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

Hillman, Alexandra

doi:10.1057/sth.2015.10

Cited by 16 publications

(17 citation statements)

References 42 publications

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“…These findings are similar to the experience of participants in related studies, such as the students in Dobrowolska and Palese's (2016) study who realized that they could not provide the care they idealized because of external constraints, such as a lack of time. Likewise, Hillman (2016) and Harvey, Thompson, Pearson, Willis, and Toffoli (2017) recognized that the culture of current health care organizations with their focus on accountability and resource management created problems of distance between health professionals and patients and the loss of the art of nursing.…”

Section: Discussionmentioning

confidence: 99%

Invisibility of the self: Reaching for the telos of nursing within a context of moral distress

2018

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Many studies have examined clinical and institutional moral problems in the practice of nurses that have led to the experience of moral distress. The causes and implications of moral distress in nurses, however, have not been understood in terms of their implications from the perspective of virtue ethics. This paper analyzes how nurses reach for the telos of their practice, within a context of moral distress. A qualitative case study was carried out in a private hospital in Brazil. Observation and semi‐semistructured interviews were conducted with 13 nurse participants. With the aid of ATLAS.ti software, the data were analyzed by using thematic content analysis using virtue ethics to theorize the findings. These nurses experienced a loss of their nursing identity as they encountered an ambiguous telos and the domination of institutional values. In their reach for the telos of their practice, nurses found an environment permeated by ethical challenges, which not only created moral distress but also created professional invisibility, a phenomenon referred to as ‘invisibility of the self’.

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Section: Discussionmentioning

confidence: 99%

Invisibility of the self: Reaching for the telos of nursing within a context of moral distress

2018

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“…Relevant structural factors include the tension between openness and emergency‐centeredness in walk‐in EMS organisations (Dodier and Camus ) – and how this is often resolved in favour of the latter, to the potential detriment of EPCCs and other EMS being open, low‐threshold institutions. Furthermore, Hillman () shows how antipathy can be linked to institutional concerns of rationalisation and efficiency, which engender a ‘combative’ relationship between EMS staff and patients. More – and preferably comparative – research is needed to flesh out the structural determinants of this ‘combative’ relationship.…”

Section: Discussion and Concluding Remarksmentioning

confidence: 99%

“…Staff notions of inappropriateness have been thoroughly investigated in sociological research, particularly in studies relating to informal patient categorisation in EMS settings (Dingwall and Murray , Dodier and Camus , Edwards and Sines , Edwards , Guttman et al . , Hillman , , , Hughes , , , , Jeffery , Kelly and May , Latimer , , Mannon , Roth , , Roth and Douglas , Vassy , Wamsiedel ).…”

Section: Introductionmentioning

confidence: 98%

Narratives and gatekeeping: making sense of triage nurses’ practice

Johannessen

2018

Sociology Health & Illness

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It is well documented that emergency service staff consider some patients to be 'inappropriate attenders'. A central example is 'trivia', denoting patients with medical problems considered too 'trivial' to warrant attention. Although research has repeatedly shown that frontline staff violate guidelines in turning away 'trivial' patients, existing research has paid insufficient attention to why staff are willing to engage in guideline-violating gatekeeping, which may put both themselves and 'trivial' patients at risk. To address this issue, the present article explores nurses' narratives about 'trivial' patients - referred to in this context as 'GP patients' - drawing on fieldwork data from a Norwegian emergency service. The article reconstructs three narrative clusters, showing that nurses' gatekeeping is motivated by concerns for the patient being turned away, for nurses and more critically ill patients, and for the service they work for. Some of the issues embedded in these narratives have been under-analysed in previous research - most importantly, the role of identity and emotion in nurses' gatekeeping, and how patient narratives can function as 'social prognoses' in nurses' assessments. Analysis of these narratives also reveals an antagonistic relationship between nurses and 'trivial' patients that contradicts nurses' ethical guidelines and indicates a need for healthcare reform.

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“…Relevant structural factors include the tension between openness and emergency-centeredness in walk-in EMS organisations and how this is often resolved in favour of the latter, to the potential detriment of EPCCs and other EMS being open, lowthreshold institutions. Furthermore, Hillman (2016) shows how antipathy can be linked to institutional concerns of rationalisation and efficiency, which engender a 'combative' relationship between EMS staff and patients. Moreand preferably comparativeresearch is needed to flesh out the structural determinants of this 'combative' relationship.…”

Section: Discussion and Concluding Remarksmentioning

confidence: 99%

Between standardisation and discretion: the priority setting of triage nurses

Johannessen¹

2018

Preprint

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This dissertation explores the relationship between standardisation and discretion in professional work at street level, using the priority setting of triage nurses as its case. Triage nurses are employed at the frontline of emergency medical services, where they work to assess the urgency of patients’ complaints. This work can be very challenging, requiring rapid assessments of a large group of unknown and unsorted patients, some of whom may be critically ill. To aid these assessments, emergency services have increasingly introduced standardised triage systems that specify how nurses should proceed in interpreting and prioritising cases. Triage systems reflects a broader trend in healthcare, which has seen a widespread introduction of clinical practice guidelines, all seeking to generate uniformity and quality control by streamlining clinical decision making. The introduction of these guidelines has been described as an unprecedented form of standardisation of professional clinical work, but there is little consensus regarding their effects. While proponents argue that clinical practice guidelines are an important means of improving quality and efficiency, critics denounce them for promoting bureaucratisation, homogenisation and so-called ‘cookbook medicine’. Observing this impasse, there have been calls for an empirically grounded ‘sociology of standardisation’ to acknowledge that guidelines can have different effects in different settings and to explore standardisation on a case-by-case basis. Informed by that proposal, this dissertation explores the relationship between standardisation and discretion in triage nurses’ priority setting. The dissertation is based on nine months of fieldwork in a Norwegian emergency primary care clinic (EPCC), where nurses were required to assess patients using the Manchester Triage System (MTS). Observations revealed that nurses regularly departed from the MTS while also seeming to be influenced by the system in a number of ways. On this basis, the dissertation addresses the question of how and why nurses departed from the MTS and, conversely, how the MTS influenced their assessments. The introduction and the four associated articles show how nurses supplemented the MTS with additional skills and knowledge, and how this led them to adjust or override the priorities formally prescribed by the system. While they had several reasons for so doing, their primary concern was to ‘correct’ the MTS and to ensure more precise prioritisation of patients. However, the MTS also played a significant role in their assessments by restricting, enabling and supporting priority setting.Beyond shedding light on discretionary practices among triage nurses, the dissertation makes three more general contributions to the sociology of standardisation. First, it helps to bridge the gaps between the sociology of standardisation and the literatures on street-level bureaucracy and categorisation. In so doing, it identifies fruitful theoretical linkages for future studies of standardisation and discretion in street-level categorisation of clients.Secondly, the in-depth exploration of nurses’ use of the MTS provides a rich account of the difficulties of streamlining clinical practice. Despite its elaborate design, the MTS was too ‘thin’ to match the complexity of triage nurses’ work, and to follow it unreflectively would be to the detriment of both patients and staff. For that reason, nurses found it necessary to render the guidelines ‘thicker’ by making situated judgments, illustrating the crucial role of additional skills and knowledge in making standards work.Finally, the dissertation shows how the MTS (despite its shortcomings) affected nurses’ work in multiple ways, illustrating how guidelines interact with professional practice. In so doing, the dissertation transcends the either/or language that characterises much of the debate around standardisation, instead providing a nuanced account of the interplay between prescribed and discretionary aspects of triage nursing.

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

Cited by 16 publications

References 42 publications

Invisibility of the self: Reaching for the telos of nursing within a context of moral distress

Invisibility of the self: Reaching for the telos of nursing within a context of moral distress

Narratives and gatekeeping: making sense of triage nurses’ practice

Between standardisation and discretion: the priority setting of triage nurses

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