This critical ethnographic study applies a social ecological perspective using the concept of person-environment fit to illuminate how problems arise from conflict between needs and expectations.  Constant comparative analysis and coding techniques take account of hospital operations and the perspectives of hospital employees and older people together.  Data included hospital observations, and interviews with older adults (N=11) and hospital employees (N=14).  Procedures to ensure rigor included continuous reflexivity, participant selection, triangulating data sources, peer debriefing, multiple checks, and an audit trail. 

            Findings yielded four areas of poor fit: architectural features, bureaucratic conditions, chaotic atmosphere, and hospital employee attitude.  These environmental features act in independent and cumulative ways to produce a disempowering synergy that erodes independence and confidence; produces stress, worry, and anxiety; and enhances disabilities when functional impairments exist. Incongruent relationships emerge only when non-ideal older people enter the hospital's cultural space.  A lack of fit exists for those considered different either because of their personal functional attribute or because hospital employees judge them to be unsuitable or inappropriate for the unit or service.  Being different is key to lack of fit in the hospital environment and the construction of problems. 

            This study also contributes the groundwork for identifying indicators for older adult-hospital environment fit, and defining quality hospital service based on what older people need and expect compared with what the hospital provides and the demands it places on older people.  This research has the potential to set the stage for assessing hospitals and ensuring policies are better suited to the needs of older people.