‘I knew I'd be taken care of’: Exploring patient experiences in the Emergency Department

Abstract Aims To explore adult Emergency Department patient experiences to inform the development of a new Emergency Department patient‐reported experience measure. Design Descriptive, exploratory qualitative study using semi‐structured individual interviews with adult Emergency Department patients. Methodology Participants were recruited across two Emergency Departments in Southeast Queensland, Australia during September and October 2020. Purposive sampling based on maximum variation was used. Participants were recruited during their Emergency Department presentation and interviewed in 2‐weeks via telephone. Inductive thematic analysis followed the approach proposed by Braun and Clarke (2012). Results Thirty participants were interviewed, and four themes were inductively identified: Caring relationships between patients and Emergency Department care providers; Being in the Emergency Department environment; Variations in waiting for care; and Having a companion in the Emergency Department. Caring relationships between patients and Emergency Department care providers included being treated like a person and being cared for, being informed about and included in care, and feeling confident in care providers. Being in the Emergency Department environment included being around other patients, feeling comfortable and having privacy. Variations in waiting for care included expecting a longer wait, waiting throughout the Emergency Department journey and receiving timely care. Having a companion in the Emergency Department included not feeling alone, and observing care providers engage with companions. Conclusion Patient experiences in the Emergency Department are multifaceted, and themes are not mutually exclusive. These findings demonstrate consistency with the core experiential themes identified in the international literature. Impact Strategies to improve patient engagement in shared decision‐making, and communication between patients and care providers about wait times will be critical to optimizing Emergency Department patient experiences, and person‐centred practice. These findings holistically conceptualize patient experiences in the Emergency Department which is the first step to developing a new Emergency Department patient‐reported experience measure.

The constructivist-interpretivist paradigm was chosen because it is based on a relativist ontological position and a subjective epistemological position (Scotland, 2012). A relativist ontological position is the belief that reality is subjective and differs from one person to the next. A subjective epistemological position is the belief that people construct meaning in different ways because we each interact with the world individually. Thus, the constructivist-interpretivist paradigm was suitable to underpin this study given its exploratory nature.

| Sample/participants
The study was conducted during September and October 2020 at two public hospital Emergency Departments in Southeast Queensland, Australia. Potential study participants were recruited using a predetermined purposive sampling frame based on maximum variation for age, gender, reason for presentation and the Emergency Department presented to (Palinkas et al., 2015). Maximum variation sampling was used to capture a range of participant perspectives, and provide a holistic understanding of the phenomenon being explored by diversifying the recruited participants on select characteristics. As the findings of this study will inform the development of an Emergency Department patient-reported experience measure, a broad spectrum of experiences is desirable to ensure that the instrument is generalizable to all adult Emergency Department populations. Participant eligibility criteria is described in Table 1.
Potential participants were recruited face-to-face during randomly allocated 6-h recruitment shifts, across seven consecutive days per site ( Figure 1). During recruitment shifts, eligible patients were approached by an Emergency Department physician or nurse after treatment had commenced (but prior to discharge or transfer), and asked to provide written consent if they agreed to be approached by the researcher (CB). Consenting patients were then approached, informed of the study and invited to participate in a telephone interview in the next 2 weeks. Consenting participants provided the recruiting researcher with their first and last name, best contact number and identified suitable days and times to be interviewed. The recruiting researcher made field notes during recruitment shifts about the Emergency Department environment, observations about patients and staff, and biases and assumptions she reflected on throughout recruitment.

| Data collection
An interview guide (Appendix 1) was developed by the research team to assist the flow of conversation, which was pilot tested with four individuals who had recently presented to the Emergency Department (interviews were not included in analysis). Interview guide questions were informed by a systematic mixed studies review of the international literature describing patient experiences in the Emergency Department (Bull et al., 2021). One researcher (CB) undertook all interviews, which were audio recorded. Regular meetings were held with the research team to discuss emerging findings. All members of the team also had access the interviewing researchers' contact summaries from each interview. Contact summaries detailed the main themes discussed in the interview, whether the interview raised new thoughts or questions for upcoming interviews, and additional comments that the interviewing researcher noted (e.g. participants tone of voice and level of detail provided). As such, the research team collectively agreed when data saturation was evident (i.e. when no new ideas emerged throughout interviews). No repeat interviews were undertaken, and transcripts were not returned to participants for member checking.
With participant consent, the following demographic information was extracted from participants' Emergency Department elec-

| Ethical considerations
Ethics clearance was given by the relevant institutions (Ref No: HREC/2020/QGC/61674 and 2020/444). All participants provided written consent to participate in the study.

| Data analysis
Preliminary data analysis occurred simultaneous to data collection, enabling constant comparison and the identification of data saturation (Whitehead et al., 2013). During interviews, notes were made about participant Emergency Department experiences. In between interviews, contact summaries were completed to guide subsequent interviews and to prompt for emerging ideas. All interviews were transcribed verbatim, cleaned and removed of extraneous content.
An inductive thematic analysis approach was used to formally analyse interview transcripts. Analysis occurred in an iterative manner to develop subthemes and themes, following the six-step approach proposed by Clarke, 2006, 2012). This included: (i) data familiarization; (ii) line-by-line coding; (iii) collating codes into potential themes; (iv) generating thematic maps; (v) refining and defining themes and sub-themes; and (vi) extracting descriptions from interviews and generating results (Braun & Clarke, 2006). Regular meetings were held by the research team to achieve a jointly developed interpretation of the data.

| Rigour
The research team members have backgrounds and expertise in nursing, nutrition, emergency care, research and patient safety. The first author (CB) undertook all interviews. She has an honours degree and this study forms part of her PhD candidature. All authors are experienced in qualitative research.

| Qualitative interview findings
Four themes were inductively identified from the qualitative data: (i)

Reflexivity
The first author maintained a field journal noting her interactions with staff and patients in the Emergency Department, observations about the Emergency Department environment, and important considerations, biases and assumptions that arose during participant recruitment, data collection and analysis (which were discussed in team meetings).

Credibility
All members of the research team were involved in the analysis process to establish consistency in the interpretation of the data. a Transferability By using a maximum variation sampling frame and recruiting participants at random times in the Emergency Department, the experiences from a broad spectrum of patients were captured. b

Dependability
The use of contact summaries, maintaining a strong audit trail and holding regular team meetings throughout the data collection and analysis periods

Being treated like a person and being cared for
Participants described being treated like a person when receiving medical care. This care was respectful and considerate of them as an individual, not a medical condition. Interactions with care providers who demonstrated 'empathy', 'concern', 'compassion' and 'reassurance' were crucial to making participants feel humanized and cared for, and had an enduring impact on their overall Emergency Department experience ( Being treated like a person was exemplified when participants were taken seriously by care providers and not dismissed about their expertise and knowledge of their own health and body. This contributed to egalitarian relationships where participants felt free to express their thoughts and opinions (

TA B L E 4 (Continued)
(e.g. bathrooms, TVs, phone chargers) ( Three sub-themes underpin this theme: (i) Expecting a longer wait; (ii) Waiting throughout the Emergency Department journey; and (iii) Receiving timely care.

Expecting a longer wait
A long Emergency Department wait time was expected by many participants, influenced by past experiences of waiting and how busy the Emergency Department appeared to be. Many participants reflected that their current experience of waiting was better than their past experiences, noting how surprised they were (

Waiting throughout the Emergency Department journey
Waiting was a phenomenon that occurred throughout participant Emergency Department journeys. Participants described waiting at several junctures in their Emergency Department experience, including waiting to be triaged, waiting to see care providers, waiting for tests/procedures to occur, waiting for results, waiting to be moved to different sections of the Emergency Department and waiting to be discharged or admitted. Some participants described how the experience of waiting throughout the Emergency Department journey made them feel that they were in the Emergency Department for too long. This was more pronounced when they actively engaged with their care providers for only a portion of their Emergency Department stay, as described by a participant waiting to learn the outcome of an injury ( Table 4: Quote 24). In particular, some participants found waiting frustrating as they felt it was delaying their stay, preventing them from knowing what was medically wrong, and knowing whether they would be discharged home or admitted (Table 4: Quote 25).
Yet despite the frustration of some, most participants were understanding and even empathic towards the reasons they needed to wait. Participants understood that the Emergency Department was busy, and that Emergency Department care providers were under pressure, and providing care to many patients. Thus, participants recognized the need to wait for care, which they were happy to do, often describing how they regulated their feelings of frustration with understanding towards the pressures on care providers (Table 4: Quote 26).

Receiving timely care
In contrast to waiting throughout the Emergency Department journey, receiving timely care was described by participants as having a minimal wait in the Emergency Department waiting room, and an experience that progressed in a timely fashion. Receiving timely care made patients feel prioritized, legitimizing their reason for presenting to the Emergency Department and positively impacting their experience ( Table 4: Quotes 27). One participant even described how receiving timely care was the best part of his Emergency Department experience ( Table 4: Quote 28).
A major aspect of timely care related to participants' receipt of analgesia. Participants experiencing pain and discomfort described this as a memorable aspect of their Emergency Department experience, and for many, the main reason for their presentation. Thus, receiving timely analgesia improved their comfort levels, and care providers' responsiveness made participants feel they were genuinely cared for ( Table 4: Quote 29). Participants who did not receive timely analgesia, however, became frustrated because it was their pain and discomfort that prompted them to initially seek emergency care. This had an overall impact on their Emergency Department experience, leaving them feeling dismissed and burdensome ( However, some participants were unable to have a companion with them (due to COVID-19 restrictions) and noted how this impacted their Emergency Department experience. Namely, that there was no one else to hear discharge advice, and no one to ask questions that the participant had not thought to ask ( Department experiences, contributing to participants' sense of confidence that they had all the information they needed before leaving the Emergency Department.

Observing staff engage with companions
Participants identified that care provider engagement with companions included acknowledging their presence, offering them food and drinks and involving them in the discussions taking place (  (Manley et al., 2011). At the core of person-centred care is supporting and enabling patients (people) to be partners in their care (Kennedy, 2017). While there are several challenges to enabling Emergency Department patients as partners in their care, including the severity of their condition (Elder et al., 2020;Kennedy, 2017), biomedically oriented cul- College of Emergency Nursing Australasia, 2020). Moreover, the close relationships shared between patients, family members, friends and carers may also be a critical source of information to Emergency Department care providers (Boyle, 2015), particularly where these social support networks take on an advocative role for patients (Marynowski-Traczyk et al., 2019). However, existing research suggests that family-centred care is poorly facilitated in some Emergency Departments (Almaze & de Beer, 2017), and that companions want to have greater communication with Emergency Department care providers and more involvement in patient care (Collom et al., 2019;Hsiao et al., 2017). Given that most research to date has focused on supporting family-centred care in paediatric Emergency Departments (Argall et al., 2021;Brown et al., 2008;Manguy et al., 2018), facilitating Emergency Department care providers' provision of respectful, accurate and timely information to adult patient companions warrants investigation. Furthermore, patient and companion preferences for involvement in Emergency Department care should be examined as to support the provision of Emergency Department care that is person-and family-centred.

| Limitations
As with all research, we acknowledge some limitations. First, there was a period of 1 to 14 days between participant recruitment and interviewing, potentially introducing recall bias. However, this period was necessary because interviewing participants while they were still in the Emergency Department would have been both impractical and unethical as it may have interrupted their receipt of care, and would have resulted in incomplete concept elicitation (i.e. their Emergency Department journey would have been incomplete). Additionally, the period between presentation and follow-up enabled participants to recover/ get well before being contacted. Second, selection bias may have impacted recruitment as Emergency Department care providers were critical to consenting participants. The use of a maximum variation sample frame aimed to negate this. Third, all interviews were conducted over the phone due to COVID-19 restrictions and ethical requirements.
Thus, the researcher was unable to utilize participants' visual cues such as non-verbal body language to prompt for further questioning (Sweet, 2002). However, considering the pandemic, this was a pragmatic and ethical decision which maximized participants' safety and comfort. The participant-researcher relationship established during face-to-face recruitment also ensured that participants knew that their opinions were respected as valid and valuable. Finally, mental health, homeless, correctional services/ police escorted and patients potentially infected with COVID-19 were not recruited, suggesting that the findings may not represent the experiences of all individuals that present to Australian Emergency Departments.

| CON CLUS ION
The findings of this study indicate that there are four critical aspects to patient experiences in the Emergency Department. These