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The patient experience in the emergency department: A systematic synthesis of qualitative research
International Emergency Nursing (2010) 18, 80– 88
available at www.sciencedirect.com
journal homepage: www.elsevierhealth.com/journals/aaen
The patient experience in the emergency department: A systematic synthesis of qualitative research Jane Gordon B Physiotherapy (Honours) (Physiotherapist) a,1, Lorraine A. Sheppard B App. Sc. (Physiotherapy), MBA, PhD (Professor) Sophie Anaf B Physiotherapy (Honours), PhD (Physiotherapist) b,2
a,b,*
,
a
School of Health Sciences, University of South Australia, City East Campus, North Terrace, Adelaide 5000, Australia James Cook University, Discipline of Physiotherapy, School of Public Health, Tropical Medicine and Rehabilitation Sciences, Townsville, QLD 4811, Australia
b
Received 20 October 2008; received in revised form 19 May 2009; accepted 25 May 2009
KEYWORDS Patient experience; Patient perceptions; Patient satisfaction; Emergency department; Review; Synthesis
Abstract The aim of this study was to systematically review qualitative literature published between 1990 and 2006 exploring the patient experience within the emergency department (ED) with the intent of describing what factors influence the patient experience. Twelve articles were retrieved following combination of key words using five databases. The overarching categories developed from this integration of literature were; emotional impact of emergency, staff–patient interactions, waiting, family in the emergency department, and emergency environment. The patient experience issue given most emphasis by the articles under review was the caring or lack of caring regarding the patients’ psychosocial and emotional needs. This was in contrast to the culture of the ED which emphasised ‘‘medical–technical’’ skill and efficiency. Satisfaction studies need to understand many factors and influences, qualitative methodologies have the ability to do so.
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* Corresponding author. Address: School of Health Sciences, University of South Australia, Adelaide 5000, Australia. Tel.: +61 8 8302 2424, mobile: +61 419 038 441; fax: +61 8 8302 2766. E-mail addresses: [email protected] (J. Gordon), [email protected] (L.A. Sheppard), Sophie.Anaf@ jcu.edu.au (S. Anaf). 1 Tel.: +61 8 8223 3057, mobile: +61 427 182 823; fax: +61 8 8302 2766. 2 Tel.: +61 7 4781 6303; fax: +61 7 4781 6868.
Background One area of the health care system which is most subject to public and media scrutiny is emergency departments (EDs). Issues such as overcrowding, waiting times, and ambulance diversion have all been publicised and debated (Nader, 2006). But what is it actually like for a patient within the
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The patient experience in the emergency department: A systematic synthesis of qualitative research ED? Many research papers have addressed patient satisfaction, patient perceptions, patient-perceived quality of care and emergency department complaints via a variety of research methods targeting a range of different groups, for example, the general populace, the elderly, parents in the ED and domestic violence victims. Several literature reviews have also been conducted regarding the patient experience within the ED including those by Nairn et al. (2004) and Taylor and Benger (2004). For example, Nairn et al.’s (2004) narrative review identified six core themes within the literature: waiting times, communication, cultural aspects of care, pain, the environment and dilemmas in accessing the patient experience. Taylor and Benger (2004) systematic review identified factors influencing patient satisfaction including patient factors such as triage category, age and race and service factors including interpersonal skills/perceived staff attitudes, provision of information/explanation and aspects related to waiting times. These reviews addressed a quantitative or mixed sample of articles. Missing is a synthesis of solely qualitative literature regarding the patients’ experience within the ED, potentially adding new insights to this ongoing emergency system challenge. Qualitative literature in this context presents an in-depth view of the patients’ lived experience of the ED, providing valuable insight into what patients are experiencing, feeling and believing about their visit. The overarching question driving this literature review is: ‘What factors affect the patient experience within the emergency department as uncovered exclusively by qualitatively-conducted literature?’
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Inclusion/exclusion criteria Criteria for inclusion: Studies claiming a solely qualitative orientation. Research related to the adult patient experience in the ED (as opposed to child, parent, accompanying relative, staff member). Published, full-text, English language journal articles. From those articles which met the inclusion criteria, exclusions were made of articles that dealt specifically with psychiatric admissions and domestic violence admissions, patients who left without being seen and articles that explored the experience of specific cultural groups (eg Canadian Inuit people) that were outside the scope of this review.
Sample The resultant sample for this systematic literature review consisted of 10 qualitative studies published between 1992 and 2005. Table 1 details the sample characteristics of the 10 studies. Five appeared in nursing journals, four in emergency medicine journals and one in a journal for caring sciences. Four articles dealt specifically with the experience of older persons, one with repeated users of the ED and one with non-urgent patients. Three of the articles were derived from the same study (Nyden et al., 2003; Nystrom et al., 2003a,b), though varying populations within the study and different aspects of the emergency experience were explored by each of the three articles.
Findings
Method Search strategy A systematic database search of published journal articles on CINAHL, Scopus, PUBMED, AMED, and Medline was performed for the years between January 1990 and December 2006. The following search strategies were used: Search strategy one: ‘‘patient satisfaction’’ AND (‘‘emergency department’’ or ‘‘emergency room’’ or ‘‘accident and emergency’’) AND (interview or ‘‘focus group’’ or qualitative). Search strategy two: (perspective or perception or experience) AND (‘‘emergency department’’ or ‘‘emergency room’’ or ‘‘accident and emergency’’) AND (interview or ‘‘focus group’’ or qualitative). A large number of articles were retrieved in response to individual search terms. For example, in the Scopus database a search using the term ‘‘patient satisfaction’’ retrieved 18,711 references whilst ‘‘emergency department’’ had 21,112 retrievals. Boolean combination of search terms refined the search to identify a more specific body of literature. The search strategies were followed by a title and abstract review to identify articles that met the inclusion and exclusion criteria.
The overarching categories developed from this integration were emotions of emergency, staff–patient interactions, waiting, family in the ED and emergency environment.
Emotions of emergency All studies addressed the emotional impact of a perceived emergency situation. Most patients arrive at the ED with the perception that their injury or condition is serious or life threatening (Baraff et al., 1992; Nystrom et al., 2003a; Olsson and Hansagi, 2001). This threat is often accompanied by some degree of pain (Britten and Shaw, 1994). The situation is one in which patients feel vulnerable, anxious, stressed and fearful. Patients, particularly repeat users of the ED and elderly patients, believe that their symptoms pose a serious threat to their life or to the control they exert over their lives (Olsson and Hansagi, 2001; Kihlgren et al., 2004), as well as entailing loss of autonomy and independence (Baraff et al., 1992). ‘‘That feeling of impending doom, that fluttery feeling in your chest – I felt I was losing ground so to speak. . .I get twinges in my chest, I was almost dying, I have no one who can sound the alarm or help me, so I went [to the ED]’’ (Olsson and Hansagi 2001, p. 432). ‘‘Why do patients have to wait so long once they get to a hospital and why do they have to wait so long just to be put in a room? I am laying there and getting scareder by
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J. Gordon et al. the minute and wondering ‘am I going to survive?’ You know when you get older that your days are numbered and wonder is this the one day. Is this it?’’ (Baraff et al., 1992, p. 816).
Staff–patient interaction Medical–technical caring A ‘‘medical–technical’’ culture was seen as dominant in the ED (Kihlgren et al., 2004, p. 172). Nystrom et al. (2003a,b) compare nursing care at the particular ED under study to a ‘‘conveyor belt in industry’’ with a great deal of fragmentation of care, with one nurse assigned to triage, another to blood tests, a third to check the patient’s temperature and so on. They report that under such circumstances the concept of ‘care’ has ‘‘a meaning in practical terms only and, consequently, a greater value is placed upon utilitarian knowledge than caring competence’’ (Nystrom et al., 2003a, p. 764). Perhaps as a result of this emphasis on technical skill the participants in the studies under review rarely call into question the medical capabilities of the ED staff. Although some studies reported a patient-perceived unnecessary delay in pain–relief (Britten and Shaw, 1994) or pain or distaste on examination (Britten and Shaw, 1994; Watson et al., 1999), much more emphasis was put on the lack of ‘caring’ behaviour. From another perspective, Nystrom et al. (2003a) report that when a patient is in a distressed emotional state it is of vital importance for them to feel trust in the technical competence of ED care-providers. Therefore perceived technical proficiency can partially allay the fears of patients (Nyden et al., 2003). Psychosocial and emotional caring The issue given most emphasis by the studies under review was the ED’s caring, or lack of caring, for patients’ emotional and psychosocial needs. Patients were very appreciative when good nursing care was given. Staff members who were friendly and attentive to the varying needs of patients and could anticipate these needs, and those who made eye contact and took their time to listen, were met with gratitude (Kihlgren et al., 2004; Nyden et al., 2003; Stuart et al., 2003). ‘‘I was impressed by the friendliness of the staff, they treated me well and made me comfortable’’ (Visually impaired person’s focus group) (Stuart et al., 2003, p. 371). ‘‘You appreciate the nurses very much when they are kind and friendly. It isn’t nice to be taken care of by someone who really doesn’t care’’ (Nyden et al., 2003, p. 272). It is apparent that in the stressful and sometimes frightening situation of an ED visit that patients value empathy and respect, but all studies report situations in which patients feel abandoned, exposed, vulnerable, ashamed, ignored or insecure. In emergency situations the ‘‘meaning of the nurse-patient encounter is subordinated to the importance of fixed schedules and practical interventions’’ (Nystrom et al., 2003a, p. 764). Those patients classified as non-urgent were made to feel that their symptoms were devalued and that they were
exerting more pressure on the already overworked nurses (Nystrom et al., 2003b; Olsson and Hansagi, 2001). Those who were repeat users of the ED were made to feel shamed and degraded (Olsson and Hansagi, 2001). Self-esteem was threatened by being deemed an inappropriate attendee (Nyden et al., 2003). According to Nystrom et al. (2003b) the chance of getting attention in spite of being deemed non-urgent depended largely on the nurses on duty. Nursing care quality was reported in this study as being a matter of personal, as opposed to collective, caring competence. In the ED setting, where the patient has to trust in the health professionals on whom they are dependent, patients felt the need to put effort into cultivating good relationships in order to be seen as good patients and to avoid the risk of being treated unkindly (Nyden et al., 2003; Nystrom et al., 2003a,b). In order to achieve this, patients tried to make jokes or respond to the jokes of nurses (Nyden et al., 2003). Other efforts to maintain good relationships involved suppressing disappointed expectations or directing their disappointment at politicians or upper management (Nyden et al., 2003; Nystrom et al., 2003b). Older patients particularly desired affectionate relationships with the nurses (Nyden et al., 2003). By forming relationships with the staff, patients may also have been trying to avoid being seen as objects rather than as people (Kihlgren et al., 2004). Being left alone was found to be an important issue for many patients and was explored by 5 of the 10 studies reviewed. The experience of being left alone was described as frustrating, worrying and frightening (Nyden et al., 2003). This was especially the case for those patients worried by symptoms such as chest pain. The prospect of being left alone and perhaps forgotten while having these symptoms was quite frightening (Kihlgren et al., 2004). Patients left alone for long periods felt as if they had been abandoned and ignored (Baraff et al., 1992; Britten and Shaw, 1994). Patients longed for staff contact while waiting alone and were anxious for information (Kihlgren et al., 2004). Those who had previous experience of the ED knew the value of having family or friends with them in the ED in order to avoid long hours of waiting alone and to have someone standing by as an advocate to fetch help or ask questions if needed (Nystrom et al., 2003b). Personal tolerance The term ‘personal tolerance’ was used in the study by Watson et al. (1999) to describe the ‘‘understanding and patience among informants when one or more care expectations were not met by the ED or hospital staff’’ (Watson et al., 1999, p. 90). Variations of this theme emerged in 8 of the 10 studies. This concept was evident in patients’ recognition of the difficulties staff members faced as a result of aggression, overwork and limited resources (Stuart et al., 2003). The blame for disappointment with ‘caring’ was shifted away from the nurses to people that patients did not meet personally, i.e. politicians and those working in management (Kihlgren et al., 2004; Nyden et al., 2003; Nystrom et al., 2003b). The result of this recognition was that patients made excuses for the nurses’ lack of caring while at the same time feeling distress or frustration at their treatment (Nyden et al., 2003). Patients felt unable to express their unmet needs to the nurses in light of the nurses’ stressful working
Sample characteristics.
Citation
Locality
Title
Journals
Participants
Qualitative method
Time of enquiry in relation to ED visit
Baraff et al. (1992)
USA
Perceptions of emergency care by the elderly: results of multicenter focus group interviews Patients’ experience of emergency admission: how relevant is the British government’s patients charter
Annals of Emergency Medicine
Elderly ED patients and community members
Focus groups
Participants had been ED patients in the past year
Interviews
Participants were interviewed whilst still in hospital, in the wards
Elderly patients’ perception of care in the emergency department
Journal of Emergency Nursing
Interviews
Participants were interviewed within 72 hours post discharge from the ED
Repeated use of the emergency department: qualitative study of the patient’s perspective
Emergency Medicine Journal
Interviews
Not specified
Non-caring encounters at an emergency care unit – a lifeworld hermeneutic analysis of an efficiency-driven organization
International Journal of Nursing Studies
Interviews open-lifeworld approach
Not specified
Unsatisfied basic needs of older patients in emergency care environments – obstacles to an active role in decision making Being a non-urgent patient in an emergency care unit – a strive to maintain personal integrity
Journal of Clinical Nursing
Interviews life-world hermeneutic approach
Not specified
Interviews life-world hermeneutic approach
Not specified
Britten and Shaw (1994)
UK
Watson et al. (1999)
USA
Olsson and Hansagi (2001)
Nystrom et al. (2003a)
Nyden et al. (2003)
Nystrom et al. (2003b)
Sweden
Sweden
Sweden
Sweden
5–13 participants per group 5 focus groups
Journal of Advanced Nursing
N = 83 Hospital patients admitted through the ED Gender: 46$, 37# Median age: 45.9 years Range: (18–91) 61 persons <65 years
N = 12 Elderly ED patients Gender: 6$, 6# Median age: 75.75 years Range (66–86)
N = 10 Adult ED patients-repeat users Gender: 5$, 5# Median age: 51 years Range (23–82)
N = 20 ECU nurses and patients(9 nurses, 11 patients) Nurses: Gender: 8$, 1# Age range: (23–51) Patients: Gender: 6$, 5# Age range (52–88)
N = 7E lderly ECU patients Gender: 3$, 5# Age range: (65–88)
Accident and Emergency Nursing
N = 11 Non-urgent ECU patients
The patient experience in the emergency department: A systematic synthesis of qualitative research
Table 1
Gender: 6$, 5# Age range: (52–88)
(continued on next page)
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Table 1
(continued)
Citation
Locality
Title
Journals
Participants
Qualitative method
Time of enquiry in relation to ED visit
Stuart et al. (2003)
Australia
Giving a voice to the community: a qualitative study of consumer expectations for the emergency department
Emergency Medicine
N > 98 Community members
Focus groups ethnography underlying philosophy ‘‘Give a voice to the community’’
No relationship to time of ED visit
Older patients awaiting emergency department treatment
Scandinavian Journal of Caring Sciences
Observation and interviews grounded theory
Rationing in the emergency department: the good, the bad, and the unacceptable
Emergency Medicine Journal
Participants were observed from reception at the ED until discharge and were interviewed prior to leaving the hospital Participants were contacted one week post discharge from the ED
Kihlgren et al. (2004)
Cross et al. (2005)
Sweden
UK
N = 20 Elderly ED patients Gender: 14$, 6# >75 years
N = 11 Adult ED patients Gender: 5$, 6# Age range: (20–74)
Interviews
J. Gordon et al.
ECU: Emergency care unit.
Visually impaired persons’ group: N = 16 Women’s group: N = 11 Elderly persons’ group: N = 11 Vietnamese group: N = 8 Spanish speaking group: N = 12 Youth focus group: N = 10 Mental health support group: N = 15 Carers support group: N = 8 Young mothers support group: N = 7 Aboriginal persons focus group: N not recorded
The patient experience in the emergency department: A systematic synthesis of qualitative research conditions (Nystrom et al., 2003b). Complaints were directed toward relatives or to the researchers but rarely towards staff (Kihlgren et al., 2004). Another way in which this theme emerged in the studies was through patients’ sensitivity and concern for the need of other patients in the ED. Patients understood and accepted that patients who were critically injured or worse off than themselves would be seen first (Baraff et al., 1992; Britten and Shaw, 1994; Cross et al., 2005). Some patients also believed that children should be given special priority in the triage process (Cross et al., 2005). Communication and information Communication and the provision of information were reported to have an important impact upon the patients’ experience in the ED. Patients were appreciative and put at ease when given information (Britten and Shaw, 1994). This review found that patients wished for more information on all aspects of the ED visit. Verbal information as well as handouts or notices in the waiting area on the triage process and waiting times were advocated by patients (Baraff et al., 1992; Britten and Shaw, 1994; Stuart et al., 2003). Stuart et al. (2003) suggested that a large proportion of the community was unfamiliar with the ED system and the triage process and therefore would benefit from this form of education. In particular, the elderly were not familiar with the processes in the ED (Baraff et al., 1992). Studies of elderly populations (Kihlgren et al., 2004; Watson et al., 1999) advocated that understandable, non-medical language be used in the provision of information. The patients in these studies specified that they disliked being spoken down to and patronized. Patients needed to have frequent personal contacts to be advised as to what is happening (Watson et al., 1999). More information on tests, diagnosis, the patient’s condition, treatment and technical procedures including what these procedures would be like for the patient and how they would feel afterwards, should be routinely presented to the patient. ‘‘It would be helpful if the nurses could tell you why you are waiting. I like to know the reason that I am waiting.. . .Keep me informed about the cause of the waits’’ (Watson et al., 1999, p. 89). ‘‘I would have just liked a little bit more information on what they were doing to my body and what medication
Table 2
85
they were putting me on and what injections they were giving me. I wanted to know what that was for and no one told me’’ (Britten and Shaw 1994, p. 1214). With regards to patients answering questions and giving information, many of the questions asked were perceived to be ‘stupid’, unnecessary or irrelevant. Patients felt they were repeating themselves to multiple different health professionals indicating a lack of communication between professionals within the ED (Britten and Shaw, 1994). The patients pointed out that it was difficult to answer questions when one was not feeling well (Britten and Shaw, 1994).
Waiting Waiting was a significant factor influencing patients’ experience of the ED. Waiting featured prominently in most of the articles reviewed. Waiting was broader than the issue of waiting for initial assessment. Much of the waiting experienced was waiting to go to X-ray, for test results or for review by the physician. The extent to which waiting influenced the patients’ experience was not solely associated with the length of the wait but also information given on why they were waiting and how long they were expected to wait, the environment and comfort of their wait and their interaction with staff during their wait. The presence of family, friends or carers was an important factor influencing how they experienced waiting. ‘‘The only thing is the big space of time between what they do and when you get to go to x-ray and all those other things. . ..There was an extremely long wait between the lung scan and the ultrasound and the X-ray’’ (Watson et al., 1999, p. 89). ‘‘We laid there and we laid there and we laid there, and pretty soon the nurse came back in to say that it was still going to be another 30 minutes’’ (Watson et al., 1999, p. 89).
Family in the ED Friends or family were reported to play a significant role in caring for the well-being of the patient in the ED. In the stressful situation of the ED the next-of-kin provided company, eased loneliness and alleviated anxiety. Having someone to talk to helped to pass the time more agreeably. The
Results of search strategy.
Database
Search strategy
Number of hits
Met inclusion and exclusion criteria
CINAHL
1 2 1 2 1 2 1 2 1 2
74 225 523 (all fields) 247 (title-Abs-Key-Auth) 63 143 0 2 54 109
3 7 10 8 4 8 0 0 4 4
Scopus PUBMED AMED Medline
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J. Gordon et al.
next-of-kin often took on the role of patient advocate asking questions on the patient’s behalf, fetching help when needed or at least giving patients the confidence of feeling that they would deal with problems if they arose. According to Nystrom et al. (2003b) the next-of-kin is forced by the system to take on the task of monitoring the patients’ medical conditions. ‘‘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’’ (Nystrom et al., 2003b, p. 24).
Emergency environment The ED environment was criticized for a number of reasons, the predominant complaint being about the hard and uncomfortable beds and trolleys (Baraff et al., 1992; Britten and Shaw, 1994; Kihlgren et al., 2004; Nyden et al., 2003; Watson et al., 1999). The waiting room was also brought under criticism, being described as uncomfortable, frightening, oppressive, claustrophobic and in need of refurbishment and facilities for children (Britten and Shaw, 1994; Stuart et al., 2003). The lack of auditory and visual privacy was an issue for some patients (Britten and Shaw, 1994; Baraff et al., 1992), exacerbated by the crowded and busy nature of the ED. Other people in the ED, especially those perceived to be drunks, drug addicts or in a great deal of pain, were reported to upset patients (Britten and Shaw, 1994). Other complaints included that the ED was dirty,
with scuffed linoleum floors, and that toilets were filthy or vandalized. Especially elderly patients were cold and hungry when they arrived at the ED, wanting to be given something to eat and drink (Kihlgren et al., 2004; Nyden et al., 2003) and to be given blankets to keep them warm (Baraff et al., 1992).
Discussion Table 2 displays the results of the literature search conducted, illustrating how the search strategies led to the articles being included in this review. With overlap between the databases the systematic literature search uncovered twelve reports relating to patient experience within the ED potentially eligible for review. These twelve articles were classified using Sandelowski and Barroso’s Typology of Qualitative Findings (2003), which classifies studies on a continuum from ‘No finding’ to ‘Interpretative explanation’ (Fig. 1). This typology emphasizes the difference between qualitative research and research that simply uses qualitative data and/or data collection or analysis techniques commonly perceived as qualitative. Discussion between researchers resulted in consensus regarding classification (see Table 3). The articles by Wellstood et al. (2005) and Watt et al. (2005) were excluded from the study on the basis of being ‘Topical Surveys’ and therefore are not classified as qualitative research on this continuum. According to Sandelowski and Barroso (2003, p. 911), topical surveys are ‘‘characterized by the emphasis on nominal or categorical data, or lists or inventories of topics covered by research participants in interviews and focus groups’’. This is illustrated by the following quotation from Wellstood et al. (2005, p. 2369), ‘‘the results demonstrated that individuals under the age of 65 had an average of 2 negative experiences while individuals over 65 had 1.’’
Quality appraisal
Figure 1 Typology of qualitative findings (Sandelowski and Barroso, 2003, p. 908).
Table 3
The remaining articles were critically appraised, using quality standards adapted from Law et al.’s (1998) critical review form, with appraisal informed by Sandelowski and Barroso’s ‘Guide for Reading Qualitative Studies’ (2002). When considering the findings of this review the quality and limitations of the articles included is important. Appraisal was not done, however, to exclude studies, as according to Sandelowski et al. (1997), studies should not be excluded for reasons of quality due to the wide variations in concep-
Classification of studies.
Classification
Number of studies
Studies
No finding Topical survey Thematic survey
0 2
Conceptual/thematic description
4
Interpretative explanation
0
Nil Wellstood et al. (2005)Watt et al. (2005) Baraff et al. (1992), Britten and Shaw (1994), Watson et al. (1999), Stuart et al. (2003),Kihlgren et al. (2004), Cross et al. (2005) Olsson and Hansagi (2001), Nystrom et al.(2003a,b), Nyden et al. (2003) Nil
X X · X · X X X X X · X X · X · X X X · · · · X X X X X X X · · · · X X X X X · X X X X X X X X X X X X X X · X X X X X · · · · · · · · · · X X X X X X X X X X · · · X · · · · X · X X X X X X X X X X · X X X X X X X X X X X X X X X X X X X Baraff et al. Britten and Shaw Watson et al. Olsson and Hansagi Nystrom et al. Nyden et al. Nystrom et al. Stuart et al. Kihlgren et al. Cross et al.
Purposive sampling Purpose and problem clearly identified Citation
Table 4
Quality appraisal of qualitative literature proved difficult due to the lack of consensus regarding assessments about qualitative research (Leininger, 1994). In light of the difficulty of analysis of quality, Table 4 was constructed to display the presence or absence of quality standards adapted from Law et al.’s (1998) qualitative critical review form from McMaster University, Canada. Member checking, which refers to the process of returning the transcripts or findings and interpretations to the participants in order for them to judge how well these represent what they said, or how well they fit with how they experienced the phenomenon, was not reported by any of the studies. Triangulation and saturation of data were also poorly represented within these studies. One of the more recent studies, Kihlgren et al. (2004), was the most rigorous in the inclusion and reporting of the quality criteria represented in the table.
Quality appraisal of literature.
Results of the quality appraisal
Relevant literature reviewed
Triangulation
Saturation of data reached
Inductive analysis
Member checking
Site adequately described
Participants adequately described
Theoretical perspective identified
Awareness of the re-searcher’s impact on study displayed
Study design identified
Analysis and integration of findings The model used to integrate the findings of the articles within this review was qualitative, descriptive meta-synthesis as described by Schreiber et al. (1997). This model encouraged a broader look at the phenomena of the patient experience within the ED, allowing for exploration of the extensive factors influencing the experience. The analysis used the process of translation as proposed by Noblit and Hare (1988). Translation involves determining how the various studies are related by deconstructing the findings into key metaphors, phrases, ideas and/or concepts used in each account and juxtaposing related concepts. In order to do this the studies were read and re-read and key metaphors, phrases and concepts were noted from each study. These concepts were transferred into table format in which those phrases or ideas which seemed in some way linked could be compared within and between studies. For example, Nystrom et al. (2003b) concept that ‘nurses’ approach is similar to a ‘conveyor belt in industry’ seemed to be highly related to Kihlgren et al.’s (2004) finding that ‘a medical– technical culture was dominant at the ED’. The next step was to translate the studies’ findings into the terms or metaphors of the others and vice versa, while maintaining the relationships and respecting the holism of the original studies. Following the same example, it was considered that the concept of ‘a medical–technical culture’ was a more apt and inclusive concept to use in the synthesis than the ‘conveyor belt’ metaphor to understand the patient experience. Finfgeld (2003) notes that synthesis within the descriptive model does not generally involve deconstructing the studies’ findings. However, the reviewers felt that the process of translation did not interfere with the descriptive intent of the synthesis.
· · · · · · · X X ·
Method trans-parent
Audit trail of data analysis
tions of what is high quality qualitative research. Appraisal of quality was incorporated within this review to allow the reader to compare the studies’ inclusion of certain qualitative criteria. The quality appraisal criteria were applied independently to all studies by the principal researcher and a second reviewer. The reviewers then conferred and discussed any discrepancies until consensus was reached about the quality of an article.
· · · X X · X X X X
The patient experience in the emergency department: A systematic synthesis of qualitative research
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88 The relative paucity of qualitative studies of the patient experience in the ED may be due to the methodological difficulties of conducting in-depth research within the ED, and the appeal of producing the ‘‘statistical signifiers of efficacy’’ (Nairn et al., 2004, p. 163). However, in quantifying the patient experience many survey methods reduce the patient experience to a set of figures representing responses to predetermined issues (Nairn et al., 2004). Satisfaction studies need to understand many factors and influences, qualitative methodologies have the ability to do so.
Conclusions Research in the area of the patient experience in the ED is dominated by quantitative measurements (Nairn et al., 2004). The small sample of qualitative articles in this review adds valuable depth and a more human perspective to the broader literature, acknowledging the very multidimensional nature of the ED experience. In line with the descriptive intent of this synthesis, five categories derived from the 10 qualitative studies illustrate the patient experience in the ED. These five categories are emotions of emergency, staff–patient interaction, waiting, family in the ED, and emergency environment. The studies considered were published across a large time span (1992–2005), various countries (United Kingdom, United State of America, Sweden and Australia) and provided consistency in their findings. What does emerge is good nursing care as described by patients. Patients appreciate the context of the ED and reported a sense of emotional urgency when attending. The expectations of technical competency from the health professionals underpinned other perceptions. Patients were able to trade off or display personal tolerance for waiting times or perceived abruptness to receive attention. However, valued and at times described as ‘‘good nursing care’ was a caring approach, explanations of what was occurring and putting the patients at ease in a stressful setting. This may be indicative of the fairly basic needs and wishes of patients in the ED and the persistent prevalence of circumstances in EDs such as overcrowding and delays in attention from health professionals.
References Baraff, L., Bernstein, E., Bradley, K., Franken, C., Gerson, L., Hannegan, S., Kober, K., Lee, S., Marotta, M., Wolfson, A., 1992. Perceptions of emergency care by the elderly: results of multicenter focus group interviews. Annals of Emergency Medicine 21 (7), 814–818. Britten, N., Shaw, A., 1994. Patients’ experiences of emergency admission: how relevant is the British government’s Patients Charter? Journal of Advanced Nursing 19 (6), 1212–1220. Cross, E., Goodacre, S., O’Cathain, A., Arnold, J., 2005. Rationing in the emergency department: the good, the bad and the unacceptable. Emergency Medicine Journal 22 (3), 171–176. Finfgeld, D., 2003. Metasynthesis: the state of the art – so far. Qualitative Health Research 13 (7), 893–904.
J. Gordon et al. Kihlgren, A., Nilsson, M., Skovdahl, K., Palmblad, B., Wimo, A., 2004. Older patients awaiting emergency department treatment. Scandinavian Journal of Caring Sciences 18, 169–176. Law, M., Stewart, D., Letts, L., Pollock, N., Bosch, J. Westmorland, M., 1998. Critical Review form-Qualitative Studies. McMaster University. http://www.fhs.mcmaster.ca/rehab/ebp/pdf/qualreview.pdf (viewed 13.02.2007). Leininger, M., 1994. Evaluation criteria and critique of qualitative research studies. In: Morse, J.M. (Ed.), Critical Issues in Qualitative Research Methods. Sage, Thousand Oaks, CA, pp. 95–115. Nader, C., 2006a. Patient waits drop but room to improve. Age, 6 (30 October). Nader, C., 2006b. Royal Melbourne calls for patience as it faces rising trauma case load. Age, 4 (17 March). Nader, C., 2006c. Worry over long wait in emergency. Age, 8 (21 June). Nairn, S., Whotton, E., Marshal, C., Roberts, M., Swann, G., 2004. The patient experience in emergency departments: a review of the literature. Accident and Emergency Nursing 12, 159–165. Noblit, G., Hare, R., 1988. Meta-ethnography: Synthesizing Qualitative Studies. Sage, Newbury Park, CA. Nyden, K., Petersson, M., Nystrom, M., 2003. Unsatisfied basic needs of older patients in emergency care environments– obstacles to an active role in decision making. Journal of Clinical Nursing 12 (2), 268–274. Nystrom, M., Dahlberg, K., Carlsson, G., 2003a. Non-caring encounters at an emergency care unit – a life-world hermeneutic analysis of an efficiency-driven organization. International Journal of Nursing Studies 40 (7), 761–769. Nystrom, M., Nyden, K., Petersson, M., 2003b. Being a non-urgent patient in an emergency care unit – a strive to maintain personal integrity. Accident and Emergency Nursing 11, 22–26. Olsson, M., Hansagi, H., 2001. Repeated use of the emergency department: qualitative study of the patient’s perspective. Emergency Medicine Journal 18 (6), 430–434. Sandelowski, M., Barroso, J., 2002. Reading qualitative studies. International Journal of Qualitative Methods 1 (1) (Article 5). Sandelowski, M., Barroso, J., 2003. Classifying the findings of qualitative studies. Qualitative Health Research 13 (7), 905– 923. Sandelowski, M., Docherty, S., Emden, C., 1997. Qualitative methasynthesis: issues and techniques. Research in Nursing and Health 20, 365–371. Schreiber, R., Crooks, D., Stern, P., 1997. Qualitative metaanalysis. In: Morse, J.M. (Ed.), Completing A Qualitative Project: Details and Dialogue. Sage, Thousand Oaks, CA, pp. 311–326. Stuart, J., Parker, S., Rogers, M., 2003. Giving a voice to the community: a qualitative study of consumer expectations for the emergency department. Emergency Medicine 15 (4), 369–375. Taylor, C., Benger, J.R., 2004. Patient satisfaction in emergency medicine. Journal of Emergency Medicine 21, 528–532. Watson, W., Marshall, E., Fosbinder, D., 1999. Elderly patients’ perceptions of care in the emergency department. Journal of Emergency Nursing 25 (2), 88–92. Watt, D., Wertzler, W., Brannan, G., 2005. Patient expectations of emergency department care: phase I – a focus group study. Journal of the Canadian Society of Emergency Physicians 7 (1), 12–16. Wellstood, K., Wilson, K., Eyles, J., 2005. ‘‘Unless you went in with your head under your arm’’: patient perceptions of emergency room visits. Social Science and Medicine 61, 2363–2373.
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The patient experience in the emergency department: A systematic synthesis of qualitative research Jane Gordon B Physiotherapy (Honours) (Physiotherapist) a,1, Lorraine A. Sheppard B App. Sc. (Physiotherapy), MBA, PhD (Professor) Sophie Anaf B Physiotherapy (Honours), PhD (Physiotherapist) b,2
a,b,*
,
a
School of Health Sciences, University of South Australia, City East Campus, North Terrace, Adelaide 5000, Australia James Cook University, Discipline of Physiotherapy, School of Public Health, Tropical Medicine and Rehabilitation Sciences, Townsville, QLD 4811, Australia
b
Received 20 October 2008; received in revised form 19 May 2009; accepted 25 May 2009
KEYWORDS Patient experience; Patient perceptions; Patient satisfaction; Emergency department; Review; Synthesis
Abstract The aim of this study was to systematically review qualitative literature published between 1990 and 2006 exploring the patient experience within the emergency department (ED) with the intent of describing what factors influence the patient experience. Twelve articles were retrieved following combination of key words using five databases. The overarching categories developed from this integration of literature were; emotional impact of emergency, staff–patient interactions, waiting, family in the emergency department, and emergency environment. The patient experience issue given most emphasis by the articles under review was the caring or lack of caring regarding the patients’ psychosocial and emotional needs. This was in contrast to the culture of the ED which emphasised ‘‘medical–technical’’ skill and efficiency. Satisfaction studies need to understand many factors and influences, qualitative methodologies have the ability to do so.
ª 2009 Elsevier Ltd. All rights reserved.
* Corresponding author. Address: School of Health Sciences, University of South Australia, Adelaide 5000, Australia. Tel.: +61 8 8302 2424, mobile: +61 419 038 441; fax: +61 8 8302 2766. E-mail addresses: [email protected] (J. Gordon), [email protected] (L.A. Sheppard), Sophie.Anaf@ jcu.edu.au (S. Anaf). 1 Tel.: +61 8 8223 3057, mobile: +61 427 182 823; fax: +61 8 8302 2766. 2 Tel.: +61 7 4781 6303; fax: +61 7 4781 6868.
Background One area of the health care system which is most subject to public and media scrutiny is emergency departments (EDs). Issues such as overcrowding, waiting times, and ambulance diversion have all been publicised and debated (Nader, 2006). But what is it actually like for a patient within the
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The patient experience in the emergency department: A systematic synthesis of qualitative research ED? Many research papers have addressed patient satisfaction, patient perceptions, patient-perceived quality of care and emergency department complaints via a variety of research methods targeting a range of different groups, for example, the general populace, the elderly, parents in the ED and domestic violence victims. Several literature reviews have also been conducted regarding the patient experience within the ED including those by Nairn et al. (2004) and Taylor and Benger (2004). For example, Nairn et al.’s (2004) narrative review identified six core themes within the literature: waiting times, communication, cultural aspects of care, pain, the environment and dilemmas in accessing the patient experience. Taylor and Benger (2004) systematic review identified factors influencing patient satisfaction including patient factors such as triage category, age and race and service factors including interpersonal skills/perceived staff attitudes, provision of information/explanation and aspects related to waiting times. These reviews addressed a quantitative or mixed sample of articles. Missing is a synthesis of solely qualitative literature regarding the patients’ experience within the ED, potentially adding new insights to this ongoing emergency system challenge. Qualitative literature in this context presents an in-depth view of the patients’ lived experience of the ED, providing valuable insight into what patients are experiencing, feeling and believing about their visit. The overarching question driving this literature review is: ‘What factors affect the patient experience within the emergency department as uncovered exclusively by qualitatively-conducted literature?’
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Inclusion/exclusion criteria Criteria for inclusion: Studies claiming a solely qualitative orientation. Research related to the adult patient experience in the ED (as opposed to child, parent, accompanying relative, staff member). Published, full-text, English language journal articles. From those articles which met the inclusion criteria, exclusions were made of articles that dealt specifically with psychiatric admissions and domestic violence admissions, patients who left without being seen and articles that explored the experience of specific cultural groups (eg Canadian Inuit people) that were outside the scope of this review.
Sample The resultant sample for this systematic literature review consisted of 10 qualitative studies published between 1992 and 2005. Table 1 details the sample characteristics of the 10 studies. Five appeared in nursing journals, four in emergency medicine journals and one in a journal for caring sciences. Four articles dealt specifically with the experience of older persons, one with repeated users of the ED and one with non-urgent patients. Three of the articles were derived from the same study (Nyden et al., 2003; Nystrom et al., 2003a,b), though varying populations within the study and different aspects of the emergency experience were explored by each of the three articles.
Findings
Method Search strategy A systematic database search of published journal articles on CINAHL, Scopus, PUBMED, AMED, and Medline was performed for the years between January 1990 and December 2006. The following search strategies were used: Search strategy one: ‘‘patient satisfaction’’ AND (‘‘emergency department’’ or ‘‘emergency room’’ or ‘‘accident and emergency’’) AND (interview or ‘‘focus group’’ or qualitative). Search strategy two: (perspective or perception or experience) AND (‘‘emergency department’’ or ‘‘emergency room’’ or ‘‘accident and emergency’’) AND (interview or ‘‘focus group’’ or qualitative). A large number of articles were retrieved in response to individual search terms. For example, in the Scopus database a search using the term ‘‘patient satisfaction’’ retrieved 18,711 references whilst ‘‘emergency department’’ had 21,112 retrievals. Boolean combination of search terms refined the search to identify a more specific body of literature. The search strategies were followed by a title and abstract review to identify articles that met the inclusion and exclusion criteria.
The overarching categories developed from this integration were emotions of emergency, staff–patient interactions, waiting, family in the ED and emergency environment.
Emotions of emergency All studies addressed the emotional impact of a perceived emergency situation. Most patients arrive at the ED with the perception that their injury or condition is serious or life threatening (Baraff et al., 1992; Nystrom et al., 2003a; Olsson and Hansagi, 2001). This threat is often accompanied by some degree of pain (Britten and Shaw, 1994). The situation is one in which patients feel vulnerable, anxious, stressed and fearful. Patients, particularly repeat users of the ED and elderly patients, believe that their symptoms pose a serious threat to their life or to the control they exert over their lives (Olsson and Hansagi, 2001; Kihlgren et al., 2004), as well as entailing loss of autonomy and independence (Baraff et al., 1992). ‘‘That feeling of impending doom, that fluttery feeling in your chest – I felt I was losing ground so to speak. . .I get twinges in my chest, I was almost dying, I have no one who can sound the alarm or help me, so I went [to the ED]’’ (Olsson and Hansagi 2001, p. 432). ‘‘Why do patients have to wait so long once they get to a hospital and why do they have to wait so long just to be put in a room? I am laying there and getting scareder by
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J. Gordon et al. the minute and wondering ‘am I going to survive?’ You know when you get older that your days are numbered and wonder is this the one day. Is this it?’’ (Baraff et al., 1992, p. 816).
Staff–patient interaction Medical–technical caring A ‘‘medical–technical’’ culture was seen as dominant in the ED (Kihlgren et al., 2004, p. 172). Nystrom et al. (2003a,b) compare nursing care at the particular ED under study to a ‘‘conveyor belt in industry’’ with a great deal of fragmentation of care, with one nurse assigned to triage, another to blood tests, a third to check the patient’s temperature and so on. They report that under such circumstances the concept of ‘care’ has ‘‘a meaning in practical terms only and, consequently, a greater value is placed upon utilitarian knowledge than caring competence’’ (Nystrom et al., 2003a, p. 764). Perhaps as a result of this emphasis on technical skill the participants in the studies under review rarely call into question the medical capabilities of the ED staff. Although some studies reported a patient-perceived unnecessary delay in pain–relief (Britten and Shaw, 1994) or pain or distaste on examination (Britten and Shaw, 1994; Watson et al., 1999), much more emphasis was put on the lack of ‘caring’ behaviour. From another perspective, Nystrom et al. (2003a) report that when a patient is in a distressed emotional state it is of vital importance for them to feel trust in the technical competence of ED care-providers. Therefore perceived technical proficiency can partially allay the fears of patients (Nyden et al., 2003). Psychosocial and emotional caring The issue given most emphasis by the studies under review was the ED’s caring, or lack of caring, for patients’ emotional and psychosocial needs. Patients were very appreciative when good nursing care was given. Staff members who were friendly and attentive to the varying needs of patients and could anticipate these needs, and those who made eye contact and took their time to listen, were met with gratitude (Kihlgren et al., 2004; Nyden et al., 2003; Stuart et al., 2003). ‘‘I was impressed by the friendliness of the staff, they treated me well and made me comfortable’’ (Visually impaired person’s focus group) (Stuart et al., 2003, p. 371). ‘‘You appreciate the nurses very much when they are kind and friendly. It isn’t nice to be taken care of by someone who really doesn’t care’’ (Nyden et al., 2003, p. 272). It is apparent that in the stressful and sometimes frightening situation of an ED visit that patients value empathy and respect, but all studies report situations in which patients feel abandoned, exposed, vulnerable, ashamed, ignored or insecure. In emergency situations the ‘‘meaning of the nurse-patient encounter is subordinated to the importance of fixed schedules and practical interventions’’ (Nystrom et al., 2003a, p. 764). Those patients classified as non-urgent were made to feel that their symptoms were devalued and that they were
exerting more pressure on the already overworked nurses (Nystrom et al., 2003b; Olsson and Hansagi, 2001). Those who were repeat users of the ED were made to feel shamed and degraded (Olsson and Hansagi, 2001). Self-esteem was threatened by being deemed an inappropriate attendee (Nyden et al., 2003). According to Nystrom et al. (2003b) the chance of getting attention in spite of being deemed non-urgent depended largely on the nurses on duty. Nursing care quality was reported in this study as being a matter of personal, as opposed to collective, caring competence. In the ED setting, where the patient has to trust in the health professionals on whom they are dependent, patients felt the need to put effort into cultivating good relationships in order to be seen as good patients and to avoid the risk of being treated unkindly (Nyden et al., 2003; Nystrom et al., 2003a,b). In order to achieve this, patients tried to make jokes or respond to the jokes of nurses (Nyden et al., 2003). Other efforts to maintain good relationships involved suppressing disappointed expectations or directing their disappointment at politicians or upper management (Nyden et al., 2003; Nystrom et al., 2003b). Older patients particularly desired affectionate relationships with the nurses (Nyden et al., 2003). By forming relationships with the staff, patients may also have been trying to avoid being seen as objects rather than as people (Kihlgren et al., 2004). Being left alone was found to be an important issue for many patients and was explored by 5 of the 10 studies reviewed. The experience of being left alone was described as frustrating, worrying and frightening (Nyden et al., 2003). This was especially the case for those patients worried by symptoms such as chest pain. The prospect of being left alone and perhaps forgotten while having these symptoms was quite frightening (Kihlgren et al., 2004). Patients left alone for long periods felt as if they had been abandoned and ignored (Baraff et al., 1992; Britten and Shaw, 1994). Patients longed for staff contact while waiting alone and were anxious for information (Kihlgren et al., 2004). Those who had previous experience of the ED knew the value of having family or friends with them in the ED in order to avoid long hours of waiting alone and to have someone standing by as an advocate to fetch help or ask questions if needed (Nystrom et al., 2003b). Personal tolerance The term ‘personal tolerance’ was used in the study by Watson et al. (1999) to describe the ‘‘understanding and patience among informants when one or more care expectations were not met by the ED or hospital staff’’ (Watson et al., 1999, p. 90). Variations of this theme emerged in 8 of the 10 studies. This concept was evident in patients’ recognition of the difficulties staff members faced as a result of aggression, overwork and limited resources (Stuart et al., 2003). The blame for disappointment with ‘caring’ was shifted away from the nurses to people that patients did not meet personally, i.e. politicians and those working in management (Kihlgren et al., 2004; Nyden et al., 2003; Nystrom et al., 2003b). The result of this recognition was that patients made excuses for the nurses’ lack of caring while at the same time feeling distress or frustration at their treatment (Nyden et al., 2003). Patients felt unable to express their unmet needs to the nurses in light of the nurses’ stressful working
Sample characteristics.
Citation
Locality
Title
Journals
Participants
Qualitative method
Time of enquiry in relation to ED visit
Baraff et al. (1992)
USA
Perceptions of emergency care by the elderly: results of multicenter focus group interviews Patients’ experience of emergency admission: how relevant is the British government’s patients charter
Annals of Emergency Medicine
Elderly ED patients and community members
Focus groups
Participants had been ED patients in the past year
Interviews
Participants were interviewed whilst still in hospital, in the wards
Elderly patients’ perception of care in the emergency department
Journal of Emergency Nursing
Interviews
Participants were interviewed within 72 hours post discharge from the ED
Repeated use of the emergency department: qualitative study of the patient’s perspective
Emergency Medicine Journal
Interviews
Not specified
Non-caring encounters at an emergency care unit – a lifeworld hermeneutic analysis of an efficiency-driven organization
International Journal of Nursing Studies
Interviews open-lifeworld approach
Not specified
Unsatisfied basic needs of older patients in emergency care environments – obstacles to an active role in decision making Being a non-urgent patient in an emergency care unit – a strive to maintain personal integrity
Journal of Clinical Nursing
Interviews life-world hermeneutic approach
Not specified
Interviews life-world hermeneutic approach
Not specified
Britten and Shaw (1994)
UK
Watson et al. (1999)
USA
Olsson and Hansagi (2001)
Nystrom et al. (2003a)
Nyden et al. (2003)
Nystrom et al. (2003b)
Sweden
Sweden
Sweden
Sweden
5–13 participants per group 5 focus groups
Journal of Advanced Nursing
N = 83 Hospital patients admitted through the ED Gender: 46$, 37# Median age: 45.9 years Range: (18–91) 61 persons <65 years
N = 12 Elderly ED patients Gender: 6$, 6# Median age: 75.75 years Range (66–86)
N = 10 Adult ED patients-repeat users Gender: 5$, 5# Median age: 51 years Range (23–82)
N = 20 ECU nurses and patients(9 nurses, 11 patients) Nurses: Gender: 8$, 1# Age range: (23–51) Patients: Gender: 6$, 5# Age range (52–88)
N = 7E lderly ECU patients Gender: 3$, 5# Age range: (65–88)
Accident and Emergency Nursing
N = 11 Non-urgent ECU patients
The patient experience in the emergency department: A systematic synthesis of qualitative research
Table 1
Gender: 6$, 5# Age range: (52–88)
(continued on next page)
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84
Table 1
(continued)
Citation
Locality
Title
Journals
Participants
Qualitative method
Time of enquiry in relation to ED visit
Stuart et al. (2003)
Australia
Giving a voice to the community: a qualitative study of consumer expectations for the emergency department
Emergency Medicine
N > 98 Community members
Focus groups ethnography underlying philosophy ‘‘Give a voice to the community’’
No relationship to time of ED visit
Older patients awaiting emergency department treatment
Scandinavian Journal of Caring Sciences
Observation and interviews grounded theory
Rationing in the emergency department: the good, the bad, and the unacceptable
Emergency Medicine Journal
Participants were observed from reception at the ED until discharge and were interviewed prior to leaving the hospital Participants were contacted one week post discharge from the ED
Kihlgren et al. (2004)
Cross et al. (2005)
Sweden
UK
N = 20 Elderly ED patients Gender: 14$, 6# >75 years
N = 11 Adult ED patients Gender: 5$, 6# Age range: (20–74)
Interviews
J. Gordon et al.
ECU: Emergency care unit.
Visually impaired persons’ group: N = 16 Women’s group: N = 11 Elderly persons’ group: N = 11 Vietnamese group: N = 8 Spanish speaking group: N = 12 Youth focus group: N = 10 Mental health support group: N = 15 Carers support group: N = 8 Young mothers support group: N = 7 Aboriginal persons focus group: N not recorded
The patient experience in the emergency department: A systematic synthesis of qualitative research conditions (Nystrom et al., 2003b). Complaints were directed toward relatives or to the researchers but rarely towards staff (Kihlgren et al., 2004). Another way in which this theme emerged in the studies was through patients’ sensitivity and concern for the need of other patients in the ED. Patients understood and accepted that patients who were critically injured or worse off than themselves would be seen first (Baraff et al., 1992; Britten and Shaw, 1994; Cross et al., 2005). Some patients also believed that children should be given special priority in the triage process (Cross et al., 2005). Communication and information Communication and the provision of information were reported to have an important impact upon the patients’ experience in the ED. Patients were appreciative and put at ease when given information (Britten and Shaw, 1994). This review found that patients wished for more information on all aspects of the ED visit. Verbal information as well as handouts or notices in the waiting area on the triage process and waiting times were advocated by patients (Baraff et al., 1992; Britten and Shaw, 1994; Stuart et al., 2003). Stuart et al. (2003) suggested that a large proportion of the community was unfamiliar with the ED system and the triage process and therefore would benefit from this form of education. In particular, the elderly were not familiar with the processes in the ED (Baraff et al., 1992). Studies of elderly populations (Kihlgren et al., 2004; Watson et al., 1999) advocated that understandable, non-medical language be used in the provision of information. The patients in these studies specified that they disliked being spoken down to and patronized. Patients needed to have frequent personal contacts to be advised as to what is happening (Watson et al., 1999). More information on tests, diagnosis, the patient’s condition, treatment and technical procedures including what these procedures would be like for the patient and how they would feel afterwards, should be routinely presented to the patient. ‘‘It would be helpful if the nurses could tell you why you are waiting. I like to know the reason that I am waiting.. . .Keep me informed about the cause of the waits’’ (Watson et al., 1999, p. 89). ‘‘I would have just liked a little bit more information on what they were doing to my body and what medication
Table 2
85
they were putting me on and what injections they were giving me. I wanted to know what that was for and no one told me’’ (Britten and Shaw 1994, p. 1214). With regards to patients answering questions and giving information, many of the questions asked were perceived to be ‘stupid’, unnecessary or irrelevant. Patients felt they were repeating themselves to multiple different health professionals indicating a lack of communication between professionals within the ED (Britten and Shaw, 1994). The patients pointed out that it was difficult to answer questions when one was not feeling well (Britten and Shaw, 1994).
Waiting Waiting was a significant factor influencing patients’ experience of the ED. Waiting featured prominently in most of the articles reviewed. Waiting was broader than the issue of waiting for initial assessment. Much of the waiting experienced was waiting to go to X-ray, for test results or for review by the physician. The extent to which waiting influenced the patients’ experience was not solely associated with the length of the wait but also information given on why they were waiting and how long they were expected to wait, the environment and comfort of their wait and their interaction with staff during their wait. The presence of family, friends or carers was an important factor influencing how they experienced waiting. ‘‘The only thing is the big space of time between what they do and when you get to go to x-ray and all those other things. . ..There was an extremely long wait between the lung scan and the ultrasound and the X-ray’’ (Watson et al., 1999, p. 89). ‘‘We laid there and we laid there and we laid there, and pretty soon the nurse came back in to say that it was still going to be another 30 minutes’’ (Watson et al., 1999, p. 89).
Family in the ED Friends or family were reported to play a significant role in caring for the well-being of the patient in the ED. In the stressful situation of the ED the next-of-kin provided company, eased loneliness and alleviated anxiety. Having someone to talk to helped to pass the time more agreeably. The
Results of search strategy.
Database
Search strategy
Number of hits
Met inclusion and exclusion criteria
CINAHL
1 2 1 2 1 2 1 2 1 2
74 225 523 (all fields) 247 (title-Abs-Key-Auth) 63 143 0 2 54 109
3 7 10 8 4 8 0 0 4 4
Scopus PUBMED AMED Medline
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J. Gordon et al.
next-of-kin often took on the role of patient advocate asking questions on the patient’s behalf, fetching help when needed or at least giving patients the confidence of feeling that they would deal with problems if they arose. According to Nystrom et al. (2003b) the next-of-kin is forced by the system to take on the task of monitoring the patients’ medical conditions. ‘‘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’’ (Nystrom et al., 2003b, p. 24).
Emergency environment The ED environment was criticized for a number of reasons, the predominant complaint being about the hard and uncomfortable beds and trolleys (Baraff et al., 1992; Britten and Shaw, 1994; Kihlgren et al., 2004; Nyden et al., 2003; Watson et al., 1999). The waiting room was also brought under criticism, being described as uncomfortable, frightening, oppressive, claustrophobic and in need of refurbishment and facilities for children (Britten and Shaw, 1994; Stuart et al., 2003). The lack of auditory and visual privacy was an issue for some patients (Britten and Shaw, 1994; Baraff et al., 1992), exacerbated by the crowded and busy nature of the ED. Other people in the ED, especially those perceived to be drunks, drug addicts or in a great deal of pain, were reported to upset patients (Britten and Shaw, 1994). Other complaints included that the ED was dirty,
with scuffed linoleum floors, and that toilets were filthy or vandalized. Especially elderly patients were cold and hungry when they arrived at the ED, wanting to be given something to eat and drink (Kihlgren et al., 2004; Nyden et al., 2003) and to be given blankets to keep them warm (Baraff et al., 1992).
Discussion Table 2 displays the results of the literature search conducted, illustrating how the search strategies led to the articles being included in this review. With overlap between the databases the systematic literature search uncovered twelve reports relating to patient experience within the ED potentially eligible for review. These twelve articles were classified using Sandelowski and Barroso’s Typology of Qualitative Findings (2003), which classifies studies on a continuum from ‘No finding’ to ‘Interpretative explanation’ (Fig. 1). This typology emphasizes the difference between qualitative research and research that simply uses qualitative data and/or data collection or analysis techniques commonly perceived as qualitative. Discussion between researchers resulted in consensus regarding classification (see Table 3). The articles by Wellstood et al. (2005) and Watt et al. (2005) were excluded from the study on the basis of being ‘Topical Surveys’ and therefore are not classified as qualitative research on this continuum. According to Sandelowski and Barroso (2003, p. 911), topical surveys are ‘‘characterized by the emphasis on nominal or categorical data, or lists or inventories of topics covered by research participants in interviews and focus groups’’. This is illustrated by the following quotation from Wellstood et al. (2005, p. 2369), ‘‘the results demonstrated that individuals under the age of 65 had an average of 2 negative experiences while individuals over 65 had 1.’’
Quality appraisal
Figure 1 Typology of qualitative findings (Sandelowski and Barroso, 2003, p. 908).
Table 3
The remaining articles were critically appraised, using quality standards adapted from Law et al.’s (1998) critical review form, with appraisal informed by Sandelowski and Barroso’s ‘Guide for Reading Qualitative Studies’ (2002). When considering the findings of this review the quality and limitations of the articles included is important. Appraisal was not done, however, to exclude studies, as according to Sandelowski et al. (1997), studies should not be excluded for reasons of quality due to the wide variations in concep-
Classification of studies.
Classification
Number of studies
Studies
No finding Topical survey Thematic survey
0 2
Conceptual/thematic description
4
Interpretative explanation
0
Nil Wellstood et al. (2005)Watt et al. (2005) Baraff et al. (1992), Britten and Shaw (1994), Watson et al. (1999), Stuart et al. (2003),Kihlgren et al. (2004), Cross et al. (2005) Olsson and Hansagi (2001), Nystrom et al.(2003a,b), Nyden et al. (2003) Nil
X X · X · X X X X X · X X · X · X X X · · · · X X X X X X X · · · · X X X X X · X X X X X X X X X X X X X X · X X X X X · · · · · · · · · · X X X X X X X X X X · · · X · · · · X · X X X X X X X X X X · X X X X X X X X X X X X X X X X X X X Baraff et al. Britten and Shaw Watson et al. Olsson and Hansagi Nystrom et al. Nyden et al. Nystrom et al. Stuart et al. Kihlgren et al. Cross et al.
Purposive sampling Purpose and problem clearly identified Citation
Table 4
Quality appraisal of qualitative literature proved difficult due to the lack of consensus regarding assessments about qualitative research (Leininger, 1994). In light of the difficulty of analysis of quality, Table 4 was constructed to display the presence or absence of quality standards adapted from Law et al.’s (1998) qualitative critical review form from McMaster University, Canada. Member checking, which refers to the process of returning the transcripts or findings and interpretations to the participants in order for them to judge how well these represent what they said, or how well they fit with how they experienced the phenomenon, was not reported by any of the studies. Triangulation and saturation of data were also poorly represented within these studies. One of the more recent studies, Kihlgren et al. (2004), was the most rigorous in the inclusion and reporting of the quality criteria represented in the table.
Quality appraisal of literature.
Results of the quality appraisal
Relevant literature reviewed
Triangulation
Saturation of data reached
Inductive analysis
Member checking
Site adequately described
Participants adequately described
Theoretical perspective identified
Awareness of the re-searcher’s impact on study displayed
Study design identified
Analysis and integration of findings The model used to integrate the findings of the articles within this review was qualitative, descriptive meta-synthesis as described by Schreiber et al. (1997). This model encouraged a broader look at the phenomena of the patient experience within the ED, allowing for exploration of the extensive factors influencing the experience. The analysis used the process of translation as proposed by Noblit and Hare (1988). Translation involves determining how the various studies are related by deconstructing the findings into key metaphors, phrases, ideas and/or concepts used in each account and juxtaposing related concepts. In order to do this the studies were read and re-read and key metaphors, phrases and concepts were noted from each study. These concepts were transferred into table format in which those phrases or ideas which seemed in some way linked could be compared within and between studies. For example, Nystrom et al. (2003b) concept that ‘nurses’ approach is similar to a ‘conveyor belt in industry’ seemed to be highly related to Kihlgren et al.’s (2004) finding that ‘a medical– technical culture was dominant at the ED’. The next step was to translate the studies’ findings into the terms or metaphors of the others and vice versa, while maintaining the relationships and respecting the holism of the original studies. Following the same example, it was considered that the concept of ‘a medical–technical culture’ was a more apt and inclusive concept to use in the synthesis than the ‘conveyor belt’ metaphor to understand the patient experience. Finfgeld (2003) notes that synthesis within the descriptive model does not generally involve deconstructing the studies’ findings. However, the reviewers felt that the process of translation did not interfere with the descriptive intent of the synthesis.
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Method trans-parent
Audit trail of data analysis
tions of what is high quality qualitative research. Appraisal of quality was incorporated within this review to allow the reader to compare the studies’ inclusion of certain qualitative criteria. The quality appraisal criteria were applied independently to all studies by the principal researcher and a second reviewer. The reviewers then conferred and discussed any discrepancies until consensus was reached about the quality of an article.
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The patient experience in the emergency department: A systematic synthesis of qualitative research
87
88 The relative paucity of qualitative studies of the patient experience in the ED may be due to the methodological difficulties of conducting in-depth research within the ED, and the appeal of producing the ‘‘statistical signifiers of efficacy’’ (Nairn et al., 2004, p. 163). However, in quantifying the patient experience many survey methods reduce the patient experience to a set of figures representing responses to predetermined issues (Nairn et al., 2004). Satisfaction studies need to understand many factors and influences, qualitative methodologies have the ability to do so.
Conclusions Research in the area of the patient experience in the ED is dominated by quantitative measurements (Nairn et al., 2004). The small sample of qualitative articles in this review adds valuable depth and a more human perspective to the broader literature, acknowledging the very multidimensional nature of the ED experience. In line with the descriptive intent of this synthesis, five categories derived from the 10 qualitative studies illustrate the patient experience in the ED. These five categories are emotions of emergency, staff–patient interaction, waiting, family in the ED, and emergency environment. The studies considered were published across a large time span (1992–2005), various countries (United Kingdom, United State of America, Sweden and Australia) and provided consistency in their findings. What does emerge is good nursing care as described by patients. Patients appreciate the context of the ED and reported a sense of emotional urgency when attending. The expectations of technical competency from the health professionals underpinned other perceptions. Patients were able to trade off or display personal tolerance for waiting times or perceived abruptness to receive attention. However, valued and at times described as ‘‘good nursing care’ was a caring approach, explanations of what was occurring and putting the patients at ease in a stressful setting. This may be indicative of the fairly basic needs and wishes of patients in the ED and the persistent prevalence of circumstances in EDs such as overcrowding and delays in attention from health professionals.
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