Being a patient in a crowded emergency department: a qualitative service evaluation.

BACKGROUND: Emergency department (ED) crowding causes increased mortality. Professionals working in crowded departments feel unable to provide high-quality care and are predisposed to burnout. Awareness of the impact on patients, however, is limited to metrics and surveys rather than understanding perspectives. This project investigated patients' experiences and identified mitigating interventions. METHODS: A qualitative service evaluation was undertaken in a large UK ED. Adults were recruited during periods of high occupancy or delayed transfers. Semi-structured interviews explored experience during these attendances. Participants shared potential mitigating interventions. Analysis was based on the interpretative phenomenological approach. Verbatim transcripts were read, checked for accuracy, re-read and discussed during interviewer debriefing. Reflections about positionality informed the interpretative process. RESULTS: Seven patients and three accompanying partners participated. They were aged 24-87 with characteristics representing the catchment population. Participants' experiences were characterised by 'loss of autonomy', 'unmet expectations' and 'vulnerability'. Potential mitigating interventions centred around information provision and better identification of existing ED facilities for personal needs. CONCLUSION: Participants attending a crowded ED experienced uncertainty, helplessness and discomfort. Recommendations included process and environmental orientation.

Emergency department workforces' experiences and perceptions of well-being from an international perspective: a scoping review.

OBJECTIVES: To identify and present the available evidence regarding workforce well-being in the emergency department. DESIGN: Scoping review. SETTING: The emergency department (ED). DATA SOURCES: CINAHL, MEDLINE, APA PsycINFO and Web of Science were searched with no publication time parameters. The reference lists of articles selected for full-text review were also screened for additional papers. ELIGIBILITY CRITERIA FOR STUDY SELECTION: All peer-reviewed, empirical papers were included if: (1) participants included staff-based full-time in the ED, (2) ED workforce well-being was a key component of the research, (3) English language was available and (4) the main focus was not burnout or other mental illness-related variables. RESULTS: The search identified 6109 papers and 34 papers were included in the review. Most papers used a quantitative or mixed methods survey design, with very limited evidence using in-depth qualitative methods to explore ED workforce well-being. Interventions accounted for 41% of reviewed studies. Findings highlighted pressing issues with ED workforce well-being, contributed to by a range of interpersonal, organisational and individual challenges (eg, high workloads, lack of support). However, the limited evidence base, tenuous conceptualisations and links to well-being in existing literature mean that the findings were neither consistent nor conclusive. CONCLUSIONS: This scoping review highlights the need for more high-quality research to be conducted, particularly using qualitative methods and the development of a working definition of ED workforce well-being.

'You're on show all the time': Moderating emotional labour through space in the emergency department.

AIMS: This is the second of two papers conceptualizing emotional labour in the emergency department (ED). This paper aims to understand the environmental 'moderators' of ED nurses' emotional labour. DESIGN: Ethnography, through an interpretivist philosophy, enabled immersion in the ED setting, gathering the lived experiences and narratives of the ED nurses. METHODS: Observation and semi-structured interviews over a 6-month period. Two hospital sites (one district general and one major trauma centre based in the United Kingdom. RESULTS: Over 200 h of observation plus 18 formal/semi-structured interviews were completed. Environmental, institutional and organizational dynamics of the emergency department instrumented the emotional labour undertaken by the nursing team. Time and space were found to be 'moderators' of ED nurses' emotional labour. This paper focusses on the relevance of space and in particular, 'excessive visibility' with little respite for the nurses from their intense emotional performance. CONCLUSION: Emotional labour is critical to staff well-being and the way in which healthcare spaces are designed has an impact on emotional labour. Understanding how emotional labour is moderated in different clinical settings can inform organizational, environmental and workforce-related decision-making.

"I don't have any emotions": An ethnography of emotional labour and feeling rules in the emergency department.

AIMS: This study aims to apply Hochschild's theory of emotional labour to emergency care, and uncover the 'specialty-specific' feeling rules driving this labour. Despite the importance of positive nurse well-being, the emotional labour of nursing (a great influencer in wellbeing) remains neglected. DESIGN AND METHODS: Ethnography enabled immersion in the ED setting, gathering the lived experiences and narratives of the ED nursing team. We undertook first-hand observations at one major trauma centre ED and one district general ED including semi-structured interviews (18). A reflexive and interpretive approach towards thematic analysis was used. RESULTS: We unearthed and conceptualized four feeling rules born from this context and offer extensive insights into the emotional labour of emergency nurses. CONCLUSION: Understanding the emotional labour and feeling rules of various nursing specialties offers critical insight into the challenges facing staff - fundamental for nursing well-being and associated retention programs. IMPACT: What problem did the study address? What were the main findings? Where and on whom will the research have impact? Academically, this research expands our understanding - we know little of nurses' feeling rules and how specialties influence them. Clinically, (including service managers and policy makers) there are practical implications for nurse well-being.

Insights into nurses' precarious emotional labour in the emergency department.

BACKGROUND: Nurses in the emergency department (ED) work in emotionally charged situations and undertake extensive emotional labour. However, that labour is not visible to others, often overlooked and therefore undervalued. Furthermore, there is a lack of literature on the topic. AIM: To explore ED nurses' experiences of emotional labour. METHODS: In-depth semi-structured interviews were conducted with two staff nurses working in the ED of a large UK teaching hospital. Rigorous methods of data collection and analysis, including a strong reflexive stance, were adopted. FINDINGS: Among three overarching themes that emerged from the data, two related more specifically to the ED: 'precarious emotional labour' and 'grieving etiquette'. Participants were found to perform sophisticated forms of emotional labour to manage the precariousness of their role, and to conceal or suppress their own feelings in order to maintain the grieving etiquette. CONCLUSION: The ED is an environment that requires sophisticated but precarious forms of emotional labour. Recognising, valuing and supporting the emotional aspect of an ED nurse's role is essential if emergency services are to remain functional, efficient and humane.

Psychodrama and Moviemaking in a Death Education Course to Work Through a Case of Suicide Among High School Students in Italy.

This study describes the psychological effects of an experience of death education (DE) used to explore a case of suicide in an Italian high school. DE activities included philosophical and religious perspectives of the relationships between death and the meaning of life, a visit to a local hospice, and psychodrama activities, which culminated in the production of short movies. The intervention involved 268 high school students (138 in the experimental group). Pre-test and post-test measures assessed ontological representations of death, death anxiety, alexithymia, and meaning in life. Results confirmed that, in the experimental group, death anxiety was significantly reduced as much as the representation of death as annihilation and alexithymia, while a sense of spirituality and the meaning of life were more enhanced, compared to the No DE group. These improvements in the positive meaning of life and the reduction of anxiety confirmed that it is possible to manage trauma and grief at school with death education interventions that include religious discussion, psychodrama and movie making activities.

A qualitative exploration of intentional nursing round models in the emergency department setting: investigating the barriers to their use and success.

AIMS AND OBJECTIVES: This research aimed to investigate the use of intentional rounding within in the emergency department setting through exploration of the staff nurse experience. The focus was its implementation at a large teaching hospital in England. BACKGROUND: Research into the use of intentional rounding in any area of practice is minimal in the UK; however, a broader evidence base comes from America. The majority of this research supports the notion of intentional rounding for improved patient care and outcomes. Research from the UK is generally more contested. There is less literature on using intentional rounding specifically in the emergency department setting. DESIGN: Qualitative methodological approach. METHODS: Semi-structured interviews (n = 5) were completed with staff nurses working within an emergency department. A purposive sampling technique was used for recruitment. The data was then analysed using 'Framework Method of Qualitative Analysis' (Spencer et al. 2014). RESULTS: The findings were categorised into four headings: (1) Improved patient experience, (2) Current unmanageability, (3) Adapting for the emergency department, (4) Benefits on achieving quality indicators and targets. CONCLUSION: The findings show that although staff felt the introduction of intentional rounding techniques could lead to improvements in patient safety and overall care experience, they also identified a range of difficulties and adaptations needed to ensure its success within this acute care environment. RELEVANCE TO CLINICAL PRACTICE: The research offers an insight into the staff's perceptions of using intentional rounding and also explains the practical difficulties faced by the nursing staff with potential suggestions that may help to address these problems. Benefits include more open communication between staff and patients and potentially more timely response to patient need, which positively impacts levels of safety and satisfaction. Barriers include lack of staff engagement, and the environmental factors and pressures, within the ED setting.

Containing families' grief: therapeutic group work in a hospice setting.

This article explores the literature relating to the needs of bereaved children and families and describes the course of a family bereavement group run in a hospice. The interventions involved dramatherapy and other creative arts media. The group comprised of four families all of whom had had a parent die in the hospice. Their ages ranged from 6-46 years. Two one-day workshops were followed by six closed-group evening sessions. The aims and interventions for each session are outlined and a short commentary on the process given. Significant aspects of containing families' grief through the use of therapeutic group work is highlighted.