Emergency department culture and the care of older patients with frailty: a focused ethnography

Background
Culture shapes care delivery, professional communication, and the development of trust between patients and providers. Culture encompasses identifiable elements, shared values and beliefs, and underlying assumptions that shape behaviour. The Emergency Department (ED) subculture arises from its complex, high-pressure focus on acute illness. ED professionals increasingly encounter older patients with frailty, whose complex but often non-urgent needs require more holistic, individualised care. However, the ED subculture may hinder the provision of appropriate geriatric emergency care. Despite its relevance, little is known of the influence of the ED subculture on the care for older patients. This study provides insight into the ED subculture in relation to the care of older patients with frailty by exploring its visible elements, shared values and beliefs, and underlying assumptions that shape behaviour.

Methods
A qualitative, micro-ethnographic study was performed. Data were collected through topic-guided observations of ED professionals over twelve days, followed by interviews. Ethnographic methods were used to analyse the data, with iterative cycles of collection and analysis.

Results
The themes ‘Equality and professional solidarity as drivers of care delivery’, and ‘Responsibility and compassion in navigating the misalignment between emergency care and the needs of older patients with frailty’ describe the ED subculture in relation to the care of older patients with frailty. The ED is highly structured, efficiency-driven, and professionals believe in equal care to all patients through responsibility and teamwork. Stabilising acute illness is prioritised during the initial assessment; other needs are considered once patients are stable or assertive. Professionals believe the ED is intended for acute problems; non-acute referrals of older patients are considered inappropriate. However, they value a strong moral responsibility, navigating between emergency care priorities and the needs of older adults with frailty.

Conclusions
The ED subculture prioritises efficient, protocol-driven care and equal care for all patients, creating a challenge for delivering holistic, patient-centred care to older adults with frailty. Improving education and communication and integrating biopsychosocial principles into emergency care are essential. The ED subculture must be considered when developing and implementing future interventions to improve emergency care for older patients.