Emergency department crowding: An examination of older adults and vulnerability

Abstract

Emergency departments in many nations worldwide have been struggling for many years with crowding and the subsequent provision of care in hallways and other unconventional spaces. While this issue has been investigated and analyzed from multiple perspectives, the ethical dimensions of the place of emergency department care have been underexamined. Specifically, the impacts of the place of care on patients and their caregivers have not been robustly explored in the literature. In this article, a feminist ethics and human geography framing is utilized to argue that care provision in open and unconventional spaces in the emergency department can be unethical, as vulnerability can be amplified by the place of care for patients and their caregivers. The situational and pathogenic vulnerability of patients can be heightened by the place of the emergency department and by the constraints to healthcare providers’ capacity to promote patient comfort, privacy, communication, and autonomy in this setting. The arrangements of care in the emergency department are of particular concern for older adults given the potential increased risks for vulnerability in this population. As such, hallway healthcare can reflect the normalized inequities of structural ageism. Recommendations are provided to address this complicated ethical issue, including making visible the moral experiences of patients and their caregivers, as well as those of healthcare providers in the emergency department, advocating for a systems-level accounting for the needs of older adults in the emergency department and more broadly in healthcare, as well as highlighting the need for further research to examine how to foster autonomy and care in the emergency department to reduce the risk for vulnerabilities.

Introduction

In this paper, we will focus on the ethical dimensions of the direct impact of care provided in unconventional spaces in the emergency department on older adult patients and their caregivers. Although all patients are vulnerable to the impact of emergency department crowding, our focus is on older adults, because there are higher and rising numbers of emergency department visits with this population, ¹ and those who visit the emergency department are more likely to have complex care needs that necessitate special care considerations. ² A feminist ethics and human geography framing will be utilized to argue that providing care in open and unconventional spaces can be unethical as the vulnerability of patients and their caregivers is heightened by this place of care. We will explore vulnerability as situationally and pathogenically generated by the place of the emergency department, with a particular focus on comfort, privacy, and communication to illustrate concrete dimensions of these ethical issues. We will discuss place as hindering healthcare providers’ capacity to promote the autonomy of patients in responding to their vulnerability. Finally, normalized inequities for older adult users of the emergency department will be discussed as further compounding vulnerability. We will then conclude with recommendations to look towards improving the current situation.

Background

Emergency department crowding, or hallway healthcare as it is often called, is a complex and multifactorial issue affecting healthcare systems worldwide whereby the need for emergency department services exceeds the available resources. ³ First emerging as an issue of concern in the late 1980s, emergency department crowding has continued to worsen internationally, impacting patient care in a variety of ways. Emergency department crowding has been linked to delayed time to treatment, poor pain control, and increased morbidity with the involved patients often being pejoratively labeled as “access blocked patients” or “boarders.”^4–6 Emergency departments provide care for patients presenting with all levels of acuity, including critical and urgent care, acting as a gateway to hospital admission and providing treatment for those seeking lower acuity and same-day care. ⁷ With physical space in emergency departments typically finite and increasing numbers of patients admitted with no available inpatient beds to receive them, many hospitals have turned to providing care in unconventional spaces. ⁵ These emergency department spaces can range from stretchers in hallways, chairs in open areas, to converted conference or multipurpose rooms. ⁸ Measurements of emergency department crowding and care provision in unconventional spaces are not standardized; however, for many nations it has been reported as a significant public health issue. ⁷

Emergency department crowding and subsequent hallway healthcare provision have been analyzed using multiple perspectives to understand their causes and effects. For example, the effects of neoliberal policy have been shown to contribute to a focus on efficiency and individualism with concurrent reductions in healthcare investment. ⁹ However, discussions surrounding compromised care in unconventional spaces in emergency departments are typically very abstract, neglecting the impact on patients and their caregivers. Instead, there is significant focus at the systems level emphasizing the improvement of patient flow, reduction of system inefficiencies, and the measurement of time—time lost, time waiting, and time gained. ⁴ The predominant input-throughput-output model using operations management concepts likewise seeks to categorize causes of emergency department crowding to identify defective health system areas at fault from the patient flow point of view.^5,10 Root cause analyses conducted at the institutional level have suggested that causes of emergency department crowding are typically organizational, such as those related to hospital in-patient bed availability and regional healthcare capacity which are causes located outside the purview of the emergency departments themselves.^11,12 These abstract operational views, however, put the everyday realities of patients and their caregivers at a distance and overlook the potentially unethical structures of hospital care provision. Moreover, these views do not account for the unique role of the place of the emergency department in influencing behavior and meaning. Patient and caregiver experiences in the crowded emergency department environment can bring into focus the ways that care can be compromised and the ethical implications of such care, considerations that can be obscured amidst the predominant discussions surrounding crowding.

A feminist ethics approach

Feminist healthcare ethics is a wide-ranging and continuously progressing ethical approach with foundations originating in the ethics of care. ¹³ Feminist ethicists critique major tenets of mainstream bioethics, including the penchant for abstract thinking, individualistic autonomy, and the universal, depoliticized, and decontextualized view of ethics that often relies on fixed moral principles. ¹⁴ Instead, feminist ethics emphasizes a more fluid ethical decision-making that is grounded in everyday experiences, and considers the uniqueness of individuals, and their interdependent, relational nature. ¹⁵ Scrutiny of power dynamics and vulnerability is important from a feminist ethics view because the approach stresses the importance of identifying how oppression and inequities factor into healthcare arrangements ultimately to address social justice concerns.

Vulnerability

Given the range of feminist approaches, we have chosen to focus primarily on one concept, vulnerability, as articulated by Mackenzie, Rogers, and Dodds ¹⁶ who recognize the central role feminists have had in drawing attention to vulnerability’s normative significance. Vulnerability can be considered a universal state for humans who are at risk for injury and illness, who age and, therefore, can experience concomitant physiological processes resulting in suffering and death. As humans, we are also social and political in nature and, therefore, can be oppressed, exploited, and be subject to violence and the violation of our rights. ¹⁶ The presence of vulnerability should signal to us that others have needs or could be harmed. ¹⁶ This perspective is congruent with nurses’ fundamental ethical responsibility to provide care for those in need, to recognize human rights, and to advocate for social justice. ¹⁷

We will use Mackenzie et al.’s ¹⁶ categorization of sources of vulnerability as inherent, situational, and pathogenic to provide conceptual clarity and the basis for further discussion. Inherent vulnerability is that which everyone can experience to varying degrees due to our shared humanity, such as hunger or thirst. Inherent vulnerability can fluctuate, as it is compounded by numerous factors, such as age, health status, and social factors. ¹⁶ Relatedly, situational vulnerability is context-specific and exacerbated by factors external to the person, such as socio-political or environmental elements that can be transient to lasting. Inherent and situational are not mutually exclusive; they can be interrelating. ¹⁶ For example, someone whose mobility is limited by arthritis can be further limited by multi-story buildings that have no elevator. Finally, pathogenic vulnerability, which will be emphasized to examine how vulnerability can be amplified by the place of the emergency department, is an especially unacceptable form of vulnerability that can arise from oppression, abuse, violence, or prejudice. ¹⁶ It can also occur when something intending to alleviate vulnerability “has the paradoxical effect of exacerbating existing vulnerabilities or generating new ones.”^18(p39) For example, people with mental illnesses can become further stigmatized if they are involuntarily hospitalized because of their inability to care for themselves.

Human geography

While relational moral theories, such as feminist and care ethics, tend to focus on the situatedness of human life in terms of social relations, they often ignore environmental relations and the built environment. ¹⁹ The work of Dodds, ²⁰ an exception, recognizes that vulnerability can be mitigated or exacerbated by both the natural and the built environment. In other words, places, such as the emergency department, can impact the embodied, social, and relational nature of vulnerability. Human geography emphasizes the material and spatial characteristics of human life and recognizes the importance of places on the relationships and affective experiences of those who dwell in them, making insights from this perspective very useful in analyzing the intricacies of the impact of place on the ethics of caregiving. ²¹ Relational geography and feminist ethics share ontological assumptions with persons being viewed through an intersectional lens and understood as being connected to others on multiple scales, both in close proximity and at a distance. “Place, ethics and practice are closely bound and interdependent”^21(p115) with normativity, in a geographical sense, an aspect of the ongoing flow of life inherent in social practices. ²² Practices and places, such as nursing practices and healthcare settings, represent and form people and conversely, people represent and form practices and places through a process of making meaning. ²¹ As such, “places possess basic agency.”^21(p43) Specifically, we examine these dynamics in the place of the emergency department from an ethics perspective.

The place of the emergency department as contributing to situational and pathogenic vulnerability

Numerous realities of the physical environment have negative implications for patients being cared for in unconventional spaces in the emergency department. For patients and their caregivers, many of these realities are extremely obvious; it would be difficult to find emergency department users to extol the benefits of receiving care in highly trafficked hallways. Because feminist ethics is concerned with the everyday realities and concrete experiences of care, ¹³ exploring these negative implications using this perspective can bring to light the ways in which the place of the emergency department exacerbates the power imbalance between patients and healthcare providers and heightens the risks for situational and pathogenic vulnerability. We specifically focus on barriers to comfort, privacy, and communication.

Lack of comfort

Care, compassion, responsiveness, dignity, and privacy are core values for nurses, ¹⁷ and they are core values when adopting a feminist ethics approach. Although emergency departments are primarily focused on urgent and critical care, as opposed to the more commonplace care needs of people, a feminist ethics approach would direct us to address not only these urgent needs but everyday needs as well. ¹³ Providing comfort as an expression of these values, however, can be very challenging in emergency departments because they are often chaotic and noisy, operating regardless of the time of day. People in need of care come to the emergency department because they are sick, injured, or in need of shelter and food, reflecting the inherent vulnerability we all possess. ¹⁶ They have also often exhausted all other ways to take care of themselves. ²³ However, for patients placed in areas of the emergency department not previously meant for care, such as a stretcher in the hallway or a reclining chair in a closet, there can be a distinct lack of comfort that contributes to their situational vulnerability. ¹⁶

There is typically insufficient personal space, no ability to dim overhead lights, and excessive noise due to other patients and positioning in busy areas.^24,25 Sleep deprivation and sensory overstimulation are common, which can lead to worsened mental health, contribute to disorientation, and aggravate the potential for delirium.^26,27 Basic personal care can be inadequate, as hygiene, toileting, and nutrition are not easily achievable in these areas, ²⁸ and a lack of access to resources, ambulation equipment and toilet facilities can reduce independence, increase powerlessness, and promote further reliance on care providers to meet needs. ²⁹ Rantala et al., ²⁴ who drew on insights from health geography to understand the experiences of their participants, described the emergency department as “a place that is both unsafe and uncaring”^(p8) for boarders, emphasizing patients’ feelings of discomfort and abandonment. Similarly, Hogan et al. (2016), who studied nurses’ perspectives of caring for dying patients in an emergency department, concluded that it “is not a nice place to die” because the environment’s busyness and lack of space and time impede the provision of compassionate care.^30(p209)

Compromised privacy

Nurses’ ability to meet their responsibility to uphold patients’ rights to be free from intrusion into their personal affairs, information, and body ¹⁷ is also constrained in these spaces because they offer a distinct lack of privacy for patients and their caregivers increasing their situational vulnerability in several ways. The amount of physical care that can be provided is limited, such as that needed for toileting or bathing non-ambulatory patients to safeguard patient modesty and dignity. A lack of curtains or walls in these unconventional spaces can contribute to poor sleep, embarrassment, and a perception or reality of a lack of safety.^24,28 A lack of auditory privacy can also violate patient confidentiality, as personal information can be overheard. ³¹ Witnessing other patients’ suffering and feeling empathy for them also contribute to patients experiencing the need to simply endure their situation. ²⁴ Additionally, physical exams can be neglected, deferred, or refused because of a lack of privacy, putting patients at risk of delayed or missed diagnoses.^32,33

Compromised communication and constraints to autonomy

The physical limitations of unconventional care spaces can compromise communication. For example, call bells and whiteboard communication tools are typically absent. Patients in these spaces can be in disjointed areas fragmented from their nurses, experiencing difficulty accessing nursing assistance or feelings of being ignored, overlooked, ²⁵ or abandoned. ²⁴ The lack of physical space can mean caregivers accompanying the patient are not easily accommodated, limiting an important source of support and advocacy for patients, while impairing important information exchange with the healthcare team. ²⁶ Likewise, in the hectic emergency department environment with multiple time-sensitive demands on staff, input from patients and their caregivers can be limited. ³⁴ Compromised communication can contribute to situational vulnerability ¹⁶ while reducing power for patients as their involvement in their care is limited.

Communication in care can be impaired by privacy concerns as patients may be more reluctant to share personal details that could impact care delivery, and care providers may be hesitant to share or ask for sensitive information. ³³ For nurses providing care in these emergency department spaces, there can be limitations to their capacity to meaningfully foster autonomy. The asymmetrical nature of care, as patients rely on care providers to address their unique needs, ³⁵ is heightened through patient positioning in unconventional care spaces as the environment contributes to situational vulnerability. Moreover, the emergency department as the place of care can frequently feature states of uncertainty and feelings of abandonment that disrupt the therapeutic nurse-patient relationship, ²⁴ which can be worsened by the inability of nurses to uphold ethically important aspects of communication in this environment, such as reciprocity in care through listening, being present and responding to patients. ³⁵

This impaired communication, and more broadly, the place of the emergency department as a care environment, forms part of the dynamics between place and relationships ²¹ that can interfere with exercising autonomy. From a feminist ethics framing, autonomy is considered relationally, that is, patients are interdependent, and their decision-making occurs within the social conditions and relational contexts in which they uniquely exist. ³⁶ Mackenzie ¹⁶ notes that a key feature of vulnerability is how it can constrain autonomy or worsen the sense of powerlessness created by inherent and situational vulnerability more generally. Fostering autonomy, therefore, becomes increasingly challenging in these care areas with the associated realities of the place of the emergency department.

Ageism and normalized inequity within emergency department care—compounding the issue

Multiple groups present to the emergency department more frequently than others that have a risk for increased vulnerability, such as people within the lowest socioeconomic groups, ³⁷ and middle-aged patients with mental health and substance use issues. ³⁸ Patients aged 65 years or older, however, account for the greatest proportion of emergency department visits and are more likely to be admitted. ³⁹ Older adults are more likely to have multiple comorbidities and experience longer boarding times with longer inpatient lengths of stay. ⁴⁰ The likelihood of longer emergency department lengths of stay and admission has been found to increase with age, particularly in the population over 85 years of age. ⁴¹

Care in emergency departments, particularly care in unconventional spaces, can add additional layers of challenge for many older adults that reflect implicit structural ageism. Defined by Chang et al. as the ways “in which societal institutions reinforce systematic bias against older persons”^42(p2) structural ageism can be seen in the failure to accommodate the unique needs of older adult patients in the emergency department. As such, the emergency department as a place of care for older adults can contribute to pathogenic vulnerability because it further compounds vulnerability through its dysfunctional approach to meeting their care needs. ¹⁶ Although certainly not a homogenous group, older adults presenting to the emergency department are more likely to have complex underlying physical, cognitive, social, and situational needs than other patient groups. ⁴³ Care in the emergency department is fundamentally not tailored to their needs. ⁴⁴ Instead of mitigating needs, care provided in unconventional spaces disadvantages these patients to greater risk for harm. As such, the place of the emergency department represents one of the “hidden geographies of aging” that contributes to the vulnerability of older adults.^45(p784)

The negative physical environment impacts, including those discussed concerning comfort, privacy, and communication, may more heavily impact the care of certain older adults. Namely, those patients that do not align with the ideal, yet fictitious, patient who has a single acute diagnosis, predictable response to treatment and determinable length of stay.^46(p1575) Consequently, such patients, often the older adult population with complex, yet relatively stable, health situations, can be problematized and seen as burdensome to a healthcare system that prioritizes efficiencies and rapid patient turnover.^46,47 Thus, the population most frequently utilizing the emergency department, most likely to be admitted and boarded there, can be seen as a problem, impeding patient flow.

Within the emergency department, the typical patient receiving care in unconventional spaces is stable, awaiting an inpatient bed. ²⁵ The stable patient is considered safe to wait in the hallway or available chair to make room for the unexamined patient yet to be assessed for critical illness. ⁴ Similarly, amidst competing priorities in the emergency department, nurses prioritize the sickest patient, prioritizing life and death situations over other care priorities, such as those related to older adult needs.^34,48 The domain of the emergency department ensures that the patients experiencing the most acute medical situations are treated, but this calls into question what domain the patients and their needs who do not meet the threshold for priority care fall under.

The ethical concern here is not that the critically ill patient is prioritized. Rather, the issue is that in the emphasis on meeting the needs of some, what becomes obscured is that certain groups and individuals must accept care that does not adequately meet their needs and can even result in harm. Patients who are not critical enough to require resuscitation, but not well enough to be discharged, are at risk of care that threatens their dignity and increases the threat of situational and pathogenic vulnerability, even if they are “stable” enough for hallway healthcare. As these patients are typically older adults, a group with higher emergency department visits increasing with age, ³⁹ they are thus bearing the brunt of the arrangement of care in crowded emergency departments. With the demographics of emergency department users reflecting the shifting in many countries toward greater numbers of older adults, the situation of emergency department crowding and hallway healthcare normalizes inequities in care for this group.

Discussion and recommendations—looking forward

Through understanding the role of place in contributing to the situational and pathogenic vulnerability of emergency department boarders, we suggest three areas that can provide possible future directions for ameliorating this complex ethical problem. These include highlighting the moral experiences of those receiving and providing emergency department care, ensuring older adult needs are addressed at the systems level, and supporting autonomy.

Making visible missing moral experiences

Making visible the moral experiences, or the everyday lived understandings, of what constitutes the ethical concerns ¹³ of patients and their caregivers in the unconventional spaces of the emergency department could be an important way to disrupt the predominantly abstract systems-oriented views of the problem that fail to capture the unethical burden on older adults and their caregivers. The feminist ethics view that “morality happens in a real world marked by profound social differentiation”^13(p188) makes room to recognize the moral experiences of those deemed suitable for care in unconventional spaces and recognize them as important. The largest demographic of emergency department users, older adults, are most likely to be admitted, ¹ and subsequently may experience extended lengths of stay there.^40,41,49 Generally, their social location, as a group results, in a greater risk for situational and pathogenic vulnerability caused by the impacts of care provided in unconventional spaces. Their moral experiences are an important missing piece to highlight the inequity of their position. For example, the minutiae of the commonplace realities of receiving hallway care, such as an individual requiring incontinence care on a stretcher in an open area or developing life-threatening delirium while having sleep disruption in the disoriented environment of a brightly lit hallway. ²⁷

The moral experiences of nurses and other clinicians in the emergency department can also reveal how environmental constraints can diminish the power clinicians have available to meet patient needs and provide ethical care. The built environment and spatial configuration of the emergency department can impede and promote certain nursing actions, through the implementation of particular patterns of clinician-patient interactions that may be outside the norms and standards of the profession. ⁵⁰ For example, what might be acceptable nursing care provided in the hallway may differ from care that is provided elsewhere in the hospital as the place of care forms part of the context that influences what care is prioritized and provided. ⁵¹ The barriers to comfort, privacy, and communication that can result in care that fails to safeguard dignity can have repercussions for clinicians amidst their everyday workplace realities of providing care in these emergency department spaces.

The ICN Code of Ethics for Nurses (2021) directs nurses to universally respect the rights and dignity of all. ¹⁷ However, emergency nurses are placed in a difficult situation as there is tension between nursing responsibility to provide care in the environmental reality of the patient in front of them while upholding the values and standards of the profession. Using the feminist “language of responsibilities,”^52(p118) nurses shoulder responsibility for bedside care provision in this unconventional space by way of their professional location, yet they do not normally hold the decision-making power to redefine societal and healthcare system priorities. ⁵³ This heavy discord between the care emergency nurses feel they ought to provide and the care possible in their workplace circumstances has been described as moral distress. ⁵⁴ Concerningly, both for individual clinicians’ wellbeing and the capacities of the broader health systems, moral distress has been associated with emergency department nursing attrition and intent to leave. ⁵⁵ Exploring the moral experiences of patients and clinicians can provide an avenue to identify forms of oppression and inequity within this emergency department care arrangement and aid in emphasizing the place of care in understanding the ethically problematic nature of hallway healthcare.

Accounting for older adult needs within the purpose of the emergency department

Since its inception and evolution, the emergency department has had and continues to have, a significant place in health care. The emergency department ethos indicates that care must be provided to all those who need it. ⁵⁶ Subsequently, the emergency department provides not only care for the critically ill and injured, but also acts as a social safety net ⁵⁷ and fills gaps in acute, urgent, and primary health services.^10,58 There is ongoing debate with several viewpoints over what the role of these departments should be^58,59 as health systems internationally grapple with challenges, including an older adult population that is growing, with increasing demands on health systems and projected future increases to emergency department visits. ⁶⁰

As this debate evolves, we suggest that the deliberations surrounding the purpose of the emergency department should encompass a heightened awareness of the contextual factors that can worsen situational and pathological vulnerability for some. In particular, increased attention must be paid to the realities for older adults who can be disproportionately impacted through the places of care that are marred by a lack of comfort, privacy, and communication, exacerbated by implicit ageist structures of the arrangement of care in the emergency department. Several studies have indicated that there is a greater preference by patients to be boarded in the unconventional spaces of inpatient wards compared to those of emergency departments,^61–63 with more positive patient experiences of those boarded reported on inpatient wards. ⁶⁴ Further pragmatic efforts that address the risks for vulnerability due to aspects of the place of care should be explored.

To impede the perpetuation of inequities that exist for those at risk for “pathogenic responses to vulnerability”^18(p45) policymakers and healthcare leaders need to be aware of and address the unique needs of older adults at a system level. Normalized inequities should be uncovered and remedied. Further, Goodin (1985) as cited in Mackenzie et al.^16(p13) suggests that those in positions of power “have special responsibilities toward those over whom they have power or who are particularly dependent on them.” Ultimately, as the purpose of the emergency department evolves, systems changes need to occur to ensure that the prevailing place of the emergency department is not one of a catchall for health system shortcomings at the expense of care for the vulnerable.

Supporting autonomy

For those receiving care in the unconventional spaces of the emergency department, there can be a failure to provide the necessary conditions to fully support autonomy in care. Future directions for research include how to specifically support the autonomy and help maintain the personal integrity of those who are especially vulnerable in this context, including some older adults. ³⁴ Multiple streams of inquiry are indicated when viewing autonomy relationally, including determining ways in which the built environment, social location, and clinician interactions can better support the autonomy and agency of older adults in the emergency department and beyond.

Curtis and Jones ⁶⁵ suggest that space is socially significant and socially constructed. We have argued previously that the unconventional spaces of the emergency department hold meanings for patients and their caregivers that do not align with the therapeutic foundations for health while simultaneously representing inequities for those at risk for increased vulnerability. A move toward fostering autonomy could include further work examining implicit structural ageism within healthcare spaces and how autonomy is fostered or diminished through care arrangements.

Conclusion

Of the prolonged and pervasive nature of care provided in hallways and other unconventional spaces, McNeilly et al. ⁶⁶ write “the chronicity of gradually evolving disasters makes them insidious.” ^(p282) They argue that protracted exposure to a disaster can result in the normalization of a subpar approach that was introduced in a time of necessity. Given that hallway care began decades ago as a temporary solution to the burgeoning problem of increasing patient volumes and ranks of admitted patients awaiting inpatient beds, ⁴ care provision in unconventional spaces has been routinized in practice. A provisional “solution” has become protracted creating another problem—one of unethical care.

A feminist ethics and human geography framing could also be applied to consider the needs of other groups of people who may have increased risk for situational and pathogenic vulnerabilities when receiving care in a crowded emergency department environment. For example, patients presenting with mental health concerns or patients with disabilities may have care needs that are not met or are even worsened, by the place of care in the emergency department, such as those issues brought forward regarding a lack of comfort, privacy, and compromised communication. While some concerns raised may be common across people with similar vulnerabilities, the unique experiences of each group warrant further exploration in future research.

In conclusion, while crowding, access block, and boarding of admitted patients in the emergency department are complex logistical problems, they are also ethical problems. The insights provided through an ethical analysis of the emergency department places of care can give rise to solutions that can aid in moving beyond the current seemingly intractable situation to instead consider how to make care more equitable.