Under the radar: The benefits of a sociological view of nurses’ ‘non-compliance’ in hospital wards at night

This paper demonstrates how a 'sociology of healthcare safety and quality' (Allen et al., 2015) can expand understanding of staff 'non-compliance'. Following Allen (2016) it uses aspects of Actor-network theory and the concept of working practices to challenge the mainstream Quality Improvement approach of treating staff concerns as 'resistance' to be overcome. This research was part of a study exploring nurses' relative 'non-compliance' with a vital signs observation protocol at night. An Early Warning System (EWS) algorithm prescribed frequency of observations when readings deviated from a 'normal' range. Semi-structured interviews were carried out with 17 nursing staff on wards with differing levels of compliance with the protocol. An electronic device had a delegating (calculating observation intervals) and prescriptive role (informing nurses when to carry out observations). Data was used by hospital management to assess ward compliance with the protocol. Interviewees described how the use of these actants (electronic device, ward compliance targets and protocol) provided some affordances. Yet the measurement of prescribed activity as 'compliant' or 'non-compliant' with no opportunity for nurse input removed nurses' mediating role and reduced their sense of professional autonomy. However nurses' accounts of decisions not to comply suggested certain patient groups might be unintentionally under-monitored at night. It was recommended that nurses' judgements about non-compliance be incorporated into the system to restore nurses' mediating role but also highlight potential risks. This research demonstrates how a sociological approach can address staff concerns and patient safety while making visible the impact of technology on ward decision making.