Improving Communication in Patient Suffering in the ED
We included 125 patients between May and June 2012. Baseline characteristics of the participants are shown in Table 1. All patients were interviewed both at the time of arrival and prior to leaving the ED. Seventy-seven patients (61.6%) reported that they were suffering, one (0.8%) patient was unsure and 47 (37.6%) patients reported that they were not suffering at the time of arrival in the ED. The distribution of pain scores, stratified by whether the patient reported that they were suffering, is shown in figure 1. Thirty-two (25.6%) patients with an initial pain score of ≤3/10 reported that they were suffering. Fourteen (11.2%) patients gave a pain score of 0/10 but reported that they were suffering. Two (16%) patients with a pain score of ≥7/10 reported that they were not suffering.
(Enlarge Image)
Figure 1.
Distribution of pain scores stratified by the patient's response to the question, "Are you suffering?" at the time of admission.
Patients reported 37 different responses to question 1 ("In what way are you suffering?") with a total of 183 responses being provided by the 125 participants (Table 2). Although 47 (37.6%) patients had reported that they were not suffering on direct questioning, only 33 (26.4%) patients listed no sources of suffering. Considering that anxiety, worry, concern, adjustment difficulties, low mood, embarrassment, agitation, bereavement, fear, uncertainty, stress and wanting to go home are all primarily emotional in nature, a total of 49 patients (39.2%) reported sources of emotional suffering. Assuming that discomfort, soreness and chest heaviness or tightness can be considered as forms of pain, a total of 58 (46.4%) patients reported that some form of pain was causing them to suffer. In contrast, 90 (72.0%) patients reported a pain score of greater than 0/10.
When asked how they hoped the staff in the ED would help them to feel better, 125 (100.0%) patients gave at least one response. Ninety-four (75.2%) patients gave one response, 28 (22.4%) patients gave two responses and three (2.4%) patients gave three responses. Most commonly, patients were hoping for diagnosis (n=35, 28.0%), reassurance (n=25, 20.0%) and analgesia (n=13, 10.4%). The entire list of responses is shown in Table 3. On being asked what had been done to ease their suffering prior to leaving the ED, 79 (63.2%) of the entire cohort listed at least one item (Table 4).
Of the patients who were hoping for analgesia (n=13), 12 (92.3%) received analgesia in the ED. Four (30.8%) of these patients later stated that the analgesia had eased their suffering. Of the patients who were hoping for explanation and/or reassurance (n=25), 12 (48%) later reported that reassurance or explanations had eased their suffering. The full range of responses to the pre-discharge questionnaire is shown in Table 4 and Table 5.
Our initial analysis identified three descriptive themes that reflected the structure of the initial and pre-discharge questionnaires: patients' reported reasons for suffering; their expectations; and on leaving the ED, their judgement about whether expectations had been met. Following Braun and Clarke's approach, we were able to move on from our initial observations and develop a conceptual framework that we were satisfied represented the underlying meanings in the data, based around: (i) characteristics of ED patient suffering; (ii) tensions in patient perceptions of need; (iii) the importance of care; and (iv) the importance of closure.
Characteristics of Patient Suffering in the ED. Physical and emotional suffering occurred together. The physical symptoms reported were dominated by pain, although nausea, vomiting, dizziness and shortness of breath were also common. A minority of patients reported feeling hungry, thirsty or too hot, symptoms that may have been triggered by their immediate environment rather than a presenting condition.
While waiting in the ED, patients' emotional distress was mainly characterised by anxiety and worry, around concerns such as fearing that they had a serious disease, not being believed by clinicians or anticipating clinical decisions that might represent bad news. For instance, one patient reported that they were anxious about being transferred from minors to majors for leg swelling.
Tensions in Patient Perceptions of Need. In terms of how clinicians may ease the suffering of patients in the ED, we identified three distinct sets of patient perceptions of need. First, participants reported wanting reassurance plus information, particularly diagnosis, explanations and advice, indicating that these were the interventions that would reduce their suffering.
Second, these patients wanted treatment to relieve both physical and emotional symptoms. Patients often reported that treatment of their physical symptoms eased their suffering. Finally, while the patients wanted treatment, treatment itself was sometimes unfortunately seen as the cause of suffering. Indeed, some patients reported increased suffering, caused by delays to receiving painkillers, or nausea and vomiting occurring between triage and discharge. For instance, six patients noted that unpleasant or painful treatment such as intravenous cannulation had caused them to suffer more. Therefore, although the patients generally sought treatment, they could be disappointed by their experience of it.
The Importance of Care. Our data tell us about the importance of care in our approach to reducing suffering. Basic care was seldom mentioned when patients were asked how they hoped that clinicians would make them feel better, suggesting that patients themselves may not recognise this at the time of arrival in the ED. However, when asked what had been done to ease their suffering, 10 patients gave the answer 'friendly staff' and a further patient gave the answer 'efficient staff'. One patient felt that an unpleasant waiting area had worsened their suffering while a further patient reported that open access to the ward area had caused them to suffer. Taken in conjunction with the expressed need for information and reassurance described above, these data highlight the importance of simple compassion and communication for reducing patient suffering in the ED.
The Importance of Closure. The theme of closure appeared to be strongly related to relief of suffering. As patients highlighted the impact of fear and uncertainty on their experiences in the ED, it is perhaps unsurprising that they valued closure, as represented by being able to go home, gaining understanding about their condition or being referred for definitive care. The data showed that prior to leaving the ED, 11 patients reported that being seen or being seen promptly had eased their suffering, four patients expressed their desire to be discharged or to go home and two patients were hoping for referral to other departments.
Considering these data together, we illustrated the themes identified in a conceptual model describing the nature of patient suffering in the ED and what our data tell us about how it may be addressed from a patient centred perspective (figure 2).
(Enlarge Image)
Figure 2.
Conceptual model of the nature of patient suffering in the emergency department.
Results
We included 125 patients between May and June 2012. Baseline characteristics of the participants are shown in Table 1. All patients were interviewed both at the time of arrival and prior to leaving the ED. Seventy-seven patients (61.6%) reported that they were suffering, one (0.8%) patient was unsure and 47 (37.6%) patients reported that they were not suffering at the time of arrival in the ED. The distribution of pain scores, stratified by whether the patient reported that they were suffering, is shown in figure 1. Thirty-two (25.6%) patients with an initial pain score of ≤3/10 reported that they were suffering. Fourteen (11.2%) patients gave a pain score of 0/10 but reported that they were suffering. Two (16%) patients with a pain score of ≥7/10 reported that they were not suffering.
(Enlarge Image)
Figure 1.
Distribution of pain scores stratified by the patient's response to the question, "Are you suffering?" at the time of admission.
Descriptive Analysis
Patients reported 37 different responses to question 1 ("In what way are you suffering?") with a total of 183 responses being provided by the 125 participants (Table 2). Although 47 (37.6%) patients had reported that they were not suffering on direct questioning, only 33 (26.4%) patients listed no sources of suffering. Considering that anxiety, worry, concern, adjustment difficulties, low mood, embarrassment, agitation, bereavement, fear, uncertainty, stress and wanting to go home are all primarily emotional in nature, a total of 49 patients (39.2%) reported sources of emotional suffering. Assuming that discomfort, soreness and chest heaviness or tightness can be considered as forms of pain, a total of 58 (46.4%) patients reported that some form of pain was causing them to suffer. In contrast, 90 (72.0%) patients reported a pain score of greater than 0/10.
When asked how they hoped the staff in the ED would help them to feel better, 125 (100.0%) patients gave at least one response. Ninety-four (75.2%) patients gave one response, 28 (22.4%) patients gave two responses and three (2.4%) patients gave three responses. Most commonly, patients were hoping for diagnosis (n=35, 28.0%), reassurance (n=25, 20.0%) and analgesia (n=13, 10.4%). The entire list of responses is shown in Table 3. On being asked what had been done to ease their suffering prior to leaving the ED, 79 (63.2%) of the entire cohort listed at least one item (Table 4).
Of the patients who were hoping for analgesia (n=13), 12 (92.3%) received analgesia in the ED. Four (30.8%) of these patients later stated that the analgesia had eased their suffering. Of the patients who were hoping for explanation and/or reassurance (n=25), 12 (48%) later reported that reassurance or explanations had eased their suffering. The full range of responses to the pre-discharge questionnaire is shown in Table 4 and Table 5.
Thematic Analysis
Our initial analysis identified three descriptive themes that reflected the structure of the initial and pre-discharge questionnaires: patients' reported reasons for suffering; their expectations; and on leaving the ED, their judgement about whether expectations had been met. Following Braun and Clarke's approach, we were able to move on from our initial observations and develop a conceptual framework that we were satisfied represented the underlying meanings in the data, based around: (i) characteristics of ED patient suffering; (ii) tensions in patient perceptions of need; (iii) the importance of care; and (iv) the importance of closure.
Characteristics of Patient Suffering in the ED. Physical and emotional suffering occurred together. The physical symptoms reported were dominated by pain, although nausea, vomiting, dizziness and shortness of breath were also common. A minority of patients reported feeling hungry, thirsty or too hot, symptoms that may have been triggered by their immediate environment rather than a presenting condition.
While waiting in the ED, patients' emotional distress was mainly characterised by anxiety and worry, around concerns such as fearing that they had a serious disease, not being believed by clinicians or anticipating clinical decisions that might represent bad news. For instance, one patient reported that they were anxious about being transferred from minors to majors for leg swelling.
Tensions in Patient Perceptions of Need. In terms of how clinicians may ease the suffering of patients in the ED, we identified three distinct sets of patient perceptions of need. First, participants reported wanting reassurance plus information, particularly diagnosis, explanations and advice, indicating that these were the interventions that would reduce their suffering.
Second, these patients wanted treatment to relieve both physical and emotional symptoms. Patients often reported that treatment of their physical symptoms eased their suffering. Finally, while the patients wanted treatment, treatment itself was sometimes unfortunately seen as the cause of suffering. Indeed, some patients reported increased suffering, caused by delays to receiving painkillers, or nausea and vomiting occurring between triage and discharge. For instance, six patients noted that unpleasant or painful treatment such as intravenous cannulation had caused them to suffer more. Therefore, although the patients generally sought treatment, they could be disappointed by their experience of it.
The Importance of Care. Our data tell us about the importance of care in our approach to reducing suffering. Basic care was seldom mentioned when patients were asked how they hoped that clinicians would make them feel better, suggesting that patients themselves may not recognise this at the time of arrival in the ED. However, when asked what had been done to ease their suffering, 10 patients gave the answer 'friendly staff' and a further patient gave the answer 'efficient staff'. One patient felt that an unpleasant waiting area had worsened their suffering while a further patient reported that open access to the ward area had caused them to suffer. Taken in conjunction with the expressed need for information and reassurance described above, these data highlight the importance of simple compassion and communication for reducing patient suffering in the ED.
The Importance of Closure. The theme of closure appeared to be strongly related to relief of suffering. As patients highlighted the impact of fear and uncertainty on their experiences in the ED, it is perhaps unsurprising that they valued closure, as represented by being able to go home, gaining understanding about their condition or being referred for definitive care. The data showed that prior to leaving the ED, 11 patients reported that being seen or being seen promptly had eased their suffering, four patients expressed their desire to be discharged or to go home and two patients were hoping for referral to other departments.
Considering these data together, we illustrated the themes identified in a conceptual model describing the nature of patient suffering in the ED and what our data tell us about how it may be addressed from a patient centred perspective (figure 2).
(Enlarge Image)
Figure 2.
Conceptual model of the nature of patient suffering in the emergency department.
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