Book review

Citation

Backhouse, T. (2021), "Book review", Quality in Ageing and Older Adults, Vol. 22 No. 1, pp. 68-69. https://doi.org/10.1108/QAOA-03-2021-072

Through Wandering the Wards, Featherstone and Northcott peek beneath the surface of cultures of hospital care to see how they shape the practices of staff and experiences of patients living with dementia. This book challenges the dominant perception that it is only the behaviours of people living with dementia that create difficulties for the staff looking after them, by showing how ward cultures driving staff practices create, perpetuate and escalate the actions of people with dementia who are not well equipped to traverse the rules of the wards. Patients living with dementia can be seen as caught in a web of exacting organisational expectations. Meticulously dissecting ward practices so as to isolate the motivators driving staff routines and actions, this book significantly contributes to the fields of hospital and institutional ethnography by adding knowledge of how underlying organisational values can shape actors’ experiences and actions.

Featherstone’s background had previously been within the field of genetics and society, and Northcott’s had been in public health. Both are now medical sociologists focussing on dementia care in acute settings. This book presents findings from in-depth ethnographic observations in the UK acute hospital settings, including shadowing staff, and interviewing patients and patients’ family members and staff. Drawing on research funded by two National Institute for Health Research Health Services and Delivery Research grants from 2015, Featherstone and Northcott aimed to elucidate the culture of care in acute wards, to reveal the organisational features and interactional work of ordinary, commonplace bedside care for people living with dementia.

At first glance, the authors may seem to have missed the mark with the book title, which incorporates the recently vilified term “wandering”. However, they explain that they do not condone this or similar terms but adopt those terms they found actors using in the setting. This can be seen as the authors deploying a shrewd device to frame their own actions while conducting ethnographic research.

An engaging, analytic and insightful examination of the drivers and consequences of ward practices is set out over the 188 pages. Chapters One and Two examine ward cultures of care and ward life. These explicate the typical acute ward environment. The authors posit that staff worked to meet the aims of the ward, not of the patients. People with dementia were perceived by staff as “non compos mentis”, unreliable witnesses to their own experiences, with their expressed clinical needs viewed as dementia-related behaviours. We are given an insight to the book’s main argument that organisational ward cultures can create and position people with dementia as misplaced and problematic, with the actions that result, detrimentally impacting on individuals.

Chapters Three and Four demonstrate the visibilities, invisibilities and recognition and attribution of dementia at the bedside. Acute ward routines were focused on managing acute conditions, where dementia was not fitting into the scope of practice. People with dementia were seen by staff to be “the wrong sort of patient”, belonging elsewhere. They therefore became invisible to staff, viewed as non-credible and so overlooked. However, when they stood up from their bedside, “the patient transformed, becoming visible, now a patient “at risk” of “falls”, “wandering” or “absconding” to be returned and contained within the bed or bedside” (p. 36). The authors note that patients without dementia did not experience such invisibilising or appear to present risks to staff in the same way.

Chapters Five, Six and Seven coherently demonstrate the main argument of the book. We see people with dementia as ill-equipped to determine and abide by the unwritten rules and routines of the ward (such as staying by their bedsides). Any agency is viewed either as an aspect of their dementia or as rejecting the ward rules and so framed as resistance. Staff then enact stricter rules, routines and restraint, which people with dementia experience as frustrating, their reactions further amplifying their perceived deviancy. As staff then further tighten the rules and this “looping” continues. The restrictions prompted some people with dementia to describe their hospital stay as “incarceration”.

Chapter Eight takes a look the lessons from these findings. Ward cultures do not value communicating well or spending time with patients as legitimate work for staff. Actions of people with dementia, viewed as resistance, are “a normal response to an abnormal world” (p. 141). The authors argue that the ensuing restrictions on people with dementia may drive their decline, as typical in acute settings, having implications for their health, cognition, recovery and futures. Ultimately, people with dementia and staff members are caught together in this system.

Although the book could go further to offer recommendations or practice implications, the authors more than meet their brief to reveal and characterise the culture of care in acute wards. They offer absorbing and distinctive detail on how organisational features may condition the interactional work of ordinary, “commonplace” bedside care. They convince in showing how behaviours of people with dementia, commonly perceived as “challenging” can be created by sidelining individuals and strictly implementing rules and practices in the wards. This book will be a necessity for readers interested in dementia care, hospital care or in understanding just how underlying cultures of care can impact on those caught up in their services and also practitioners. Thought-provoking notions of identity, visibility, labelling, efficiency, containment and legitimate work will all be applicable to other fields. Available free to download online, it is a riveting read offering pertinent and affecting field note excerpts throughout that cannot be overlooked if we want to equitably reframe the place of people with dementia within services.