Reasonableness: legitimate reasons for illegitimate presentations at the ED

Abstract

Most studies on gatekeeping at the emergency department (ED) have emphasised the assessment of clients in terms of perceived legitimacy and deservingness, showing that lay considerations lead to exclusionary practices, and the ED contributes to the social reproduction of inequality. Some recent works have challenged this representation, providing compelling evidence of staff's concern for the access to care of the most vulnerable users. I extend this perspective by presenting the criterion of reasonableness of the visit to the ED that nurses in Romania commonly use during the triage admission interview. Reasonableness constitutes an acceptable departure from the mission of the ED that offsets the negative evaluation in terms of legitimacy. Patients deemed to have legitimate reasons for making illegitimate claims for admission escape staff's disciplining efforts. However, the staff-devised understanding of reasonableness is restrictive and does not attend to most cultural and structural barriers in access to quality health care. I argue that reasonableness indexes structural sensitivity, a fragmentary, tacit, and imperfectly consistent orientation to structural deficiencies in the organisation and provision of primary care.

The health of segregated Roma: first-line views and practices: a case study in Slovakia using ethnographic methods

“…We also found that the rationale for adopting such an attitude varied between frontliners showing more and frontliners showing less resilience to negative attitudes towards segregated Roma in general. These findings resemble the findings of the only other study we found on a similar topic regarding CEE segregated Roma, by Wamsiedel (2018). In Romania hospital triage frontliners also incorporated into their clinical decision-making their personal views regarding both their facilities' capacities and the served minorities' moral eligibility.…”

“…We also found that in the case of healthcare frontliners, this often resulted in gradually becoming cynical regarding Roma patients. Our findings match scarce previous related studies showing similar difficulties and outcomes among both kinds of frontliners addressing segregated Roma in Romania (Schneeweis 2013;Wamsiedel 2018). Our findings are also in line with research on factors contributing to and consequences of healthcare staff burnout in general (Glasberg et al 2007;Hall et al 2016;Rose et al 2017).…”

“…However, they remained unable to improve the situation significantly. Our results resemble 174 Discussion Andrej Belak Chapter 8 findings from other studies examining similar themes, that identified extensive and partially effective anti-discriminatory improvisation among healthcare frontliners and health mediators in Romania (Schneeweis 2013;Wamsiedel 2018). However, our findings are also in accord with epidemiological evidence from elsewhere (Krieger 2011;WHO 2010a;WHO 2010b) showing that the root determinants of steep social inequalities lie beyond the access to and quality of services for people who are already sick.…”

Yonder: District nursing, deprescribing, psychotropic drugs, and reasonableness

“…The question is ultimately one that is explored during the triage admission interview in the emergency department, which was recently the topic of a Romanian sociological study. 4 Although previous studies on gatekeeping in emergency departments have emphasised the assessment of individuals in terms of legitimacy and deservingness, the concept of 'reasonableness' presented in this study is more nuanced, and is concerned with the possibility of the visit to have been avoided. Individuals who put on a favourable presentation of themselves, and who had a narrative of 'reasonableness' in their medical and social circumstances, were more likely to be exempted from blame from triage clinicians.…”

Negotiated Discretion: Redressing the Neglect of Negotiation in “Street‐Level Bureaucracy”

“…In detailing triage nurses' gatekeeping, the article also contributes to the medical sociological literature on how frontline staff perceive and treat patients in walk‐in emergency services (Buchbinder ; Dingwall and Murray ; Dodier and Camus ; Hillman , ; Hughes ; Jeffery ; Johannessen ; Mannon ; Roth ; Vassy ; Wamsiedel ). Of particular relevance in the present context are those studies that find that frontline staff regularly attempt to turn “illegitimate attenders” away from the service altogether (cf.…”