Background
Methods
Study setting
Study design
Ethnography
Data collection
Observations
Interviews
Ethics
Data analyses
Meaning unit | Condensed: description close to the text (manifest) | Condensed: interpretation of the underlying meaning (latent) | Subtheme | Theme |
---|---|---|---|---|
“Following the present guidelines, we ask about smoking and alcohol, but you don’t do anything about it No action is taken on the information provided” (Doctor, field notes, day 28) | The doctors ask about alcohol and smoking habits but do not act on the info | Health policy requires lifestyle issues to be addressed, practice follows requirements without further action | Professional differences | The encounter |
”It’s also a matter of subjective assessment (…) I’m a little suspicious and think… I look at their clothes and they are maybe a little untidy and I wonder if their home situation is OK” (Interview 7) | Patients appearing unkempt with an unclear home situation may give rise to suspicion of an unhealthy alcohol use | Clinical assessment of an unhealthy alcohol use is (among other things) based on both visual appearances and patients’ capabilities | Gut-feeling vs. clinical parameters | The encounter |
"If they initiated a dialogue, they should also finish it, which they did not feel they had time for It would be unethical to start something they could not finish” (field notes, day 7) | It is unethical to start a talk you cannot finish | Time is a barrier for asking about alcohol and is used as an ethical argument, that governs the patient encounter | Ethical reasoning | The encounter |
"An alarm sounds […] Secretary said that a ‘drunk’ man had punched a female patient in the face So, they had ‘kicked’ him out” (field notes, day 27) | The alarm went off. An intoxicated man hit a fellow patient and has been thrown out of the hospital | A safe hospital stay is a top priority. Patients who cross the line of accepted behavior must leave | From compliance to zero tolerance | The encounter |
Results
Themes | Subthemes | |
---|---|---|
1 | Setting the scene | Patient flow in acute medicine |
A risky environment | ||
Physical spaces and artefacts | ||
2 | The encounter: addressing patients’ alcohol use | Professional differences |
Gut-feeling vs. clinical parameters | ||
Ethical reasoning | ||
From compliance to zero tolerance | ||
3 | Collective repertoires | ”Occupiers” |
“Alcoholic” or “party animal”? |
Theme 1
Setting the scene
We take care of two things here: detoxification and withdrawal symptoms. When people are severely affected consciously, we must of course rule out that nothing else is wrong. When that’s clarified, they must be detoxed and then sent home (Field notes, Doctor, day 16)
This is a patient group that we have to accept, but we always associate it with a feeling of unease and instability in the ward … we know them, you see (Interview, Nurse 3)
I also think that's why we sometimes isolate them in the observation room, even though it was never the intention […].But when older ladies grab ones’ hand and says: “I'm scared to lay in the bed next to him and now he's doing that … now he’s saying this… I don’t want to be here”. Understandably, it creates insecurity (Interview, Nurse 4)
On the electronic board I can see that they are expecting the arrival of a patient who has been drinking too much. It doesn’t take long before two paramedics enters the office. They tell the coordinating nurse: “we are here with [name] and he has been drinking a bottle of vodka. […] we’ve placed him in the observation room”. The coordinating nurse says: “why did you put him there without asking?” and the paramedic says: “that’s where they usually are, so we just assumed”. The coordinating nurse shrug her shoulders. The patient stays in that room for the rest of my shift. (Field notes, day 14)
It is a misunderstood consideration, because we care for the other patients, by treating one group very badly by isolating them from the rest. We tend to… those who smell we put there, but an old lady can also smell badly, because she doesn’t shower anymore. But we would never consider putting her in that room (Interview, Nurse 8)
A man in his thirties entered the ED with ankle-pain after a fall. While waiting for a physiotherapist, he suddenly gets withdrawal symptoms, and they realise he needs a longer admission and is placed in the observation room (Field notes, day 4)
We enter the office and the doctor shows me the board and says: ”Look, there are no alcoholics today, totally empty”. I tell him that I’m particularly interested in those patients who might come in under a different diagnosis with an undiscovered high alcohol intake [and thereby potentially all patients]. ”They’re usually here” he says and point at the observation room, ”There are none today”. (Field notes, day 24)
Theme 2
The encounter: addressing patients’ alcohol use
If he is tossing and turning in bed, of course, I try to find out what’s wrong... If he's just a nice guy with an excessive alcohol intake, I might not notice it… it doesn’t strike me (Interview, Nurse 5)
He enters carrying a clinking bag [with beer bottles]. He is in a cheerful mood and jokes a lot […] The nurse asks what has happened […] She cleans the wound on the big toe, applies a bandage, and gives him a tetanus vaccination. She doesn’t ask about alcohol (Field notes, day 7)
The nurse asks if he has been drinking and he says yes. “That’s ok, you’re allowed to”, says the nurse. (Field notes, day 33)
The senior doctor says he is not interested in alcohol. He is interested in the heart and lungs. Typically, the junior doctors handle “the alcoholics” (Field notes, day 16).
She refers to a patient who is a frequent visitor in the department, and she says: "I already know what he will say and what he wants". So, we will probably give people like him a lower priority, because we have already tried EVERYTHING. (Field notes, day 11)
Theme 3
Collective repertoires
I think it’s a difficult group to deal with. The group is challenging and require a disproportionate amount of time and energy […] They occupy a great deal of resources with their presence! (Interview, Nurse 2)
We lose interest in these patients because we feel there is no progress. We don’t feel that what we do helps. Not at all. I just feel that we are some sort of storage facility. (Interview, Nurse 3)
We have… I allow myself to call them the poorest of the poor. We rarely admit the ones you mention [patients with an alcohol use, admitted with another diagnosis] […] It's mostly the hardcore types, who in my opinion are not interested in getting any help. (Interview, Nurse 9)
I asked the nurse of the patient who had been admitted intoxicated yesterday [if I could follow her]. She said, she had already talked to him and he was being discharged. She said: ‘He is not an alcoholic. I just told him to go home and drink some coke’ (Field notes, day 2)