An ethnographic study of classifying and accounting for risk at the sharp end of medical wards☆
Introduction
Recent years have seen powerful arguments in favour of investigating how people reason about risk issues and account for their corresponding actions (Horlick-Jones, 2005a). Organisational participants at the ‘sharp end’ (Cook & Woods, 1994) of health care, who are charged with the everyday tasks of caring for patients, may not always share the same risk understandings, definitions or priorities as those at the ‘blunt end’ who seek to manage safety. In this paper, we are interested in how staff working on medical wards characterise risks related to patient safety. We do not start from the position that staff accounts of risk have any inherent qualities that make them more or less valid or legitimate than any other. But we do wish to argue that it is important to understand how staff identify, classify and orient towards patient safety risks, not least because such understandings are likely to influence efforts to manage risk and to target change.
Having insights into staff practices and discourses relating to risk is especially important when attempts are made to evaluate purposeful efforts at improving patient safety. Here, we report an ethnography undertaken in four UK medical wards that were taking part in a patient safety improvement programme. The Health Foundation's Safer Patients Initiative (SPI) is a sociologically interesting example of an attempt to improve patient safety (Health Foundation, 2009). It seeks to penetrate organisations, changing not only processes and standards, but also the attitudes and motives of staff and how they understand the nature of their work. A multiple-site organisation-wide intervention, the centrepiece of its formal programme theory of change is a structured process for identifying problems and developing, testing, and evaluating customised solutions for organisations and users (Dixon-Woods, Tarrant, Willars, & Suokas, in press). Such solutions include standardisation, simplification or modification of processes, use of protocols and checklists, use of constraints and forcing functions, decreasing reliance on vigilance, and improving handovers. A key feature of the approach is its rejection of a top-down, edict-driven model. Instead, it tries to engage people working at the front line or ‘sharp end’ in small scale tests of change so that they can see ‘with their own eyes’ whether the new ways of doing things makes a positive difference, using a technique known as Plan-Do-Study-Act (PDSA) (Varkey, Reller, & Resar, 2007). This approach would appear to engage many of the inclusive and participatory principles, including the active involvement of workers in the management of risk, that are argued to be ideal in regulation (Hutter, 2001, Macrae, 2008). However, one of the enduring insights of Anselm Strauss's (1978) work on organisations is that changes to the existing order, though itself always dynamic, require renegotiation. It is thus critical that the existing order be understood, and ethnographic methods are especially well suited to such investigation.
The use of ethnography to study aspects of patient safety has been increasing for some time, dating back to Millman's Unkindest Cut (1976) and Bosk's (1979, 2003) classic, Forgive and Remember. The recent increase in research activity can be traced at least in part to the growing emphasis on patient safety as a management, policy, and governance problem (Department of Health, 2000). However, much research has so far taken place in evidently high risk areas including surgery (Waring, Harrison, & McDonald, 2007) and anaesthesia (Mort, Goodwin, Smith, & Pope, 2005), and there has been a relative neglect of more apparently mundane settings, such as medical wards. Much of the ethnographic research in high risk areas has vividly reported on the uncertainties and ambiguities that attend diagnosis and formulation of treatment plans, and the exercise of discretion in relation to the realisation of medical goals (Pope, 2002). However, the interdependence of staff and processes in everyday hospital work away from the episodic drama of the operating theatres, caring for patients who are not ‘etherised upon a table’, has remained much less studied.
The focus of our work, following Horlick-Jones' (2005b) approach to risk reasoning, was on how staff on medical wards made sense of the formal and informal practices in which they were engaged, how these were rationalised, and how they gave accounts of these. The analysis we report is based on data collected around the time of the introduction of the SPI in the four hospitals, and therefore at too early a stage to be conclusive about any effects or impacts of the programme. What this analysis can do is begin to generate insights into what might be needed to secure commitments to any new way of doing things, and produce hypotheses that can be tested empirically and theoretically.
Section snippets
Methods
This paper is based on an ethnographic study of four hospitals, one in each member country of the UK, that participated in the pilot phase of the Health Foundation's Safer Patients Initiative (SPI). The study areas for the ethnography included two respiratory wards, one general medical ward, and one ward for the care of the elderly. These wards were selected for study as they admitted large numbers of acutely ill patients aged over 65 who were likely to have many co-morbidities. This group is
Findings
Around 150 h of ethnographic observations were carried out across the four wards, and semi-structured interviews were conducted with 49 staff including 7 consultants, 3 doctors in training, 26 qualified nurses including ward sisters and ward managers, 7 health care assistants, and 6 members of staff in managerial posts.
We found that staff practices, reasoning, and accounts of risk were strongly shaped by their experiences of life at the sharp end, where staff constantly faced competing demands
Discussion
How categories and standards are brought to bear in the pragmatic conduct of everyday work is a focus of growing interest in many disciplines (Roth, 2005). This ethnography of patient safety on four medical wards suggests that staff are routinely engaged in the classification and response to risks. They engage in practices of determining what gets to count as a risk, how such risks should properly be managed, and how to account for what they have done. These practices emerge through their
Conclusions
The ways in which staff identify, evaluate and address risks are likely to be highly influential in staff responses to efforts to effect change. Our study suggests that staff are routinely engaged in the classification and response to risk, both to patients and their own professional identities and roles. This has important consequences for understanding how targeted interventions may work, suggesting that efforts to formalise systems and increase the weighting of patient safety must be
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We thank Charles Bosk and Tom Horlick-Jones for valuable feedback on earlier drafts. We thank the Health Foundation for funding the evaluation of the Safer Patients Initiative on which this paper is based. We gratefully acknowledge the participation of the hospitals in this study.