Risk, governance and the experience of care

Effects of a medical admission unit on in-hospital patient flow and clinical outcomes

BACKGROUND

the burden of acute complex patients, increasingly older and poli-pathological, accessing to Emergency Departments (ED) leads up hospital overcrowding and the outlying phenomenon. These issues highlight the need for new adequate patients' management strategies. The aim of this study is to analyse the effects on in-hospital patient flow and clinical outcomes of a high-technology and time-limited Medical Admission Unit (MAU) run by internists.

METHODS

all consecutive patients admitted to MAU from Dec-2017 to Nov-2019 were included in the study. The admissions number from ED and hospitalization rate, the overall in-hospital mortality rate in medical department, the total days of hospitalization and the overall outliers bed days were compared to those from the previous two years.

RESULTS

2162 patients were admitted in MAU, 2085(95.6%) from ED, 476(22.0%) were directly discharged, 88(4.1%) died and 1598(73.9%) were transferred to other wards, with a median in-MAU time of stay of 64.5 [0.2-344.2] hours. Comparing the 24 months before, despite the increase in admissions/year from ED in medical department (3842 ± 106 in Dec2015-Nov2017 vs 4062 ± 100 in Dec2017-Nov2019, p<0.001), the number of the outlier bed days has been reduced, especially in surgical department (11.46 ± 6.25% in Dec2015-Nov2017 vs 6.39 ± 3.08% in Dec2017-Nov2019, p=0.001), and mortality in medical area has dropped from 8.74 ± 0.37% to 7.29 ± 0.57%, p<0.001.

CONCLUSIONS

over two years, a patient-centred and problem-oriented approach in a medical admission buffer unit run by internists has ensured a constant flow of acute patients with positive effects on clinical risk and quality of care reducing medical outliers and in-hospital mortality.

Patient dignity and dignified care: A qualitative description of hospitalised older adults perspectives

AIMS AND OBJECTIVES

The aim of this study was to explore older adults' perspectives about dignity and dignified nursing care during acute hospitalisation in Ghana.

BACKGROUND

Maintaining hospitalised older adults' dignity is an essential component of nursing care and one of the most important determinants of wellbeing. To date, no study has been published on older adults' perspectives of dignified nursing care in the African context.

STUDY DESIGN

A qualitative descriptive research design.

METHODS

Twenty hospitalised older adults were purposively selected from the medical and surgical wards of a teaching hospital in Ghana. Data were gathered through semi-structured interviews between April and August, 2021, and analysed using reflexive thematic analysis techniques. The SRQR checklist was used to document reporting of the study.

RESULTS

The following four themes were identified: Effective nurse-patient communication, Maintaining patients' privacy, Respectful and compassionate care provision and Providing quality and safe care. Dignity was preserved when patients were treated with respect and compassion, provided privacy, and had close family members involved in physical care. Identified barriers to dignity included inadequate information about their health condition, poor communication by the nurses, lack of autonomy, poorly designed healthcare infrastructure and inadequate privacy.

CONCLUSIONS

Several enablers and barriers to dignified nursing care have been identified that have been discussed in previous studies. The unique factors identified in the Ghanaian context were family members' involvement in physical care influenced by cultural and religious beliefs, environmental barriers to privacy and dignity and inadequate involvement in decision making.

RELEVANCE TO CLINICAL PRACTICE

Nurses must treat older patients with respect, educate them about the health condition, involve them in care decisions, and identify their preferences regarding provision of hygiene needs, particularly in consideration of religious and cultural beliefs, including involvement of family members. Future planning of healthcare infrastructure needs to consider the importance of private cubicles with disability-accessible ensuite bathrooms for patients' comfort and privacy.

Satisfaction with the quality of nursing care among older adults during acute hospitalization in Ghana

Aim

This study assessed the level of satisfaction with the quality of nursing care among hospitalized older adults and the factors associated with it.

Design

This was a quantitative descriptive cross‐sectional survey.

Methods

We used a validated questionnaire to collect data from a convenience sample of 206 older adults from three government hospitals in Tamale, Ghana. Data were analysed using descriptive statistics, independent sample t test and one‐way ANOVA.

Results

Most of the participants (72.3%) reported moderate levels of satisfaction with the quality of nursing care, while 23.8% reported high levels of satisfaction. The association between gender, religion and level of satisfaction with nursing care was not statistically significant. However, patients differed on levels of satisfaction based on healthcare facility: patients at the Tamale Central Hospital were more satisfied with the quality of nursing care than those at the Tamale Teaching Hospital. There is a need for capacity building and sensitization workshops on the rudiments of geriatric care for nurses in the metropolis to serve as an impetus for improvement in the quality of care.

Social vulnerability and the impact of policy responses to COVID-19 on disabled people

In this paper, we propose a conceptual framework for understanding the impact of the policy responses to COVID-19 on disabled people. These responses have overwhelmingly focused on individual vulnerability, which has been used as a justification for removing or restricting rights. This suggests the need to shift the attention towards the social determinants of disabled people's vulnerability. We do this by bringing literature on social vulnerability in disaster risk management or 'disaster studies' in contact with key concepts in disability studies such as the social model of disability, independent living, intersectionality, and biopower. Empirically, we draw on the findings of the global COVID-19 Disability Rights Monitor (www.covid-drm.org), as well as on reports from academic journals, civil society publications, and internet blogs. We put the proposed conceptual framework to work by developing a critical analysis of COVID-19 policies in three interrelated areas-institutional treatment and confinement of disabled people, intersectional harms, and access to health care. Our conclusion links this analysis with strategies to address disabled people's social vulnerability in post-pandemic reconstruction efforts. We make a case for policies that address the social, economic, and environmental conditions that disproportionately expose disabled people to natural disasters and hazards.

Dignity equals distance? Pursuing dignity in care for older adults

This paper explores how dignity is articulated and pursued by care workers in two currently prominent policy initiatives seeking to reform Danish care services for older people. Based on ethnographic case studies of ‘reablement’ practices and the use of ‘welfare technologies’, the paper shows how these attempts to create dignified care services transform interactions between care recipients and care workers. The analysis is inspired by a socio-material perspective on dignity as ‘crafted’ and ‘co-laboured’ in daily practices, in an interplay between multiple human and non-human actors. In the cases studied, dignity is articulated as closely related to older people's increasing autonomy and independence of formal care, and is pursued through enhancing care recipients’ self-care ability, and through technological automation of care tasks. However, these articulations and pursuits of dignity do not stand alone. When everyday care practices are closely examined, dignity is also pursued by care workers as increased co-operation and equality between care workers and care recipients, as de-objectification, and as promotion of enjoyment and quality of life. In these practices, care is ambivalently positioned as both a potential threat to dignity, and as a prerequisite to achieving it. The paper concludes by discussing the risks of policy agendas pursuing a narrow understanding of dignity as simply independence of care.

Building safety cultures at the frontline: An emancipatory Practice Development approach for strengthening nursing surveillance on an acute care ward

AIM

To evaluate an emancipatory Practice Development approach for strengthening nursing surveillance on a single medical-surgical ward.

BACKGROUND

Registered nurses keep patients safe in acute care settings through the complex process of nursing surveillance. Our interest was understanding how frontline teams can build safety cultures that enable proactive nursing surveillance in acute care wards.

DESIGN

A year-long emancipatory Practice Development project.

METHODS

A collaborative relationship was established around a shared interest of nursing surveillance capacity and researcher embedded on a medical-surgical ward. Critical analysis of workplace observations and reflection with staff generated key sites for collective action. Ward engagement was supported by creative Practice Development methods including holistic facilitation, critical reflection and action learning. An action learning set was established with a group of clinical nurses, facilitating practitioner-led change initiatives which strengthened nursing surveillance and workplace learning. Evaluation supported an iterative approach, building on what worked in an acute care context. Immersive researcher evaluation, drawing on multiple data sources, generated an analysis of how ward nursing surveillance capacity can be strengthened. COREQ criteria guided reporting.

RESULTS

The ward moved through a turbulent and transformative process of resistance and retreat towards a new learning culture where nursing surveillance was visible and valued. Staff developed and sustained innovations including the 'My MET Call series', a 'Shared GCS initiative', an enhanced 'Team Safety Huddle', and staff-led Practice Development workshops. These new practices affirmed nurses' agency, asserted nurses' clinical knowledge, positioned nurses to participate in team decision-making and humanised care.

CONCLUSION

Working collaboratively with frontline staff enabled bottom-up sustainable innovation to strengthen nursing surveillance capacity where it mattered most, at the point of care.

RELEVANCE TO CLINICAL PRACTICE

Emancipatory Practice Development enables the profound impact of small-scale, microsystem level practice transformation. It is an accessible methodology for clinical teams to develop effective workplace cultures.

Theorising health professionals' prevention and management practices with children and young people experiencing self-harm: a qualitative hospital-based case study

Self-harm in young people remains a significant concern. Studies of emergency departments have centred on negative professional attitudes. There has been limited interrogation and theorisation of what drives such attitudes, and the contexts that sustain them. Adopting a complex systems lens, this study aimed to explore how systems shape professional and patient interactions. It draws upon interviews with healthcare and affiliated professionals (n = 14) in a UK case study hospital, with primary focus on the emergency department. Data were analysed using a thematic approach and the principles of grounded theory. Four themes emerged, with the first three centralising how professionals' practices operate within: (1) a framework of risk management; (2) expectations of progressing patients through the care pathway; and (3) a culture of specialist expertise, with resulting uncertainty about who is responsible for self-harm. The fourth theme considers barriers to system change. A small number of participants described efforts to enact positive modifications to practices, but these were frustrated by entrenched system structures. The potential detrimental impacts for patient care and professional wellbeing are considered. Future practice needs systemic action to support professionals in treating patients experiencing self-harm, while future research requires more ethnographic explorations of the complex system in situ.

Risk work in dental practices: an ethnographic study of how risk is managed in NHS dental appointments

Ideas about disease risk underpin many preventive health strategies. These have assumed even greater importance in recent years as health policies place a growing emphasis on personal responsibility. This is reflected in new national contracts for National Health Service (NHS) dentistry that emphasise informing patients on their oral health risk status to persuade them to be accountable for their health. Thus, 'risk' is now central to the practice of dentistry, particularly primary care delivery. An ethnographic study in dental practices in England looked at how risk is acted on in dental settings. 368 dental appointments were observed in five dental practices over a year. The analysis shows three interrelating forms of risk work. Dentists position risk work as administrative to gain consent, translate risk through temporality to encourage action, whilst protecting rapport and their professional reputation through interactional risk work. This qualitative study demonstrates that the everyday nature of risk work in NHS dental practices is often implicit, defensive and focused on social interaction rather than the explicit discussions of individual lifestyle risks that policymakers assume. The study contributes to the literature on 'risk work' by illustrating how health professionals use risk to manage situationally sensitive contexts.

Strengthening nursing surveillance in general wards: A practice development approach

AIMS AND OBJECTIVES

To explore the context and culture of nursing surveillance on an acute care ward.

BACKGROUND

Prevention of patient deterioration is primarily a nursing responsibility in hospital. Registered nurses make judgements and act on emerging threats to patient safety through a process of nursing surveillance. Organisational factors that weaken nursing surveillance capacity on general wards increase the need for patient rescue at the end point of clinical deterioration with poorer outcomes. Yet little is known about cultures that enable and sustain ward nursing surveillance for patient safety.

DESIGN

Workplace observations and semistructured interviews using a critical lens as the first stage of a larger emancipatory practice development project.

METHODS

Researcher immersion including 96 hr of nonparticipant observation with 12 semistructured interviews during July-August 2017. This study adhered to the COREQ guidelines.

RESULTS

We offer a metaphor of nursing surveillance as the threads that support the very fabric of acute care nursing work. These hidden threads enable nurses to weave the tapestry of care that keeps patients safe. This tapestry is vulnerable to internal and external forces, which weaken the structure, putting patients and staff at risk.

CONCLUSION

Understanding local context is essential to supporting practice change. This workplace observation challenges us to find ways to creatively engage nurses with the underlying cultural and systems issues that so often remain hidden from view in the deteriorating patient literature.

RELEVANCE TO CLINICAL PRACTICE

Building cultural values that strengthen nursing surveillance is a prerequisite for safe and effective hospital care. As such, practice-based research that empowers frontline nurses and teams to develop person-centred workplace cultures can hold the key to unlocking sustainable improvements in patient safety.

Wandering as a Sociomaterial Practice: Extending the Theorization of GPS Tracking in Cognitive Impairment

Electronic tracking through global positioning systems (GPSs) is used to monitor people with cognitive impairment who "wander" outside the home. This ethnographic study explored how GPS-monitored wandering was experienced by individuals, lay carers, and professional staff. Seven in-depth case studies revealed that wandering was often an enjoyable and worthwhile activity and helped deal with uncertainty and threats to identity. In what were typically very complex care contexts, GPS devices were useful to the extent that they aligned with a wider sociomaterial care network that included lay carers, call centers, and health and social care professionals. In this context, "safe" wandering was a collaborative accomplishment that depended on the technology's materiality, affordances, and aesthetic properties; a distributed knowledge of the individual and the places they wandered through, and a collective and dynamic interpretation of risk. Implications for design and delivery of GPS devices and services for cognitive impairment are discussed.

Advantages and limitations of virtual online consultations in a NHS acute trust: the VOCAL mixed-methods study

Background

There is much enthusiasm from clinicians, industry and the government to utilise digital technologies and introduce alternatives to face-to-face consultations.

Objective(s)

To define good practice and inform digital technology implementation in relation to remote consultations via Skype™ (Microsoft Corporation, Redmond, WA, USA) and similar technologies.

Design

Multilevel mixed-methods study of remote video consultations (micro level) embedded in an organisational case study (meso level), taking account of the national context and wider influences (macro level).

Setting

Three contrasting clinical settings (Diabetes, Antenatal Diabetes and Cancer Surgery) in a NHS acute trust.

Data collection and analysis

Macro level – interviews with 12 national-level stakeholders combined with document analysis. Meso level – longitudinal organisational ethnography comprising over 300 hours of observations, 24 staff interviews and analysis of 16 documents. Micro level – 30 video-recorded remote consultations; 17 matched audio-recorded face-to-face consultations. Interview and ethnographic data were analysed thematically and theorised using strong structuration theory. Consultations were transcribed verbatim and analysed using the Roter interaction analysis system (RIAS), producing descriptive statistics on different kinds of talk and interaction.

Results

Policy-makers viewed remote video consultations as a way of delivering health care efficiently in the context of rising rates of chronic illness and growing demand for services. However, the reality of establishing such services in a busy and financially stretched NHS acute trust proved to be far more complex and expensive than anticipated. Embedding new models of care took much time and many resources, and required multiple workarounds. Considerable ongoing effort was needed to adapt and align structures, processes and people within clinics and across the organisation. For practical and safety reasons, virtual consultations were not appropriate for every patient or every consultation. By the end of this study, between 2% and 20% of all consultations were being undertaken remotely in participating clinics. Technical challenges in setting up such consultations were typically minor, but potentially prohibitive. When clinical, technical and practical preconditions were met, virtual consultations appeared to be safe and were popular with both patients and staff. Compared with face-to-face consultations, virtual consultations were very slightly shorter, patients did slightly more talking and both parties sometimes needed to make explicit things that typically remained implicit in a traditional encounter. Virtual consultations appeared to work better when the clinician and the patient knew and trusted each other. Some clinicians used Skype adaptively to support ad hoc clinician-initiated and spontaneous patient-initiated encounters. Other clinicians chose not to use the new service model at all.

Conclusions

Virtual consultations appear to be safe, effective and convenient for patients who are preselected by their clinicians as ‘suitable’, but such patients represent a small fraction of clinic workloads. There are complex challenges to embedding virtual consultation services within routine practice in the NHS. Roll-out (across the organisation) and scale-up (to other organisations) are likely to require considerable support.

Limitations

The focus on a single NHS organisation raises questions about the transferability of findings, especially quantitative data on likely uptake rates.

Future research

Further studies on the micro-analysis of virtual consultations and on the spread and scale-up of virtual consulting services are planned.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Cultures of caring: Healthcare 'scandals', inquiries, and the remaking of accountabilities

In the UK, a series of high-profile healthcare 'scandals' and subsequent inquiries repeatedly point to the pivotal role culture plays in producing and sustaining healthcare failures. Inquiries are a sociotechnology of accountability that signal a shift in how personal accountabilities of healthcare professionals are being configured. In focusing on problematic organizational cultures, these inquiries acknowledge, make visible, and seek to distribute a collective responsibility for healthcare failures. In this article, I examine how the output of one particular inquiry - The Report of the Morecambe Bay Investigation - seeks to make culture visible and accountable. I question what it means to make culture accountable and show how the inquiry report enacts new and old forms of accountability: conventional forms that position actors as individuals, where actions or decisions have distinct boundaries that can be isolated from the ongoing flow of care, and transformative forms that bring into play a remote geographical location, the role of professional ideology, as well as a collective cultural responsibility.

Afterword: materialities, care, 'ordinary affects', power and politics

In this paper I explore how the papers in this volume offer ways of thinking about materialities of care in terms of political ecologies, including hierarchies of value as well as assemblages, in which strategic agendas are made present in everyday practices, with profound and ordinary affects, as well as effects. I show how power can work through the association of multiple and heterogeneous materials and social processes to create 'thresholds', as spaces through which people must pass in order to be included as patients, and which circulate specific imaginaries over what counts as an appropriate need. I go on to suggest how some material practices are made mundane and immaterial, that is inconsequential, so that by drawing attention to their importance in how care is done (or not done) the papers help disrupt the commonplace production and reproduction of the 'neglected things' (Puig de la Bellacasa ) of healthcare environments, and by so doing help reimagine what is important for occasions to actually be caring. I then shift to thinking about a sensibility, one that is highly valued in this collection of articles, that helps illuminate different imaginaries of care to those that dominate healthcare environments, an approach that I have called elsewhere 'relational extension', and in the example I offer here show how shifts in extension as a form of motility disrupts stabilities and their reproduction, to accomplish different forms of world-making.

'I'd rather die happy': residents' experiences with food regulations, risk and food choice in residential aged care. A qualitative study

BACKGROUND

Food regulations exist to protect older people in residential aged care, leading to the restriction of potentially hazardous foods. The impacts of malnutrition, resident centred care and the importance of maintaining individual autonomy for older people are well documented. By contrast, there is scant literature describing residents' perceptions of food regulations and food risks in the residential aged care setting.

AIMS

The aim of this study is to explore resident perceptions of food choice and food restrictions in residential aged care.

METHODS

Using a qualitative, hermeneutic phenomenological design, semi-structured interviews were conducted with six participants recruited from two residential aged care facilities. Interviews were audio-taped, transcribed verbatim and thematically analysed.

RESULTS

The following key themes emerged in this study: participants were largely unaware of food regulations and risks, yet expressed the desire to make their own choices. Participants provided contradictory accounts of their experiences with food in residential aged care, which emphasises the ongoing challenge of meeting individual preferences.

CONCLUSION

These themes warrant further investigation, particularly in relation to the impact of food regulations on food choice and the meaning of risk to older people in residential aged care. This research provides new insight into the perceptions of residents regarding their individual autonomy and independence against legislated risk minimization strategies. Impact statement This article raises the issue of risk taking and food choices from the perspective of residents in a residential aged care facility.

Being Accountable or Filling in Forms: Managers and Clinicians' Views About Communicating Risk

PURPOSE

Assessment, documentation, and prevention of risk are central to mental health services. However, there is a paucity of research examining how risk is perceived by key stakeholders including managers and clinicians.

DESIGN AND METHODS

Qualitative, exploratory design. In-depth interviews were held with 22 senior managers and 21 clinicians.

FINDINGS

Communicating risk was a major theme to emerge. For managers, accountability was a primary consideration in communicating risk and therefore influential over nursing practice. Clinicians were more likely to view the organizational processes of communicating risk as a bureaucratic exercise.

PRACTICE IMPLICATIONS

The significant difference between managers and clinicians is problematic for achieving consumer-focused mental health service delivery, a more critical approach to risk is essential in preserving the therapeutic relationship.

Preserving Dignity in Later Life

Cet article examine comment les personnes âgées qui recoivent l’aide sociale dans la communauté subissent une perte de la dignité et comment ils conservent leur dignité. La recherche qualitative a révélé que la perte de dignité est une préoccupation majeure pour ces aînés, et qu’ils conservent leur dignité de differentes manières, variant de s’engager activement à la vie jusqu’à s’en détacher. Nous concluons que, dans la vie plus tard, la préservation de la dignité tout en recevant des soins sociaux diffère de conserver la dignité dans le contexte des soins de sante, en particulier les soins de santé fournis dans un cadre institutionnel. En outre, conserver la dignité en fin de vie, tout en recevant des soins sociaux, est un processus complexe, qui dépend non seulement de l’exécution des activités et la prise des actions individuelles et de leurs responsabilités, mais aussi d’autres actions, dont certaines impliquent une certaine inactivité/passivité, ainsi qu’interagir avec les autres, surtout les soignants. Cet article propose meilleures politiques et pratiques pour la promotion de la dignité des personnes âgeés dans le contexte de la protection sociale à base communautaire.

Lying to ourselves: rationality, critical reflexivity, and the moral order as 'structured agency'

A report suggests that United States' army officers may engage in dishonest reporting regarding their compliance procedures. Similarly, nurses with espoused high ethical standards sometimes fail to live up to them and may do so while deceiving themselves about such practices. Reasons for lapses are complex. However, multitudinous managerial demands arising within 'technical and instrumental rationality' may impact on honest decision-making. This paper suggests that compliance processes, which operates within the social structural context of the technical and instrumental rationality manifest as 'managerialism', contributes to professional 'dishonesty' about lapses in care, sometimes through 'thoughtlessness'. The need to manage risk, measure, account, and control in order to deliver efficiency, effectiveness, and economy (technical rationality) thus has both unintended and dysfunctional consequences. Meeting compliance requirements may be mediated by factors such as the 'affect heuristic' and 'reflexive deliberations' as part of the 'structured agency' of nurses. It is the complexity of 'structured agency' which may explain why some nurses fail to respond to such things as sentinel events, a failure to recognize 'personal troubles' as 'public issues', a failure which to outsiders who expect rational and professional responses may seem inconceivable. There is a need to understand these processes so that nurses can critique the context in which they work and to move beyond either/or explanations of structure or agency for care failures, and professional dishonesty.

The social practice of rescue: the safety implications of acute illness trajectories and patient categorisation in medical and maternity settings

The normative position in acute hospital care when a patient is seriously ill is to resuscitate and rescue. However, a number of UK and international reports have highlighted problems with the lack of timely recognition, treatment and referral of patients whose condition is deteriorating while being cared for on hospital wards. This article explores the social practice of rescue, and the structural and cultural influences that guide the categorisation and ordering of acutely ill patients in different hospital settings. We draw on Strauss et al.'s notion of the patient trajectory and link this with the impact of categorisation practices, thus extending insights beyond those gained from emergency department triage to care management processes further downstream on the hospital ward. Using ethnographic data collected from medical wards and maternity care settings in two UK inner city hospitals, we explore how differences in population, cultural norms, categorisation work and trajectories of clinical deterioration interlink and influence patient safety. An analysis of the variation in findings between care settings and patient groups enables us to consider socio-political influences and the specifics of how staff manage trade-offs linked to the enactment of core values such as safety and equity in practice.

Institutions of care, moral proximity and demoralisation: The case of the emergency department

This article draws on concepts of morality and demoralisation to understand the problematic nature of relationships between staff and patients in public health services. The article uses data from a case study of a UK hospital Emergency Department to show how staff are tasked with the responsibility of treating and caring for patients, while at the same time their actions are shaped by the institutional concerns of accountability and resource management. The data extracts illustrate how such competing agendas create a tension for staff to manage and suggests that, as a consequence of this tension, staff participate in processes of 'effacement' that limit the presence of patients and families as a moral demand. The analysis from the Emergency Department case study suggests that demoralisation is an increasingly important lens through which to understand health-care institutions, where contemporary organisational cultures challenge the ethical quality of human interaction.

Rounding, work intensification and new public management

In this study, we argue that contemporary nursing care has been overtaken by new public management strategies aimed at curtailing budgets in the public hospital sector in Australia. Drawing on qualitative interviews with 15 nurses from one public acute hospital with supporting documentary evidence, we demonstrate what happens to nursing work when management imposes rounding as a risk reduction strategy. In the case study outlined rounding was introduced across all wards in response to missed care, which in turn arose as a result of work intensification produced by efficiency, productivity, effectiveness and accountability demands. Rounding is a commercially sponsored practice consistent with new public management. Our study illustrates the impact that new public management strategies such as rounding have on how nurses work, both in terms of work intensity and in who controls their labour.

Risk, rationality and learning for compassionate care; the link between management practices and the 'lifeworld' of nursing

The nursing care experiences of older people in the United Kingdom, has been much reported in the national and international press. Reasons for that poor quality of care in hospitals often focus on the 'culture' of organisations, as well as focusing on individual failings. However, discussions about culture change are partial explanations without a deeper analysis of how cultures and leadership operates in socio-political contexts which characterise nurses' 'habitus' and 'lifeworlds'. Therefore the solutions may not address wider determinants of care such as risk governance, managerialism, instrumental rationality and of course staffing and skill mix. Instead, organisations may be exhorted to change their cultures, without addressing these wider determinants and thus poor care practices may continue to occur. If targets are abolished, this may still leave a layer of managerialist thinking. This impacts on education because students, who are 'working and learning', experience occupational socialisation through immersion in the lifeworlds of their clinical colleagues. What is required is much less manageralism in the care of older people. Instead, there is a need for clinical leadership, based on critical reflective understanding of the occupational socialisation of nurses operating in a context of risk and rationality and organisational objectives; collegiate political and moral action by health professionals and society on behalf of the older person, and support for front line staff who require more autonomy and control over care practices.

'Why must I wait?' The performance of legitimacy in a hospital emergency department

This article examines the processes of negotiation that occur between patients and medical staff over accessing emergency medical resources. The field extracts are drawn from an ethnographic study of a UK emergency department (ED) in a large, inner city teaching hospital. The article focuses on the triage system for patient prioritisation as the first point of access to the ED. The processes of categorising patients for priority of treatment and care provide staff with the opportunities to maintain control over what defines the ED as a service, as types of work and as particular kinds of patients. Patients and relatives are implicated in this categorical work in the course of interactions with staff as they provide reasons and justifications for their attendance. Their success in legitimising their claim to treatment depends upon self-presentation and identity work that (re)produces individual responsibility as a dominant moral order. The extent to which people attending the ED can successfully perform as legitimate is shown to contribute to their placement into positive or negative staff-constituted patient categories, thus shaping their access to the resources of emergency medicine and their experience of care.