When I commenced fieldwork, initially my focus was on the ward in general and
getting to know the daily processes and tasks which staff carried out. I was interested in the accounts staff gave of patient symptoms and treatments required. I spent time in the nurses’ office, the doctors’ office and observing nurses and doctors in their daily
routines. I attended handover meetings at different times of the day and also the twice weekly MDT meetings. After some time I was able to gain more access to their involvement with patients as the process for approaching patients improved. Thus I developed a routine of attending meetings, spending time with members of staff, and going with them as they saw patients. I followed the different working patterns of nurses and doctors, from the early morning handover shift to the night shift. I became aware that there were differences in the nature of what I would hear in these different settings. In the handover meetings a formal account was given of what had happened on the previous shift; this was regarded as objective, factual information, of what had occurred. In MDT meetings several accounts were given about the same patient and while often similar, it would sometimes be openly acknowledged that different professionals received different versions of events, or interpreted them differently. These discrepancies or differences in interpretation were discussed and provided different insights into the dynamics of a situation.
These formal accounts were substantiated by observations in the ‘backstage’ areas of the MDT office (where doctors and some allied healthcare professionals worked) and the nursing office. When handovers were not taking place these were informal meeting rooms where staff gathered between jobs, or between seeing patients, pausing to write in notes or to discuss what to do next. In the MDT office doctors often discussed patients, both before and after they had been to see them. They may have discussed what had happened or been done in the past, or tried to convey a general impression of what was going on. When they returned after seeing a patient they would often debrief, either mulling over or asking one another what to do.
Nurses, qualified and unqualified, rarely talked in their office about what was going on from a medical perspective, or discussed what to do for a patient. They would talk about the emotive nature of a situation, or describe some detail about a family member which compounded a tragic situation, or even talk about how difficult a patient was
85 being. In general they did not talk about what drugs patients were on, or what was happening from a clinical perspective. Instead, conversations in the nurses’ office were more often about the personal lives of patients, their own personal lives, or those of celebrities. Occasionally if I walked into the office after being away and asked what had been happening in a general way, I would receive an account of the ‘difficult’ patients of the time. These patients were ‘difficult’ because they were demanding in some way; I came to realise this may be physical or emotional in nature. A difficult patient may be one who demands a lot of attention, or who has some trait which marks them out as being different. They may have needed attention because of uncontrolled physical or psychological symptoms; or it may have been the impact which they had on staff which marked them out as being ‘difficult’. A young patient with children, for example, might be ‘difficult’ simply by the nature of their situation – this may be more emotionally demanding of staff and thus make them more ‘difficult’ to look after. This marking out as being difficult was a combination, therefore, not only of the patient’s traits but also of the impact of the situation on staff. While the ‘difficult’ patients were discussed in the nurses’ office, it became clear that it was hard to access their
‘backstage’ accounts of other patients by simply being in their office; I had to engage in some way with what the nurses were doing. I found a useful way of doing this on the early shift was to go with one of them on their drug round. Here, whilst staying quiet and observing during drug dispensation, nurses would often give more of a personal account of what they thought was happening, or why they were giving a particular drug. This was especially the case overnight, when they were not only dispensing drugs, but anticipating problems overnight. They would describe this, what they were seeing and how they would try to manage this.
From the start of the observation I wanted to be able to be in a position to observe as freely as possible, and change environments throughout the course of a day. I did not stay with one individual for a full shift, which would have been one way to approach this. I felt this may limit my exposure as well as being more likely to directly influence decisions which were subsequently taken. By moving around I felt I was in more of a position to observe front and backstage; observing directly what was seen from one perspective, then changing to another’s, then hearing the accounts given to other members of the team.
86 Consultant ward round were another opportunity to observe ward processes and
decision-making. One or more junior doctors, a nurse and sometimes a medical student would be present. Consultants, either before or during their ward rounds, would ask for an update of what was happening. This would normally be given by a junior doctor while the nurse present may add further information. The interaction with the patient, in the presence of at least 4 or 5 people, created a different perspective, and the subsequent decision or clarification of the decision, was made again outside the patient’s room.
Through all of these processes I became aware of patients who were receiving sedative drugs. I began fieldwork with the intention of gaining an overview of how sedation was defined in practice and an account of the attitudes towards and intentions of staff
regarding sedation. Therefore I had to be able to take an overall perspective of which sedative drugs were used, the reasons stated for giving them, their effects and outcomes. I became aware of a number of different ways in which sedation was prescribed and reasons given by staff for sedation being administered.
One of the main distinctions formed early on in fieldwork was between patients who were considered to be dying and those who were not. While continuing to observe in a general sense, I focused my observations regarding sedation towards those who were considered to be dying, or for whom there was uncertainty about whether or not they were dying. While I was still in a position to observe those who were receiving sedation and not considered to be dying, I was able to examine in more depth those situations where patients were receiving sedation at the end of life. In addition, I was able to observe the transition into the dying phase and changes in the use of sedation from one phase into another. I came to understand this transition to be of great importance as I analysed the data and developed a theoretical understanding of how sedation was used; this will be appreciated in the following data chapters.
I observed situations in which sedation appeared to be unproblematic, as well as those in which sedation was considered to be of great concern. I identified this concern in different ways; through observation of discussions, comments in handover meetings, or I would be told about an ‘interesting case’ by an ‘informant’. Reasons for concern or a heightened awareness of sedation taking place varied; what was clear however was that they were not ‘everyday’ cases of sedation. It seemed important to access what it was
87 about these cases which marked them out as ‘deviant’ cases, from which I could expect to learn more about ‘everyday’ sedation (Hammersley and Atkinson, 2007 p.169, Silverman, 2010 p. 281). I followed these cases more purposively; I observed nurses or doctors at different times as they interacted with these patients and their significant others. Having been alerted to a more unusual situation in which sedation was being used, I selected ways in which I would be able to observe interactions with staff. This may have been to attend nursing drug rounds, consultant ward rounds or junior doctor consultations. In this way I gathered more information about specific cases in which sedation was used.
In total, 45 patients consented to participate in the observation phase of the study. 289 hours of observations were carried out, over 51 days, spread over a period of 11 months from September 2009 to July 2010. Periods of time away from the field were required to fulfil teaching requirements, for analysis or for leave.