Situational impropriety in emergency departments: a qualitative frame analysis from nurses' perspective in England and Italy

This thesis explores the frame informing emergency department nurses’ definition of situational impropriety from users and the suitable informal dealing strategies. Despite the dramatic scale of abuses recorded against emergency department nurses, the vast majority of these events go unreported and very little is known about nurses’ informal dealing strategies. Among the identified reasons for this low reporting rate is the suggestion that it is due to the unique definition of unacceptability developed by nurses, which is overlooked in literature and in practice. Drawing upon Goffman’s social theory, a qualitative, multi-case study research design was implemented. Data was gathered from an English and an Italian hospital using qualitative checklists and semi-structured interviews. The bi-lingual data collection was semantically translated to English and findings were analysed following Ensink’s sociolinguistic frame analysis. Following a within-method triangulation strategy, the frame was explored from two perspectives: a perspective by incongruity, thus through perceived situational improprieties; and a perspective by expectation, thus through informal dealing strategies – or frame-clearing strategies. Findings suggest that a unique frame is informing both teams’ perceptions, definitions of what is happening and reactions. The definition of unacceptability is strongly informed by nurses’ expectations, in terms of users’ capacity to respect the Parsonian patient-role. Five types of impropriety were identified, all defined as behaviour not in line with nurses’ expectations – independently from the intrinsic nature of the behaviour. Moreover, seven informal dealing strategies aimed at assuaging a perpetrator and preventing escalations were identified. The thesis casts light on nurses’ informal definitions and social constructions of reality, uncovering discrepancies, with approaches based on non-staff members’ perspectives. Moreover, it provides seven interrelated contributions to knowledge at theoretical and policy level, identifying potential solutions to reduce the impact of users’ situational improprieties on nurses’ wellbeing.