- Email: [email protected]
Being a non-urgent patient in an emergency care unit—a strive to maintain personal integrity
Accident and Emergency Nursing (2003) 11, 22–26 ª 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0965-2302(02)00135-2
Being a non-urgent patient in an emergency care unit—a strive to maintain personal integrity Maria Nystro¨m, Kristoffer Nyde´n, Martin Petersson
The aim of this study was to analyse and describe experiences of being a non-urgent patient in an ECU (emergency care unit). Eleven non-urgent patients were interviewed. The research approach was inductive and interpretative. Seven tentative interpretations and an interpreted whole, i.e., an existential interpretation, revealed that the informants tried to be ‘good’ patients by not demanding much attention from nursing personnel, in an attempt to maintain good relations with the nurses in order to be assured of a positive reception. As health related problems jeopardise personal integrity, patients cannot afford the risk of being looked upon as inappropriate clients in the ECU. ª 2003 Elsevier Science Ltd. All rights reserved.
Maria Nystro¨m RN, PhD Kristoffer Nyde´n RN, BSc Martin Petersson RN, BSc, School of Health Sciences, Bor as University College, Gothenburg, Sweden Correspondence to: Maria Nystro¨m RN, PhD, School of Health Sciences, Bor as University College, Sunnerviksgatan 14, 418 72 Gothenburg, Sweden Manuscript received: 2 April 2002; accepted: 4 June 2002
22
The assessment of patient satisfaction is a part of any quality improvement activity in an ECU (emergency care unit). The interaction between care-provider and patient is described as the core of nursing care (see for example Altschul 1971; Peplau 1991; Travelbee 1971). As a consequence, the interpersonal dimension of the interaction between care-provider and patient is most important in determining overall patient satisfaction (Raper 1996). Surveys have shown that a majority of patients are satisfied with the level of care in ECUs (see for example Bruce et al. 1998). However, according to Rhee and Bird (1996), it is evident from the literature that consumers generally tend to give overall positive ratings of satisfaction regarding healthcare. The fact is that not every non-urgent patient has reasons to be satisfied, as emergency staff tend to gravitate towards clients with urgent physical needs (Crowley 2000). Lewis and Woodside (1992)
Accident and Emergency Nursing (2 0 0 3 ) 11, 22–26
conclude that there is a tendency for ECU staff to concentrate on technical competence rather than on psychosocial care. Additionally, little attention is paid in ECUs to the special needs of elderly persons (Watson et al. 1999). Sanders (1992) states that emergency healthcare professionals feel less comfortable when caring for elderly patients with non-urgent health-related problems. Hence, it is fair to assume that non-urgent patients do not always get appropriate attention and adequate nursing care. The aim of this study was thus to analyse and describe experiences of being a non-urgent patient in an ECU.
Method Data collection Interviews were conducted with eleven persons, six women, and five men, aged
ª 2003 Elsevier Science Ltd. All rights reserved.
Being a non-urgent patient in an emergency care unit
between 52–88 years, each with several experiences of being non-urgent patients in various ECUs. The purpose was to obtain in-depth information about their perceptions of the nursing care provided. The principles of an open life-world approach (Dahlberg et al. 2001) were followed, and the interviews were aimed at understanding the meaning of everyday life experiences. This approach is characterised by openness and pliability to the research phenomenon on the part of the researcher, in order to give a valid picture of human experiences. The one-to-one interviews, lasting one hour, were audio taped and transcribed verbatim. Analysis An inductive interpretative approach, i.e., no predetermined hypotheses, was used in order to identify the meanings and patterns that emerged in the data. The first step began with an open reading, the purpose of which was to get a sense of the whole. Then tentative interpretations were constructed, which illuminated underlying intentions in the statements of the informants. The open reading was complemented by a critical reading in order to make explanatory interpretations (Ricoeur 1976). The relevance of the tentative interpretations was estimated by using some criteria of quality (Dahlberg et al. 2001). Consequently, valid interpretations should be consistent. Interpretations of parts were compared with interpretations of the whole. The researchers repeatedly went back and forth between the parts and the whole in order to determine if there were any discrepancies between the understanding of the parts in relation to the emerging interpretations. In the second step, all tentative interpretations found to be valid were compared with each other in order to understand the existential situation of being a non-urgent patient in an ECU. In this comprehensive interpretation phase, the abovementioned criteria of quality were also used. Ethical considerations The ethics committee approved the study. Information about the study was given, and all participants were assured confidentiality.
ª 2003 Elsevier Science Ltd. All rights reserved.
The analysis was conducted with the intention of maintaining the integrity of all persons who took part in the study.
The first step: tentative interpretations The non-urgent patients’ situation is fragmented The nurse’s routine work in an ECU has similarities with the conveyor belt in industrial work. One nurse is responsible for triage, another performs blood tests, a third checks temperature, and so on. The patients puzzle together their fragmented impressions in order to try to make sense of the situation. Sometimes I am puzzled when I am lying on a trolley in the corridor. The same nurses are running back and forth with papers in their hands. I don’t know if it is the same paper or not, I have never enquired. But I have been wondering a lot why they rarely speak to me. They never tell me what they are going to do to me. I know nothing.
It is difficult for non-urgent patients to make themselves seen or heard When a large amount of work has to be done, nursing personnel have little time left to care for non-urgent patients. Hence, non-urgent patients, who do not clearly express their essential needs, are left alone to wait for hours before being seen by a physician. It is horrible to be left in a waiting room and no one bothers to come and check on you. They seem to think that there is nothing wrong with me. They seem to think that I am just coming to the ECU for no reason. I have heard them say as much.
Non-urgent patients take part in nurses’ problems The informants related that nurses often explain that they are short of time and under-staffed. They said that the nursing personnel have a stressful work situation with many patients to take care of. The nurses’ stressful work situation seems to negatively affect the patients’ expectations of nursing care, leaving non-urgent patients with a feeling of exerting more pressure on the nurses.
Accident and Emergency Nursing (2 0 0 3 ) 11, 22–26 23
Being a non-urgent patient in an emergency care unit
Every time I talk to the nurses they always mention the fact that they are under-staffed. It is a constant problem.
Non-urgent patients feel unable to express their needs in the light of the nurses’ stressful work situation All informants reported that at times they are dissatisfied due to inadequate nursing care. However, in the next sentence, they try to find excuses for the lack of caring they described a moment ago. It would appear that the informants are suddenly ashamed at having voiced their complaints. The nurses have many patients to take care of, they say, and perhaps other patients are in greater need of attention than they are. It thus seems fair to assume that the patients are unable to express their needs once they become aware of the shortage of personnel and the high amount of caring work required in the ECU. I don’t think it’s fair to complain about the nursing personnel. I simply can’t do it, but the waiting is horrible.
The possibility of getting attention in spite of non-urgent problems varies, depending on the nurses on duty According to the informants, some nurses appear to find caring less stimulating than medical tasks. While sitting in the waiting room, the patients notice that waiting for prescriptions from physicians takes up much of the nurses’ time. Some nurses spend this time finding out more about patients’ needs, but most nurses do not. Hence, the quality of nursing care is a matter of personal as opposed to collective caring competence. Patients are thus dependent upon which nurses are on duty when they attend an ECU. In spite of a severe headache, I took a shower before I went to the ECU. I know that some nurses can be very critical if the patients are not clean enough.
A next of kin has the function of a nurse when a non-urgent patient is waiting for a medical examination As the informants had attended an ECU on several occasions, they were well aware of the necessity of bringing a next of kin. Otherwise
24
Accident and Emergency Nursing (2 0 0 3 ) 11, 22–26
they would have to spend many hours of waiting alone. When, for example, the patient is left in a room to wait for a medical examination, it is of vital importance that the next of kin can go and look for a nurse after several hours have passed without any attention from nurses or physicians. Additionally, the next of kin is also forced by the system to take on the task of monitoring the patients’ medical condition. Being left in a room makes me feel lonely. If you don’t bring a next of kin it is much worse to be kept waiting in a room than in the corridor. People are running around in the corridor and you can always call for a nurse if you want to ask about something. If my wife doesn’t accompany me to the ECU, I just lie there, gazing at the ceiling.
Despite everything, being in hospital gives a sense of security Patients’ perceptions of the urgency of their medical problems make them visit an ECU. When the informants are afraid, it is of vital importance for them to be able to trust the medical competence of all care-givers in the ECU. When a nurse ‘‘triages’’ them as non-urgent, putting them in a room to wait on their own for the physician, they simply have to trust the nurse’s judgement. Otherwise fear will take over. I just want to say that I feel secure after having arrived at the ECU. I know that I will get help. If they can’t do it, no one can.
The second step: the existential situation of non-urgent patients A comparison of the tentative interpretations identified three strategies, all of which appear to meet the purpose of maintaining personal dignity in spite of being a lowly prioritised patient in an ECU. Maintaining personal integrity by keeping critical reflections to oneself All informants were, at least to some extent, critical when talking about their experiences of being a non-urgent patient. They had a feeling of detachment and experienced themselves being considered as an object by the nurses and not as an individual.
ª 2003 Elsevier Science Ltd. All rights reserved.
Being a non-urgent patient in an emergency care unit
They could explain a bit more. Even if you are sick it is important to be able to understand what is going on. I brought a physician’s letter of referral, because I didn’t want to look silly if there was no cerebral haemorrhage.
The informants did not, however, broach the matter with the nursing personnel. The expressions of disappointment about negligent personnel were only discussed with the next of kin and in the research interview. By being clear about not receiving the level of care to which they are entitled, yet avoiding directly confronting the nurses with their dissatisfaction, the non-urgent patients appeared to strike a balance in order to protect their personal integrity. They knew that they had the right to attend the ECU but avoided the risk of making themselves unpopular by complaining about the lack of care. Maintaining personal integrity by directing one’s dissatisfaction elsewhere The informants did not only avoid directly confronting the nurses with their dissatisfaction. They also tried to find other expedients to express their feelings. The easiest way out was to put the blame on persons whom they did not meet, for example managers and politicians. I blame our politicians, because they do not pay nurses and doctors enough. Instead politicians travel quite a lot and spend a great deal of money. The patients are the ones who suffer the consequences. The newspapers have made me aware of the shortage of personnel in the ECU. You can’t expect the nurses to care for the patients under such circumstances.
Hence, the informants directed their criticism away from the nurses, who were dashing around without taking any notice of them, instead blaming organisations and persons with whom they had no personal contact. By so doing they probably sub-consciously tried to increase the possibility of having good relations with the nurses and being treated in a friendly manner by them. It is presumably easier to maintain one’s personal integrity during the long hours of waiting in the ECU under such circumstances.
ª 2003 Elsevier Science Ltd. All rights reserved.
Maintaining one’s personal integrity by being a ‘good’ patient The informants were also anxious to emphasise that they were not in the habit of complaining. They claimed to be well aware of the fact that other patients were in much greater need of the nurse’s attention. If other patients need more help, of course I stand aside. If someone has heart trouble he must be taken care of before me. I’m sure that I would receive the same attention if I suffered from heart disease. I wish it was possible to give me more attention. But I am not the only patient in this ECU. If you think about it, it makes sense.
Being a good patient is the third strategy used by patients in order to maintain their personal integrity. In fact, all informants expressed their dissatisfaction and, at the same time, their ambitions to maintain good relations with the nurses. A vital part of this strategy seems to be not to challenge the nurses’ self-esteem.
Discussion and conclusions Emergency nursing appears to be a mere extension of medicine and, as a consequence, the goals of medical tasks are much clearer than those of nursing care. Another consequence is that nursing personnel waste a great deal of their time waiting for prescriptions from physicians. It is hard for non-urgent patients who are left on their own, waiting for hours, to understand why nurses just stand there instead of talking to them. Under such circumstances, patients will regard nursing personnel as mere physicians’ assistants. If nursing personnel place a low value on nursing care, the patients will do likewise. However, the consequences revealed in this study are more serious than that. Patients with non-urgent medical problems seem to be forced into situations in which they have to strive to maintain their personal integrity by relinquishing the possibility to take an active part in their own health process. Health-related problems jeopardise personal integrity. Hence, patients cannot afford the risk of further humiliation by being unkindly treated and devalued by professional care-givers. Under such circumstances, and as
Accident and Emergency Nursing (2 0 0 3 ) 11, 22–26 25
Being a non-urgent patient in an emergency care unit
an unconscious strategy for the purpose of maintaining personal integrity, patients become dishonest with themselves and abandon all efforts to take an active part in their own health process. Accordingly, patients ignore their feelings of being neglected. They keep their criticism to themselves and try to direct their dissatisfaction elsewhere, in order to be ÔgoodÕ patients. In order to analyse the interaction between patient and care-provider in medical settings, Mishler (1984) has provided a suggestive metaphor, the concept of voice. According to Mishler, there are two voices in health and medical care; the ‘‘voice of medicine’’, representing the technical–scientific assumptions of medicine, and the ‘‘voice of the lifeworld’’, representing the natural attitude of everyday life. According to this metaphor, non-urgent patients in ECUs appear to suppress the ‘‘voice of the lifeworld’’ in order to adapt themselves to the ‘‘voice of medicine’’. As a consequence, they try very hard to understand why other patients must be taken care of immediately while they themselves have to wait. Only by adapting to the ‘‘voice of medicine’’ is it possible to suppress the ‘‘voice of the lifeworld’’ and accept the lack of caring in respect of personal needs. But, just like other people, non-urgent patients are self-reflecting and seeking to connect with others. In spite of only brief encounters with patients, nursing personnel in ECUs have a range of available possibilities to help non-urgent patients to speak with the ‘‘voice of the lifeworld’’. Furthermore, it is necessary to clearly define nursing care in acute and emergency settings. According to Peplau (1991), each care-provider can take responsibility for expanding his or her own
26
Accident and Emergency Nursing (2 0 0 3 ) 11, 22–26
insight into professional functioning. Hence, education that aims at developing ECU nursing competence must deal with the importance of being present for and attentive to the patient, irrespective of whether his/her health-related problems are urgent or not. References Altschul A 1971 Nurse–Patient Interaction. Churchill Livingstone, Edinburgh Bruce TA, Bowman JM, Brown ST 1998 Factors that influence patient satisfaction in the emergency department. Journal of Nursing Care Quality 13(2): 31–37 Crowley J 2000 Psycho-social a clash of cultures: A&E and mental health. Accident and Emergency Nursing 8(1): 2–8 Dahlberg K, Drew N, Nystr€ om M 2001 Reflective Life-world Research. Studentlitteratur, Lund Lewis KE, Woodside RE 1992 Patient satisfaction with care in the emergency department. Journal of Advanced Nursing 17: 959–964 Mishler EG 1984 The Discourse of Medicine. Dialectics of Medical Interviews. Ablex, Norwood, NJ Peplau H 1991 Interpersonal Relations in Nursing. Macmillan Education Ltd., London Raper JL 1996 A cognitive approach to patient satisfaction with emergency department in nursing care. Journal of Nursing Care Quality 10(4): 48–58 Rhee KJ, Bird J 1996 Perceptions and satisfaction with emergency department care. Journal of Emergency Nursing 14: 48–58 Ricoeur P 1976 Interpretation Theory. Discourse and the Surplus of Meaning. Texas Christian University Press, Fort Worth Sanders AB 1992 Care of the elderly in emergency departments: conclusions and recommendations 21(7): 830–834 Travelbee J 1971 Interpersonal Aspects of Nursing. F.A. Davis Company, Philadelphia, PA Watson WT, Marshall ES, Fosbinder D 1999 Elderly patients’ perceptions of care in emergency department. Journal of Emergency Nursing 25(2): 88–91
ª 2003 Elsevier Science Ltd. All rights reserved.
Being a non-urgent patient in an emergency care unit—a strive to maintain personal integrity Maria Nystro¨m, Kristoffer Nyde´n, Martin Petersson
The aim of this study was to analyse and describe experiences of being a non-urgent patient in an ECU (emergency care unit). Eleven non-urgent patients were interviewed. The research approach was inductive and interpretative. Seven tentative interpretations and an interpreted whole, i.e., an existential interpretation, revealed that the informants tried to be ‘good’ patients by not demanding much attention from nursing personnel, in an attempt to maintain good relations with the nurses in order to be assured of a positive reception. As health related problems jeopardise personal integrity, patients cannot afford the risk of being looked upon as inappropriate clients in the ECU. ª 2003 Elsevier Science Ltd. All rights reserved.
Maria Nystro¨m RN, PhD Kristoffer Nyde´n RN, BSc Martin Petersson RN, BSc, School of Health Sciences, Bor as University College, Gothenburg, Sweden Correspondence to: Maria Nystro¨m RN, PhD, School of Health Sciences, Bor as University College, Sunnerviksgatan 14, 418 72 Gothenburg, Sweden Manuscript received: 2 April 2002; accepted: 4 June 2002
22
The assessment of patient satisfaction is a part of any quality improvement activity in an ECU (emergency care unit). The interaction between care-provider and patient is described as the core of nursing care (see for example Altschul 1971; Peplau 1991; Travelbee 1971). As a consequence, the interpersonal dimension of the interaction between care-provider and patient is most important in determining overall patient satisfaction (Raper 1996). Surveys have shown that a majority of patients are satisfied with the level of care in ECUs (see for example Bruce et al. 1998). However, according to Rhee and Bird (1996), it is evident from the literature that consumers generally tend to give overall positive ratings of satisfaction regarding healthcare. The fact is that not every non-urgent patient has reasons to be satisfied, as emergency staff tend to gravitate towards clients with urgent physical needs (Crowley 2000). Lewis and Woodside (1992)
Accident and Emergency Nursing (2 0 0 3 ) 11, 22–26
conclude that there is a tendency for ECU staff to concentrate on technical competence rather than on psychosocial care. Additionally, little attention is paid in ECUs to the special needs of elderly persons (Watson et al. 1999). Sanders (1992) states that emergency healthcare professionals feel less comfortable when caring for elderly patients with non-urgent health-related problems. Hence, it is fair to assume that non-urgent patients do not always get appropriate attention and adequate nursing care. The aim of this study was thus to analyse and describe experiences of being a non-urgent patient in an ECU.
Method Data collection Interviews were conducted with eleven persons, six women, and five men, aged
ª 2003 Elsevier Science Ltd. All rights reserved.
Being a non-urgent patient in an emergency care unit
between 52–88 years, each with several experiences of being non-urgent patients in various ECUs. The purpose was to obtain in-depth information about their perceptions of the nursing care provided. The principles of an open life-world approach (Dahlberg et al. 2001) were followed, and the interviews were aimed at understanding the meaning of everyday life experiences. This approach is characterised by openness and pliability to the research phenomenon on the part of the researcher, in order to give a valid picture of human experiences. The one-to-one interviews, lasting one hour, were audio taped and transcribed verbatim. Analysis An inductive interpretative approach, i.e., no predetermined hypotheses, was used in order to identify the meanings and patterns that emerged in the data. The first step began with an open reading, the purpose of which was to get a sense of the whole. Then tentative interpretations were constructed, which illuminated underlying intentions in the statements of the informants. The open reading was complemented by a critical reading in order to make explanatory interpretations (Ricoeur 1976). The relevance of the tentative interpretations was estimated by using some criteria of quality (Dahlberg et al. 2001). Consequently, valid interpretations should be consistent. Interpretations of parts were compared with interpretations of the whole. The researchers repeatedly went back and forth between the parts and the whole in order to determine if there were any discrepancies between the understanding of the parts in relation to the emerging interpretations. In the second step, all tentative interpretations found to be valid were compared with each other in order to understand the existential situation of being a non-urgent patient in an ECU. In this comprehensive interpretation phase, the abovementioned criteria of quality were also used. Ethical considerations The ethics committee approved the study. Information about the study was given, and all participants were assured confidentiality.
ª 2003 Elsevier Science Ltd. All rights reserved.
The analysis was conducted with the intention of maintaining the integrity of all persons who took part in the study.
The first step: tentative interpretations The non-urgent patients’ situation is fragmented The nurse’s routine work in an ECU has similarities with the conveyor belt in industrial work. One nurse is responsible for triage, another performs blood tests, a third checks temperature, and so on. The patients puzzle together their fragmented impressions in order to try to make sense of the situation. Sometimes I am puzzled when I am lying on a trolley in the corridor. The same nurses are running back and forth with papers in their hands. I don’t know if it is the same paper or not, I have never enquired. But I have been wondering a lot why they rarely speak to me. They never tell me what they are going to do to me. I know nothing.
It is difficult for non-urgent patients to make themselves seen or heard When a large amount of work has to be done, nursing personnel have little time left to care for non-urgent patients. Hence, non-urgent patients, who do not clearly express their essential needs, are left alone to wait for hours before being seen by a physician. It is horrible to be left in a waiting room and no one bothers to come and check on you. They seem to think that there is nothing wrong with me. They seem to think that I am just coming to the ECU for no reason. I have heard them say as much.
Non-urgent patients take part in nurses’ problems The informants related that nurses often explain that they are short of time and under-staffed. They said that the nursing personnel have a stressful work situation with many patients to take care of. The nurses’ stressful work situation seems to negatively affect the patients’ expectations of nursing care, leaving non-urgent patients with a feeling of exerting more pressure on the nurses.
Accident and Emergency Nursing (2 0 0 3 ) 11, 22–26 23
Being a non-urgent patient in an emergency care unit
Every time I talk to the nurses they always mention the fact that they are under-staffed. It is a constant problem.
Non-urgent patients feel unable to express their needs in the light of the nurses’ stressful work situation All informants reported that at times they are dissatisfied due to inadequate nursing care. However, in the next sentence, they try to find excuses for the lack of caring they described a moment ago. It would appear that the informants are suddenly ashamed at having voiced their complaints. The nurses have many patients to take care of, they say, and perhaps other patients are in greater need of attention than they are. It thus seems fair to assume that the patients are unable to express their needs once they become aware of the shortage of personnel and the high amount of caring work required in the ECU. I don’t think it’s fair to complain about the nursing personnel. I simply can’t do it, but the waiting is horrible.
The possibility of getting attention in spite of non-urgent problems varies, depending on the nurses on duty According to the informants, some nurses appear to find caring less stimulating than medical tasks. While sitting in the waiting room, the patients notice that waiting for prescriptions from physicians takes up much of the nurses’ time. Some nurses spend this time finding out more about patients’ needs, but most nurses do not. Hence, the quality of nursing care is a matter of personal as opposed to collective caring competence. Patients are thus dependent upon which nurses are on duty when they attend an ECU. In spite of a severe headache, I took a shower before I went to the ECU. I know that some nurses can be very critical if the patients are not clean enough.
A next of kin has the function of a nurse when a non-urgent patient is waiting for a medical examination As the informants had attended an ECU on several occasions, they were well aware of the necessity of bringing a next of kin. Otherwise
24
Accident and Emergency Nursing (2 0 0 3 ) 11, 22–26
they would have to spend many hours of waiting alone. When, for example, the patient is left in a room to wait for a medical examination, it is of vital importance that the next of kin can go and look for a nurse after several hours have passed without any attention from nurses or physicians. Additionally, the next of kin is also forced by the system to take on the task of monitoring the patients’ medical condition. Being left in a room makes me feel lonely. If you don’t bring a next of kin it is much worse to be kept waiting in a room than in the corridor. People are running around in the corridor and you can always call for a nurse if you want to ask about something. If my wife doesn’t accompany me to the ECU, I just lie there, gazing at the ceiling.
Despite everything, being in hospital gives a sense of security Patients’ perceptions of the urgency of their medical problems make them visit an ECU. When the informants are afraid, it is of vital importance for them to be able to trust the medical competence of all care-givers in the ECU. When a nurse ‘‘triages’’ them as non-urgent, putting them in a room to wait on their own for the physician, they simply have to trust the nurse’s judgement. Otherwise fear will take over. I just want to say that I feel secure after having arrived at the ECU. I know that I will get help. If they can’t do it, no one can.
The second step: the existential situation of non-urgent patients A comparison of the tentative interpretations identified three strategies, all of which appear to meet the purpose of maintaining personal dignity in spite of being a lowly prioritised patient in an ECU. Maintaining personal integrity by keeping critical reflections to oneself All informants were, at least to some extent, critical when talking about their experiences of being a non-urgent patient. They had a feeling of detachment and experienced themselves being considered as an object by the nurses and not as an individual.
ª 2003 Elsevier Science Ltd. All rights reserved.
Being a non-urgent patient in an emergency care unit
They could explain a bit more. Even if you are sick it is important to be able to understand what is going on. I brought a physician’s letter of referral, because I didn’t want to look silly if there was no cerebral haemorrhage.
The informants did not, however, broach the matter with the nursing personnel. The expressions of disappointment about negligent personnel were only discussed with the next of kin and in the research interview. By being clear about not receiving the level of care to which they are entitled, yet avoiding directly confronting the nurses with their dissatisfaction, the non-urgent patients appeared to strike a balance in order to protect their personal integrity. They knew that they had the right to attend the ECU but avoided the risk of making themselves unpopular by complaining about the lack of care. Maintaining personal integrity by directing one’s dissatisfaction elsewhere The informants did not only avoid directly confronting the nurses with their dissatisfaction. They also tried to find other expedients to express their feelings. The easiest way out was to put the blame on persons whom they did not meet, for example managers and politicians. I blame our politicians, because they do not pay nurses and doctors enough. Instead politicians travel quite a lot and spend a great deal of money. The patients are the ones who suffer the consequences. The newspapers have made me aware of the shortage of personnel in the ECU. You can’t expect the nurses to care for the patients under such circumstances.
Hence, the informants directed their criticism away from the nurses, who were dashing around without taking any notice of them, instead blaming organisations and persons with whom they had no personal contact. By so doing they probably sub-consciously tried to increase the possibility of having good relations with the nurses and being treated in a friendly manner by them. It is presumably easier to maintain one’s personal integrity during the long hours of waiting in the ECU under such circumstances.
ª 2003 Elsevier Science Ltd. All rights reserved.
Maintaining one’s personal integrity by being a ‘good’ patient The informants were also anxious to emphasise that they were not in the habit of complaining. They claimed to be well aware of the fact that other patients were in much greater need of the nurse’s attention. If other patients need more help, of course I stand aside. If someone has heart trouble he must be taken care of before me. I’m sure that I would receive the same attention if I suffered from heart disease. I wish it was possible to give me more attention. But I am not the only patient in this ECU. If you think about it, it makes sense.
Being a good patient is the third strategy used by patients in order to maintain their personal integrity. In fact, all informants expressed their dissatisfaction and, at the same time, their ambitions to maintain good relations with the nurses. A vital part of this strategy seems to be not to challenge the nurses’ self-esteem.
Discussion and conclusions Emergency nursing appears to be a mere extension of medicine and, as a consequence, the goals of medical tasks are much clearer than those of nursing care. Another consequence is that nursing personnel waste a great deal of their time waiting for prescriptions from physicians. It is hard for non-urgent patients who are left on their own, waiting for hours, to understand why nurses just stand there instead of talking to them. Under such circumstances, patients will regard nursing personnel as mere physicians’ assistants. If nursing personnel place a low value on nursing care, the patients will do likewise. However, the consequences revealed in this study are more serious than that. Patients with non-urgent medical problems seem to be forced into situations in which they have to strive to maintain their personal integrity by relinquishing the possibility to take an active part in their own health process. Health-related problems jeopardise personal integrity. Hence, patients cannot afford the risk of further humiliation by being unkindly treated and devalued by professional care-givers. Under such circumstances, and as
Accident and Emergency Nursing (2 0 0 3 ) 11, 22–26 25
Being a non-urgent patient in an emergency care unit
an unconscious strategy for the purpose of maintaining personal integrity, patients become dishonest with themselves and abandon all efforts to take an active part in their own health process. Accordingly, patients ignore their feelings of being neglected. They keep their criticism to themselves and try to direct their dissatisfaction elsewhere, in order to be ÔgoodÕ patients. In order to analyse the interaction between patient and care-provider in medical settings, Mishler (1984) has provided a suggestive metaphor, the concept of voice. According to Mishler, there are two voices in health and medical care; the ‘‘voice of medicine’’, representing the technical–scientific assumptions of medicine, and the ‘‘voice of the lifeworld’’, representing the natural attitude of everyday life. According to this metaphor, non-urgent patients in ECUs appear to suppress the ‘‘voice of the lifeworld’’ in order to adapt themselves to the ‘‘voice of medicine’’. As a consequence, they try very hard to understand why other patients must be taken care of immediately while they themselves have to wait. Only by adapting to the ‘‘voice of medicine’’ is it possible to suppress the ‘‘voice of the lifeworld’’ and accept the lack of caring in respect of personal needs. But, just like other people, non-urgent patients are self-reflecting and seeking to connect with others. In spite of only brief encounters with patients, nursing personnel in ECUs have a range of available possibilities to help non-urgent patients to speak with the ‘‘voice of the lifeworld’’. Furthermore, it is necessary to clearly define nursing care in acute and emergency settings. According to Peplau (1991), each care-provider can take responsibility for expanding his or her own
26
Accident and Emergency Nursing (2 0 0 3 ) 11, 22–26
insight into professional functioning. Hence, education that aims at developing ECU nursing competence must deal with the importance of being present for and attentive to the patient, irrespective of whether his/her health-related problems are urgent or not. References Altschul A 1971 Nurse–Patient Interaction. Churchill Livingstone, Edinburgh Bruce TA, Bowman JM, Brown ST 1998 Factors that influence patient satisfaction in the emergency department. Journal of Nursing Care Quality 13(2): 31–37 Crowley J 2000 Psycho-social a clash of cultures: A&E and mental health. Accident and Emergency Nursing 8(1): 2–8 Dahlberg K, Drew N, Nystr€ om M 2001 Reflective Life-world Research. Studentlitteratur, Lund Lewis KE, Woodside RE 1992 Patient satisfaction with care in the emergency department. Journal of Advanced Nursing 17: 959–964 Mishler EG 1984 The Discourse of Medicine. Dialectics of Medical Interviews. Ablex, Norwood, NJ Peplau H 1991 Interpersonal Relations in Nursing. Macmillan Education Ltd., London Raper JL 1996 A cognitive approach to patient satisfaction with emergency department in nursing care. Journal of Nursing Care Quality 10(4): 48–58 Rhee KJ, Bird J 1996 Perceptions and satisfaction with emergency department care. Journal of Emergency Nursing 14: 48–58 Ricoeur P 1976 Interpretation Theory. Discourse and the Surplus of Meaning. Texas Christian University Press, Fort Worth Sanders AB 1992 Care of the elderly in emergency departments: conclusions and recommendations 21(7): 830–834 Travelbee J 1971 Interpersonal Aspects of Nursing. F.A. Davis Company, Philadelphia, PA Watson WT, Marshall ES, Fosbinder D 1999 Elderly patients’ perceptions of care in emergency department. Journal of Emergency Nursing 25(2): 88–91
ª 2003 Elsevier Science Ltd. All rights reserved.