Fase 1: Producto para baños de ignifugación

In keeping with the tenets of ethnographic inquiry, the study was conducted in the natural setting of an acute medical assessment unit (AMU) in a Foundation Trust hospital in the North West of England. The hospital did not have a critical care outreach service. The AMU incorporated separate male and female ward areas, comprising a total of 70 beds. The individual ward designs are represented in figures 1 and 2 (pg 102 & 103). An ambulatory care area was housed in a discrete location off the AMU female ward area.

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The AMU is a hybrid environment, bearing some similarity with general medical wards in terms of design, patient accommodation and routines such as meal times and visiting hours. However, in contrast to a general ward, the AMU provides care and accommodation for patients admitted to hospital with a medical emergency, having exceptionally acute care needs more similar to those patients admitted to the A&E department. However, the AMU is neither an emergency department (which has specific areas for triage and resuscitation with high levels of nursing and medical staffing), nor is it comparable to a general hospital ward, where patients may be cared for over a number of days once the acute phase of their illness has passed. The AMU is a distinct department within the hospital having specific characteristics which have influenced the development of acute medical nursing as a field of practice and which played an influential role in the ways that nurses made their observations of patients.

The AMU was split into separate male and female ward areas, each with a very different design. Since there was no purpose built area for the AMU, it was housed within existing hospital accommodation which had been constructed many years earlier. The male AMU had originally been designed as a rehabilitation and physiotherapy suite, providing enclosed bays of 4 beds with additional single room accommodation, ideal for the independent patient and affording high levels of privacy to patients. However, this ward layout proved to be an adverse environment for nurses making observations of acutely ill patients. In contrast, the female AMU was housed within a traditional open plan ward with beds placed in a linear formation, offering a clear line of sight from one end of the ward to the other

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and affording nurses an environment conducive to patient observation. However, in contrast to an A&E department, neither of the two AMU wards provided designated beds for patients with critical illness, nor were these patients cared for in a designated area of the ward or with dedicated nursing staff. Whereas in A&E these patients would be cared for in a designated resuscitation area with high ratios of staffing, in the AMU patients with varying severity of illness were managed side by side by a single nurse supported by an HCSW. For example, it was not unusual to see a patient with a stroke being nursed alongside patients with pneumonia, myocardial infarction and septicaemia.

The AMU had an ambulatory care area referred to as the GPAU (GP assessment unit). This was a distinct area directly accessible to the female AMU via a link corridor. The AMU operated 24-hours a day, 7 days per week basis, meaning that patients might be admitted, discharged or transferred at any time in the 24-hour period. This was essential to facilitate the flow of admissions from the accident and emergency department. The average number of admissions in to the AMU was 50 per day. The ratio of nurses to patients was generally 1:8. The split of qualified nurses to unregistered staff was 50:50. A nursing support worker usually assisted each nurse. However, the support worker would be responsible for

‘portering’ duties on a frequent basis, thus spending considerable lengths of time away from the ward transferring or escorting patients between departments, fetching notes or busy on other errands.

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Generally, each shift would have a ‘ward co-ordinator’ on duty, whose responsibility it was to supervise the staff and to ensure that the flow of patients through the department was co-ordinated and efficient. This role tended to be allocated to the most senior nurse on duty (usually a band 6 or 7 ward sister) and was heavily focussed on the movement and allocation of patients to and from the ward area, highlighting the emphasis given to meeting the A&E target. The ward co-ordinator was available to assist the other nurses if necessary but had no patients allocated to them for the shift.

The AMU wards had a set ‘order of the day’ which was visible from the observational data, some of which was inherited from the routine of a general ward such as meal times for example. In stark contrast with general medical wards the doctors' rounds took place twice daily, when a team of medical staff and allied health professionals arrived to review each patient in turn. These rounds generally took place between 8-9am and again at 4-6pm and lasted approximately two hours. The objective of the ward round was to see every new patient as it was imperative to make an early diagnosis, commence treatment and to expedite the patient’s management plan. Patients would then be discharged or transferred to the most appropriate destination; hence the AMU ward rounds were different to those conducted in other wards and usually included attendance by an occupational therapist, physiotherapist and pharmacist. These were extremely busy times of the day for the nurses, who were expected to attend the round but were also busy giving out meals and drinks to patients, administering medications, making beds, helping patients to bathe or go to the bathroom, dealing with

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telephone enquiries, making documentary entries, as well as admitting, transferring or discharging patients.

At the start of the shift, handover took place at the bedside between the two nurses finishing shift and commencing the shift, since there was no time to have a shift handover with all staff present. The two nurses would discuss the presenting complaint of each patient, any concerns and any outstanding investigations. The focus for the nurses was on speed and efficiency in completing the outstanding management plan actions in order to allow onward transfer of the patient and to release the bed for the next patient. The ward co-ordinator liaised with the nursing staff regularly during the shift regarding the patients’ diagnoses and management plans. It was the co-ordinator's job to prioritise patients for transfer to other wards.

Despite the very different ward designs of the male and female AMU, the ward staffing, ward rounds and duties were allocated and performed in a similar fashion.

The impact of the differences in ward environment is explored in chapter 5.

Nurses spent significant periods of time completing various pieces of documentation which included laboratory requests, admissions proforma, risk assessments, patient menus and nursing records, and ensuring that all patients had been ‘processed’ for admission. The admissions process involved having various blood test obtained, an ECG recorded and often a chest X-Ray performed.

Drug preparation and administration also occupied long periods of the nurses’

time.

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The AMU environment was constantly busy and noisy, due to the high levels of activity and the equipment in use. In the main, beds were surrounded by various pieces of equipment, including cardiac monitors, drip stands with infusion pumps, and other electronic kit such as the bed or mattress. Many patients were receiving infusions, had catheters, chest drains or receiving oxygen and were highly complex in that each patient had different yet multifaceted care needs. Often, patients would need a higher degree of nursing and medical support for organ failure, such as respiratory failure. Patients often needed specific support with their breathing using non-invasive ventilation (NIV) equipment, or monitoring of the ECG for a cardiac complaint. Unlike a general medical ward, Level 2 high dependency care was a regular feature of nursing work in the AMU. Irrespective of their medical diagnosis or level of care, patients were allocated to the next available bed. In contrast to an A&E department where critically ill patients would be triaged to the resuscitation area for close monitoring, the AMU had no designated level 2 care beds.

The majority of patients admitted to AMU were over 65-years of age and also had mobility difficulties and other age related co-morbidities. The nurses cared for patients with a diversity of undifferentiated and undiagnosed acute medical illnesses, responding to the specific needs of the patient as well as providing interventions specific to the presenting complaint. Patients presented to the AMU with cardiology, respiratory, gastroenterology, gerontology, oncology, endocrine, renal, hepatology and neurological complaints as well as general medical illnesses.

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