The Rhetorical Life of Surgical Checklists: A Burkean Analysis with Implications for Knowledge Translation by Sarah Whyte A thesis presented to the University of Waterloo in fulfillment of the thesis requirement for the degree of Doctor of Philosophy in English Waterloo, Ontario, Canada, 2018 © Sarah Whyte 2018 Examining committee membership The following served on the Examining Committee for this thesis. The decision of the Examining Committee is by majority vote. External Examiner Carolyn Miller Emeritus Professor, North Carolina State University Supervisor Jay Dolmage Associate Professor, University of Waterloo Internal Member Catherine Schryer Professor, Ryerson University Internal Member Randy Harris Professor, University of Waterloo Internal-external Member Kathryn Plaisance Associate Professor, University of Waterloo Other Member (Non-voting) Lorelei Lingard Professor, Western University ii Author’s declaration This thesis consists of material all of which I authored or co-authored: see Statement of Contributions included in the thesis. This is a true copy of the thesis, including any required final revisions, as accepted by my examiners. I understand that my thesis may be made electronically available to the public. iii Statement of contributions I am the sole author of this thesis, except for Chapter 4, which reproduces a significant portion of a published article on which I am the first author with six co-authors. That chapter also draws more selectively upon three additional co-authored articles. I was the first author of one and substantive co-author of the other two. iv Abstract This dissertation uses the terms of Kenneth Burke’s dramatism to identify rhetorical aspects of surgical team checklists as they have been promoted, performed, studied, and surveilled. I argue that these terms can help to account both for the rapid uptake of checklists into policy and for their more variable effects and uptake into practice. I develop this argument by analyzing a large archive of texts published between 1999 and 2017, including popular media, news coverage, promotional campaigns, primary research, and other forms of scholarship. These published texts are considered alongside ethnographic fieldnotes from a study in which I collaborated to design, introduce, and evaluate an early version of a preoperative checklist at four Canadian hospitals. My analyses are guided heuristically by the first principles and central terms of dramatism, including action and motion; motive and situation; identification and division; attitude, form, and circumference. I use these terms to chart the early emergence of checklists within professional literature; to trace their rapid uptake as a standard of professional communication; to discern their multiple purposes and effects; to illustrate how and why they are enacted, accepted, and sometimes rejected in the operating theatre; and to locate blind spots in applied health services research. Taken together, these analyses demonstrate the importance of diverse rhetorical processes both to the uptake and to the basic functions of checklists. They also demonstrate the value and versatility of dramatistic terms. I contend in particular that the concept of rhetorical situation, as elaborated by Burke, holds significant potential for understanding and mediating the material and symbolic dimensions of practice and practice change. This dissertation points the way toward a uniquely rhetorical approach to the study and practice of knowledge translation in healthcare work. v Acknowledgements This dissertation has been cultivated from seeds planted over many years. For those seeds and their now-sturdy roots, I am thankful to the members of my committee: Catherine Schryer, Randy Harris, Lorelei Lingard, and Jay Dolmage. Each of their roles has shifted over time as this research has grown in the spaces between disciplines and institutions. All of them have inspired the substance of this work in deeply formative ways. I am especially grateful that their support has endured, without hesitation, even when I have been neither swift nor graceful in clearing the hurdles of this degree. For any shortcomings of this work, the fault is mine. And Kenneth Burke’s. Randy got me hooked on the discipline of rhetoric and the rhetoric of science in 2000, when I first arrived to the University of Waterloo seeking a bridge from biomedical science into English. At the same time, Catherine introduced me to genre theory, qualitative research, education in the health professions—and to Lorelei. I ultimately returned to do a PhD because these introductions to the field had yielded so many questions and because there was still so much to learn from both Catherine and Randy. Many of those questions grew from my time working with Lorelei. This doctoral proJect was possible because she blazed many trails, created opportunities for me within her research team, and then gave me the freedom to chart my own course from that work. I am more grateful still for what I have learned from Lorelei about teaching and research as dynamic and rigorous rhetorical practices. Her direct mentorship largely preceded my doctoral studies but continues to guide me at every turn. As my original supervisor and then co-supervisor, Catherine guided the foundational stages of this work. She has modelled ways of drawing social and rhetorical theories into the close analysis of communication in context. She drew my attention toward concepts that later emerged into this proJect—and are still emerging—in important but unexpected ways. I am grateful too for her confidence and enthusiasm, which have persisted through diversions in my life, along with professional moves in her own. vi Randy’s teaching, writing, and incisive feedback have deepened my understanding of rhetorical theory, Kenneth Burke, form, and cognitive rhetoric—all of which run to the core of this proJect in explicit and implicit ways. Along with his intellectual generosity, they serve as guides for me whenever I am seeking inspiration, direction, conceptual clarity, or a renewed sense of rhetorical possibility. It is largely thanks to Jay Dolmage that I ultimately completed this proJect. As my supervisor at Waterloo, he kept me connected and optimistic during the more isolated stages of this work. His ease, encouragement, constant availability, and nimble feedback enabled me to regain a sense of perspective and to keep moving whenever I got stuck. Long before I did, he saw completed theses amidst my work. He kept insisting that I was almost finished until I could see it, and make it so, for myself. Two fellowships provided the most formative and intellectually exciting experiences of my doctoral studies. It was a joy and privilege to be part of the vibrant community of scholars at Health Care, Technology, and Place. The Wilson Centre is an academic home that never fails to lift my spirits and celebrate incongruous perspectives. Along with the Department of English at the University of Waterloo, these communities have enabled me to believe seriously in the ideal of transdisciplinary scholarship that discovers its relevance by pursuing difficult questions wherever they lead. I do not take this belief or its enabling conditions for granted. I am especially thankful to particular members of these communities. Tina Martimianakis has been a constant source of encouragement and wisdom. The collaboration and friendship of Erica Sutton and Holly Witteman made this process worthwhile independent of the degree at the end. For various forms of support and dialogue that directly enabled this work at one stage or another, I would like to thank Mariana Arteaga, Doug Buller, Carrie Cartmill, Tina Davidson, Sherry Espin, Brian Hodges, Patricia McKeever, Nancy McNaughton, and Aimée Morrison. For making my writing days brighter, I’m thankful to Cynthia Vo, Pamela Cunningham, Yaania Veerasingam, and my friends in the Academic Ladder Writing Club—especially vii Emily Michelson and Eleanor Carlson, who (as anonymous scholars) kept me company at odd hours and pulled me through the home stretch from Italy and Japan. I am thankful to the surgeons, nurses, and anesthesiologists who were so hospitable toward the Team Talk proJect that gave rise to this work. Both that proJect and my doctoral research were supported by funding from the Canadian Institutes of Health Research. I am also grateful to Richard and Elizabeth Currie, who not only fund a Fellowship for education research in the health professions but also host an annual dinner for recipients and listen keenly to updates on our work as it evolves. For rewarding collaborations that also enabled me to pay bills, and the flexibility to prioritize my doctoral proJect when I needed to, I am thankful to Cynthia Whitehead, Sophie Soklaridis, and Tina Martimianakis. To Kari Osmar, I am thankful for these things along with friendship and conversations about professional education and practice that wended their way through three seasons of ironman training and beyond. My work and life are forever enriched and energized by Michelle Janutka. I have more gratitude than words for Michelle, Christopher Turner, and Jean-François Daignault, who blur the lines between friends and family in the most wonderful ways. They have gracefully shared many visits and vacations with this proJect tagging along uninvited. Above all—for sun, soil, water—I am grateful to my parents, Sally and Doug, whose generosity and care run constant and deep. They have given resolve, humour, fierce belief, and support of every kind, always. I am thankful, finally, for my daughters, Morgan and Tamsin, who teach me every day about rhetoric and its limits in ways that are funny and grounding and wise. And for Anna, who is also funny, grounding, and wise—and who didn’t know what she was getting herself into. Her support comes in the steadfast, day-in and day-out variety. She has navigated the start, middle, and end of all my endurance events with love, resilience, and sometimes hand-painted signs reminding me to just keep swimming. viii Dedication This is for my grandmothers, Jessie and Dorothy, and my aunt Janet, all of whose resilient, quiet voices I can still hear cheering for me.