Edinburgh Napier University

  Institutional Ethnography (IE) is a method of inquiry into the social organisation of knowledge. It begins with a disjuncture/troubling experience impacting a specific group of workers and adopts their standpoint/subject positon to look out into the wider institution and trace the work and textual practices that organised (and produced) the disjuncture under investigation.

The study took the standpoint of Senior Social Care Workers (SSCWs) from one RCH in Scotland to uncover the complex social organisation of “abandonment” SSCWs described when there was insufficient support from NHS services to care appropriately for sick and dying residents. The focal point of inquiry was on SSCWs descriptions of being “pushed” into “difficult” decision-making conversions with family members about “serious illness” and the Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) – without the support of doctors (or nurses).

To inquire into how SSCWs work had become tied into the medical, legal and bureaucratic practices that rule death, dying and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision making in Scotland’s RCHs the study drew on ten open-ended interviews (SSCWs, n= 4 and others whose work influenced SSCWs working practices, n= 6). Interview transcripts were examined to uncover SSCWs accounts of their knowledgeable work related to managing illness, death and dying - along with the characteristic tensions, frustrations and contradictions embedded in those accounts.

The study traced how doctors and nurses were routinely, and systematically, absent from RCHs - leaving residents systematically excluded from the level of care that they needed. It also traced how SSCWs work with “serious illness” and “difficult” conversations was co-ordinated in disquieting ways in an apparent commitment to high quality “palliative care”.

What was discussed between SSCWs and family members during conversations about “serious illness” and the DNACPR form was out of step with the DNACPR policy, the rhetoric of palliative care, and the actual needs of SSCWS, family members, and residents for medical support. However, the study shows that what happened in the RCH was not simply an error of practice. This is because it was textually planned, organised, and co-ordinated across healthcare institutions, professional groups, the regulatory body acting on behalf of the Scottish Government and the management and care staff of the RCH itself. SSCWs - and others – were organised to take up the powerful ruling discourse of palliative care in ways which treated residents and family members with increasing objectivity, where institutional needs to reduce NHS spending and to protect the income generating potential of the care home as a business ruled over individual needs. In taking up and enacting the powerful ruling discourse of palliative care, SSCWs – and others- (intentionally but unknowingly) took up the very tools of oppression that dominated and overpowered their own and others lives.

The knowledge generated by this research can be used to show SSCWs and others how they unknowingly participate in taking up actions that are not in their own or others interests. This is the basis of changing the conditions of SSCWs and others lives thereby advancing anti-oppressive work.