Barriers to nursing care in emergency wards.

BACKGROUND: Caring is the essence of nursing. Since care is influenced by cultural, economic, and social factors, various diverse barriers exist in the realization of care. The aim of the study was to clarify barriers to caring in emergency patients based on experiences of nurses and patients and their relatives.
MATERIALS AND METHODS: A qualitative design of content analysis was used to identify the barriers to caring in emergency patients. In-depth interviews were conducted with 18 Iranian nurses working in a university hospital emergency ward and with seven patients. Participants were selected purposefully. Data were analyzed according to qualitative content analysis.
RESULTS: After the classification analyses and integration of codes, seven categories were acquired. Finally, following three themes were extracted: Identified barriers to nursing care in emergency wards - the nature of critical ward, performance weakness of nurses, and deficiency in clinical management.
CONCLUSIONS: According to the results of this study fundamental and management education for nurses, empowerment of nurses, principle and scientific triage, effective supervision, nurses' support, wage increase, and motivation in nurses are important to achieve the research purpose.

INTRODUCTION

The concept of caring has a special place in the nursing literature. Caring is the essence of nursing by renowned nursing scientists, including Laynyngr, Pender, and Watson.[1]

Nurses, as the largest occupational group in the national health science, have an important role in enhancing quality of care and patient safety by helping to identify safety problems and implementing solutions.[2]

Some studies identify and describe operational and financial barriers to resolving the crisis ED crowding, along with a variety of institutional and public policy strategies proposed or implemented to overcome those barriers.[3]

Almost and Laschinge mentioned that weak performance of the nurse managers is due to the reduction factors motivated nurses and only considered the implementation of medical orders in their work.[4]

A study by Kihlgren et al. in Sweden on taking care of elderly patients in the emergency department was done and the results showed that emergency department nurses must have knowledge and deep understanding of the position of patient in the community. Emergency nurses must take proper responsibility to take care of patients, and should have special attention to care. Also, this group of nurses should have enough experience in caring and know that such patients need different care than other patients.[5]

A study by Beckstrand et al. in USA about nursing care perceptions about patients in the emergency department showed that the range of care in the emergency department was very broad. Many factors are involved in caring in this area. Colleagues and the environment are important factors for ED.[6]

Another study by Curtis and Wiseman in Australia about care in the emergency department reported that the relationship among various parties involved in patient care is one of the pillars of emergency care. Thus in the emergency department nurses must communicate effectively with patients, their own colleagues, and other care providers.[7]

Background in Iran

In Iran countrywide, over 70,000 nursing staff have been employed to provide nursing care in Iranian hospitals. Nursing is the largest healthcare profession in Iran responsible for the care of their patients.[8] Road traffic accidents are considered to be the second highest cause of mortality in Iran.[9]

All teaching hospitals in Iran have at least one ED according to the Iranian ministry of health. All EDs must treat all patients with emergency conditions and provide emergency care for all age groups with varied complaints. Teaching hospitals provide patients with low cost services; therefore, many patients seek medical and nursing care from the teaching health care facilities. On the one hand, hard working conditions and hospital overcrowding result in nurses’ lack of interest to work in EDs. On the other hand, general nurses who have not passed any additional emergency care course are employed in EDs.[10]

Overall studies on barriers to care in the emergency department so far are not substantial. Since care is affected by cultural, economic, organizational, and social factors, various obstacles in the realization of care may exist. It is necessary that the whole process-oriented and qualitative approach should be adopted to investigate. This study was designed to carry out a qualitative investigation with the aim of identifying barriers to care in emergency patients from views of nurses and patients.

MATERIALS AND METHODS

Design, participants, and settings

This study to be designed to acquire the answer to the basic question: What are barriers to patient care in an emergency department from the nurses, patients, and their relatives? The study was done with the qualitative approach and content analysis method. Research participants including nurses and patients in emergency departments were selected purposefully. The nurses and patients in the emergency department who had interest and tendency to describe their experiences for the researchers were selected. The study was carried out in the second half of 2010 in a selected hospital in Tehran.

Data collection

The main method of collecting data in this study was nonstructured interview and use of open questions. Also, the field notes method was used. Interviews were done individually in calm environment and at good time and proper place. Interviews with 23 participants reached the saturation. To ensure authenticity of information, two more nurses were interviewed. With informed consent from participants, according to their willingness or the need for future interviews, their address and phone number at the end of the interview were recorded. Interviews with nurses initially began with general questions. For example, how long do you work in this section? Please explain your working day to me? In your daily activities for patients what problems do you face? How the problems are affecting your work? Questions asked from patients and their relatives included: What was your main problem? How nurses deal with your problem? Why you and nurses couldn't help to solve your problem? For knowing the depth of problem, of questions were asked further. For example in this regard, please can you explain further? What's this? Why? What is your view about it? Questionnaire was organized in order to aim the research question. Because, the recorded data immediately used by the researchers for qualitative research. Interviews were recorded with the consent of participants, and were then immediately transcribed word for word was. Eighteen nurses participated in this study. Nurses who had at least 6 months worked in the emergency department were included. Interviews were taken in one to two different sessions. Other criteria for inclusion included having the minimum degree of nursing technician. The location of interview was near to the place of nurses’ work. The average duration of each interview was 49 minutes. Interviews continued until data saturation. All interviews were conducted by one interviewer.

Data analysis

Qualitative content analysis was used as the research method. This approach was used to subjective interpretation of data. In this method, through systematic classification process, Codes and themes were identified. Content analysis is beyond objective extraction of content. In this way we could reveal the themes and hidden patterns from within the content data from the study participants.[11]

In this study, data collection and analysis were performed concurrently. From the recorded interviews, transcription was carried out and reviewed several times. Then the initial codes were extracted. The initial codes that were related to each other were placed in a category. After that the categories were used to shape relevant themes. Then, each of these potential themes was reviewed. Themes of the each participant was then adapted with the recorded interview. Finally, it was modified and the final theme was then defined.[Tables 1 and 2]

Table 1

Themes of the each participant

Table 2

Themes of the each participant

Trustworthiness

To validate the content of this study, codes extracted from the participants and also by the two independent researchers were evaluated. Informed consent, anonymity, confidentiality, right to withdraw during the study, and other moral obligations were considered. Throughout the process of collecting and analyzing data, any new ideas that came to mind of researchers were recorded and were used for the next interview.

During this study the method adopted was carried out in a manner to ensure the accuracy and reliability of data. Credibility, dependability, fittingness, and confirm ability are the criteria for scientific accuracy in qualitative research and were taken care of to utmost extent in this study.[12]

One of the best ways to build credibility is long-term involvement with the issue. In this study, researcher for 15 years has been involved with subject of research and emergency patients. The researcher before the study and during the investigation as a nurse and instructor in the emergency department has also been present. Before and during the research, the researcher always had communication and good interaction with the participants. Before the interview the researcher was a colleague of the participants. As the study progressed, participants’ trust was also gained by the researcher. Proper space was provided for performing interviews. Member check was done with participants. An external check was done with supervisors. For this purpose, sections of the interview text with relevant codes and emerging categories were sent to some observers. For evaluation, the flow analysis was done for their accuracy.

For confirming the accuracy, the acquired results were compared with the number of nurses who did not participate in research. They were confirmed authenticity of the findings. In this study the sampling technique with the maximum variation that helped in getting authentic data and transferability of findings was considered. Also, for confirming and auditing the research findings, various steps of the research process were exactly recorded and reported so as to be possibly used for follow-up for other researchers in future.

Ethical considerations

This study is a part of the results of an approved nursing PhD thesis at the Faculty of Nursing of the Baqiyatallah University of Medical Sciences that was approved by the university ethics committee. Before starting work, permission was acquired from relevant authorities. Interview timings were coordinated previously with the participants as to avoid any interference in their daily professional activities.

RESULTS

Interviews were taken from 18 nurses (average age 28.8 years, range, 23-49 years). Seven patients were involved in the study. In the first stage, over 821 first level codes extracted. After the classification and integration, seven categories were acquired. Finally, three themes were extracted. The resulting themes included the nature of critical ward, functional weakness, of nurses and failure in management.

The nature of the critical ward

The nature of stressful crowded environment and conflicts in the emergency department is one of the major barriers recognized in providing optimal care. This theme consists of the three categories including stress barrier in caring, crowded barrier in caring, and conflict barrier in caring.

Stress

Stress has been recognized as a barrier in the realization of caring. Stress that interferes with the nurses’ professional activities, and created panic, was a cause of dysfunction and loss of nurse's efficiency at work. An experience of one of the participants is given below:

“My colleague was quite nervous. He took the file and went towards the head of a patient. Again he went there, without doing anything and my colleague because of the intensity of stress could not do anything.” [A nurse with 11 years’ experience]

A source of stress in nurses in the emergency department is multitude of responsibilities and accountability to people and different resources. An experience of one of the participants is corroborated issue:

“I as a nurse must be held accountable for smallest default. Most of the stress is related to being at the same place. If the nurses do not control their stress, they can even mislead the physician.” [A nurse with 18 years experience]

Stress does affect all professional activities of nurses as one of the nurses says:

“Stress can seriously affect all the activities of a nurse. For example, to give drug, I have serious problem. To check physician's orders I have difficulty. I face trouble in the checking.” [A nurse with 14 years experience]

Crowding

One of the factors that participants had remembered as a barrier in caring and more about the nature of the emergency department was crowd. Usually patients arrive in the ward with few friends or relatives. High workload should be done in limited time. This condition causes loss of the quality of care, reduced accuracy in caring, nursing errors, confusion in the patient and accompanying person, and even death of the patient. Participants expressed these things with different experiences:

“Due to crowding, care is not possible to be done properly. For example, the heart patient who died recently in the ward was attended in a very busy environment.” [A nurse with 26 years experience]

Patients and their relatives also complained of this type of situation. Their experiences are expressed as:

“There was no systematic way to attend me. They must take delivery of the patient, and perform the tests. It was all over crowded.”[Patient 7]

Nurses conflict with the patient and accompanying the patient

Another issue that caused intensified critical condition in the emergency department is stressful conflict with the nurses. From nurses’ point of view it is a long time issue and the incidence of conflict is an obstacle in the provision of timely care. Some of the relatives, because of an argument, lead to threats and sometimes beatings, and were involved with nurses and this is a major barrier in nursing work. The experience of participants’ shows that indeed it is:

“One of persons accompanying the patient fainted as soon as he saw the blood. I wanted to attend to patient and secure IV line. The IV line of the patient had leaked. The patient's hand and arm became bloody. As soon as I returned, I was confronted by the second relative of the same patient. Now if I was not attending to the first accompanying person of that patient, the other one was yelling at me, forcing me to attend him… I did not know what I should do.” [A nurse with 8 years experience]

In addition, the problem of conflict reduces useful time that nurses spend for caring. Also calmness and stability of the nurses is affected.

“Because most conflict is due to accompanying persons, patient don't conflict or fight with the nurses. In this situation, you are around the patient but you cannot do anything for the patient. [A nurse with 18 years experience]

Performance weakness of nurses

Another theme that was inhibiting effective and beneficial care in nurses in the emergency department was nurses’ functional weakness. This theme was extracted from three categories that include fatigue, indifference, and ineffective triage.

Fatigue of nurses

Fatigued nurses that could be affected by the critical nature of emergency ward are obstacle in performing effective and comprehensive care. Fatigue reduces a nurse's accuracy in caring. Participants’ experiences are suggestive of this issue.

“Of course, nurse fatigue and insomnia decrease accuracy in caring.” [A nurse with 15 years experience]

“Nervous exhaustion is more powerful than physical fatigue. Nervous exhaustion causes the speed ​​and accuracy in caring to come down.” [A nurse with 14 years experience]

Indifferent attitude of nurses

Indifferent attitude of nurses that could affect the critical nature of emergency ward are obstacle in performing effective and comprehensive care. Negligence resulted from the failure of such attitude of nurses toward the patients. This situation was understood and felt by the patients’ negligence their dissatisfaction. Experience of patients represents the subject:

“A team that shifts on Friday neglected their work. I said that I have fever. One of the nurses’ assistances was sent to me. However, afterwards nothing was known, no practical action was taken.” [Patient 4]

Ineffective triage

Ineffective triage was a barrier in caring. So patients were led to admissions in nonemergency sections or wards and thus immediate or necessary care was delayed and/or disrupted. Nurse say about it:

“A patient with a double forearm fractures were referred at first to general physician. Four hours were wasted until making up splint. If it was done by appropriate triage, this time wouldn't be wasted.” [A nurse with 14 years experience]

Deficiency in clinical management

Another factor mentioned by the participants which was introduced as a barrier in caring was management failure. This theme is composed in two different categories which include ineffective management and low salary.

Ineffective clinical management

Participants in this study repeatedly mentioned about inappropriate supervision, lack of motivation, absence of effective law enforcement, almost no management support and nonadherence to basics of nursing management.

Shallow and nonprofessional supervision, leads to cynicism, mistrust and reduces nurses’ motivation to cooperate with management.

“Unfortunately, the supervisors don't care about the quality of work criteria. Instead, they monitor the basic nursing work; their attention is mainly for routine work.” [A nurse with 10 years experience]

The existence of discrimination in the supervision and lack of law enforcement causes lapses in attention and lack of trust among nurses toward management in the emergency. One of the nurse's experiences confirms this issue:

“One of the physicians who were resident in hospital came visit the patient after 4 hour's delay. Therefore, the patient care was delayed. Unfortunately, the hospital manager did not want the doctor to explain why the late come.” [A nurse with 15 years experience]

Lack of manager's support and inefficient management for nurses led to conflicts with those nurses who have been inattentive in their work.

“Necessary and legally ordained practical help when corpses are being transferred is lacking from management and sometimes accompanying family members get emotional and harsh with the security and they get physical with them. Unfortunately there is no support system; even the nurse's office provides no support.” [A nurse with 4 years experience]

The patients also complain. They state that usually no one is responsive to them. Their work is not followed properly. The experience of a patient represented this issue.

”Came to the emergency, It was very crowded. Workload was high, so the workload was not compatible with the available staff. There was no system that would deliver me. No one answered my questions and responded to my call.” [Patient 2]

Negligence and lack of compliance of some nurses with management were other issues that some nurses mentioned. One of the nurse's experiences confirms the issue:

“Some of the staff members are negligent although they have several years experience of working in the emergency ward, but they don't work. How many times should you ask them to do a task?” [A nurse with 11 years experience]

Low salary

Nurses participating in this study indicated that the wages they are receiving were not appropriate for the amount of work they are doing. Additionally, the amount paid was not appropriate to the amount of stress they were undergoing during the work. The nurses complained of less amount paid to them. Participants also expressed that less income and inappropriate distribution of wages reduced their work motivation. One of the nurses’ experiences confirms this important issue:

“Income is not appropriate for the amount work that nurses do. When I was known that by working further contribution to my great, I work better and more motivated.” [A nurse with 15 years experience]

Nurses laid emphasis that their salary was less than what they were doing and this matter caused disappointment. Nurses emphasized on the elimination of discrimination that existed in their income.

“Compared to the stress that I undergo in the emergency department, my wage is low. Wherever wage is more, nurses go there. The wages should be different for the nurses who work less and those whose work is more in emergency department. If the wage is appropriate, nurse will not leave emergency ward.” [A nurse with 28 years experience]

DISCUSSION

This study reviewed barriers to care from the perspective of emergency department nurses, patients, and their relatives in one of the main hospitals in Tehran. This study shows that several factors related to nursing, clinical management, and the innate nature of the emergency care profession can serve as a barrier.

Beckett and colleagues in their study expressed that the nurses’ lack of time, shortage of nurses, low value of their professional activities and low motivation have always been a significant barrier for nurses.[13]

Among the four factors proposed by Beckett, two factors nurse shortage and low motivation were similar in our study, but two factors shortage of nurses’ time and low value of nursing activities is different from results of our study. It seems that the cause of similarity is the similar nature of caring in different locations and the cause of difference is that the environments’ care is different.

Hajbaghery quoted studies of Laschinger and his colleagues from 1996 to 2001 which show that shortage of nurses in emergency wards is a structural variable that puts pressure on nurses and leads to feeling of dissatisfaction, incontinence, and helplessness.[14] It seems that the shortage of nurses is a global problem and almost all of caring environments are somewhat involved in it.

In our study one of the barriers to care has been nursing management issues. Other studies have shown that increased costs of caring, reduction in the number of professional nurses, and use of untrained nurses or employment of other medical staff instead of expert nurses have adverse impact on the quality of care.[15]

However, several studies have reported that workplace conditions, giving value to nurses by managers and team collaboration, have a major positive impact on the development of nurses’ professional performance.[16171819]

In a study that was conducted by Judkins in one of the medical centers in the Victoria, Australia, satisfaction levels, after changes in the physical environment and caring of patients, were clearly improved.[20] These findings suggest that the managers need to create a favorable working environment, give value to scientific evidence and decision making by adopting strategies for encouraging and strengthening positive supervision systems.

In our study the nature of the emergency unit theme with two categories, such as stress and crowding, has been suggested as a barrier to care. In the Woodhouse study it was shown that there are large fluctuations in workload in the emergency department which makes it difficult to predict and prevent problems such as changes in the transport of patients, whether it will require special services due to the difference distance and differences in the location of patients, rapid transfer of critically ill patients to specialized units by the nursing workforce and it decreased by 25% when the nurses are absent because of illness.[21]

It seems that the unpredictable nature of the emergency department is because of crowding, nursing shortage, and critically ill patients and this is not unique and is also found in other environments leading to the stress. Bennett et al., Melnyk et al., and Nagy also reported that the lack of time and a large number of patients are barriers in the nursing for use of research evidence in the care.[172223]

In another study by Healy and Tyrrell, in Ireland about Stress in emergency departments, experiences of nurses and doctors showed that the effects of stressful incidents on the emergency department staff can be profound.[24]

In the study conducted by Greenfield et al., stress and workload were considered the most important factors to nursing. Additionally, these researchers have shown that the conduct of emergency clinical tasks for patients and dealing with dying patients, and similar professional stressors reduce the quality of patient care.[25]

A study by Kihlgren and colleagues in Sweden reported the effect of caring for older patients at an emergency department, on emergency nurses’ reasoning. The results showed that emergency department nurses must have knowledge and deep understanding of the elderly in the community. Emergency nurses have the responsibility toward patients and must have to special attention to care. Also the nurses have experience in caring, and should know that elderly patients’ needs are different.[5] Considering that in our study, conflict is one of the barriers to care. It seems that the cause of conflict has been lack of complete attention to the patient and lack of complete attention to different aspects of caring.

Several factors such as crowding, stress, fatigue, sleep deprivation, high working pressure, and the presence of multiple diverse stimuli in the environment can cause loss of accuracy in the night working nurses and have been reported as a barriers to effective care.[26] Also in another study ineffective triage has been reported as a barrier to effective care.[27]

As we can see that the results of our study are compatible, it seems that the same nature of care in different environments is affected by several factors and affects professional competence in care.

Additionally, in a study by Curtis and Wiseman conducted in the Australia, communication was introduced as one of the pillars of emergency care. This study investigated other aspects of care such as the effect of a special place for patients who need more time in the emergency department, attention to the social and psychological status of patients, pain relief, and controlling the infection. Thus in the emergency department, nurses should pay special attention to effective communication with patients and their relatives and other care providers.[7] Considering that in our study conflicts in the emergency ward is one of the barriers to care it seems to cause conflict and lack of comprehensive attention to the meaning or concept of care in the emergency department.

These findings indicate that barriers to emergency care are the very nature of the emergency department including stress, crowding, and involved. Also ineffective clinical management and deficiencies in the performance of nurses have been the other barriers to care in the emergency department. Based on these findings management education for nurses, empowerment of nurses, principle and scientific triage, an effective supervision, nurses’ support, wage increase, and motivation in nurses can be a step forward to eliminate barriers to care for patients in the emergency department.

LIMITATION

According to the characteristics of qualitative studies, generalization the results of this study is limited to specific environment of an emergency ward and therefore more studies are recommended to identify the barriers to effective and timely emergency care.