Beat the clock! Wait times and the production of 'quality' in emergency departments

From Subversion to Hard-Wiring Equity: A Discourse Analysis of Nurses' Equity-Promoting Practices in Emergency Departments

Nursing has articulated a shared commitment to equity in response to inequities in health and health care; however, understandings of how nurses enact equity are needed to uphold this professional mandate. This Foucauldian discourse analysis examined how nurses' equity-promoting practices are shaped by dominant discourses within the emergency department and illustrated that within this institutional context that constrained equity, nurses engaged in equity-promoting practices through subversion of discursive power. This study illustrates the need for embedding equity discourses within health care systems and ensuring meaningful supports for nurses in enacting equity-promoting practices within the emergency department setting.

Institutional ethnography of hemodialysis care: Perspectives of multidisciplinary health care teams in Nepal

Background

Hemodialysis is the most commonly used renal replacement therapy for end-stage renal disease. The collaborative efforts of multidisciplinary teams comprising nephrologists, nurses, pharmacists, and dietitians play a crucial role in enhancing patient outcomes, improving the quality of care, and reducing treatment costs. However, various factors such as healthcare cost reduction, limited resources, profit-driven systems, organizational structure, and involvement in patient care decisions impact the provision of hemodialysis care by the multidisciplinary teams.

Objective

This study aimed to explore the institutional practices of multidisciplinary teams within a hemodialysis unit.

Methods

This institutional ethnography study was conducted between April 2019 to February 2020 in a hemodialysis unit of a public university hospital in Kathmandu, Nepal. Data were collected through face-to-face interviews with ten nurses (including supervisors and incharge), two nephrologists, two dietitians, two pharmacists, and two technicians. Additionally, 167 hours of observation, two focus groups with nurses, analysis of institutional texts, and field notes were conducted. Participants were purposively selected based on their ability to provide diverse information regarding institutional practices in hemodialysis care. Interviews were recorded and transcribed.

Results

The analyzed data were presented in: 1) the context of hemodialysis care, 2) textual practices: the ruling relations of hemodialysis care (staffing, protocol, job description), 3) hemodialysis decision, and 4) institutional support.

Conclusion

Hemodialysis care provided by multidisciplinary teams is constrained by limited resources, particularly in terms of physical space, dialysis machines, nurses, doctors, and dietitians. The hospital's cost-cutting policies lead to reduced investment in patient care equipment, particularly dialysis machines, which significantly impact the workload of nurses and technicians. Insufficient nurse staffing necessitates the provision of other renal care responsibilities, resulting in increased workload, reduced time available for hemodialysis care, and unfinished tasks. The absence of clear job descriptions for hemodialysis care places an additional burden on nurses, who are often required to fulfill the responsibilities of other healthcare teams. Doctors hold the authority in making care decisions, which are subsequently followed by other team members.

Predictive care: a protocol for a computational ethnographic approach to building fair models of inpatient violence in emergency psychiatry

INTRODUCTION

Managing violence or aggression is an ongoing challenge in emergency psychiatry. Many patients identified as being at risk do not go on to become violent or aggressive. Efforts to automate the assessment of risk involve training machine learning (ML) models on data from electronic health records (EHRs) to predict these behaviours. However, no studies to date have examined which patient groups may be over-represented in false positive predictions, despite evidence of social and clinical biases that may lead to higher perceptions of risk in patients defined by intersecting features (eg, race, gender). Because risk assessment can impact psychiatric care (eg, via coercive measures, such as restraints), it is unclear which patients might be underserved or harmed by the application of ML.

METHODS AND ANALYSIS

We pilot a computational ethnography to study how the integration of ML into risk assessment might impact acute psychiatric care, with a focus on how EHR data is compiled and used to predict a risk of violence or aggression. Our objectives include: (1) evaluating an ML model trained on psychiatric EHRs to predict violent or aggressive incidents for intersectional bias; and (2) completing participant observation and qualitative interviews in an emergency psychiatric setting to explore how social, clinical and structural biases are encoded in the training data. Our overall aim is to study the impact of ML applications in acute psychiatry on marginalised and underserved patient groups.

ETHICS AND DISSEMINATION

The project was approved by the research ethics board at The Centre for Addiction and Mental Health (053/2021). Study findings will be presented in peer-reviewed journals, conferences and shared with service users and providers.

Emergency care under the magnifying glass: a review of ethnographic studies in the scientific literature on hospital emergency services

The article presents a review of ethnographic studies in the scientific literature on hospital emergency services, with the objective of systematizing the studies and their principal findings, referring to the health-disease-healthcare process in hospital emergency services from an ethnographic perspective. An integrative literature review was performed of studies published in Argentine and international indexed journals and in the following electronic databases: PubMed, VHL, Scopus, Redalyc, and SciELO. The corpus of the analysis consisted of a total of 69 articles, which were submitted to content analysis, having identified the following analytical dimensions: quality of care, communication and bonds, subjectivity, application of information technologies, methodological reflection, patients' experiences and practices, decision-making, and violence. The results allowed identifying a process that differs from guidelines and protocols, in which healthcare workers' subjective aspects, communication and interpersonal relations, and working conditions shape, orient, and condition the treatment and care provided in the hospital. The article thus highlights the approach to subjective aspects in health studies, to understand not only health workers' perspectives and experiences but also the persistent barriers to providing better quality of care, complexifying a problem ignored by a large share of the analyses.

Understanding competing discourses as a basis for promoting equity in primary health care

Background

Globally, health inequities persist with effects on whole populations and the most profound effects on populations marginalized by poverty, discrimination and other forms of disadvantage. In the current neoliberal political-economic context, health inequities are produced and sustained by the inequitable distribution of social determinants of health and structural inequities such as discrimination and institutional racism. Even in the context of healthcare organizations with an explicit commitment to health equity, multiple intersecting discourses, such as ongoing efficiency discourses, and culturalist and racialized discourses, are in constant interaction with healthcare practices at the point of care and the organizational level, limiting providers’ and organizations’ capacities to address structural inequities. Attention to discourses that sustain inequities in health care is required to mitigate health inequities and related power differentials. In this paper, we present findings from a critical analysis of the relations among multiple discourses and healthcare practices within four Canadian primary health care clinics that have an explicit commitment to health equity.

Methods

Informed by critical theoretical perspectives and critical discourse analysis principles, we conducted an analysis of 31 in-depth interviews with clinic staff members. The analysis focused on the relations among discourses and healthcare practices, the ways in which competing discourses influence, reinforce, and challenge current practices, and how understanding these dynamics can be enlisted to promote health equity.

Results

We articulate the findings through three interrelated themes: equity-mandated organizations are positioned as the “other” in the health care system; discourses align with structures and policies to position equity at the margins of health care; staff and organizations navigate competing discourses through hybrid approaches to care.

Conclusions

This study points to the ways in which multiple discourses interact with healthcare organizations’ and providers’ practices and highlights the importance of structural changes at the systemic level to foster health equity at the point of care.

An inquiry into what organised difficult advance care planning conversations in a Scottish residential care home using institutional ethnography

Aim

This paper provides an institutional ethnographic analysis of how advance care planning discussions, which included advance decisions about serious illness, hospital admission and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) forms, were systematically placed into the hands of senior social care workers (SSCWs) in a residential care home (RCH). RCHs are care settings where there are no on-site nurses, and access to hospital and/or community doctors and nurses is limited.

Methods

The paper traces the organising features of day-to-day work gathered from interviews with SSCWs (n = 4) and others (n = 6) whose (well-intentioned) work shaped what happened in the RCH.

Results

It shows how the experience of SSCWs was socially organised to happen as it did as they (and others) complied with powerful organising texts such as national and local policy documents, care plans and audit forms. The paper concludes that although SSCWs decision-making conversations were out of alignment with the national DNACPR policy, they cannot simply be described as poor practice. This is because they were socially organised by a complex web of institutional practices related to the occupancy rate in the RCH, the inspection process of the care home scrutiny body, the quality assurance process of the RCH company, the funding of palliative care education, and powerful political and fiscal drives to reduce spending on over-75s. These practices had little to do with the actual care needs of RCH residents or the actual support needs of RCH staff.

Conclusions

The paper points towards necessary policy changes. It also highlights how 'competent' work driven by ideological institutional practices can result in ethically troubling situations in day-to-day working life. This emphasises the importance of carefully examining the social organisation of situations typically described as poor practice if we are to understand how they are (re)produced. It also offers a different account of care home deaths than is typically presented in the professional literature.

Avaliação da satisfação dos usuários atendidos por serviço pré-hospitalar móvel de urgência

RESUMO O objetivo deste estudo foi avaliar a satisfação dos usuários atendidos pelo Serviço de Atendimento Móvel de Urgência do estado do Rio Grande do Norte. Trata-se de pesquisa transversal, analítica e quantitativa, realizada de janeiro a junho de 2016, com 384 usuários. Obteve-se satisfação na estrutura e no processo. O indicador de estrutura que gerou mais insatisfação foi o conforto das ambulâncias, e o de processo foi o tempo resposta. Conclui-se que os usuários, em sua maioria, estão satisfeitos com o serviço do estado, porém, pesquisas de satisfação dos usuários são sempre necessárias para o monitoramento constante desse serviço.

Nurses' Perspectives on Lean Redesigns to Patient Flow and Inpatient Discharge Process Efficiency

As hospitals around the world increasingly face pressure to improve efficiency, "Lean" process improvement has become a popular approach to improving patient flow. In this article, we examine nurses' perspectives on the implementation of Lean redesigns to the inpatient discharge process. We found that nurses experienced competing demands and tensions related to their time and professional roles and responsibilities as a result of Lean. Four main themes included (a) addressing the needs of individual patients, while still maintaining overall patient flow; (b) meeting discharge efficiency targets while also achieving high patient satisfaction scores; (c) "wasting time" to save time; and (d) the "real" work of providing clinical care versus the "Lean" work of process improvement. Our findings highlight the importance of soliciting hospital nurses' perspectives when implementing Lean process improvements to improve efficiency and patient flow.

Failure to cope: the hidden curriculum of emergency department wait times and the implications for clinical training

PURPOSE

The study explored optimal intraprofessional collaboration between physicians in the emergency department (ED) and those from general internal medicine (GIM). Prior to the study, a policy was initiated that mandated reductions in ED wait times. The researchers examined the impact of these changes on clinical practice and trainee education.

METHOD

In 2010-2011, an ethnographic study was undertaken to observe consults between GIM and ED at an urban teaching hospital in Ontario, Canada. Additional ad hoc interviews were conducted with residents, nurses, and faculty from both departments as well as formal one-on-one interviews with 12 physicians. Data were coded and analyzed using concepts of institutional ethnography.

RESULTS

Participants perceived that efficiency was more important than education and was in fact the new definition of "good" patient care. The informal label "failure to cope" to describe high-needs patients suggested that in many instances, patients were experienced as a barrier to optimal efficiency. This resulted in tension during consults as well as reduced opportunities for education.

CONCLUSIONS

The authors suggest that the emphasis on wait times resulted in more importance being placed on "getting the patient out" of the ED than on providing safe, compassionate, person-centered medical care. Resource constraints were hidden within a discourse that shifted the problem of overcrowding in the ED to patients with complex chronic conditions. The term "failure to cope" became activated when overworked physicians tried to avoid assuming care for high-needs patients, masking institutionally produced stress and possibly altering the way patients are perceived.

Management of everyday work in Emergency Departments - an exploratory study with Swedish Managers

INTRODUCTION

Through their formal mandate, position and authority, managers are responsible for managing everyday work in Emergency Departments (EDs) as well as striving for excellence and dealing with the individual needs of practitioners and patients. The aim of the present study is to explore managers' experiences of managing everyday work in Swedish EDs.

METHOD

A qualitative and exploratory design has been used in this study. Seven managers were interviewed at two EDs. Data was analysed using qualitative content analysis with focus on latent content.

RESULTS

Managers experience everyday work in the ED as lifesaving work. One of the characteristics of their approach to everyday work is their capability for rapidly identifying patients with life-threatening conditions and for treating them accordingly. The practitioners are on stand-by in order to deal with unexpected situations. This implies having to spend time waiting for the physicians' decisions. Management is characterised by a command and control approach. The managers experience difficulties in meeting the expectations of their staff. They strive to be proactive but instead they become reactive since the prevailing medical, bureaucratic and production-orientated systems constrain them.

CONCLUSION

The managers demonstrate full compliance with the organisational systems. This threatens to reduce their freedom of action and influences the way they perform their managerial duties within and outside the EDs.