Reasonableness: legitimate reasons for illegitimate presentations at the ED

Abstract

Most studies on gatekeeping at the emergency department (ED) have emphasised the assessment of clients in terms of perceived legitimacy and deservingness, showing that lay considerations lead to exclusionary practices, and the ED contributes to the social reproduction of inequality. Some recent works have challenged this representation, providing compelling evidence of staff's concern for the access to care of the most vulnerable users. I extend this perspective by presenting the criterion of reasonableness of the visit to the ED that nurses in Romania commonly use during the triage admission interview. Reasonableness constitutes an acceptable departure from the mission of the ED that offsets the negative evaluation in terms of legitimacy. Patients deemed to have legitimate reasons for making illegitimate claims for admission escape staff's disciplining efforts. However, the staff-devised understanding of reasonableness is restrictive and does not attend to most cultural and structural barriers in access to quality health care. I argue that reasonableness indexes structural sensitivity, a fragmentary, tacit, and imperfectly consistent orientation to structural deficiencies in the organisation and provision of primary care.