How do emergency care providers and law enforcement officers navigate the competing imperatives of saving lives and serving justice? A qualitative case study in a Ghanaian secondary hospital

Abstract

Objective

Emergency care departments often navigate the dual imperatives of providing timely medical care and cooperating with police as law enforcement officers (LEOs) involved in injury-related cases. Using Strauss’ negotiated order theory, we examined the engagements between clinicians and the police at the Upper West Regional Hospital in Ghana, analysing the structural and negotiation contexts shaping their interactions.

Design

We used a qualitative case study design.

Setting

The study was conducted at the Upper West Regional Hospital in Ghana.

Participants

Participants included clinicians (n=11; 7 nurses and 4 doctors) and police officers (n=10; 6 Criminal Investigation Department and 4 Motor Traffic and Transport Department) with experience engaging with each other during patients’ visits at the emergency department of the Upper West Regional Hospital.

Methods

Participants were recruited through snowball sampling. We first conducted semi-structured interviews (April 2024 and February 2025) with the 21 participants. We then conducted a validation workshop with clinicians, healthcare managers and police in April 2025, incorporating key insights from the workshop into the thematic analysis to strengthen the study’s credibility and contextual relevance.

Results

We found that interactions between clinicians and police were shaped by three key structural factors: (1) organisational structures like role boundaries and decision-making authority; (2) the policy environment, particularly legal and ethical obligations; and (3) wider cultural contexts, such as societal norms. Within these contexts, negotiations centred on how clinicians and police balanced autonomy with collaboration, shared information, resolved disputes and built interprofessional trust. Informal networks and feedback were particularly important mechanisms for building smoother engagements.

Conclusion

Clinician–LEO interactions are dynamic and require continuous negotiation to align healthcare priorities with law enforcement mandates. Clear policies on engagements, interprofessional training programmes and culturally responsive frameworks are needed to enhance emergency care.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• Applying Strauss’ negotiated order theory provided a strong conceptual lens for analysing clinician–law enforcement officer (LEO) engagements.

• Inclusion of both clinicians and LEOs offered a balanced perspective on interprofessional engagement.

• Conducting a validation workshop with diverse stakeholders (clinicians, managers and police) enhanced the credibility and contextual relevance of the study.

• The study was conducted in a single hospital in one region of Ghana, which may limit the transferability of findings to other settings.

• Primary coding by a single researcher may introduce subjectivity, though team-based review and member-checking through the validation workshop were employed to mitigate this.

Introduction

Injuries constitute a significant component of the global mortality burden, with low-and middle-income countries (LMICs) accounting for 90% of injuries globally and 83% of injury-related deaths.¹ In 2021, an estimated 1.19 million road traffic deaths occurred globally, with 92% occurring in LMICs.^{2 3} Addressing this alarming injury burden is reflected in various Sustainable Development Goals (SDGs), including targets to halve road traffic deaths (SDG 3.6), promote road safety (SDG 11), reduce violence (SDG 16.1) and end abuse against children (SDG 16.2).⁴ Achieving these targets requires not only robust emergency care systems but also effective collaboration between healthcare providers and law enforcement officers (LEOs).^{5 6}

However, a fundamental challenge in achieving these goals is the delicate interface between emergency care and law enforcement.^{6 7} The intersection of medicine and law in emergency care settings represents a complex medico-legal territory with significant ethical implications. Healthcare providers operate under legal frameworks governing patient confidentiality, informed consent and mandatory reporting requirements, while LEOs, in contrast, are guided by legal mandates concerning evidence collection, public safety and criminal investigation.⁶ These parallel but distinct frameworks often create tension within the emergency department (ED), as clinicians must navigate their duty to protect patient privacy under confidentiality laws, while LEOs seek information essential to their investigations.^{5 6 8} In Ghana, the legal framework governing health information privacy is less comprehensive than in some high-income countries, potentially creating additional complexity in clinician–LEO interactions.^{9 10}

The ED is characterised by two key institutional features. First, it manages a significant percentage of life-threatening injuries requiring immediate clinical care without prior appointments.⁸ Second, injured patients presenting to the ED often include victims of road traffic accidents, interpersonal violence or other unintentional injuries, where the presence of law enforcement becomes particularly prominent.^{5 11} Road traffic injury is a major contributor to the high prevalence and mortality of unintentional injuries in Ghana.^{12 13} Interpersonal violence is also a significant concern, with 36.4% of women reporting some form of intimate partner violence.¹⁴ Such cases involving violence and crime often necessitate law enforcement presence, making the ED a critical site of clinician–LEO engagement.

While the current literature has noted the need for systematic empirical examination of clinician–LEO engagement in the ED, studies have predominantly focused on patient characteristics rather than interaction processes and outcomes.^{8 15} The few studies that have examined engagement processes are concentrated in high-income Western settings, with a notable dearth of evidence from LMICs.^{5 6 16} The Ghanaian context presents unique challenges in this domain, as healthcare workers must navigate these tensions with limited institutional guidance or legal precedent specific to emergency care settings. Additionally, clients without health insurance membership often pay out of pocket through the cash and carry system, meaning that anyone who brings a victim to the hospital is expected to bear the cost of treatment if the victim is unable to pay and their family has not yet been identified.^{17 18} Drawing on Strauss’¹⁹ negotiated order theory, this study examines the structural contexts and negotiation processes that shape engagements between clinicians and police as LEOs in the ED of the Upper West Regional Hospital in Ghana.

Negotiated order is a theory within symbolic interactionism that views social action as occurring through people’s negotiation with each other.^19–22 Negotiation is a ‘means of “getting things accomplished” when parties need to deal with each other to get those things done’.²⁰ In hybrids (ie, inter-organisational relations) such as clinician–LEO engagement, negotiation is a central tool for managing differences in mandates and roles among professionals involved in them.^{21 22} For instance, Strauss and colleagues¹⁹ showed how the hospital as an institution represents a negotiated order characterising the day-to-day interactions between physicians, nurses and patients. Negotiated order theory serves as a useful tool for understanding the role of collective action in tackling complex social problems in healthcare.^{23 24} Organisations involved in collective action can uncover deficiencies in the existing negotiated order, negotiate the terms of their engagement in future and define policies and procedures to mould their inter-organisational field.^{21 25} Our study presents an integrated analysis of the structural contexts (macro/supra-institutional boundaries and domains) and negotiation contexts (micro-level institutional contexts and dynamics) underlying clinician–LEO engagements in the ED of the Upper West Regional Hospital, a secondary-level hospital in Ghana.

Methods

Study setting and design

At the time of this research, the Upper West Regional Hospital had a 160-bed capacity. The hospital is an interesting case to study as it receives patients from other regions and neighbouring countries like Burkina Faso. This potentially increases the diversity of patients and cases in the hospital’s ED. The region covers approximately 18 478 square kilometres, constituting 12.7% of Ghana’s total land area. The region is bordered on the North and West by the Republic of Burkina Faso, on the East by the Upper East Region and on the South by the Northern Region.

We conducted a qualitative case study of clinician–LEO engagement in the ED, a design that aligns closely with negotiated order theory’s focus on understanding both structural contexts and negotiation processes in hybrid institutional settings.^{21 22} This study design best captures the complex, interpersonal and localised nature of these interactions in an in-depth manner while allowing us to examine diverse perspectives simultaneously.²⁶ Our design was informed by medico-legal research orientations that recognise the distinct epistemological traditions of medicine and law while seeking points of integration.²⁷ Medical research typically emphasises empirical evidence and clinical outcomes, while legal research often focuses on normative frameworks and procedural justice. Our qualitative case study design bridges these traditions by examining both the procedural aspects of clinician–police engagements and their impact on clinical care, enhancing our understanding of how legal frameworks operate in healthcare settings and their consequences for patient outcomes and system functioning.²⁸

Sample and sampling procedure

Emergency healthcare providers (clinicians) and LEOs (police officers) were eligible to participate in the study if they had direct experience engaging with each other during patients’ visits at the ED of the Upper West Regional Hospital. For clinicians, this included medical doctors and nurses actively working in the ED. For police officers, eligibility was limited to officers from the Criminal Investigation Department (CID) and the Motor Transport and Traffic Department (MTTD) of the Ghana Police Service, as the mandate of these units necessitates regular presence at the ED to escort patients, secure crime suspects and collect medical reports for legal purposes.

We used snowball sampling to recruit participants. We contacted the head of the ED and the regional commander of the Ghana Police Service for leads to the first potential participants in their respective units. We then invited the named potential participants to the study, and following their willingness to participate, we conducted our first interviews with them and requested them to recommend potential participants who had meaningful experience on the subject under investigation. All recommended participants were invited to participate through in-person contact, telephone call or WhatsApp text.

During recruitment, we moved back and forth between the two groups to generate alternative accounts on emerging data, make constant comparisons between accounts of each group and identify similarities and differences, ensuring that no particular group was inadvertently given a voice over the other. Sampling was guided by information power principles, emphasising data depth and diversity over predetermined participant numbers, with recruitment continuing until saturation was achieved.²⁹ We emphasised data depth and diversity over participant numbers, with sampling continuing until we achieved saturation. In all, 11 clinicians (7 nurses and 4 doctors) and 10 police officers (6 CID and 4 MTTD) were recruited for the study.

Data collection

We used a semi-structured interview guide developed by the research team (see online supplemental file 1), drawing on a review of the relevant literature on medico-legal concerns in emergency care settings, including confidentiality requirements, statutory reporting obligations, forensic evidence collection protocols and dual-loyalty conflicts.^{6 15 30} Questions were specifically selected to elicit participants’ decision-making processes in situations presenting competing legal and clinical imperatives. The interview guide was organised around four themes: participants’ professional backgrounds and prior experiences of inter-professional engagement; the processes and institutional dynamics of clinician–LEO interactions in the ED, including ethical and legal considerations and role conflicts; training and education for collaboration; and participants’ recommendations for improving engagement.

The guide was reviewed and discussed by the entire research team before and throughout data collection to ensure clarity, relevance and contextual appropriateness. Although the guide was not formally pilot tested with external participants, it was progressively refined in response to insights emerging from the data collection process, reflecting an iterative qualitative approach. We incorporated scenario-based questioning techniques adapted from legal case method approaches³¹ and medical ethical case analyses³² to elicit participants’ decision-making processes in situations presenting competing legal and clinical imperatives. This approach allowed us to explore how participants navigate complex situations, such as managing requests for patient information from the police or documenting forensic evidence, while prioritising patient care.³³

Two authors (GD and TMZ) and two trained research assistants, all of whom had prior experience conducting qualitative research and were familiar with the institutional context of the Upper West Regional Hospital, conducted 21 interviews (11 clinicians and 10 police officers) between April 2024 and February 2025. Interviews lasted between 45 and 60 min. Interviewers took field notes during and after each session to record context, non-verbal cues and reflections for use in analysis. Clinicians possessed varied levels of professional experience, ranging from 1 year to over a decade of practice. Nurses had transitioned from outpatient departments to emergency care, with some specialising in emergency nursing. All doctors interviewed had undergone housemanship before assuming medical officer roles in the ED. LEOs had extensive professional experience, ranging from 4 years to over two decades. Their experience in emergency care involved escorting patients, securing crime suspects and collecting medical reports for legal purposes.

Interviewers initially explored broad contexts and processes of the engagement, but subsequently focused on probing critical incidents and emerging themes from previous interviews. This approach provided rich information about nuanced situations and their underlying processes. Participants were interviewed at locations and times they considered convenient, creating an environment conducive to open discussion. Clinicians and police officers were interviewed simultaneously, allowing our participant selection to flow naturally from emerging themes. Interviews were audio-recorded with consent and later transcribed verbatim.

In addition to the interviews, we held a validation workshop in April 2025, providing a member-checking forum to assess the accuracy and relevance of preliminary findings. The workshop was attended by 18 participants, including clinicians (7), healthcare managers from the hospital and the regional health directorate (8) and police officers (3). The workshop lasted approximately 2 hours and 30 min and was facilitated by GD and TMZ and supported by a research assistant. Participants were presented with preliminary findings and themes emerging from the interviews and were invited to reflect on, critique, and validate the accuracy and relevance of the interpretations in relation to their professional experiences. Discussions were audio-recorded and transcribed verbatim. Key insights from the workshop were incorporated into the final analysis to strengthen the credibility and contextual relevance of the findings, serving as a forum that allowed us to assess whether the emerging themes resonated with participants’ lived experiences of clinician–LEO engagement in the ED.

Data analysis

Interview transcripts were uploaded into NVivo 12, coded by GD and analysed using both deductive and inductive strategies. GD developed an initial coding scheme, which was discussed with TMZ and GAA, and approved before all transcripts were coded. Deductively, we drew on Strauss’ negotiated order theory to frame two overarching themes: structural contexts (stable institutional and social conditions shaping interactions) and negotiation contexts (the immediate, micro-level processes through which these interactions are enacted).^19–21 Inductively, we applied Braun and Clarke’s³⁴ thematic analysis framework to identify specific categories and themes that emerged from the data reflecting these two domains. This iterative and dynamic process involved moving between theory, data and emerging insights. Regular discussions within the research team and a validation workshop helped to enhance analytical rigour, validate interpretations and ensure contextual relevance of the study. The findings are presented using carefully selected quotes that demonstrate the intricate dynamics of professional interactions within the structural and negotiation contexts of emergency healthcare. We reported our results following the Standard for Reporting Qualitative Research, specifically the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist (see online supplemental file 2), to ensure comprehensive and transparent reporting of the study.³⁵

Results

Table 1 presents a summary of the emergent themes underlying the structural and negotiation contexts of clinician–police engagement in the ED. In the subsequent subsections, we have described in detail the specific structural and negotiation contexts.

Table 1. Structural and negotiation contexts of clinician–police engagement.

Broad theme	Specific subthemes
Structural context
Organisational structure	Role boundaries
	Decision-making authority
The policy environment	Legal and ethical obligations
	Standard operating procedures
Cultural contexts	Societal norms around authority
	Behavioural characteristics
Negotiation context
Balancing autonomy and collaboration	Role adjustment
	Information sharing and exchange
	Dispute resolution
Establishing interprofessional trust and respect	Developing feedback mechanisms Leveraging informal social networking

Structural contexts

Organisational structure

Organisational structure, namely, the formally established roles, authority and coordination relationships within both the hospital and law enforcement agencies, presented structural effects on clinician–police engagements in emergency care. This includes formal lines of command, the allocation of roles and the authority to make decisions, which influence collaboration, communication and conflict resolution. Two sub-themes of organisational structure emerged: role boundaries and decision-making authority.

Role boundaries

On the one hand, participants acknowledged that formal role distinctions, where clinicians focused on stabilising and treating patients while police ensured security and legal oversight, provided a framework for engagement that minimised disputes. This clarity in role demarcation structured engagements, enabling both professional groups to work toward their respective mandates of patient care and public safety without unnecessary encroachment into each other’s domains.

I don’t think there are any conflicting roles. Everybody knows what they are supposed to do. […] We focus primarily on making sure the patient is alive and safe. The police officers also know what they can do or cannot do when they come here. (C008: ED Doctor)

We [police] go there basically for obvious public safety reasons, to enforce the law. The nurses and doctors are also looking at the safety of the patient. […] I personally haven't had a confrontation where a nurse wouldn't want me to do my work or would want to prevent me from assessing the patient. (L001: Police Officer, MTTD)

Strict adherence to institutional roles sometimes caused friction, especially in unpredictable ED cases that demanded flexibility. Rigid boundaries could hinder collaboration, limit situational awareness, and reduce responsiveness in time-sensitive emergencies.

A suspected robber was beaten by a gang and was rushed in by the police. But later, one officer confronted me, saying they needed him out of the ward quickly because the gang might follow up here to finish him off or even disrupt our care. […] At that moment, I was focused on stopping the bleeding and stabilising him, and I hadn’t even considered that risk. (C006: ED Nurse)

Decision-making authority

Hierarchical structures in both hospital and law enforcement agencies shaped engagement decisions. ED nurses lacked the authority to determine if a patient was fit for interrogation or discharge. These decisions were reserved for doctors, who had formal clinical judgement authority and were responsible for writing reports to the police. Delays in obtaining a doctor’s approval often frustrated LEOs, requiring timely medical reports for investigations.

Recently, a policeman came over to follow up on a patient when I was on duty. He asked how the patient was doing and whether the condition was improving […] and all that. So, whatever information he wanted and I could provide, I shared that with him. But if they need a written police report on the patient, we mostly direct them to the doctor. (C002: ED Nurse)

Decision-making between clinicians and police involved complex scenarios, creating tension when procedural constraints interfered with care provision, particularly regarding healthcare financing. Clinicians regularly demanded that police pay the medical expenses of accident victims when their relatives are not present, revealing structural challenges where medical and legal responsibilities intersect but misalign. This financial precondition thrust police into decision-making roles beyond their professional mandate.

As investigators, there is an experience that we are not comfortable about, that is, you can take an injured patient to the hospital and the nurses will demand that you pay some bills […] It is putting a lot of burden on us because sometimes, you can’t even trace the family of the patient for a refund of your money.’(L006: Police Officer, CID)

However, both clinicians and LEOs at the validation workshop concluded that while the research participant’s experience represents a valid account that should remain in the findings, it does not reflect the standard practice at the Upper West Regional Hospital, where patients at the ED receive immediate treatment regardless of payment status. Workshop participants agreed that any payment discussions occur only after stabilisation and treatment, not as a precondition for care provision.

The police operated within a strict command structure and were required to follow hierarchical lines of authority before making key decisions regarding their work with clinicians. This structure, while essential for maintaining order and accountability within law enforcement, added another layer of complexity to clinician–police engagements. Police officers had to obtain authorisation from their superiors before disclosing critical investigative details to clinicians.

We don’t always have the freedom to disclose certain information right away. Sometimes, even if I know something is relevant to the doctors, I have to wait for clearance from my superior before saying anything. (L002: MTTD Officer)

This hierarchical process slowed real-time coordination despite mutual recognition of urgent needs. Patient care and security outcomes were compromised by institutional constraints rather than an unwillingness to collaborate. Participants suggested establishing direct liaison roles between hospitals and law enforcement to streamline communication and expedite decision-making.

The policy environment

Participants referenced laws, regulations, ethical guidelines, and procedures that influenced collaboration between healthcare providers and law enforcement personnel. Two distinct sub-themes emerged: legal and ethical obligations and standard operating procedures.

Legal and ethical obligations

Legal requirements shaped clinician–police engagement frameworks. Police officers cited the Criminal Offences Act of 1960 (Act 29), mandating clinician cooperation in cases involving suspected violence, gunshot wounds or robbery. Healthcare providers were required to report incidents and disclose patient information to avoid obstructing justice.

Cases like assault and murder sometimes end up at the courts and the doctors themselves know that under the criminals code of Ghana, they have an obligation to give us all relevant information on such cases. If we ask them for the information and they don’t want to do it, the court may charge them for contempt. […] So, we have some authority [through the court] and we can use that authority to get the information. (L010: Police Officer, CID)

Although police have investigative interests, healthcare professionals prioritise patient welfare and confidentiality. This created tension when law enforcement restricted patient movement or care access without proper documentation, forcing clinicians to navigate between professional ethics, legal expectations and institutional policies.

There was a patient who came to the emergency ward and was later moved to the orthopaedic ward. Then, these police officers came around and told us that we shouldn’t discharge him until they [police] tell us to do so without any official document like a court order granting them the power to enforce such a directive. […] And as a citizen and a health practitioner, you have to consider the safety of the patient first because that is the primary obligation. (C005: ED Doctor)

Clinicians invoked confidentiality, patient autonomy and privacy as core ethical obligations; police referenced police conduct codes. Both acknowledged ethical dilemmas from a ‘dual loyalty fix’, simultaneous obligations to patients and the state. Clinicians faced tensions between law enforcement demands and patient care priorities, while police struggled to execute responsibilities while respecting medical ethics.

Sometimes when you get to the hospital, they don't feel that the case you brought is necessary, but to you, the investigator, you know, that it is a mandate you must execute. So I think it’s necessary that we do joint training to understand ourselves. (L003: Police Officer, MTTD)

Standard operating procedures

There were no standardised coordination mechanisms that governed how clinicians and police should interact in the ED. In particular, clinicians frequently expressed worry about the lack of a standardised procedure where LEOs must check in and out with a designated liaison, such as a senior clinician or administrator, to follow-up on patients reporting to the ED with injuries. According to healthcare providers, this procedural gap enabled unrestricted access to ED patients:

We want to care for the patients but they [police] don't give us space when they bring in patients. […] Our attention is to the clients first and there need to be some form of boundary when they bring in their patients. They should just allow us, give us the space and then we take care of the patients. So, I think we really need some policy to guide how we do things in the emergency ward. We have to define what everyone is supposed to do. (C002: ED Nurse)

In contrast, police observed that cases of mutual interest often presented immediate security risks requiring swift responses. From their perspective, strict entry protocols might create ‘unnecessary’ barriers undermining responsive law enforcement. Law enforcement participants suggested alternative approaches, including embedding clinician–police engagement in educational curricula and organising joint training programmes:

We are not saying hospitals should ignore their rules, but there should be a way of ensuring both law enforcement and patient care. Sometimes, we just need some information about the patient when it’s a sensitive case like a suspected robbery but they [clinicians] tell us to go and come back later when the person is okay. […] Maybe some joint workshop will give us the opportunity to discuss and agree on how to collaborate. (L008: Police Officer, CID)

During the validation workshop, participants debated the appropriate point of entry for police officers arriving at the ED, with some clinicians expecting officers to first report to the hospital’s administration before proceeding to the clinical area, while police officers preferred direct access to the patient. This highlights the need for clearer protocols governing the process of engagement.

Cultural contexts

Cultural contexts emerged as informal practices and personal characteristics shaping interaction dynamics between hospital and law enforcement professionals. Two sub-themes included societal norms around authority and behavioural characteristics of clinicians and police.

Societal norms around authority and community

Both groups acknowledged traditional leaders’ and religious/political figures’ significant authority. When these leaders were involved in ED injury cases, police or clinicians might defer to each other’s authority to maintain community harmony and respect local norms, particularly in high-stakes situations involving accidents or criminal suspects.

Some of the cases like road crashes are quite delicate, especially when politicians, chiefs and opinion leaders are involved. The engagement flows differently. When people like that are connected to the case, the dynamics become more complicated and everyone [clincians and police] tries to operate with caution. ((L002: Police Officer, MTTD)

‘Ti gyaa bonyeni’, meaning ‘we are all one people’ in the Waala dialect, reflects a strong communal culture in the study context. This norm fostered expectations of flexibility and preferential treatment, leading both clinicians and police to prioritise community demands over institutional procedures. Clinicians were pressured to withhold information or hasten discharges, while police were expected to show leniency or bypass formal processes for familiar individuals, complicating objective law enforcement in the ED.

It’s sometimes difficult to enforce the law here. You know this common saying that ‘ti gyaa bonyeni’? When you get there [the ED] and want to insist on due process, people feel you are not respecting the community culture or that kind of bond. They think you are being difficult. It’s quite difficult handling some of the cases because of these issues. (L010: Police Officer, CID)

These insights imply clinicians and police might prioritise patient care or public safety decisions out of respect for broader societal norms, even when these potentially conflict with their professional ethics.

Behavioural characteristics

Individual behavioural traits and accumulated experiences significantly shaped interaction patterns between clinicians and police. Both groups maintained a ‘memory bank’ of previous engagements that influenced their approach to current interactions. The findings demonstrate how clinician–police interactions can be shaped by individual temperament, professional socialisation, and accumulated experiences.

We’ve had instances where they [police] just walk into the ward demanding to see a patient without following any protocol. When you try to explain, they get upset. […] So now, when we see such officers, we know how to handle them. (C009: ED Doctor)

When you join the service, you hear from your seniors that some hospitals won't cooperate unless you push hard. So, when you go there, you already expect a certain reaction from them [clinicians]. (L010: Police Officer, CID)

Negotiation contexts

Balancing autonomy and collaboration

A key dynamic of the engagement between clinicians and police was the need to strike a balance between maintaining their independent professional mandates and working collaboratively in emergency care. Three key mechanisms were critical to this process.

Role adjustment

The urgency and complexity of ED cases often led to overlapping roles between clinicians and police, requiring ongoing role clarification. Participants saw police as key to maintaining safety in the ED, with responsibilities such as securing patients for questioning and protecting victims, staff and others during crime-related incidents.

So yesterday we had two suspected cases of robbery and the police officers were here. […] They did assure us that they were going to also deploy their men to run shifts with us; […] just as we are taking care of the clients, they will also be here to provide security and their interest was to protect us, our safety, the safety of the other patients and then that of the victims themselves. (C001: ED Nurse)

Clinicians and police frequently spoke about encountering situations where their institutional roles overlapped and required real-time negotiation to adjust institutionally defined roles. Police recognised that their presence in the ED sometimes meant deferring to clinicians’ authority.

We needed to interrogate a suspect, but the doctor insisted the patient wasn’t stable enough. We had to wait. It was frustrating, but we understood because at that moment, saving the patient’s life first was important. (L004: Police Officer, MTTD)

Role adjustment varied with the type of injury. For accident victims, immediate medical care took priority before police intervention. In suspected robbery cases, heightened security was needed, with active police presence sometimes required to protect staff, patients and the hospital environment.

For those who come as accident victims we concentrate on trying to stabilise them, then afterwards the police will come and also take their history or whatever, trying to find out what has led to the road traffic accident. In the case of suspected robberies, aside from managing their illness, we also want to provide some level of security for both the workers and the other patients around because we don't know the level of danger these people can pose to us and even other patients, some might be armed and all that. So usually we want the police to be around as we take care of them. (C001: ED Nurse)

This suggests that successful clinician–police engagements require flexibility in role execution, clear communication and a shared understanding of when to uphold or adjust institutional mandates to ensure both patient care and public safety.

Information sharing and exchange

Participants saw information exchange as the key to balancing autonomy and collaboration. Clinicians emphasised that withholding information aimed to protect patients does not hinder justice, revealing tensions between legal and ethical duties. The lack of clear policy guidelines made clinicians cautious when sharing patient information with police.

It’s not that we don’t want to cooperate, but we have to be sure we are not violating patient confidentiality requirements. Because there’s no clear guideline on what exactly we can share without breaching confidentiality, we try to be careful. (C011: ED Nurse)

While police officers required access to patient details for investigative purposes, clinicians were bound by ethical and legal obligations to protect patient confidentiality. Participants described a fluid process of determining when information could be shared and with whom.

Normally, when a suspect is conscious and can speak, we may push to get some information. But when they [clinicians] explain that the patient isn't in a good condition to talk, we have to step back and wait. We’re not fighting with them [clinicians]; it’s a matter of finding a middle ground. (L007: Police Officer, CID)

Dispute resolution

Both clinicians and police viewed dispute resolution in the ED as a negotiated process shaped by communication and mutual understanding. Clinicians explained medical constraints while assuring police of future access, and police adapted their approach to avoid conflict. In the absence of clear protocols, both relied on informal strategies to manage tensions and uphold their roles.

Sometimes a police officer will insist on questioning a dying patient, and I’ll say no. You [clinicians] need to have a conversation with them [police]. ‘Look, I understand your job, but right now, this patient is unconscious, so let me attend to him first. […] Most of the time, when you explain things calmly, they understand. (C008: ED Doctor)

Establishing interprofessional trust and respect

It could be observed that trust and respect were not static qualities but rather outcomes of ongoing negotiation processes that required consistent effort from both groups. We found two key mechanisms through which trust and respect were negotiated, including developing feedback mechanisms and leveraging informal social networks.

Developing feedback mechanisms

Views from participants on how they established interprofessional trust and respect revealed initiatives to develop feedback mechanisms for continuously improving negotiation practices and protocols. Both professional groups actively engaged in informal feedback processes to refine their interactions. This included discussions about past encounters, lessons learnt and adjustments needed for future engagements.

I remember there was a time they [police] came on account of an accident victim. After taking the victim’s motorbike to the police station, they were following up to see the patient. […] So, I casually just mentioned to them [police] that there are times we also invite them to come and then we do not get any response. They wanted to know who exactly we called and so on. […] They told me that there is a crime officer whom we should always contact in such cases. (C001: ED Nurse)

You know it’s a learning process. Initially, I didn’t know much about hospital procedures, so I would walk in and expect immediate attention from the nurses and doctors. But over time, I have learned to be patient because timing matters. […] So now, I assess the situation first before proceeding to engage with them [clinicians]. (L009: Police Officer, CID)

While these feedback mechanisms were largely informal, participants suggested that institutionalising discussions through periodic joint meetings or training sessions could further enhance interprofessional understanding. Participants of the validation workshop highlighted a recurring gap in follow-up on medico-legal cases, noting that police officers often leave the ED after bringing patients, making it difficult to complete documentation and file police reports, with many reports remaining incomplete due to missing contact information. This corroborated the interview findings on the absence of effective feedback mechanisms between clinicians and LEOs and underscores the need for formalised follow-up protocols to sustain trust and accountability across the two professional groups.

Leveraging informal social networking

Informal social ties, including shared cultural practices, played a key role in easing tensions and promoting cooperation. Participants highlighted the strategic use of inter-ethnic humour, especially between Frafra and Dagaaba professionals, as a tool to defuse tension and foster smoother clinician–police interactions.

[named doctor] and I always tease each other about who is the master and slave–Dagaaba or Frafra. So when I’m following up on an urgent [medical] report, I first joke with him: “My brother, don’t forget you owe your master some information” […] It makes the conversation lively, and usually, he gets back to me with the report as soon as he can. (L004, Police Officer, MTTD)

Social interactions outside the workplace, at events, churches, bars or sports venues, strengthened clinician–police relationships. These encounters built social capital and goodwill, which supported smoother negotiations during high-stakes emergencies.

You know, we [clinicians and police] are related in many ways and that helps sometimes. For example, [named police] and I first met one Sunday after church and just talked casually about normal things. Then, one day, he brought a motor accident patient to the ward for treatment. […] That connection at church made our interactions more natural and straightforward. (C006, ED Doctor)

I have personal relations with some of the doctors. And so if I go and they are not there, I even place a call on them and they will call their colleagues to attend to me. (L005: Police Officer, CID)

Discussion

This study explored the complex interplay between emergency care and law enforcement within a hospital setting in Ghana, revealing how clinicians and LEOs negotiate their professional mandates within shared spaces. Our findings highlight three structural contexts (organisational structure, policy environment and cultural contexts) and two negotiation contexts (balancing autonomy and collaboration and establishing interprofessional trust and respect) that shape these interactions.

Structural constraints and enablers

The foundation of clinician–police interactions rests on various structural elements that both constrain and enable their engagements. First, the ED represents an organisational hybrid, a space where multiple institutional logics, in this case, clinical care and law enforcement, must coexist and find alignment.^{36 37} Our findings reveal that this hybridity creates tension points but also opportunities for collaborative practice. When clinicians and police navigate cases involving road traffic injuries or interpersonal violence, they must simultaneously uphold their distinct professional identities while finding common ground to serve both patient care and public safety imperatives.

Second, the policy environment within which these interactions occur is characterised by significant gaps. The absence of standardised protocols for information sharing between clinicians and police creates ambiguity that necessitates case-by-case negotiation. This aligns with Tahouni et al’s⁸ observation that the lack of clear policies governing law enforcement presence in EDs can lead to inconsistent practices and potential conflicts. Additionally, the lack of a comprehensive legal framework governing health information privacy in Ghana, compared with high-income countries, further complicates these interactions.¹⁰

Third, cultural contexts emerged as both constraints and enablers in our study. The ‘Ti gyaa bonyeni’ (we are all one people) cultural norm creates expectations of flexibility that sometimes conflict with professional mandates. This finding resonates with Barley’s²⁵ concept of ‘coalface institutionalism’, where macro-level institutional structures are interpreted and enacted through local cultural practices. Similar cultural influences on professional interactions have been documented in other African healthcare settings,^{38 39} suggesting this may be a regional phenomenon that deserves greater attention in the negotiated order literature.

Fourth, power dynamics in the ED reflect what Nugus et al²³ described as ‘negotiated power’, where authority is not static but constantly (re)negotiated through interactions. When LEOs defer to clinicians’ authority regarding patient stability before questioning, they acknowledge the situational nature of power in the ED. This supports Strauss’²⁰ concept of ‘negotiation context’ as a key determinant of interaction outcomes and aligns with suggestions that power in healthcare settings is often conditional and context-dependent.^{23 40}

Negotiation mechanisms

Healthcare and law enforcement professionals in our study employed various strategies to navigate the inherent tensions in clinician–police engagements. Role boundary negotiations were particularly evident when managing cases involving road traffic injuries or interpersonal violence. Our findings show that clinicians and police were actively negotiating the limits of their respective authorities to maintain effective working relationships despite divergent institutional mandates. This aligns with widely acknowledged evidence that professional boundaries are not fixed but are constantly renegotiated through everyday practices.^{21 36}

The leveraging of informal social networks extends what Strauss conceptualised as a ‘negotiation context’ to include broader community connections. In the Ghanaian context, boundaries between professional and personal relationships were more permeable than typically described in Western literature,^{15 20} allowing for greater flexibility in negotiation approaches. This finding aligns with evidence on the prevalence of informal networks in Ghanaian healthcare delivery^{41 42} and suggests that negotiated order theory may need adaptation when applied to contexts where community ties significantly influence professional interactions. While this study is set in a Ghanaian secondary hospital, the informal negotiation dynamics described may resonate beyond the LMIC context. The Western literature documents similar reliance on interpersonal relationships over formal protocols in urban-focused clinician–LEO interactions,^{5 30} suggesting these mechanisms may transcend settings, including in under-resourced rural EDs in high-income countries.

The use of Frafra-Dagaaba inter-ethnic humour as a negotiation tool represents a uniquely Ghanaian approach to managing professional boundaries. This cultural practice served as a relational space where professionals could temporarily suspend formal hierarchies to facilitate cooperation.^{43 44} Similar culturally specific negotiation mechanisms have been documented in other African healthcare settings,^{38 39} highlighting the importance of cultural context in shaping interprofessional work like clinician–police engagements in the ED.

Clinicians in our study employed various strategies to navigate what Harada et al⁵ termed the ‘dual loyalty fix’, balancing competing obligations to patients and the state. This mirrors findings on ethical dilemmas in emergency medicine, particularly regarding confidentiality and reporting obligations.^{7 39} However, our findings suggest that in the Ghanaian context, these tensions can be effectively mediated through cultural mechanisms like inter-ethnic humour and social networking that may not be as prominent in Western settings. This supports assertions that cultural context significantly shapes how ethical dilemmas are perceived and managed in healthcare settings.^{11 30}

Implications for policy and practice

Our findings have several implications for improving clinician–police engagements in emergency care settings. First, the findings suggest that formal policies governing these interactions should acknowledge the inevitability of negotiation and provide frameworks that facilitate rather than restrict this process. As Strauss²⁰ observed, effective policies in hybrid organisations must allow for situational adaptation while maintaining core professional values. This aligns with arguments that healthcare policies should embrace rather than eliminate adaptability,^{40 45} recognising that rigid standardisation often fails in complex, dynamic environments.

Second, our study highlights the need for interprofessional education and joint training programmes that foster mutual understanding between clinicians and LEOs. Such initiatives could formalise the feedback mechanisms that our participants reported developing organically, creating structured opportunities for reflection and continuous improvement in collaborative practices. This recommendation echoes Crilly et al’s³⁰ findings on the benefits of interprofessional education in emergency care settings and discussions on collaborative practice in healthcare.^{23 24}

Thirdly, cultural competence should be a core component of both clinical and law enforcement training in Ghana. The cultural contexts that emerged as significant in our study, such as societal norms around authority and community expectations, shaped how professionals navigated their interactions. This aligns with arguments that cultural competence is essential for effective healthcare delivery and extends this principle to interprofessional interactions.^{40 46} By incorporating cultural dimensions into professional training, institutions can better prepare clinicians and LEOs to navigate the complex social terrain of emergency care.

Finally, while maintaining flexibility, the development of basic communication protocols could reduce ambiguity in information sharing while still allowing for context-specific adaptation. This approach aligns with what Faraj and Xiao⁴⁷ term ‘pragmatic coordination’, where formal structures provide a foundation for improvisation rather than rigid constraints. Similar balanced approaches have been advocated by Kaba et al⁴⁸ in their work on teamwork interventions in healthcare settings.

Limitations and future research directions

While our study provides valuable insights into clinician–police engagements in a Ghanaian ED, the study captured participants’ perceptions at a single point in time, potentially missing how these engagements evolved. Future research could employ longitudinal designs to better understand how negotiated orders develop and change in response to shifting structural contexts. Additionally, we were unable to obtain data on the ED’s annual patient census or the proportion of law enforcement-related presentations, which limits our ability to contextualise the frequency and volume of clinician–LEO interactions at the study site. Future studies should seek to collect such data to better characterise the scope of these interactions.

Additionally, our focus on clinicians and police excluded other stakeholders, such as patients and family members, who may influence these interactions. Future studies could adopt a more comprehensive approach that includes these perspectives to provide a more holistic understanding of emergency care as a negotiated space.

While our findings underscore the role of cultural contexts in clinician–police engagements, further research is needed to explore how these factors interact with institutional frameworks across settings. Comparative studies could reveal how local cultures shape the implementation of similar mandates. Future research might also refine the application of negotiated order theory to medico-legal interfaces by expanding theoretical frameworks to better capture the cultural dimensions of negotiation.

The primary coding was conducted by a single researcher, which may introduce subjectivity in the interpretation of findings. However, regular discussions and consensus building around emerging themes among all authors, member-checking through a validation workshop, and verbatim transcription were employed to enhance rigour.

Conclusion

This study contributes to our understanding of clinician–police engagements in emergency care settings by applying negotiated order theory to analyse both structural contexts and negotiation processes. Our findings reveal that these interactions are shaped by a complex interplay of organisational structures, policy environments and cultural contexts, which professionals navigate through ongoing negotiation of roles, information sharing and relationship building. The ED emerges as a hybrid space where clinical and law enforcement imperatives must be continuously balanced through negotiation. This negotiation is not merely a response to institutional constraints but a creative process through which professionals actively construct workable arrangements that serve both patient care and public safety goals. By highlighting the importance of cultural contexts and informal negotiation processes, our study extends existing applications of negotiated order theory in healthcare settings. It suggests that effective policy and practice in emergency care must acknowledge and leverage these cultural and interpersonal dynamics rather than attempting to eliminate negotiation through rigid standardisation.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.