DISRUPTIONS, DISCONTINUITIES, AND DISPERSIONS: AN ETHNOGRAPHY OF DISJUNCTURES IN ORTHOPAEDIC WARDS

Enhanced Recovery Pathways (ERPs) have become viewed as evidence-based medicine being brought to bear. Events are sequential, aiming to maximise throughput, productivity and quality. It is notable that usual care is full of multiple types of disjunctures (disruptions, discontinuities and dispersions) for patients, carers as well as health and social care professionals. Patients featuring on the cognitive impairment continuum (living with dementia and/or delirium) can present particular disruptions to usual practice. As part of the Peri-operative Enhanced Recovery hip FacturE Care of paTiEnts with Dementia (PERFECTED) research programme, focused ethnographic observations were conducted to unpick the everyday lived experiences of how patients experiencing delirium and/or dementia impact on ERP orientated practices on Orthopaedic Trauma wards. Observations of routine “public” care places and activities were conducted across the 24 hour cycle, over 4 weeks in 3 secondary care settings across the United Kingdom. The spaces were selected due to the presence of care delivery processes aiming to provide ‘enhanced recovery’ to PEREFCTED’s target population. Consisting of 144 hours of fieldnotes, data identifies multiple types of disruptions and discontinuities for patients and staff, with patients living with dementia posing particular and specific disruptions to usual practice, conditioning and staff responses. We will discuss how such practice dilemmas are well-known but not well-captured in this setting in relation to there specific impact on clinical care. The paper will conclude by demonstrating the value of ethnographic observations in health science research and how ERP procedures can be situated in usual care practices.