Vidar Melby & Donna McConnell
University of Ulster
Dr Vidar Melby, UU, Joint Research and Writing with
Mats Holmberg, PhD-Student
Karolinska Institute, Stockholm, and Professor BO
Suserud, Prehospital Research Institute, Borås,
Sweden
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Patient experience stressful, injured or ill,
awaiting ambulance clinicians, or strapped
to chair or trolley, unfamiliar environment,
limited space in ambulance. Care is often
urgent.
Limited research focus on core caring
concepts in prehospital emergency care.
Melby V. et al. 2012. Patient comfort in
pre-hospital emergency care: a challenge
to clinicians. Journal of Paramedic Practice,
4, 7, pp 389 - 399
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A development from being
lonely to being cared for.
A temporary presence.
A caring presence.
After the presence ends –
back into a lonely struggle
despite being under hospital
care.
•Quotation:
“Then something happens and people come to help you and open up
themselves. They talked and cared as I was a family member…You get
very warm and happy from that. I got that feeling.”
•Holmberg,M., Forslund, K., Wahlberg, A.C. and Fagerberg, I. (2013) To surrender in
dependence of another; the relationship with the ambulance clinicians as experienced by
patients (Submitted)
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Encounter the person as unique
and in a unique situation.
The patients feel that the whole
caring encounter is managed by
the clinicians.
Assessments are based on
physical, psychological and social
perspectives.
•Quotation:
•“…that the doors are locked and the oven is switched off if the
patient is alone in the apartment. You always have in mind if there
are pets, younger people or children in the apartment.”
•Holmberg, M. and Fagerberg, I. (2010) The encounter with the unknown: Nurses lived experiences
of their responsibility for the care of the patient in the Swedish ambulance service. Int. J. Qualitative
Stud Health Well-being 5 (2) DOI: 10.3402/qhw.v5i2.5098
Ambulance Nurses
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To inform and prepare.
Understand the patients’
experiences.
Ambulance Patients
• Being involved.
• Being respected and acknowledged.
• Being important.
Encounter without pre-made
assumptions.
Quotation:
“In a practical way I try to tell the
patients what my thoughts are. What
will happen next. So that not a lot of
things happens that the patient
doesn’t understand.” (Nurse)
Quotation:
“They talked directly to me they really
did. They asked me where I had pain
and if they should get the stretcher.
They talked in a daily manner and I felt
immediately a relief…” (Patient)
The balance between medical treatment based
on set protocols and personcentred care.
• Maintaining Core Caring Concepts while effecting Evidence Based
Emergency Interventions.
• Shared Decision Making – are patients happy to relinquish autonomy?
• Effective Communication – collaboration in care.
• Innovative Working Culture – freedom to be innovative – working
within strict medically based protocols.
Exploring
Person-Centredness in the
Emergency Department
Donna McConnell PhD Student
Prof Tanya McCance
Dr Vidar Melby
Dr Paul Slater (adviser)
‘It’s a war zone, people
were crying in pain’, ED
patient, Belfast Telegraph, 23.03.12
Pensioner dies
alone on hospital
trolley U105fm, 2012
‘We’re at breaking point’,
warns Northern Ireland
director of nursing , Belfast
Telegraph 2012
I saw a nurse
just standing
there in tears’, ED
patient, Belfast Telegraph,
23.03.12
Person-centred practice has shown to
transform practices for patients...
• increased choice and involvement in decision making
• improved quality of nurse/patient engagements
• staff taking time to get to ‘know’ the person in a
more meaningful way
• staff were more person-centred, in their language
and team-work
• a reduction in ritual and routine
....and staff
• a shift in values to appreciate caring over the
technical aspects of nursing care
• increased effectiveness of teamwork and workload
management
• improved staff relationships with more effective
collaborative working
• increased personal and professional job satisfaction less intention to leave posts
• a more effective use of resources
McCormack et al (2010)
Themes from the literature
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Outcomes for patient and relatives
what they want vs. what they received
Outcomes for staff
- Aggression and violence
Staffs’ values and beliefs
- a culture of ‘worthiness’
- medical tasks and technology valued over caring
Staffs’ role in managing the service
What the literature said patients and
relatives wanted in ED
• Competence of staff
• Developed interpersonal skills
• Waiting times
• Pain controlled
• - nurses taking care of the patient
and engaging in active listening
• Provision of information and
explanation tailored to needs
• - being present and fully engaged
with them in the moment
• Small actions which gave
physical comfort
• To be near their relatives and
touch or talk to them and know
what was happening to them
• A family presence
Literature - patients experienced…
..abandoned,
exposed, vulnerable,
ashamed, ignored,
insecure, frightened
forgotten or
unwelcome (Kihlgren et al
A feeling of not being
considered as an
individual and a lack of
caring as predominant
features (Nyström et al 2003)
2004, Gordon et al 2010, Möller
et al 2010, Elmqvist et al 2011).
Non-urgent patients received a series of fragmented courtesy
encounters and found it difficult to make themselves seen or heard.
They projected their dissatisfaction elsewhere and tried to maintain
relationships with staff by being ‘good’ patients (Nyström et al 2003, Nyden et al
2003, Elmqvist et al (2011)
Literature - staff experienced…
– aggression and violence
Negative consequences
include powerlessness,
frustration, isolation and
vulnerability, anger, anxiety,
fear, worry, decreased job
satisfaction
One nurse described a feeling as
if the whole waiting room hated
them and stated ‘it just wrecks my
spirit’ (Hislop and Melby 2003)
OUTCOMES
•Satisfaction with care
•Involvement with care
• Feeling of well-being
• Creating a therapeutic
culture
‘it felt like ‘being
kicked in the
teeth’ (Pich et al 2011)
Pain, anxiety, lengthy waiting
times, alcohol and substance
misuse, overcrowding, lack of
information
At times staff may
inadvertently contribute to
violence by being overtly
authoritative, being
judgemental and
confrontational, rude and
condescending (Ferns 2005,
Lau et al 2012, Pich et al 2011)
All experienced ED nurses understood
the term ‘eat our young’ … (BaumbergerHenry 2012)
Literature - staff values and beliefs…
- a culture of worthiness
Staff held a collective belief
system beliefs of what was
considered ‘true’, ‘right’
and ‘good’ (Fry 2012)
Staff experienced
frustration with
“frequent fliers” and
“regulars” (Bergman
2012, Muntlin et al 2010)
Patients who arrived with trivial conditions, prior
expectations of treatment and expectations of
preferential treatment breached cultural beliefs (Fry 2012).
‘‘You have a positive
bag sign, when I see the
ambulance pull up and
the bag’s on the trolley. I
just immediately think,
right, you’re in the
waiting room’’ (Fry 2012)
Sbaih (2002) states this
is a reflection of staffs’
desire to keep the
department running
smoothly rather than a
moral judgement of
worth.
Literature - staff values and beliefs…
- medical tasks and technology valued over caring
Medical treatment is
highly valued while
nursing care is
undervalued…ED
nurses are socialised
by the social authority
and status of medicine
We are not good at
giving nursing care. We
are trained in acute
care, giving nursing care
does not come
automatically (Kihlgren at al
2005)
(Nyström 2002)
‘our patients do not need nursing
care, they are just waiting for a
medical examination’ (Nyström et al
2003a)
Interactions with patients were only
initiated when undertaking doctor’s
instructions. These nurses defined
good trauma care by good technical
care (Winman and Wikblad 2004)
Literature – the care environment…
- staffs’ role in managing the service
Processes outside the
departments impact on the
quality of care. ED staff are
at the mercy of other
departments to allow transfer
of patients (Nugus and Forero 2011,
Pickard et al 2004)
CARE ENVIRONMENT
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Appropriate skill mix
Shared decision making systems
Effective staff relationships
Supportive organisational
systems
• Power sharing
• Potential for innovation & risk
taking
• The physical environment
Paradoxically nurses
have managerial
responsibility of the ED
but do not have
managerial control
over medical staff
there. When doctors do
not come to see the
patient’s nurses do not
know what to tell them
(Elmquist et al 2012).
Inability to move patients on in the system leads to overcrowding, low
staff satisfaction, decreased compliance with clinical guidelines,
decision-making errors, an increase in adverse events, and waiting
times (Nugus and Forero 2011)
Literature –care processes…
- staffs’ role in managing the service
Efforts to achieve workflow
can cause work to become
mechanical where
interpersonal encounters are
reduced to a technical
meeting preventing the
establishment of a patient
relationship on individual
level (Andersson et al 2011, Khokher et
al 2009)
CARE PROCESSES
• Working with patient’s
beliefs and values
• Engagement
• Having sympathetic presence
• Sharing decision making
• Providing holistic care
There was no strategy
for patient participation.
It was offered when
staffs’ conditions were
met i.e. time to engage
with the patient, staffs’
genuine interest and
the patient’s medical
priority being the
current focus for
attention (Frank et al 2008)
Due to commitments of other tasks registered nurses found it
difficult to provide individualised care leaving basic nursing care
to be carried out by unqualified staff (Hwang et al 2008, Bergman 2012).
Aim
The aim of this study is to explore personcentred practice within the ED environment.
Methodology
Stage 1,
objective 1
2 stages
Stage 2,
objective 2
Staff
questionnaire
Staff
interviews
Patient
interviews
Pilot study
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Undertaken in August 2013
4 Minor Injury Units
23 registered nurses
19 fully completed questionnaires returned or
completed online
The Prerequisites scale appeared to have good internal consistency, a = .97
Professionally Competent
Developed Interpersonal Skills
Being Committed to the Job
Knowing Self
Clarity of Beliefs and Values
a = .841
a = .896
a = .945
a = .885
a = .903
The Care environment scale appeared to have good internal consistency, a= .96
Skill-Mix
Shared Decision-making Systems
Effective Staff Relationships
Power Sharing
Potential for Innovation and Risk Taking
The Physical Environment
Supportive Organisational Systems
a = .706
a = .828
a = .945
a = .928
a = .838
a = .843
a = .90
The Care Processes scale appeared to have good internal consistency, a = .961
Working with Patients Belief and Values
Shared Decision-making
Engagement
Having Sympathetic Presence
Providing holistic care
a = .887
a = .932
a = .883
a = .862
a = .862
The 30 item PREREQUISITES SCALE 5 point likert scale
[1 = Strongly Disagree to 5 = Strongly Agree].
Total sum score 130 (Mean 4.3)
Staff agreed that they possessed the necessary prerequisites
for person-centred practice
Professionally Competent (8 items)
Strong agreement (mean = 4.5)
Developed Interpersonal Skills (5 items) Strong agreement (mean = 4.6)
Being Committed to the Job ( 7 items)
Agreement (mean = 4.4)
Knowing Self (5 items)
Agreement (mean = 4)
Clarity of Beliefs and Values (5 items)
Agreement (mean = 3.9)
The 36 item CARE ENVIRONMENT scale 5 point likert scale
[1 = Strongly Disagree to 5 = Strongly Agree].
Total sum score 137.16 (mean 3.8)
Staff agreed that they worked in a care environment
conducive to person-centred practice
Skill-Mix (3 items)
Agreement (mean = 4.2)
Shared Decision-making Systems (5 items)
Neutral (mean = 3.4)
Effective Staff Relationships (5 items)
Agreement (mean = 4.2)
Power Sharing (6 items)
Agreement (mean = 3.9)
Potential for Innovation and Risk Taking (6
items)
Agreement (mean = 4)
The Physical Environment (4 items)
Agreement (mean = 4.1)
Supportive Organisational Systems (7 items) Neutral (mean = 2.9)
The 30 item CARE PROCESSES scale 5 point likert scale
[1 = Strongly Disagree to 5 = Strongly Agree].
Total sum score 124.32 (mean 4.1)
Staff agreed that they engaged in the necessary care
processes to deliver person-centred practice
Working with Patients Belief and Values Agreement (mean = 4)
(7 items)
Shared Decision-making (5 items)
Agreement (mean = 4)
Engagement (7 items)
Agreement (mean = 4.1)
Having Sympathetic Presence (6 items)
Agreement (mean = 4.3)
Providing holistic care (5 items)
Agreement (mean = 3.9)
Methodology
Stage 1,
objective 1
2 stages
Stage 2,
objective 2
Staff
questionnaire
Staff
interviews
Patient
interviews
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