Organizational Qui-Vive: An Intermediate Approach to Structuring the Link Between Attention and Action


Jacques Orvain

Management des Organisations 
de Santé (EA 7348)               

Ecole des Hautes Etudes en 
Santé Publique                  

Rennes, France               
jacques.orvain@ehesp.fr 

Organizational Qui-Vive: An Intermediate
Approach to Structuring the Link
Between Attention and Action

Jacques Orvain 

Abstract. Since the pioneering work of Simon, several avenues of research have 
investigated the attention structuring processes in organizations. While the 
research based directly on Simon's theories focused on the role of management 
tools in structuring attention, more recent research based on Weick's work has 
focused on the role  of the cognitive processes of the actors rather than tools, 
emphasizing  a particular pattern of action, namely mindfulness. In this study, we 
re-examine the role of tools in the structuring of attention while  recognizing the 
empowerment of the actors as described by Weick. In doing so, unlike the 
majority of current research, which focuses on mindfulness, we consider the 
existence of patterns of actions that are different from mindfulness. An empirical 
study in hospitals demonstrated a particular pattern of action that we call 
Organizational Qui-Vive. This pattern consists of an action script, tools that 
support the script, and processes that channel the attention of the actors. 
Organizational Qui-Vive is similar in structure to Mindfulness but differs in several 
respects. It alerts to a specified danger, it brings consciousness into the action 
using tools prepared in advance and gives meaning to the action through mutual 
understanding. We compare the two patterns linking attention and action to point 
out the different structuring processes that respond to  different situations. 
Organizational Qui-Vive is emerging as an intermediate structuring approach that 
is heavily influenced by the importance of tools, but which nevertheless 
empowers the actors.

! Since the pioneering work of Simon (1983), several researchers have 
focused on attention as a core principle of organization and developed  theoretical 
frameworks to express this view (Gavetti, Levinthal, & Ocasio, 2007). Three 
avenues of research have examined how attention is structured in organizations 
(Ocasio, 1997). The first endeavored to show how attention could be allocated  in 
the organization (Cyert, 1992); the second how certain action scripts develop  a 
particular attention allocation pattern that has been described as Mindfulness 
(Weick & Sutcliffe, 2003); the  third, known as ABV (Attention Based View of the 
firm), has focused specifically on the role of attention in organizations (Ocasio, 
1997). 
! The pattern described by Weick, which is a loose form of coordination with 
little emphasis on tools (Weick, 1976; Weick & Roberts, 1993), has gradually 
been recognized in the literature. However, the  focus on mindfulness raises the 
question of whether there  are other patterns structuring the link between attention 
and action in which tools could play a role. In this paper, we re-examine the  role 
of tools in the study of patterns of coordination. In doing  so we study attention 
structuring patterns other than mindfulness, and we explore the possibility of 

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structuring and distributing different varieties of attention in different situations 
(Ocasio, 2011). 
! Through our participation in a program to improve  the quality of hospital 
care in preventing and  treating pressure ulcers, we observed a particular 
approach to structuring attention which, while still empowering the front-line 
actors, made it possible to structure the link between attention and action. Among 
the hospitals studied, the best-performing ones had developed  a form of 
collective  coordination of attention and action, expressed as a particular pattern 
of action. This attention-action pattern combined an acute awareness of the issue 
of pressure ulcers, modes of action promoting  fast response and special 
interaction arrangements among agents. This form of coordination, supported by 
the managers, was an illustration of the  ability of actors to induce  specific types of 
activity coordination by structuring attention and action. This special way of 
structuring attention and action - which we call Organizational Qui Vive - differs 
from other models because of the way tools are  used to emphasize attention in 
the execution of the action. It also alerts a network of sentinels for a previously 
identified hazard and makes sense of the action in the form of a special type  of 
coordination. 
! In the first section, we review the three main schools of thought that focus 
on attention as a powerful factor in guiding the activities in organizations. The 
next section presents our scope and methodology. In the results section, we first 
propose  a structured interpretation of the attentional processes that have been 
developed  by healthcare teams, and we then describe the functions performed by 
Organizational Qui-Vive. Finally, in the discussion, we show that Organizational 
Qui-Vive corresponds to an intermediate approach to structuring the link between 
attention and action.

A T T E N T I O N A N D A C T I O N S T R U C T U R I N G 
MECHANISMS

! The role of attention in organizations has been conceptualized differently 
depending on the period and the schools of thought. We will review the three 
interpretations that have had the most influence on this issue in management 
science, namely the structural approach (Simon, 1983; Cyert, 1992), the 
cognitive approach (Weick & Roberts, 1993) and the approach developed by 
Ocasio (1997).

T H E S T R U C T U R A L A P P R O A C H : A L L O C AT I N G  AT T E N T I O N I N 
ORGANIZATIONS 

! Simon (1983) and Cyert (1992) attributed two roles to attention: the role of 
guiding action by indicating what was important for the organization, and  the role 
of focusing on certain problems and the corresponding solutions. Organizational 
allocation of attention mechanisms was highlighted as a way of structuring 
attention. As stated by Simon (1983), rationality is not limited by the lack of 
information, but rather information overload is the problem. The attention of the 
actors becomes a scarce resource that must be channeled. To overcome the 
limitations of human rationality, it is possible to partition and  prioritize problems 
and entrust the resolution to different parts of the organization. The role of the 
decision maker is then to allocate the questions, and the attention given to them, 
to various organizational actors (or groups of actors) through the structuring of 
the firm. With this model, Simon emphasizes both the importance of non-
computational mechanisms, which are  more in the nature of the social structuring 

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of attention, and the manager's ability to influence the decision-making 
mechanisms by structuring the allocation of these mechanisms in the firm. 
! Cyert and March (1992) went further in the analysis of the structuring of 
attention by developing the concepts of perspective and sequential attention. 
According to them, the allocation of attentional processes in the organization 
helps identify clear perspectives assigned  to different parts of the organization. 
Problem solving involves a series of partial solutions developed by the different 
parts. This approach has the advantage of creating specializations, focusing the 
effort and providing routines and  procedures that reinforce the attention in the 
execution. This conception of the structuring of attention in the firm highlights the 
role of repertoires, in other words catalogues of tools to help  recognize specific 
signals and/or problem solving tools. These repertoires help  channel perceptions 
or actions without fully imposing the action, since it is always possible to choose 
among the tools in the repertoire. Repertoires can also constitute an 
organizational memory allowing the firm to capitalize on experience and plan for 
the future. The key issues here are the concept of repertoires and the ability to 
build enduring toolsets to support attentional mechanisms.

THE COGNITIVE APPROACH: LINKING ATTENTION AND ACTION

! Another line  of research initiated by Weick focused on the link between 
attention and action, and in particular the collective cognitive mechanisms of 
sensemaking that go beyond  individual rationality (Weick & Roberts, 1993). This 
school of thought differs from the first because it focuses on the cognitive 
processes of attention allocation, rather than tool-based processes. This view 
(Weick, 2006; Weick & Sutcliffe, 2007) describes processes of collective 
representation of action (sensemaking), structuring of collective action based on 
interpersonal interactions (enacting) and forms of behavioral dependence that are 
built by these collective action patterns (mindfulness). These processes create 
action patterns that can be distinguished  not only by the individual attitudes they 
encourage, but by the way individuals act together. The collective behavior that is 
thus encouraged cannot be contained in the action of a single individual. It is a 
result of the interrelationships between actors that channel attention into the 
action (Weick & Roberts, 1993; Ocasio, 1997). 
! This view reintroduces conscious thought into the action, not just as a 
foreshadowing of the action in its consequentialist form, but as a cognitive 
process of consciousness in the  action. Karl Weick describes a special mode of 
linking attention and action he called Mindfulness (Weick & Sutcliffe, 2003; 
Weick, 2006; Weick & Sutcliffe, 2007). This pattern can be described as the 
preoccupation with failure, reluctance  to simplify, sensitivity to operations, 
commitment to resilience and deference to expertise. These  different attitudes 
establish a special link between attention and action that has been studied by 
cognitive science (Chatzisarantis & Hagger, 2007). 
! Weick's view of attention in action, despite its many qualities, is not 
however, without its problems, especially because it basically ignores the ability 
of tools to structure attention (Brabet 2005; Lorino, 2005a). Structuring is almost 
exclusively expressed through the concept of sensemaking, which involves 
interpreting the structuring  processes as the memory of the action rather than as 
a presupposition of the  action. This is a frequent criticism of this model of the link 
between attention and action, which is based essentially on the constitution of 
attentive behaviors and excludes conventional management tools (Eisenberg, 
2006). The key issues here are three major themes: the role of retrospective 
processes of sensemaking and engagement in action, looking at action based on 
interpretation frameworks, and finally the use of action scripts for understanding 
the collective attention processes. We also  note the  importance of studying action 
scripts, which we define as a set of activities linked by a common goal.

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THE ACTIVITY-BASED APPROACH: BUILDING ATTENTIONAL PROCESSES

! Finally the two previous theoretical frameworks – the structural approach 
and the cognitive approach – were combined by Ocasio (1997) who studied the 
primary mechanisms of development of attention in managers and in the context 
of strategic decision making. A few years later, Ocasio (2011) continued his 
reflection on attention, extending  it to different kinds of activities. Based on recent 
developments in neuroscience, he classified  three varieties of attention. The first 
type – attentional perspective – describes the ability of organizations to focus on 
a perspective. This is attention that can be allocated to certain previously 
identified issues or situations or simply determined  by the social, political or 
economic context. This type of attention is produced by guiding the awareness 
and efforts of actors toward certain questions or issues. This can be  done by 
clearly stating goals, prioritizing  a project and expressing logics of action or 
special interests. This is often the result of top-down processes.
! The second type of attention, which Ocasio calls attentional selection, 
describes the ability of organizations to select the issues and solutions in order to 
focus their efforts on the  execution. Attentional selection results from the choices 
made to address certain issues and use certain solutions rather than others. It is 
associated with both top-down and bottom-up  mechanisms that are influenced by 
attentional carriers.
! Finally, Ocasio introduces a third variety of attention, attentional 
engagement, which describes the ability to engage the attention on new signals 
that will produce changes in sensemaking and may be a source of innovation. 
This variety of attention corresponds to cognitive efforts that must be made to 
solve problems, analyze situations and make sense of the activity. It generates 
variations in patterns of thinking, decision making and interpretation of situations 
and is often the result of bottom-up  processes that start from the performance of 
the concrete activity and then make sense of it.
! Ocasio  classifies these varieties of attention to  clarify the different theories 
of attention in organizations. Although originally largely inspired by strategic 
decision making, this approach addresses the issue of attention much more 
broadly. In particular, it shows a new interest in the bottom-up  relations that 
structure attention through processes of interpretation of activities at all levels of 
the organization.
! Another advantage of the approach developed  by Ocasio is that it focuses 
on patterns of attention (i.e., special combinations of varieties of attention) and 
connects these patterns to factors such as the success of the organization and/or 
its ability to innovate and change. Ocasio  (2011) has also developed several 
propositions to describe the reciprocal influences among the different varieties of 
attention. Thus, for Ocasio, attentional engagement facilitates variations in 
perspectives based on bottom-up  relationships, while attentional perspective 
focuses efforts and frees up  resources to produce variations in forms of 
engagement. Ultimately, this view reinstates learning as an attention-structuring 
process. We will use this framework to analyze the Organizational Qui-Vive we 
encountered in hospital wards. 
! The typology of attention proposed by Ocasio describes the different 
patterns that lead to reliable behaviors in situations characterized by uncertainty, 
and in particular mindfulness as described by Weick (2006). This model of 
coordination predominantly involves attentional engagement and facilitates the 
detection and performance processes that bring  consciousness into the action. 
However, it rarely involves attentional perspective, which guides actors to specific 
types of actions in a top-down manner. It also rarely involves channeling attention 
by selection. We  use the chart of attentional processes to compare 
Organizational Qui-Vive and Mindfulness and show how these two patterns 
linking attention and action differ from one another. 

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1. The author of the article participated for three 
years in the program, which was concluded with a 
symposium attended by over a hundred 
participants from all institutions in the health 
territory on February 13, 2014. 
2. For the entire program, including the original six 
hospitals, 25 interviews were conducted, but only 
those involving hospitals H1, H2 and H3 are used 
because they correspond to the phenomenon 
observed. 

SCOPE AND METHOD

! The study on which this research is based is part of a skills and good 
practices development program involving the management of pressure ulcers in 
hospitals. This program, supported by a French regional health authority, initially 
involved six French public and private hospitals1 located in the region of Brittany. 

DIFFICULTIES IN TREATING PRESSURE ULCERS

! The frail elderly in Critical Care and Rehabilitation Units have a very high 
risk of forming pressure ulcers, in other words, necrotic ulcers on pressure points 
between the body and the mattress. In common parlance the term bedsore is 
often used as a synonym. The  principles of prevention and treatment are well 
known and taken singly are relatively simple: patients must be frequently 
mobilized so as not to keep  the pressure of the body in the same place; 
malnutrition and dehydration should be avoided and personal hygiene 
maintained; therapeutic devices, in particular pressure redistribution mattresses, 
have proved effective (European Pressure Ulcer Advisory Panel and National 
Pressure Ulcer Advisory Panel, 2009). However, many hospital teams experience 
difficulties (Gunningberg & Stotts, 2008), because pressure  ulcer management 
involves coordinating teams and especially paying constant attention to  this often 
overlooked risk. The ability to structure the activity is one of the characteristics of 
teams that succeed in effectively managing pressure ulcers (Orvain, 2013). 

INDUCTIVE ANALYSIS OF CARE ACTIVITIES

! We chose to start with the description of activities as a prerequisite for 
understanding the work structures. This is in line with research that considers 
practices as central to social organization (Feldman & Orlikowski, 2011). Thus 
attention is seen not as a resource that is given, but as a resource that is built by 
interaction and structuring processes (Giddens, 1979). The action of an individual 
is integrated into a collective  pattern of action, which allows other members of the 
group  to recognize the action and  acknowledge  it by an appropriate action in 
return (Goffman, 1983; Goffman, 1991). In order to collect the  data for analysis, 
we used an inductive grounded theory method (Strauss & Corbin, 1990; 
Charmaz, 2006). 

DATA COLLECTION IN THREE SUCCESSFUL HOSPITALS

! The study focuses on three of the six hospitals involved in the regional 
study on pressure ulcer management practices. These  three  hospitals (H1, H2 
and H3) were selected because their teams are known for their success in 
managing pressure ulcers. In these hospitals we studied in detail the link 
between attention and action by interviewing hospital employees, observing the 
work in the critical care and rehabilitation units, and participating in working 
meetings. 
! As shown in Table  1, which summarizes all the sources of data collected in 
this study, this article is based in particular on the 12 interviews2 with employees 
from hospitals H1, H2 and H3. The 12 interviewees represent the different 
professions involved in the management of pressure ulcers. Our sample base 
was selected to ensure that within each hospital, representatives of different 
professions were interviewed  (Table 1 below). Open-ended questions were asked 
during the interviews, so the participants could  express themselves freely, while 
ensuring that the following topics were addressed: concrete care practices, use of 
tools (informal rules, management tools, equipment), the nature of the 

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3. The people quoted all signed consent forms for 
participating in the study. All interviewees are 
quoted except two: the director of hospital H2 and 
the manager of hospital H1. In both cases the 
statements were not first hand: in the first case 
the remarks seemed to be a duplication of those 
of the doctor, and in the second case it was a 
person who had just started in the position and 
who explicitly repeated the statements of the other 
people interviewed. These two interviews are 
used in the analysis, but provide no new material 
that would make them worth repeating verbatim.

relationships in the teams, symbolic meanings and emotions. The interviews 
lasted between 90 and 120 minutes and were all recorded and transcribed. They 
were performed between 2009 and 2010. During the interviews, the respondents 
often used  the  term “bedsore” as a synonym for "pressure ulcer." When this term 
was used in the interviews, it was kept in the written transcript, but in the rest of 
the article the term "pressure ulcer" was preferred.
! The 12 interviews were completed both by observations of care practices – 
the author accompanied a doctor and a nurse during a visit of the ward at 
hospital H1 and accompanied the nurse assistants of hospital H2 on one of their 
rounds – and discussions with all the teams. The discussions took place during a 
staff meeting (Hospital H1) and more informally in the nurses' lounge (hospitals 
H1, H2 and H3). 
! Finally, the author of this article also participated in three working meetings 
organized as part of the regional program where participants shared  information 
on risk identification methods, prevention and treatment practices and the 
equipment used. The author did  not participate in the  theme-based meetings 
organized as part of the research program, but, at plenary meetings, he was able 
to report on the initial results of the study and get feedback from the participants.

Table 1. Interviews, observations and discussions at hospitals H1, H2 and H3
Hospital H1 Hospital H2 Hospital H3

People interviewed
Nurse assistants 1 1
Care managers 1 1
Dieticians 1
Directors 1
Nurses 1 1
Doctors 1 1 1
Pharmacists 1
Total interviews 4 3 5

Observations 1 1
Discussions 2 1 1
Regional Meetings 333

! The teams raised  no objections to the interviews and observations 
because of the medical training of the author. This enabled the researcher to be 
accepted and quickly immerse himself in the investigation, but professional 
recognition and empathy may be potential factors of bias3. 
! Memos were  written after the discussions and  meetings to encourage the 
emergence of analytical themes. One of these memos mentioned attention as an 
important mechanism. This led us to search for theoretical data on attention 
mechanisms to support the analysis.

DATA ANALYSIS

! The data were analyzed and presented using the method proposed by 
Gioia, to inductively generate a new way of understanding the empirical facts 
(Gioia, Corley, & Hamilton, 2013). We began with an empirical situation that we 
observed  several times and that we interpret (Langley & Abdallah, 2011). The 
interviews were analyzed in three phases. 

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4. French narratives have been translated into 
English by a professional translator.
5. We kept the French term Qui-Vive because 
there is no real equivalent in English. Qui-Vive 
can be translated as "to be on alert," but this term 
does not fully describe the specific nature of the 
phenomenon observed.

! First, the primary phenomena, which are described by the interviews 
(primary results corresponding to types of action) were coded by the author using 
NVivo software  (version 8). This consisted of constantly going back and forth 
between the codes and all the empirical data to specify the data structure, while 
remaining as close as possible to the  survey data without inferring any specific 
meaning at first. Recurring actions carried out by the  three hospitals studied were 
grouped into 15 categories which constitute the primary coding of the  interviews 
(Tables A1 to A5 in the Appendix4).
! Second, the primary coding elements were grouped by the author, so as to 
constitute a summary in the form of sub-themes (secondary results 
corresponding to the development of an action script). The 15 categories 
previously identified were reorganized  into five common sub-themes that 
describe a common action script. A chart showing the structure of the data and 
verifying the constant link between the field data and the sub-themes is provided 
in the results section (Figure 1). The tools associated with these sub-themes 
were also  identified at this point in the analysis and their role in the 
implementation of the action script was defined. 
! Third, the action script and corresponding tools were compared with the 
chosen theoretical framework to analyze  the attentional processes. Again, we use 
a flowchart to demonstrate  the relationship  between the  action script, the role of 
the tools and the attentional processes (Figure 2). The memos written during the 
study mobilized the symbolic representations of the pattern studied during 
specific situations. Some of the memos are reproduced  as narratives in the body 
of the article to describe these situations where the pattern is expressed.

TERMINOLOGY

! In this study we  will use various terms that we need to define. We have 
already defined the term "action script" as a set of different actions combined to 
achieve a given objective and that are observed repeatedly. In our study, the 
action script consists of the actions developed by the care team to prevent and 
treat pressure ulcers. The associated tools include repertoires of signs 
(assessment forms for example), action principles (decision-making rules, action 
logic diagrams, procedures) and toolsets of equipment (mainly therapeutic 
devices). These tools support and equip  the action script. Finally, the combination 
of attentional processes and an action script create a particular pattern linking 
attention and action.

ORGANIZATIONAL QUI-VIVE 

! We call the action pattern that we have identified  in the study 
Organizational Qui-Vive, which we will describe below. The term Qui-Vive5, which 
was spontaneously used  by several of the interviewees to describe their 
activities, comprises various characteristics. It emphasizes the notion of collective 
alert, it includes the  notion of preparedness and it promotes organizational 
cohesion through a particular form of engagement. And by using the adjective 
"Organizational" we emphasize the collective  nature of this pattern linking 
attention and  action. We will outline these characteristics by describing the action 
script that produces the pattern, then by describing the  tools that support the 
script and finally by the attentional processes that accompany the script. 

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THE ACTION SCRIPT

As shown in Figure 1, the primary coding, and its reorganization during the 
secondary coding, helped identify the action script, which includes five elements: 
a collective  alerting process; collective preparation of attention through the 
creation of risk recognition repertoires; action-taking channeling by common 
action principles; the provision of a toolset; and finally the ability to update and 
make sense of the action script. The  coding details are presented in Appendices 
A1 to A5.

Figure 1. Data structure describing the action script

Everyone	
  is	
  involved	
  in	
  the	
  collective	
  activation	
  of	
  attention	
  
1	
  Attention	
  is	
  a	
  collective	
  
alert	
  mechanismPersonal	
  engagement	
  is	
  elicited

The	
  organization	
  shows	
  the	
  importance	
  it	
  attaches	
  to	
  attention

2	
  Attention	
  is	
  prepared	
  	
  by	
  
creating	
  repertoires

Trivialization	
  is	
  avoided	
  by	
  raising	
  awareness

Attention	
  is	
  a	
  learned	
  technique	
  

Raising	
  the	
  alert	
  is	
  defined	
  as	
  a	
  specific	
  role

3	
  Action-­‐taking	
  is	
  facilitated	
  
and	
  channeled	
  by	
  principles	
  
of	
  action

4	
  A	
  toolset	
  is	
  made	
  available

5	
  The	
  action	
  is	
  constantly	
  
justified	
  

The	
  situations	
  are	
  qualified	
  and	
  recognized

The	
  transition	
  from	
  attention	
  to	
  action	
  is	
  modelled	
  to	
  occur	
  quickly

General	
  principles	
  guide	
  the	
  action

Rituals	
  and	
  routines	
  are	
  established	
  and	
  constantly	
  reviewed

Toolsets	
  and	
  trainings	
  facilitate	
  the	
  action-­‐taking

Opportunities	
  for	
  immediate	
  action	
  are	
  given	
  to	
  operators

Attention	
  is	
  focused	
  on	
  the	
  results

Advisory	
  mechanisms	
  are	
  used	
  to	
  continually	
  review	
  the	
  script

The	
  attention-­‐action	
  script	
  is	
  constantly	
  reassessed	
  collectively	
  

Primary	
  coding	
  categories Sub-­‐themes

! The five main themes that make up the architecture of the action script are 
described in more detail below and are then shown in the flowchart of the pattern 
(Figure 2).

A collective alert mechanism 
! In the three hospitals studied, we observed that managers emphasize the 
importance of collective management of pressure ulcers. The way they place 
their wards on alert, however, varies from one hospital to another. In hospital H1, 
the doctor has made the issue of pressure ulcers a personal commitment that he 
dramatizes and brings to center stage in the  name of "good  medicine." The 
doctor at hospital H2 however, draws attention to the major public health issues 
as defined by the  Ministry of Health. Finally, in hospital H3, attention to pressure 
ulcers is a positioning strategy of the hospital in its health territory. Table  A1 in the 
Appendix reflects the collective construction of attention. The doctor at hospital 
H2 described this process in his ward: "There were lots of meetings with nurses, 
this led to  the first dressing record form, we evaluated the type of bedsore and 
[noted] the dressing we used. A procedure was developed for the prevention of 
bedsores throughout the hospital. A poster was written and put up  in the wards. 
Training sessions were held." 

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Risk recognition repertoires 
In order to  effectively support the collective alert mechanism, pressure ulcer risk 
recognition repertoires are made  available to team members, in particular nurse 
assistants who are  on the front lines. The teams at the three hospitals use risk 
assessment forms and cards with photographs to classify the severity of pressure 
ulcers and  indicate the possible treatments. Specifically these  assessment tools 
enable them to reclassify redness as the first stage of necrosis, which avoids 
trivializing these signs. Other repertoires also facilitate early action processes by 
helping staff recognize the risk of pressure ulcers. Finally, the nurse assistants 
and nurses at the three  hospitals studied are equipped with repertoires that allow 
them to implement specific expertise for identifying pressure ulcers and their 
precursors. Table A2 in the Appendix describes the use of the repertoires. A nurse 
assistant at hospital H1 describes the process: "Malnutrition and dehydration are 
also important. We monitor these issues. If a patient doesn't get out of bed, we 
know we should give him a Nimbus [mattress]. If one becomes available we give 
it to the patient... We had a training seminar two or three years ago which lasted 
two hours to see how much we know. It's important to be vigilant." 

Facilitating and channeling action-taking by action principles 
! The care teams use tools (protocols, record forms, visual aids) and special 
coordination processes that facilitate and guide the action. The nursing teams for 
example use a channeling  mechanism they call "targeted handover 
reports" [focus charting]. "Targeted handover reports" prioritize  the information 
handed over between the teams to guide the collective efforts on a specific 
aspect of patient care. The vigilance for a given patient is thus transferred  during 
shift changes. General rules of action are also established. For example, as a 
result of the improper use of a compression bandage, the doctor at hospital H1 
reminded his team of the different causes of pressure  points. In doing so, he 
transformed a particular collective experience into a general principle of attention 
on the role of pressure. This principle can be mobilized in many other situations 
and will empower the front-line actors to make decisions. Table A3 in the 
appendix gives some examples of the formulation of action principles. The doctor 
at hospital H2 summarizes one of these principles: "We said: all patients with 
bedsores should have a pain chart and we checked to make sure this was the 
case. We monitored the situation, we conducted audits."

Providing a toolset
! We also  observed  that as soon as the early signs are  seen, the health care 
staff in the three hospitals can act quickly thanks to the  existence of a toolset. 
The nurse assistants at hospital H2 were trained to use a decision flowchart for 
the allocation of equipment, allowing them to optimize the use of the pressure 
redistribution mattresses available. Special fortified meals were developed with 
the kitchen at hospital H3. This new tool shortens the  time required  for dietary 
management to be implemented. Emergent processes involving the constitution 
of a reserve stock of meals, invented by the nurse  assistants at hospital H2, also 
help  get around  dietary prescription requirements. Finally, hands-on training in 
using the tools can result in quicker and more effective action. Table A4 in the 
appendix gives several examples of the work of preparing the toolset, in 
particular by the ward  managers: "The role of the manager is to  ensure that the 
information on curative and preventative techniques is communicated and 
understood. When it comes to using the equipment, the manager's role is to 
make sure everyone is aware of what's available and that everyone  works toward 
the same goal... New staff members arrive all the time, we need  to educate 
everyone." 

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Sensemaking 
! Doctors are readily available to answer the questions of nurses and 
nursing assistants and  give  the necessary explanations. This reverses the 
prescription rules and makes the doctors available to front-line agents. The ability 
to consult with the doctors for advice prevents the situation from deteriorating, 
keeps it in a manageable state and especially makes sense of the action 
undertaken. Re-assessment processes are also regularly conducted. In hospital 
H1, patient cases are discussed after the fact at weekly staff meetings, while 
hospital H2 frequently conducts audits on practices to verify the results. The head 
of the department at hospital H3, meanwhile, participated  in many conferences 
where he  presented encouraging  results on new techniques, which generated 
recognition for his expertise and  that of his team. The pharmacist of this hospital, 
whose remarks are reported in Table A5, expressed the need to renew the 
commitment of the teams by reporting on their practices: "It's important to 
document the care provided to get better results, to work together better. We can 
share know-how, the  same equipment, monitor patients at risk. We can pool our 
knowledge." 

THE TOOLS THAT SUPPORT THE ACTION SCRIPT

! The tools used in the prevention and treatment of pressure ulcers have a 
special importance in the  management of pressure ulcers (Orvain & Routelous, 
2012), in particular when it comes to  identifying problems, choosing the actions to 
be  taken and  selecting the right equipment. They facilitate, delimit and guide the 
action without dictating it too specifically. We  can group  them into three types of 
tools that correspond to themes 2, 3 and 4 of the action script (see Figure 1). The 
health care staff interviewed described first using repertoires of signs to identify 
people at risk, anticipate the risk of developing an ulcer and assess the  severity 
of the risk. These repertoires also contain a number of stories that keep  the 
experiential memory alive. 
! Next, principles of action form another category of tools. They are  often 
expressed  in terms of general principles which must then be interpreted by the 
actors. Avoiding pressure points is often emphasized, whether it be the pressure 
of a sheet, a bandage or simply the weight of the body against the edge of a 
chair. This focus on pressure  points guides the action based on a general 
principle that can be mobilized in many different situations. 
! Finally therapeutic equipment, mainly dressings and pressure redistribution 
mattresses, is a third type of toolset that guides and facilitates action-taking.
! The range of tools available (repertoires, principles, toolsets) conditions the 
possibility of selecting problems and solutions in the  action phase. The tools also 
interact with other themes of the action script. For example, prior to  the action 
phase, assessment forms for identifying  patients at risk are provided as part of 
the institutional policy of hospital H2 in the fight against pressure ulcers, thus 
placing the teams on alert. After the action phase, the tools form a memory of 
past action that factors the experience into the  equipment available. For example, 
the too narrow compression bandages that caused an ulcer were removed from 
the cabinets at hospital H1, after discussion among the team. The tools help 
solicit and renew the engagement of the teams. 

ATTENTIONAL PROCESSES

! Each of the themes of the action script can be  mapped to  one of the three 
forms of attention proposed in the literature (Ocasio, 2011).

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Attentional perspective 
! Each doctor, along with the ward manager, puts the issue of pressure 
ulcers into perspective. Alerting people to the issue of pressure ulcers is thus a 
collective  mechanism that recruits their attention and makes each person co-
responsible  for collective vigilance. The nurse  at hospital H1 provides an 
example: "Preventing bedsores is on everyone's mind, even before redness 
appears, we set everything up, the bed, [the diet] with the dietician..."  
Vigilance is not a spontaneous process, but a social construct that alerts the  team 
to a previously identified  risk. The risk is put into perspective by linking it to 
broader perspectives that make sense of the corresponding care activities.

Attentional selection of problems and solutions
! In the execution phase, the action is supported by attentional selection of 
the problems, solutions and actions. 
! First, the collective attention is supported by technical preparedness that 
makes it possible  to identify risk situations. Describing the danger encourages 
people to switch from simply observing to actively watching out for the event and 
already anticipating what action to take. Next, the rules of action are usually 
expressed  in terms of simple, easy to  understand  principles that enable people to 
take fast action and monitor the  results. In this respect, the  targeted  handover 
process by the nurses was mentioned several times by the interviewees. An 
excerpt from Table A3 shows the importance  of this process for channeling the 
collective  attention: "When we have something to say we say it. Targeted 
handover is short, we don't spend a lot of time, we  need to focus on what's 
important. We have our handover notebooks. We  have a handover board. We 
look at the board and we see  if there are bedsores, if there is a big bedsore, we 
know about it." The doctors and managers also emphasize certain principles of 
action they wish to promote. Finally, the quality and speed of response depend 
on the  availability of a toolset that can be used to respond to emerging events 
and work overload situations. The toolset gives direct access to common tools 
developed  in advance, which provides guidance  while allowing  freedom in the 
final selection of the tool.

Attentional engagement
! When the meaning  of the  action is in doubt, the ability to consult with an 
expert for immediate advice  helps people reassess and understand the situation. 
Doctors, occupational therapists and dieticians therefore make themselves 
readily available to the  teams in the wards. In the longer term, these interactions 
result in frequent updates to the assessment forms, action principles and tools. 
For all three  hospitals, the goal is to make  sense of the work and  identify areas 
for improvement in the perspective that has been chosen. The manager of 
hospital H2 forcefully states that "In decision-making, we must readjust until 
things are  going well. And let people know that things are going well. Go from the 
action to the result. And the  result should  lead to the elimination of the problem. 
That's the idea. This must be [the mindset] at all times..." The entire system is 
regularly re-evaluated, discussed and adjusted, which helps maintain, strengthen 
and make sense of the collective engagement.

THE QUI-VIVE PATTERN

! Qui-Vive is a pattern, as we  defined  it in the method section, because it 
closely combines an action script, special tools that support it and different types 
of attention. Figure 2 shows the correspondence between the sequences of the 
action script that correspond to the  five analysis themes, the tools that support 
the script and the three varieties of attention described by Ocasio (2011). 

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! The preceding analysis has demonstrated the essential role of tools in 
supporting the sequences of the script associated with attentional selection. 
These relationships are represented  in Figure 2 by solid arrows linking each type 
of tool to a particular type of action. These tools facilitate  action in the execution 
phase. The  abundance of detail on this second form of attention shows how 
important it is in the pattern that we observed.

Figure 2. Organizational Qui-Vive pattern

1	
  Alerting	
  collectively

2	
  Recognizing	
  the	
  risk

3	
  Channeling	
  action	
  by	
  
principles	
  of	
  action

4	
  Using	
  	
  a	
  toolset

5	
  Making	
  sense	
  of	
  the	
  
action	
  

Action	
  script Tools

Repertoires

Principles

Toolset

Attentional	
  processes	
  

Attentional	
  
selection

Attentional	
  
perspective

Attentional	
  
Engagement

! Tools also have  a role, albeit more indirect, when it comes to actions 
corresponding to attentional perspective and attentional engagement. These 
relationships are shown by dotted arrows. Tools prepare the way for sounding the 
alert and help  indicate  the perspective in which the action is situated. The 
pressure ulcer risk assessment forms are a prime example of this. Tools also act 
as a record of past actions and make sense of the action. This adaptation of tools 
is particularly evident at hospital H3, which, to position itself as referral facility, 
invests in new technologies. 
! Tools thus play a triple role in attentional processes. Mainly mobilized 
during the execution phase, they help  to channel attention to  the selection of risk 
situations and the choice of treatment tools. But they also have relationships with 
the other two processes. Prior to the execution phase they reaffirm the 
perspective  chosen by anticipating risk situations and prevention methods; after 
the fact, they constitute a memory of past actions, which reinforces the 
engagement in preventing  and treating pressure  ulcers. In the words of Ocasio 
(2011, p 1293), tools are attentional carriers.

WHAT ORGANIZATIONAL QUI-VIVE ACCOMPLISHES

! The attention-action pattern can now be characterized by what it makes it 
possible to accomplish using the  different varieties of attention. We  can define 
Organizational Qui-Vive by showing how it helps the  actors anticipate the action 
by alerting a network of sentinels, how it equips the actors by giving them the 
means to act quickly and bringing consciousness into  the action, and finally how 
it makes sense of the action and keeps the actors engaged.

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The doctor at hospital 2 explained during  a visit that to  improve  the practices of 
her team, she draws on the major national health programs. She has worked 
hard on pressure ulcers and she wants to work on malnutrition in the coming 
years. When I asked her why she doesn't carry out these projects 
simultaneously, she explained to me that to change people's habits, she  has to 
focus on one project at a time and integrate it into a general improvement 
program.
The ward manager has set up  an information sharing system by fax with general 
practitioners. This allows her to announce the  arrival of a new patient and to 
collectively prepare the teams. She believes this helps make the teams aware of 
the person's situation and anticipate their needs, especially regarding the 
management of pressure ulcers for which the ward physician has set up  a plan 
for improving practices.

QUI-VIVE ANTICIPATES THE ACTION

! The healthcare staff is placed on alert by the channeling of their attention 
to the development of pressure ulcers. Equal attention is not paid to all kinds of 
events; instead a large part of the attention is focused on a particular event 
designated in advance. This focus on the occurrence of a particular event makes 
it possible  to anticipate the action in the attention. Thus, the team at hospital H2 
obtains information from the general practitioners before the patient is admitted, 
which allows them to order a pressure redistribution mattress in advance when 
necessary. The dietician at hospital H3 has set up  fortified meals, and she  lets the 
nurse assistants decide when to  administer them. This makes it possible to take 
early action and short-circuit the long prescription process. A dietary diagnosis 
can subsequently confirm or reverse this action. 
! Narrative 1 illustrates this property of Qui-Vive. It shows how the physician 
and healthcare manager at hospital H2 specifically channel the attention of the 
teams to the  risk of pressure ulcers and make it part of a more general 
perspective of action. 

Narrative 1. Hospital H2

! Qui-Vive expresses a form of collective response that closely combines 
awareness of the problem and ways to address it early. The  tools, which are 
prepared in advance, encourage quick action by a group  that is aware of the 
problem and ready to take  pro-active action to address an undesirable  situation 
designated by the organization.

QUI-VIVE BRINGS CONSCIOUSNESS INTO THE COLLECTIVE ACTION

! The teams are  on the alert or take alert action, which does not determine 
the action itself but rather how the action is carried out. Fast action is highly 
valued by teams who practice Organizational Qui-Vive. Pressure ulcers can 
develop  at any time and anywhere, and they can worsen quickly. The teams who 
are used to  dealing with pressure  ulcers are accustomed to being vigilant and 
taking resilient action. The doctor at hospital H1 explained that his team takes 
faster action than the other teams when it comes to treating pressure ulcers. 
What other hospital teams see as a chronic occurrence is considered on his ward 
as a very acute problem along  the lines of a myocardial infarction. Fast action is 
seen as a cardinal virtue that guides the  choices without waiting for an accurate 
diagnosis or a carefully thought out therapeutic strategy.

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Treating malnutrition is an important part of the management of pressure ulcers. 
The treatment usually consists of costly nutritional supplements. In most wards 
this leads to a prescription principle that entails a long chain of command: the 
nurse assistant reports nutritional problems to the nurse, who alerts the doctor. 
The doctor prescribes a dietary assessment by the dietician and then the 
supplements will be ordered from the pharmacy and ultimately administered by 
the nurse assistant. 
The dietician at hospital H3 came up with a completely different circuit to save 
time. She spoke to the kitchen staff and asked them to prepare meals fortified in 
sugars and fats. When the nurse assistants are worried about the nutritional 
health of a patient, they order him this type of meal. The dietician goes to the 
kitchen every day and sees which patients have had fortified meals. She then 
establishes a more accurate diagnosis and reports to the doctor, who prescribes 
more sophisticated supplements. The patient did not have to wait for an 
immediate solution to his nutritional difficulties.

! Narrative 2 shows how the  desire to take fast action changes the ways the 
action is carried out.

Narrative 2. Hospital H3

! Organizational Qui-Vive  brings consciousness into the action by indicating 
particular cognitive methods for the  performance of the action. It promotes 
collective  attitudes of vigilance and speed that will condition both the choice and 
the sequence of actions. This conception of action, supported by attention-action 
patterns, differs from the more classical cognitive vision that introduces a gap 
between thought and action. In the classical conception of action, solutions are 
chosen prior to the reflection on how they will be carried  out (Marshall, 2008). 
With Organizational Qui-Vive, it is not so  much the action itself that is anticipated 
as the manner in which it can be  accomplished. In the example provided in 
narrative 2, the rules of prescription were reversed to meet the need for quick 
action. Qui-Vive prevailed over the conventional process of diagnosis followed by 
treatment.

QUI-VIVE MAKES SENSE OF THE ACTION AND SUPPORTS ENGAGEMENT 

Qui-Vive is a collective expertise that facilitates mutual understanding among the 
different professions. The actions implemented by front-line actors can trigger 
actions by other actors. For example, the arrival of a patient with a pressure ulcer 
at hospital H3 will immediately raise  an alert for the doctor, the dietician and the 
occupational therapist. Hospital H1 (narrative 3) provides another example  of this 
mutual understanding  process, in which a new interpretation of the causes of 
pressure points is developed based on a shared experience. All the team 
members are thus bound  by common interpretations that determine how they 
deal with pressure ulcers and create reciprocal engagements. This gives a 
collective sense to each person's actions.

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During a visit to hospital H1, I witnessed an adverse event. The ward physician 
took me to see a patient presenting redness on one leg. Two nurses 
accompanied us. Recently a new nurse applied too narrow a compression 
bandage on the patient's leg. The doctor commented on the  event and explained 
that the pressure  of the bandage probably impeded blood flow. At first, this 
appeared to me to be a routine event, but I later realized during various meetings 
that the information had spread quickly and was being commented on throughout 
the ward. The collective emotion aroused by the event led to the creation and 
rapid spread  of new collective knowledge. Everyone is now aware  that it is 
important to pay attention to  the width of compression bandages. The ward 
manager plans to make it a rule and inform newcomers to the ward because they 
do not have the same experience as the more senior agents.

Narrative 3. Hospital H1

!
! Organizational Qui-Vive is actually a kind of ideal of the action to  be 
undertaken, or in other words a primary framework for action as described in 
Goffman's frames of experience (1991). This ideal guides perspectives, leads to 
mutual understanding of actors and aligns their individual actions. In this type of 
action, the actors gain empowerment, but by making use of a particular attention-
action pattern, namely Organizational Qui-Vive. The  Organizational Qui-Vive 
pattern is a rhetoric of action (Lorino, 2005b), a narrative principle that enables 
actors to situate their contributions in a collective pattern of action (Pentland & 
Feldman, 2008).

DISCUSSION

! Contemporary approaches to  safety in hospital healthcare have recently 
moved away from a standard instrumental conception of risk management. The 
processes that are based on long chains of reporting and feedback have reached 
their limits and do not result in substantial gains (Saintoyant, Duhamel & 
Minvielle, 2012). The coordination models based  on quick feedback mechanisms 
and a stronger link between attention and action, according to the mindfulness 
principle, are considered both as effective and as ushering in a new culture 
(Vogus, Sutcliffe, & Weick, 2010). However, the emphasis on mindfulness 
overlooks the tools routinely used to ensure safety in healthcare. 
! In comparing Organizational Qui-Vive and Mindfulness using the 
categories of attention proposed by Ocasio (2011), we will first discuss the 
distinguishing features of the pattern that we observed. We  can then extend  this 
reflection by considering that Qui-Vive belongs to  a broader range of patterns 
linking attention and action that are used to respond  to different situations. Finally 
the use of this coordination model in other areas than healthcare  can be 
discussed and we will also show its limitations. This will open up  new avenues of 
research.

ORGANIZATIONAL QUI-VIVE AND MINDFULNESS

! With the concept of Mindfulness, Weick and Sutcliffe (2006) semantically 
emphasize the issue of mindful attention in action. Weick attaches great 
importance to the  immediate or retrospective nature of this attention rather than 
its ability to anticipate. We have shown, however, how Organizational Qui-Vive 
can anticipate the  action in the attention. This difference can be further explained 
by comparing the two patterns based on the three varieties of attention. The two 
patterns, which both create a strong link between attention and action, are 

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compared based on the different varieties of attention in the  table below (Table 
2). 

Table 2. Comparison of different patterns linking attention and action

Type of attention Qui-Vive Mindfulness

Perspective
Early vigilance with respect to a 
particular risk

Mind open to all perspectives

Selection
Tools prepared in advance rather 
than tinkering (bricolage)

Intelligent tinkering (bricolage)

Engagement
Reassurance as to the meaning of 
the action and adjustments as 
needed

Sensemaking during the course of 
the action

! Attentional perspective. Qui-Vive prepares sentinels for a particular type 
of event without necessarily indicating exactly what action to undertake. This 
early vigilance points out the perspectives and possibilities for action. 
Mindfulness however has a much broader perspective. It focuses attention on a 
situation where a coming event is quite unexpected, hence the title of Weick's 
book: "Managing the Unexpected" (Weick & Sutcliffe, 2007). For Organizational 
Qui-Vive, this aspect of attention is important because it channels vigilance. The 
importance of guiding perspectives calls to mind the distinction between 
sensegiving and sensemaking (Gioia & Chittipeddi, 1991). Attentional perspective 
is based on channeling perspectives, which gives meaning to the action, while 
sensemaking occurs during or after the action. In other words, while Mindfulness 
emphasizes sensemaking, Organizational Qui-Vive emphasizes attentional 
perspective.
! Attentional selection. Qui-Vive empowers actors by providing them with 
shared knowledge  and a range of shared actions through significant investment 
in the preparation of tools that will equip  the action. In contrast, Mindfulness 
recommends seeking out expertise that is distributed in the organization, it 
encourages opportunities for bricolage to  invent solutions, but it does not 
anticipate these  opportunities. Invention and innovation are important resources 
of attention for the Mindfulness pattern, while Organizational Qui-Vive is 
essentially based on a toolset prepared in advance. Bricolage does exist in Qui-
Vive, but the resulting action tends to become  an enduring resource that will 
anticipate future situations.
! Attentional engagement. Qui-Vive can content itself with supporting the 
action without creating new types of engagement. It simply needs to reaffirm the 
primary meaning of the action. In contrast, Mindfulness invests heavily in making 
sense of the action and creating new types of engagement in the action. For 
Mindfulness, changing the  meaning  of the action helps manage unexpected 
situations by not limiting actors to an initial pattern of interpretation. In contrast, 
for Organizational Qui-Vive the goal is to reaffirm the  perspectives selected. 
Again, Organizational Qui-Vive can make new sense of an action, but the effort 
made to define perspectives and engage the attention towards a particular risk is 
greater.

QUI-VIVE IS AN  INTERMEDIATE APPROACH  TO  STRUCTURING 
COORDINATION

! Weick distinguishes two types of couplings that directly affect the  opposing 
principles of efficiency and  reliability (Orton & Weick, 1990; Weick & Roberts, 
1993). The first type, described as a tight coupling between actors, is often used 
in situations where there are  very few unexpected events, with low-risk 

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technologies and direct reporting lines. In contrast, the second type of coupling is 
described as a loose coupling between actors. Mindfulness is part of a loosely 
coupled system. This type of coupling is used in complex situations where the 
actions to be undertaken cannot be predicted accurately because interactions 
play an important role. By focusing on pre-defined tools, Organizational Qui-Vive 
moves towards tighter couplings along a continuum that allows for coordination 
models that vary between loose couplings and  tight couplings. Qui-Vive appears 
as an intermediate approach to structuring the link between attention and action. 
! This idea of a continuum supports the theory developed by Levinthal and 
Rerup  (2006), who state that mindfulness does not exclude routines but rather 
that the two are  complementary (see also Levinthal & Warglien, 1999). The need 
to use different varieties of attention has also been described in the management 
of rare crises (Rerup, 2009). Because the different types of loose couplings are 
distinguished by the importance granted to one or the other of the varieties of 
attention described by Ocasio, it is possible to contextualize the action in the field 
of safety (Elsbach, Barr & Hargadon, 2005; Journé & Raulet-Crosset, 2008, 
Hollnagel, 2009). 

TRANSFERABILITY AND LIMITATIONS OF ORGANIZATIONAL QUI-VIVE

! The attitudes that are specific to Organizational Qui-Vive, and that we 
observed  in the hospitals during this study, can be extrapolated to  enhance the 
reliability of organizations in general. In different contexts, different situations may 
arise. In the case of a known risk that may occur at any time, the reliability of the 
organization is based on the ability to select the varieties of attention and to 
prepare tools to respond to the situation. This will empower the front-line actors, 
while delimiting the range of solutions based on the type of tools made available. 
However, when the risk is totally random, the Mindfulness pattern seems more 
appropriate because  it helps make sense of the action without prejudging the 
circumstances. 
! The different patterns linking attention and action actually organize  an 
attention economy: they can optimize  the use of attention, and they can degrade 
its performance. The Qui-Vive  pattern, and probably even more so the 
Mindfulness pattern, by calling  for vigilance, may indeed run the risk of 
generating burnout among front-line actors. Qui-Vive could exacerbate the 
worries of the actors and undermine their performance. This is one of the 
limitations of this pattern, which cannot be applied in all types of situations 
because of the risk of burnout. Clearly, it is necessary to contextualize the use of 
Organizational Qui-Vive.
! The limitations of Organizational Qui-Vive give rise to new research 
questions. It would be interesting to study how the different attention-action 
patterns emerge in organizations. Are the  patterns different depending on the 
functions and work schedules within the organization? Do we observe mimicry or, 
conversely, segregation in the choice of patterns? Are  there processes for 
transitioning from one  pattern to another depending on the evolution of risk? All 
these questions typically fit into the program of Simon, March and Cyert on the 
possibilities of allocating attention within organizations (Simon, 1983; Cyert & 
March, 1992).

CONCLUSION

! The study of a particular type  of care in hospitals has revealed  a common 
pattern linking  attention and action we have called Organizational Qui-Vive. The 
centerpiece of the Organizational Qui-Vive pattern consists of an action script and 

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tools that support different attentional processes. Organizational Qui-Vive recruits 
different types of attention that have been described in the literature: attentional 
perspective, attentional selection and attentional engagement in the action. 
! Organizational Qui-Vive creates a working  organization that structures, in a 
particular manner, the link between attention and action, but it is different from 
other patterns linking attention and action. It stands out in particular from 
Mindfulness as described by Weick, which has been used to characterize safety 
processes in hospital settings (Vogus & Sutcliffe, 2007). In both cases, the 
description of the activity relies heavily on a close relationship  between attention 
and action. But in the case of Organizational Qui-Vive the focus is on the first two 
categories of attention (attentional perspective and  attentional selection), while in 
Mindfulness the last category predominates (attentional engagement). In 
addition, predefined tools play a more important role in Organizational Qui-Vive.
These different patterns linking attention and action are part of a larger family of 
coordination involving more or less loosely coupled activities. These couplings 
provide a framework for the  actors while still empowering them, which may have 
applications far beyond risk management in hospitals.

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APPENDIX A. STRUCTURE OF PRIMARY AND SECONDARY THEMES

Table A1. Attention is a collective alert mechanism
Everyone is involved in the collective 
activation of attention

"When patients arrive, it's the first thing we look for... Bedsores are not normal, it's our boss 
who said that. We follow along, but he's right." (Nurse Assistant H1)
"Preventing bedsores is on everyone's mind, even before redness appears, we set 
everything up, the bed, [the diet] with the dietician... The whole team is involved in the 
process." (Nurse H1)
"Here it is not completely hierarchical, everyone should give the alert, everyone has a role, if 
you use too many tools that can be counter-productive. What's important is not to achieve 
quality for quality's sake What's important is when the team follows along, I think that's 
great. I don't want to be a bedsore specialist, it is better to provide training. Work on the 
culture of the ward. (Doctor H2)
"Here in the hospital we pay attention to changing [patient] positions and hydration. It's rare 
to see bedsores. If the patients arrive with bedsores, they don't leave with them, that's just 
how it is! This shows that we provide good care." (Nurse Assistant H3)

Personal engagement is elicited "Compared to 25 years ago, things have changed, it’s had a huge effect... On our ward we 
are very attentive to this issue, and we’re successful. I'm totally sincere. Our boss taught us 
that." (Nurse Assistant H1)
"For me it was clear: I am the person of reference for bedsores in the hospital, so there 
absolutely cannot be any bedsores on the ward. There is multidisciplinary communication, 
the nurse assistant knows that people will pay attention to what she says. (Doctor H3)
"We've encouraged the staff, be it the nurse assistants or the nurses, by showing them, 
getting them directly involved." (Doctor H3)

The organization shows the 
importance it attaches to attention.

"The message spreads quickly throughout the team. The first time a new girl had to say that 
a red spot had appeared, it wasn't easy. The fact that there is this fear, we do everything we 
can to make sure we provide the best care possible." (Nurse H1)
"There were lots of meetings with nurses, this led to the first dressing record form, we 
evaluated the type of bedsore and the dressing we used. A procedure was developed for the 
prevention of bedsores throughout the hospital. A poster was written and put up in the 
wards. Training sessions were held." (Doctor H2)
The hospital has a good reputation in this area. The families don't pay attention to this issue. 
It's more among hospitals, we judge our colleagues." (Pharmacist H3)

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Table A2. Attention is prepared by creating repertoires
Trivialization is avoided by raising 
awareness.

"I act based on my emotions because if we trivialize it we simply don't see it any more. 
There is a fatalism that sets in." (Doctor H1)
"Bedsores are not inevitable. The nurse assistants' vigilance is the most important thing. 
They are the first people who should be trained. If they don't give the alert, none of the rest 
will work." (Doctor H2)
"The general public is not really aware of this issue, people need to be more attentive, there 
should be therapeutic education on the importance of nutrition. The general public is 
uninformed and not educated about the issue. There is a fatalistic attitude." (Dietician H3)

Attention is a learned technique. "Malnutrition and dehydration are also important. We monitor these... issues. If a patient 
doesn't get out of bed, we know we should give him a Nimbus [mattress]. If one becomes 
available we give it to the patient... We had a training seminar two or three years ago which 
lasted two hours to see how much we know. It's important to be vigilant." (Nurse Assistant 
H1)
"A dynamic system has been set up: first a dressing group in 2002, a dressing record form 
for traceability, staff training, a handbook was produced." (Doctor H2)
"It was very hard, because I wanted there to be trained nurse assistants, i.e. certified... So 
we had to assess their knowledge and they realized that in fact they didn't necessarily have 
the knowledge and therefore the skills couldn't be fully implemented." (Manager H2)
"The nurses talk openly about the issue. They dare to say that there are bedsores. That 
makes people want to review the stages of severity, I do that from time to time. We could 
calculate the impact of nutrition based on the stages. (Dietician H3)

Raising the alert is defined as a 
specific role

"It's based on people, discussions, communication. Dr. B is a great actor. When redness 
appears he puts on a big show [of being upset]." (Nurse H1)
"The nurse assistants have been educated, whenever there is redness they report it, they 
give the alert. This is really the first thing, it's what's most important." (Doctor H2)
"The nurse assistants play a major role in terms of observing and reporting if there is a risk. 
We raise the alert." (Nurse Assistant H3)

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Table A3. Action-taking is facilitated and channeled by principles of action
The situations are qualified and 
recognized

"The doctor talks about it regularly, both explaining preventive methods, focusing on it when 
he goes to see this kind of thing. When there is a problem he focuses on it and gets 
everything going right away." (Nurse H1)
"We held a meeting where we made everything very clear. When I receive someone I 
indicate it on the schedule, I indicate where she is coming from, why she is coming and what 
her level of autonomy is. Why she is coming, whether she has bedsores or not." (Manager 
H2)

The transition from attention to action 
is modelled to occur quickly.

"When we have something to say we say it. Targeted handover is short, we don't spend a lot 
of time, we need to focus on what's important. We have our handover notebooks. We have a 
handover board. We look at the board and we see if there are bedsores, if there is a big 
bedsore, we know about it." (Nurse Assistant H1)

General principles guide the action "We said: all patients with bedsores should have a pain chart and we checked to make sure 
this was the case. We monitored the situation, we conducted audits. We set up dressing 
record forms in the wards. We had 2 types of record forms, now it's computerized." (Doctor 
H2)
"And at that point we said, well, we just have to work. We start with an observation, an 
observation that there are things that are not acceptable. So we can't let these things go 
because there is an impact on the patient, there is an impact on the caregiver. Here there 
are a lot of things that are done in terms of training about patient abuse." (Manager H2)

Table A4. A toolset is made available 
Rituals and routines are established 
and constantly reviewed

"The nurses and assistants know what to do. The problem is to make sure they do it at the 
right time. So I say it has to be an obsession... It has to become second nature. We can't 
forget important things, it's an automatic ritual." (Doctor H1)
"In all the different hospitals, we need to provide the same management and care. We need 
to have the same monitoring, for patients who are in transit." (Pharmacist H3)
"For direct admissions, we developed a form that we send by Internet to the doctor who 
sends it back by Internet to provide us information about the person's condition. We created 
the form and sent it to all the general practitioners. Based on that, I fill out my info sheet, a 
label. I put it on the card that goes on the wall chart." (Manager H2)
"When I did the audit I went to see if they used focus charting and targeted handover 
methods. Targeted handover was introduced in 2008. Targeted handover makes sure things 
are documented in the patient chart." (Doctor H2)

Toolsets and trainings facilitate the 
action-taking

"A well-organized team will make the best use of everyone’s skills. You have to have the 
knowledge, training, hands-on training, and then find the best way to get the entire staff to 
work efficiently.
The problem with bedsores is that to prevent them you have to take quick action. In wards 
where we're used to [managing this type of risk], things are organized. (Doctor H1)
"The role of the manager is to ensure that the information on curative and preventative 
techniques is communicated and understood. When it comes to using the equipment, the 
manager's role is to make sure everyone is aware of what's available and that everyone 
works toward the same goal... New staff members arrive all the time, we need to educate 
everyone." (Nurse H1)
"Information is provided on the correct use of dressings for each stage. The nurses talk 
openly about the issue." 
(Dietician H3)

Opportunities for immediate action are 
given to operators

"We established a flow chart to decide which type of mattress to use. We realized that the 
mattresses were not assigned correctly. The Nimbus mattress was assigned to people who 
didn't need it. We don't indicate the specific type because I want to involve the nurse 
assistants and nurses in the decision." (Doctor H2)
"Here we do an admission assessment, there is a protocol on the treatment carts showing 
how to recognize the different stages. There is a booklet that helps determine the stage. We 
have a basic list for the dressings, but everyone sort of works on their own. There is a broad 
range [of dressings], on the wards they don't always know which to use. It isn’t easy to 
[choose which to use] based on category or class. [The doctor] does the most complicated 
dressings. So the nurse is motivated [to learn and improve]." (Pharmacist H3)

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Table A5. The action is constantly justified (sensemaking)
Attention is focused on the results We know that we're being effective when the bedsores are gone... On the team, if there is a 

bedsore, we ask ourselves what we did wrong. And we'll be three times more vigilant when 
treating it." (Nurse Assistant H1)
"In decision-making, we must readjust until things are going well and let people know that 
things are going well. Go from the action to the result. And the result should lead to the 
elimination of the problem. That's the idea. This must be [the mindset] at all times and we 
should see the person's condition improve or see the problem resolved." (Manager H2)

Advisory mechanisms are used to 
continually review the script

"When you're worried about a particular patient, when there is a problem, redness, a friction 
blister, whatever. We know we can ask [the doctor] for advice, ask what kind of dressing we 
should use. When we ask for advice, we know he pays attention, when we need advice we 
know we can ask and he will listen and tell us how to treat [the bedsore], which dressing to 
use, what product to use, and even how to apply it. (Nurse H1)
"I try to go see as many wounds as possible. My colleagues do as well. When we look at the 
wound we talk to the nurses, they let us know when there are difficulties, they have their 
ideas and I have mine; we come to a consensus." (Doctor H2)
As soon as there is a wound somewhere there is a request for consultation both externally 
and internally. If there are bedsores on the third floor, they will ask the doctor." (Doctor H3)
"The home health nurses tell me how upsetting it is. They don't know what to do. They may 
be very effective, but when it's necessary we can take the patient back and treat him with 
powerful painkillers. There has to be a recourse strategy. We have an environment that 
makes it possible to use resources that require a safe environment. We can priorities the 
recourse process." (Doctor H3)

The attention-action script is 
constantly reassessed collectively

"[At the staff meeting] the doctor reports on each patient, explaining what the patient has, 
explaining the therapy used, the treatments, the progression and what will comes next for 
the patient... The doctor explains, and each person gives his opinion on the progression, 
what we think, if there needs to be an adjustment in any area." (Nurse H1)
"We use premedication a lot, we have a large consumption of opioids. We routinely evaluate 
pain based on pain scales. If it hurts we don't do it, the doctor, nurses and nurse assistants 
discuss things together to decide whether we should do it." (Doctor H2)
"It's important to document the care provided to get better results, to work together better. 
We can share know-how, the same equipment, monitor patients at risk. We can pool our 
knowledge." (Pharmacist H3)

Jacques Orvain is professor  at EHESP (French School of Public Health). His 
research focuses on organizational behavior in healthcare and medico-social 
organizations, specifically on structuring mechanisms within these organizations. 
He is a medical doctor, specialized in epidemiology and got a PhD in 
Management Science in 2012. From 1996 to 2008 he held managerial positions: 
he  was Vice President of medical services and  health economic evaluation in 
HMR  (USA), Director of Evaluation in  ANAES (Paris, France) and Vice Dean 
for Studies and Research in ENSP (Rennes, France).

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