title: The habitus of 'rescue' and its significance for implementation of rapid response systems in acute health care.
abstract: The need to focus on patient safety and improve the quality and consistency of medical care in acute hospital settings has been highlighted in a number of UK and international reports. When patients on a hospital ward become acutely unwell there is often a window of opportunity for staff, patients and relatives to contribute to the 'rescue' process by intervening in the trajectory of clinical deterioration. This paper explores the social and institutional processes associated with the practice of rescue, and implications for the implementation and effectiveness of rapid response systems (RRSs) within acute health care. An ethnographic case study was conducted in 2009 in two UK hospitals (focussing on the medical directorates in each organisation). Data collection involved 180 h of observation, 35 staff interviews (doctors, nurses, health care assistants and managers) and documentary review. Analysis was informed by Bourdieu's logic of practice and his relational concept of the 'field' of the general medical ward. Three themes illustrated the nature of rescue work within the field and collective rules which guided associated occupational distinction practices: (1) the 'dirty work' of vital sign recording and its distinction from diagnostic (higher order) interpretive work; (2) the moral order of legitimacy claims for additional help; and (3) professional deference and the selective managerial control of rescue work. The discourse of rescue provided a means of exercising greater control over clinical uncertainty. The acquisition of 'rescue capital' enabled the social positioning of health care assistants, nurses and doctors, and shaped use of the RRS on the wards. Boundary work, professional legitimation and jurisdictional claims defined the social practice of rescue, as clinical staff had to balance safety, professional and organisational concerns within the field. This paper offers a nuanced understanding of patient safety on the front-line, challenging notions of the 'quick fix' safety solution.
authors.affiliation: King's College London, Division of Women's Health, School of Medicine, UK. Electronic address: nicola.mackintosh@kcl.ac.uk.
authors.forename: Nicola
authors.initials: N
authors.lastname: Mackintosh
authors.affiliation: King's College London, School of Nursing and Midwifery, UK.
authors.forename: Charlotte
authors.initials: C
authors.lastname: Humphrey
authors.affiliation: King's College London, Division of Women's Health, School of Medicine, UK.
authors.forename: Jane
authors.initials: J
authors.lastname: Sandall
mesh_terms: D003299:Cooperative Behavior; D004632:Emergency Medical Services; D057209:Hospital Rapid Response Team; D006760:Hospitalization; D006801:Humans; D007407:Interviews as Topic; D019370:Observation; D061214:Patient Safety; D036301:Qualitative Research; D011787:Quality of Health Care; D006113:United Kingdom
keywords: Acute care; Bourdieu; Division of labour; Early warning systems; Ethnography; Failure to rescue; Interprofessional working; Patient safety