Meanings of immediate: the practical use of the Patient's Charter in the accident and emergency department

The publication of the Patient's Charter in Britain enabled patients to have access to a series of documented standards relating to health care provision in a variety of situations. However since its introduction much discussion has taken place as to its application in clinical practice. An initial interest in the accomplishment of routine accident and emergency (A&E) nursing work led to the identification of issues associated with the use of the Patient's Charter standards; particularly those associated with immediate assessment in the A&E department. Data were collected from 60 nurses in five A&E departments and analysed using a multidisciplinary multistage approach. Findings suggest that nurses are expected to juggle the daily tensions produced by the Charter standards, associated with initial assessment, alongside the accomplishment of other aspects of the work dedicated to the safe movement of patients through the system. Tensions are rooted in two particular issues. Firstly, the meanings of immediate assessment continue to remain open to interpretation and therefore difficult to capture and manage. Secondly, the Patient's Charter standards, associated with immediate assessment, deal with one aspect of the work only and yet the accomplishment of A&E work is dependent upon maintaining a perception of order and shape throughout the whole department. Ultimately both issues have an impact on nurses' recognition and management of what they know to be the normal appearances and shape of routine work.