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Abstract

Overcrowding in the emergency department is a frequent topic in the news. This results in long waiting time and dissatisfaction among patients, but also involves medical risks for the individual patient. When a high workload occurs in the emergency apartment, staff members have to work harder, which leads to reactive behavior. To improve both patient safety and the working environment, staff members and management need to be flexible, patient-focused, and proactive. Being proactive means taking control and making things happen, anticipating and preventing problems, as well as seizing opportunities. Emergency nurses perform advanced nursing interventions, a prerequisite of which is proactive behavior based on practical nursing wisdom. Being proactive requires something beyond normal work performance. However, not all staff members have sufficient knowledge and experience. Identifying proactive interventions that everyone can perform would be valuable.

Keywords

advanced nursing interventions patient safety practical wisdom proactivity

Introduction

At emergency departments in Sweden, long waiting times and overcrowding have become the norm, which does not only create dissatisfaction among patients but also involves medical risks. Such departments are affected by patient intake and discharge, as well as internal processes and staffing, thus waiting times are difficult for staff to handle (Derlet & Richards, 2000; Swedish Council on Health Technology [SBU], 2010).

There have been numerous cases of medical error in Swedish emergency departments (Källberg, Göransson, Östergren, Florin, & Ehrenberg, 2013; The National Board of Health and Welfare [Socialstyrelsen], 2013). Bodily harm and mental suffering occur as a result of contact with the health services. In Sweden, patient safety is defined by law as protection against medical error, and each hospital must work actively to reduce such risk (SFS, 2010:659). To work proactive is a way to reduce the risks and according to Crant (2000), proactivity results in individual questioning of the status quo to create change, rather than passively adapting to the existing situation.

Previous studies have revealed that a high workload makes emergency department staff members become more reactive, that is, reacting to something that already has happened. Reactive can be defined as reacting to problems when they occur instead of doing something to prevent them (Rollenhagen, 2005), that is, a patient who becomes hypotensive while waiting for medical assessment. The organization’s approach to patient safety also becomes reactive as the deviation from standard procedure is only focused upon after an incident has occurred. The area of patient safety is still underdeveloped and has been described as too focused on the individual, that is, the professionals are subject to supervision and sanctions as opposed to the organization and authorities responsible for the healthcare system as a whole (Rollenhagen, 2005).

To improve patient safety and the working environment, staff and management must be flexible, patient-focused, and proactive (Rollenhagen, 2005). The latter implies taking control and making things happen, anticipating and preventing problems, as well as seizing opportunities (Parker, Bindl, & Strauss, 2010). The following is a comprehensive description of the concept of proactivity based on previous research:

The emergency room can be defined as a closed system where its different parts affect each other. The activities at the emergency room are, as Donabedian already highlighted in 1978, a triad of structure, process, and outcome (Donabedian, 1978). A proactive personality identifies opportunities to act and to avoid obstruction between these parts. This quality has been found to have positive effects on work performance and innovation. From a team perspective, the proactive individual exhibits greater productivity and efficiency. Personal initiative is when an individual actively takes the initiative, even if it means going beyond the stated job description. High confidence in one’s ability to carry through own decisions increases the individual’s chances of performing beyond her or his official duties. Personal initiatives that exceed prescribed assignments and challenge the status quo are constructive for an organization (Crant, 2000; Morrison Wolfe & Phelps, 1999). An employee who is both willing and able to perform beyond her or his professional duties is important for the flexibility of an organization. The purpose of proactive behavior is improvement, which may require the individual to develop or even reformulate her or his role, representing a situation-based approach to proactivity (Crant, 2000; Morrison Wolfe & Phelps, 1999; Parker, 1998).

A narrative study by Kucera, Higgins, and McMillan (2010) presents nurses’ perceptions of advanced nursing care. A characteristic of nurses who perform such interventions is that they have foresight and consider the consequences for all involved before taking action. Advanced nurses focus on the patient, and their interventions often alleviate patient suffering. Their thoughts and actions form a unit, as theoretical knowledge and experience constitute the foundation of advanced practice. Experience-based knowledge has been defined as a combination of theoretical and tacit knowledge, intuition, experience, personal maturity, and practical wisdom. It is developed in practical situations by interaction with patients and discussion with colleagues (Coles, 2002; McCutcheon & Pincombe, 2001).

When nurses perform advanced nursing interventions based on knowledge and experience, it can be compared with what Crant (2000) defined as a proactive personality. Advanced nurses can be said to work on the basis of proactive behavior, which requires something beyond the usual job performance. However, not all nurses have sufficient knowledge and experience. Identifying proactive interventions that less advanced nurses can perform in stressful situations in the emergency department would be valuable. In this study, we focus on proactive actions as no previous study on proactive activities in the emergency department has been found.

Aim

The aim of this study is to describe emergency nurses’ proactive activities as well as barriers to and opportunities for proactive work.

Method

By focusing on human interactions, the researcher can understand and describe the participants’ social reality by participating in it. The ethnographic approach enables descriptions of both events and actions as well as comprising an emic and an etic perspective together providing a balanced picture of the reality (Fetterman, 1998; Hammersley & Atkinson, 2007).

Design

A case study with a qualitative approach inspired by ethnography was performed. During the field work in an ethnographic study, the participants’ behavior is more or less influenced by the researcher’s presence (Hammersley & Atkinson, 2007). Pellatt (2002) described this as reactivity in a group. Participant observation is a data collection strategy that requires the researcher to be open to the various processes. There is a risk of the researcher becoming more subjective and lacking objectivity by “going native” (Hammersley & Atkinson, 2007). Thus, reflexivity is the basis for credibility and accuracy in ethnographic research and requires the researcher to highlight emerging social relationships and their possible impact on future work (Pellatt, 2002). Observations are a qualified form of data collection, during which a person’s condition, non-verbal language, and specific activities are studied. An ethnographic design also contains interviews with key persons (Polit & Beck, 2012).

In a qualitative study, it is important to reflect on one’s own pre-understanding of the phenomenon in question and how it can influence the observations (Hammersley & Atkinson, 2007). The data were collected by the first author, who has 14 years of experience as a registered nurse, 10 of which were spent in an emergency department.

Setting and Participants

The case study was conducted at a Swedish emergency department with an annual patient flow of about 57,000 and based on both participant observations and interviews. The extent of the data, such as the number of observations and interviews, is determined by what emerges during the data collection. For this reason, the number of observations was not determined in advance. The observations were performed over the course of 1 week in spring 2013.

Interviews complemented the observations to gain a deeper understanding of the phenomenon of proactivity. A strategic selection of participants working during the actual study period was made by the first author, leading to the recruitment of one man and two women aged between 22 and 45 years. Nurses with varying lengths of experience of working in the emergency department were chosen to explore whether the number of years in the profession influenced the perception of proactivity.

Data Collection

The observations were carried out by the first author who followed four emergency nurses in their daily work and made field notes structured as a protocol. Their time in the profession ranged from 6 months to 19 years. This included the time at which and location where the observation was carried out, details of the various situations, who acted and in what way. The researcher’s own reflections were also documented. A total of 32 hr of observations were conducted to identify proactive interventions.

Three other emergency nurses were interviewed. An interview guide with the following open-ended questions was used; in your opinion, what does a proactive approach mean? Do you see any barriers to working proactively? Do you see any opportunities for working proactively? The interviews were audio-recorded and transcribed verbatim.

Analysis

The field work was conducted in parallel with the reading of and reflection on the field notes. This constituted a preliminary analysis, where the first reading provided ideas for new approaches and questions for future observations. Nineteen field notes were analyzed by means of content analysis and various proactive interventions identified (for an example, see Table 1).

Table 1.

Matrix With an Example of the Analysis of the Observations.

Meaning unit	Condensation	Code	Subcategory	Category
Nurse asked the physician to come to the triage room to assess the patient as she thought he required a chest radiograph	Requested the physician to assess the patient	Care of the patient	Preventing the suffering of care	Seeing the patient

The interviews were also analyzed by means of content analysis on a manifest level (Graneheim & Lundman, 2004), meaning that it is the transcribed text itself that is analyzed, without interpretation. The recorded interviews were thus transcribed verbatim and formed the unit of analysis. The text was read several times and broken down into meaning units, which were then condensed and abstracted to make the text shorter and more manageable, while preserving the core content. The condensed text was grouped into categories that illustrate the nurses’ opinions of various proactive interventions (for an example, see Table 2).

Table 2.

Matrix With an Example of the Analysis of the Interviews.

Meaning unit	Condensation	Code	Subcategory	Category
Being one step ahead. Identifying and eliminating risks before something serious happens	Identifying and eliminating risks before something happens	Having a clear care plan	Preventing injuries caused by care	Being one step ahead

Ethical Reflection

Ethical approval was obtained from the University West Ethics Committee before the study began (No. 2013/128B22). The manager of the emergency department approved the study, and each of the participating nurses provided written consent. Only the nurses were observed, and the patients were not included (Central Ethical Review Board, 2012). In ethnographic studies, the researcher has close contact with the participants, making it important to establish a good relationship with them. The researchers must be aware that their presence may be perceived as intrusive or unpleasant and should therefore leave in sensitive situations or ask the participants to inform them when observations are not appropriate (Hammersley & Atkinson, 2007). This was taken into account during the study. The four ethical principles governing the humanities and social sciences were adhered to, thus the study meets the requirements on information, consent, confidentiality, and utilization (World Medical Association Declaration of Helsinki, 2008).

Findings

The results of the observations and interviews, which have been grouped into categories and sub-categories, are presented below.

Being One Step Ahead

The nurses identified risks in their assessment and prioritization and tried to address them, such as giving medications based on general prescriptions, meaning that pharmaceutical treatment can be given by the nurse before the physician encounter the patient. They would like more general prescriptions and memorandums but worried that their own expertise might be insufficient. The interviews revealed that the nurses made risk assessments to maintain patient safety. “Being one step ahead, identifying risks and taking action before anything serious happens” (Nurse 1).

When the nurses had clear patient goals and care plans, they could identify safety risks and take action to prevent them. The observations revealed that with a higher inflow of patients, the greater the importance of a proactive approach. In particular, this concerned nurses who were responsible for allocating internal resources by arranging various examinations, such as in radiology, at the early stage of the care continuum.

Figure 1.

Prerequisites for proactive work.

Preparing the patient before the medical assessment reduced the total time of the care process, which also benefited the patient. “In triage it takes more time to write a note about the deep vein thrombosis on the assessment form, although I think it benefits the patient in the long run” (Nurse 3).

Being Able to Start Proactive Interventions

One of the observations highlighted teamwork between a physician and a nurse. The team took care of patients upon arrival. The collaboration between the two professional categories ensured focus on the patient and the formulation of a clear care plan, which shortened the administrative procedure. An example was when the physician and the nurse accompanied the patient for a chest X-ray test and obtained direct response. This patient passed quickly through the emergency chain, demonstrating a proactive approach.

The observations showed that the number of proactive interventions carried out when the patient inflow was high largely depended on the nurse responsible for coordinating the work in the emergency department.

If you work in a different way [more proactively] it may well be that it will lead to less work and quicker handling, which will prevent a bottleneck developing here and having to move patients around. If we stay on our toes from the start, we can save time. (Nurse 1)

Prerequisites for Proactive Work

The gradual development of a proactive approach was described by a nurse as follows:

Proactivity develops gradually. You may not be very proactive when you are new on the job as an nurse . . . it will come with time, experience and understanding of what you’re doing. (Nurse 1)

During the interviews, the nurses highlighted the importance of gaining skills through training, which to some extent would make them willing to assume more responsibility. They considered that there was a need to upgrade the skills of all staff members as well as for additional memorandums and guidelines. “It would be possible to do more if it was made clear how we should work, i.e., more guidelines” (Nurse 3)

In the observations, it was noted that experienced nurses could identify new questions and cues that facilitated a more accurate assessment based on patients’ narratives. They could also clearly envisage the likely treatment plan and therefore worked more proactively than their less experienced colleagues.

An example from the observations was the treatment of a patient with newly discovered diabetes. The experienced nurse took an arterial gas sample shortly after the patient had entered the triage room to determine further interventions. She then performed the routine checkups and put the patient on a drip. The patient’s blood glucose was 24 mmol / l (432 mg/dl), and when the result of the arterial gas sample was available, no acidosis or electrolyte disorders were found. The nurse knew that if the blood glucose could be corrected in the emergency department, the patient could probably go home after medical assessment. The nurse asked a physician to prescribe rapid insulin, which she administered to the patient. When the patient was subsequently assessed by a physician, the blood sugar had normalized and she or he was able to return home with oral treatment for the diabetes and follow-up at her or his health center. This nurse used advanced nursing interventions thanks to her long emergency department experience.

Working Reactively

Organizational barriers to a proactive approach were mentioned by all the informants. Such barriers included time constraints, shortages, hierarchy, an increased number of patients, poor collaboration between hospital departments as well as between municipal care, primary care, and the county council. When the continuum of care did not function in an optimal way, the staff lost control of patients’ care plans and reverted to a reactive approach, which meant patients having to spend more time in the emergency department as well as a risk to their safety. The nurses’ work environment was also affected, resulting in negative stress.

The patient has to wait before being transferred to the ward . . . continue caring for those who are ready for transfer to the ward. . . . there is no time to work proactively with other patients. (Nurse 2)

Less proactive interventions were used if the nurse had little skill and experience. The observations also highlighted a difference between nurses in terms of length of prioritization and assessment experience. For example, two nurses with between 1 and 3 years of experience asked standard questions about the patients’ condition and lacked the ability to follow up on important cues that emerged from patients’ narratives. They carefully adhered to and based their assessment on standard care plans. This was in contrast to the work conducted by two other nurses with between 14 and 19 years of experience. In addition to standard questions, they were able to identify new questions and cues that facilitated a more accurate assessment. They could also clearly envisage the likely treatment plan and therefore worked more proactively than their less experienced colleagues.

To illustrate proactivity a narrative was constructed from the data.

A morning at the emergency department

10:16 a.m.: Some patients have been in the emergency department overnight but generally it is quiet. New patients begin arriving, and within 2 hr the department is crowded. When the seventh patient’s name is called, the nurse notices an elderly woman who was brought to the ward in a wheelchair by a relative. On the referral note, the nurse read that the General Practitioner (GP) suspected a deep venous thrombosis in the left leg. The relatives had driven the patient 60 kilometers in their own car from the health center to the hospital. The nurse takes the patient’s medical history while an assistant nurse checks the patient’s blood pressure, pulse, oxygenation capacity, respiratory rate, and temperature. The nurse then examines the patient’s leg and comes to the conclusion that the referral is incorrect and diagnoses a partial Achilles tendon rupture, an orthopedic disorder, being one step ahead. The emergency orthopedic clinic is located in a hospital 30 kilometers away. However, the nurse does not have the authority to change the referral, which can only be done by a physician after examination of the patient. The nurse now tries to contact the emergency physician on duty, but without success. Expected waiting time for the physicians on the medical emergency ward is about 4 hr for low priority patients. The nurse’s goal is for this patient to obtain appropriate care from the right physician as quickly as possible. She realizes that the patient will have to stay in the emergency department for at least 4 hr before probably being referred to the orthopedics department. She phones the orthopedic clinic at the same hospital and contacts the orthopedic surgeon on call, and start proactive interventions. The orthopedic department staff usually only treat patients who have an appointment. However, the orthopedic surgeon is able to come to the triage room to examine the patient and confirms a partial Achilles tendon rupture. The patient is brought to the orthopedic clinic where she is set in plaster and discharged.

Figure 2.

Factors leading to a reactively work.

In this narrative, the nurse was one step ahead and envisaged the patient’s passage through the continuum of care as well as the probable treatment plan. The definitive treatment plan is determined by the physician after her or his assessment of the patient. The use of standard care plans for various medical conditions is common in the emergency department. Although these are helpful when the patient’s diagnosis is clear, they are not individualized and require the nurses to assess the patient’s medical condition. In the above scenario, the patient had leg pain and the GP suspected a deep vein thrombosis. Experience combined with practical and theoretical knowledge is a prerequisite for nurses to act in accordance with a likely treatment plan and provide individualized care. In the above example, the nurse used advanced nursing interventions and exhibited practical wisdom as prerequisites for proactive work.

Discussion

The proactive interventions described are only possible if the necessary conditions are in place. Many obstacles to proactive work were organizational. Lack of time, overcrowding, as well as poor internal and external collaboration are some examples. We observed that opportunities for proactivity increased when the care plan was established at an early stage of the continuum of care and when all team members were aware of it.

Patient safety would probably be improved by nurses continually assessing risk and priority. A clear care plan facilitates and simplifies risk assessment, which is likely to enable nurses to work toward a common goal where proactive patient care is in focus. Formulating a care plan requires theoretical, practical, and experiential knowledge. The nurses who performed advanced nursing interventions had such knowledge. The fact that some nurses possessed practical wisdom, which according to Crant’s (2000) theory can be equated with a proactive personality, meant that they worked more proactively.

Oberle and Allen (2001) attempted to define what is required for nurses to be able to perform advanced nursing interventions and suggested that practical wisdom is a hallmark of such nurses. Practical wisdom enables the nurse to know when a particular action should be initiated and when it gives maximum benefit to the patient, indicating that skills, ability, and maturity are the main attributes of the advanced nurse in practice. Aristotle described three forms of knowledge: episteme, techne, and phronesis. Episteme is “true” knowledge, as it is general and safe. Techne is preparedness for how to perform practice. Phronesis is reflection in the form of moral reasoning with the intention of doing “good” in a given situation and important for the development of practical wisdom (Connor, 2004; Dahlborg-Lyckhage & Pennbrant, 2014).

By informing patients about the likely care plan, nurses are in a position to prevent the suffering of care as well as increasing patients’ feeling of being looked after, thus alleviating their sense of powerlessness and uncertainty. Patients’ experience of care is of great importance both for the individual herself or himself and as an indicator of the quality of care and what needs to be improved. Patient satisfaction is influenced by the care process (Cooke, Watt, Wertzler, & Quan, 2006; Dahlberg & Segesten, 2010).

During the observations, it was found that teams comprising a physician and a nurse were beneficial for patients, as there was greater focus on them and the treatment was provided with less delay. Problems arose when the team had to deal with too many patients, as for example, the physician had time to examine a new patient while the nurse did not; thus, the positive effects of teamwork were lost. Previous studies have revealed that teamwork functions best when the team members jointly conduct the first assessment of each patient (Lau & Leung, 1997; Mazzocato, Hvitfeldt Forsberg, & Von Thiele Schwarz, 2011).

The long waiting times due to an increase in the number of patients led to the suffering of care and also posed a risk to patient safety. When nurses had to keep track of too many care plans, continuous re-prioritization and risk assessment became impossible. The nurses experienced this as negative stress, which in turn can lead to decreased cognitive functioning and is one reason why there is a greater risk of making mistakes while under stress. While individual professionals can handle stress, it becomes more difficult in a context where both the organization and the technology make high demands. Tools that can provide an overview of patients’ care plans would be valuable (Rollenhagen, 2005; SOU, 2008).

The nurses considered that there was a need for all staff members to develop higher skills in order to be able to work proactively. A high level of competence is important for both the individual patient and the emergency department organization (SBU, 2010). The ability to perform advanced nursing interventions may thus evolve over time, which means that nurses can gradually develop a proactive approach. The study revealed various proactive interventions that nurses perform irrespective of their level of skill, such as improving various forms of documentation and guidelines.

In other parts of the world, emergency departments are staffed by specially trained “nurse practitioners.” In the United Kingdom, this has generally led to benefits for patients (Byrne, Richardson, Brunsdon, & Patel, 2000; Sakr et al., 2003). Nurse practitioners perform advanced nursing interventions and their skills are utilized, which could also increase the quality of emergency department care in Sweden.

The observations indicated both organizational and skills related barriers to and opportunities for maintaining a high level of patient safety. Due to the long waiting time for physicians, the nurse’s skill in prioritizing patients’ medical conditions was important. The study revealed that the nurses’ experience affected their assessment of a patient’s medical condition. Lack of skills and time renders the organization vulnerable, possibly resulting in poorer patient safety (Andersson, Omberg, & Svedlund, 2006). In an organization such as that in which the study was conducted, staff members possess different levels of experience and skills; thus, not everyone can perform advanced nursing interventions. It is therefore important that the organization provides nurses with opportunities and conditions to work in a way that can develop their practical wisdom over time. Being involved in and able to influence their workplace promotes individuals’ learning ability, as they are shaped by each other. The organization plays a major role in supporting human relations, work ethics, motivation and the creation of a stimulating learning environment (Andersson, 2013).

Organizational conditions that sustain and enhance staff skills could be a first step in promoting more concrete proactive interventions which, in combination with a clear focus on the patient, would ultimately generate a higher level of patient safety and indirectly cost-effectiveness (Olsson, Hansson, Ekman, & Karlsson, 2009).

Limitations of the study

Performing an observational study at one’s own workplace involves both advantages and disadvantages. The benefit of an emic perspective is that the researcher’s pre-understanding can lead to a deeper comprehension of and a trusting relationship with the participants. A disadvantage may be that it is difficult to be objective. The first author’s pre-understanding included experiences as a nurse and theoretical knowledge, but also preconceptions. Taken together, this may have influenced the results of the data collection as well as the analysis and interpretation. During the observations, the role of participant observer enabled the researcher to be close to the participants, but without losing the distance necessary for the objectivity of the data collection and subsequent analysis (Labaree, 2002).

The first author was known in the department, which made it easier to perform the study in the limited timeframe. However, the researcher is also influenced by the participants. In the present study, this meant that on some occasions the researcher had to prevent herself from entering into a nurse role. Reflexivity can be achieved by moving between reflection and the field notes, something that was done. To achieve credibility, sources of potential influence should be made visible and discussed with the co-author throughout the study. Citations have been presented to strengthen credibility, and the analysis remained close to the original text. However, a certain degree of abstraction and interpretation is needed for the result to be deemed meaningful and comprehensible (Hammersley & Atkinson, 2007; Pellatt, 2002).

Conclusion

It is not easy to identify and describe proactive interventions, as emergency work is very complex and dynamic. Various care interventions, tasks, and processes are interdependent. When something is done in one part of the system, it affects another. Nevertheless, the study has contributed knowledge of proactivity within emergency departments and highlighted various ways of increasing patient safety, which involve looking beyond the organizational problems and cost efficiency to ensure that the patient is prioritized. The proactive interventions concerned concrete actions aimed at benefiting patients in both the short and the long term. More research is needed on how proactive interventions can be implemented in practice. Much of the frustration experienced by patients as well as staff in an emergency department concerns anticipation. Patients and nurses have to wait for, among other things, the physician, patients to be admitted to a ward, and X-ray test results. For nurses, this study may contribute to the understanding of how one can work proactively to promote the patients’ progress in the continuum of care while maintaining patient safety. The results presented might be useful for nurses who have not yet developed practical wisdom and the hope is that they will become a basis for discussion, contributing new ideas that can help them in their daily work. Opportunities for education and systematic reflection must be present in the organization to enable nurses to work proactively.

Footnotes

Acknowledgements

We wish to thank the research and development unit of NU-care as well as Kristofer Bengtsson and University West. We would also like to express our thanks to the management and the staff of the emergency department.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research and/or authorship of this article.

Author Biographies

Elisabeth Dahlborg-Lyckhage is a registered nurse and nursing teacher. She is a professor in Caring sciences and associated professor in Pedagogics. Her research is mainly qualitative, i.e. discourse analysis.

Karin Rehnström is a registered nurse and works in the emergency department at NU Hospital Group in Trollhättan. She has a Degree of Master of Science whit a major in Caring Sciences.

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