Study Design
We employed a mixed-method approach at the technique level, incorporating semi-structured interviews, a structured questionnaire, and structured observation to collect data. To analyze the data, we adopted an interpretive description approach, as outlined by Thorne et al. (1997). This approach entails situating the findings within the current body of knowledge and drawing upon the contributions of other scholars, as highlighted by Mitchell and Cody (1993). This study aims to provide rich descriptive information of the key barriers and facilitators based on the language of the people involved, which inherently requires some degree of interpretation. The existing knowledge is not an organizing structure, rather, it serves as a foundational framework, providing a starting point and acts as an appropriate platform “upon which the design logic and the inductive reasoning in interpreting meanings within the data can be judged” (Thorne et.al., 1997, p. 173).
Study Context
The implementation of SurgeCon in this study follows a stepped-wedge cluster trial design, specifically focusing on emergency departments within Category A hospitals. These hospitals offer round-the-clock physician coverage in their emergency departments. All the hospitals involved in the study are located within Eastern Health's jurisdiction, operating under the same governance and management structure. The two rural intervention sites in this trial are similar in size, each with a capacity of 8 emergency department beds. They have a staff roster consisting of approximately 6–10 physicians and 12 nurses, divided into two teams that work on rotating schedules.
As for the urban sites, one of them is an acute care facility that provides services to the entire province. The other urban site has 15 beds and shares a physician roster of approximately 40 physicians with the other urban site. Each emergency department at the urban sites is staffed with 55 and 70 nurses, respectively. Both urban sites offer a wide range of inpatient and outpatient services, including several tertiary services (Table 1).
Table 1
Intervention Site Information (2021)
Emergency Departments | # of ED Physicians | # of ED Nurses | # of ED Visits/Month | # of ED Beds | LOS (Minutes - Monthly Avg) |
---|
Rural 1 | 6 | 12 | 1700 | 8 | 130 |
Rural 2 | 6 | 12 | 1800 | 8 | 150 |
Urban 1 | 40 | 70 | 4500 | 15 | 240 |
Urban 2 | 40 | 55 | 3200 | 23 | 210 |
Table 1: Intervention Site Information (2021)
SurgeCon: A quality improvement program
SurgeCon includes three components: implementing an eHealth system to automate an action-based surge capacity plan, restructuring the ED organization and workflow, and fostering a more patient-centric environment. SurgeCon’s eHealth system predicts surge levels which sets appropriate automated workflows in motion to enact proactive measures to improve patient flow and associated outcomes. Crucially, eHealth interventions are generally reported to have a positive impact on patient care (Wildenbos et al., 2016) wherein its impact ranges from an increase in availability of patient information, enhanced communication between healthcare workers, improved healthcare accessibility, and reduced patient wait times (Patey, et al., 2019; Elbert et al., 2014; Catwell, 2009). The evolution of eHealth services can be attributed to solving critical challenges faced by healthcare institutions around the world, such as wait times and overcrowding which are significant challenges for EDs globally (Canadian Institute for Health Information, 2021; Torjesen, 2018). In addition to SurgeCon's eHealth system, a comprehensive approach to improving ED efficiency is also provided by including a patient flow course for frontline nurses and physicians. This course focuses on patient-centeredness and introduces process improvement strategies such as enhancing collaboration between physicians and mid-level providers like nurse practitioners, prioritizing stable patients based on factors beyond just acuity, and aiming to decrease the duration between a patient's arrival and their first assessment by a physician. Furthermore, SurgeCon's implementation process aims to improve the patient experience while in the department. This involves identifying problem areas that could negatively impact a patient's physical and mental well-being, such as their comfort level, ease of navigation, cleanliness of the department, clutter in the ED, and other related factors.
Data Collection
Semi-structured interviews, patient-reported experience and satisfaction surveys, and structured observations at four Canadian EDs (two rural and urban) were conducted. During the period of investigation from March 2021 to December 2022, 33 healthcare providers (22 and 11 from rural and urban EDs respectively) participated in this study. This included 14 nurses, 9 physicians, 7 managers, 2 patient care facilitators, and 1 program coordinator with 1 to 32 years of work experience in EDs and with 69% of participants identifying as female. Additionally, 341 patients who visited one of the four selected were interviewed, 136 and 205 were from rural and urban EDs respectively. The mean age was 55.7 (SD = 16.8) with 66% of participants identifying as female.
The data collected and referenced in this analysis was originally collected for an innovative pragmatic cluster randomized trial that aims to assess the impact of the SurgeCon ED management platform on wait times and patient satisfaction. The subset of data that was considered relevant to our analysis was collected from March 2021 to December 2022. All data used in this study were collected prior to the implementation of SurgeCon at the four EDs selected for the cluster randomized trial. Even though each dataset was gathered and analyzed independently, they were considered as complementary to each other instead of being mutually exclusive.
Semi-structured, in-depth interviews with providers including physicians, nurses, and managers were conducted. The interview questions were informed by the Consolidated Framework for Implementation Research (CFIR), Organization Readiness for Knowledge Translation (OR4KT) domains, and the clinical/content expertise of the team. Further questions emerged from the dialogue between interviewers and ED staff members. The interview guide contained questions regarding organizational climate and support, change content and motivation, organizational contextual factors, leadership, management, and communication. Purposeful sampling, snowball sampling, and theoretical sampling were utilized and one of the staff members was responsible for facilitating the coordination of the 28 interviews. Then, web-conference/telephone interviews were arranged with the participants and the research team in a private setting at their convenience. Five more participants were recruited and interviewed in-person during the in-person training session related to the implementation of the intervention. The recruitment continued until data saturation was achieved (Throne, 2016). The interviews ranged in length from 25 to 45 minutes, were conducted by two members of research team, experienced in qualitative studies, and were audio recorded and transcribed verbatim.
Data on patient satisfaction and patient reported experiences with ED wait-times were collected through telephone interviews with randomly selected patients who had visited the ED between March 1, 2021 and August 31, 2021. The interview guide contains 79 questions in total, ten of which are open-ended questions pertaining to patients’ perceptions of the ED’s environment. For the purpose of this study, only the open-ended questions were analyzed. They shared experiences which assisted in gaining insight about the environment at each of the selected EDs. A trained interviewer randomly selected patients based on the date and time they visited the ED and contacted them via telephone, a maximum of three times, to see if they would like to participate in the survey which took approximately 15 minutes to complete. Randomly selected prospective participants were contacted within three to five days of ED discharge during the trial period to complete the telephone interview. The interview guide adapted questions from previously validated questionnaires which include the Ontario Emergency Department Patient Experience of Care Survey, the CIHI Canadian Patient Experiences Survey, the Press Ganey Emergency Department Survey, and the NHS Accident and Emergency Department Questionnaire.
Structured observations were conducted by research team members who were also healthcare staff and had special permission to visit each of the sites which were locked-down and only accessible to authorized ED personnel and patients due to COVID-19 pandemic restrictions. The research team members had prior experience in improving ED efficiency and assessed the department with the help of local staff at each of the selected intervention sites over a period of a few hours. A ‘Site Assessment Checklist’, designed to gather information prior to the implementation, was used to assess each of the four EDs in terms of the ED’s available resources (e.g., medical, human, and technological), staff communication, pervious experiences of intervention, staff readiness and tension for change. The checklist was developed through a Delphi approach which included the input of research team members, ED staff, and patients who selected key criteria to assess the EDs. For the purpose of this study only notes left by observers, rather than checklist items per se, were utilized from the observational data.
Data Analysis
Data from patient-reported experiences, structured observations, and in-depth interviews with ED staff was analyzed according to an interpretative description approach, while utilizing constant comparative analysis. Each set of data has been repeatedly read by a qualitative researcher to comprehend the overall phenomena with questions such as “what is happening here? and “what am I learning about this?”, to become familiar with the data, to identify the potential themes or patterns and to achieve a broader insight about the phenomena (Alshehri et al., 2022; Wong, et al., 2017; Throne, 2016; Thorne, et al., 1977, 174). The data was then coded in a broad manner, and continually compared and examined for similarities, differences, and relationships to help formulate major themes. A set of five facilitator-barrier pairs were extracted in this study.
All stages in the coding process were conducted by a qualitative researcher and were then categorically reviewed by members of the team to reach a consensus. Data analysis started with structured observation, extended across the semi-structured interviews data set, and subsequently ended with analysis of the collected data by means of surveys (i.e., patient interviews). Although each method collected data from different participants, it produced complementary results that captured multidimensional interpretations of the topic. Extracted data from the semi-structured, in-depth interviews with providers were supplemented with structured observational data and patient reported experiences with EDs for more clarification; more specifically, observational data and patient reported experiences were integrated and incorporated as auxiliary and confirmatory. The integrated blend of findings collected from various stakeholders through disparate methods not only explains multiple dimensions of phenomena, but also targets different audiences. In this study, data triangulation (gathering data in different time from various sources), investigator triangulation (multiple researchers study the topic of interest), and methodological triangulation (utilizing multiple methods) were utilized as cross-validation checks (Denzin, 1978; Patton, 1990). Additionally, internal auditing was carried out after completing the first draft of analysis.
Findings
The barriers and facilitators to the implementation of SurgeCon fell into five themes, each of which plays a dual role of a barrier and facilitator (see Fig. 1). These key pairings were: (1) management and leadership, (2) available resources, (3) communications and network, (4) previous experience of interventions, and (5) need for change. There were no significant differences in terms of barriers and facilitators between the groups (i.e., rural and urban EDs) and neither across data collection methods (i.e., interviews with healthcare providers, patients satisfaction survey, and structured observations). In the following sections, we discuss each of these barrier and facilitator pairs.
Management and Leadership
One of the most important facilitators of the SurgeCon implementation was the overarching leadership and management of EDs. Having a receptive, accessible, and supportive senior manager who is continually engaged with all aspects of the transition phase paired with an effective management system where the staff are involved in the decision-making process, stimulates positive managerial-clinical communications along with an increasing likelihood for the positive reception of an implementation program. Active early involvement, support, and engagement of managers in two EDs were deemed crucial facilitators to fostering a nurturing and motivating environment that encourages physicians and nurses to proactively engage in the implementation process.
“I think the manager has a fairly proactive role within the department, and I think she's doing plenty to advocate and facilitate any changes that can help us” [Healthcare provider]
“I can converse openly and there is an open-door policy. Furthermore, just in terms of communication, there is always a timely response and the manager is very proactive” [Healthcare provider]
“The site manager, the direct manager of the staff, comes every morning to the department to see what was happening last night. If there is any new issue, [the manager offers assistance and any logistical resolutions] that can be done or offered immediately. Additionally, they have free access to the director and to the manager through email. The manager’s office is just a few meters away from them, so they can just reach them at any time. For the doctors, the situation is also the same” [Healthcare provider]
“I feel our managers are very accessible and very understanding, especially in emerge. Our emergency manager is very open and easy to access and I feel comfortable going to him with any of my concerns in the emergency department.” [Healthcare provider]
Management and staff appear to be engaged within the EDs. [Observer]
However, management and leadership could also pose a barrier to a successful implementation. Barriers such as low participation and contribution by managers in the intervention program, unreceptive and inaccessible managers, low staff autonomy and involvement in decision-making, and the lack of staff consultation all emerged in the analysis.
“You know a couple of years ago with the previous manager, everything was unilaterally implemented. As in, it was put forward and we had to strictly abide by it irrespective of what we felt the outcome was going to be. There were several instances where you had to accept what was told to you and consequently, there was very little room for discussion or negotiation.” [Healthcare provider]
When working in a small emergency department with limited staff turnover and a long-standing team who are familiar with daily routines and operations, it was deemed integral for managers to involve and engage frontline ED staff in the decision-making process while also managing strategies for running the department. Failure to give staff autonomy in their roles has been identified as a barrier to a successful implementation within this framework.
“The emergency department was say anywhere from 98–99% senior. So, when you got a small department that is pretty much occupied by senior staff, it runs itself. Most of us have been nursing for 30 plus years. So, we know how the system works; we know what we have to do; we know how to solve problems; we are familiar with critical thinking to get issues resolved. However, this other manager was always critiquing us, and certainly not in a constructive manner”. [Healthcare provider]
Amplifying these issues was the fact that there was a history of struggling with unapproachable, autocratic and unavailable managers in the ED. It left the healthcare providers with sentiments of neglect and varying overdue demands and expectations. This in-turn caused a “toxic environment” which served as a critical barrier for implementation:
“But it really was like I said before, a toxic environment which placed everybody in on a defensive stance at all times and people did not want to go to work and more crucially, people did not like to work. If they did statistics on it, I am sure there was a huge spike in sick leave as people were just not wanting to go to work. That's the bottom line.” [Healthcare provider]
“I feel that that was a hindrance in the beginning because there was so much stuff that was neglected over the last few years as being passed on to staff.” [Healthcare provider]
“From a manager prior to her, who thankfully has since moved on to another position as it had seemed more of a dictatorship under her supervision, caused a lot of poor communication. Nobody liked to come to work! It was a very toxic atmosphere at that particular time; he wasn't approachable at all.” [Healthcare provider]
Available Resources
A critical facet to the mobilization of SurgeCon was the availability of resources. As such, disparate resources, that crossed technological, human, and medical resources among several other silos, were found to be necessary considerations to ensure the long-term tenability of the SurgeCon intervention. Participants at all four EDs unanimously identified excess workload, and staff shortages, and absence of opportunities to ease workloads as the most significant barriers to implementation. To incorporate the new implementation system, not only was it asserted that all healthcare providers need to be available and have sufficient time to attend a staff training program, but they also need to be interviewed by the research team members while regularly entering and updating SurgeCon data. Virtually all participants expressed the lack of human resources (i.e., insufficient medical staff) as a crucial barrier.
“Human resources can be a bit harder to come by because nurses are often treated as a commodity. There is so much overtime at the current time and requires increased staff.” [Healthcare provider]
“I think more family doctors are needed to lower the congestion in the ED.” [Patient]
“Need more staff. Patient asked multiple times to be taken to the bathroom after being left alone in a wheelchair... She asked again hours later and received no help so she peed in her wheelchair fully clothed and left without seeing a doctor due to embarrassment and such a lack of help.” [Patient]
“if we don't have enough staff or if we don't have enough beds. To me it don't matter what you're doing, it’s not going to work. It's going to be harder for it to work if you don't have the resources.” [Healthcare provider]
“Usually, our issues are staffing related because we are always short-staffed the flow of the patients. We have a lot of issues there as we are getting our patients from the emergency department to the inpatient ward. Lots of times the patients are left in emergency for a long time because, as an example, the MED Surge department were not ready to take the patient.” [Healthcare provider]
Other than staff shortages, high staff turnover rates were cited as another barrier to implementation. The high level of staff turnover during the intervention was found to adversely impact the level of communication among staff, and it was also perceived as a significant challenge with regards to training and accommodating necessary implementation activities.
“We have a lot of new nurses that are just coming out of program. So, helping mentor them with an overwhelmed emergency department is difficult as they are also trying to get their footing within the emergency department, and learn new skills and tasks. I find communications a bit lacking right now because we have so much new staff and they're just trying to get their footing and learn. In doing so, it is hard to have that communication. Like everyone helps wherever they can but you're also trying to, within that time, train your new staff as well. It's kind of a bit hectic.” [Healthcare provider]
“Rapid turnover of staff at HSC. So some of the staff have been through process improvement while many others have not.” [Observer]
Insufficient admission space (e.g., inadequate number of beds) and the lack of physical space and rooms in EDs were often identified by healthcare providers as the primary cause of backlogs and overcrowding in EDs. These factors were viewed as barriers to the implementation process, as they affect patient admissions, transfers, discharges, as well as the restructuring of the ED organization and workflow.
“Some of the barriers would certainly be the inability to have free or vacant beds to transfer patients out of or transporting patients out of our department to a tertiary care facility.” [Healthcare provider]
“There needs to be more beds and seating arrangements.” [Patient]
“Only 4 beds were available for COVID patients- how is this practical or safe?” [Patient]
“There is no current space adequate enough to run the flow center model.” [Observer]
“Rooms are sticky at times; space is small and overpopulated.” [Observer]
The lack of technological infrastructure available to the respective EDs impeded optimal resource allocation. The participants frequently felt that the staff struggled to deal with the confusion arising from technological limitations in communicating information about wait times and the availability of medical resources. Several complaints were made regarding complications in scheduling appointments, inconsistent wait times, and misallocation of scarce resources which diminished the overall efficiency of the ED.
“The sites lacked a digital patient tracking system that resulted in communication lapses between units.” [Observer]
“[Our province] is far behind in technology compared to other provinces.” [Patient]
ED Performance data was not easily accessible for frontline staff review. [Observer]
A sweeping determination that all sites will require digital whiteboards and iPads. [Observer]
Communications and Network across Organization
To ensure the successful adoption of SurgeCon, intra and inter-departmental communication was deemed as a critical consideration to ensure the long-term sustainability of the implementation. Thus, consistent and frequent communication between healthcare providers, particularly among physicians and nurses, is necessary to execute implementation activities successfully. However, this theme received mixed evaluations by participants. Poor communication and fragmented relationships between nurses and physicians, and lack of teamwork among staff were evaluated as significant barriers to the implementation of SurgeCon. In this context, it was seen that physicians and nurses do not have any formal joint meetings and there was scarce communication between different units within EDs. The lack of shared multidisciplinary meetings in EDs decreases the chance of developing mutual understanding and commitment, building empathy and awareness toward each other’s challenges, and enhancing unity and teamwork.
“There seems to be a huge miscommunication between staff, mainly to do with rules surrounding COVID.” [Patient]
“We do not sit down at the same table. There are family practice meetings, there are student emergency doc meetings and then, there are nursing meetings; you are not set at the same table. So, I cannot realistically know, feel nor empathize with anybody else’s needs if I am not even aware of them. We are never really made aware of that stuff.” [Healthcare provider]
“More communication between staff and patients would be very useful as most people will be more patient and understanding.” [Patient]
“Although we work together in the same area, we do not have direct meetings. Well, sometimes we do on a necessary base if we think that there’s something crucial like what happened during COVID.” [Healthcare provider]
We are not aware of challenges that physicians are dealing with…. Nothing really.. There's no formal way that they do it, not even informal. I think they talk amongst themselves, and they don't voice their concerns to us. [Healthcare provider]
Even in the case of personal conflicts and tensions arising between nurses and physicians, formal meetings of managers were considered as a predominate strategy to resolve the respective issues rather than directly involving staff. While the lack of intergroup (i.e., nurses and physicians) communication was evaluated as a barrier, participants positively evaluated intragroup communication, citing regular weekly formal meetings and informal daily meetings when necessary. Furthermore, nurses at one of the sites participated in a Facebook group to share their concerns.
“There is a Facebook group… it was outlined that they are short a nurse, and they are looking for an extra nurse to come in. So, they posted that on the Facebook group in hopes that somebody will see it and come to their rescue.” [Healthcare provider]
In general, a collaborative, supportive, receptive and cooperative environment emerged as a facilitator to implementation. The staff valued a culture of support, transparency, and availability. Also, it was assessed that working in a small ED, where the healthcare providers are familiar with one another more intimately and for a prolonged duration of time, positively fostered teamwork and supportive communication.
“One main ED unit and there seemed to be good communication and in the smaller sites its quite easy to communicate” [Observer]
Another barrier under this construct was identified as the lack of communication and dialogue between staff in two different units within the EDs. As these units operated independently, the minimal contact and communication between them became routine. Communication between the two units was restricted to the end of the shift and pertained primarily to handing-over patients. When problems arose, the most common means of communication to resolve or discuss the issue was conducted via email.
“We’re taking care of the patients in unit one or unit two, and someone else is taking care of the patients in the other unit. So, I don't really talk to the other person. So, the only time when we communicate is around handover. S,o that's often sort of one we're saying, “Well, I am leaving, so you take over this patient.” [Healthcare provider]
“When we asked staff if they felt the areas of the departments communicated well together they said yes but while we watched it certainly seemed like all the areas functioned independently of each other. NO situational awareness.” [Observer]
“Both units seem to operate separately from each other; do pull staff to other units based on subjective business.” [Observer]
“Most of the conflict, I think, comes up on email. So, there's been one conflict that was around which came up a few years ago. So, I think that was addressed when that came up via email and the group, I think, are talking about it over email.” [Healthcare provider]
A common concern among participants pertained to the lack of engagement and involvement of other departments in the hospital during the implementation process of the intervention. The interlocutors believe that the implementation cannot be successful if other departments and stakeholders in the hospital have no intention to participate. Given the interconnectedness of a hospital’s departments, an intervention aimed to improve ED patient flow must also comprise meaningful engagement from external departments and must be prioritized at all levels of the organization rather than having the ED treated as an individual entity.
“We've done a lot of improvements. For instance, our stroke process or STEMI process, those are things that we've implemented within our department to help streamline that category of patient, that were more focused on just the ED which were more successful. We haven't been able to be successful because of the barriers that lie outside of our department which are a little bit more systems or like, organizational wide. It becomes harder because maybe there's been an unwillingness to participate or not seeing the value because a lot of people don't see what it is like in our department all the time. So, they think that it's just value for us as opposed to value for them as well.” [Healthcare provider]
“I think the biggest barrier like is outside of the department. More precisely, managing to engage stakeholders outside of our department to help us- help our department or help us with flow.” [Healthcare provider]
Another potential barrier to implementation was the lack of participation of physicians in the implementation process. Nurses constantly emphasized the crucial role of physicians in the uptake of the intervention and furthermore desired assurance that the physicians will be well-informed about the implementation and will not be disengaged during the process.
“I just find the biggest barrier is people being able to have the same goal and same interests. There's always been resistance from one wing or another wing. Traditionally, it's just that everybody hasn't been on the same page.” [Healthcare provider]
“I think physicians are older, more experienced positions or maybe just set in their ways and are less open to change. Some of the physician group will be more resistant.” [Healthcare provider]
Despite the busy clinical environments, the success in the development and undertaking of the implementation hinged on constant and regular communication, including routine informal and formal meetings, that took place between the research team and healthcare providers. Although in-person meetings were preferable, due to COVID-19 pandemic related restrictions, videoconferencing was utilized to facilitate communication. Scheduling and arranging a meeting with healthcare providers because of the heavy workload, busy clinical schedule and demands was deemed as extremely challenging and proposed a critical barrier to implementation. Additionally, some of the research members do not have a direct line of communication with healthcare providers if not through internal facilitators or champions– i.e., nurse practitioners. Although a champion or facilitator demonstrated knowledge about the workload of healthcare providers which facilitated the scheduling of meetings, the lack of direct communication and in-person meetings served as a critical barrier to implementation as the level of social engagement and connectedness between research staff and medical staff was adversely impacted.
Previous Intervention Experiences
The previous experiences of staff members in implementing other interventions were evaluated as mostly positive by healthcare providers and researchers who conducted structured observations. However, some barriers were reported as well. Prior experience of interventions in EDs was partially evaluated positively by the participants. Positive experiences of past interventions, which improved workflow efficiency, simplified, and organized patient assessments, prioritized triage, and reduced wait-time were perceived as supportive for future implementations.
“The X32 program was overall an effective program in my opinion. We did implement a lot of changes, overall infrastructure changes- the way that we introduce patients into our department and get them through the department to finally get them discharged. After the X32 program, we've seen dramatic improvements and changes versus the way that we were doing it.” [Healthcare provider]
However, negative experiences of past interventions including the lack of communication between researchers and staff, and the lack of follow-up evaluations to meet the contextually specific needs of the EDs were main barriers to coordinate future intervention-related activities.
“Initially, there was a fair bit of communication between staff, the researchers and the end users but after it was implemented, I don't think there was any follow-up or any review of the X32.” [Healthcare provider]
Failures of pervious interventions were perceived as a crucial barrier to the implementation of SurgeCon in one of the assessed urban hospitals.
“SurgeCon is new to us, but we've tried lots of different things over the years, and they've all failed. We've all put work into it… we'll try something, and we'll get all motivated to do it- we'll try it for six months, and everything that we've done falls apart inevitably.” [Healthcare provider]
“We had many previous wait time related interventions over the past number of years and front line staff report mostly failures with staff reverting to old ways.” [Observer]
Need for Change
Tension for change was deemed as an important concept for leaders seeking to improve performance in their organizations. It is a mechanism that created the energy and motivation needed to mobilize human beings into action. Although dissatisfaction with the current approach was the most common perspective as described from patients and providers in four EDs; this was considered concurrently as a strong motivation and potential barrier for healthcare providers to actively engage in the implementation process. Dissatisfaction with long wait-times and poor workflow was perceived as a major aspect of motivation; the most endorsed facilitator was found to be the perception of necessity of the intervention to rectify deficiencies in wait-time and workflow efficiency. Healthcare providers valued the change and deemed it as urgently necessary and beneficial. They valued the intervention and possessed an intrinsic inclination towards change as they had long-lasting concerns about the wait-time and workflow; they anticipated that SurgeCon might help to resolve the issues faced in EDs. Thus, healthcare providers in these EDs collectively valued the intervention and demonstrated an appreciation for the actions taken, which was seen to be one of the more crucial facilitators and implementation drivers.
“I had to wait for 7 and a half hours which felt ridiculously long, even though there were not a lot of other people waiting.” [Patient]
“Wait times need to be improved.” [Patient]
“We have been waiting for 2 days because there were no in-patient beds available.” [Patient]
“The most important motivation is improving the quality of management for the patients and then, that will be reflected to the wellbeing of the patient as well as the smooth flow of the patient within the department. So, if there is any new idea that can facilitate this- they usually are very eager to adapt and undertake it.” [Healthcare provider]
“I think efficient and timely patient care is the most important. We don't want people sitting in the waiting-room waiting for hours if we can get to see them in a more timely fashion and even I know that not everything that comes to the emergency department is a full blown emergency, but it's not nice to have people waiting so long. If we could improve the flow, it will be so much better for everybody. It's frustrating for us as well.” [Healthcare provider]
Participants expressed some dissatisfaction with the planned implementation as a result of not having enough time to participate, staff shortages, and heavy workloads. Two of the selected EDs were found to be particularly affected by this issue, which posed a significant obstacle to the adoption of the intervention, even during the initial stages of implementation which involved training staff and conducting semi-structured interviews. Furthermore, it was observed that the sites that were less engaged in the implementation process encountered the most barriers in the adoption of the intervention. As one of the participants noted:
“I think that's going to be the biggest challenge is just getting them on board. Just the word “change” or “implementation” right now is a bit challenging.” [Healthcare provider]
Specifically, the process of implementation of the quality improvement program might be initiated, albeit with poor engagement and support from the ED staff, that consequently resulted in a lapse in realizing the full potential of the adopted intervention.
“But I think access to your family doctor has got way out of hand here. I know there are people without a family doctor who can go to our family practice clinic at the Hospital, but I think people aren't able to access their own family doctors like they used to be able to, and that has resulted in the overflow to our department” [Healthcare provider]
“I mean morale in the past few years… it’s not in a good place and I think it's because of the increased business, and staff feel like they're burning out, so it's not that they don't do a good job. We need more resources.” [Healthcare provider]
“It’s still the emergency department. It’s still busy and trying to make changes. It is just difficult.” [Healthcare provider]
Two EDs chosen for this study had rejected a previous intervention, (i.e., X32 Healthcare’s Online Staffing Optimalization), which implies that the organizational climate might not be change-oriented. This phenomenon, other than dissatisfaction, was rooted in being resistant to changes (including technological changes) while conforming to the existing status-quo and being reluctant to adopt the consulted changes suggested from outside of the organization. To the participants, interventions meant novel systems, processes and skills which inherently implied altering the quondam workplace routine to adopt a newer system. While emergency department staff constantly struggled with the internal forces for change (e.g., heavy workload, staffing issues, and long wait time), they were not receptive to the external research team’s attempts at initiating change through the implementation of the intervention. This extended to not only external stimuli for change, but also propositions for change initiated by insiders which were not mobilized in either of the urban sites.
Repeated resistance to technological changes expressed by staff in general. [Observer]
“A few years back, we moved the charts from one location to another. It doesn't sound like a big deal but I’m telling you, it was a big deal. The charts removed from a space inside back to triage, which is where they belong, because the patients in the waiting room belong to the triage nurse. So, that was met with all kinds of resistance from nursing, from physicians- you name it.” [Healthcare provider]
“If there is any issue implementing anything new, it's going to be with staff because staff don't like change. A lot of times they don't like change or they're afraid of it.” [Healthcare provider]
“It was unknown- you hear this company from outside is going to come in and fix your emergency department. A lot of people felt like, ‘Well, why do we need an outside company? Why don’t they just speak to the staff that actually works there to see how they could fix it?’ We knew what needed to be fixed but I kind of felt amused as to why did an external entity do it when they didn't ask the people that worked in a department first.” [Healthcare provider]
“I feel like change is a big thing for people personally and professionally. So, it is just going to take a while for people to get used to it and, it's something new that’s breaking our old routine of how we did things. I feel those will be some barriers. Technology is going to be a challenge and like I said, it’s a big change.” [Healthcare provider]
It is evident that the engagement of ED staff in implementation activities in the context of all four EDs during the pandemic had created a challenging environment to initiate change where frontline staff were having to deal with exhaustion, frustration, burnout, isolation, and a higher volume of sick patients. Healthcare providers often lacked the prerequisite energy to attend the training sessions or participate in interviews even with compensation and other proffered incentives. In describing their experiences, one participant states:
“We're just basically keeping our heads above water at this point.” [Healthcare provider]
Low motivation to participate was caused due to feeling burdened by a heavy workload, COVID-19 regulations and subsequent procedure alterations. Thus, these dismayed healthcare providers struggled with the pandemic and thereby, served as another major barrier to the intervention.
“With this pandemic, there's constant policy changes, procedure changes, and they're frustrated with it. So, if you want to bring in something else, even though it's going to help them a lot of times- they're resistant because it's just something else on their ‘To Do List’ and they don't want to be bothered with having to learn something else.” [Healthcare provider]
“We're a few years into the pandemic. So, everyone's a bit burnt out, but I feel like we want to change that but it's hard right now because we have so many other factors pushing down on our Emergency Department.” [Healthcare provider]
“But I can tell you that the morale in our department right now is not overly good and that partly has to do with this pandemic… we're all enduring, of course” [Healthcare provider]