Mediating hospital attendance: Invisible administrative work and structural vulnerability in outpatient care.

Non-attendance at outpatient appointments is commonly understood as a problem of patient behaviour. However, this perspective overlooks how organisational arrangements shape patients' opportunities to attend care. This study examines non-attendance as an organisationally mediated outcome, focusing on how administrative practices influence access to outpatient services. Using an institutional ethnographic approach, we conducted observations and interviews with medical secretaries in two outpatient surgical departments in Denmark and analysed relevant policy documents. The analysis was informed by the concepts of structural vulnerability and invisible work. Findings show that non-attendance emerged through the interaction of organisational conditions and patients' capacities to navigate them. Long waiting times, complex communication systems, and monolingual administrative infrastructures created barriers to attendance, particularly for patients facing linguistic, social, or practical challenges. Although both departments operated within the same regulatory framework, they differed in how these challenges were managed. One department relied on flexible, relational practices, whereas the other followed a more standardised and procedural approach, resulting in different forms of support, follow-up, and discharge. Medical secretaries played a central mediating role by coordinating communication, compensating for infrastructural gaps, and adapting organisational routines to patients' circumstances. The study demonstrates that non-attendance is not solely the result of individual behaviour but is shaped by how healthcare systems organise the conditions for participation. Efforts to reduce non-attendance should therefore address organisational and communicative barriers.