Gilles van Wijk - Open-ended tasks and time discipline.pdf

Article

Open-ended tasks andtime discipline

Gilles van WijkEssec Business School

Abstract

This paper uses data from the healthcare sector to explore how clock time

organization influences therapeutic performance. The case of a pediatric physio-

therapist offers an important opportunity to examine how clock time, mediated

by a variety of organizational and social systems, imposes limitations to the

individual activity, in terms of learning, experimenting, and innovating. Social,

cultural, institutional, and organizational layers have developed around this uni-

versal time reference. They impose an in-depth and taken for granted time

discipline on organizational actors. The job of the physiotherapist conflicts

with this clock time discipline when she has to respond to the evolving needs

of her patients. Based on her expertise, the therapist decides on the necessary

care, including duration and frequency of treatment. The measured time allo-

cation imposed by the healthcare system and the time-based reward system

generate pressure on, and interfere with, the unfolding activity. The study illus-

trates how the therapist escapes these multiple constraints and how this

enables her to focus on the therapeutic acts. Taking the therapeutic process

as temporal reference reveals the impact of clock time discipline on the unfold-

ing therapeutic activity. I conclude that open-ended activities are inhibited and

distorted by this socially constructed time not only because they cannot unfold

but also because the temporal framing prevents deliberation and initiative.

Keywords

Clock time, open-ended task, time discipline, exploration, learning, task

centered, time centered

Time & Society

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DOI: 10.1177/0961463X15572175

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Gilles van Wijk, ESSEC Business School, Avenue Bernard Hirsch, Cergy Pontoise 95021, France

Email: [email protected]

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Feeling out of control over personal time is a familiar symptom among white-collar workers and professionals (Menzies, 2005; Perlow, 1997). Managers aswell as independent contractors describe their work situation as an unendingflow of activities to which they must attend (Bianchi et al., 2006; Schor, 1992).Job stress and burnout are common occupational diseases (Kristensen et al.,2005; Maslach et al., 1996; Nairne, 2010: 517–539). The successes of self-helpliterature, coaching, and consulting on the management of time, are evidenceof the attempts to regain control (Fine, 1998; Linenberger, 2010; Potter,2005). Because of the prevalence of time pressure and the consequences forperformance, the interaction between the amount of work and the time avail-able deserves particular attention. Previous research has provided insight intothis issue. First, Perlow (1997) found that imposing quiet time on engineers,where they could work alone and uninterrupted, resulted in more productivework for the group as a whole. Second, Amabile et al. (2002) found that themore time pressure people feel, the less likely they will be to think creatively.Yet, it has proven difficult to change workday norms (Perlow, 1997), andthere is instead a continuous acceleration in society and in the work envir-onment (Rosa, 2010). Time-related tensions that develop in organizations aresupposedly caused by disorganization and by differences in professional cul-ture (Bangle, 2001; Dubinskas, 1988; Perlow, 1997). It is the objective of thisresearch to demonstrate that clock time by itself creates tensions and affectsthe unfolding of open-ended activities to the extent of curtailing or preventingthem altogether.

Healthcare offers a good setting to explore open-ended activities understrong time discipline. Indeed the health of patients and the delivery ofproper care are of great importance while the temporal resource of healthprofessionals is typically very scarce. The challenge is how to fulfill theopen-ended mission, and fit the time discipline.

Data collected from a physiotherapist specialized in the treatment of clubfoot show that this professional has to make great efforts and commitunaccounted time on each case to provide effective care. The norms gov-erning the duration of a therapy impose either to ignore the specific require-ments of the patient’s situation or to spend ‘‘unbillable’’ time on the case.Yet, as a recognized practitioner, our physiotherapist should be in controlof her schedule. She does not need to take extra patients for the professionalsecurity it provides (Evans et al., 2004), because there is a sustained need forspecialized physiotherapeutic care and she has a good reputation. Yet, thisprofessional frequently modifies her working schedule in the short term,puts in extra hours, skips lunch, and often takes patients on weekendsand in after hours.

It is the objective of this paper to explore how clock time mediated bysocial constructions influences open-ended activities. Social constructions as

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diverse as organizational workflow, rules and procedures, professionalstandards, and social norms are impregnated with clock time disciplineand in turn impose it coherently on all organized and social activity. Inother words, organized activity is the dependent variable, while clock time isthe independent variable. I will focus on open-ended activities defined as theemerging character of the interaction between actor and context. Open-ended activities bring innovation, discovery and new production processes,as intended by the ‘‘exploration of new possibilities’’ (March, 1991), but notonly. Beyond exploration, an important other part of the open-ended activ-ities entails ad hoc developments: the actor responds to a non-recurrentsituation in a unique fashion combining observation, invention, experimen-tation, and learning. When a manager makes sense of the situation of hisorganization in an on-going way and when he progressively develops hismanagerial and strategic decisions on that basis (Stacey, 2001; Weick,1995), he faces an uncertain environment and invents solutions on theway. The diagnosing, the experimenting, and the learning are ongoing pro-cesses taking place in a variation, selection, and retention loop (Burgelman,1991; Lovas and Ghoshal, 2000). In the domain of healthcare, the physicianmakes a diagnosis and adapts a treatment in resonance with the specific andevolving condition of the patient. Because some cases can be very unstable,the standard organizational solution is to provide slack resources and admitvariations in time span to achieve better outcomes (Holmberg, 2006).

Open-ended activities include the exploration of new possibilities and canpose a problem of resource allocation (March, 1991). But with open-endedactivities including important endeavors such as inventing, creating, develop-ing, experimenting, learning, and improving, the issue is in the first place oneof task fulfillment, not one of resource allocation. Resource allocationimplies the anticipation of the need and in effect counteracts the emergenceof open-ended activities.

Clock time and the rationalization of organizations

The dominant role of clock-time in western society dates back to the nine-teenth century (Mumford, 1934; Thompson, 1967). Thrift has related theemergence of a capitalist consciousness to the diffusion of clock time(Thrift, 1990). However, clock time is not just the widespread, quantifiedand unified temporal reference; it is also an essential step in the subsequentdevelopment of rational organization in society (Mumford, 1934).Contemporary social organization is the result of at least two long-termprocesses: the diffusion of clock-time awareness in the population, and therationalization process in organizations. The two processes have takenplace at different times, one following and building upon the other.

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With the general availability of clock time, the individual has a new formof control initially introduced by Saint Benedict in the 6th century for theorganization of monastic life: the actor can effect a temporal ordering offuture activities by synchronization, sequence and rate (Moore, 1963: 8–9).Thompson (1967) argues that the emergence of clock time is closely asso-ciated with the transition from work in the fields to work in the factory.Indeed, during the second half of the nineteenth century, things change rad-ically with rationalization and the spread of machine powered production.Mumford (1934) claims that the role of clock time is more important than thedevelopment of the steam engine for the modern industrial age (14). Nowotny(1989:96–97) considers that the clock has subdued the working class afterhaving been meticulously adopted by the Bourgeoisie. The combination ofmachine work and clock time made the rationalization of the organization ofsociety possible (Zerubavel, 1982). McGrath and Rotchford describe the pro-cess: ‘‘As the focus of the work organization shifted to the machine, the timeschedule became a key feature of organizational plans, and time schedulesbecame geared to the pace of the machines. The human parts of the organ-ization had to become adapted to (perhaps we can call it ‘entrained to’) thosemachine-paced time schedules. The clock became a major instrument forcoordination and control’’ (1983:69). Clock time brings far reaching longitu-dinal and cross-sectional interdependences under control, across all fieldsincluding manufacturing, commerce, and the civil society. Industrial produc-tion of planes, cars or smartphones involves multiple sub-contractors inter-nationally, demands precise coordination of the deliverables with legallyenforceable contracts ensuring long time commitments, but also with regularchanges in design and adaptation to local legislation, and many further dead-lines to deal with market and administrative requirements. This networkedorganization is, however, a double edged sword. While coordination andintegration of activities reach ever higher levels, clock time organizationimposes an increasingly tight web of interdependences in the pursuit of eco-nomic performance and competitiveness, reminiscent of Weber’s (1968) ironcage of rationality. The need to synchronize activities in the rational organ-ization has led to the emphasis on clock time as an essential component of therationalist order (Lauer, 1980). The standard measurement of time has henceempowered bureaucracy: ‘‘[ . . . ] pressures for synchronization force much ofour time sense to become objectified and constrained. In order to be orga-nized, we must frequently subscribe to times which are rational and external’’(Hassard, 1991: 111). Clock time eventually had a very broad effect on theorganization of work and social life in the Western world beginning in thenineteenth century: railways (Zerubavel, 1982), industry (Thompson, 1967),manufacturing (Taylor, 1911), education (Hassard, 1991:109–110; Thrift,1990), and technology (Mumford, 1934).




There is a class of events that naturally fits clock time organization.It follows a very regular course and hence appears to be ‘‘in time’’ (Clark,1985: 40). This class of events lends itself to all kinds of clock time-basedoperations like observation, analysis, manipulation, prediction, and plan-ning into wider interdependences. Such fixed end activities typically includeindustrial production but also a number of service businesses such as banks,logistical services, some hotels, all with many repetitive and standardizedprocesses. At the individual level, they are either very repetitive as in thegarment industry or forced into standard patterns as for the call centers. Asa result, clock time is the unescapable and universal reference and socialorganization has progressively achieved a very tight and efficient systemexploiting and contriving these regularities (Nowotny, 1989). But this isonly one class of events, characterized by predictability and repetition.

For another class, events have their own time: time is ‘‘in’’ events (Clark,1985). This class includes important value creating processes like: creativity,sense-making, learning, and innovation. Because they develop according totheir own time, events in this class are emergent and require unaccountedtime. The change from time centered to task centered is a shift in thecultural perspective on time. Task-centered organization is ‘‘procedural-tra-ditional’’ (Graham, 1981). In the procedural-traditional pattern, the amountof time spent on an activity is irrelevant. What is important is that a thing bedone the right way, not that it be done on time (Bourdieu, 1990; Evans-Pritchard, 1940: 103). The time is ‘‘in events’’; coordination rests with thecompletion of events. The time-centered organization is ‘‘linear-separable’’(Graham, 1981): time is linear, abstract, homogeneous, and divisible. There isan implication that we can do only one thing at a time. This conception oftime gives control over events: instead of waiting for activities to be com-pleted, activities are ordered a priori into time slots for a coordinated execu-tion. Time is an external dimension along which events can be ordered;‘‘events happen in time’’. In this perspective, time is a scarce and valuablecommodity and time becomes money: clock time provides a single universalmeasure to assess all activities. This form of control reaches across all activ-ities, and enables the far reaching integration of organizational activities intoa global system. With this time-based rational organization, our society hasachieved enormous progress leveraging the impact of technology (Mumford,1934). However, the shift in cultural values from focus on doing things theright way, to doing things in the right time has another importantconsequence.

The focus on clock time favors activities that can be planned withschedules, rules, and procedures and resists activities that are intrinsicallyuncertain because they cannot be planned. Experimentation, invention,learning, and creation have less certain outcomes, no clear time horizons,

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and more diffuse effects than do predictable, repetitive, and programmableactivities. In addition, the returns of open-ended activities are difficult toassess, as is the case in particular for exploration of new possibilities(March, 1991: 71). Yet, such activities include important tasks like learn-ing, teaching, exploring, inventing, diagnosing, creating, performing,cultivating, etc.

Those in charge of open-ended activities are typically professionalsincluding managers, researchers, and artists. They master a complex setof knowledge and skills through formal education and practical experience.When tensions and conflicts emerge, typically about being late or slow, orundisciplined, these are explained by flawed organizational design and dif-ferences in professional culture, not by conflict in task temporalities(Bangle, 2001; Dubinskas, 1988; Perlow, 1997).

I claim, instead, that the problem is not one of organization, culture, orprofession, but more fundamentally one of incompatibility between open-ended activity and clock time discipline. Clock time organization imposestime pressure, external to the task, which can seriously disrupt internalemerging developments. Inside the organization, high time pressure worksagainst creativity (Amabile et al., 2002). Indeed, when engineers haveuninterrupted quiet time during specified periods each day, they are ableto get more done on their projects (Perlow, 1997). A manager describesthe challenge of mediating between the production engineers and thedesigners within the company (Bangle, 2001) ‘‘I have to construct a bar-rier around model development so that time-to-market pressures don’tdisrupt or harm the actual work’’(p.48), ‘‘[In the design process] eachstep can take anywhere from months to more than a year’’ (p. 51).Researchers recognize that industrial society, social network, and organ-ization claim and regulate time extensively (Hassard, 1991). I argue thatclosed-ended timing does not just generate ‘‘time famine’’ (Perlow, 1997)or other forms of time squeeze (Gersick, 1989; Luhmann, 1971) but it alsoaffects the open-ended process intrinsically. The organization demands amanagement in resonance (McNaghten and Urry, 1998) with its temporalprocesses whether industrial with clock time control, or open-ended withemergent time requirements.

Method

In this research, I will focus on health services because open-ended andtime-framed events have to co-exist: the health professional has an emerginginteraction with the patient on one hand and a clock time interaction withthe health organization on the other. The structuration of the time envir-onment in the health services determines a standard duration of the therapy




session. But the practitioner has to make a diagnosis and define a treatment,a creative, open-ended activity. The patient will respond in some way to thetreatment, and the practitioner will interactively adapt the treatment to thepatient’s response. These events take their own time. But, events are also intime because institutional and organizational requirements define the sche-duling of professional services (Zerubavel, 1979). Observing the effect ofclock time as an independent variable on work presents a methodologicaldifficulty because clock time is taken for granted by all, even by researchers(Adam, 1990: 14; Barley, 1988: 126). The dominant clock time perspectivegives priority to the overall organization in which the task is embedded(Graham, 1981). In contrast, viewing how the task itself develops andhow it is influenced by temporal framing, requires a task-centered perspec-tive. In order to observe the impact of the organizational temporalities, thepresent research will focus on the unfolding task as reference (Langley,1999) and observe to what extent external elements interfere with the activ-ity of the practitioner. By concentrating not on the organization but on thework of one actor, the impact of the environment on the intrinsic tempor-ality of the evolving activity becomes visible. Social, organizational, andeconomic constraints become interferences to the natural course of events.

Data collection methods include interview, archival data, patient ques-tionnaires, and direct observation. Health statistics and regulatory frame-work provisions constitute additional background data. Extensive access todata and actors involved was authorized under condition of strict confiden-tiality. I studied the impact of the institutional environment on the evolvingtreatment of twelve cases over a year and a half. In addition, to assess longterm outcomes, I have had access to the history of over 50 cases with10-year retrospect.

I collected the data between 2008 and 2010 conducting 12 in-depth inter-views (five with the focal therapist, one with the therapist who developedthe technique in France, two with orthopedists, three with parents, and twowith administrative personnel), many occasional discussions and about15 hours observation of the physiotherapist at work. She works in asmall private practice in the eastern part of Switzerland offering pediatricmedical services and specialized physiotherapeutic treatment for babiesand children. Two longstanding medical assistants assist one pediatricianand the therapist. These assistants work part-time, taking phone calls, receiv-ing patients with their parents, keeping records, and collecting and preparingspecimens for laboratory testing. The medical practice disposes of threeample rooms for consultation and treatment. One is dedicated to physiother-apy and the two others are equipped for medical consultation. Furthermore,the practice has simple laboratory equipment and an X-ray. The assistantgreets patients at the desk upon arrival, and directs them to a waiting space.

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The physical space available for parents with their children to wait is scarce:one patient with his parents can be waiting for each of the practitioners.Therefore, they must work on appointment only, and must hold the sched-uled time unless the waiting room will become crowded and hectic. Thefacility is otherwise bright, comfortable, and friendly for children.

The practitioner has 35 years’ experience in pediatric physiotherapy. Shehas specialized over the past 10 years in the treatment of club foot. Thisdeformity is difficult to treat, having a marked tendency to recur, and causesa real disability (Wynne-Davies, 1965). The club foot deformity can bemuch or less important, single (48% of cases in sample) or double-sided,and the newborn can have other complicating ailments, i.e. comorbidities(26% of cases). The treatment method proposed by the focal therapist isthe ‘‘French method’’ or Bonnet-Dimeglio method. The method is non-operative with high quality outcomes in terms of mobility and balance. Itoperates corrections in small steps. By intervening immediately upon birth,the therapist takes advantage of the softness of the developing organism.She stimulates dynamic and soft structures, releases connective tissues, pos-itions the displaced anklebones, and stretches shortened tendons and mus-cles into the correct position. Full correction is achieved in about eightweeks with three to four sessions a week depending on the response.After two months, the decision is made with the supervising orthopedistto do a minor surgery if the heel is not entirely positioned. Because the riskof relapse is significant, the treatment is continued with reduced frequencyuntil the child walks. The therapist in this study learned the French methodfollowing the recommendation of a senior orthopedist who supervised her.The training involved several visits over six years in Montpellier (France)where she was trained by Ms. Bonnet. The therapist would spend time therewith a patient and the parents, on own costs.

Club foot patients are referred to the therapist by an orthopedist’s pre-scription. While parents have final decision power regarding the treatmentmethod, the orthopedist is the referent person who has the responsibility forthe implementation of the treatment of the malformation. Hence, if thepediatrician while inspecting the baby upon birth has some suspicion, hewill request the pediatric orthopedist, the parents, and the therapist to meetand discuss the case.

The quality of the interaction between the therapist and the baby hasinfluence on the evolution of the process. The duration of the sessionsvaries. They will take more time if the child is tense and nervous. Afterseveral sessions, the hands of the therapist know the particular morphologyof the patient’s feet, and the baby recognizes the therapist’s handling. Bestresults obtain therefore when one therapist only does the whole treatmentfrom beginning to end, until the child starts walking. Furthermore, the




deformation can be single or double-sided, and the degree of muscularstress of the newborn varies. Also, older patients require more dialogueduring the treatment and claim more of the therapist’s time. Time is inevents not only because of the deformation, single or double-sided, thepresence of other affections, the tenseness of the muscles, and the age ofthe patient, but also because best results are achieved if one professionaldoes the entire treatment. Taking care of a patient is therefore a commit-ment extending over a whole year. The following fine grained descriptionwill further explore the impact of the environment on the treatment processwith its evolving time requirements.

The therapist’s performance

Taking a task-centered approach for an open-ended activity poses the prob-lem of performance evaluation: a high number of patients treated in a singleday does not reflect good performance, nor do the hours spent working inthemselves. Professional competence, self-discipline and deontology areneeded to ensure performance, and it is best observable at the level of theoutcomes. The assessment of performance for such open-ended activitieswill be discussed next.

The assumption that the practitioner is effective is difficult to ascertainfor open-ended activities, be it in healthcare (Loeb, 2004), or in club foottreatments (Issler-Wuthrich et al., 2009: 2041). In order to assess the ther-apist’s success in the treatment of club foot, several indicators are available:

. reputation measured by the relative number of cases entrusted over10 years,

. satisfaction of parents with outcome,

. the therapist’s personal assessment of individual cases, and

. number of crossover cases, patients joining or leaving the care of theobserved therapist.

Reputation measured by the number of cases entrusted by orthopediststo our therapist has increased from 4 to 9 per year over the 10 last years. Tohave an idea of the share of club foot babies treated, these data are com-pared to the statistical estimate of club foot births in the region (see Figure1). Data about club foot births are not collected in Switzerland. An estimateof the number of babies born with club foot deformity has to rely on stat-istics. In Western Europe, the frequency of births with deformity is about1.2 per thousand (Wynne-Davies, 1965).

The representativeness of these data as a measure of the reputation of thetherapist is limited by several factors. (1) The orthopedists can support or

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not this form of treatment for reasons other than strictly medical, biasingthe arrival of new patients. This circumstance involves professional politicsto be discussed later. (2) The small numbers involved, from 15 to 18 clubfoot births per year, make the estimate of new births unstable. (3) In 2007,the therapist was away from work for three months. Given these limita-tions, these data still suggest an overall growing trend in which the initiallearning and the developing reputation of the therapist among orthopedistsand pediatricians are likely to play a role.

The parents’ satisfaction with the outcome is assessed with a question-naire mailed by a local research team including the therapist herself, inApril 2011. Out of the 38 questionnaires mailed to the parents of the chil-dren treated over the last 10 years, 25 were returned and could be exploited.The questionnaire covers issues from initial information about the treat-ment methods available, to the parental investment, and to the final out-come. The items included questions like difference in gait, child’s feeling ofmaladjustment, physical pain, child’s ability to participate in athletics, andfitness activities (for those who were four years and over). In particular,respondents indicated that their child could normally participate in play-groups with other children (3.61 out of 4) and 100% indicated that theywould choose this method again.

The questionnaire was circulated by a team including the therapist her-self. This may cause some bias in the responses because dissatisfied parentsmight decide not to respond, and other parents may want to be overlypositive (though the questionnaires were anonymous). Still, the parents’ratings are coherent, and indicate that treated club foot children comparefavorably with children without such birth deformity.

The therapist’s personal assessment of the outcomes was available for 54cases, including 42 ‘‘clean’’ cases treated from the beginning and 12 incom-ing ‘‘crossover’’ cases that had had another treatment in the months before

20

15

10

5

Club foot births

Treated club foots

02001

20022003

20042005

20062007

20082009

2010

Num

ber

of c

ases

Figure 1. Club foot births compared with number of patients treated by therapist.




being taken on by the observed therapist. The qualitative assessmentof each case by the specialized professional offers a high level of preci-sion and detail of each patient’s antecedents and development regardingboth feet position and walking balance. The data describing the outcomewere coded from 1 to 5 with the following scale: very insufficient – insuffi-cient – acceptable – good – excellent. Table 1 separates clean and crossovercases.

The French method yields best results for children treated from birth;nevertheless, a relatively important number of cases has been assigned thathad received a different treatment and presented a problematic develop-ment. Because these crossover children are not newborns anymore, goodresults are more difficult to attain. The evaluation of treatment outcome forchildren of one year or more indicates clearly better results for clean casesthan for crossover cases. The ratings of outcomes by the therapist indicatethat results are overall good to excellent for clean cases, and acceptable togood for the crossover cases.

Crossover patients are those who either join or leave the therapist’s carebefore their treatment is concluded (Table 2).

The crossover movements indicate that the therapist attracts a number ofcases either upon parents’ relocation or that failed to achieve satisfactoryoutcomes elsewhere. The change requires deliberate action, generally fromparents assisted by their pediatrician or informed by the Internet. Close

Table 1. Therapist’s ratings of French treatment outcomes.

Very

insufficient Insufficient Acceptable Good Excellent Missing

Average

rating N

Clean

cases

2 0 4 13 19 4 4.2 42

Crossover

cases

1 0 4 3 2 2 3.5 12

Table 2. Crossover patients during 2001–2010 period.

Patients joining Patients leaving Total number of patients

10 4 54

18.5% 7.4% 100%

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inspection of the ‘‘patients leaving’’ indicates that the four cases break downinto:

1. two children moved abroad with their families,2. one conflict situation among parents, and3. one planned transition to a less intensive treatment process for practical

reasons.

Some bias might exist in the evaluation of the treatment by parents or bythe therapist herself, but the coherence across the different sources and theconsistency of the results over the 10-year period confirm the therapist’sexcellent performance. Task performance and the subordination to timediscipline are the result of multiple factors. In the following sections,I will successively explore professional training, the organizational contextof the medical practice, the economic environment, and the medical super-vision of the patients by orthopedists.

Physiotherapists’ training and work in the hospital

Basic physiotherapeutic training lasts for four years with three years oftheory and one year of internship. During the internship, the traineemoves through different hospitals and gathers a broad experience. Thephysiotherapist in this study spent four months in the Children’sHospital, two months in the Rheumatology Clinic, and six months in aregional general hospital. The diversified experience helps the future ther-apist determine his interest for a specialized domain, or to remain a gener-alist. Once graduated, the therapist in this study decided to apply for a fulltime job at the Children’s Hospital. She was recruited, and she specialized inpediatric physiotherapy over a period of 4.5 years working as a regularmember of the team. During these years, she followed several specializedtraining courses for pediatric care.

At the Children’s Hospital, the workday ran from 8 to 12 and from 1 to5:30. There was no fixed sequence for visiting patients; indeed the availabil-ity of the patients for physiotherapeutic treatment is unpredictable becausea variety of events such as X-rays or MRIs, appointments, and treatmentstake place anytime during the day. Also, the amount of time required totreat a patient varies from case to case, depending on that patient’s condi-tion. Some require a mere 15 minutes’ visit; some other patients require longand delicate care. The daily challenge is making sure that all patients whoneed it receive proper care despite the unpredictability of their availabilityat any particular time, the variety of cases, and the daily changing numberof patients.




During the internship, the physiotherapy group for in-patients includedtwo trainees, five full time physiotherapists and one supervisor. The traineespent her day following a senior therapist who showed her how to deal withthe different cases, and who watched the trainee carry out some of thesimpler manipulations. Few cases were handled by the trainee alone whothen worked within broad overall guidelines. The therapist explains: ‘‘Thebasic training does not prepare to any specialized activity, it just gives aflavor of the job, and it determined my career choice [i.e. pediatric physio-therapy].’’ The experience in the Children’s Hospital also helped her find ajob there as a young therapist: ‘‘Having worked in the Children’s Hospitalas a trainee has definitely helped me to get the job afterwards. The super-visor liked my way of working and it is she who eventually hired me inher unit.’’

In April 1976, the physiotherapist began working at the Children’sHospital, and she stayed until December 1980. During this period, shelearned the fine aspects of the job, mostly from her supervisor, who wasan outstanding and widely respected pediatric physiotherapist. ‘‘Her exam-ple, her passion, her talent and her loving dedication have completely deter-mined me in my future career. She trusted me; she helped me do someimportant advanced courses, so that when I left the hospital to begin asan independent therapist, I had the means to operate independently.’’

This short description of the early work experience of the therapist in theChildren’s Hospital gives some insights into the working conditions:

1. Physiotherapeutic treatment is non-standard, and it responds to thepatient’s condition;

2. Acquiring the specialized expertise and the capacity to adapt to the casesrequires extensive involvement with senior practitioners;

3. The therapists provide care in a flexible manner depending on the avail-ability of in-patients; and

4. All patients must receive care within the working hours.

The professional training prepares the practitioner for the open-endednature of the job. Depending on the case and its evolution, he determinesthe course of action for proper care. The learning is complex becausepatients respond differently and the therapist has to adjust continuously.The therapist had this expression ‘‘at the end of the basic training, we wereabsolutely not ready for any specialized or complex treatment. It takes timeand effort to acquire a sense of the patients’ situation and the adapted care[during the specialization period]’’. Together with autonomy, the job givessignificant responsibility to the therapists. They have to decide andimplement.

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Because of the independence and the autonomy, the therapists can inter-vene flexibly during the day in the hospital. This flexibility is not subordin-ation but could be constructed as such. Therapy sessions are not a priorityin the ward. In turn, this temporal subordination is taken for a hierarchicalsubordination by a part of the hospital personnel: there is no advancewarning that a patient will be undergoing some scheduled exploration ora treatment. The therapists just have to adapt to the circumstances. Physicaltherapy gets a secondary status simply because it is available upon request.

From an organizational point of view, the need for flexibility in the dailyworkflow renders proper physiotherapeutic care even more difficult to pro-vide. It is unlikely that the therapists can finish their visits within the normalworking hours. A therapist confirmed this: ‘‘some do not make too much ofa fuss; they will spend a little less time here and there to have a little moreflexibility and to finish on time.’’ Such behavior is legitimate because itconforms to the official schedule. Given the therapists’ autonomy, this isa choice between being time-centered or task-centered. Occupational social-ization strongly encourages conformity and time discipline as a part oflearning a job. The therapists are therefore in an ambiguous situation;either they follow the comfortable and legitimate path of fitting the dailyschedule, or they concentrate on the patients, end late, and overlap withother (scheduled) hospital services. The outcome is visible for the patientsonly after several months, or even several years for the newborns.

Among the mechanisms that reproduce professional norms, training andinternships play an important role. Beyond the acquisition of expert know-ledge, the main purpose of a learning process is to communicate and imple-ment rules and standards of behavior. To become part of the legitimatemembers of a profession, physicians as well as physiotherapists have toaccept and respect its rules and standards (DiMaggio and Powell, 1983:153). Institutionalized norms both produce and reproduce not only thebehavior but also the rhythms and patterns of activity. They providethe time template for behavior (Hassard, 1991: 110).

For the therapist in this study, the choice of being task-centered wasstrongly influenced by the supervisor. Thanks to the mutual professionalappreciation and the friendship that developed, the therapist in this studyhad an intensive and rich learning experience which enabled her to start aprivate medical practice with the skills and techniques required to besuccessful.

Working in the medical practice

After finishing her specialized training, the physiotherapist began profes-sional life in a medical practice that she founded together with a




pediatrician 30 years ago. At the time of the data collection, she had beenoffering the club foot treatment by the French method for 10 years.

The organization of her work concentrates almost exclusively on thepatients and their physiotherapeutic treatments. Her only additional activ-ity is to make appointments, essentially by returning calls that come induring the day. All other administrative activities, billing, ordering supplies,filing insurance claims, and tax returns are taken over by the colleaguepediatrician.

While appointments should be a minor issue for the private practitioner,she organizes her agenda herself. She determines how much time she willdedicate to each case: ‘‘Because I know the patients, I know how difficult itis going to be. I can anticipate how much time I will need.’’ Still, she issometimes behind schedule and patients will wait. They have no alternativeand consider anyway it to be normal to wait for the therapist. On occasion,the appointments are exchanged: ‘‘Sometimes, babies are very agitated, theykeep crying. With all their muscles tense, the treatment is difficult and thesession lasts much longer. When parents come from far away, I ask them towait and try to calm the baby, while I take care of the next. I return to thefirst one afterwards.’’

The medical practice is organized according to an 8 to 12 and 2 to 6schedule. These are the working hours for the two clerical employees. Thepediatrician will do overtime if needed, but he tends to respect the normalschedule. The therapist does not follow this schedule: ‘‘I want at least todecide when I work. Some parents come from far away and appreciate thefact not to have an 8 o’clock appointment, and I need some time to myself.I don’t want to hurry in the morning.’’ She tried to begin at 9:30 a.m., tohave a one hour break around 1:30 p.m. and to end around 7 p.m. The co-workers in the medical practice, including the pediatrician resented thefreedom the therapist took in (re)scheduling her activity and more thanonce this led to passing tensions.

This schedule of the therapist actually changed frequently. She couldhave an 8 a.m. appointment to take care of a newborn in one of the hos-pitals. She could make herself available upon the request of an orthopedistfor a delicate taping or cast to position the foot of a baby after a surgery.Surgeries are scheduled according to hospital logic: the therapist is expectedto be available whenever, and more often than not she is kept waiting or thesurgery is postponed at the last minute. Describing these demands from thehospital, she says, ‘‘I never missed a call from the hospital to see a newborn,but they just take it for granted that I am available.’’ At the end of the day,she might have an extra meeting with the team and the parents to decidehow to proceed for a newborn or simply to decide how serious a particularcase is. These external activities take often place outside the boundaries of

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the preferred working hours, and, compounding the difficulty of managinga busy schedule, some appointments tend to be rescheduled by the hospitaladministration at very short notice. As a result, she will take patients overthe week end if necessary, and she frequently forgoes lunch breaks.

The daily activity of the therapist is determined in the following way:

1. The therapist defines her own schedule in line with patients’ needs;2. The co-workers in the medical practice exert explicit pressure on the

therapist to get her to follow a normal schedule;3. The hospital administration is indifferent to the private activity of the

therapist and asks her to attend surgeries as if she were anotheremployee; and

4. The therapist goes out of her way to respond to requests from the hos-pital and from orthopedists.

The four factors that affect the activity are very different in nature, yetthey converge strictly in terms of resulting time discipline. The co-workersin the medical practice exert social control. The normative expectations andthe practical conditions of collaboration tend to impose a strict adhesion tothe normal schedule on her, but she enjoys a high degree of flexibilitybecause she is part of the ‘‘managers’’ in an organization working byappointment, and she has thorough control over her appointments becauseshe makes them herself. It would be acceptable and normal to work over-time occasionally when the need is there, as does the pediatrician. But herhabit of not considering the normal schedule at all causes objections by herco-workers even after so many years. The therapist opposes this socialcontrol and shows a fair degree of independence. She emphasizes and jus-tifies her attitude as follows: ‘‘I work hard, and I want to respond to hos-pital calls and accommodate patients who need it’’.

While she refuses to give in to her co-workers, she is instead forthcomingwith the requests coming from the hospitals. She will always make timeeither to take care for a premature baby in the hospital, to attend a surgery,or to meet with the parents and the orthopedist. This availability is disrup-tive for the daily schedule. It can reflect a number of motives. First, in astrategic perspective, she has to manage carefully her relation with the ortho-pedists because they alone recommend her, make the prescription, and willcall upon her if she is available when needed: her supply of new cases iscontrolled by the orthopedists. Second, being asked to attend a surgeryand do the taping or the cast is recognition of her talent by members ofthe medical profession. Third, seeing babies very soon after birth is necessaryto achieve best results, even if they are still in the hospital. Only this lastmotive is a consequence of the task-centered behavior. Her high level of




availability for the physicians and the hospital services instead interferes withthe task-centered priority. While it makes sense in terms of future business,pride, and reputation, it also requires costly adjustments. The cost is skip-ping lunch, working longer days, and seeing some patients on weekendsbecause they need the care. There does not seem to be a heroic self-sacrificein this behavior, but a simple sense of obligation. She used to say: ‘‘if it weremy child, I would want it to get the best care possible’’. On the other hand,considering the permanent rush in which she seems to have lost the sense ofpurpose, she also said several times: ‘‘I must be stupid. I can’t deal with itanymore. I had three cry babies. I just want to give it all up.’’

Despite the difference in nature of the interferences, social, organiza-tional, and strategic they all tend to impose clock time discipline. Some,like social control, are simply resisted, others like the hospital appointmentsare accepted but they end up being paid at a high price because they must becompensated with private time. Giving up regularity and private time maybe normally rewarded with supplementary income.

Economic environment

Health insurance imposes strict operating conditions on the profession.Cases are grouped in three categories: general, intensive, and complex.Treating complex cases like club foot earns the therapist 30 tariff pointsin addition to the intensive 77 points rate. The rules are strict withrespect to extra charges beyond the authorized rates: any therapist char-ging more will be excluded from the list of certified therapists, i.e. his/herpatients will not benefit from any insurance reimbursement. Moreover,charging a patient for a double session is forbidden (Source: Insuranceregulation). This restrictive frame does not include any indication ofduration. Asked about the reference time for one session, the publichealth insurance organization Santesuisse indicated in a private corres-pondence that it had dropped indicative durations in 1998. ‘‘A treatmentwith intensive movement therapy is rated at 77 tariff points and lastsperhaps sometimes 45 minutes.’’ The value of the tariff point remainedunchanged since 1998, while the consumer price index has increased by11.5%.

The insurance rules define a difficult economic environment:

1. The therapist is paid a depreciated rate for a complex treatment2. The fact that club foot can be double-sided (2/3 of the cases) is ignored3. There is no minimal time for treatment4. There is no recognition of any particular therapy beyond complexity of

case by the insurance institution.

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The treatment of one foot, though the duration varies strongly depend-ing on the baby’s condition and mood, requires roughly 40 minutes for onefoot when all goes well and taking advantage of the therapist’s long experi-ence. It typically includes receiving parents and baby upon arrival, doingthe movement therapy, and taping or making a cast for fixation of thecorrection. In principle, the therapist can hence operate within thebounds defined by public insurance assuming that everything goes well:patients arrive on time, babies are behaving, and the foot is not a difficultcase. If the patient is a cross-over baby or if s/he is a couple of months old,more time is required. If the malformation is double sided, there is no wayto provide treatment within the indicative time of 45 minutes.1 In order todeal with these challenging conditions, it would make economic sense totreat as many cases as possible within short time, just to have a reasonableincome. The classification used by the insurance company does not give anexplicit duration but simply sets a standard level of compensation, in effectcreating an incentive for a ‘‘quick job’’.

The observed therapist instead made arrangements to be forthcomingwith her time and gave every baby and every foot the time and the attentionneeded in her judgment. Newborns affected with double-sided club foot arehaving their appointments at the end of day as far as possible, when she candedicate the time required by the patient’s condition without upsetting thedaily schedule. When there are many double-sided clubfeet patients thesame day, the therapist will simply set the schedule according to their indi-vidual needs. She was not even aware of the removal of the indicative dur-ation by the insurance administration, until this researcher pointed it out toher. Consistently with the previous observations, the therapist focuses oneach patient, even if she has to give her own time abundantly.

The lack of economic value attached to physiotherapeutic treatment is anincentive for therapists to offer only basic care. In a self-reinforcing process,this reduces the respect that orthopedists garner for physiotherapy and itspotential. This in turn will reduce chances for physiotherapy to be reas-sessed by the medical profession and the insurance companies. The higherthe pressure towards productivity, the lower will be the quality of outcomes,particularly in a profession that requires expertise and empathy with thecondition of the patient. The number of skilled people willing to work undersuch conditions is very limited. Physiotherapy is relegated to ‘‘movementtherapy’’ and has low status.

In order to ensure a comfortable balance between work and income, theobserved therapist with her specialized skills could have chosen to acceptonly simple cases. Given her good reputation, she could select the bestcases, e.g. one-sided club foot patients, and take care of them immediatelyat birth. She would work less, have best results good for her reputation, and




earn more. By accepting all patients, in particular the cross over cases, shehas done the contrary. The therapist observed is an outlier and she achievesoutstanding results. For good reason, no young therapist is attracted to amethod that is difficult to learn and does not promise any financial comfort.

Medical supervision

The normal activity of the therapist includes monthly visits to the hospital,for meetings with the referring orthopedist. On such days, 3–6 patientscome to the hospital with their parents for a consultation. The orthopedistcontrols the physiotherapist’s work in reviewing each case. He will decide ifan additional surgery is necessary on some occasions: 6 out of 42 of thepatients treated from birth. This means that in about 85% of the cases, theorthopedist validates the treatment and the therapist continues her normalsequence.

These interactions between the orthopedist and the therapist are smooth.The therapist achieves good results without active intervention of the ortho-pedist. She actually takes care of the baby for the whole treatment, with thephysician merely monitoring the process. Commenting on some of thecases, the orthopedist however repeatedly stated, ‘‘[t]he initial score [mea-suring the deformity] wasn’t really that bad,’’ or ‘‘this was of course not avery critical case.’’ The evidence on hand indicates that the initial score,measuring the deformation at birth, was instead very high. The therapistconfided that she was frustrated and that she simply could not figure outhow the orthopedist, otherwise mindful and involved, could make such astatement. She has sometimes protested showing evidence to the contrary,to no avail. Other comments of this sort were made. The participants to amedical congress expressed the same disbelief to Ms Bonnet (who contrib-uted in an essential way to the development of the therapeutic process),when she presented her results at an international conference (private com-munication). In the best cases, physicians recognize the good results, butthey softly discount them: ‘‘the method is costly and can hence be offeredonly in rich countries.’’

Reviewing the costs attached to alternative treatments suggests that it isnot obvious that the French method is more costly. The casts according tothe alternative method are significantly more expensive because they aremade once a week for four weeks under the more expensive supervision ofthe orthopedists. Most of the time, this technique requires a small surgery,clipping the heel cord, again by the orthopedist. The resulting cost is com-parable, and the orthopedist has a central role in the process. Over the past10 years of specializing in club foot treatment, the therapist has had to deal

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with 44 feet (47% of total) for which the initial treatment by alternativemethods were less successful. Such remedial work is particularly difficult forthe therapist and the combined costs of the two methods are higher.

The medical supervision offers new insights in the process:

1. The referring orthopedist has a limited role in the treatment process2. The orthopedists put down the outcomes of the French method.

With the balance between the actual contribution and the compensationheavily tilted in favor of the therapist, the orthopedist could be relieved ofan extra burden in his daily activities. Instead, the orthopedist remains veryreluctant to accept the good outcomes of the French method. Interestingly,this is not just an awkward behavior by one person. The lack of recognitionfor the therapists’ performance is observed in medical conferences. It seemsto denote a deliberate effort by the profession.

This resistance of the medical profession has multiple roots, but it hasalso far reaching consequences for the method’s proper implementation.Despite the lack of professional legitimacy, research, training, and finan-cing, the method remains an interesting alternative and those who practiceit marginal actors. Without recognition of the medical profession, insurancewill not provide adequate means in terms of time and money, and very fewtherapists who put quality of long-term outcome before personal comfortand recognition will dedicate their time to learn the method. This situationillustrates how the healthcare organization tends to exclude an emergingtreatment process, and how the temporal frame mediates this exclusion.

Reducing the observation data

Assembling the data collected by observation in a single table and seekingthe common trends suggests three principal components (cf. Table 3). Thefirst covers the items describing the open-endedness. It is a characteristicintrinsic to the task, and it is observed in the training and learning processwith the acquisition of institutionalized professional norms and in actualbehavior in terms of autonomy and independence. The second componentdescribes the temporal subordination. It is a characteristic of the task envir-onment. This component includes data from the hospital environment,from the medical practice, and from the health insurance system. In thehospital environment, subordination is required from the physiotherapist asa part of the institutional functioning. In the medical practice, time discip-line is present as pressure towards conformity from peer workers, as accept-ance of hierarchical control of the hospital’s organization, and ascompliance to the orthopedists’ demands because of the professional




Table 3. Principal components affected by institutional time framing.

Observations

Open-

endedness

Temporal

subordination

Long term

recognition

Hospital

training

(1) Physiotherapeutic treatment is nonstan-

dard, it responds to the patient’s condition

Emerging

activity

(2) Acquiring the specialized expertise and the

capacity to adapt to the cases requires

extensive involvement with senior

practitioners

Learning Professional

norms

acquisition

(3) The therapists provide care in a flexible

manner depending on the in-patients

availability

Flexibility

(4) All patients must receive care within the

working hours

Discipline

Medical

practice

(1) The therapist defines her own schedule in

line with patients’ needs

Autonomy

(2) The co-workers in the medical practice

exert explicit pressure on the therapist

to get her to follow a normal schedule

Social control

(3) The hospital administration is indifferent to the

private activity of the therapist and asks her to

attend surgeries as if she were another

employee

Hierarchical

control

Status

(4) The therapist goes out of her way to

respond to requests from the hospital

and from orthopedists

Dependence Professional

values

Economic

& regulatory

(1) The therapist is paid a depreciated rate for

a complex treatment

Indifference

to income

Status of

profession

(2) The fact that club foot can be double-sided

(2/3 of the cases) is ignored

Organization

process

(3) There is no minimal time for treatment Deregulation

(4) There is no recognition of any particular

therapy by the insurance institution

Status of

profession

Profession (1) The referring orthopedist has a limited role

in the treatment process

Status

challenge

(2) The orthopedists put down the outcomes

of the French method

Defense

van Wijk 21



values and the therapist’s dependence. The health system furthermoreimposes strict rules and ignores patient’s specific situations.

The first and the second components contain the tension between thetask-centered behavior of the therapist and the time-centered operation ofthe environment. The third and last component reflects the problem of long-term recognition. It cements the subordination of the therapist’s activity tothe prevalent time discipline, giving in effect legitimacy to time-centeredbehavior. The subordinate status is expressed through the insurance rulesand through the resistance of the medical profession to acknowledge valu-able results. This third component does not directly affect the daily activity,but it has the effect of banishing change and hence entrenching the para-doxical situation where a good method cannot be recognized and adopted,preventing research, training, and financial rewards. This last group ofobservations reflects the entrenchment of an alternative method like theFrench method in physiotherapy in a marginal situation.

The three components closely resemble the natural selection process,variation in open-endedness, selection in temporal subordination and reten-tion in long-term recognition. Selection translates into compliance to timediscipline, which is in effect a reproduction of the prevalent social order.A variety of factors in the task environment converges to enforce timediscipline and hence oppose the development of open-endedness in thetherapeutic method, cementing an elaborate adverse selection process.Because the clock-time is taken for granted, the selection process is adverseto the open-ended activity. Contrary to common conceptions, performancealone does not lead to recognition and adoption following a variation selec-tion retention process even in a field like healthcare where performance andoutcome are essential.

The activity of the physiotherapist is not alone subject to time discipline.Only few activities like research and creation are not subordinated to therule of clock time. Social control, economic strictures, industry standards,and organizational contingencies, all converge to impose the temporal orderbecause they are themselves constructions leaning on the clock time frameof reference. Most activities are therefore caught in an unobtrusive tem-poral grid that opposes temporal uncertainty: emergence, change, innov-ation, exploration, and learning must all take place in a priori time frames.More often than not, this means that such processes cannot take place atall. As a consequence, the prevailing organization will reproduce itself notbecause of rigidities only, but largely because its operations can simply notbe called into question given the time frame. We are stuck in one modethough there are probably many more ways to conduct our human activ-ities. Though we may understand how we are stuck, we do not know how tochange because of the far reaching interlocks that society created.




Discussion

In this article, I have explored the effect of the standardized measure of timeon open-ended activities. Though I believe my conclusions to apply to allopen-ended activities in our standard time society, I concentrated on health-care for two reasons: (i) the interaction between the professional and thepatient is open-ended and is constrained by the clock time patterns of theorganizational context; and (ii) each patient represents a case that is wellidentified with its history and with good visibility on the process and theoutcome of the treatment. Our organizations based on regularity, planning,deadlines, and time measurement do not fit open-ended activities. Open-ended activities are seen to play a disruptive role in organizational life, not acentral one, because of their uncertain nature both in terms of process andoutcome. In those instances in which open-ended activities are the focus ofattention, researchers still avoid their analysis. The research problem isframed in terms of time and time allocation: time scarcity, time conflict,the social construction of time, and differences in time culture are typicalthemes. The organization theory literature has assumed that analysis beginswith the division of labor and the corresponding integration of tasks in asynchronized workflow. Since researchers, with few exceptions, have takenclock time for granted, they have accepted that open-ended activities do notfit the overall organizational pattern rather than the reverse. Unlike the caseof standardized activities, little attempt has been made to explore open-ended activities. The impact of clock time mediated by society, institutions,organizations, and social groups has been ignored.

In trying to demonstrate that the division of time curtails open-ended activ-ities, and that such interference has central, not marginal, consequences on theemergence and on the outcome of the activity, I have narrowed my focus onhealthcare cases because they are well identified and well documented in termsof process and outcome. I have also focused on a specific physiotherapeuticmethod for club foot treatment as an illustration of an activity where expertaction is determined by the natural growth process and not by any form ofscheduling. In this sense, this research may appear to have more relevance tothe healthcare sector than to the general organizational context. But the centralissue is not the unfolding physiotherapeutic activity, it is the way in which thecontext interferes with the activity. The main thrust of time division is to enablethe coordination of tasks, thus deflecting attention from the requirements ofthe task itself. This focus and the pervasive concern with efficiency it impliesdiscourage the attention to the impact of the time-centered organization andthus disqualify open-ended activities.

I suggest in contrast that, while the importance of time division for organ-izational and social life is unquestionable, it is a good working hypothesis

van Wijk 23



that open-ended activities are important in translating human ingenuity intoproductive outcomes, hence generating essential renewal. What looks to theanalyst like disruptive behavior may be quite sensible when the dominanttemporal structure is not taken for granted and its interference with emergentprocesses is recognized as such. When the situation of professionals in theiruncertain task environment is analyzed, their opposition to organizationalconstraints and their demand for financial autonomy look like reasonableresponses to their actual situation. The therapist who evades temporalboundaries and fights to deliver adequate care, at the cost of her privateinterests and without wider recognition, is acting non-rationally in somestrict professional and economic sense; but when her action is analyzed ina task-centered perspective, the behavior is easily interpreted.

That such behavior is rational is readily seen if we note that it aims notonly at healing the patient but also at giving way to the responsibility of theprofessional to act upon her insight into the specific situation. Organizationtheorists rarely see such goals as rational in part on account of the import-ance of economic motives underpinning their analysis. These motives inturn led to emphasize the certainty of standardized tasks over the uncer-tainty of emergent tasks and to assume that these open-ended tasks occur indedicated and autonomous organizational units or in altogether independ-ent organizations. The notion that organizational rationality is derailed byopen-ended activities has discouraged detailed analysis of such processesbecause they are contrary to the normal organization and has encouragedthe focus on predictable processes. My claim is that while this analyticalapproach has fostered enormous developments, it has had the secondaryeffect of reducing tasks to their simplest expression and freezing them intothis basic functionality fit for rational organization but excluding renewal.

Finally, I should add that the task-centered perspective adopted is asmuch a proximate one as the time-centered approach, but it offers a radic-ally different vision of the situation. While the division of time putsthe focus on how organizations achieve best coordination, it alsoimplies modularity and standardization of activities by division of labor.The task-centered perspective instead does away with the division of timeand labor focusing instead on the deployment of the activity, allowingfor variation as opposed to standardization. Variation in the execution ofthe task restores the capacity of initiative and invention to the actor. Ihave had little to say about what macro-structural circumstances haveled organizations to adopt the in-time organization they do, so I makeno claims for this analysis to answer large-scale questions about timescarcity and acceleration in modern organization or about the long-termeffects of the division of time on renewal behaviors in organizations. Butthe focus on proximate causes is intentional for these broader questions




cannot be satisfactorily addressed without more detailed understandingof the mechanisms by which new ways to do things emerge respectivelyhow such new ways can be suppressed. My claim is that one of the mostimportant and least recognized of such mechanisms is the temporal con-tingency imposed on the variety of activities routinely carried out inorganizations. If this is so, no adequate link between macro- andmicro-level organization theories can be established without a muchfuller understanding of the task evolution when temporal boundariesare removed.

The healthcare context, important as it is, is presented here mainly asan illustration. I believe the open-endedness argument to have very generalrelevance and to demonstrate not only that there is a need to reconsidersome fundamental assumptions about organization, but that this reanaly-sis will offer some very important insights into the relation between task,responsibility, and human ingenuity. In avoiding the analysis of phenom-ena like exploration, researchers have unnecessarily cut themselves offfrom an essential part of human activity in which the organization processis only a special, if important, part of human activity. I hope to haveshown that this enlargement of the analytical perspective is consistentwith and required by some of the commonly observed organizationalshortcomings.

Acknowledgments

Special thanks to the physiotherapist who patiently described her job, the workingconditions, and who shared her professional perspective and her experience on the

health care delivered to newborns. For very helpful comments and suggestions,I thank Arijit Chatterjee, Jerome Barhtelemy, Anca Metiu, and MatthiasThiemann of ESSEC Business School Management Department, Paris, and Peter

Ring of Loyola Marymount University, Los Angeles.

Conflict of interest

None declared.

Funding

This research received no specific grant from any funding agency in the public,commercial, or not-for-profit sectors.

Notes

1. Unless the French method is officially recognized by the orthopedists andthe insurance companies, there is no way to compute an average duration of

van Wijk 25



treatment of club foot, as suggested by one reviewer, because it would conflate

time disciplined treatments with task-centered treatments, and the difference inoutcomes would not be in the interest economic and political interests of keyactors.

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