Emergency Service Perceptions and Experiences of Patients: “Not A Great Place, But Not Disturbing”

Abstract

This study was conducted to determine the emergency department experiences and perceptions of a group of patients who applied to the tertiary emergency department. The study was carried out using a qualitative approach. Forty patients who were admitted to the emergency department were included in the study. Data were collected by face-to-face interview. The frequency count (f) and participant codes (P) were used for the presentation of the findings. The themes and frequency counts obtained by analyzing the interviews with the patients were as follows: “Uncertainty/Obscurity: Anxiety and fear (f = 108),” “Waiting/being patient (f = 39),” “Pain and procedures (f = 119),” “Doctor and nurse comforting attitudes (f = 98),” “Being treated and recovering (f = 48),” “Calm and comfortable environment (f = 14).” This study showed that the emergency department is generally perceived as a healing environment, the most important need of the participants is to relieve the anxiety and fear caused by the unknown and the pain they feel.

Introduction

An emergency is a situation that affects the well-being of society or individuals in the event of an unexpected injury, trauma, or illness. On the other hand, emergency departments are all services provided by teams that have completed their training in this field, either during transport or at the crash spot by health institutions and organizations (1,2). Emergency services are also defined as the departments provided by the health worker to protect the patient from death or permanent disability in cases such as sudden injury, accident, or illness. Since incidents called emergencies can be encountered at any time, emergency departments are provided 24 hours a day, 7 days a week (3). In order to provide effective care in emergency departments, qualified personnel with sufficient knowledge and skills should work (4).

Admissions to emergency departments have increased significantly in recent years. According to the statistics of the Public Hospitals Association for 2017, the number of applications to the emergency departments of the hospitals affiliated to the ministry is approximately 101 million people. Among all applications, the rate of applications made to the emergency department is 28.4% (5). Patients are thought to apply to emergency departments for different reasons, such as waiting less queues in emergency units than outpatient clinics, being able to receive service 24 hours a day, willing to do their work without losing much time, and not having sufficient knowledge about the concept of emergency (6). Ekinci and colleagues reported that the patients applied to the emergency department because they were working at the hours of the outpatient clinic service, they did not want to wait, and they had their analysis done in a shorter time (7). Besides, Öztürk observed that although patients did not consider their situation urgently, they applied to the emergency department (8).

Nurses working in emergency units determine the direction of health interactions between patients and the health system (9). Emergency department nurse provides the necessary nursing care in a short time and under different conditions to individuals who have not yet been diagnosed and need emergency interventions (10). However, emergency department nurse may have confusion in providing care because of limited time, busy working environment, and lack of a systematic nurse–patient relationship (11).

There is a gap in the existing published studies regarding the evaluation of emergency service experiences and perceptions of the patients. Therefore, this study was conducted to describe the perceptions and experiences of a group of patients who applied to the tertiary emergency department. The research question was determined as “What are the perceptions of the patients who applied to the tertiary emergency service and what did they experience?” It is thought that the results obtained will bring a different perspective to emergency department nurses and other health care professionals in terms of understanding patients better and providing quality care, will develop hospital institution policies, guide new studies, and contribute to the literature.

Materials and Methods

Study Design and Setting

We conducted the research was conducted with a qualitative approach and a phenomenological design between March and July 2018 in an emergency department of a university hospital in the west of Turkey.

Forty patients who underwent applied emergency department were selected as the sample by using a purposeful sampling method. Although 18 patients withdrew due to time constraints, the study was completed with 40 patients. In qualitative studies, there is no rule regarding sample size, and the criteria for the assignment of the sample size are the point at which the data start to replicate; in other words, when data saturation is reached (12). In order to obtain a large type and amount of data during sample selection, diversity was provided by including patients with varying characteristics in terms of age, work, education, and so on. The following criteria were determined by criterion sampling through a purposeful sampling observation: able to answer questions and being conscious, being above 18 years of age, applying to a tertiary emergency department, and volunteering to participate in the study. The descriptive characteristics of the patients are summarized in Table 1. Patients were aged between 21 and 65 years. Twenty-one patients were female, 19 were male, 31 were married. It was determined that 36 of the participants had previously applied to the emergency department for any reason. Although 28 of 40 participants stated that some of their existing complaints are still ongoing, it was defined that 12 participants did not have any complaints during the speech (Table 1).

Table 1.

Descriptive Characteristics of the Sample.

Participant no	Female						Participant no	Male
	Age	Education level	Marital status	Previously emergency department application history	Reason for application	Current complaint		Age	Educational level	Marital status	Previously emergency department application history	Reason for application	Current complaint
P1	35	Primary school	Married	Yes	Trauma-STI	Yes	P2	21	High school	Single	Yes	Pain	Yes
P6	38	University	Married	Yes	Pain	Yes	P3	46	Primary school	Married	Yes	Pain	Yes
P7	34	High school	Married	Yes	Infection	No	P4	36	High school	Single	Yes	Infection	Yes
P9	41	High school	Married	No	Trauma-STI	No	P5	55	Primary school	Married	Yes	Trauma-STI	No
P10	35	Primary school	Married	Yes	Pain	Yes	P8	28	University	Single	Yes	Trauma-STI	No
P11	65	Primary school	Married	Yes	Trauma-STI	Yes	P15	48	Primary school	Married	Yes	Trauma-STI	Yes
P12	49	High school	Married	Yes	Trauma-STI	Yes	P16	42	High school	Married	Yes	Pain	Yes
P13	35	University	Married	Yes	Pain	Yes	P17	41	High school	Married	Yes	Pain	No
P14	28	University	Married	Yes	Pain	No	P19	55	High school	Married	Yes	Trauma-STI	Yes
P18	52	High school	Married	Yes	Infection	Yes	P20	51	Primary school	Single	Yes	Infection	Yes
P22	52	Primary school	Married	Yes	Trauma-STI	Yes	P21	32	High school	Married	No	Pain	No
P25	48	High school	Married	Yes	Pain	No	P23	45	Primary school	Married	Yes	Infection	No
P26	33	University	Married	Yes	Trauma-STI	Yes	P24	26	University	Single	Yes	Pain	Yes
P28	44	Primary school	Married	Yes	Pain	Yes	P27	41	High school	Married	Yes	Trauma-STI	No
P30	30	University	Single	Yes	Infection	Yes	P29	32	University	Single	No	Infection	Yes
P32	55	Primary school	Married	Yes	Pain	Yes	P31	45	High school	Married	Yes	Trauma-STI	Yes
P33	58	Primary school	Married	Yes	Pain	Yes	P35	32	High school	Single	Yes	Infection	No
P34	29	University	Single	Yes	Pain	No	P37	40	High school	Married	Yes	Pain	Yes
P36	33	High school	Married	Yes	Pain	Yes	P39	55	High school	Married	Yes	Pain	No
P38	48	Primary school	Married	Yes	Trauma-STI	Yes
P40	58	Primary school	Married	Yes	Pain	Yes

Data Collection

Descriptive characteristic form consisted of 7 questions that aimed to obtain the demographic and other descriptive characteristics of the patients, including gender, age, educational status, previous emergency admission experience, diagnosis of the patient, and complaints.

Interview form consisting of 6 open-ended questions (Table 2). In-depth interviews with these questions tried to reveal the emergency department experiences of the patients. Each question had an alternative (probing questions). Answers to open-ended questions were recorded in the data collection tool. For the questions of Interview Form, opinions were taken from 4 specialists working in surgical diseases nursing, public health nursing, medical faculty surgical diseases department.

Table 2.

The Questions of Interview Form.

1. What did you feel during your time in the emergency department? What do you remember?

2. What bothered you the most during your located in the emergency department?

3. What made you most comfortable during your located in the emergency department?

4. What did you feel during your located in the emergency department? Can you talk about your feelings?

5. How would you describe “staying in the emergency department and receiving treatment” to someone in your circle?        What would you say?

6. Can you complete this sentence? Being in the emergency room……………………………………………….

Procedure

The interview form was prepared in terms of the comprehensibility and functionality of the questions for capturing the first impressions of the patients applied to emergency department the pilot implementation was carried out with 3 patients. The necessary revisions were made, and the data of the pilot implementation were not included in the analysis. Before the interview process, the patients were informed about the content of the study and purpose of how the data obtained were to be used. Written and verbal consents of the patients were obtained. Patients were interviewed in the observation room of the emergency department. The patients were interviewed when brought back to the observation room immediately after their most recent emergency department. Following the applying of the descriptive characteristics form, face-to-face interviews were conducted with the patients with the use of the interview form. A calm and quiet environment was preferred for the interview to be comfortable, and attention was paid to privacy. “In the following stage, furthermore information about the patients’ thoughts and feelings about the emergency department was obtained by directing appropriate supportive questions.” These questions were “What did you feel during your time in the emergency department?” “What do you remember about your time in the emergency department?” Although care was taken to continue the interview, which was planned as semistructured, until the data saturation was reached, there was a problem in terms of time due to the very crowded emergency department and patient circulation. For these reasons, a design from qualitative research approaches was not used in the study; however, qualitative question analysis in the data analysis process was carried out within the framework of an inductive approach. During the interviews, clarifications were provided at times where the participant had misinterpreted the question or difficulty in answering the question, and information was offered when necessary or additional brief reminders. In some cases where the participants tried to avoid sharing their experiences about a certain topic, additional questions that persistently attempted to broach that topic were avoided. The interviews took approximately 15 to 30 minutes. The patients were not compensated in any way for their time.

Ethical Considerations

Only volunteers were included in the study. Before the in-depth interview process, the patients were informed about the content of the study and purpose of how the data obtained were to be used. The real names of the patients who expressed their views during the study, and any additional information that could lead to the recognition of these patients were kept confidential within the framework of the ethical principles of protecting privacy. Each participant was appointed a unique code (P) to record and present their data; for example, P9 referred to Participant 9.

Data Analysis

In the analysis of the responses of the patients, coding was done first, then similar codes were collected in certain categories. Content analysis was performed to interpret and gather similar data within the framework of certain themes and concepts. This process was done in the form of prereading, coding of qualitative data, accessing themes, interpreting, reporting, and organizing the data (13). Categorical analysis technique was used in content analysis. Categorical analysis is the division of a certain message into units first and then grouping these units into categories according to certain criteria. NVIVO 12 Pro software was used for the data analysis. The frequency counts (f) and patient codes (P) were used to present the findings. One of the researchers (A.Ç.) was certified in qualitative data analysis. The authors emphasized accuracy, honesty, and self-confidence in the interviews and data analysis. The Consolidated criteria for Reporting Qualitative research (COREQ) checklist (Supplemental material) was used in the study report (14).

Results

The content analysis of the statements of 40 participants about their emergency department experience revealed 6 themes, which are shown in Figure 1 with their frequency counts. The expression “Not a great place, but not disturbing” used by participant 10 (P10) was determined as the main theme. Because this theme tag was an expression containing the meanings of all themes. Themes and frequency counts reached by analyzing the interviews with the participants: “Uncertainty/Obscurity: Anxiety and fear (f = 108),” “Waiting/being patient (f = 39),” “Pain and procedures (f = 119),” “Doctor and nurse comforting attitudes (f = 98),” “Being treated and recovering (f = 48),” and “Calm and comfortable environment (f = 14).”

Figure 1.

Themes revealed by the qualitative data analysis and their frequency counts.

Theme 1

“Pain and Procedures” (f = 119): This theme has received the most cited from the participants; in this theme, experiences are detailed. Participants emphasized that they felt pain during the procedure and due to their existing complaints.

Below are some excerpts related to this theme:

I feel like I’m going to die because of my pain. I pray to my God that no one falls to the hospital. The disease is very difficult and the person feels hopeless and helpless if he or she needs someone else. (P25, female, 48 years old, abdominal pain)

I felt pain, dizziness, anxiety, and restlessness. I wonder if I have anything serious, I was afraid would it hurt more. I had a feeling of pessimism and guilt…(P15, 48 years old, traffic accident—trauma)

The interventions made by the nurses and doctors…I felt pain because I was very afraid of the injection…the vascular access was opened. It was pretty frightening for me. I think it is a little messy around…(P30, female, 30 years old, infection)

Theme 2

Uncertainty/Obscurity: Anxiety and Fear (f:108): Emotional expressions were the most frequently expressed within this theme, which were cited 108 times from 40 participants. They also used various adjectives such as “fearful, anxious, hectic, depressed, unhappy, restless, boring, disturbing,” for a total of 78 times. Apart from these, the participants stated that they were curious about their current situation and felt helpless (f = 30).

Below are some excerpts from 5 participants on this theme:

X-rays were taken several times and my statement was taken. My shoulder and back hurt a lot. I think I have fractures so. I was a little scared and worried. I am working now, will I be able to go back to work. I have worries…(P9, female, 41 years old, traffic accident—trauma)

Firstly, I was anxious, unhappy and painful. I am a little better when my pains start to decrease with the medication. I’m feeling better now. (P16, male, 42 years old, abdominal pain)

I’m not very comfortable and I’m afraid…I still have worried about what will happen. I guess it won’t pass until I get home. (P30, female, 30 years old, infection)

I always prayed. I am worried but there is nothing else to do to relax. I wonder when my pain and numbness will go away. I have a neurological condition, I wonder if the pain is due to it or is there another reason? (P32, female, 55 years old, leg pain)

I felt anxious. I wanted to go back to my house. There are some uncertainties and I would like to be informed more. For example, I do not know what will happen after the medication is over and when I will go…(P34, female, 29 years old, backache)

Theme 3

Doctor And Nurse Comforting Attitudes (f = 98): This theme has received 98 cited. Participants stated that they were directly attended to (f = 40), explanations were made (f = 15), and the attitudes of the doctors and nurses relieved them (f = 43).

Below are some excerpts related to this theme:

Nothing bothered in terms of staff. Nurses and doctors are doing their job. God bless you. They always made a statement, took care immediately, but patients’ relatives should be quieter outside. (P4, male, 35 years old, traffic accident)

No, everyone is doing their job. I am only afraid of drugs and injections, just because it will hurt…so I was uncomfortable with the applications when I first came, but now I am fine, it was not what I expected…The nurse’s hand was light. (P19, male, 55 years old, acetabulum fracture—trauma)

The nurses and doctors made me comfortable, thanks. According to what they say I have nothing important except that…I am better now anyway. That’s why I feel comfortable. (P24, male, 26 years old, abdominal pain)

I was relieved after my wife came to my near. Because it’s hard here alone. Generally good at nurses and they talked with me and I relaxed. (P27, male, 41 years old, trauma)

My son is always with me, the nurses and doctors relieved my pain. Relieving my pain made me comfortable. (P33, female, 58 years old, abdominal pain)

Theme 4

Being Treated and Recovering (f = 48): This theme received 48 cited from 40 participants. Participants stated that they came for treatment and recovery (f = 28) and wanted to find a remedy and immediate recovery (f = 20).

Some excerpts related to the subthemes under this theme are presented below:

Being in the emergency department means first treatment and recovery, but also refers that fear for your health. (P4, male, 35 years old, traffic accident—trauma)

Being in the emergency department means looking for a solution to your pain and complaints. (P33, female, 58 years old, abdominal pain)

Emergency department means waiting for the light at the end of the road, that light means for me to come home, go out, be fine. (P34, female, 29 years old, backache)

Theme 5

Waiting/Being Patient (f = 39): In this theme, which received 39 cited from 40 participants. They used expressions about waiting in the emergency department were frequently. For example “to be patient (f = 18), weird, desperate (f = 21).”

Below are some excerpts related to this theme:

Waiting…the doctor didn’t come right away and I couldn’t get information. I wonder if I will have surgery or when. I do not know. I also had a lot of pain for a long time…(P3, male, 46 years old, traffic accident—trauma)

Waiting and not giving enough explanation bothered me…(P19, male, 55 years old, acetabulum fracture—trauma).

Those who will come to the emergency department should know that they will wait in queue. Don’t get depressed in the first stage because they will feel good with the attitude of doctors and nurses. (P1, female, 35 years old, soft tissue injury).

Theme 6

Calm and Comfortable Environment (f = 14): This theme received the least number of cited from the participants, with 14 cited. Participants used comfortable, calm, and safe environment expressions about the emergency department.

Some excerpts related to the subthemes under this theme are presented below:

Nothing bothered in terms of staff. Nurses and doctors are doing their job. God bless you. They always made a statement, took care immediately, but patients’ relatives should be quieter outside. (P4, male, 35 years old, traffic accident—trauma)

Nothing much bothered me around. My pain bothered me. Nurses and doctors doing their job. (P11, female, 65 years old, acetabulum fracture—trauma)

I am not a person who comes to hospital a lot. It was my first time in a long time and it was less crowded than I expected. This situation seemed a little strange to me. You know, emergency service is always complicated, it seemed calm to me. I had abdominal pain, I was relieved after the serum was inserted. Emergency department is a better place than I expected. (P24, male, 26 years old, abdominal pain)

Discussion

In this study, the emergency department experiences of the patients were examined, and it was determined that the emergency department is generally perceived as a healing environment, and the team has an important place in this perception. In a study, Mollaoğlu and Celik, it was found that in the emergency department, patients’ being able to reach nurses whenever they need increases patient satisfaction. In addition, the necessity of providing education and psychological support to patients outside of physical care was emphasized (15). Skaggs et al determined that patient satisfaction increased as a result of emergency department nurses providing care to patients with evidence-based practices (16). Similarly, in different studies, it was observed that patients were generally satisfied with the care provided in the emergency department (17 –19). Eroğlu also reported that the patients in the emergency department were satisfied with the nursing care provided (20). In contrast, a study by İnce and Bingöl reported that nurses were not sufficient to meet the psychological needs of patients due to their intensity and treatment-oriented work (21). In a study by Gül and Dinç examined that a higher number of patients than the number of nurses increases the workload of nurses and negatively affects patient care (22). Ensuring patient satisfaction in the emergency departments of hospitals is related to the quality of the service provided by nurses and physicians as well as all emergency personnel. In addition to the knowledge and skills of the emergency nurse, who spends one-on-one time with the patient, the professional stance increases the patient satisfaction with the quality of the care (23). Emergency services are the areas where patients first apply and where the first intervention is performed in hospitals. Nurses working here exhibit a professional attitude toward patients and approach them holistically while providing care, which will positively affect the patients’ perception of emergency departments.

Participants stated that they experienced feelings of anxiety and fear caused by the unknown in the emergency department. It is known that the emergency department can cause anxiety in patients due to its noisy and confused environment (24,25). Latif and coworkers found that patients admitting to hospital due to urgent surgical need increased the level of anxiety in patients (26). Derrick and colleagues were also evaluated the effects of anxiety and panic experienced by patients who applied to the emergency department on treatment, and the importance of finding the underlying factors that cause anxiety and panic in the treatment was mentioned (27). Ekwall found that explaining the conditions of the patients admitted to the emergency department to themselves in an understandable way will decrease the anxiety level of the patients and increase their satisfaction (28). Patients usually apply to the emergency department due to sudden emergencies. This situation brings anxiety as well as the feeling of uncertainty in patients. Providing a clear and adequate explanation to the patients about their condition and providing psychological support will make the patients feel better.

Our study reported that the most important need of the participants was to relieve the anxiety and fear caused by the unknown and the pain they felt. Aydın et al noted that the majority of nontraumatic patients who applied to the emergency department had pain such as abdominal pain (29). Similarly, Kılıçaslan and coworkers emphasized that the most common nontraumatic complaints such as abdominal and chest pain negatively affect patients (30). In another study reported that most of the patients who applied to the emergency department presented to the hospital with complaints of pain such as abdominal pain (31). Delayed diagnosis of patients admitted to the emergency department with acute abdomen leads to unwanted adverse situations during the treatment process. The emergence of different complications, the prolongation of the treatment process, and the increase in mortality and morbidity rates are among these situations (32). Pain management methods, one of the indispensable roles of nursing, enable the patient to relax or feel comfortable (33,34). Thanks to the treatments applied to the patients who come to the emergency department with severe pain and using pain management methods to these patients provided to relieve the pain.

Limitations

There are some limitations. The sample size of this study was limited due to the characteristics of qualitative research. Patients with multiple trauma admitted to the emergency department were excluded from the study due to their severe condition. For this reason, the experiences of this patient group with the highest number of emergency department admissions could not be obtained. Another limitation of the study is that they may omit some details related to the patient’s high level of pain and stress during the interviews in the emergency department. Although the research data were collected in Turkish, it was translated into English, which may have caused distortions in the contextual structure of the expressions while describing the interpretations and experiences. Because language is one of the basic elements of cultural creation and is very effective in the construction and transmission process of culture. Efforts have been made to protect cultural concepts in translations. Last limitation also may be time constraints.

Conclusion

Emergency department nurse provides the necessary nursing care in a short time and under different conditions to individuals (10). Patients’ ability to reach nurses whenever they need increases patient satisfaction in the emergency department (15). This situation can affect patients’ perception of the emergency department. If patients can relieve the pain they feel in addition to the anxiety and fear created by the unknown, their perception of the emergency department can change positively. The finding obtained cannot be generalized due to the nature of qualitative research. However, the findings indicate that the emergency department is generally perceived as a healing environment, the most important need of the participants is to relieve the anxiety and fear caused by the unknown and the pain they feel.