Research setting

This study was designed to take place the inpatient unit of a hospice. Hospices have been studied through ethnographic methods previously (Dean and Gregory, 2004, Lawton, 2000) however not with the intention of examining the practice and attitudes towards sedation. The hospice selected was local to me and a site where one of my supervisors held a senior clinical role. There were pragmatic reasons for choosing this research site in that it was likely that the initial access would be possible and it was a site where, at least in theory, research would be supported. This was known through both my previous personal experience and the close links with my supervisor in his working relationships with other members of staff. Additionally, having a supervisor on site helped both to negotiate access and to provide safeguards when considering potential problems in carrying out research in a sensitive context. The hospice inpatient unit has 22 beds and patients are admitted for a range of different reasons and

conditions. While the majority of patients have a malignancy, patients with

neurological conditions, heart failure or chronic respiratory conditions may also be admitted. Admissions may be for a fixed period of time (short planned admission – SPA- or ‘respite’) or more open-ended, with the focus on treating symptoms until they are controlled. Some patients are referred for end of life care and will die during their admission; others are referred for symptom control and may be effectively treated and discharged. Alternatively those referred for symptom control may deteriorate and die during their admission whereas those referred for end of life care may in fact be discharged.

69 The hospice was purpose-built with the inpatient unit on one floor. There are three four-bedded rooms and twelve single rooms. It has a day care unit which runs during the week; patients come into the hospice for part of the day, share stories, engage in activities, physiotherapy, complementary therapies, or see a doctor if they wish. Many patients admitted to the inpatient unit have attended day care in the past and are known to staff through the close links between day care and the inpatient unit.

The staff in the hospice include: healthcare assistants, staff nurses, nurse practitioners, junior doctors on training contracts (rotating through the hospice as part of more general training, e.g. in general practice), registrars training in palliative medicine, consultants, social workers, physiotherapists, occupational therapists, children’s worker and

complementary therapists. All of these groups may be represented on the inpatient unit in different numbers – clearly those represented in the greatest number are nurses and doctors. For the purposes of maintaining confidentiality, they have been grouped, in the data sections of this thesis, into larger groups of nurses, doctors, and allied health

professionals. Seniority of nurses or doctors is indicated where relevant, but the overriding concern in the presentation of the data is to protect confidentiality. On the inpatient unit, nurses are divided into two different ‘teams’ or ‘sides’; the Don and the Dee (fictional names) teams. On arrival to the hospice patients are allocated to a team. This is largely geographical – the ward is arranged in an ‘L’ shape where one arm is the Dee side, the other the Don. Nurses for one side would look after the patients on their side and not be involved in the other side unless it was necessary. Generally, nurses would be a ‘Don’ or a ‘Dee’ nurse and would expect to be on this side for every shift. On average there would be two ‘qualified’ nurses and two ‘unqualified’ nurses on each side; falling to one of each overnight. Staffing levels of nurses were problematic during the period of observation, with several recent departures and absences due to sick leave. This meant that frequently nurses would switch between the Dee and the Don side, depending on where there was greatest need. In addition, the number of qualified nurses was often reduced and this created practical concerns about both care for patients and the ability to dispense drugs. This also led to some bed closures during the period of observation.

There were two consultants with clinical responsibility for patients on a day to day basis. Many other consultants did out of hours ‘on-call’ work, in the evenings and over

70 weekends. There was considerable restructuring of senior medical cover during the study period, with two senior members of staff leaving, some interim cover and a period of significant uncertainty. Registrars training in palliative medicine changed over on average every six months, with some staying on for longer periods. Some would be in the hospice on a full time basis but most spent only part of their working week in the hospice, with some only spending one morning or afternoon session based in the

inpatient unit. Junior doctors training in General Practice would also change over every six months, but would change at a different time to the registrars. They would either be part time (spending two to three days in the hospice) or full time. Thus doctors would be present on the ward every day, in varying numbers and levels of seniority.

Consultants, like nurses, looked after one side of the ward – the Don or the Dee. They were responsible for all of the patients’ care on their side. Unlike the nurses they did not change sides frequently but would be called upon to ‘cover’ in periods of absence. Consultant ward rounds occurred once a week, with more regular ‘catch ups’ occurring through the week, or if there were patients about whom the junior doctors were

concerned.

In addition to the consultant ward rounds, medical ‘handovers’ of patients occurred regularly. Nursing handovers occurred at 0730, from the night shift to the early shift. Representatives from the nurses on the morning shift would then handover to the doctors, social workers, physiotherapists, occupational therapists and sometimes ward or unit manager at 0930. Planning of admissions would occur at this meeting in

addition to handing over anything which they felt the assembled group needed to know or to action. Further handovers occurred between nurses from the early shift and those on the late shift, and again from the late to the night shift. In general these handovers lasted approximately half an hour. In addition, once weekly multidisciplinary team (MDT) meetings were held with all professions represented. These ‘MDTs’ were held separately for the Dee and Don team, so approximately eleven patients would be discussed over the course of an afternoon. The scope of these meetings was much broader and focused more on non-medical aspects of care, the impact of a situation on family and on discharge planning.

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