Wandering the Wards

"Wandering the Wards provides a detailed and unflinching ethnographic examination of life within the contemporary hospital. It reveals the institutional and ward cultures that inform the organisation and delivery of everyday care for one of the largest populations within them: people living with dementia who require urgent unscheduled hospital care. Drawing on five years of research embedded in acute wards in the UK, the authors follow people living with dementia through their admission, shadowing hospital staff as they interact with them during and across shifts. In a major contribution to the tradition of hospital ethnography, this book provides a valuable analysis of the organisation and delivery of routine care and everyday interactions at the bedside, which reveal the powerful continuities and durability of ward cultures of care and their impacts on people living with dementia.

Routines of resistance: an ethnography of the care of people living with dementia in acute hospital wards and its consequences

Background: There is little research examining resistance, refusal or rejection of care by people living with dementia within acute hospital wards despite the prevalence of dementia in adult hospital populations. Objectives: To explore the ways in which resistance to care manifests within the acute setting and is understood, classified and subsequently managed by ward staff. Design: Ethnography Setting: Acute medical units and trauma and orthopaedic wards in five NHS hospitals in England and Wales. Participants: People living with dementia and nursing team members (registered nurses and healthcare assistants) on participating wards. Methods: Observational fieldwork and ethnographic interviews collected over a period of 20 months (155 days of non-participant observation (minimum 2 h, maximum 12 h, total hours: 680) focusing on staff delivering care to patients with dementia. Interviewees included patients, visitors, and staff working on and visiting the ward. Data collection and analysis drew on the theoretical sampling and constant comparison techniques of grounded theory. Results: We found that resistance to care by people living with dementia was a routine and expected part of everyday care in the participating acute hospital settings. The timetabled rounds of the ward (mealtimes, medication rounds, planned personal care) significantly shaped patient and staff experiences and behaviours. These routinized ward cultures typically triggered further patient resistance to bedside care. Institutional timetables, and the high value placed on achieving efficiency and reducing perceived risks to patients, dictated staff priorities, ensuring a focus on the delivery of essential everyday planned care over individual patient need or mood in that moment. Staff were thus trapped into delivering routines of care that triggered patterns of resistance. Conclusions: Nursing staff struggle to respond to the needs of people living with dementia in acute care settings where the institutional drivers of routines, efficiency and risk reduction are not mediated by clinical leadership within the ward. Cycles of resistance in response to organisationally mandated timetables of care can result in poor care experiences for patients, and emotional and physical burnout for staff. More research is needed into how institutional goals can be better aligned to recognise the needs of a key hospital population: people living with dementia

East Midlands Research into Ageing Network (EMRAN) Discussion Paper Series

Academic geriatric medicine in Leicester . There has never been a better time to consider joining us. We have recently appointed a Professor in Geriatric Medicine, alongside Tom Robinson in stroke and Victoria Haunton, who has just joined as a Senior Lecturer in Geriatric Medicine. We have fantastic opportunities to support students in their academic pursuits through a well-established intercalated BSc programme, and routes on through such as ACF posts, and a successful track-record in delivering higher degrees leading to ACL post. We collaborate strongly with Health Sciences, including academic primary care. See below for more detail on our existing academic set-up. Leicester Academy for the Study of Ageing We are also collaborating on a grander scale, through a joint academic venture focusing on ageing, the ‘Leicester Academy for the Study of Ageing’ (LASA), which involves the local health service providers (acute and community), De Montfort University; University of Leicester; Leicester City Council; Leicestershire County Council and Leicester Age UK. Professors Jayne Brown and Simon Conroy jointly Chair LASA and have recently been joined by two further Chairs, Professors Kay de Vries and Bertha Ochieng. Karen Harrison Dening has also recently been appointed an Honorary Chair. LASA aims to improve outcomes for older people and those that care for them that takes a person-centred, whole system perspective. Our research will take a global perspective, but will seek to maximise benefits for the people of Leicester, Leicestershire and Rutland, including building capacity. We are undertaking applied, translational, interdisciplinary research, focused on older people, which will deliver research outcomes that address domains from: physical/medical; functional ability, cognitive/psychological; social or environmental factors. LASA also seeks to support commissioners and providers alike for advice on how to improve care for older people, whether by research, education or service delivery. Examples of recent research projects include: ‘Local History Café’ project specifically undertaking an evaluation on loneliness and social isolation; ‘Better Visits’ project focused on improving visiting for family members of people with dementia resident in care homes; and a study on health issues for older LGBT people in Leicester. Clinical Geriatric Medicine in Leicester We have developed a service which recognises the complexity of managing frail older people at the interface (acute care, emergency care and links with community services). There are presently 17 consultant geriatricians supported by existing multidisciplinary teams, including the largest complement of Advance Nurse Practitioners in the country. Together we deliver Comprehensive Geriatric Assessment to frail older people with urgent care needs in acute and community settings. The acute and emergency frailty units – Leicester Royal Infirmary This development aims at delivering Comprehensive Geriatric Assessment to frail older people in the acute setting. Patients are screened for frailty in the Emergency Department and then undergo a multidisciplinary assessment including a consultant geriatrician, before being triaged to the most appropriate setting. This might include admission to in-patient care in the acute or community setting, intermediate care (residential or home based), or occasionally other specialist care (e.g. cardiorespiratory). Our new emergency department is the county’s first frail friendly build and includes fantastic facilities aimed at promoting early recovering and reducing the risk of hospital associated harms. There is also a daily liaison service jointly run with the psychogeriatricians (FOPAL); we have been examining geriatric outreach to oncology and surgery as part of an NIHR funded study. We are home to the Acute Frailty Network, and those interested in service developments at the national scale would be welcome to get involved. Orthogeriatrics There are now dedicated hip fracture wards and joint care with anaesthetists, orthopaedic surgeons and geriatricians. There are also consultants in metabolic bone disease that run clinics. Community work Community work will consist of reviewing patients in clinic who have been triaged to return to the community setting following an acute assessment described above. Additionally, primary care colleagues refer to outpatients for sub-acute reviews. You will work closely with local GPs with support from consultants to deliver post-acute, subacute, intermediate and rehabilitation care services. Stroke Medicine 24/7 thrombolysis and TIA services. The latter is considered one of the best in the UK and along with the high standard of vascular surgery locally means one of the best performances regarding carotid intervention

Wandering the Wards: An Ethnography of Hospital Care and its Consequences for People Living With Dementia

This is an open access book chapter. To view the full text of the chapter click on the link below.Wandering the Wards provides a detailed and unflinching ethnographic examination of life within the contemporary hospital. It reveals the institutional and ward cultures that inform the organisation and delivery of everyday care for one of the largest populations within them: people living with dementia who require urgent unscheduled hospital care. Drawing on five years of research embedded in acute wards in the UK, the authors follow people living with dementia through their admission, shadowing hospital staff as they interact with them during and across shifts. In a major contribution to the tradition of hospital ethnography, this book provides a valuable analysis of the organisation and delivery of routine care, and everyday interactions at the bedside, that reveal the powerful continuities and durability of ward cultures of care, and their impacts on people living with dementia

Wandering the Wards

"Wandering the Wards provides a detailed and unflinching ethnographic examination of life within the contemporary hospital. It reveals the institutional and ward cultures that inform the organisation and delivery of everyday care for one of the largest populations within them: people living with dementia who require urgent unscheduled hospital care. Drawing on five years of research embedded in acute wards in the UK, the authors follow people living with dementia through their admission, shadowing hospital staff as they interact with them during and across shifts. In a major contribution to the tradition of hospital ethnography, this book provides a valuable analysis of the organisation and delivery of routine care and everyday interactions at the bedside, which reveal the powerful continuities and durability of ward cultures of care and their impacts on people living with dementia.

The Presentation of the Clothed Self on the Hospital Ward: An ethnographic account of perceptual attention and implications for the personhood of people living with dementia

The file attached to this record is the author's final peer reviewed versionThis study contributes to our understanding of the ‘medical gaze’ and its impact upon the ways in which people living with dementia experience care during a hospital admission. Visual perception has a powerful effect upon our emotional and moral reactions to others. One aspect of how we perceive and respond to others is through clothing, which relates strongly to class and social position. Our focus is on exploring the ways in which patient clothing may affect not only the perceptions and response of others, but also self-perception and resulting behaviour. We draw upon ethnographic research within acute hospital wards in 5 hospitals across England and Wales, examining the everyday organisation and delivery of care to people living with dementia. People living with dementia are a significant population who have poor experiences and outcomes of care within the acute setting. Our data suggests that the twin aspects of clothing and appearance – of self-perception, and of perception by others - may be especially important in the fast paced context of an acute ward environment, where patients living with dementia may be struggling with the impacts of an additional acute medical condition within in a highly timetabled and regimented and unfamiliar environment of the ward, and where staff perceptions of them may feed into clinical assessments of their condition and subsequent treatment and discharge pathways

Pad cultures: an ethnography of continence care and its consequences for people living with dementia during a hospital admission

Background There is little research examining how continence care is organised and delivered to people living with dementia across an acute hospital admission, despite the prevalence of this patient population and their vulnerability within these settings. Objective To explore how continence care is delivered to people living with dementia during an acute hospital admission. Design Ethnographic. Setting(s) Acute medical units and wards within three hospitals across England and Wales. Participants People living with dementia and ward staff (registered nurses and care assistants) on participating wards. Methods Ethnographic fieldwork collected over a period of 12 months (180 days of non-participant observation) focussing on the organisation and delivery of continence care to people living with dementia. Observations were supported with in situ ethnographic interviews (n = 562) with patients, visitors and staff within the six observed wards. Data collection and analysis drew on the theoretical sampling and constant comparison techniques of grounded theory. Results The findings comprised of five overall themes: (1) visibility of continence; (2) rationales of continence care; (3) containment and contagion; (4) consequences of continence care and (5) supporting continence. Conclusions We introduce the term ‘pad cultures’ to refer to the established routine use of continence pads in the care of a wider group of people living with dementia (regardless of continence status and independence), with the rationale to provide safeguards, ensure containment and prevent ‘accidents’ or incontinent episodes. There was an expectation within acute wards that people living with dementia not only wear continence pads but that they also use them

Using Signs and Symbols to Label Hospital Patients with a Dementia Diagnosis: Help or Hindrance to Care?

The file attached to this record is the author's final peer reviewed version. The Publisher's final version can be found by following the DOI link.Philosophical and biomedical perspectives both agree that the ways in which someone is seen is critical to their wellbeing. Empirical work confirms the philosophical claims that attention is an active process, a relationship between the subject and the observer, which changes both of them. How one is seen affects how one sees oneself and studies suggest that this impacts on physical functioning and independence, clinical outcomes, recovery from disability, longevity, and the ‘will to live’. This may be particularly important for older people and people living with dementia, who are a large population within acute wards. We draw on the empirical findings of our 18 month ethnography within 5 hospitals across England and Wales (NIHR HS&DR researcher led funding) to explore the ways in which everyday technologies are enrolled to drive attention to the existence, diagnosis, and needs of people living with dementia at the bedside. Within the acute setting, seeing ‘dementia’ and the person living with dementia and their essential bedside care has been transformed into technical products and routinized task focussed approaches to delivery. We explore the ways in which these everyday technologies both produce and maintain the invisibilities of people living with dementia and bring about particular understandings of the condition. We show the ways in which the use and reliance on technical approaches to perceived problems of attention and ‘seeing’ people living with dementia, instead, narrows attention on particular tasks and ‘symptoms’, which can compete with a wider appreciation of people’s individual care needs and restrict the expertise of ward staff