The everyday work at a Swedish emergency department – The practitioners’ perspective

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Abstract

In the everyday work at emergency departments (EDs), the patients being cared for have different needs and perceived symptoms. To meet their need for emergency care, knowledge of the work is important. The aim of this study is to explore the everyday work at a Swedish ED from a practitioner’s perspective.

Method

This study has a qualitative, exploratory design with observations and interviews at two EDs. Data were analysed by content analysis.

Findings

The everyday work is characterised by a rapid, short and standardised encounter with limited scope to provide individualised care, which leads to a mechanical approach. It is also characterised by an adaptive approach in which practitioners strive to be adaptable by structuring everyday work and cooperation to achieve a good workflow.

Conclusions

The study shows that the practitioners’ encounter with patients and relatives is rapid and of limited duration. The care activities that practitioners mainly perform comprise standard medical management and are performed more mechanically than in a caring way. The practitioners strive to balance the requirements and the realisation of the everyday work through structures and in cooperation with other practitioners, although they work more in parallel than in integrated teams.

Introduction

In the everyday work at emergency departments (EDs), the patients being cared for have different needs and perceived symptoms of illness or injury and the condition of these patients can change rapidly (Nyström et al., 2002, Wiman and Wikblad, 2004). This everyday work is an essential part of the ED and its practitioners. It is routine and is characterised by numerous short encounters and a constant need to re-prioritize the care provided (Larsson Kihlgren et al., 2005).

The care system at EDs in Sweden is based mainly on team nursing (Finkelman, 2006), which means that assistant nurses (ANs) and registered nurses (RNs) work together to provide care for a group of patients, such as surgery patients. The proportion of ANs and RNs in Sweden varies according to the time of day but in general staffing comprises about 40% ANs and 60% RNs (Andersson and Nilsson, 2009) with 1–4 medical doctors (MDs) depending on the specialisation. The team-nursing model thus includes ANs, RNs and MDs, who in this study are designated ‘practitioners’.

In the everyday work, the above practitioners perform specific tasks and activities, individually or together. National descriptions of required competences are available for RNs (The Swedish Emergency Nurses Association, 2010) and MDs (The National Board of Health and Welfare, 2008), but not for ANs (Nilsson et al., 2008). Ultimately, it is the manager who determines the necessary competences at an ED (The National Board of Health and Welfare, 2005). ANs and RNs normally work close to the patient but with different tasks. The ANs mainly check vital signs, attend to dressings and basic hygiene tasks and generally ensure the patient is comfortable. The RNs are responsible for triage assessment, administering medication and assuming overall responsibility for patient care (The Swedish Emergency Nurses Association, 2010). Finally, the main tasks of MDs are to assess, diagnose and treat the patient (The National Board of Health and Welfare, 2008). The practitioners’ level of autonomy is socially constructed and determines the practitioners’ independence in their everyday work, although the everyday work is also influenced by society – political decisions for example – and guidelines as well as the ED itself through the work organisation, managers, other practitioners or the practitioners themselves (Ellström, 1997).

An ED can be viewed as a system which means that the ability of an ED to perform its task is based on interaction between the totality (the ED and its environment) and its parts (structures, functions and practitioner relationships) as well as communication and an interconnection between the parts (Senge, 1995). In this system the everyday work can be seen from the point of view of the practitioners-‘ relationship to the organisation, its managers, and other practitioners (Møller, 1994) as well as the patients seeking care at the EDs.

In recent years, work at EDs has undergone a significant change. Nowadays, diagnosis and treatment are initiated at the EDs more often than in the past and the structure of society has led to more patients with specific health needs. This change took place subsequent to the hospitals reducing the length of stay for inpatients and the number of hospital beds (The National Board of Health and Welfare, 2006, The National Board of Health and Welfare, 2009a, The National Board of Health and Welfare, 2009b, Säfwenberg, 2008). Finally, people increasingly expect to be diagnosed and treated at the ED (Russ et al., 2010). The logistics and the working environment at the EDs are influenced by all these changes (Henneman et al., 2010, Moskop et al., 2009). Displeasure has been expressed by patients regarding the long wait to be examined by an MD, as well as the lack of treatment and inadequate information from the ANs and RNs (Bridges et al., 2010, Muntlin, 2009). The dilemma is that the practitioners are expected to satisfy all the patients’ needs (Asplin et al., 2003, Wiler et al., 2010), and at the same time provide a fast, safe and effective care (ACEP, 2005) and fulfill political demands, e.g. a maximum of 4 h waiting time at the ED (Larsson, 2010).

Everyday work at an ED is complex, routine and with few dramatic situations. Practitioners sometimes lack efficient strategies for performing their work (Andersson and Nilsson, 2009, Frank, 2010). Knowledge of the work at an ED from the practitioners’ perspective is important. However, this also requires knowledge of what support practitioners need in order to develop their work (Fetzer, 2005). No Swedish studies of everyday work at EDs from the point of view of the practitioners have yet been performed. International studies are conducted in ED contexts that are different from the Swedish context, e.g. by providing access to specially trained RNs or MDs and the development of health systems (Arnold and Corte, 2003, Cooke et al., 2004, Schneider, 2010, Turris et al., 2007, Uranüs and Lennqvist, 2002). There is thus a knowledge gap with regard to Swedish EDs that the present study aims to address.

The purpose of this study is to explore the everyday work of the ANs, RNs and MDs and their care and treatment of patients with urgent and non-urgent conditions at Swedish EDs. Specific issues are;

  • What does the practitioners’ everyday work consist of?

  • How do the practitioners describe their everyday work?

Section snippets

Design

To facilitate a description of the practitioners’ everyday work, a qualitative exploratory study design, was chosen based on data from observations and interviews (Patton, 2002).

Setting

Data was collected at two EDs in western Sweden. They were chosen based on differences in size, the presence of emergency MDs and access to basic specialties, in this case medicine, surgery and orthopaedics. The main functions of these EDs are to provide 24-h care for patients with medical, surgical or orthopaedic

Results

The results show that the everyday work can be broken down into four categories: Patient relations, Care activities, Structuring of everyday work and Co-operation. The everyday work is grouped into two main categories; Mechanical approach in the encounter and Adaptive approach to the everyday workflow. An overview of the results from the observation data and the interview data is presented in Table 4.

Discussion

This study shows that the efforts made by the practitioners’ to achieve a work flow can cause the everyday work to become mechanical where the interpersonal encounter with patients and their relatives is reduced to a technical meeting preventing the establishment of a patient relationship on an individual level.

In line with findings by Berg (2006) and Frank et al. (2009), this study shows that the relationship with the patient is essential to provide security and patient participation in the

Conclusions

The practitioners’ encounter and interaction with patients and relatives are rapid and of limited duration and the care activities that practitioners mainly perform take the form of medical management of the patient. The practitioners’ strive to structure and balance the requirements and the realisation of the everyday work in collaboration with other practitioners, but they work more in parallel than as part of an integrated team. It is important to draw attention to practitioners’ adaption

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