his perceived truth of the situation and his fantasies about his own role therein (Neisser, 1982; but see the excellent critique in Edwards and Potter, 19921). People cannot remember accurately how they felt in the past: they take the present as a benchmark and then work from a currently held belief about change or stability in their attitudes: thus when asked how you felt six months ago about, say, a TV series, your memory will necessarily be colored by what has happened since in that series (Linton, 1982). If all history is history of the present, then one might surely think of memory as ineluctably a construction of the present. These studies from cognitive science suggest that truth or falsity is not a simple concept when it comes to analyzing organizational memory in science or elsewhere (cf Hacking, 1995, Chapter 17 - on the indeterminacy of the past). Thus Bannon and Kuutti, 1996 stress that if ]`organizational memory' is at all a useful concept, it is so to the extent that it refers to active remembering which carries with it its own context - so that it comes in the form not of true or false facts but of multifaceted stories open to interpretation.
Neisser (1982), building on Tulving's famous distinction between episodic and semantic memory (remembering what vs remembering how) introduces a third kind of memory - `repisodic memory' (remembering what was really happening). Against this increasing differentiation and specialization in the concept of memory, we find a single and undifferentiated definition of `forgetting' - it is `not remembering'. Further, forgetting in all its guises has frequently been seen as necessarily a problem. Freud encouraged the recall of suppressed memories (see Hacking, 1995 for a discussion of memory and veracity in Freud). Historians insist that we must learn the lessons of the past. Yrjo Engestrom, in his memorable paper on `organizational forgetting' (1988) discusses problems raised by the ways in which doctors forget; though his activity theoretical perspective on the organic links between internal and external memory traces is particularly fruitful in that it provides a model for ethnographic studies of collective memory. Bitner and Garfinkel (1967) are among the few to observe and describe an ecology of forgetting, in their account of `good' organizational reasons for `bad' clinical records'.
Total recall, in individuals or organizations, is neither desirable nor possible. Recent work in organizational theory has suggested that perhaps it is good on occasion to forget everything about the past, in order to start over without being trapped in old routines (Wackers, 1995). There are indeed several good reasons for organizations to forget things about their own past. First, it might be the case that rediscovery is easier than remembering, especially where the overhead of constructing a sufficiently precise archive so that a fine-grained situation can be remembered is high. Thus in order to remember down to the level of detail that the English employees might not understand `z' when pronounced `zee' one would need an immense archive surely unnecessary for a telephone company but perhaps vital for a nuclear power plant where quick interpretation of a loudspeaker broadcast of `Z-Alpha-One' might have safety consequences. Secondly, extending Chandler (1977), one can see the development of statistics as a filtering mechanism that allows a central office not to have to remember everything about a company's day to day running in order to make things run smoothly: the filtering works as proactive forgetting. A third positive mode of forgetting is when an organization wants to change its identity. In such a case the argument that `we have always done things this way' stands in the way of breaking new ground. Hughes (1989 ) described the change at Rugby school under Arnold in this light, showing Arnold imperceptibly changing the way things were done in such a way that group memory was never mobilized against the changes. In general, if memory is being used as a tool of reification or projection then it can have harmful consequences.
This paper is about how organizations forget things selectively about the past in the process of producing knowledge. I shall argue that there are two major kinds of organizational forgetting in the process of producing and then maintaining classification systems in the workplace:
I shall then argue that the classification systems which are created permit the organization to move from heterogeneous forms of memory operating within multiple frameworks to the privileging of a form of memory (potential memory) operating within a well-defined information infrastructure subtended by classification systems. I shall demonstrate that in this process, the decision of whether to opt in to an infrastructure, with its attendant memory frames and modes of forgetting, or to stay out of it, is of great political and ethical import . I shall firstly follow this set of arguments through with respect to a case study of the development of a classification of nursing work, and will then broaden the discussion out to more general considerations of classification and memory.
Part 1 - Nursing classifications and organizational forgetting
The common thread for this part will be an analysis of the ways in which a nursing group in Iowa city is classifying nursing work. Nursing is particularly interesting with respect to forgetting, since nursing work has traditionally been invisible and removed at the earliest opportunity from the medical record. In the 1988, a group was formed in the College of Nursing at the University of Iowa to create what they call a Nursing Interventions Classification - henceforth NIC (McCloskey and Bulechek, 1996), see Diagram 1 and Diagram 2. There was already in place a somewhat badly maintained classification system for nursing diagnoses (which is to say what specific nursing needs a given patient had); but there was no standardized language for describing what it was that nurses did. The group published a first edition of their system in 1992, and a revised and expanded version came out in 1996.
In general, nursing has not been able as an institution to draw on an active memory. Rather, nursing has been seen as an intermediary profession that does not need to leave a trace. As nursing informatician Castles notes, citing Huffman on medical records management: Athe nursing records are the first to be purged from the patient records; there is thus no lasting documentation of nursing diagnoses or nursing interventions and no method of storage and retrieval of nursing data. (Castles, 1981, p.42)
NIC itself is a fascinating system. Those of us studying it see it as an ethnomethodological nirvana. Some categories, like bleeding reduction - nasal, are on the surface relatively obvious and codable into discrete units of work practice to be carried out on specific occasions. But what about the equally important categories of hope installation and humor (see Diagram 3)? Hope installation includes the subcategory of `Avoid masking the truth'. This is not so much something that nurses do on a regular basis, as something that they should not do constantly. It also includes: `Help the patient expand spiritual self'. Here the contribution that the nurse is making is to an implicit lifelong program of spiritual development. With respect to humor, the very definition of the category suggests the operation of a paradigm shift: "Facilitating the patient to perceive, appreciate, and express what is funny, amusing, or ludicrous in order to establish relationships"; and it is unclear how this could ever be attached to a time line: it is something the nurse should always do while doing other things. Further, contained within the nursing classification is an anatomy of what it is to be humorous, and a theory of what humor does. The recommended procedures break humor down into subelements. One should determine the types of humor appreciated by the patient; determine the patient's typical response to humor (e.g. laughter or smiles); select humorous materials that create moderate arousal for the individual (for example `picture a forbidding authority figure dressed only in underwear'); encourage silliness and playfulness and so on to make a total of fifteen sub-activities: any one of which might be scientifically relevant. A feature traditionally attached to the personality of the nurse (being a cheerful and supportive person) is now attached through the classification to the job description as an intervention which can be accounted for.
The Iowa group, the kernel of whom were teachers of nursing administration, made essentially three arguments for the creation of a nursing classification. First, it was argued that without a standard language to describe nursing interventions, there would be no way of producing a scientific body of knowledge about nursing. NIC in theory would be articulated with two other classification systems: NOC (the nursing sensitive patient outcomes classification scheme) and NANDA (the nursing diagnosis scheme). The three could work together thusly. One could perform studies over a set of hospitals employing the three schemes in order to check if a given category of patient responded well to a given category of nursing intervention. Rather than this comparative work being done anecdotally as in the past through the accumulation of experience, it could be done scientifically through the conduct of experiments. The Iowa Intervention project made up a jingle: NANDA, NIC and NOC to the tune of Hickory, Dickory, Dock to stress this interrelationship of the three schemes. The second argument for classifying nursing interventions was that it was a key strategy for defending the professional autonomy of nursing. The Iowa nurses are very aware of the literature on professionalization - notably Schon (1983) - and are aware of the force of having an accepted body of scientific knowledge as their domain. (Indeed Andrew Abbott, taking as his central case the professionalization of medicine, makes this one of his key attributes of a profession.) The third argument was that nursing, alongside other medical professions, was moving into the new world of computers. As the representational medium changed, it was important to be able to talk about nursing in a language that computers could understand (see Diagram 4) - else nursing work would not be represented at all in the future, and would risk being even further marginalized than it was at present.
Forgetting 1 - Clearance
Grand Historiographer, Sima Qin (1994 [ca 100BC]), writing of the burning of the books in 213BC, notes that the Chief Minister advised the emperor that: Aall who possess literature such as the Songs, the Documents, and the sayings of the hundred schools should get rid of it without penalty. If they have not got rid of it a full thirty days after the order has reached them, they should be branded and sent to do forced labor on the walls. there should be exemption for books concerned with medicine, pharmacy, divination by tortoise-shell and milfoil, the sowing of crops, and the planting of trees (31). In response to this, the Emperor ordered the famous burning of the books - to cite Qin: Athe First Emperor collected up and got rid of the Songs, the Documents, and the sayings of the hundred schools in order to make the people stupid and ensure that in all under Heaven there should be no rejection of the present by using the past. The clarification of laws and regulations and the settling of statutes and ordinances all stared with the First Emperor. He standardized documents. (31).
There was a primitive act of clearance in the establishment of NIC. By clearance, I mean a complete wiping away of the past of nursing theory in order to start with a clean slate - much as the first cultivators burned the forest to create land suitable for tilling in ordered rows (I am drawing here on Serres' (1993) work on clearance and origins in geometry). The nurses said that until now there had been no nursing science and therefore there was no nursing knowledge to preserve. There is, one nursing informatician ruefully noted: AIt is recognized that in nursing, overshadowed as it is by the rubrics of medicine and religion, no nurse since Nightingale has had the recognized authority to establish nomenclature or procedure by fiat. There are no universally accepted theories in nursing on which to base diagnoses, and, in fact, independent nursing functions have not yet gained universal acceptance by nurses or by members of other health professions". (Castles, 1981, 40) Nursing, it was argued, had until now been a profession without form; nothing could be preserved. There was no way of coding past knowledge and linking it to current practice - it was noted at a conference to establish a standardized nursing minimum data set (information about nursing practice that would be collected from every care facility) that: "The lists of interventions for any one condition are long partially because nursing has a brief history as a profession in the choosing of interventions and lacks information for decision-making. As a profession, nursing has failed to set priorities among interventions; nurses are taught and believe they should do everything possible". (McCloskey and Bulechek, 1992, 79)
In the face of this view of the nurse as the inglorious other - doing everything that nobody else does - should all previous nursing knowledge be abandoned? William Cody, in an open letter to the Iowa Intervention Team published in Nursing Outlook in 1995 charged that this was precisely what would follow from widespread adoption of NIC: AIt would appear that the nursing theorists who gave nursing its first academic leg to stand on, as it were, are deliberately being frozen out. I would like to ask Drs McCloskey and Bulechek, Why is there no substantive discussion of nursing theory in your article? How can you advocate standardizing 'the language of nursing' by adopting the language of only one paradigm? How do you envision the relationship between the 'standardized' masses and those nurse scholars with differing views? (Cody, 1995, 93). The Project team responded that indeed clearance was an issue: Athe Iowa group contends that taxonomic development represents a radical shift in theory construction in which the grand conceptual models are not debated, but transcended. We believe that, as a scientific community, nursing has moved to the point of abandoning the conceptual models of nursing theorists as forming the science base of the discipline (McCloskey, Bulechek and Tripp-Reimer, 1995, 95).
It is not just at the level of nursing theory that this act of clearance is seen as unsettling. Practicing nurses implementing NIC at one of four test bed sites have complained that learning to use NIC together with the new computer system it is embedded in is like going to a foreign country where you have to speak the language; and to make matters worse you have to go to a new country every day. More prosaically, they say that they feel they are going from being experts to novices The argument was made that quite simply there has been no work done in the past: AThe discipline of nursing has not yet constructed a cohesive body of scientific knowledge (Tripp-Reimer et al, 1996, p.2). However, there is a complexity here that often arises in connection with the strategy of clearance. One wants to be able to say that nurses now do something which is valuable and adaptable to scientific principles; while at the same time maintain that nurses have not yet (until the development of the classification system) been able to develop any nursing theory and thence any systematic, scientific improvement in practice. This same article, on the dimensional structure of nursing interventions, tackles this problem directly. Tripp-Reimer argues that there must be a cycle of forgetting in the development of the new classification scheme. The article begins with a quote from Chung Tzu:
The purpose of a fish trap is to catch fish. When the fish are caught, the trap is forgotten.
The purpose of a rabbit snare is to catch rabbits. When the rabbits are caught, the snare is forgotten.
The purpose of words is to convey ideas. When the ideas are grasped, the words are forgotten.
Seek those who have forgotten the words. (p.2)
It is argued that the traditional grand theories had a Acertain limited utility beyond their historical importance in that they provided a structure for educational programs. However, in the field expert nurses soon `forgot' these words and developed their own schemata to get at the deep structure of the nursing situation (there is indeed a reference to transformational grammar here). Now using NIC categories as a research tool, one could uncover the three key dimensions of nursing work (the intensity, focus, and complexity of care) - which experts always already new about, without there having been a nursing science. Having passed through the purifying cycle of forgetting, one could finally Abring intuitive clinical decision-making to a conscious level. There is a double complexity to this cycle. First is the fact that the first author, Toni Tripp-Reimer, is a cultural anthropologist turned nursing informatician well versed in Kuhn, Lakoff and others. The organization that produces NIC has to be broadly enough construed, on occasion, to include the community of sociologists of science and linguistics, even though this inclusion may never be represented overtly in the records of the classification scheme. (In passing, this can form a kind of organizational memory that can flip into forgetting - storing information in locations once within the network of an organization but now outside of it; a variety of outsourcing gone sour). The second is that it reflects a tension between what nurses already know and what the science of nursing will tell them. The NIC team in general are claiming both that nursing is already a science, and that it is one which has not yet been formulated: they need to maintain the former in order to justify the profession against current attacks, and the latter in order to justify their classification system, which when in place will protect it from future attacks. One is reminded of Piaget's (1969) assertion that our earliest intuitions are of the relativistic nature of time, and that we need to unlearn our school lessons in order both to access the latest science and to get back in touch with our childhood insights. The act of clearance is to take away useless theory; then ethnographic work will uncover the true science (always already there) which NIC can express. The act of clearance, then, is not one of simple denial of the past - though complex historical narratives need to be constructed in order to distinguish the two.
I am not of course here accepting the position that such clearance leads to the creation of true science - the issue of the validity or not of nursing knowledge is entirely orthogonal to my purpose. I am producing an anatomy of what it has meant in the case of nursing to create such a science - and I will argue later that this is not an accidental feature of their work, but can be seen as a core strategy over the centuries in the creation of sciences. The strategy itself provides a way of managing a past that threatens to grow out of control: one can declare by fiat that the past is irrelevant to nursing science (while, in Tripp-Reimer's case validating the past as embodied in current best practice) in the development of a classification scheme which will provide for a good ordering of memory in the future - so that nothing henceforth deemed vital will be lost.
Forgetting 2 - Erasure
Donald Crowhurst went quietly mad on a round-the-world yachting race and lay becalmed on the ocean developing a theory of the cosmic mind whilst at the same time completing and radioing in an immaculate official log that had him winning the race at a record pace. Crowhurst's double log surfaces within his madness as contemplation on the nature of time: AThe Kingdom of God has an area measured in square hours. It is a kingdom with all the time in the world - we have used all the time available to us and must now seek an imaginary sort of time' (Tomalin and Hall, 1970, 259).
With the strategy of clearance, we saw the complete wiping-clean of the slate so that a single origin for nursing science could be created and so that from that point of origin nursing actions could be coded and remembered in an organizationally and scientifically useful fashion. A second mode of directed forgetting in organizations is erasure: the constant filtering out of information deemed not worthy of preserving for organization's future purposes.
The selective erasure of nursing records within hospital information systems has been drastic. As noted above, nursing records are the first destroyed when a patient is released: the hospital administration does not need them (nursing is lumped in with the price of the room); doctors consider them irrelevant to medical research; and nursing theorists are not well enough entrenched to demand their collection. Huffman (1990, 319), in a standard textbook on medical records management writes:
As nurses' notes are primarily a means of communication between the physicians and nurses, they have served their most important function during the episode of care. Therefore, to reduce the bulk and make medical records less cumbersome to handle, some hospitals remove the nurses' notes from record of adult patients when medical record personnel assemble and check the medical record after discharge of the patient. The nurses' notes are then filed in chronological order in some place less accessible than the current files until the statute of limitations has expired, and they are destroyed.
Traditionally nurses have facilitated themselves out of the equation: though they may not have an official trace of their own past, their duty is to remember for others. In one of those vague but useful generalizations that characterize information statistics, it was asserted, in a book on next-generation nursing information systems, that 24 percent of total hospital operating costs were devoted to information handling. Nursing, it is stated, A accounted for most of the information handling costs (28 percent to 34 percent of nurses' time); and what is worse, Ain recent years, external regulatory factors, plus increasing organizational and health care complexity, have augmented the central position of information in the health care environment." (Zielstorff et al., 1993, 5) The nursing profession acts as a distributed memory system for doctors and hospital administrators but in so doing is denied its own official memory.
Even when the erasure is not mandated, it has been voluntary. One text on a nursing classification system cites as a motif of the profession an observation that: A'The subject of record-keeping has probably never been discussed at a convention without some agitated nurse arising to ask if she is expected to neglect her patients in order to write down information about them. ....' (Martin and Scheet, 1992, 21 - echoing a 1917 source). And Joanne McCloskey, one of the two principal architects of NIC notes that: A...the most convincing argument against nursing service or Kardex care plans is the absence of them. Although written care plans are a requirement by the Joint Commission for Hospital Accreditation and a condition for participation in Medicare, few plans are, in fact, written. (McCloskey, 1981, 120). In her magisterial study of the International Classification of Diseases, Ann Fagot-Largeault (1989) notes the same reluctance on the part of doctors to spend time accurately filling in a death certificate (itself a central tool for epidemiologists) when they might be helping live patients. Thus there is, in Engestrom's (1988) terms, a block between internal memory and external memory: because representational work takes time, the form fillers systematically erase complex representations that they hold in their heads in favor of summary ones - in the case of the ICD there are many complaints because of the overuse of general disease terms or `other' categories; in the case of a computerized NIC, nurses are suspected by the NIC implementation team of using the choices that appear before them on a screen (which they can elect with a light pen) rather than searching through the system for the apt descriptor.
One of the main problems that the nurses have is that they are trying to situate their activity visibly within an informational world which has both factored them out of the equation and maintained that they should be so factored - since what nurses do can be defined precisely as that which is not measurable, finite, packaged, accountable. In nursing theorist Jenkins' terms: ANurses have functioned in the post-World War II era as the humanistic counterbalance to an increasingly technology-driven medical profession (Jenkins, 1988, 92). They have tried to insert nursing as something that fits naturally into a world partly defined by the erasure of nursing and other modes of invisible and articulation work - it is like technicians seeking new ways of writing scientific papers so that their work gets acknowledged and yet the nature of scientific truth is not impeached. Sometimes, as we will see, the nurses are driven by their logic to impeach medical truth; sometimes to challenge orthodoxy in organization science; sometimes to restructure nursing so that these challenges will not be necessary. At the end of the day there will be an information infrastructure for medical work which contains an account of nursing activity: the move to informational panoptica is overwhelming in this profession as in many others. With projects like NIC, which offer new classification systems to embed in databases, tools, and reports we get to see what is at stake in making invisible work visible.
I have in this section explored two strategies, clearance and erasure. Some of the points made here in the context of organizational forgetting relate to arguments within the sociology of science about the nature of scientific representations of nature - notably deleting the work (Star, 1989, 1991; Shapin, 1989), and the deletion of modalities in the development of scientific texts (Latour, 1987) - that is to say the argument that as a scientific statement gets ever closer to being accepted as fact, historical contingencies get progressively stripped from its enunciation. Why, then, talk at all about memory and forgetting when representation and its literature can do much of the same work? The concept of representation tends naturally to abstract away the ongoing work of individual or organizational agents (compare here Woolgar, 1995, 163). It is difficult to express the fact that the representation can have different meanings at different times and places in the organization in a language which has been used rather to demonstrate the conjuring of a single articulation of `fact'. The act of remembering a fact organizationally involves not only mobilizing a set of black-boxed allies (in Latour's terms) but also translating from the context of storage to the present situation (one might store a fact for reason x but recall it for reason y). Further, within an organizational context it is easier to explore the distribution of memory and forgetting than the distribution of representation. Finally, there it is always a temptation when talking of representation to fall into a cognitivist trap of assuming the primacy of the cognitive act. By concentrating on `following the actors', sociologists of science have as a rule produced a language which privileges the scientific `fact' and its circulation and which puts the infrastructure supporting that fact relatively into the background (what goes on inside the black box, or indeed what black boxes look like, is seen as irrelevant). From the perspective of organizational memory, a modality can be deleted in a number of different ways: it might be distributed (held in another part of the organization than in that which produces the text); built into the infrastructure (the work environment is changed such that the modality is never encountered); or simply dismissed. Looking at ways of distributing memory and operating forgetting we can, therefore, look in more fine-grained detail at what happens as the representation moves into and out of circulation.
Clearance is a strategy employed internally within the profession of nursing as a tool for providing an origin for the science of nursing; erasure is employed externally on the profession of nursing as a tool for rendering nursing a transparent distributed memory system. The logic of the relationship between clearance and erasure has been that the nurses are operating the clearance of their own past in order to combat the erasure of their present in the records of medical organizations. Medical information systems, they argue, should represent the profession of nursing as if it just began yesterday - for otherwise they will copy the transparency of nursing activity from one representational space (the hospital floor and paper archives) to another (the electronic record). This poses, then, the question of what happens when a new ecology of attention (what can be forgotten and what should be remembered) is inaugurated with the development of a new information infrastructure.
Forgetting, classification and potential memory
James Fentress and Chris Wickham (1992, 13), in a work reminiscent of Frances Yates' (1966), argue that artificial memory systems went on the wane after Descartes: AInstead of a search for the perfectly proportioned image containing the 'soul' of the knowledge to be remembered, the emphasis was on the discovery of the right logical category. The memory of this system of logical categories and scientific causes would exempt the individual from the necessity of remembering everything in detail. ... The problem of memorizing the world, characteristic of the sixteenth century, evolved into the problem of classifying it scientifically.
Memory - individual and organizational - is in general filtered through a classification system, which permits encoding of multiple bits of information about the environment into a single coherent framework (see Schachter, 1996: 98-133). Edouard ClarapËde (who performed the initial notorious experiment of having a stranger rush into the classroom, do something outrageous, and then have students describe what happened) noted as early as 1907 that: "that the past - even of a simple event - was less a record than a sort of taxonomy. Not perceptions, but categorization of familiar types was the major function of memory" (cited in Matsuda, 1996: 109).
Any information infrastructure to an organization - paper or electronic; formal or informal - claims by its nature to contain all and only the information that is needed for the smooth running of the organization. Organizations frequently want to know everything relevant about some past action. For example if there is a black-out along in the West due to a tree falling in Idaho, an awful amount of information needs to be recalled in order for the connection to be made. Frequently, a prime function of record keeping in the organization is to keep track of what is going on such that, should anyone ever want to know (auditors, a commission of inquiry and so forth) a complete reconstruction of the state of the organization at a particular moment can be made. For example Hutchins (1995: 20) talks about the role of the logs kept by navy ships of all their movements: "Aboard naval vessels records are always kept - primarily for reasons of safety, but also for purposes of accountability. Should there be a problem, the crew will be able to show exactly where the ship was and what it was doing at the time of the mishap". However, in order for something to be remembered officially by an organization it must be recorded on a form; and forms necessarily impose classification systems (Berg and Bowker, forthcoming). The reconstruction will not cover literally everything that was going on at a particular moment, but only things that fit into the organization's accepted classification scheme of relevant events. I shall refer to the kind of memory that is encoded in an organization's files for the purposes of a possible future reconstruction as `potential memory'. I am using the word `potential' to draw attention to the distributed, mediated nature of the record: no one person remembers everything about a medical intervention; and generally it can be processed through an organization without ever having been recalled. However, there is a possible need to recall any one intervention in huge detail: and the only way that the possible need can be met is through the construction of a classification system which allows for the efficient pigeon-holing of facts.
Within the hospital, nursing work has been deemed irrelevant to any possible future reconstruction; it has been canonically invisible, in Star's (1991) term. The logic of NIC's advocators is that what has been excluded from the representational space of medical practice should be included.
Operating within the space of erasure which is at once home for them and a threat to their continued existence, the nurses in Iowa have thought long and hard about the politics and philosophy of classifying their activities such that they fit into the hospital's potential memory. They do not want to flip over from being completely invisible to being far too visible. They have decided to name, but not to name too much. To this end they have adopted their own practice of continuing partial erasure (where they limit the nature and scope of erasure) - for three reasons:
They have decided to specify uniquely down to the level of interventions, but to leave the sub-categories of activities as relatively fluid - several possibly contradictory activities are subsumed under a single intervention (see Diagram 3). This allows, they argue, for a recognition of local differences and local autonomy (so central to the nursing self-image) whilst providing the necessary degree of specification for entry into the world of potential memory.
It is harder to hive off aspects of nursing duties and give them to lower paid adjuncts if that work is relatively opaque. The test sites that are implementing NIC have provided some degree of resistance here, arguing that activities should be specified - so that, within a soft decision support model a given diagnosis can trigger a nursing intervention constituted of a single, well-defined set of activities. As Marc Berg (forthcoming 1996) has noted in his study of medical expert systems, such decision support can only work universally if local practices are rendered fully standard. A key professional strategy for nursing - particularly in the face of the ubiquitous process re-engineer - is realized by deliberate non-representation in the information infrastructure. What is remembered in the formal information systems resulting is attuned to professional strategy and to the information requisites of the nurses' take on what nursing science is.
There is a brick wall that they come up against when dealing with nurses on the spot: if they overspecify an intervention (that is break it down into too many constituent parts), then it gets called, in the field, an NSS classification - where NSS stands for `No shit, Sherlock' and is not used (Timmermans, Bowker and Star, forthcoming). The project team sees the classification scheme as having to be very prolix at present; but when the practice of nursing itself is fully standardized, some of the words will be able to wither away. They point to intervention classifications used by doctors, which are much less verbose - and can afford to be, they argue, because every doctor knows the standard form of treatment for, say, appendicitis. (Though they also argue that there are local variations in medical practice which have been picked up by good reporting procedures, and that NIC will be able to provide such a service for nursing - leading to an improvement in the quality of practice). It is assumed that any reasonable education in nursing or medicine should lead to a common language wherein things do not need spelling out to any ultimate degree. The information space will be sufficiently well pre-structured that some details can be assumed. Attention to the finer-grained details is delegated to the educational system, where it is overdetermined.
These NIC erasure strategies - dealing with overspecification and the political drive to relative autonomy by dropping things out of the representational space - are essential for the development of a successful potential memory. The two forms of erasure of local context are needed in order to create the very infrastructure in which nursing can both appear as a science like any other and yet nursing as a profession can continue to develop as a rich, local practice. The ongoing erasure is guaranteed by the classification system: only information about nursing practice recognized by NIC can be coded on the forms fed into a hospital's computers or stored in a file cabinet.
Nursing informaticians agree as a body that in order for proper healthcare to be given and for nurses to be recognized as a profession, hospitals as organizations should code for nursing within the framework of their memory systems: nursing work should be classified and forms should be generated which utilize these classifications. However, there has been disagreement with respect to strategy.
To understand the difference that has emerged, recall one of those forms you have filled in (we have all experienced one) which do not allow you to say what you think. You may, in a standard case, have been offered a choice of several racial origins; but may not believe in any such categorization. There is no room on the form to write an essay on race identity politics. So you either you make an uncomfortable choice in order to get counted, and hope that enough of your complexity will be preserved by your set of answers to the form; or you don't answer the question and perhaps decide to devote some time to lobbying the producers of the offending form to reconsider their categorization of people. The NIC group has wrestled with the same strategic choice: fitting their classification system into the Procrustean bed of all the other classification systems that they have to articulate with in any given medical setting in order to form part a given organization's potential memory; or rejecting the ways in which memory is structured in the organizations that they are dealing with. We will now look in turn at each of these strategies.
Let us look first at the argument for including NIC within the potential memory framework of the hospital. They argue that NIC has to respond to multiple important agendas simultaneously. Consider the following litany of needs for a standard vocabulary of nursing practice:
It is essential to develop a standardized nomenclature of nursing diagnoses in order to name without ambiguity those conditions in clients that nurses identify and treat without prescription from other disciplines; such identification is not possible without agreement as to the meaning of terms. Professional standards review boards require discipline-specific accountability; some urgency in developing a discipline-specific nomenclature is provided by the impending National Health Insurance legislation, since demands for accountability are likely both to increase and become more stringent following passage of the legislation. Adoption of a standardized nomenclature of nursing diagnoses may also alleviate problems in communication between nurses and members of other disciplines, and improvement in interdisciplinary communication can only lead to improvement in patient care. Standardization of the nomenclature of nursing diagnoses will promote health care delivery by identifying, for legal and reimbursement purposes, the evaluation of the quality of care provided by nurses; facilitate the development of a taxonomy of nursing diagnoses; provide the element for storage and retrieval of nursing data; and facilitate the teaching of nursing by providing content areas that are discrete, inclusive, logical, and consistent . (Castles, 1981, 38)
I have cited this passage at length since it unites most of the motivations for the development of NIC. The development of a new information infrastructure for nursing, heralded in this passage, will make nursing more `memorable'. It will also lead to a clearance of past nursing knowledge - henceforth prescientific - from the textbooks; it will lead to changes in the practice of nursing (a redefinition of disciplinary boundaries) - a shaping of nursing so that future practice converges on potential memory.
Many nurses and nursing informaticians are concerned that the profession itself may have to change too much in order to meet the requirements of the information infrastructure. We murder, they note, to dissect. In her study of nursing information systems in France, Ina Wagner (1993) speaks as follows of the gamble of computerizing nursing records:
Nurses might gain greater recognition for their work and more control over the definition of patients' problems while finding out that their practice is increasingly shaped by the necessity to comply with regulators' and employers' definitions of 'billable categories' (Feldberg 1990).
Indeed, a specific feature of this 'thought world' into which nurses are gradually socialized through the use of computer systems is the integration of management criteria into the practice of nursing.
She continues: AWorking with a patient classification system with time units associated with each care activity enforces a specific time discipline on nurses. They learn to assess patients' needs in terms of working time. This analytic perspective is shared by the Iowa nurses. They argue that documentation is centrally important; it not only provides a record of nursing activity but structures same:
While nurses complain about paperwork, they structure their care so that the required forms get filled out. If the forms reflect a philosophy of the nurse as a dependent assistant to the doctor who delivers technical care in a functional manner, this is the way the nurse will act. If the forms reflect a philosophy of the nurse as a professional member of the health team with a unique independent function, the nurse will act accordingly. In the future, with the implementation of price-per-case reimbursement vis-a-vis diagnosis related groups, documentation will become more important than ever. (Bulechek and McCloskey, 1985, 406).
As the NIC classification has developed, observes Joanne McCloskey, the traditional category of `nursing process' has been replaced by `clinical decision making plus knowledge classification'. And in the representation of NIC that she produced (Diagram 5), both the patient and the nurse had dropped entirely out of the picture (both were, she said, located within the `clinical decision making box' on her diagram) (IIP 6/8/95). A recent book about the next generation nursing information system argued that the new system:
cannot be assembled like a patchwork quilt, by piecing together components of existing technologies and software programs. Instead, the system must be rebuilt on a design different from that of most approaches used today: it must be a data-driven rather than a process-driven system. A dominant feature of the new system is its focus on the acquisition, management, processing, and presentation of 'atomic-level' data that can be used across multiple settings for multiple purposes. The paradigm shift to a data-driven system represents a new generation of information technology; it provides strategic resources for clinical nursing practice, rather than just support for various nursing tasks. (Zielstorff et al., 1993, 1).
This speaks to the progressive denial of process and continuity through the segmentation of nursing practice into activity units. Many argue that in order to `speak with' databases at a national and international level just such segmentation is needed. The fear is that unless nurses can describe their process this way (at the risk of losing the essence of that process in the description), then it will not be described at all. They can only have there own actions remembered at the price of having others forget, and possibly forgetting themselves, precisely what it is that they do.
Some nursing informaticians have chosen rather to challenge the memory framework existing in the medical organizations they deal with. They have adopted a Batesonian strategy of responding to the threat of the new information infrastructure by moving the whole argument up one level of generality and trying to supplant `data-driven' categories with categories that recognize process on their own terms. Thus the Iowa team pointed to the fact that women physicians often spend longer with patients than male doctors, but they need to see patients less often as a result: they argue that just such a process-sensitive definition of productivity needs to argued for and implemented in medical information systems in order that nursing work gets fairly represented (IIP 6/8/95). They draw from their secret (because unrepresented) reservoir of knowledge about process in order to challenge the data-driven models from within.
Within this strategy, the choice of allies is by no means obvious. Since with the development of NIC we are dealing with the creation of an information infrastructure, the whole question of how and what to challenge becomes very difficult. Scientists can only, willy nilly, deal with data as presented to them by their information base, just as historians of previous centuries must, alas, rely on written traces. When creating a new information infrastructure for an old activity, questions have a habit of running away from one: a technical issue about how to code process can become a challenge to organizational theory (and its database). A defense of process can become an attack on the scientific world view. One of the chief attacks on the NIC scheme has been made by a nursing informatician, Susan Grobe, who believes that rather than standardize nursing language computer scientists should develop natural language processing tools so that nurse narratives can be interpreted. Grobe argues for the abandonment of any goal of producing: A a single coherent account of the pattern of action and beliefs in science (Grobe, 1992, 92); she goes on to say that: Aphilosophers of science have long acknowledged the value of a multiplicity of scientific views" (92). She excoriates Bulechek and McCloskey, architects of NIC, for having produced work: Aderived from the natural science view with its hierarchical structures and mutually exclusive and distinct categories. (93). She on the other hand is drawing from cognitive science, library science and social science (94). Or again, a recent paper on conceptual considerations, decision criteria and guidelines for the Nursing Minimum Data Set cited Fritjof Capra against reductionism, Steven Jay Gould on the social embededness of scientific truth and praised Foucault for having developed a philosophical system to Agrapple with this reality (Kritek, 1988, 24). Nurse scientists, it is argued, Ahave become quite reductionistic and mechanistic in their approach to knowledge generation, at a time when numerous others, particularly physicists, are reversing that pattern (27). And nursing has to find allies amongst these physicists:
Nurses who deliver care engage in a process. It is actually the cyclic, continuous repetition of a complex process. It is difficult, therefore, to sketch the boundaries of a discrete nursing event, a unit of service, and, therefore, a unit of analysis. Time is clearly a central force in nursing care and nursing outcomes. Nurses have only begun to struggle with this factor. It has a centrality that eludes explication when placed in the context of quantum physics. (Ibid., 28)
The point here is not whether this argument is right or wrong. It is an interesting position. It can only be maintained, as can many of the other possible links that bristle through the NIC literature, because the information infrastructure itself is in flux. When the infrastructure is not in place to provide a `natural' hierarchy of levels, then discourses can and do make strange connections between themselves.
In order to not be continually erased from the record, nursing informaticians are risking either modifying their own practice (making it more data driven) or waging a Quixotic war on database designers. The corresponding gain is great, however. If the infrastructure itself is designed in such a way that nursing information has to be present as an independent, well defined category, then nursing itself as a profession will have a much better chance of surviving through rounds of process re-engineering and nursing science as a discipline will have a firm foundation. The infrastructure assumes the position of Bishop Berkeley's God: as long as it pays attention to nurses, they will continue to exist. Having ensured that all nursing acts are potentially remembered by any medical organization, the NIC team will have gone a long way to ensuring the future of nursing.
Part 2 - Classification systems: potential memory and forgetting
Three social institutions, more than any others, claim perfect memory: the sister institutions of science, the law and religion. The legal and clerical professions claim perfect memory through an intricate set of reference works which can be consulted for precedence on any current case. The applicability of past to present is a matter of constant concern: argued in the law courts or in theological disputes. Scientific professionals, though, tend to claim that by its very nature science displays perfect memory: and they structure their recall primarily through a myriad of classification systems that gives them a vast reserve of potential memory (scientific articles are in principle - though never of course in practice - coded in such a way that an experiment performed one day in Algeria can be entirely replicated a hundred years later in Afghanistan). We will now go on to draw some more general conclusions about the ways in which classification systems structure memory within organizations, taking as a chief example the nature and operation of classification systems in science. There are two major reasons for choosing the institution of science for our wider discussion - the NIC development team claims to be rendering nursing scientific, and so these wider examples develop naturally out of Part 1 above; and classification work has been more formalized in science than in other institutions
It can readily be accepted that great discoveries were made but not recognized as such at the time (the cases of Kepler and Mendel are canonical). But not that discoveries were made, recognized, and then forgotten. Traditionally in science the discourse of perfect memory has not been that of the file folder - though notable publications have claimed to be `archives' for their respective disciplines. The more general claim to perfect memory is that this is in the very nature of science. Take, for example, Henri Poincare's Science and Hypothesis (1905). All scientific work, for Poincare and many positivists, went towards the construction of an eternal palace. Poincare uses the metaphor of an army of scientists, foot soldiers, each adding a brick or so to the edifice of science: AThe scientist must set in order. Science is built up with facts, as a house is with stones (101). The thing about bricks is that they don't get forgotten: they are there in the nature of the edifice. Nobody need actively recall them: buildings don't remember. But each brick that is in a building is continuously present and is therefore ageless. In another metaphor, he sees the work of doing physics as similar to building a collection of books - with the role of the theorist being to facilitate information retrieval, to catalogue:
Let us compare science to a library that ought to grow continually. The librarian has at his disposal for his purchases only insufficient funds. He ought to make an effort not to waste them.
It is experimental physics that is entrusted with the purchases. It alone, then, can enrich the library.
As for mathematical physics, its task will be to make out the catalogue. If the catalogue is well made, the library will not be any richer, but the reader will be helped to use its riches. (104)
The very nature of theory, then, is that it furnishes a classification system which can then be used to remember all (and only that) which is relevant to its associated practice.
All classification systems, however, face a bootstrapping problem. In a world of imperfect knowledge, any classificatory principle might be good, valid, useful: you won't know what makes a difference until you have built up a body of knowledge that relies, for its units of data, on the classification scheme that you have not yet developed. This is Spinoza's problem. Consider its form in the world of medical record keeping - a world in which every trace might count. In order to maintain a good system of medical records, a state needs to classify a huge mount of information about not only its own citizens, but about citizens of countries that it is in contact with (classification systems are necessarily imperialistic; witness the protests of African doctors to pressures from western AIDS researchers). The need for information and thence the burden of classificatory activity is effectively infinite. A wish-list for a national medical information system in America included the following:
all factors affecting health ... genetic and biological, environmental, behavioral, psychological, and social conditions which precipitate health problems; complaints, symptoms and diseases which prompt people to seek medical care; and evaluation of severity and functional capacity, including impairment and handicaps (Rothwell, 1985, 169-170).
Each of these sets of factors involves a classification scheme. There is no telling what information will be relevant:
to classify a chisel, a hand drill, and a spanner together as `hand tools', or the first two as `cutting and piercing instruments' may be obscurantist, or even misleading. Whereas to one accident researcher it is significant that a chisel is edged, a drill pointed, and a spanner neither, to another it may be more important that the chisel is pushed, the spanner turned and the drill operated by rotary motion. (Heidenstrom, 1985, 76)
In a world in which, as Ann Fagot-Largeault (1990, 6) has pointed out, it is impossible to die of old age (the category of being `worn out' having been removed from the ICD) it appears that we are afloat in a sea of multiple, fractured causalities each demanding their own classification systems - and their own apparatus of record collection. To deal with the plenum of information that all good organizations logically need, one can operate a distribution of memory in space (such and such a subgroup needs to hold such and such knowledge) and a distribution of memory in time (such and such a memory will only be recalled if a given occasion arises).
Classification systems provide both a warrant and a tool for forgetting at the same time as they operate this distribution. To take an overview of this process, let us consider the case of the classification of the sciences. Auguste Comte wrote about this in the first volume of his course of positive philosophy, wherein he lays out a new classification of all the sciences in hierarchical order, each science having a statics and a dynamics. He argued that it was only at the current state of advancement of science that a true classification system could emerge: since only now were the forces of religion and metaphysics sufficiently at bay that a true picture of the nature of knowledge could emerge. At the same time, the sum total of scientific knowledge was sufficiently great that it was inconceivable to learn a science by tracing its history: there were too many wrong turns, blind allies, vagaries. (Just, one might note, as one does not want to remember where one's keys are by tracing the series of actions that one has made in the past several hours). With the new classification system, knowledge could be arrayed logically and naturally - one would lose chronological order but gain coherence. Indeed, only in this way could science be logically taught; indeed: A... the most important property of our encyclopedic formulation ... is that it directly gives rise the true general plan of an entirely rational scientific education. (Comte, 1975 [1830-45], 50) What is left, in Comte's work, is the positivist calendar, where certain great scientists have their days, just as the saints had theirs in the age of religion. Serres annotates this passage with the observation that the formation (training) of scientists covers up and hides the formation (production) of scientific knowledge (51).
Indeed Comte sets in train a double motion. On the one hand, you will only learn science if you forget its history; on the other hand, you will only understand the history of science if you look at the entire history of humanity:
This vast chain is so real that often, in order to understand the effective generation of a scientific theory, the mind is led to consider the perfectioning of some art with which it has no rational link, or even some particular progress in social organization without which this discovery would not have taken place. ... It follows therefore that one cannot know the true history of any science, that is to say the real formation of the discoveries it is composed of, without studying, in a general and direct manner, the history of humanity. (52)
On the one side we have the complete history of humanity, where nothing can be forgotten because everything might be relevant; and on the other an efficient classification system which allows us to remember only what we need to remember about science. The classification system operates a clearance, in that all that was religious and metaphysical is wiped away with a single gesture; it operates selective erasure in that even in the current scientific age the processes of the production of knowledge will have to be erased from the account of the knowledge itself. The classification system tells you what to forget and how to forget it. It operates a double distribution in space of scientific memory. Firstly, the social story of science will be excluded from the organization of the sciences, and held outside of it (if at all) by historians. This is a form of erasure. Secondly, it offers a naturally hierarchy of the sciences, saying that a given discipline (say geology, statics) will need to remember all and only a given set of facts about the world. It also operates a distribution in time, saying that all scientific problems can be progressively unfolded - so that at one point along the path in treating a social problem you will need to draw on biology, then chemistry, then physics, then mathematics: each type of memory which has been distributed in space will also be sequenced in time. The plenum is contained by the overarching organization constituted by the scientific community precisely through a controlled program of first clearance then continuing erasure. The work of conjuring the world into computable form (cf Hutchins, 1995) has already been begun by the setting up of a certain kind of formal memory system - for example, one in which facts can be stored in linear time and space.
In the history of science, we frequently encounter an apposition between clearance, the deliberate destruction of the past, and establishment of a classification system. When Lavoisier set out to found the new discipline of chemistry, he wrote a textbook which standardized the names of the elements (so that Ag became silver: not Diane's metal, a name that 'remembered' the alchemical prehistory of the discipline). He also rewrote the history of chemistry so that his rivals, arguing the theory of affinities, no longer occupied a place in the textbooks: they were written out of the historical record. (Bensaude-Vincent, 1989).
The strategy of clearance is a complete wiping clean of the slate, so that one can start anew as if nothing had ever happened. As in the example of the burning of the books, it is doubtful if clearance can ever work in the short term since people do remember things and institutional arrangements do bear traces of their past - as in the case of an outmoded classifcation system being reflected in the arrangements of artifacts in a museum; however in the long term, by the time that the curricula have been redesigned, the manuals rewritten and new nursing information systems produced it can be a highly effective tool. Clearance is a pragmatic strategy: it may well be the case that a given organizational routine or piece of knowledge has roots in the distant past, and yet it may also be the case that dealing with said routine or knowledge it is easier to act as if it had just arrived on the scene. It is for this reason that the issue of truth or falsity of memory can be a red herring in treatments of organizational memory as well as analytically undecidable: a false memory, well constructed through a program of forgetting, can be of great use.
Erasure is a key dimension of classification work in all organizations. There is a famous passage in the Sherlock Holmes stories where Watson informs Holmes that the earth circles the sun; Holmes politely thanks Watson and then remarks that he will try to forget this fact as soon as possible, since it is a kind of fact that cannot possibly be relevant to the task that is ever at hand for him: the solution of crime. In scientific organizations, things get deliberately forgotten in a variety of ways. They classify away traces that they know to be relevant but which should not be officially recorded. For example, when I looked at the early archives of the Schlumberger company, I was struck by a change in the written traces being left of company activity. In the early days the boxes contained a series of highly detailed reports of daily activity sent by engineers in the field across the world to the company's center of calculation, to borrow Callon's felicitous phrase, in Paris (Callon, 1986). The theory, explicitly stated, was the company needed the best possible records of what went on in the field in order to build up a sufficiently large database so as to construct scientific knowledge, and so as to co-ordinate strategies for the insertion of the company into the oil field environment. Then one day things changed. Detailed accounts in French of work practice became sketchy tables in English of numbers of oil wells logged. What had happened? The company had gotten involved in a legal suit with Halliburton and had come to realize that its own internal traces of activity were open to potential scrutiny by US courts determining patent claims. There were two simultaneous realizations: first the records should be in English, since the French language could be read by a Southern court as a foreign code; and secondly the records should only contain kinds of facts that leant weight to the company's official presentation of itself: that is to say the cycle of accumulation of messy half-truths should be carried out elsewhere than in the organization's own potential memory system (Bowker, 1994, Chapter 3). This strategy of distributed erasure is more punctillist than that of clearance: it involves the systematic and deliberate forgetting of some actions in order to better remember others. In Adrienne Rich's words, this is an act of silence (AThe technology of silence/The rituals, etiquette/the blurring of terms/silence not absence ... Silence can be a plan/rigorously executed (Rich, 1978, 17)).
Classification systems subtending information infrastructures operate as tools of forgetting (without representation in the medical informatics infrastructure the profession of nursing is progressively erased from the annals both of history and of science). They also operate as tools for delegating attention (Latour, 1996 has an extended discussion of this sense of delegation). Nurses do not want to have to carry around in their heads what drugs the patients on their wards need to be taking and when: they either use written traces or electronic means to hold the memory and perhaps automatically remind them (either directly by commanding attention through a beeping sound or routinely by constituting distributed traces that the nurse will encounter on their normal rounds - for example the canonical chart at the foot of the patient's bed). The storage of information in a section of an organization's permanent record guarantees that heedful attention (Weick, 1993) is paid to that information in either the production of organizational knowledge (formal accounts of how the organization works) or the organization's production of knowledge (how the hospital, say, contributes to the production of nursing knowledge).
In order to produce nursing (and other) knowledge, then, various kinds of forgetting need to be operated on the permanent record held by organizations. This suggestion is fully complementary to the results from science studies and organization theory that many significant memories are held outside of formal information infrastructures. Ravetz (1971), Latour (1987) and many others have noted that one cannot do scientific work without being able to draw on information about specific local, organizational details of the operation of a given laboratory; and yet that information is nowhere systematically stored. In a series of studies of Xerox technicians, Julian Orr has shown that formal representations of fault diagnosis is often, on the spot, supplemented and indeed replaced by the swapping of war stories (`I had a machine that did something like that...' and so forth). I do not go into the preservation of nursing stories - which Julian Orr's work (e.g. Orr, 1990) and others' assures us will be generated alongside of and as a complement to formal representations of nursing work. Further, new information infrastructures such as a hospital information system adopting NIC will in fact retain traces of organizational work and will despite themselves allow for the sharing of organizational memory. Later work by Star and myself will develop the concept of organizational repression (by analogy to repressed memories) to discuss this. The argument comes down to asking not only what gets coded in but what gets read out of a given scheme (for example for the latter, who learns what from the fact that the coding book always falls open on a given page? - cf Brown and Duguid, 1994 on the importance of such peripheral clues). However, just as oral history is a significant form of community memory, it is a different kind of memory (dates are far less important, stories migrate between characters and so forth - see Vansina, 1961) from that retained in the written record. My emphasis in this paper has been purely on the nature and articulation of what goes down in the continuing formal record that the organization preserves of its own past activity. This latter area is interesting in its own right because it is by using these memories that transportable formal accounts used in law, science, management will be constructed.
Information, in Bateson's famous definition, is about differences that make a difference. Designers of classification schemes constantly have to decide what really does make a difference; along the way they develop an economy of knowledge which articulates clearance and erasure and ensures that all and only relevant features of the object (a disease, a body, a nursing intervention) being classified are remembered - for in this case the classification system can be incorporated into an information infrastructure that is delegated the role of paying due attention. A corollary of the `if it moves, count it' theory is the proposition `if you can't see it moving, forget it'. The nurses we looked at tried to guarantee that they won't be forgotten (wiped from the record) by insisting that the information infrastructure pay due attention to their activities.
In this paper, I have argued that here may indeed be good organizational reasons for forgetting. I have also argued that the ways in which things get forgotten are not merely images in a glass darkly of the way things get remembered; rather they are positive phenomena worthy of study in their own right. I have discussed two kinds of forgetting: clearance and erasure. From this emerged a consideration of forgetting and potential memory (mediated by classification systems).
I have stressed that representation in the formal record is not the only way to be remembered: indeed there is a complex ecology of memory practices within any one organization. However, the shift into long-term memory that the infrastructure provides is significant, if fraught. The production of transportable knowledge used in other registers (scientific texts, the law) at present assumes that this knowledge can be stored and expressed in a quite restricted range of genres. At the limit, as we saw with Poincare, it can be argued that scientific theory is about the storage of information in such long-term memory. In order to prevent continuing erasure within hospital information systems, nurses have had to operate a clearance of their own past (recorded history begins today). The prize before their eyes is a science and a profession; the danger oblivion (either being definitively excluded from ongoing information practices and thus relegated to an adjunct role or being included but then distributed through re-engineering).
There is much to be done to understand the processes of commemoration, memory, history and recall in organizations. Organizational forgetting and organizational memory are useful concepts here because they allow us to move flexibly between the formal and the informal, the material and the conceptual. Designers of information superhighways need to take the occasional stroll down memory lane.
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I am grateful to Leigh Star, Marc Berg, Jesper Doepping, Dick Boland, two anonymous reviewers and to members of the Illinois Research Group on Classification for comments on this paper. I wish to acknowledge the unfailing support and interest of the Iowa Intervention Project, notably JoAnne McCloskey, Gloria Bulechek and Bill Donahue.