Is it surprising that prisons resemble factories, schools, barracks, hospitals, which all resemble prisons? (Foucault 1977, p. 228)
The field site was a mid-late 20th century multi-storied tertiary rectangular shaped hospital built of brick and unpainted cement set in an urban area. It appears quite uninviting
57 almost distasteful in appearance yet compelling as a necessary place to be when one’s health goes awry. It could be most anywhere in a North American or Australian mid-size city – an ambiguous design, yet recognisable as a hospital. A usual first tell-tale sign is a large green H road sign (blue in Australia). Upon entering into the inner sanctums of the hospital units one’s nostrils are commonly exposed to a curious mix of smells - stringent antiseptics to foul bodily excretions reflecting the pure to profane embodiment of what is a hospital. Hospitals, however, are part of the health care industry. They resemble an industrial complex of assessment, measurement, cure and remediation, operating by dividing practices that objectify and categorise patients by diagnoses and levels of care required. Discursive analytics problematise in this study how hospitals, as both objects and strategies of the health care industry, operate by way of spatially oriented and time-sensitive practices such as examined in a study on “length of hospital stay” (Heartfield 2002).
Discursively the word “hospital” can depict a hospital site as a heterotopia, a place of intersecting contradictory and paradoxical time/space dimensions. Hospital is an ironic concept hailing from a mix of root-words ranging from hospitality and hostel, to hostile and hostage – a profoundly contradictory mix of meanings for an institution presumably a place of healing or at least of cure. In today’s language, hospitals are places of health care services for clients as health care systems are imbricated in a consumerist society immersed in a neoliberal environment, market driven and structured in economic terms (see chapter six). In any event, “hospital” has an apt etymology because hospitals can be as much toxic or cold and calculating places of business as refuges or protections from the spread of
communicable diseases and infections, places of cure where surgeries exorcise tumours, fix broken bones, repair defective heart valves amongst other wondrous cures and fixes. Paradoxically, hospitals can be hostile environments harbouring toxic nosocomial infections with medication errors, lack of sleep, falls and other dangers lurking, an ensemble of perils referred to as iatrogenesis or at times ‘hazards of hospitalisation’ (Rennke & Fang 2011). In contemporary times, as this study revealed, iatrogenesis also known as “hazards of
hospitalisation” are associated with functional decline in hospitalised older adults.
This urban tertiary care hospital is one of several in a region of over 2,500 square kilometres comprised of urban, suburban and rural areas in a health authority servicing over 720,000 people where almost 9% of individuals are 74 years and older. This age group
58 contributes over 24% of all hospital admissions and accounts for over 40% of inpatient days across the health authority where this hospital is located.
The field site, a 25-bed acute surgical orthopaedic unit and affiliated 30-bed sub- acute rehabilitation unit enabled observing care across temporal/spatial trajectories of care. The ideal length of stay for surgical repair of hip fracture in older adults is 5 to 7 days but as many as 80% or more patients may go to an affiliated acute care rehabilitation unit for a further 5 to 7 days. Or these patients may be directly discharged home or be deemed “awaiting alternate placement” receiving rehabilitation on the surgical unit until stable and/or an available bed in a Long Term Care Facility.
The interior geography
The acute surgical and rehabilitation units are on one floor encircled by a hallway; a dividing practice with patient rooms on the outside/window-side of the hall, care providers’ work areas on the inside/windowless side. Geographically and symbolically separating patient rooms from care provider work areas used for pouring medications, meetings, charting and handover. Care providers have ready access to patients either visibly, physically or audibly via wireless communication systems, a modern “panopticon” allowing an “all- pervasive gaze” (Foucault 1979) ostensibly to facilitate effective yet efficiently managed care. Both units have rooms configured as single and multi-bed.
The hospital routines and spaces have a totalising institutional effect similar to those Goffman (1961, p. 6) explained as
all aspects of life are conducted in the same place and under the same single
authority… carried on in the immediate company of a large batch of others…[and] all phases of the day’s activities are tightly scheduled.
Patients in multi-bed rooms share one bathroom with a sink, toilet and shower, making it temporally and geographically easier for monitoring a scheduled bathing regime. Single bed rooms with a bathroom offer private space but first priority for these rooms is given to patients under infection control regulations, then for patients considered too disruptive or threatening to be anywhere else, those needing palliative or extra complex care and lastly for those willing/able to pay extra for a single room. These spaces are organised according to a ‘rational plan purportedly designed to fulfil the official aims of the institution’ (Goffman 1961, p. 6).
59 Staffing
At the time of the study the orthopaedic surgery unit staff ratio mix on day shift, 0700 to 1900, was one Registered Nurse (RN), one Licensed Practical Nurse (LPN or Enrolled nurse) for eight patients or five RNs and two LPNs from 0700 to 1500 for all patients. There was one unregulated Care Aide from 0700 to 1500 who floats helping out where needed. On night shift, 1900 to 0700, were four RNs and no LPNs. LPNs work eight-hour shifts 0700 to 1500. When the LPNs went home at 1500 their patients were cared for by the RN who shared their patient load from 0700 to 1500 with a float LPN from 1500 to 2300 to help where needed. The 1900-0700 unit charge nurse could ask for “extra help” from a hospital wide float pool and may get an RN or LPN, if available.
The rehabilitation unit staff mix: for the 0700-1500 and 1500-2300 was one team of two Registered Nurses (RN), two Licensed Practical Nurses (LPN or Enrolled nurse) and one Registered Care Aid (RCA) and the other team was RN, two LPNs and one RCA. The 2300- 0700 shift: two RNs, one LPN and one RCA with workload divided up according to an acuity/intensity matrix of the all the patients. An Occupational Therapist (OT) and a Physiotherapist (PT) worked Monday to Friday from 0800 to 1600. However, on the weekends there was a rotation of therapists shared amongst several units and floors.
There were two fulltime Physiotherapists (PT) Monday to Friday 0800 to 1600 for each unit but each unit shared PTs between two floors. An ill PT was not replaced, other PTs rejigged their workload, prioritising who was most urgent, usually the most recent post- operative patients. On weekends and holidays there was a “float” PT from 0800 to 1600 only who was shared between two hospital floors again prioritising urgent physio needs and fresh post-operative patients. When no “PT” was present or available the nurses did the work of “mobilising” patients as per a clinical pathway.
Entering the field
There were no issues encountered in entering the field as hospital administrators and unit staff members were open to my presence, supportive of my research and ready to facilitate the study. I entered the field by discussing the study with the health authority’s Nursing Research Facilitator who outlined how to work with the Health Authority on research projects, emailed potential “gatekeepers”, orthopaedic surgical and rehabilitation
60 unit administrators to introduce me and the study including my Executive Summary of the study. All were fully supportive of the study including time lines of expected dates proposed for in-person meetings to set up entering the field.
The administrators I met with on several occasions always supported the study. They introduced me to nurse leaders on the respective units to work as my go-to-persons throughout the field work. While I clearly differentiated past roles with the current researcher role and maintained clarity throughout the field work. These processes were facilitated by my past work with managers as a former liaison between academia and clinical settings.