Emergency care under the magnifying glass: a review of ethnographic studies in the scientific literature on hospital emergency services La urgencia bajo la lupa: una revisión de la producción científica sobre servicios de emergencia en hospitales desde la etnografía A urgência sob a lupa: uma revisão da produção científica sobre serviços de emergência em hospitais do ponto de vista da etnografia

The article presents a review of ethnographic studies in the scientific literature on hospital emergency services, with the objective of systematizing the studies and their principal findings, referring to the health-disease-healthcare process in hospital emergency services from an ethnographic perspective. An integrative literature review was performed of studies published in Argentine and international indexed journals and in the following electronic databases: PubMed, VHL, Scopus, Redalyc, and SciELO. The corpus of the analysis consisted of a total of 69 articles, which were submitted to content analysis, having identified the following analytical dimensions: quality of care, communication and bonds, subjectivity, application of information technologies, methodological reflection, patients’ experiences and practices, decision-making, and violence. The results allowed identifying a process that differs from guidelines and protocols, in which healthcare workers’ subjective aspects, communication and interpersonal relations, and working conditions shape, orient, and condition the treatment and care provided in the hospital. The article thus highlights the approach to subjective aspects in health studies, to understand not only health workers’ perspectives and experiences but also the persistent barriers to providing better quality of care, complexifying a problem ignored by a large share of the analyses.


Introduction
A first approach to the available literature with qualitative studies on hospitals shows that the point of departure for most of the studies is the perspective of the services' users, with their perceptions, expectations, and degree of satisfaction with the care received 1,2 , as well as physician-patient relations and communication 3,4,5 .An aspect frequently associated with the above is institutional violence 6,7,8,9,10,11 .Another important line of work has been medical residency training in public hospitals: ethnographic studies include those of Byron Good 12 in the United States and Bonet 13 and Ferrer 14 in Argentina (although all three take an ethnographic perspective in the hospital, the main focus is on medical residency).
Ethnographies in hospital institutions date to the Chicago school, with the study by Goffman, "Asylums" 15 , and much of the revealing work has been performed in psychiatric institutions 16,17,18,19 .
In general hospitals, we can cite numerous studies around the globe 20,21,22,23,24,25,26,27,28,29,30,31,32,33 .In Latin America 34,35,36,37,38,39,40,41,42,43 , although there have been studies in Argentina and México, most of the research has been done in Brazil.Of the total body of work analyzed, only a few studies focus specifically on the healthcare workers' perspective.We agree with Graça Carapinheiro 44 , who states that most of the studies on the topic are based on fundamental principles, the first of which refers to the hospital as a structure of care to serve the ill, and the second that assumes good human relations as the key to improvement and efficacy of the institution's mechanisms.Underlying these postulates is a certain organizational and social instrumentality.This article's particular interest stems from the preliminary results of our ethnographic research in the emergency ward of a public hospital in the province of Buenos Aires, Argentina, focusing on the healthcare workers' perspective.The research revealed the emergency ward as a space with the convergence of emerging and/or conjunctural and problems and demands from the lower-income population, requiring a response to medical urgencies and emergencies (defined and/or regulated as such) in this hospital service.Notably, the demand does not always coincide with what the institution defines and regulates as medical emergencies and/or urgencies or with the medical staff's expectations and daily work process.The current study thus aims to analyze the tensions and contradictions condensed in the space of medical emergency services, which will be the determinants of the perception of those working in hospitals concerning their work process.
A relevant task is a systematic search that we present as an integrative review 45 of the literature published in scientific journals indexed in international databases in order to produce a description of the work published on this theme.

Methodology
The elaboration of this article included a literature review aimed at identifying studies by Argentine and international authors that mention the health-disease-care process in hospital emergency services, from an ethnographic perspective.
For the purposes of this study, the health-disease-care process is defined as a social process operating in all societies and involving large amounts of collective symbolizations and representations related to the knowledge and ways of preventing, treating, controlling, relieving, and/or curing certain illnesses 45,46,47 .We incorporate into the health-disease-care process the category of care, defined as a continuous and open process, without predefined limits and that involves a team (healthcare workers, machines, medicines, bodies, patients, and other relevant persons), with a series of daily tasks to achieve improvement in the illness 48 .In the field of collective health, Ayres 49 develops the notion of care linked to its humanization, in which the intervention points beyond the technical and normative realm.
Among the various types of reviews, we opted to work with the methodological proposal of an integrative literature review.This approach allows retrieving, identifying, analyzing, and summarizing the publications referring to a given theme 50,51 .The approach is characterized by the breadth of data sources, favoring a comprehensive understanding of the target problem, contributing to the development of new conjectures, hypotheses, and theories 51,52 .
Cad. Saúde Pública 2021; 37(1):e00026120 In this particular review, we proceeded according to the five stages proposed by Whittemore46 for conducting an integrative review.The first stage consisted of demarcating the research problem, where it is essential to clearly orient the review (as presented in the article's introduction).The second stage involves the search strategies, determining the databases and search terms.The third is the evaluation of the collected data, i.e., the theoretical and methodological rigor, in our case studies actually based on ethnographic methods, and the data's relevance (the results of the second and third stage are presented in this methods section).The fourth stage is the analysis, comparing the extracted data to classify and group and code them in categories, according to content analysis, using the method of constant comparison to relate, elaborate hypotheses, and achieve a higher level of abstraction with the coded categories.The fifth and final stage consists of the elaboration of a presentation of the review's results (the information resulting from the fourth and fifth stages was developed in the results section), presenting the analytical categories that result from the coding and a synthesis of the main arguments until the final remarks on the topic.
As part of the second stage, searches were conducted in May and June 2019 in the following electronic libraries: Virtual Health Library (VHL), PubMed, Network of Scientific Journals of Latin America and the Caribbean, Spain, and Portugal (Redalyc), Scientific Electronic Library Online (SciELO), and Scopus.Box 1 provides a description of each database's scope.Some initial exploratory searches were conducted with various keywords/descriptors/MeSH, followed by a preliminary evaluation of the results in order to determine the most adequate keywords/ MeSH and/or descriptors to obtain the closest results for our purposes.The searches were performed with free terms, except in PubMed, where they included both MeSH and free terms (for technical reasons and due to the availability of this resource).The searches were performed in all the databases with the terms in English, since the exploratory stage had shown that more results are obtained this way.The search field included the title, abstract, and keywords, with variants and/or limitations proper to each database, as described in Box 2. No particular time period was determined for the article searches, since our thematic interest (ethnographic methodologies developed in hospital emergency services) was the prime criterion for building the study's corpus.
This procedure yielded a total of 156 articles, 48 of which were discarded as duplicates.The inclusion criterion was scientific articles that address the hospital space from an ethnographic or anthropological perspective, or a social sciences perspective (using a methodology and techniques proper to ethnography).
After reading each article's title and abstract, some exclusion criteria were determined: (1) articles not situated in medical emergency departments in hospitals; (2) articles situated in the hospital emergency department but that address adverse health events and/or some specific health problem (e.g., suicide, alcoholism, and/or accidents, among others).Importantly, no criterion was specified as to the healthcare workers' professional class.
Using these criteria, 25 articles were initially excluded, and 13 more were excluded after reading the full text.The total corpus was thus 69 articles (Figure 1).All of these articles adopted qualitative methodological approaches, including the following techniques: participant observation, interviews, case studies, and informal conversations.
The timeline of the analysis began with a first reading of the title and abstract to produce a preliminary classification of the articles in different categories, which was modified after reading the full text and reworked until reaching the definitive categories: "quality of care"; "communication and bonds", either among the staff or between the staff and patients; "workers' subjectivity"; "information technologies"; "qualitative methodologies", "decision-making", "patients' experiences and practices", and "violence" (as proposed for the third stage of the integrative review).
When we speak of "subjectivity", we refer to Sherry Ortner 53 , who proposes that there is a cultural configuration of subjectivities in the social world traversed by unequal power relations; and it involves modes of perception, affect, thinking, desire, and fear, which mobilize acting subjects and that are linked to cultural and social formations that shape, organize, and generate certain "structures of feeling" 53 (p. 25).When we speak of culture, we are referring to the construction of meaning that occurs through symbolic processes in a worldview shared by the members of a given social group 53 .
With regard to the process of categorization and analysis, in addition to the definition of each of the categories, cross-controls were performed with the classification and analysis of each of the established levels, having elaborated and agreed on the mechanisms of analysis among the current article's four authors.
Finally, the integrative review has limitations related to the search strategies, which limits the findings to indexed scientific journals (leaving out books and other formats, where a large share of the ethnographic production is published).Thus, the review does not cover the entire production on the topic, but a cross-section that allows building a corpus with a certain homogeneity for the analysis.In this sense, it establishes a good point of departure for elaborating a synthesis of part of the scientific knowledge produced on this research topic, including an overview that allows glimpsing opportunities for future studies 45 .We now present the results of the classification and analysis of the articles (according to the fourth stage of the analysis, as described).

Figure 1
Diagram of the selection process for the literature references comprising the study's corpus.
Source: prepared by the authors.

Results
A first reading and analysis of the studies identified some overall characteristics common to all of them, which to some extent are consistent with the established search criteria.
First, all the studies approach the emergency service as a place and in one way or another base their investigation on ethnography as a methodological strategy or recourse, although we did not retrieve any "ethnographies" in the strict sense of the term.When one refers to the ethnographic methodology, it includes fieldwork, observations and interviews, in some cases also additional techniques such as focus groups and space for discussion and communication of results, among other possible variations.
Most of the studies we analyzed also present commentary on the value and contributions of the ethnographic approach and methodology to produce data that contribute to healthcare, besides emphasizing this methodology's possibility for revealing data that could not be obtained through quantitative analyses.
The apparent methodological and technical homogeneity that unfolds in a unique setting like the hospital emergency department contrasts with the thematic diversity and variety of countries we found in the studies comprising the corpus.
Cad. Saúde Pública 2021; 37(1):e00026120 Most of the studies are from English-speaking countries, namely the United States, Australia, and United Kingdom, with much smaller proportions from Brazil and Canada (Table 1).Other countries have no more than one article each.Concerning the Australian studies, the country has one of the highest per capita GDP investments in science and technology, the equivalent of the United States and exceeding that of the United Kingdom 54 .As for the research topic, most of the articles address communication and the relations between healthcare personnel and quality of care.Australia is the country with the highest proportion of articles on these categories, followed by studies that deal with subjective aspects of health work (Table 2).Interestingly, the United States is the only country with studies on all the categories described and the one with the most studies on information technologies applied to health.Meanwhile, the United Kingdom features studies on quality of care and decision-making and is the country with the largest proportion of articles on these topics.
In the other countries, the studies are fewer in number and the themes vary, with no possibility of identifying regular patterns.
We now present a description of the articles, analyzed according to each of the respective dimensions.

Quality of care
This includes articles whose central theme is the study of work processes that contribute to and/or hinder care in the emergency departments.
Concerning factors that can affect work processes, a recurrent theme is "interruptions", referring to discontinuity in the work process due to interference by patients, the healthcare staff, and/or lack of inputs or resources 55 .
Another factor that affects care is the so-called "weekend effect", indicating greater risk of dying on weekend shifts compared to weekdays 56 .
The approach to issues that can improve quality of care refers to variations or improvement in the circuits of care in the emergency department, oriented towards increasing efficiency 57,58 or supervision of tasks on the ward that would have an impact on both patient and staff safety 59 .Concerning specific emergency services such as the obstetrics department 60 , additional proposals include the use of patient identification bracelets 61 and person-centered care 62 .Studies also approach the ward classification system as a decision-making tool in emergency services 63 .
Other authors focus on the way waiting time operates in quality of care 64,65,66 or the space, time, and power dimensions in hospital care 67 .Other studies discuss the ethics of daily care in the hospital emergency department, analyzed in terms of an "ethics of care" 68 .

Communication and bonds
This category includes articles centered on the relations established among workers in the emergency services, highlighting the relational dimension as central to work processes in hospitals, which significantly affects the processes of care and treatment.Importantly, medical emergency work has its own beliefs, logic, and underlying values that extend beyond what is drafted explicitly in the organizational values.
The articles grouped in this category can be distributed in three groups.The first group includes studies centered on relations between health teams, analyzing the way they can favor or hinder interprofessional practices oriented to greater patient safety 69,70 .They also discuss the strengths and limitations of interprofessional teamwork 71,72 and the team's influence on handover and continuity of treatment in other services 73,74 .
The second group of articles explores the roles played by certain workers and how they shape certain relations, responsibilities, and practices of care, focusing on the work by nurses 75 and physicians in the emergency department 76,77 .
The third group discusses the communication processes between healthcare workers from different professions, centered on management of medications 78,79 and the approach to patient referrals from the emergency department to other services 80 .These studies reveal how the ways of communicating the interpretative frameworks used by healthcare workers have consequences for patient safety and quality and efficiency of care.

Subjectivity
This category includes the articles focusing on healthcare workers' experiences, perceptions, and emotions towards the processes of care and treatment.All of them highlight the importance of healthcare workers' subjectivity when analyzing their practices and improving the quality of care.
Cad. Saúde Pública 2021; 37(1):e00026120 We can thus divide the articles into two groups.One discusses the effects of working conditions on healthcare workers: feelings of anguish, fear, stress, or gratification, among others.The other group includes articles that describe the influence of feelings, beliefs, values, and customs on processes of care as facilitators or obstacles to such processes.Some studies in the first group explore the feelings associated with working in situations of death on a daily basis 81,82 or with patients suffering chronic sequelae 83 .The other group of articles refers to the feelings associated with working conditions, exploring how the characteristics of hospital emergency services such as overload, urgency, constantly changing priorities, pressure, and the mismatch between the care they would like to provide and what they actually achieve generates anxiety and distress among the workers 84,85,86 , and many of them reflect on the need to analyze different emotions from the work in order to improve the management and quality of care 27,85 .
The second group of articles shows how these feelings, beliefs, values, and cultures affect the care the services provide to patients.The studies on the concept of culture analyze the emergency department as a different culture from that of other hospital departments, which particularly affects the work processes, decision-making, and quality of care 87,88,89 .We also found articles that analyze how patients' or certain social groups' stigmas 90 and physicians' interpretative frameworks 91 influence their professional work.

Information technologies
This category includes articles that present the results of studies on acceptance, application, or revision of virtual technological resources in health institutions.These studies emphasize the integration of various disciplines like information technology, administration, statistics, and the social, cognitive, and biomedical sciences.
The aim of these studies is to improve the quality of patient care 92 , in some cases through the incorporation of electronic patient files with clinical histories as a way of ensuring the information and guaranteeing patient safety 93,94 or as a way to expand the usefulness of electronic records of complementary tests 94 , and with the potential of reusing secondary data on clinical history from a system for control of care 95 .These studies feature the discussion on access to the available information (i.e., for whom and how it is accessed).
Another group of studies focus on the use of information for decision-making, patients' referral between departments 92,94 , and the prehospital communication interface and patient transport 96 .
Finally, some studies analyze the installed technologies to implement improvements and adapt the system, through follow-up of the healthcare workers and teams 96,97 .Unlike the previous studies, Tang et al. 97 conduct a comparative study of an information system no longer used by the health staff and the strategies to achieve acceptance and continuity with the incorporation of a new system.Most of these studies emphasize the place occupied by health workers' subjectivity, initiative, and culture in using and making decisions on this type of technologies.

Qualitative methodology in health
This category covers articles on the application of ethnographic methods and/or fieldwork techniques, specifically in hospitals and/or emergency departments.
Some of these studies focus on discussion and development of the specificity of the qualitative methodology and/or ethnographic techniques for understanding patient care practices, decisionmaking, and health interventions 98,99,100,101 .Others analyze ethical issues, in some cases associated with difficulties in obtaining ethical permission for conducting such studies 102 , and in others on the reflexivity of aspects affecting those performing the studies, who in many cases play the dual role of investigator and hospital worker 103,104 .

Patients' experiences and practices
The studies in this category mostly explore the behavior patterns and/or perceptions of patients, family members, or accompanying persons in hospital emergency services.Some focus on critically ill patients 105,106,107 , others on bonds with the hospital staff 108 and the use of the emergency department for reasons other than urgency in various population groups such as children 109 and/or indigenous peoples 110 .The number of articles in this category was quite small, since many were excluded because they dealt with specific health problems (as explained in the exclusion criteria).

Decision-making
The articles included in this category analyze the way healthcare workers use the institution's guidelines or protocols and how they practice agency and act according to their experience, judgment, and tacit knowledge in their choices and actions in the process of care.
The articles reflect on how medical practice is part of a structure consisting of policies, protocols, standards, norms, hierarchies, knowledge, and forms of institutional organization that shape such practice but do not determine it entirely.Agency exists in healthcare workers, leading them to make decisions based on their experience and tacit knowledge, when their judgment does not coincide with the established standard, when the protocol (generated from the assumed reality, i.e., the "must be") fails to coincide with the concrete reality of the emergency service.Examples are studies on the decision-making process related to patients' referral to different departments and services 111 with the prioritization of cases for treatment 112,113 and the organization and procedures to be used 114,115,116 .On this point, both physicians and nurses have wide room to act in this process, which underscores the impossibility of predicting all the practices, besides healthcare workers' power to transform the practices of treatment and care and to institute new forms of action and the need to investigate how this decision-making process is performed and the implicit knowledge and experiences at play.

Violence
This category includes articles that discus situations of physical or verbal aggression in hospital emergency departments.Most of them analyze violence by patients and/or family members or accompanying persons towards healthcare staff 117,118,119,120 .Only one article describes violence by medical staff against patients, expressed as "inhuman care" 121 .Many of these studies use the "risk" category, seeking to identify possible causes that can give rise to these situations 119,121 , such as waiting time for treatment and the impact of empathy on the process of care.Some of these studies also report the healthcare staff's perceptions and the fact that they take such violence for granted 118,120 , plus the reporting (or rather the underreporting) of such events in the institutions 117 .

Summary
A literature review's challenge is to transcend the analysis and description of each article or set of articles comprising the corpus, to reach beyond the descriptive level in order to generate inferences and hypotheses with a broader scope.The body of articles analyzed in our study allows mapping the themes that have become an object of knowledge from an ethnographic perspective in hospitals, thereby inferring, as the point of departure, a problem or problematization in the sphere of health institutions.
Most of the studies reflect the potential of qualitative approaches, particularly those focusing on ethnographic methods, commenting on the theoretical and methodological contributions of the various qualitative techniques and methodologies applied to the field of health, particularly in institutional healthcare settings.On the one hand, they highlight access to practices by ethnographic approaches when such practices are difficult to capture with other nonintrusive techniques, even qualitative ones.On the other hand, they illustrate how the contribution is not only technical, but also opens an essential discussion on ethical aspects of work in healthcare institutions and particularly those based on Cad.Saúde Pública 2021; 37(1):e00026120 cases in which the healthcare workers themselves conduct the research in their own workspace, with all the subjective and ethical implications for the production of knowledge.
As for the mapping of themes and problems approached in the literature, we identified a central category in the analysis that appears in different ways in all the articles: "quality of care", where we placed in quotation marks the general analytical categories and in italics the analytical dimensions identified within them.In fact, when grouping the articles by each study's central theme, only a few studies were included in the "quality of care" category, but the vast majority worked with some particular topic or problem with the ultimate objective of contributing to quality of care in hospitals.
Among the articles that included "quality of care", waiting, circuits of care, person-centered care, and interruptions appeared as central dimensions, although waiting is also a category associated with the studies on the theme of "violence", which mostly focus on situations of aggression between patients or from patients towards healthcare staff.Another issue related to "quality of care" is patients' experiences and practices, where the central problem is the use of the medical emergency department for problems that do not involve an urgency or emergency.Related with this, we identified questions addressed in health workers' "subjectivity", since patients' stigmas and healthcare workers' interpretative frameworks, beliefs, values, and culture act to condition the care they provide."Quality of care" appears again, in this case associated with healthcare workers' "subjectivity".On this point, the workers' perceptions of their working conditions, overload, urgency, and pressure create a gap between the desired care and the care actually provided, expressed as anxiety and suffering that necessarily impact patient care.Another issue related to subjectivity and quality of care is "interpersonal communication and relations", and the related roles, organization, and the responsibilities, which become central.
Meanwhile, many articles reveal the gap between the real working conditions and the assumed reality on which institutions' policies, protocols, and standards are based.This observation leads to an interesting hypothesis, namely the gap between what the institution assumes (as established, standardized, or protocoled) and the reality (working conditions and possibilities that do not "fit" the norm), enabling a certain creativity and agency by healthcare workers.In the face of what is supposed to be, the emergency department encounters what is actually possible, which assumes decisionmaking based on experience, clinical criteria, and tacit knowledge.This process is interesting because it is not about something inherently negative or positive, but something that can contribute differently to the quality of care, according to each healthcare worker's particularities.It thus becomes essential to inquire into these decision-making processes, motivations, and circumstances in various situations that lead to acting and deciding autonomously and creatively, outside the box or the institution's standards.
Thus, the way decisions are made, the communications processes and bonds, time and circuits of care, the way technologies are implemented, and even the ways patients move through the healthcare system are traversed by this gap between what is supposed to be and what actually is.In this sense, the processes can improve the quality of healthcare provision; hence the importance of studying these aspects, using qualitative methodologies that allow an in-depth approach centered on the hospital emergency department's concrete reality.

Final remarks
The analysis allowed identifying a trend in which healthcare workers' subjectivity, creativity, and agency shape the processes of care and treatment and interpersonal communication and relations.The latter shape and traverse workers' subjectivity, and in this sense, together with working conditions, they orient and condition their creativity and action.
Based on this, we can also signal that the gaps between institutional standards and daily reality, day and night shifts, weekdays and weeks, treatment aspirations and actual reality, create a suffering capable of producing, reproducing, and even transforming subjectivities, so the approach to subjective aspects is indispensable in health studies, not only to understand healthcare workers' perspectives and experiences, but also to understand the persistent obstacles to better quality of care, thereby complexifying the problem and the most frequent analyses.
Cad. Saúde Pública 2021; 37(1):e00026120 A future task lies in the challenge of tackling work that has still not been addressed in Argentina, while contemplating and bringing into play the study of possible similarities and differences between countries.By way of hypothesis, we dare to say that there are more similarities than differences, more common gaps, and shared suffering.Apparently, in the face of suffering, urgency, and the imminence of death, regardless of nationality, health policy, and institutions, the suffering and problems found here were inherently human and therefore universal.

Contributors
A. Sy participated in the idea, literature search, analysis, writing, and revision of the text.B. Moglia y G. Aragunde contributed in the article searches, analysis, and writing.P. Derossi contrituted in the analysis and writing.

Table 1
Number of articles and percentage according to country of publication.
Source: prepared by the authors.

Table 2
Number of articles and percentage according to categories of analysis.