Hospital transfers from care homes: conceptualising staff decision-making as a form of risk work

When making decisions about whether to transfer residents to hospital, care home staff consider the possible benefits and risks of different courses of action. However, to date, an in-depth and theoretically informed engagement with these decision-making processes and their associated behaviours has been lacking. We conducted an ethnographic study of care home staff’s decision-making about resident hospital transfers in England between May 2018 and November 2019. We combined staff interviews at six care home sites, with 30 members of staff, with 113 hours of ethnographic observation at three care homes sites. ‘Risk’ and risk management emerged as important overarching themes. In this article we conceptualise staff decision-making about potential hospital transfers for residents as a form of risk work. In doing so, we identify the different forms of risk knowledge that staff used to conceptualise risk and explore the ways staff navigated tensions between different forms of risk knowledge. We highlight the ways individual understandings of risk were influenced by social interactions with others, both at an interpersonal and organisational level, before identifying strategies that staff use to manage risk. By understanding transfer decisions explicitly in terms of the different forms of risk that care home staff manage, our analysis provides new insights into hospital transfers from care homes and contributes to the wider literature around risk work, demonstrating the utility of this concept in researching organisations that fall under the umbrella of social care, which have been previously neglected in academic research.