Performing a crisis: Institutional politics and the construction of (ir)responsibility

Abstract

The article adopts a performative perspective to examine how tangible spaces are produced through publicly contrived performances, with the intention of shaping organizational practices, mindsets and politics. We focused on the deliberate and consensual production of the Neonatal Intensive Care Unit (NICU) as a crisis zone—one that is ruled by turbulence and uncertainty. Severe shortage of funds and a public policy of abstention turned the NICU into a liminal space. Consequently, a new domain for the operation of power came into existence—one where life is put ‘in question’ and can be both protected and eliminated. By way of paradox, operating under a continuing state of emergency created degrees of freedom for all involved, especially regarding the outcomes of care.

‘The performative functions to produce that which it declares’ states Butler (1993: 107). She thus sensitizes us to the ways in which relations of domination materialize in organizational environments (Borgerson, 2001; Dale, 2005; Taylor and Spicer, 2007). The landscapes within which ‘doing’ or performing is conducted become dramatic sites in which social categories are fervently negotiated (Iedema et al., 2004). Inspired by Foucault’s works, several authors call upon us to consider the ways in which materiality incorporates forms of control, which are then enacted and embodied on an everyday basis (Appadurai, 1986; Dale, 2005; Foucault, 1980a, 1980b; Tyler and Cohen, 2010). In this view, workspaces shape, enable or constrain certain performances. However, how these performances shape spatial materialization is still underexplored in current organizational literature. We thus ask how the Neonatal Intensive Care Unit, a tangible space was publicly constituted as a ‘disaster zone’, or ‘heterotopia’, to use Foucault’s terminology, and to what strategic or political end? Finally, we show how this particular spatial configuration shaped the lived experiences of its inhabitants, namely physicians, nurses and patients.

The article begins by examining how diverse stakeholders appearing before the Israeli Parliaments’ Special Committees for the Rights of the Child (PSCRC) discursively produced the NICU as a ‘disaster zone’, and how this spatial reconstruction entailed a specific logic for the care of others in the NICU. In so doing, we call attention to the collective, dialogical and intentional construction of space (Lefebvre, 1991). We contend that participants’ choice of stories or anecdotes as means of participation in this public arena both uncovers the backstage of organizing in this public healthcare system, and reveals the moral and political aspects of day to day decision-making in the NICU. Exploring how this specific public performance converted the under budgeted and impoverished NICU into a manageable site for the provision of care; allows us to explore the unsettling yet creative implications of constructing the NICU as a disaster zone (Simpson et al., 2009; Sturdy et al., 2006). We thus contribute to current understanding of the complex relationships between spatiality, performativity, and politics—a relationship that is still underdeveloped in organizational politics studies (Flemming and Spicer, 2004).

The politics of spatial performance—the birth of tangible spaces

The relationship between materiality and performativity can be broadly divided into three streams of thought: studies of space as materialization of power relations, studies of space as props or scenery, and studies of space as representation. We draw on all three to uncover the politics of declaring the NICU a disaster zone.

Studies of space as materialization of power relations

Drawing heavily on both Foucault’s and Butler’s works, this stream of studies looks to uncover the power relations underpinning both spatial configurations, and organizational performances. Space serves as both a site where power is realized, and a mechanism or an apparatus of power and domination (Foucault, 1980a, 1980b). Both subjectivities and spaces are manufactured and inscribed on the body through performative iterations that are embedded in a specific time and place (Butler, 1993: 95). These performances are powerful invocations of ‘regularized and constrained repetition of norms’. They are thus fairly persistent and static entities containing ‘fixed cultural codes, norms and scripts’ that actors’ simply enact.

Though fairly stable, performances can potentially denaturalize social categories and destabilize dominant forms of social reproduction. For example, occupants may ‘rescript’ organizational spaces through its deliberate misappropriation and misuse (Borgerson, 2005; Gregson and Rose, 2000; Taylor and Spicer, 2007). However, concludes Butler, such contestation is rarely significant enough to alter relations of domination.

Space as props or scenery—a dramaturgical perspective

While Butler refused a notion of a social agent that exists prior to its production through enacted discourse, Goffman (1959) views the subject as an active and conscious performing self. Performance is thus a communicative means through which joint realities are negotiated. Interaction is an engagement between individual(s) and audience(s), to whom individuals perform and who, in turn, interpret their actions (Gregson and Rose, 2000). In these incessant iterations, the skillful and culturally astute social actors adjust the ‘expressions’ they ‘give’ and ‘give off’ so as to convey the ‘impression’ that they are what they claim to be. Performance is thus an aesthetic experience, a ‘type of production which excites, motivates, and persuades its audience. Specific spaces are really locations or stages on which the appropriate scripts are staged, interpreted and responded to. If so, spaces can be manipulated to suspend the existing order. Drawing on Turner’s definition of a ‘liminal’ space, Clark and Mangham (2004) write:

[these performances] are suspensions of daily reality, occupying privileged spaces where people are allowed to think about how they think about the terms in which they conduct their thinking or to feel about how they feel about daily life. (Turner, 1984: 23, c.f Clark and Mangham, 2004: 43)

And so, contend Clark and Mangham (2004) these publicly contrived performance may actually advance the process of discursive exploration, since it creates a sequestered time-frame in which all participants are ‘temporarily undefined’ and have no rights over others. Temporarily liberated from their structural obligations’, participants can come together and reflect upon their organizations’ values and performance (Turner, 1982: 27, c.f Czarniawska and Mazza, 2003: 272). To sum, this perspective views performance as a one off occurrence that brings into play ‘multi-stranded stories of experiences that lack collective consensus, and hence foreground ‘the ambiguities of social construction and the indeterminacy of organizational experiences’ (Boje, 2008: 9; Keenoy and Oswick, 1997: 149). As such it serves the locus of significant political action, not for its subversive potential, but because it occasions legitimate efforts to affect another to feel, think or behave in a desired fashion.

Studies of space as representation

The third stream of research analyses space as text. Lefebver was the first to coin the term ‘representational space’ or ‘lived space’ to denote ‘space as directly lived through its associated images and imagined through various forms of symbolism, including language. Yanow (1998) for instance asks how our aesthetic experiences of space are shaped by the meanings we ascribe to them. In this view, the same space may have different meanings for different occupants, and is decided through interaction, dialogue and experience, as signs, images and symbols are made material.

How, then are spaces produced through publicly contrived performances? And, once constituted, what types of doing (political and other) do they entail? To attempt an answer, we pay close attention to interchanges that are characterized by the physical co-presence of performers and audience, in occurrences that are transitory, and never again will occur or be perceived in the same way (Biehl-Missal, 2010). This, of course, requires the development of a more sensitive methodological lens for describing a totality or at least an ensemble of both potential signification and materiality.

Methods

The performance at the Israeli Parliaments’ Special Committees for the Rights of the Child (PSCRC) follows certain theatrical styles (Brown et al., 2009; Gabriel, 2000: 9–10). It is thus a form of collective doing that provides guidance about how action (or in our case inaction) should play out in particular settings (Mattingly, 2008). We focus on the polished and rehearsed monologues produced by powerful healthcare officials in their attempt (with varying degrees of success) to shape healthcare policy. We are particularly interested in how these public performances produced a space where the political categories of (ir)responsibility and inaction could emerge and shape everyday practice.

This article presents the results of a qualitative research project which integrates an in-depth analysis of archived data, with data obtained from interviews and observations conducted in Natal Hospital (a pseudonym) between 2007 and 2008. We collected a wealth of archived documentation in the form of protocols of meetings in the PSCRC, newspaper articles, and pages from various websites. The multiplicity of methods was designed to give voice to multiple perspectives and storylines, and to enhance the validity of our assertions. In addition, we showed how the public performance in the PSCRC resonated with various media reports. Our first inclination was to analyse this data chronologically, so to study the progression of the crisis management. However, once we realized that the actors were deliberately sustaining a state of crisis and emergency we decided to trace the manner in which they performatively reached a consensus. We therefore coded actors’ anecdotes according to the different aspects of the crisis they revealed (feelings of uncertainty, the construction of patients’ and practitioners’ subjectivities, issues of blame, responsibility, and justifications of ‘improper’ practices). Slowly a gap between the explicit level of the text and its subtext revealed itself. We then examined how the public performance in the PSCRC corresponded with practices and mindset at the NICU. We conducted 37 semi-structured interviews with the head of the NICU and head nurse, physicians, nurses, social worker, physiotherapist, and outside consultants. The practitioners were asked to describe their work environment. The interviews lasted approximately 30 minutes duration, which were recorded on audio-tapes before being transcribed by the researchers and subjected to analysis. Three research assistants recruited for this study observed nurses’ and physicians’ work in the unit. Observations in the NICU were conducted at different days and times, and documented in a field journal. Our research assistants approached each potential interviewee individually, presented themselves and stated that they were interested in learning about their daily activities in the unit. We let the interviewees know that participation in the research was voluntary, and that a refusal to participate will not be reported, or noted in any way. We use pseudonyms to conceal the interviewees’ identity. We analysed the observations in conjunction with the interview transcripts (Currie and Brown, 2003).

Natal Medical Center is a state hospital situated half-way between Haifa and Tel Aviv. The financial state of the hospital is representative of many other state owned hospitals situated in the periphery, as will become evident. The hospital serves a population of approximately 310,000 inhabitants. ¹ In 2008, 422 infants were admitted to Natal’s NICU, 70 of whom were under the weight of 1750 gm. The average length of stay is 11 days, however in extreme cases an infant may be hospitalized up to 120 days. The hospital offers no out-of-pocket services for birthing women.

‘Metzukat Hapagiot’—the poor state of the Israeli NICUs following the 1995 Health Care Reform

Israeli legislation is explicitly pro-natal. Prenatal care and hospital birth are covered by Israeli mandatory National Health Insurance (NHI). Israel also has the highest rate of government subsidized conceptive technologies. With 26 fertility clinics for a population of just over 7 million inhabitants, Israel is the world’s leading country in the field of New Reproductive Technologies (Ivry and Teman, 2008). Advances in reproductive technologies have caused a considerable rise in the rate of low-weight births. Recent government statistics indicate that 10% of all live babies are born prematurely (c.f. protocol of the 104th meeting of the Israeli Parliament’s Special Committee on the Rights of the Child, 2008). ² In 2008, the Parliament’s Center for Research and Information compiled a brief report reviewing the state of the Israeli NICUs. The report concluded that these reproductive trends directly affect the crowding of Israeli NICUs. Moreover, significant improvements in technologies of resuscitation, monitoring, and treatment in the NICUs have dramatically reduced the mortality rates of term and preterm babies treated in them, but have consequently extended the average length of stay, the volume and complexity of performed clinical procedures (Vitner et al., 2011; Weiner, 2009).

Michael Gross (2002) was the first to compare the policies of the United States, Denmark, the United Kingdom and Israel regarding late abortions and selective non-treatment of newborns as feasible management strategies for fetuses and neonates diagnosed with severe abnormalities. He concluded that the prevalent protocol in Israel is one whereby newborns are resuscitated and treated as a rule until death or discharge. Since birth confers legal and moral personhood, the newborn enjoys an undisputed and state protected right to life. Prevailing treatment protocols follow an aggressive management strategy and discourage selective non-treatment of newborns. Formally, there is no threshold below which babies are not treated, no wait and see attitude, no room to withdraw treatment and little room to withhold treatment at the sole request of the parent (Gross, 2002: 208). Actual observations in the Israeli NICU indicate that in practice practitioners do consider withholding or withdrawing intensive therapies for both preterm newborns and impaired neonates. This is especially true when the when the estimated chances of their survival or intact survival are low and treatment is viewed as futile. Weiner thus claims that neonatal practices would be more accurately depicted as ‘initiate and reevaluate’ (Weiner, 2009: 322). This gap between stated policy and practice can be explained if we consider that maternal wards and NICUs are not included in the basic package of health services. In both cases, the reimbursement is prospective. For each episode of care provided to a patient (woman giving birth), the hospital receives a flat fee directly from the National Insurance Institute (NII), regardless of the actual amount of care given (Shmueli, 2001). If the patient uses less care, the hospital gets to keep the remainder. However, if the patient uses more care, then the hospital has to cover its own losses. The NII transmits a fixed sum of money to cover four days of hospitalization for the mother and an additional sum of money for the hospitalization of the premature baby, provided that his birth weight is no higher than 1,750 grams, and that he was hospitalized for at least four days in the NICU. Given the current system of remuneration, it is understandable why hospital directors consider the NICUs ‘money draining’ wards. In 2004, the State Comptroller was called upon to examine the conditions of care in Israel’s NICUs. His report indicated a serious shortage of qualified staff, equipments and poor physical conditions. The Comptroller critiqued both the Ministry of Health (MOH) and Ministry of Finance (MOF) for not considering the changes in demographics, as well as the public’s demand for extensive investment with state-of-the-art resources. He recommended that the formula for remuneration and staffing would urgently be updated, in a way that factors the steady increase in the rate of premature births. Finally, the Comptroller noted a gradual yet growing shortage of neonatologists and qualified nurses, due to their abandonment of this specialty. Dr David Bader, Head of the NICU in Bnei Tzion hospital explains how the precarious status of the preemie ³ is institutionalized in the National Health Insurance law:

The NHI law … makes a clear distinction between a baby with asthma that is admitted to the NICU and an Israeli preemie. The latter is in fact unrecognized as a person … We take the money for his treatment out of the NII birth package … We want the State to acknowledge the preemie as a separate person, with an identity, and a member card in one of the sick funds. Either the sick fund or the State should pay for each day that he is in treatment. (Special Committee on the Rights of the Child, 2001)

In early 1995 a new National Health Insurance (NHI) law went into effect. Its main goals were to provide universal health coverage; spell out residents’ rights to a basic package of health services; promote increased equity; assure the solvency of the healthcare system; give residents greater freedom of choice among health funds; and absolve the MOH of operational responsibility for the provision of health services, thereby allowing MOH to devote more effort to monitoring and regulating the system (Horev and Babad, 2005). In effect, there has also been little progress toward attainment of greater financial stability for the whole system. The results are heavy workload and fear of declining clinical quality (Gross and Harrison, 2001; Harrison and Shalom, 2002). As a response, hospital managements went into great lengths to offer services not covered by National Health Insurance (NHI) to provide higher quality and luxury care. Among these services are: a choice of surgeon and hospital, special procedures and improved ‘hotel’ services in maternal wards, and inpatient care facilities (Shirom, 2001; Shmueli, 2001). They also attempted to reduce the average length of stay (LOS) whenever possible.

Parliament’s Special Committees: the discursive making of a crisis zone

The Parliament’s Special Committees are crucially important to the legislative process. Emplaced to lessen the burden of deliberations from the Knesset, they allow for relatively elaborated discussion on legislative proposals, and a follow-up on the parliament’s work. The Committees’ mandate varies according to its jurisdiction (constitution, finance, foreign affairs and security, immigration and absorption, economics, education and culture, internal affairs and environment, labor and welfare, and state control). Usually, bills are formulated in these committees and are voted on in the Knesset. The Parliaments’ Special Committees for the Rights of the Child (PSCRC) proved a wake discursive arena where powerful institutional stakeholders skillfully employed stories to designate NICU a ‘disaster zone’.

In the 2004 meeting of the PSCRC, Dr Yitzhak Berlovitch, then the MOH’s deputy director made a rather bold suggestion to alter the system of remuneration, so to amend the status of the preemie as an ‘annex’ of his mother. Interestingly, he chose to make his point by telling a heart breaking story of an impoverished public system that sacrifices its patients.

We must not budget the mother and the preemie as a packaged deal. Payments should be separated, so the more preemies the NICU treats, its funding increases, rather than decreases. Today, if the IVF unit flourishes, the NICU is drowning … it’s an absurd … I want the preemie to be a welcomed patient in its own right … When we shut down Misgav Ladach Hospital … we had three preemies and we had to transfer them to other hospitals in Jerusalem. I personally called every hospital in Jerusalem and, in the current state of affairs, none of them were willing to admit the babies … I assume that if each preemie would have been funded separately, they would have made the effort. At the end we sent the babies to Ashkelon and the mother went with them. I personally called the hospital, and Dr Sher consented as a personal favor to me. It is obvious to me that he had nothing to gain from the gesture—not respect and definitely not money. It was just our personal relationship that made him do it, plus I’m his boss—So he didn’t have much of a choice in the matter, really.

The deputy director of the MOH depicts a deteriorating public system that runs on favors and relies on the good will (or lack there of) of the hospital directors. His story opened the gate to others told by highly ranked health officials, all of which depict the ‘cruelty of the system’. Yaacov Quint, head of Neonatal Unit in Sheba hospital tells of a practice that became almost a routine in light of the units’ overloads:

In central Israel and in Beer-Sheeva [Southern Israel], we are on the verge of total collapse, with respect to occupancy. At least twice a year we announce that we have no vacancies. At that same moment, in the high risk unit, ten women are threatening to give birth to a preemie, and I ask that they be transferred to another hospital. Ten birthing women!!! A gynecologist of ours got bitten up because he came up to a woman and said that he wanted to send her to a hospital in Ashkelon, where there is room. We are constantly arguing with these women. The crisis is real, and we are terribly burnt out.

Professor Ehud Zmora gives a similar account:

During the last week I was busy sending mothers to give birth elsewhere. Yesterday I sent away a mother of twins that resides in Beer-Sheva (Southern Israel) to Hillel Yaffe hospital (in the center of Israel), because I didn’t have room for her twins. Now, this is a mother of limited means that resides in Beer-Sheva. They had to take her by ambulance to Hillel Yaffe. Her whole family will now have to commute back and forth between Beer-Sheva and the hospital for the whole duration, which could be several months even … We are sending these women all over. Sometimes, we send away babies after they are born, and this is a much riskier situation because these babies are transferred in ambulances … We have no one to take care of them and no means to do it with. It is a constant state of crisis.

The three healthcare officials depict the NICU as one that no longer acts as a privileged place that is reserved for individuals who are in a state of crisis, but rather is a place in crisis. The NICU is experienced as a ‘geography of disaster’ where much suffering and loss is endured, alongside a full or partial collapse of the system of time-space (Kreps, 1998). In 2005, a series of well publicized incidents indicated a severe decline in the quality of care. The rhetoric and actions of hospital directors became more militant and blunt. Professor Zeev Rotstein, the director of Sheba hospital ordered to shut down the NICU in Sheba hospital due to the early detection of contamination. He explained this extreme measure, as a precautionary step, but warned that with each passing year it gets tougher to eradicate contaminators due to the outrageous mismatch between the required beds, staff and allocated [manpower] standards. He then stated that in all State hospitals, and Sheba included, the MOF cut manpower standards by 4%, forcing Sheba’s management to let 23 physicians go, four of which were pediatricians. Three months later, the NICU in Ichilov, a neighboring hospital, was shut down in fear of mass contamination.

The gist of these stories is simple and straight forward having to work in an unstable environment that is in a perpetual state of emergency, makes it impossible to impose standard procedures, rules of ethical conduct or even state laws. The Israeli NICU is gradually but systematically turned into a site where precarious lives or ‘vulnerable subjectivities’ are produced. It has become a heterotopia of deviation where individuals who deviate in relation to the required norm are placed, or rather displaced (Foucault and Miskowiec, 1986).

Creating ‘vulnerable neonatal subjectivities’

Giorgio Agamben (1998) claims that the hidden foundation upon which the entire political system rests is the act of ‘at once excluding bare life from and capturing it within the political order’ (p. 9). When a ‘state of exception’ is declared, death and life interface each other. It is when organization has been perverted, claims Agamben, that life ceases to be politically relevant and becomes ‘bare life’—an existence that ceases to have any political significance and is therefore disposable. ‘Homo sacer’ is that person whose life can be eliminated without punishment, or killed but not murdered or sacrificed. In 2001, the first issue on the agenda was the urgency of deciding on an appropriate classification of the premature baby as a patient in his own right.

What is a preemie? Asked Dr David Bader, Chairman of the Forum of NICUs, and head of NICU in Bnei Tzion hospital, as he opened the 2001 meeting:

The main problem, as we see it, is that the preemie is not recognized as a patient by the health authorities in Israel. Our strategic goal is to amend the status of preemies in Israel, and also to change the status of the healthy baby.

In a subsequent meeting of the PSCRC, Dr Yoram Bentel, who took over as the chairman of the forum, elaborated on the serious implications of being unrecognized:

The NIH law defined the ‘standard baby’, and set a budget of 6000 NIS … later on they added the definition of the ‘deferential preemie’, referring to any child that weighs less than 1750 kg and survived at least 96 hours. They allocated an extra sum to those babies. But anyone in the trade knows that it is the first two to three days that are the most intensive and expensive. It is then that we spend the most on medical and nursing care, equipment, and medication. This definition of weight is purely technical and has nothing to do with reality. In reality, we can come across a baby that weighs 1751 and is sicker than a baby that weighs 1749 kg. The first will not be recognized as a preemie. He will be budgeted at 6000 NIS even if he is admitted for a whole month. (Bental, Special Committee on the Rights of the Child, 2004)

It is interesting to note how these public debates resonated in the media and was taken up by Lahav, the Israeli Association for Preemies. Both sought to call the public’s attention to the humanitarian aspects of the depicted ‘classification crisis’. As part of a public campaign to ‘rescue the Israeli NICUs’, Lahav published a cynical web article titled ‘Don’t give birth to Preemies’. In it an anonymous writer calls birthing mothers to hold it in and not give birth prematurely:

There is no time to wait for negotiations. No time to wait. Everyday preemies die. Everyday a new infection is discovered. We call birthing mothers to hold it in and not give birth to premature babies, because the State of Israel isn’t equipped to handle them. Please, refrain from giving birth before your due date until such a day where the MOF will resuscitate our dying NICUs, and our children who lie there. Until such day that our preemies will stop dying from diseases and other problems that cost more, in the long run, then what it does to save the lives of our children, and the quality of their lives while hospitalized in the NICU.

In July of 2009, a series of disconcerting news reports on premature babies showing signs of life after being declared stillborn and released for burials, stirred anew a heated discussion not only on the merits of this classification but also on the MOH’s definition of viability. It was then revealed that in Israel, there is no uniform procedure for declaring a preemie dead. Moreover, despite the directives of the MOH to regard birth before the 22nd week as miscarriage, neonatologists in Israel have opposed setting a minimum week for treating preemies since the week of pregnancy is not precise, especially in multiple pregnancies. Seeing that Israel’s laws on treating dying patients has purposely been left vague on this point, Professor Ehud Zmora, the current chairman of the forum of Neonatal Intensive Care Units in Israel and head of the NICU at Soroka Medical Center urged the MOH to issue a clear policy demanding that a neonatologist be present at the delivery room to declare a premature infant dead.

Dr Tzangen, a senior neonatologist, responded by suggesting that due to a serious shortage of neonatologists, such a directive would be impossible to uphold. Moreover, he argued that the shortage of qualified physicians manifests itself in the high frequency of contaminations in the Israeli NICUs. Indeed, a report issued by the MOH reveals that 31% of the preemies weighing less than 1500 g (10% of the preemies population) suffer from an inflammation of the blood contracted during hospitalization. So, at issue here is not just the preemies’ status of viability but also practitioners’ capacity to deliver an appropriate level of care and decide the fate of their patients. Again, the preemies are constructed as ‘vulnerable subjectivities’ in the sense that their lives are tentative and reversible.

In 2010 the Israeli public was again outraged by a photograph showing a senior nurse in an Israeli hospital taking a preemie out of its incubator and putting it in her pocket as part of an ad campaign for her unit. Appalled by the photo, Oren Malberger, head of Lahav announced ‘This incident demonstrates the grave shortage of personnel in such units. Sometimes hospitals have to hire people who fail to meet the high standards required of neonatal professionals.’ ⁴

Producing preemies as ‘vulnerable subjectivities’ also entailed the production of both nurses and physicians as ‘vulnerable subjectivities’. Dr Bentel cites the Amorai report to depict the grim state of Neonatology, but most importantly of the Neonatologist:

The Amorai Report ⁵ declared Neonatology, a profession in crisis, and I think we must take their declaration very seriously. They talked about an exhausted staff that is severely overloaded. It is an ‘unattractive profession’ to both physicians and nurses … today, in times of crisis and over crowdedness in the units, nurses are working double and triple shifts. There is such a concept as the ‘burnt out professional’. Again the MOH is called upon to take responsibility for the deteriorating level of care and issue a clear and long term policy.

Liminal beings are ‘individuals without space’, states Douglas (1977). Indeed in these stories the NICU comes across as ‘a place for those who have no place, or no longer have a place’ (Lefebvre, 1991:163). A deliberate withdrawal of care or services due to the politicization of the health care system classifies the preemie and the professional nurse and physician as ‘Bare Lives’. These are people who have been forsaken or abandoned, and their rights violated (Agamben, 1998). Turned into ‘personas non grata’, Israeli preemies are pushed around from one hospital to another, with no one taking responsibility for their well-being, or even their right to life. The continuous and unresolved crisis brings about a state of exception, that although is not officially proclaimed, de facto gives rise to situations whereby life is abandoned, forsaken, and exposed to a variety of physical threats.

The MOF’s and MOH’s contribution to the making of a crisis zone

In situations of crisis and uncertainty, the main task of management is to contain the crisis, as quickly as possible (Ophir, 2003; Shenhav, 1999). However, in our case, it seemed as if the MOH collaborated with the MOF to deliberately create uncertainty, and irrationality. Chaos and arbitrariness were employed as an efficient means for control (Handel, 2007). In what follows we discuss some of the ways in which uncertainty and disruption were created.

For more than a decade now, the MOF persistently refuses to award the NICUs a status of an intensive care unit. Apparently, such a move would have forced the MOF and the hospital directors to staff the units according to the standard set by the MOH. In the meantime the hospital directors are free to distribute funds as they see fit. Between the years 2004 and 2008 a one-time sum of money was awarded by the MOF and allocated to the NICUs. Head of departments appearing before the committee held in 2008 claimed the money had never reached them. Enraged by this state of affairs, department heads urged the MOH to exercise his authority and rigidly define the standards for resource allocation to the NICUs. Professor Ehud Zmora, the head of NICU in Soroka hospital attests:

When we approach [the hospital’s Directors] and demand more resources they tell us that [we] are a losing ward … We [the hospital] keep loosing money over you. What is the point in investing in you? Why should we extend [your budgets], we will only be increasing our expenses’. We are treated like parasites feeding on of the hospital.

Shlomo Politis, a lawyer and a father to a four-month old preemie implied that the MOH turns a blind eye to the deprivation of the NICUs. He bluntly asked ‘why doesn’t the MOH exercises its authority to issue a clear policy that defines the manpower standards required to run an NICU’?

MOF’s representatives stirred the conversation away from their responsibilities and around the meaning of efficiency and effectiveness. Consider the following dialogue between Gal Hershkovits, a representative of the MOF and Ehud Zmora:

Hershkovitz: I expect a hospital director who runs a deficit NICU, but also runs profitable wards, to act sensibly. He can shift resources from one place to another. The Director speaking before me argued that she has the patient interest at heart. If so, than the complaint that directors do not invest in the NICU because it is a money-draining ward is easily rectifiable. We can, if you wish, reduce the overall payments for birthing mothers and raise payments for preemies. As for the number of beds, hospital directors have no authority in deciding the number of beds per unit. The Ministries of Health and Finance decide that…You can’t therefore say that since the hospital director has no incentive to invest in the NICU, he cancels beds. But, you can say that since there is no incentive, the hospital rejects patients so he wouldn’t have to work in full capacity.

Professor Zmora: I think that the words of the MOF’s representative are crude and aggressive. He tries to cover up the real issue. His solution is a patch work. You take from one place to give to another. What he suggests is that regardless of our real needs, we must not breach the budget.

The crisis was now constructed in terms of appropriate management. Hospital directors were accordingly treated as business executives, rather than public servants. They are expected to creatively balance the clinical aspects of care, with exigencies such as resource expenditures, budget overruns, and issues of treatment proceduralization (Iedema et al., 2004). It is thus their failure to grasp how the rules for using the NICU as a space of care have changed causing the NICUs to plummet. Dr Yurman, head of Hillel Yaffe’s NICU accusingly argued that hospital directors were in fact collaborating with the MOH and MOF in evading the issue of mandating manpower.

The moment our units will be defined as intensive care units, they [hospital directors] will be obligated by law to allocate the mandated number of staff…The hospital director will not be able to say, ‘I decide’ because if he doesn’t fill these posts, he will be breaching labor agreements.

The MOF’s and MOH’s refusal to budget the preemie as an individual patient, their reluctance to broaden the definition of ‘a deferential preemie’, and their abstinence from awarding the NICUs the status of intensive care units contributed to a continuous state of crisis. Called upon to solve this immediate emergency, the MOF and MOH immersed themselves in the day-to-day running of the hospital, leaving both hospital directors and department heads with very little autonomy over budgeting, and the recruitment of nurses and physicians; let alone long and short term strategizing. The ministries’ deliberate silence over long-term strategic matters and their apparent incoherency in decision making was contrary to the spirit of the NHI law’s intent to reduce governmental involvement in the daily running of the hospitals, curtail costs and introduce the principles of managed competition (Harrison and Shalom, 2002). Paradoxically, their laissez faire attitude intensified hospitals’ dependency on public funds, and created a public outrage that demanded the government’s immediate intervention. This policy of disengagement perverted order causing the de facto suspension of the NHI law thus creating a ‘state of exception’: a situation where law and order are put into action in order to place human beings outside law and order.

Escaping responsibility: the institutional construction of ‘beyond our control’

In addition to creating ‘bare lives’, a constant state of disruption entails a constant change in the values which decide the acceptable use of space (Handel, 2007). The variety of techniques employed by the MOF to create uncertainty made the discussion on the proper use of the NICU as a space of care, inevitable. Perhaps symbolically it was Dr Yitzhak Kadman’s, the Executive Director of the National Council for the Child who in 2008, sealed the last meeting of the PSCRC dedicated to the crisis in the NICUs. Kadman detailed the sharp contrast between Israel’s explicit pro-natal policy and its actual treatment of preterm newborns and ‘impaired’ neonates.

The State of Israel is interested in children up until the moment they are born. We invest a fortune in reproductive treatments … Premature babies are a major consequence of these reproductive treatments … Today the situation at the NICUs is catastrophic. It ends in death, and sometimes in a faith worst than death … Children’s lives are at stake. When they tell me that they tube feed babies that are able to feed independently, because in this way they are able to minimize supervision during feeding, and the same goes for breathing, when in actual fact the baby can breathe on his own, it’s a crime harbored by the state…Doesn’t the state of Israel want these children? The state has to make up her mind. Does a child weighing less than one kilo has no right to live? The state has to make this judgment call, if she doesn’t she is escaping her responsibility for the welfare and quality of life of these children

The accounts described here are stylized as anecdotes of human suffering. Their dramatic effect ensues not only from the harsh realities they depict, but from the gap they denote between the normative views engulfed in the professional imperative to alleviate pain and suffering, and their actual practices in situ. These accounts point to a tragedy that forces practitioners to exceptional heroics. However, at the same time these stories also serve to relax practitioners’ responsibility for the outcomes of care. After all, under these harsh conditions, they can not possibly be held responsible for the deteriorating quality of care they provide. Tzipi Sade, the head nurse of Klalit Health Service, Israel’s largest HMO’s spoke:

It is not that the hospital managements are indifferent or undisturbed by the Units’ inadequate staffing. It can’t be helped. At night, they turn and toss in agony for not having the capacity to adequately staff these Units … If we talk about awarding these units an ‘Intensive care’ status we need to train the nursing staff. We are talking about a training period that can take up to two years. And the same goes for doctors. We have a serious fiscal problem. We all know that the preemies fit the definition of Intensive care … only today, we read in the papers about another preemie that was fed his medication rather than having it injected through an IV. The load is tremendous. We urgently need a steady increase in budget. We can’t wait any longer. The distress is very deep. Awarding us a one-time funding is charlatan.

Dr Brian Reichman, a researcher at the Gertner Research Institute added:

We feel we are failing our patients and our nurses. We overload them. A week ago, a report was submitted to the Sheba disciplinary committee blaming nurses for the accident of injecting unnecessary drugs … everyone is on the clear except for the nurses … if we keep on blaming the nurses, even if we add [nursing] standards, there will be none left to do the job. No nurse will want to sit [next to a patient] day and night, only to be blamed for the errors caused by our overloading them.

But who is this ‘we’, ‘us’ and ‘they’ that speakers keep referring to? Speakers’ general appeal to the State seems more like a meta-social commentary, than concrete assignment of blame or the offering of operational routs for action. These elaborated discussions yield no tangible legislative or other products. Moreover, when stakeholders (mainly, heads of departments) made operative suggestions, they were systematically ignored, yielding no operative steps, thus perpetuating a state of crisis. Consider Dr Berlovitch’s account:

For reasons endorsed by the Israeli society … the bottom line is money. It is a financial consideration that guides their [hospital directors] decision-making, and when a financial consideration is forced on Hospitals’ managements—not that they desired it, but they are made to function economically—then they have to assess the profitability of various healthcare services, and naturally they develop those services that can be a source of revenue. Services that the hospital suspects will be money draining, are underdeveloped and avoided’.

Again, there are no villains, only victims of a society that retreated from the welfare ideals, and is now promoting the ones of consumerism and managed competition. On a more tacit level, there is acquiescence to the status quo—a sort of tacit agreement that costs need to be curtailed; that profitable hospitals, eventually, serve the greater good, and that hospital directors must demonstrate a good business sense even if it makes their stomachs turn. So in effect, participants were jointly constructing a story of a community united under crisis. Stylized as anecdotes and containing little factual information, these stories amounted to a public bemoaning of the NICUs’ state. Nobody is to blame, except this ‘state of affairs’—impersonal, and apolitical. In this sense, these testimonies aren’t really committed to change; on the contrary they define this ‘state of affairs’ as extenuating circumstances. So while these narrators supplied a meta-cultural commentary on the failures of the reformed health care system to attain financial stability and secure social equality, they in effect reproduced existing norms. Complaining provided some wriggle room to allow stakeholders to find a comfortable position as they accommodate themselves to the imposed definition of the situation (Weeks, 2005).

Publicly speaking in the committee inhabited a ritualistic site in which (practical and political) knowledge can manifest, be realized, and negotiated. And so, these performed stories were primarily anchored in the perpetuation and survival of communal and hands-on knowledge shared by those attending the performance (Noy, 2007). Is it possible that their public performance was not intended to resolve the state of emergency, but rather to publicly announce it?

A state of emergency is often created without being proclaimed by the sovereign, contends Ophir (2003). Usually the state claims no direct responsibility for this breach of order and for all the exceptions it entails, states Ophir who offers that even if the state’s policies generated the disaster, its coming into being cannot be ascribed to or represented as the result of ‘a decision to make an exception’ on the sovereign’s part (Ophir, 2003: 18). Its only responsibility thus becomes the appropriate application of crisis management techniques. In other words, the timely mobilization of ‘various techniques to alleviate pain and suffering and save lives. The disaster zone is turned into an ad-hoc place of morality—that will disappear when life returns to normal (Ophir, 2003). The care for life in distress becomes a moral imperative that goes beyond the ‘call of duty’. Indeed, by constructing a (continued) state of emergency on the institutional level, state agencies and hospital directors were successful in mobilizing the moral sentiments of ward staff. This state of affairs heralded the heroics of those practitioners that are forced to save lives in sub-optimal conditions. In this way, the MOH and MOF were able to get practitioners’ to work in full capacity in a system that is ill rewarding but and terribly stressful. They were thus successful in containing the crisis without implementing any structural changes, or investing the demanded extra funds and resources. The practitioners, on their part, enjoyed a relaxed responsibility to the quality of care, giving rise to a new category of events that inherently induced inaction- a category we named ‘beyond our control’.

‘Beyond our control’—practitioners’ interpretation of Institutional discourse

In the Israeli NICUs chaos precludes any attempt at planning and rationality. Arbitrariness rules every aspect of daily functioning at the ward. Dr Foust, ⁶ a senior physician in Natal’s NICU describes a strong feeling of helplessness:

We are terribly overloaded. We are burned out … Here, not all of the tests are performed everyday, and you have to maneuver … The parents are not stupid. If you tell them that their child suffers from hemorrhaging in the brain, and that to verify we need to do an ultrasound to the brain, the parent will ask ‘when will you do the ultrasound?’ I then start to ramble something like ‘It is not that important that we do it right away, and stuff like that’. Because I know that the expert doctor who does the ultrasound only comes in twice a week, and she happens to be away for the next ten days, so there isn’t anyone that can perform the test…I hate that I have to lie. I hate that I need to cover up for the system. Or, for example, if I know that a certain test is only done in one specific hospital up north, but the transportation has already left … so now you have to wait three more days … I tell the parents that the answer is on its way, but I know that the test tubes haven’t even left the hospital. Let’s say we need to perform a heart surgery. We don’t have a cardiologist here to perform the surgery, so I need to find the baby a place that does. And then when I finally do, they say ‘we will operate, no problem, but you have to find him a bed in the NICU where he will recuperate’. So I have to beg, to ask for favors as if it were my own son. That is the horrors of our everyday reality.

Narrators perceived crisis as anything that had to be done urgently, taking time away from the work that they would ‘normally’ had done to make progress on their individual deliverables. Both nurses and physicians often felt on the brink of unthinkable anxiety which prohibited them from long-term planning. They revealed an overwhelming preoccupation with the day to day running of the shift:

Merav: We are short of equipment. I don’t have the necessary equipment and I have to start looking for things … it takes up a lot of my time … it also disrupts my concentration … umm … I am short of staff. It is difficult to skip from one child to another. Nothing is organized. I can’t give all I can give of myself, and often, at the end of the shift I feel frustrated that I didn’t get a lot of things done. I feel bad about it.

But are these really stories of helplessness and desperation? A closer reading of Dr Foust’s account reveals an astute and skillful social actor who cleverly manipulates the system and ‘get things done’. And so, the impoverished system and the rule of chaos actually allow for personal heroics. Shlomit, a nurse, also depicts the heroics of problem-solving and administering care against all odds.

It is terribly crowded in here. There are budgeting problems. We are short of staff. We have no equipment. There were instances were we admitted a preemie and suddenly the monitor stopped working. There are so many technical glitches, and I find myself solving these problems rather than taking care of the baby. It is very stressing, especially in the very early stages, when a child comes in straight from surgery or the delivery room.

Despite their experience of crisis and disruption, physicians and nurses perceived the NICU as a space resembling Foucault’s notion of heterotopias of crisis a privileged, sacred or forbidden place, reserved for individuals who are in a state of crisis. The NICU was often described as a techno-medical setting, where death lurks in the corner but must be heroically fought.

Osnat: The noise, the monitor, the million tubes going in and out of the babies little bodies, their sizes … Even with all the expert knowledge that we have, and the experience, it is still very frightening. There is something really terrifying about the NICU, because, often, things can not be expected. The child can be doing fine, and then in a heartbeat everything can go wrong.

Verra, a nurse at the unit describes the NICU as a sequestered space with its own codes of ethics, ways of being, and unique time progression:

I thought of this mother, seeing that life goes on while her baby’s condition deteriorates, and we can do nothing to help her. If only we had ‘jumped’ him, perhaps she would have felt there was hope. But there was nothing left to be done. We just let him die, slowly … and I didn’t know what to say to her. Sometimes early in the morning he died … we worked very hard all night. We had a lot to do, so I didn’t even had the time to just sit and talk to her, ask her how she was holding up. When I finally did get around to conveying my condolences, I felt it was tasteless.

Compassion, and a strong sense of empathy drive the physicians and nurses to endure the encountered hardships and ‘go the extra mile’ for their patients. The precariousness of the preemies’ lives defines their work heuristics. Sigal, a nurse at the ward commented on the challenge of working near imminent death

When a baby comes in and he was born very early in terms of gestational weeks, you know right then and there that it is hopeless. You do a lot of work on this baby, but all the while you know that it is hopeless. There is a dilemma here … you give everything you have to give but for what really?

If the moral practitioner is someone who ‘gives everything he has’, and is willing to do ‘whatever it takes’, then the harsh working conditions and endemic uncertainty act as strong motivators of dedicated care. Dr Starr offers a rather prominent view on the responsibility of the consciousness and professional physician:

From a surgical point of view, our goal is that the baby will leave here in a good shape. It is not enough that he weighs 900 g or 1100 g, he also got a severe defect … even more so if he has intestinal infection … in addition to being a preemie he also suffers from this serious disease. So our job is to make sure that he leaves here in a good shape, functional and with no reason to think that he will suffer in the future. This is our biggest problem. It is a major difficulty.

And so, on the one hand, a state of crisis absolves the practitioners from taking full responsibility to the quality of care provided, on the other it also allows for ‘grand gestures’ to take place. We thus conclude that maintaining a state of crisis significantly benefited all the MOF, MOH, hospital directors and healthcare professionals. It absolved the MOH and MOF from devising long-term strategy—one which may have entailed further privatization of the healthcare system and reduced their involvement in the day-to-day running of the system. It allowed the MOH to retain its authority to define manpower and equipment standards. Hospital directors retained their autonomy to distribute hospital funds as they see fit, without having to worry about making units such as the NICU, geriatrics, and general medicine profitable (as they would, if the whole healthcare system be privatized). They were also given the opportunity to safely call into question the merits of the healthcare reform, propose significant changes in the system of remuneration, and define new categories for the distribution of responsibility. The practitioners were absolved from taking responsibility for a category of events that could, in principle, be predicted but for lack of resources, could not be managed or prevented. Proving their remarkable abilities, calling on personal favors, and enacting a general attitude of ‘getting things done’, bolstered practitioners’ professional image, strengthen their standing at the ward, and allowed them a considerable measure of leniency.

Conclusion

How are spaces produced through publicly contrived performances? And, once constituted, what types of doing (political and other) do they entail? The PSCRC served as a sequestered time-frame in which all participants could come together and reflect upon their organizations’ values and performance (Turner, 1982: 27, c.f Czarniawska and Carmelo Mazza, 2003: 272). But contrary to Turner’s apolitical notion of communitas, these deliberations had a distinct political nature. The performative production of the NICU as a crisis zone—one that is ruled by turbulence and uncertainty—gave rise to a ‘moral economy’ where severe shortage of funds heightened the reliance on practitioners’ professional integrity and compassion (Sayer, 2008). Consequently, a new domain for the operation of power came into being, one where life is put ‘in question’ and can be both protected and eliminated (Agamban, 1998; Ophir, 2003).

We illustrate how a series of performative acts produce tangible spaces as sites of crisis and emergency, only to tacitly create a political climate that not only reifies existing norms of organizing, but shaped both practitioners’ crisis mentality and heroic heuristics. Yet, by way of paradox, operating under everlasting conditions of crisis created degrees of freedom for all involved, especially regarding the outcomes of care. Expected to operate in a liminal space where normal rules of engagement were wooly, blurred or inapplicable, without question added to practitioners’ burden. However, it also enabled a sense of autonomy, and personal freedom. As the burden of many of the rationalistic rituals of the organization is suspended, lessened or proscribed, opportunities for creativity revealed themselves (Sturdy et al., 2006).

In light of the evidence presented here, we prompt scholars to look for technologies and managerial strategies that are designed to intentionally create uncertainty and irrationality, rather than contain it. In so doing, we advance an analytical perspective that asks how chaos is performed, maintained and practiced, rather than how organization forges order out of chaos. In this regard, our findings are relevant to multiple work settings where managements not only adopt chaos and crisis as a mechanism of control, but thrive on a crisis mentality. We problematized how this continuing state of crisis and disarray brings into existence an emerging order that demands improvisation, manipulation, commitment and heroism. This prompts us to consider how workers interpret, co-opt or resist such an environment.