Guest blog: Researching Medical Decisions in an Accident and Emergency Unit

Studying the to- and fro- of a busy medical facility is not easy, though the promise is that the results can bear on what are literally life or death matters. Vasiliki Chrysikou and Fiona Stevenson give us a fascinating account of working in a UK Accident and Emergency unit.

Will Gibson, Caroline Pelletier, Fiona Stevenson and Vasiliki Chrysikou - the University College, London research team (Sophie Park not pictured)

Will Gibson, Caroline Pelletier, Fiona Stevenson and Vasiliki Chrysikou – the University College, London research team (Sophie Park not pictured)

Setting up our study was a complex business, and threw up all sorts of issues which needed thoughtful – and sometimes sensitive – decisions. Here are some of the most salient things to come out of our  team’s journey towards collecting video and audio recordings, and ethnographic material, for our CA study of decision making in A&E.

 A stepwise approach

Securing NHS ethics and R&D approval took a number of attempts and became a project in its own right, resulting in a paper reflecting on the whole process(1).   Once we got permission the work of negotiating recording in practice commenced. We took a stepwise approach as we started to unravel the complexity of the setting, with multiple, ever-changing actors. We had to collect and collate multiple, often conflicting ideas, about how to conduct the study and try to find a way of conducting the research that was acceptable to all, including our research goals.

Should we wear ‘scrubs’ and blend in?

A single but telling example of this was the lead consultant who facilitated our entry in the department advocated that we should wear scrubs (the loose top and trousers worn by medical staff). He argued this would help us ‘blend in’, implicitly presenting this as an aid to our acceptance.

“Scrubs’ worn by staff

The consultant suggested a range of  colours we should wear so as to not be mistaken for a member of the medical staff but to still fit in. This initiated a range of other opinions in terms of what we should wear. We discussed our options with other members of staff such as the departmental secretaries (who wore their own clothes) and nurses (who all wore scrubs) and took into consideration messages from our conversations with junior doctors, registrars and consultants (who varied in their choice of scrubs or own clothes) and the reasons why they chose, or not, to wear scrubs.

We ended up wearing our ordinary clothes, although we chose those which respected the departments’ overall infection control policy and dress code. This allowed us to flag up our unique, ‘research’ identities, creating our own space and disentangling ourselves from one single group of professionals in the department. This was also one out of many other ways of conveying the message that potential participants, in particular patients, had choice as to whether to participate or not in the research and to display our commitment to avoid privileging one voice in our research.

Who were we?

Having made a decision about what we wore, we then needed a way of understanding how the department worked, and also ‘a role’. The through-put of staff, patients and relatives / friends, together with our hospital badges, generally facilitates unchallenged access. However, untangling what is happening is difficult. We therefore decided to shadow different doctors, giving us unchallenged access to observe all aspects of the working of the Department, providing an understanding of the working of the Department as well allowing us to consider how cameras could be used in such a complex site.

What the cameras tried to capture

Our project was on decision making between junior doctors and patients. It turned out that the organisation of the fieldwork was itself a study in decision making in relation to how to gain acceptance to enable the topic of recording to be broached, and who to approach and how. On top of all of that, there were tricky practical issues in video recording interactions when we could not predict which space would be used for consulting.

The A&E ward during a night shift

The A&E ward during a night shift

First we had to get consent from the patient, but then the medical work took over, and all the actors could suddenly move location at any point. The logistics of setting up and recording within such constraints were extremely challenging. The practical constraints on recording meant that at times participants orientated strongly to it causing us to question the extent to which the recording impacted on those local practices which the research attempted to uncover (2).

  1. Stevenson, F., Gibson, W., Pelletier, Chrysikou, V. and Park, S. (2015) Reconsidering ‘ethics’ and ‘quality’ in healthcare research: the case for an iterative ethical paradigm. BMC Medical Ethics, 16:21. doi:10.1186/s12910-015-0004-1
  2. Chrysikou, V., Stevenson, F., Gibson, W., Pelletier, C. and Park, S. (2015) ‘Are you recording?’ Conducting naturalistic research in an A&E setting: the impact of video-based research on members’ local practices, Revisiting Participation: Language and Bodies in Interaction, Basel, Switzerland, 24-27 June 2015.