How things (actor-net)work:

Classification, magic and the ubiquity of standards

Geoffrey C. Bowker

Susan Leigh Star

Graduate School of Library and Information Science

University of Illinois at Urbana-Champaign

November 18, 1996

to appear in a special issue of Philosophia

"A classified and hierarchically ordered set of pluralities, of variants, has none of the sting of the miscellaneous
and uncoordinated plurals of our actual world." (Dewey, 1989: 49)

INTRODUCTION

"We do many things today that a few hundred years ago would have looked like magic". We all know versions
of this banal assertion - we've probably all made it ourselves at some point or another. And if we don't
understand a given technology it looks like magic: we are perpetually surprised by the mellifluous tones read
off our favorite CDs by (we believe) a laser. Star (1995b) notes that even engineers black box and think of
technology `as if by magic' in their everyday practical dealings with machines. A common description of a good
waiter or butler (one thinks of Jeeves in the Wodehouse stories) is that she clears a table `as if by magic'. Are
these two kinds of magic or one or none?

The following paper is an attempt to answer this question, which can be posed more prosaically as:

 What work do classifications and standards do? We want to look at what goes into making things work
like magic: making them fit together so that we can buy a radio built by someone we have never met in
Japan, plug it into a wall in Champaign, Illinois and hear the world news from the BBC.

 Who does that work? We want to explore the fact that all this magic involves much work: there is a lot
of hard labor in effortless ease[1]. Such invisible work is often not only underpaid - it is severely
underrepresented in theoretical literature (Star and Strauss, in press). We will discuss where all the
`missing work' that makes things look magical goes.

 What happens to the cases that don't fit? We want to draw attention to cases that don't fit easily into our
created world of standards and classifications: the left handers in the world of right-handed magic,
chronic disease sufferers in the world of allopathic acute medicine, the onion-hater in MacDonalds (Star,
1991b) and so forth.

These are issues of great epistemological, political and ethical import. It is easy to get lost in Baudrillard's
(1990) cool memories of simulacra. The hype of our times is that we don't need to think about the work any
more: the real issues are scientific and technological - in artificial life, thinking machines, nanotechnology,
genetic manipulation... Clearly each of these are important. However, we endeavor to demonstrate that there is
rather more at stake - epistemologically, politically and ethically - in the day to day work of building
classification system and producing and maintaining standards than in these philosophical high-fliers. The
pyrotechnics may hold our fascinated gaze; they cannot provide any path to answering our questions.

(…)

We draw attention here to the places where the work gets done of assuring that delegation and mediation will
work: to the places where human and non-human are constructed to be operationally and analytically
equivalent. And following both Dewey and Latour, we also question the indifference -- of nature, and of
machines. So doing, we explore the political and ethical dimensions of actor-network theory, restoring the
interlinked and webbed relationships between people, things, and infrastructure.
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TWO DEFINITIONS

We will take a ‘classification’ to be a spatial, temporal or spatio-temporal segmentation of the world. A

 the operation of consistent classificatory principles (for example being solely a genetic classification
(Tort, 1989) classifying things by their origin);
 mutual exclusivity of categories;
 completeness (total coverage of the world being described).

No working classification system that we have looked at meets these ‘simple’ requirements and we doubt that
any ever could (Desrosières and Thevenot, 1988).

For example, consider the International Classification of Diseases, which will be one of our major examples
throughout this paper. The full title of the current (10th) edition of the ICD, is: "ICD-10 - International
Statistical Classification of Diseases and Related Health Problems; Tenth Revision". Note that it is designated a
‘statistical’ classification. By this is meant that only diseases which are statistically significant are to be entered
in (it is not an attempt to classify all disease). It calls itself a ‘classification’, even though many have said that it
is a `nomenclature' since it has no single classificatory principle (it has at least four; which are not mutually
exclusive (Bowker and Star, 1994). In many cases it represents a compromise between conflicting schemes:
"The terms used in categories C82-C85 for non-Hodgkin's lymphomas are those of the Working Formulation,
which attempted to find common ground among several major classification systems. The terms used in these
schemes are not given in the Tabular List but appear in the Alphabetical Index; exact equivalence with the terms
appearing in the Tabular List is not always possible". (ICD-10, 1, 215). However, it presents itself clearly as a
classification scheme and not a nomenclature. Since 1970, there has been an effort underway by the World
Health Organization to build a distinct International Nomenclature of Diseases, whose main purpose will be to
provide: "a single recommended name for every disease entity" (ICD-10, 1, 25). The point here is that we want
to take a broad enough definition so that anything that is consistently called a classification system can be
included. If we took a purist view, the ICD would be a nomenclature and who knows what the IND would be.
With a broad definition we can look at the work that is involved in building and maintaining a family of entities
that people call classification systems - rather than attempt the Herculean, Sisyphian task of purifying the
(un)stable systems in place. Howard Becker makes the point here: "Epistemology has been a ... negative
discipline, mostly devoted to saying what you shouldn't do if you want your activity to merit the title of science,
and to keeping unworthy pretenders from successfully appropriating it. The sociology of science, the empirical
descendant of epistemology, gives up trying to decide what should and shouldn't count as science, and tells
what people who claim to be doing science do..." (1996: 54-55).

We will take a ‘standard’ to be any set of agreed-upon rules for the production of (textual or material) objects.
There are a number of histories of standards which point to the development and maintenance of standards as
being a key to industrial production. Thus, as David Turnbull points out, it was possible to build a cathedral like
Chartres without standard representations (blueprints) and standard building materials (regular sizes for stones,
tools etc.) (1993). However it is not possible to build a modern housing development without them: too much
needs to come together - electricity, gas, sewer, timber sizes, screws, nails and so on. The control of standards is
a central, often underanalyzed (but see the work of Paul David - for example David and Rothwell, 1994 - for a
rich treatment) feature of economic life. They are key to knowledge production as well - Latour (1987)
speculates that far more economic resources are spent creating and maintaining standards than in producing
`pure' science. Key dimensions of standards are:
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 They are often deployed in the context of making things work together - computer protocols for Internet
communication involve a cascade of standards (cf. Abbate and Kahin, 1995) which need to work
together well in order for the average user to gain seamless access to the web of information. There are
standards for the components to link from your computer to the phone network, for coding and decoding
binary streams as sound, for sending messages from one network to another, for attaching documents to
messages and so forth;
 They are often enforced by legal bodies - be these professional organizations; manufacturers'
organizations or the State. We can say tomorrow that volapük (a universal language that boasted some
23 journals in 1889[2]) or its successor Esperanto shall henceforth be the standard language for
international diplomacy; without a mechanism of enforcement we shall probably fail.
 There is no natural law that the best (technically superior) standard shall win - the QWERTY keyboard,
Lotus 123, DOS and VHS are often cited in this context. Standards have significant inertia, and can be
very difficult to change.

Classifications and standards are two sides of the same coin. The distinction between them (as we are defining
them) is that classifications are containers for the descriptions of events - they are an aspect of organizational,
social and personal memory - whereas standards are procedures for how to do things - they are an aspect of
acting in the world. Every successful standard imposes a classification system.

UNDERSTANDING CLASSIFYING AND STANDARDIZING

This paper will offer four major themes for understanding classifying, standardizing (and the related processes
of formalizing) and their politics and histories. Each theme operates as a gestalt switch - it comes in the form of
an infrastructural inversion (Bowker, 1994). Inverting our commonsense notion of infrastructure means taking
what have often been seen as behind the scenes, boring, background processes to the real work of politics and
knowledge production[3] and bringing their contribution to the foreground. The first two, ubiquity and material
texture, speak to the space of actor-networks; the second two, the indeterminate past and the practical politics,
speak to their time. Taken together, they sketch out features of the historically creation of the infrastructure
which (ever partially, ever incompletely) orders the world in such a way that actor-network theory becomes a
reasonable description.

The first major theme is seeing the ubiquity of classifying and standardizing. Classification schemes and
standards literally saturate the worlds we live in. This saturation is furthermore intertwined, or webbed together.
While it is possible to pull out a single classification scheme or standard for reference purposes, in reality none
of them stand alone. So a subproperty of ubiquity is interdependence, if not smooth integration.

The second major theme is to see classifications and standards as materially textured. Under the sway of
cognitivism, it is easy to see classifications as properties of mind and standards as ideal numbers or settings. But
both have material force in the world, and are built into and embedded in every feature of the built environment
(and many of the borderlands, such as with engineered genetic organisms). When we think of classifications and
standards as material, we can afford ourselves of what we know about material structures, such as structural
integrity, enclosures and confinements, permeability, and durability, among many others. We see people doing
this all the time in describing organizational settings, and a common way to hear people's experience of this
materiality is through metaphors. So the generation of metaphors is closely linked with the shift to texture.

The third major theme is to see the past as indeterminate[4]. This is not a new idea to historiography, but is
important in understanding the evolution of ubiquitous classification/standardization and the multiple voices
that are represented in any scheme. No one classification orders reality for everyone -- e.g. the red light-green
light-yellow light categories don't work for blind people or those who are red-green color blind. In looking to
 4

classification schemes as ways of ordering the past, it is easy to forget those who are overlooked in this way.
Thus, the indeterminacy of the past implies recovering multi-vocality; it also means understanding how
standard narratives that seem universal have been constructed (Star, 1991a).

The fourth major theme is uncovering the practical politics of classifying and standardizing. There are two
aspects of these politics: arriving at categories and standards, and, in the process, deciding what will be visible
within the system (and of course what will thus then be invisible). The negotiated nature of standards and
classifications follows from indeterminacy and multiplicity that whatever appears as universal or, indeed,
standard, is the result of negotiations or conflict. How do these negotiations take place? Who determines the
final outcome in preparing a formal classification? Visibility issues arise as one decides where to make the cuts
in the system, for example, down to what level of detail one specifies a description of work, of an illness, of a
setting. Because there are always advantages and disadvantages to being visible, this becomes crucial in the
workability of the schema.

Ubiquity

In the built world we inhabit, thousands and thousands of standards are used everywhere, from setting up the
plumbing in a house to assembling a car engine to transferring a file from one computer to another. Consider the
canonically simple act of writing a letter longhand, putting it in an envelope and mailing it. There are standards
for (inter alia): paper size, the distance that lines are apart if it is lined paper, envelope size, the glue on the
envelope, the size of stamps, their glue, the ink in the pen that you wrote with, the sharpness of its nib, the
composition of the paper (which in turn can be broken down to the nature of the watermark, if any; the degree
of recycled material used in its production, the definition of what counts as recycling). And so forth.

Similarly, in any bureaucracy, classifications abound -- consider the simple but increasingly common
classifications that are used when you dial an airline for information now ("if you are traveling domestically,
press 1"; "if you want information about flight arrivals and departures, press 2...."). And once the airline has
hold of you, you are classified by them as a frequent flyer (normal, gold or platinum); corporate or individual;
tourist or business class; short haul or long haul (different fare rates and scheduling applies); irate or not
(different hand-offs to the supervisor when you complain).

A systems approach would see the proliferation of both standards and classifications as a matter of integration --
almost like a gigantic web of interoperability. Yet the sheer density of these phenomena go beyond questions of
interoperability. They are layered, tangled, textured; they interact to form an ecology as well as a flat set of
compatibilities. There ARE spaces between (unclassified, non-standard areas), of course, and these are equally
important to the analysis. A question: it seems that increasingly these spaces are marked as unclassified and
non-standard. How does that change their qualities?

It is a struggle to step back from this complexity and think about the issue of ubiquity broadly, rather than try to
trace the myriad connections in any one case. We need concepts for understanding movements, textures, shifts
that will grasp larger patterns in this. For instance, the distribution of residual categories ("not elsewhere
classified" or "other"), is one such concept. "Others" are everywhere. The analysis of any one instance of a
residual category might yield information about biases or what is valued in any given circumstance; seeing that
residual categories are ubiquitous offers a much more general sweep on the categorizing tendencies of most
modern cultures. Another class of concepts which are found ubiquitously, and which speak to the general
pervasiveness of standards and classification schemes, concern those which describe tangles or mismatches
between subsystems. For instance, what Strauss calls a "cumulative mess trajectory" is a useful notion (Strauss,
et al., 1985). In medicine, this occurs when one has an illness, is given a medicine to cure the illness, but incurs
a serious side effect, which then needs to be treated with another medicine, etc. If the trajectory becomes so
tangled that you can't return and the interactions multiply, "cumulative mess" results. We see this phenomenon
 5

in the interaction of categories and standards all the time -- ecological examples are particularly rich places to
look.

Texturing Classification and Standardization

How do we "see" this densely saturated classified world? We are commonly used to casually black-boxing this
behind-the-scenes machinery, even to the point, as we noted above, of ascribing a casual magic to it. All
classification and standardization schemes are a mixture of physical entities such as paper forms, plugs, or
software instructions encoded in silicon and conventional arrangements such as speed and rhythm, dimension,
and how specifications are implemented. Perhaps because of this mixture, the web of intertwined schemes can
be difficult to "see." In general, the trick is to question every apparently natural easiness in the world around us
and look for the work involved in making it easy. Within a project or on a desktop, the seeing consists in
seamlessly moving between the physical and the conventional. So when a computer programmer writes some
lines of C code, she moves within conventional constraints and makes innovations based on them; at the same
time, she strikes plastic keys, shifts notes around on a desktop, and consults manuals for various standards and
other information. If we were to try to list out all the classifications and standards involved in writing a
program, the list could run to pages. Classifications include types of objects, types of hardware, matches
between requirements categories and code categories, and meta-categories such as the goodness of fit of the
piece of code with the larger system under development. Standards range from the precise integration of the
underlying hardware to the 60Hz power coming out of the wall through a standard size plug.

Merely reducing the description to the physical aspect such as the plugs does not get us anywhere interesting in
terms of the actual mixture of physical and conventional. A good operations researcher could describe how and
whether things would work together, often purposefully blurring the physical/conventional boundaries in
making the analysis. But what is missing there is a sense of the landscape of work as experienced by those
within it. It gives no sense of something as important as the texture of an organization: it is smooth or rough?
Bare or knotty? What is needed is a sense of the topography of all of the arrangements -- are they colliding? co-
extensive? gappy? orthogonal? One way to begin to get at these questions is to begin to take quite literally the
kinds of metaphors that people use when describing their experience of organizations, bureaucracies, and
information systems (Star, in press). So, for example, when someone says something simple like "things are
running smoothly," the smoothness is descriptive of an array of articulations of people, things, work and
standards. When someone says, "I feel as though the whole project is moving through thick molasses," it points
to the opposite experience. These are not merely poetic expressions, although at some level they are that, too.
As Schon pointed out in his seminal book, Displacement of Concepts, a metaphor is an import, meant to
illuminate aspects of a current situation via juxtaposition (1963). It is also a rich and often unmined source of
knowledge about people's experience of the densely classified world.

The Indeterminacy of the Past

There is no way of ever getting access to the past except through classification systems of one sort or another -
formal or informal, hierarchical or not ... . Take the unproblematic statement: "In 1640, the English Revolution
occurred; this led to a twenty year period in which the English had no monarchy". The classifications involved
here include:

 The current segmentation of time into days, months and years. Accounts of the English revolution
generally use the Gregorian calendar, which was adopted some hundred years later - so causing
translation problems with contemporary documents;
 6

 The classification of `peoples' into English, Irish, Scots, French and so on. These designations were by
no means so clear at the time - the whole discourse of national genius really only arose in the nineteenth
century;
 The classification of events into revolutions, reforms, revolts, rebellions and so forth (cf. Furet, 1978 on
thinking the French revolution). There really was no concept of `revolution' at the time; our current
conception is marked by the historiographical work of Karl Marx.
 And then, what do we classify as being a `monarchy'? There is a strong historiographical tradition which
says that Oliver Cromwell was a monarch - he walked, talked and acted like one after all. Under this
view, there is no hiatus at all in this English institution; rather a usurper took the throne.

There are two major schools of thought with respect to using classification systems on the past - one saying that
we should only use classifications available to actors at the time (authors in this tradition warn against the
dangers of anachronism - Hacking (1995) on child abuse is a sophisticated version) and the other that we should
use the real classifications that progress in the arts and sciences has uncovered (typically history informed by
current sociology will take this path - for example Tort's (1989) work on `genetic' classification systems, which
were not so called at the time, but which are of vital interest to the Foucaldian problematic). Whichever we
choose, it is clear that we should always understand classification systems according to the work that they are
doing -the network within which they are embedded.

When we ask historical questions about the deeply and heterogeneously structured space of classification
systems and standards, we are dealing with a 4-dimensional archaeology - some of the structures it uncovers are
stable, some in motion; some evolving, some decaying. An institutional memory, about say, an epidemic, can be
held simultaneously and with internal contradictions (sometimes piecemeal or distributed and sometimes with
entirely different stories at different locations) across [a given institutional] space.

In the case of AIDS, for example, there are shifting classifications over the last 20 years, including the invention
of the category in the first place. There is then a backwards look at cases which might have been AIDS before
we had the category (a problematic gaze to be sure, as Bruno Latour (forthcoming) has written about
tuberculosis; see also Star and Bowker, 1997). There are the stories about collecting information about a
shameful disease, and a wealth of personal narratives about living with it. There is a public health story and a
virology story, which use different category systems. There are the standardized forms of insurance companies
and the categories and standards of the census bureau; when an attempt was made to combine them in the 80s to
disenfranchise young men living in San Francisco from getting health insurance, the resultant political
challenge stopped the combination of this data from being so used. At the same time, the blood banks refused
for years to employ HIV screening, thus refusing the admission of another category to their blood labeling -- as
Shilts (1987) tells us, with many casualties as a result.

Practical Politics

Someone, somewhere, often a body of people in the proverbial gray suits and smoke-filled rooms, must decide
and argue over the minutiae of classifying and standardizing. The negotiations themselves form the basis for a
fascinating practical ontology -- our favorite example is when is someone really alive? Is it breathing, attempts
at breathing, movement....? And how long must each of those last? Whose voice will determine the outcome is
sometimes an exercise of pure power: we, the holders of Western medicine and of colonialism, will decide what
a disease is, and simply obviate systems such as acupuncture or Ayruvedic medicine. Sometimes the
negotiations are more subtle, involving questions such as the disparate viewpoints of an immunologist and a
surgeon, or a public health official (interested in even ONE case of the plague) and a statistician (for whom one
case is not relevant) (Neumann and Star, 1996).
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Once a system is in place, the practical politics of these decisions are often forgotten, literally buried in archives
(when records are kept at all) or built into software or the sizes and compositions of things. In addition to our
archaeological expeditions into the records of such negotiations, we provide here some observations of the
negotiations in action. Finally, even where everyone agrees on the way the classifications or standards should be
established, there are often practical difficulties about how to craft their architecture. For example, a
classification system with 20,000 "bins" on every form is practically unusable. (The original International
Classification of Diseases had some 200 diseases not because of the nature of the human body and its problems
but because this was the maximum number that would fit the large census sheets then in use). Sometimes the
decision about how fine-grained to make the system has political consequences as well. For instance, in
describing and recording the tasks someone does, as in the case of nursing work, may mean controlling or
surveilling their work as well, and may imply an attempt to take away discretion. After all, the loosest
classification of work is accorded to those with the most power and discretion, who are able to set their own
terms.

These ubiquitous, textured classifications and standards help frame our representation of the past and the
sequencing of events in the present. They can best be understood as doing the ever-local, ever-partial work of
making it appear that science describes nature (and nature alone) and that politics is about social power (and
social power alone). Consider the case discussed at length by Young (1995) and Kirk and Kutchins (1992) of
psychoanalysts who in order to receive reimbursement for this procedures need to couch them in a biomedical
language (the DSM) that is anathema to them, but is the lingua franca of the medical insurance companies.
There are local translation mechanisms that allow the DSM to continue to operate and to provide the sole legal,
recognized representation of mental disorder. A `reverse engineering' of the DSM or the ICD reveals the
multitude of local political and social struggles and compromises which go into the constitution of a `universal'
classification.

(…)

In order to clarify our position here, let us take an analogy. In the early nineteenth century in England there
were a huge number of capital crimes - starting from stealing a loaf of bread and going up... . However,
precisely because the penalties were so draconian, few juries would ever impose the maximum sentence; and
indeed there was actually a drastic reduction in the number of executions even as the penal code was
progressively strengthened. There are two ways of writing this history - one can either concentrate on the
creation of the law; or one can concentrate on the way things worked out in practice.

(…)

The point for us is that both of these are valid kinds of account.

Early [studies of science from the tradition of] actor-network theory concentrated on the ways in which it comes
to seem that science gives an objective account of natural order: trials of strength, enrolling of allies, cascades
of inscriptions and the operation of immutable mobiles. It drew attention to the importance of the development
of standards (though not to the linked development of classification systems); but did not look at these in detail.
We were invited to look at the process of producing something which looked like what the positivists alleged
science to be. We got to see the `Janus face' of science. In so doing we `followed the actors'. We shared their
insights (allies must be enrolled, translation mechanisms must be set in train so that, in the canonical case,
Pasteur's laboratory work can be seen as a direct translation of the quest for French honor after defeat in the
battlefield).

However, by the very nature of the method, we also shared their blindness. The actors being followed did
not see what was excluded: they constructed a world in which that exclusion could occur. Thus if we just follow
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the doctors who create the International Classification of Diseases at the World Health Organization in Geneva,
we will not see the variety of representation systems that other cultures have for classifying diseases of the body
and spirit; and we will not see the fragile networks these classification systems subtend. Rather, we will see
only those actants who are strong enough, and shaped in the right way, to impact the fragile actor-networks of
allopathic medicine. We will see the blind leading the blind.

(…)

A good example (…) comes from the nursing administrators we are studying at present. We will see how they
are producing a classification of nursing work whose political edge is in the technical work of meshing this
classification system with those already operating within the sociotechnical framework of the hospital. There is
a play of resistances around this political of representation.

The Iowa Intervention Team are producing a classification of all nursing work - a nursing interventions
classification (NIC) (McCloskey and Bulechek, 1996). 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? 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.

Within the context of the hospital's sociotechnical system, nursing work has been deemed irrelevant to any
possible future reconstruction; it has been canonically invisible, in Star's (1991a) term. The logic of NIC's
advocators is that what has been excluded from the representational space of medical practice should be
included. 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
 9

of his key attributes of a profession [1988].) 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 - else nursing work
would not be represented at all in the future, and would risk being even further marginalized than it was at
present.

However, there is also a danger in representing. It is more difficult to hive off aspects of nursing duties and give
them to lower paid adjuncts, if nursing 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 (in press) 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.

Further, 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 (Bowker, Star and Timmermans, 1996).
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 the 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-related strategies of 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 actor-
network system that includes nursing. These 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 health care 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.

(…)
 10

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.

(…)

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