Aim The aim of this qualitative research study was to explore the provision of high dependency care in children's wards in SW England and to identify and evaluate individual and organisational factors influencing this care. Background Concerns about paediatric intensive care have been reported, leading to the implementation of many changes in practice. High dependency care, which is usually provided on children's wards, is included in the organisational framework for critical care, but has received far less attention. Definitions and recommendations lack clarity, which could lead to difficulties in determining the most appropriate environment, staffing and equipment for care provision. Methods A two-stage approach was adopted. In the Preparatory Work, focus groups were conducted with nurses to identify key factors influencing high dependency care for children. The emerging factors formed a basis for the Main Study, which used an ethnographic approach. Fieldwork was undertaken in three children's wards using observation, individual interviews and selective documentary scrutiny. Data from each ward were analysed separately, then combined to enable the comparison of findings across settings. Findings Three main themes were identified: the child's 'journey' to high dependency care, obstacles to high dependency care, and facilitators. Despite nurses recognising deterioration, high dependency care could be delayed, especially if a child needed to be moved to a high dependency unit. Differences demonstrated between the wards appeared to be influenced by the organisational culture of the hospital setting. Conclusions The findings contribute to our understanding of high dependency care provision in children's wards and reveal differences between hospital settings that have not previously been recognised. These differences are partially explained by theories of organisational culture that have received limited attention in nursing to date. Ethnography and observational methods are rarely used in children's nursing, but in this study enabled identification of variations in the child's journey to high dependency care in the wards studied. The influence of organisational culture and care setting should be acknowledged in future policy and practice.

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