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An Emergency Department Patients’ Perception of Safety Paul R. Clark RN, MSN, MA The University of Texas Health Science Center at San Antonio - School of Nursing ABSTRACT Model RESULTS MATERIAL and METHODS
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Paul R. Clark RN, MSN, MA
The University of Texas Health Science Center at San Antonio - School of Nursing
MATERIAL and METHODS
Fourteen Emergency Department patients (eight females, six males, five whites, six Hispanics, and three African Americans aged 22 to 86) were interviewed over a 4 month period within 30 days of their visit. Interviews ceased when data saturation was reached and no new data was forthcoming. Three main themes emerged with several subthemes under each primary theme:
1) Accurate Caring:
Diagnostic Precision: care bringing about an accurate and timely diagnosis
Efficiency: time efficient, organized, prioritized, and attentive care provision
2) Protective Caring
Comfort Measures: care affecting body or psyche
Proficient Caring: adept care providing patient with confidence in staff professional practice skills
Anticipatory Caring: care preventing potentially harmful outcomes of treatments, medicines, or other care
Collaborative Caring: care which is the result of several staff working together
Assuring Security: attention to the patient care environment preventing patient injury or compromise of confidentiality
3) Communicative Caring
Responsive Listening: Listening / hearing the communicated message from the patient and following up w/ resources (person, specific request, etc.)
Empathy: Carrying out practice related activities while acknowledging the patients’ feelings and concerns and adapting / changing practice activities as a result
There is a real and significant problem in the United States healthcare system of providing safe, efficient care to patients which is free from preventable health care errors. Patients are not empowered to take an active role in their care by being asked how they, from their role and view as patient, perceive safety. This study researches the patient’s outsider perspective of healthcare safety using ethnographic methodology, which may generate data pertinent to the development of safer health care processes.
Patient safety involves all healthcare system components, not just a single person, machine, or process1. However, research studies point to a glaring lack of patient safety:
● In one study 3.7% of 30,000 patients had been harmed by preventable healthcare errors2.
● Poor or insufficient communication contributes to patient errors and poor patient outcomes3,4,5.
● From the patient’s perspective, US healthcare providers perform poorly on domains such as patient safety, patient centeredness, timeliness, efficiency, effectiveness, and equity6.
Probably one of the most significant ways to prevent harm and poor outcomes is through active patient care involvement7,8,9,10,2,11, including patient perception of care. Patient care perception is under considered, leaving a knowledge gap that is more canyon than crack12,13,8,9,10,14,3,4.
The patients’ perspective is important because:
● Patients are outsiders to the healthcare cultural system with a unique perspective (little if any professional healthcare training)
● As outsiders, patients can discern safety gaps that providers within the healthcare system may miss9.
This patient perspective investigation goes beyond the surveys, summaries, studies, and analyses of the health care system (indeed the healthcare culture) getting at the heart of unmined safety data with the potential to uncover a significant source of information for error reduction and safety improvement.
Research questions include: 1) what do patients perceive as safe and unsafe aspects of their care; 2) what experiences of unsafe care do patients have; 3) how has staff addressed/not addressed these experiences; 4) what are safe actions and their characteristics in the ED?
This study has uncovered many patient perspectives of safe healthcare practices: explaining treatment and medication issues in plain language, care that is perceived as proficient, provided quickly, and which meets patient needs; care that anticipates problems and patient physiological needs; and care that meets the human (social, psychological-emotional, and comfort) needs of the patient. Patients also revealed perspectives of unsafe care: patient needs not being heard or responded to; treatment rationale not communicated; and, concerns regarding cleanliness or pain management not taken seriously. Staff who are overburdened or who don’t share patients’ concerns can be (either virtually or in reality) considered unsafe care providers by patients (who do raise valid concerns).
1. Reinforce good practices and behaviors noted by patients.
2. Make patient concerns staff concerns regardless of staff insider knowledge that a patient concern may not have the seriousness the patient perceives the concern to have.
3. Address staff burnout (because of understaffing, burden with high acuity patients, or long term care exhaustion) which may prevent staff from giving patient concerns due consideration.
What do patients perceive as safe and unsafe aspects of their care:
● separating out symptoms of a medical nature from medication and treatment side effects;
● comfort measures like pillows & blankets, food & drink, family presence, etc. and actions (arranging for a cab ride home, “friendly, sweet, caring, nice behavior”) – SAFE
● reducing/eliminating embarrassment or concern – SAFE
● anticipating allergies to contrast media & severe pain upon IV catheter insertion – SAFE
● teamwork and staff with multiple roles working together to coordinate care on the same patient - SAFE
● explanation to the patient of step-by-step treatment protocols or rationale for treatment, discharge instructions, treatment results, or medication information (rationale for administration, side effects, etc.) - SAFE
● verbalizing to the patient in plain language / laymen’s terms understood by the patient putting them at ease – SAFE
● staff introducing self and role to patient – SAFE
● Not taking patient complaints seriously or not acknowledging the seriousness of a patient complaint – UNSAFE
● Staff failure to understand course of treatment is not understood by the patient - UNSAFE
● Lack of communication to patients regarding treatment delays, progress of care, or delays in response to call lights/patient requests - UNSAFE
What experiences of UNSAFE care do patients have:
“So you know, I tried to explain that to him, and he was like, ‘But, that’s not what I’m asking you. I’m asking you this.’’ [raises voice, uses sharper tone]. So I was like if you would just listen to what I’m saying, you might have been able to diagnose me better. Instead he said, ‘Well, I’m going to order a PAP smear on you.’ He ordered a PAP smear and started pushing around at things, and I was really uncomfortable. And I felt like he was in the wrong area, you know, to even be looking at because it was more gastrointestinal than a problem with my female anatomy.” (UNSAFE – Diagnostic Precision)
INTERVIEWER: Did you ask for something for pain or did they just offer, or how did that work?
Patient: “They just kind of gave it to me. And see, the thing was it wasn’t like a pain like that. I was bloated, so them giving me pain medicine didn’t help. [Laughs] You know? . . . But I felt like at that point my stomach was going to explode. But he could have at least diagnosed me and said ‘Hey, you’re lactose intolerant,’ or you know, ‘This is what it is.” But he didn’t even listen to what I was describing in order for him to do that.” (UNSAFE Comf. Meas.)
“She gets the needle, and she does some rummaging, and it’s not working. So she takes her gloves off, and the needle out. I don't remember seeing where they were put until later when my mom came in, and there was blood and the needle that she was using on the floor. And also, the tourniquet was on the floor, which was particularly disturbing to me because I don’t remember seeing her leave with the needle, but how do I know that was the needle she was using on me, and I was barefoot. So it was just really gross. And then I was thinking, ‘Oh my God! I’m barefoot, and I’ve been off and on standing up for one reason or another on this floor. And who knows what’s on the floor.’ I know you can’t walk on the floor and get something, but it’s just icky. But the idea of stepping on the needle was really important to me.” (UNSAFE – Assuring Security)
What are SAFE actions and their characteristics in the ED:
INTERVIEWER: With the family in the room, how did that make you feel having your family around you?
“Fine. It makes you feel good. It makes you feel real good, feel safe. And I really do feel safe with the other operations I had. All the nurses were very, very nice to let my family come in. And periodically my grandson came with his wife, and my other grandson came with his wife. Periodically they came, and the nurses were very, very nice. They came in to see what was going on, you know.”(SAFE – Comfort Measures)
“. . . and in a little bit I knew I was going to have to go to the bathroom. So then I called, and the little girl, the uh, female nurse, took me. And she showed me where this thing was when I got through, and she would knock at the door. And she held my arm all the way to the bathroom and all the way back. And then I have to do it another time because I’m drinking so much water. . .” (SAFE – Assuring Security)
“Oh, he came in and stood up, and he talked to you. You know, he didn’t come in and say, ‘Dah dah dah,’ you know how they do. They talked to you. He talked to me very, very nice. And then he went out, he said, ‘I want to take an x-ray.’ So when I went and took the x-ray, came back, and he explained everything to me. He said, ‘You don’t have, very little arthritis,” but he said, ‘There is something there that you need to go have an MRI.’ So he said, ‘They can tell more when they have an MRI.” (SAFE – Caring Communication)
● Qualitative, focused ethnographic study of ED patients’ descriptions and perceptions of their ED visit experience
● Content analysis used to discover pertinent themes
● NVivo 8 (QSR International, 2009) used in interview analysis
● Themes found in two or more participants became data
● Novel data was generated from patient interviews by:
● limiting the study to one area (ED)
● utilizing purposive sampling
● collecting data until no new themes or information from additional participants were found (data saturation)
● utilizing Spradley’s ethnographic interactive question guide during the interview
● member checking (strengthens data trustworthiness / reliability) ● Limitations included interviewing patients from one department (ED) of one hospital system in one US geographical area.