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					Working in an overcrowded accident and emergency department: Nurses’
narratives.

As part requirement of the Master of Health Sciences (Advanced Nursing/Midwifery
Practice), NUI Galway, Mary Kilcoyne (CNM A&E) utilised unstructured
interviewing within an interpretive phenomenological approach to explore nursing
issues associated with overcrowding in the A&E department.

The problem of overcrowding reflects an international trend, with discussions from
Ireland (Department of Health & Children, 2005), New Zealand (Richardson, Asplin,
& Lowe 2002), United States (Trzeciak & Rivers 2003), Cananda (CAEP & NENA
Joint Position Statement 2001), and Australia (Fatovich 2002). In pursuit of an
understanding of nurses’ experiences of working in an overcrowded A&E, eleven
nurses were interviewed and their narratives analysed using Colaizzi’s (1978)
framework of 7 procedural steps. Each nurse was asked to confirm the interpreted
findings. In addition, an external peer review was obtained from an experienced
nurse researcher, based in New Zealand, with extensive emergency nursing
experience, who validated the study findings.

Three central themes emerged from the data, with inter-related sub-themes (Table 1).

Table 1. Themes and sub themes arising from nurses’ narratives

Themes               Lack of space       Elusive care           Powerlessness

Sub themes           Poor     service Lack                  of Not feeling valued
                     delivery         respect/dignity
                                                         Moral distress
                     Health and safety Unmet basic human
                                       needs             Stress/burnout
                     Infection control
                     issues            Hovering




Theme: Lack of space: All the study participants clearly reflected lack of space in
the emergency department, as a major obstacle to service delivery, patient care, health
and safety, and infection control

Theme: Elusive care: In an overcrowded emergency department, there is an illusion
of nursing care being provided to patients, which in reality, is not the case. This was
reflected in the nurses’ narratives. Nurses talked emotively about their frustration in
failing to provide quality care, and their empathy for patients’ lack of privacy and
dignity.

Theme: Powerlessness
The study participants expressed feelings of frustration, anger, not being valued, and
stressed, and all felt powerless in their role as nurses in a working environment which
they felt has become an accepted norm.



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Discussion
All of the participants revealed lack of space as a significant barrier to the nursing role
in the department. Anxiety, stress, fear, frustration, a poor sense of safety and
security are just some of the aspects influenced by the physical environment. These
factors all play a part in motivating quality and productivity in the functioning of the
hospital staff (Carver, 1990). However, Carver further contends that hospital staff
adapt to their environment, learn to live with the problem and fit their patient care
around the problems. This would appear relevant to the nurses working in an
overcrowded emergency department, where nurses are continually moving patients
and trolleys in and out of cubicles, to enhance the functioning of the department and
allowing new patients to be assessed and treated.

All of the participants in this study expressed that ‘overnight stay’ patients had unmet
basic human needs, while being nursed in the emergency department. This alludes to
lack of privacy, dignity/respect, sanitary facilities, and space. Respecting privacy is a
vital part of holistic care and meeting individual needs. The nurses in this study also
reveal their experience of moral conflict since they are unable to carry out their role
due to factors beyond their control. As most patients are vulnerable, they need
protection as well as skilled and appropriate care. Yet nurses may not always be able
to protect patients or supply all their care needs, for a multiplicity of reasons. When
the professional goals of nurses are hindered, they suffer moral distress (Corley 2002).
Moral distress arises when one must act in a way that opposes personal beliefs and
values.

In conclusion, the nurses’ narratives reveal a rich, if somewhat, disturbing,
interpretation of their experience of nursing in an overcrowded A&E department. The
central issues of lack of space, a feeling of powerlessness and the inability to deliver
quality care to patients, contribute to moral distress and burnout among nurses.

Recommendations
If the delivery of patient focused quality care in the A&E department is to be
achieved, it is imperative that nurses are listened to, their expertise acknowledged and
they are involved in the decision-making process. Nurse managers play a central role
with regard to supporting A&E nurses performing their role in a climate created by
factors beyond their control.         The issues, and difficulties, associated with
overcrowding in the emergency department are complex, and multifaceted, and it is
imperative that A&E nurses, at constant risk of moral and emotional distress, are not
forgotten in strategic attempts to manage this issue.

You can find out more about this study and read samples of the nurses’ narratives in:
Kilcoyne, M. & Dowling, M. (2007) Working in an overcrowded Accident and
Emergency department: Nurses’ narratives. Australian Journal of Advanced Nursing
25(2): 21-27

References
Canadian Association of Emergency Physicians, National Emergency Nurses
Affiliation. 2001. Joint Statement on Emergency Department Overcrowding. Journal
Canadian Association of Emergency Physicians. 3: 81-86.




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Carver, A. M. 1990. Hospital design and working conditions. In Moran, R,.
Anderson R., and Paoli, R. (Eds). Building for People in Hospitals Workers and
Consumers Dublin: European Foundation for the Improvement of Living and
Working Conditions.

Colazzi, P. 1978. Psychological Research as the phenomenologist views it. In Valle,
R. S. and King M. (Eds.) Existential phenomenological alternatives for psychology.
New York: University Press.

Corley M. 2002. Nurse moral distress: a proposed theory and research agenda.
Nursing Ethics. 9 (6): 636-650.

Department of Health and Children (2005) Press Statement. Statement by an Tanaiste
on the Health and Safety Authority’s inspection of A&E Departments.
http://www.dohc.ie/press/releases/2005

Fatovich, D.M. 2002. Emergency Medicine. British Medical Journal. 324: 958-962.

Richardson, L.D. Asplin, B.R. and Lowe, R.A. 2002. Emergency department
crowding as a health policy issue: past development, future directions. Annals of
Emergency Medicine. 40: 388-393.

Trzeciak, S. and Rivers, E.P. 2003. Emergency department overcrowding in the
United States: an emerging threat to patient safety and public health. Emergency
Medical Journal 20: 402-405.




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