Organisational priorities for health care focus on efficiency as the health and care needs of populations increase. But evidence suggests that excessive planning can be counterproductive, leading to resistance from staff and patients, particularly those living with cognitive impairment. The current paper adds to this debate reporting an Institutional Ethnography of staff delivering care for older patients with cognitive impairment on acute orthopaedic wards in three National Health Service hospitals in the United Kingdom. A key problematic identified in this study is the point of disjuncture seen between the actualities of staff experience and intentions of protocols and policies. We identified three forms of disjuncture typified as: ‘disruptions’, where sequenced care was interrupted by patient events; ‘discontinuities’, where divisions in professional culture, space or time interrupted sequenced tasks; and ‘dispersions’, where displaced objects or people interrupted sequenced care flow. Arguably disruption is an integral characteristic of care work; it follows that to enable staff to flourish, organisations need to confer staff the autonomy to address systemic disruptions rather than attempt to eradicate them. Ultimately, organisational representations of ‘good practice’ as readily joined up, impose a care standard ‘stereotype’ that obscures rather than clarifies the interactional problems encountered by staff.

The growing influence of transnational process, institutions and policy communities has contributed to the emergence of a global public policy that is distinct (although not separate) from the national process of policy-making. In this context gender equality and gender mainstreaming have become dominant policy and political narratives for addressing gender injustice. The focus of this paper is on developing the conceptual and theoretical links between global policy paradigms and gender equality and incorporating multi-scalarity, translation and disjuncture into our understanding of the ways in which policies are made, processed and enacted. The discussion begins by extending Hall's concept of policy paradigm as a nationally bounded entity and highlighting the transnational processes and institutions contributing to the emergence of a global policy paradigm and global policy space. It then goes on to highlight the fluidity of policy paradigms and the importance of moving beyond the focus on techno-managerial “order” as the essence of the policy paradigm and indicators of change and instead to bring into sharper focus disjuncture and tensions.