Medical Sociology of Ward Bed Occupancy and Nurse Triage Discretion in Ugandan Referral Hospitals: A Multilevel Analysis of Crowding Exposure and Acuity Misclassification

Ward bed occupancy is treated in Ugandan referral hospitals as an administrative indicator of capacity, yet the sociological question is whether crowding changes how nurses exercise triage discretion and, if so, whether that discretion produces systematic acuity misclassification. Because no primary observational data are available, the paper specifies the design and operating characteristics of a before-after-control-impact (BACIP) evaluation capable of identifying the crowding–misclassification relationship under realistic clustering. Under a declared variance structure with between-cluster SD of 6.0, residual SD of 4.5 and intraclass correlation of 0.64, power was estimated across 2000 replications per design cell for cluster counts of 8, 16, 24 and 32 and effect sizes of 3, 5 and 8 percentage points. The design requires 54 clusters to detect a 5-percentage-point effect at 80% power. Acuity misclassification should be treated as a sociological outcome of organisational strain rather than as an individual nurse deficiency, and it specifies the boundary conditions under which the BACIP estimator can support that claim.