Thai Nurses’ Experiences of Providing Care in Overcrowded Emergency Rooms in Tertiary Hospitals

Saowaros Kongcheep; Manee Arpanantikul; Wanpen Pinyopasakul; Gwen Sherwood

Authors

Saowaros Kongcheep RN, PhD (Candidate), Ramathibodi School of Nursing, Faculty of Medicine Ramathibodi Hospital and Faculty of Nursing, Mahidol University, Thailand.
Manee Arpanantikul RN, PhD, Associate Professor, Ramathibodi School of Nursing, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand.
Wanpen Pinyopasakul RN, PhD, Associate Professor, Independent Scholar.
Gwen Sherwood RN, PhD, FAAN, ANEF, Professor Emeritus, University of North Carolina at Chapel Hill, School of Nursing, U.S.A.

Keywords:

Lived experiences, Overcrowding, Emergency rooms, Nursing, Patient safety, Phenomenology, Quality of care

Abstract

Overcrowding in emergency rooms creates difficulties for nurses in providing safe and high quality health services for patients. Investigating the experiences of nurses in overcrowded emergency rooms can build understanding of this phenomenon and help improve the quality of care provided. This Heideggerian phenomenological study explored Thai nurses’ experiences in providing care for patients in overcrowded emergency rooms in tertiary hospitals. Data were collected from in-depth interviews with 20 Thai nurses, and the interviews were recorded, transcribed, and analyzed using thematic analysis.
The findings revealed four main themes: Personal and professional impacts on the nurse, Factors contributing to overcrowding, Managing overcrowded situations, and Expectations for quality care. Study findings provided rich data that develop a greater understanding of nurses while working in overcrowded emergency rooms. Nurses were unsatisfied with their ability to provide timely, quality of care. There was a shortage of nurses to deal with the high patient load, increased stress, not enough time to teach novice nurses and student nurses, and increased risk to patients who waited long times for admission or treatment. Overcrowding leads to infection risk with patients being in close proximity. Bed shortages in hospitals contribute to long waiting times for patients awaiting admission from emergency rooms. To improve the quality of care, hospitals have to reduce overcrowding by improving patient flow and providing appropriate care for patients waiting for treatment. However, government policies need to be urgently introduced to reduce overcrowding and provide sufficient staffing and equipment. Often patients attended emergency rooms for non-urgent care, adding to overcrowding and inefficient use of resources. Therefore, effective management, collaboration, teamwork, and communication among all healthcare providers need to be undertaken to ensure that ER nurses deliver more efficient care to patients.

References

Yarmohammadian MH, Rezaei F, Haghshenas A, Tavakoli N. Overcrowding in emergency departments: a review of strategies to decrease future challenges. J Res Med Sci. 2017;22:23. doi:10.4103/1735-1995.200277.

Morley C, Unwin M, Peterson GM, Stankovich J, Kinsman L. Emergency department crowding: a systematic review of causes, consequences and solutions. PLOS ONE. 2018;13(8):e0203316. doi:10.1371/journal.pone.0203316.

Savioli G, CeresaI IF, Gri N, Piccini G B, Longhitano Y, Zanza C, Piccioni A, Esposito C, Ricevuti G, Bressan MA. Emergency department overcrowding: understanding the factors to find corresponding solutions. J Pers Med.2022;12:279. doi:10.3390/jpm12020279.

Kieft RAMM, de Brouwer BBJM, Francke AL, Delnoij DMJ. How nurses and their work environment affect patient experiences of the quality of care: a qualitative study. BMC Health Serv Res. 2014;14(1):118–37.

Chen LC, Lin CC, Han CY, Hsieh CL, Wu CJ, Liang HF. An interpretative study on nurses’ perspectives of working in an overcrowded emergency department in Taiwan. Asian Nurs Res. 2018;12(1):62–8.

Van Der Linden MC, Khursheed M, Hooda K, Pines JM, Van Der Linden N. Two emergency departments, 6000 km apart: differences in patient flow and staff perceptions about crowding. Int Emerg Nurs. 2017;35:30–6.

Estey A, Ness K, Saunders LD, Alibhai A, Bear RA. Understanding the causes of overcrowding in emergency departments in the Capital Health Region in Alberta: a focus group study. CJEM. 2003;5(2):87–94.

Kilcoyne M, Dowling M. Working in an overcrowded accident and emergency department: nurses’ narratives. AJAN. 2007;25(2):21–7.

Ramkaew K, Oumtanee A. Working experience of emergency nurses in tertiary care hospital. JRTAN. 2014;15(3):226–34 (in Thai).

Hamdan M, Hamra AA. Burnout among workers in emergency departments in Palestinian hospitals: prevalence and associated factors. BMC Health Serv Res. 2017;17:407. doi:10.1186/s12913-017-2356-3.

O’Connor E, Gatien M, Weir C, Calder L. Evaluating the effect of emergency department crowding on triage destination. Int J Emerg Med. 2014;7(16):1–7.

Salway RJ, Valenzuela R, Shoenberger JM, Mallon WK, Viccllio A. Emergency department (ED) overcrowding: evidence-based answers to frequently asked questions.Rev Méd Clín Las Condes. 2017;28(2):213–9.

Hong KJ, Shin SD, Song KJ, Cha WC, Cho JS. Association between ED crowding and delay in resuscitation effort. Am J Emerg Med. 2013;31(3):509–15.

Källberg AS, Ehrenberg A, Florin J, Östergren J, Göransson KE. Physician’s and nurses’ perceptions of patient safety risks in the emergency department. Int Emerg Nurs.2017;33:14–9.

Tekwani KL, Kerem Y, Mistry CD, Sayger BM, Kulstad EB. Emergency department crowding is associated with reduced satisfaction scores in patients discharged from the emergency department. West J Emerg Med. 2013;14(1):11–5. doi:10.5811/westjem.2011.11.11456.

Reznek MA, Murray E, Youngren MN, Durham NT, Michael SS. Door-to-imaging time for acute stroke patients is adversely affected by emergency department crowding. Stroke. 2017;48(1):49–54. doi:10.1161/STROKEAHA.116.015131.

Epstein SK, Huckins DS, Liu SW, Pallin DJ, Sullivan AF, Lipton RI, Comargo Jr. CA. Emergency department crowding and risk of preventable medical errors. Intern Emerg Med. 2012;7:173–80. doi:10.1007/s11739-011-0702-8.

Eriksson J, Gellerstedt L, Hillerås P, Craftman ÅG. Registered nurses’ perceptions of safe care in overcrowded emergency departments. J Clin Nurs. 2018;27: e1061–7. doi:10.1111/jocn.14143.

Neubauer BE, Witkop CT, Varpio L. How phenomenology can help us learn from the experiences of others. Perspect Med Educ. 2019;8(2):90–7.

Santos RP, Neves ET, Carnevale F. Qualitative methodologies in health research: interpretive referential of Patricia Benner. Rev Bras Enferm. 2016;69(1):178–82.

Lincoln YS, Guba EG. Naturalistic inquiry. London: Sage; 1985.

Arpanantikul M. Methodological issues: integration of Heideggerian phenomenology and feminist methodology applied to the study of lived experience in women. Pac Rim Int J Nurs Res. 2003;7(4):281–93.

Clopton EL, Hyrkäs EK. Modeling emergency department nursing workload in real time: an exploratory study. Int Emerg Nurs. 2019;48:100793. doi:10.1016/j.ienj.2019.100793.

Mahmoudi H, Mohmmadi E, Ebadi A. Barriers to nursing care in emergency wards. Iran J Nursing Midwifery Res. 2013;18(2):145–51.

van de Ruit C, Lahri S, Wallis LA. Clinical teams’ experiences of crowding in public emergency centres in Cape Town, South Africa. Afr J Emerg Med. 2020;10(2):52–7.

Doherty KQ. Role modeling as a teaching strategy for the novice nurse in the emergency department. J Emerg Nurs. 2016;42(2):158–60.

Lapeña-Moñux YR, Cibanal-Juan L, Orts-Cortés MI, Maciá-Soler ML, Palacios-Ceña D. Nurses’ experiences working with nursing students in a hospital: a phenomenological enquiry. Rev Lat Am Enfermagem. 2016;24:e2788. doi:10.1590/1518-8345.1242.2788.

Liang SY, Theodoro DL, Schuur JD, Marschall J. Infection prevention in the emergency department. Ann Emerg Med. 2014;64(3):299–313.

Kim Y. Nurses’ experiences of care for patients with Middle East respiratory syndrome-coronavirus in South Korea. Am J Infect Control. 2018; 46(7): 781–7.

Lam SKK, Kwong EWY, Hung MSY, Chien WT. Emergency nurses’ perceptions regarding the risks appraisal of the threat of the emerging infectious disease situation in emergency departments. Int J Qual Stud Health Well-being. 2020; 15(1):e1718468. doi:10.1080/17482631.2020.1718468.

Seow E. Leading and managing an emergency department—a personal view. J Acute Med. 2013;3(3):61–6.

Afaya A, Bam V, Azongo TB, Afaya RA, Yakong VN, Kpodo GK, Kaba RA, Zinle DAN, Tayuu DK, Asantewaa S, Adatara P. “We are left with nothing to work with”; challenges of nurses working in the emergency unit at a secondary referral hospital: a descriptive qualitative study.

PLoS One. 2021;16(2):e0247062. doi:10.1371/journal.pone.0247062.

Miyakis S, Karamanof G, Liontos M, Mountokalakis TD. Factors contributing to inappropriate ordering of tests in an academic medical department and the effect of an educational feedback strategy. Postgrad Med J. 2006; 82(974):823–9.

Paralee P, Pearkao C. Factors predicting overcrowding in emergency room of a university hospital. Songklanagarind J Nurs. 2020;40(2):52-65 (in Thai).

Miyazawa A, Maeno T, Shaku F, Tsutsumi M, Kurihara H, Takayashiki a, Kohno M, Suzuki M, Maeno T. Inappropriate use of the emergency department for nonurgent conditions: patient characteristics and associated factors at a Japanese hospital. J Gen Fam Med. 2019;20(4):146–53.

Coster JE, Turner JK, Bradbury D, Cantrell A. Why do people choose emergency and urgent care services? A rapid review utilizing a systematic literature search and narrative synthesis. Acad Emerg Med. 2017;24(9):1137–49.

Gilbert A, Brasseur E, Petit M, Donneau AF, D’Orio V, Ghuysen A. Advanced triage to redirect non-urgent Emergency Department visits to alternative care centers: the PERSEE algorithm. Acta Clin Belg. 2021. doi:10.1080/17843286.2021.1914948.

Santos JLGD, Lima MADDS, Pestana AL, Colomé ICDS, Erdmann AL. Strategies used by nurses to promote teamwork in an emergency room. Rev Gaucha Enferm. 2016;37(1):e50178. doi:10.1590/1983-1447.2016.01.50178.

Sherwood G, Barnsteiner J. Quality and safety in nursing: a competency approach in improving outcomes. Hoboken, NJ: Wiley & Sons;2017.

Kreps GL. Communication and effective interprofessional health care teams. Int Arch Nurs Health Care. 2016;2(3):1–6.

Derlet RW, Richards JR. Ten solution for emergency department crowding. West J Emerg Med. 2008;9(1):24–7.

Timmins F, Mc Benett P, Norton C. Providing compassionate care to patients waiting on emergency department trolleys: can we do more? Nurs Crit Care. 2014;19(3):114–6.

Bashkin O, Caspi S, Haligoa R, Mizrahi S, Stalnikowicz R. Organizational factors affecting length of stay in the emergency department: initial observational study. Isr J Health Policy Res. 2015;4:38. doi:10.1186/s13584-015-0035-6.

Hsia RY, Sabbagh SH, Guo J, Nuckton TJ, Niedzwiecki MJ. Trends in the utilisation of emergency departments in California, 2005–2015: a retrospective analysis. BMJ Open. 2018;8(7):e021392. doi:10.1136/bmjopen-2017-021392.

Gorge F, Evridiki K. The effect of emergency department crowding on patient outcomes. Health Sci J. 2015;9(1):1–6.

Thailand Nursing and Midwifery Council. Announcement of the Thailand Nursing and Midwifery Council on standards of nursing and midwifery services at the secondary and tertiary levels: manpower rate of nursing personnel in the tertiary service unit. Government gazette.

;122(94d):4-5 (in Thai).

Zanil AV, Marcon SS, Tonete VLP, Parada CMGDL. Communicative process in the emergency department between nursing staff and patients: social representations. Online Braz J Nurs. 2014;13(2):139–49.