The ED environment could prove stimulating to staff who enjoyed high levels of activity:
I like . . . the challenges and the fact you don’t know what each day’s going to bring, . . . and the type of people you get through. . . . I don’t get bored in A&E whereas I did on the wards a little bit.
Waterbury practitioner 5
A valued feature of some EDs was the culture of teamwork: ‘We’ve always got each other and . . . you never have to make a decision all by yourself if you don’t want to’ (Waterbury practitioner 1). However, relations could become strained with professional groups and units outside EDs and MAUs that had different time frames and priorities.
Tension between emergency departments and medical specialty wards
The drive to avoid admissions was more visible in EDs than in other parts of the system, because of the pressure of continuous arrivals. MAUs also depended on possibilities for onward referral:
Acute medical units are . . . reliant on the wider medical wards. . . . we do everything we can do to speed up our processes . . . , but if beyond the back door [the unit] isn’t working, then we’re not going to work . . . and then that builds up to . . . a pile-up in ED, for want of a better phrase.
Underbridge manager 1
Target breaches officially belonged to trusts, but ED co-ordinators often carried prime responsibility for averting them. Practitioners from within and outside EDs could feel that they were being made individually responsible for delays affecting throughput:
[A specialty consultant] arrives at this point and takes the [patient’s] notes. The [ED manager] points out the time on the clock forcefully to him and reminds him of the breach target. He rather irritatedly says ‘Yes I know’.
Churchtown fieldnotes 4
Emergency department practitioners on all sites made efforts to reduce patients’ duration of hospital stay, even if this meant keeping them in the department for longer periods of observation and testing. Staff expressed concern about patients, especially the elderly, getting lost in the system. When people left the ED, the sense of urgency could be lost on the wards, paperwork became burdensome, and patients could
‘languish in the system’ (Churchtown fieldnotes 4), resulting in iatrogenic illnesses:
if you let people progress beyond [the ED] . . . they get unnecessarily trapped in a diagnostic and therapeutics spiral which takes days, costs hundreds of thousands of pounds, and doesn’t benefit the
Underbridge staff identified their single-point-of-entry model as a system that attempted to avoid the above-mentioned loss of momentum, by enabling management of all patients – both those needing emergency care and those referred for medical assessment – to be initiated in the ED within the 4-hour limit.
Tipping points
Staff spoke of ‘tipping points’ that took them from a calm situation to one that felt unsafe. A nurse described these as regular rather than exceptional, feeling there were ‘just too many’ patients: ‘they overrun us and we couldn’t cope with it’ (Churchtown practitioner 6). Objective situations of bed occupancy blended with subjective limits when they started to feel out of control:
the department goes from a state of kind of normal business where it is flowing, we are meeting the targets, . . . we’ve got our noses above the water, and then suddenly, whether it be a surge in patient numbers or acuity or whatever it is and we tip over to, . . . we need to make people safe now, and the targets are largely irrelevant. But I find the most stressful bit of my work is . . . trying to hold onto the reins while we are tipping into crisis management.
Consultant in learning set 1
Moving patients through the system
Several nurses and some clinicians commented that the managerial drive for efficiency tended towards packaging and moving patients through the system like objects on a production line:
I think as nurses, um, if you forget that you’re dealing with human beings and you start thinking you’re dealing with boxes, which is sometimes how you get made to feel you should do.
Churchtown practitioner 7
Practitioners sometimes gave positive connotations to commodification of flow, which they explained in terms of not only achieving targets but also reducing delays:
we’ve tried to explain that I have 10 expecteds to come in and I’m moving them because it’s the right thing to do, because we shouldn’t have people awaiting beds, we shouldn’t have people
awaiting treatment.
Underbridge manager 2
However, staff’s attention to flow meant that time for basic nursing care was reduced:
the human element to me is why I do my job, and it’s vital that we have the time to do that. . . . we get site management phone us and say, ‘This patient is on . . . 3 hours 55, why haven’t they gone to the ward?’ And it’s like, ‘Because they’ve just been incontinent and actually I want to wash them and put them on a clean bed, because I wouldn’t want to be wheeled down the corridor on a bed covered in urine, would you?’ . . . and I understand that that’s their job, to do the boxes: move that box from there within 4 hours, and it just doesn’t always work like that.
Churchtown practitioner 7
Time for patient care and communication
Flow management under pressure left little time for dialogue with patients and relatives, and staff acknowledged that this generated problems:
there’s lots of complaints that are made against the hospital and against the emergency department, most of which are to do with communication.
Porthaven practitioner 2 PRACTITIONER EXPERIENCE AND ORGANISATIONAL ETHNOGRAPHY
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Senior clinicians tended to focus on ‘hard’ safety outcomes rather than ‘softer’ aspects of quality of care. Some associated spending time on practitioner–patient interaction with other staff roles, levels or ‘styles’ of delivery:
I get around very quickly, I discharge. . . . I don’t get any more complaints. My readmission rate’s no higher than anybody else, my mortality – so it’s not like I’m discharging people willy-nilly without any sort of safety checks in place. . . . some of the others will have some of the softer stuff that’s a bit more educational with the trainees. . . . they may spend a bit more time with the patients than I would. . . . it’s just a style thing really.
Underbridge practitioner 2
Practitioners made decisions by ‘ruling out’ risk factors rather than ‘ruling in’ to acute care (Underbridge practitioner 3), giving an expulsive movement to the service. A clinician in a stakeholder workshop said that the ‘ED is designed to frontload diagnostics, not “care”’. A learning set participant, however, expressed concern about communication with patients:
a quick way that would make a difference to the patient experience is how we manage to improve our communication of what’s happening with the patient, so that we have a policy where the patient knows what’s going on, . . . why they are waiting at all times.
Learning set 2
When staff did not feel pressured, they could show sensitivity in persuading patients to agree to a move that they considered appropriate. This was apparent in the case of a Churchtown specialist geriatrician who took time to visit the ED with the care of the elderly team, in search of patients they might help to discharge:
Senior geriatrician:What do you think about that? Would you be happy with that?
Patient:You’re the doctor, you tell me what to do [laughing]. . . .
Senior geriatrician [to patient’s daughters]:What do you think? Does that sound okay? [laughing]
Daughter 1:Yeah. If Mum’s happy – if you’re happy for her to go home and you’ve obviously done a lot of tests and whatever and that’s fine.
Churchtown practitioner 8
Some practitioners linked being ‘busy and manic’ (Underbridge manager 2) with a default to admit patients. This state could generate a hyper-efficient, but confusing, mode of delivery, observed in MAUs as well as EDs, that unwittingly obstructed two-way communication:
Nurse:Sorry about that. . . . such efficiency. . . . If you’re in in the morning, the doctors do a ward round. They usually finish by about 12 o’clock but you’re more than welcome to ring and see how she’s got on, but they might say, ‘We can’t give you any new information until the consultant has seen you’. All right? Any other questions that I can answer for you?
Relative:No that’s –
Nurse:Are you going to go home and put your feet up and have a sleep? Are you going to be all right to drive home? As long as you – do you want to call a taxi? Do you want to use our phone here? Do you know a taxi number that you’d like to use?
Relative:No.
In observation and ambulatory facilities at Churchtown and other sites, the less pressured model of care gave opportunities for more relaxed and frequent communication with patients:
[The nursing assistant] takes it as part of her responsibility to check with patients while they are in the ambulatory area . . . if they have had fluids and foods.
[The staff nurse] comes in to ask [a patient] about her drugs and discusses the dosage . . . before she goes. . . .
Doctors are not based in ambulatory care but keep up with [patients’] progress via Patient First, and go in to see them as needed.
A junior doctor comes to speak to a patient who is waiting to go home. . . .
The junior doctor [says to another patient], ‘You can go home now. [We] will send the letter to the GP in the post. You can take ibuprofen. [I] suspect things will settle down in time. If it doesn’t, you can see your doctor’.
The nursing assistant says to a patient: ‘Sorry for the wait’ [for transport].
Churchtown fieldnotes 5
Effects of pressure on staff
Staff experienced strain between delivering patient-centred care and guarding acute beds:
family members think we’re holding our opinions more important and we’re thinking about resources.
. . . an acute bed is a very special thing nowadays . . . so therefore we have to ring-fence them even more . . . everyone should be happy to try and not have you in one, as opposed to the other side that’s always been that a hospital is always there, it’s always safe, it’s always open, it’s always got beds, and that now just doesn’t exist any more.
Waterbury practitioner 6
A staff member described the effects of pressure on a cohort of senior nurses who left one ED:
we were getting more pressure to hit targets, and as senior nurses they were just saying . . . I don’t need this. . . . Roughly at the time . . . we all kind of went, hmm . . . we’ll just take a side-step. . . . [The ED has] lost a lot of nurses, . . . and the new nurses that we’ve recruited have had to be taught the skills to work in A&E, . . . we had to frantically put a lot of them through the triage training. . . . there’s 10 nurse posts out to advert at the moment for A&E here.
Churchtown practitioner 7