Evaluation of the Impact of Challenges in the Emergency Department on the Quality of Care and the Humanist Concept in Tunisia

Evaluation of the Impact of Challenges in the Emergency Department on the Quality of Care and the Humanist Concept in Tunisia

MENSI Nidhal, MD., MAGHRAOUI Hamida, MD,

Emergency Department at La Rabta Teaching Hospital – Tunis – Tunisia

Associate Professor of Emergency Medicine, Emergency Department at La Rabta Teaching Hospital – Tunis – Tunisia

DOI: https://dx.doi.org/10.47772/IJRISS.2024.8080173

Received: 29 July 2024; Accepted: 06 August 2024; Published: 10 September 2024

ABSTRACT

Introduction: Providing healthcare services in an emergency setting, such as an emergency department, follows a strict and precise protocol, prioritizing patient satisfaction and well-being above all else. Patient satisfaction is closely linked to both the quality of care delivered and the way in which patients were treated.

Objective: Describe the concepts of quality of care and humanist concept among health professionals in Tunisia and assess the impact of the main challenges faced by emergency departments on these concepts.

Methods: We conducted an observational study between July and September 2022 which included 130 healthcare professionals working in the emergency departments of various hospitals and specialized centers in Tunisia. Each participant completed a self-administered questionnaire about their perception of the quality of care they provide.

Results: Our findings revealed that the definitions of quality of care and the humanist concept varied among individual healthcare providers, often influenced by personal interpretation and discretion. We also identified key challenges faced in emergency departments, which included workload overload, staff shortages, limited time for patient care, and patient behavior. In response to these challenges, some professionals reported a negative attitude, while most maintained their professional composure, seriousness and their sense of ethics.

Conclusions: We believe that high-quality care rooted in a shared humanist concept is achievable through collaborative efforts among all stakeholders responsible for the smooth operation of emergency department services.

Keywords: challenges – emergency department – quality of care – humanist concept

INTRODUCTION

The emergency department provides comprehensive medical care 24/7, without discrimination, for patients presenting with both life-threatening and non-life-threatening emergencies. According to the World Health Organization (WHO), the role of an emergency department is to deliver high-quality healthcare that ensures each patient receives a tailored set of diagnostic and therapeutic interventions aimed at achieving optimal health outcomes.

These interventions are grounded in current medical knowledge, prioritizing cost-effectiveness while minimizing adverse effects, with the ultimate goal being a greater patient satisfaction with treatment procedures, health outcomes, and human interactions within the healthcare system. To achieve this goal, emergency departments therefore operate according to a precise protocol that enables them to handle unplanned emergency care efficiently and reliably, despite facing various constraints.

In this context, healthcare professionals working in emergency departments have one of the highest rate of professional burnout. Research has also shown that increased workload contributes to decreased patient safety and satisfaction, as well as higher morbidity and mortality rates [1]. As such, healthcare professionals require a broad range of knowledge and skills covering the entire spectrum of nursing and care expertise.

The humanist concept of Caring, rooted in values influencing attitudes and guiding behaviors, underpins our nursing science practice across all settings [2]. The impact of the caregiver-patient relationship on the quality of care provided in the emergency department cannot be overstated. A positive caregiver-patient relationship reduces hospital stays and improves patient satisfaction for both parties, whereas a poor relationship diminishes patient autonomy and compromises the safety and quality of care [3].

Reflecting on the daily practices in the emergency department has led to the recognition of the importance of assessing how constraints experienced by healthcare professionals affect their humanistic values of care and idealized standards.

This study therefore aims to describe the concepts of quality of care and humanist concept among healthcare professionals in Tunisia, as well as assess the impact of key constraints faced in the emergency department on these concepts.

METHODS

Study population

W performed a cross-sectional, prospective, multicenter study. over a 3-month period, from July 2022 to September 2022, which included all medical, paramedical and juxtamedical personnel who agreed to take part in our survey and who were working in five emergency departments in Tunisia during the study period :

– The emergency department at the Rabta University Hospital in Tunis which caters for patients from the capital’s northern and western districts and suburbs, as well as certain north-western regions of the country.

– The emergency department at Habib Thameur University Hospital in Tunis which caters for patients from the southern region of the capital, as well as certain north-western regions of the country.

– The emergency department at Farhat Hached University Hospital in Sousse which caters for patients from the governorate of Sousse as well as certain central-eastern and central-western regions of the country.

– The emergency department at the Maternity and Neonatology Center of Tunis which is a specialized center for gynecology-obstetrics and neonatal care catering for patients from the capital’s northern and western districts and suburbs, as well as certain north-eastern and north-western regions of the country.

– The emergency department at Al Aghaliba Kairouan Regional Hospital which is a regional hospital located in the governorate of Kairouan and caters for the patients from all regions of said governorate.

Data collection

We used a self-administered questionnaire consisting of 15 closed-ended multiple-choice questions, divided into two sections: a first section containing the general characteristics of each respondent in the study population and a second section a second part containing questions on each respondent’s perception of the quality of care, the humanist concept and the constraints they encounter and their impact on these concepts.

To gather data, we approached healthcare professionals in each emergency department unit or care area, introducing our study and its objectives before seeking their consent to participate. Once permission had been obtained, we observed the care delivered by each professional, and then gave them the questionnaire that focused on their perception of quality of care provided and their relationships with patients.

To define quality of care in our questionnaire, we used the framework established and put forth by the Institute of Medicine[4], which consists of 6 principles: Equitability (providing care of equivalent quality to all patients), Effectiveness (providing health services based on scientific knowledge), Efficiency (making optimal use of resources and avoiding waste), Timeliness (reducing waiting times and delays for both patients and caregivers), Safety (preventing care from causing harm or injury to patients) and Patient-centric care (providing care that respects and responds to each patient’s preferences, needs and values).

As for the humanist concept of care, its definition in our questionnaire is inspired by the principles of Caring theory [2], according to which caregivers actively get their patients involved in the care process, listen to their requests and complaints, and support them throughout the progress of the care process.

Statistical analysis

Statistical analysis was performed using IBM SPSS (Statistical Package for the Social Sciences) version 24. Since most of the variables in our study were qualitative variables, simple frequencies were therefore calculated. Frequency comparisons on independent series were made using Pearson’s Chi-squared test or Fisher’s exact test as necessary.

RESULTS

Population characteristics

During the study period, we included a total of 130 healthcare professionals working across five emergency departments. The main characteristics of our population are presented in Table I.

Table I: Description of the main characteristics of the study population (N=130)

Over half (55.4%) of the participants were under 30 years old and only 2.3% aged 50 or above. We observed a female predominance among our respondents, as approximately 70.0% were females while the remaining 30.0% were males. The professions of these healthcare professionals varied greatly within their respective departments. Nurses were the most prevalent professionals, accounting for approximately 59.9%, while nursing aides were the least represented with only 3.9%. Furthermore, the majority of our participants (55.7%) were employed in emergency departments affiliated with university hospitals (La Rabta, Farhat Hached, Habib Thameur), while about 23.1% worked at a regional hospital (Al Aghaliba hospital) and approximately 19.2% were employed in an emergency department of a specialized center (Maternity and Neonatology Center).

Lastly, we found that the majority of our participants had less than five years’ experience in their respective departments, with approximately 63.9% falling into this category, and only around 0.8% of respondents reported having more than two decades of tenure.

Quality of care

Regarding quality of care, over 90% of healthcare professionals agreed that it should be effective (98.5%) and safe (91.5%) (Figure 1). However, ensuring timely delivery of care was the least emphasized principle, with around 75% of respondents agreeing (Figure 1). Interestingly, 61.5% of healthcare professionals believed that quality of care encompassed all the stated principles.

Figure 1: Frequency of respondents for principle of Quality of care

We then analyzed the differences in responses based on the various characteristics of our population.

Age-wise, we found differences in response patterns among caregivers across different age groups. Caregivers aged between 40 and 50 considered efficiency and timely delivery of care as the most important principles, while those aged between 50 and 65 were less inclined towards timeliness but more towards fairness (Table II). However, none of these differences were statistically significant.

Table II: Breakdown of respondents for each quality of care principle by age group

Regarding gender, participants’ responses were more or less uniform across all principles, although male caregivers placed greater emphasis on the principle of efficiency, whereas female caregivers favored equitability as a key principle, though these differences were not statistically significant (Table III).

Table III: Breakdown of respondents for each quality of care principle by gender

In terms of professional profile, midwives placed less emphasis on the principles of efficiency and timely delivery of care compared to other professions while nursing aides placed greater emphasis on the principles of efficiency, safety and patient-centered care (Table IV). However, these differences among professions were not statistically significant.

Table IV: Breakdown of respondents for each quality of care principle by profession

Lastly, we found that healthcare professionals with more than 20 years of tenure generally did not prioritize safety, timeliness or patient-centric principles in their responses but put more emphasis on fairness and efficiency, whereas the distribution of answers was fairly similar across other categories; though none of these differences were statistically significant (Table V).

Table V: Breakdown of respondents for each quality of care principle by length of tenure

Humanist concept

In our survey, most healthcare professionals (90%) agreed on the importance of “listening” as a key aspect of the humanist approach to care, and nearly 86% emphasized the value of “being supportive”. In contrast, “compassion” and “engagement with patients” were seen as less crucial with around 48% for compassion and 54% for engagement (Figure 2).

Figure 2: Frequency of respondents for each quality of the humanist concept of care

Additionally, about one-third (30.0%) of the respondents believed that the humanistic concept encompasses all of the stated qualities.

We then analyzed the difference in responses according to the main characteristics of our population.

For the different age groups, caregivers aged 50 and over placed greater emphasis on the attitude of engagement with patients than other age groups, at the expense of the attitudes of compassion and collaboration with patients (Table VI). However, these differences were not statistically significant.

Table VI: Breakdown of respondents for each quality of the humanist concept by age group

Regarding gender, male caregivers were more in favor of collaborating with patients than female caregivers whereas the latter were more in favor of listening to and engaging with patients, though these differences were not significant (Table VII).

Table VII: Breakdown of respondents for each quality of the humanist concept by gender

In terms of profession, nursing aides and emergency technicians selected each quality of the humanist concept more frequently than other professionals, although these differences were not statistically significant (Table VIII).

Table VIII: Breakdown of respondents for each quality of the humanist concept by profession

With regard to seniority, healthcare professionals with over 20 years of experience prioritized engagement with patients compared to others, but attitudes such as compassion and collaboration were not part of the humanist concept for this group – again without statistical significance (Table IX).

Table IX: Breakdown of respondents for each quality of the humanist concept by length of tenure

On a separate note, nearly one-third (30.8%) of respondents believed that the humanist concept requires both professional expertise and personal effort from caregivers.

Workplace environment

The majority of participants in our study did not have a favorable view of their working environment (Table X). Only about one-third reported having a well ventilated workplace, while less than 20% felt they had adequate staffing levels within their department.

Table X: Workplace characteristics according to the study population

When it came to the amount of work they were expected to handle, the majority of healthcare professionals considered their workload, according to the Workload Score (WLS), to be heavy (36.2% of respondents) to overwhelming (36.2% of respondents). In contrast, around 7% of respondents considered their workload to be light, with only a small fraction describing it as very light (1.5% of respondents).

Main challenges and their impact

The majority of our study participants reported facing significant challenges in the emergency department. The most common issues they encountered were an overwhelming workload (nearly 91%) and staffing shortages (over 84%), with only about half of respondents (52.3%) identified not having enough time to interact with each patient as a constraint (Figure 3).

Furthermore, three caregivers pointed out additional challenges such as insufficient equipment, lack of respect, and a lack of recognition for their efforts.

Figure 3: Frequency of respondents for each challenge encountered in the emergency department

The extent to which these challenges were perceived varied among healthcare professionals. Most workers (78.5%) believed that these issues impacted not only the quality of care but also the humanist concept with only a small minority (3.9%) feeling that these challenges had no effect on either concept.

Furthermore, faced with these challenges, half of the healthcare workers managed to maintain a professional demeanor and a sense of professionalism towards their work, with only 30.0% saying they didn’t lose their seriousness when approaching their tasks and 25.4% maintained their sense of ethics. However, many respondents reported adopting a negative attitude when faced with these challenges with 15.4% saying they became less productive as a result and 13.9% saying they struggled with poor communication and behavior towards patients and colleagues.

We next analyzed how our population’s characteristics influenced their responses.

When it comes to age groups, healthcare professionals over 30 maintained a professional demeanor when faced with these challenges more often than those aged 20-30, with statistically significant differences. Additionally, lower performance was reported by the 40-50 age group while those aged 50 and over reported adopting poor behavior, although these differences were not statistically significant (Table XI).

Table XI: Breakdown of respondents for each behavior adopted in response to challenges by age group

Regarding gender, female caregivers became less productive as a result of these challenges compared to male ones with statistically significant difference. In contrast, male caregivers tended to maintain a more professional attitude, but this difference was not statistically significant (Table XII).

Table XII: Breakdown of respondents for each behavior adopted in response to challenges by gender

With regards to professions, emergency technicians and nursing aides reported no poor behavior when dealing with these challenges, while nurses and doctors reported maintaining a professional attitude less often than the other categories. However, these differences were not statistically significant (Table XIII).

Table XIII: Breakdown of respondents for each behavior adopted in response to challenges by profession

Finally, considering tenure length, healthcare professionals with at least 20 years of experience reported more often adopting poor behavior in the face of challenges, those with less than 5 years’ tenure maintained a serious and ethical attitude, and those between 5-10 years’ tenure adopted a professional attitude; with no statistical significance difference for all behaviors except for professionalism (Table XIV).

Table XIV: Breakdown of respondents for each behavior adopted in response to challenges by length of tenure

DISCUSSION

Access to healthcare is a fundamental right; however, it’s essential to recognize that access alone does not necessarily correlate with improved health outcomes. In fact, healthcare quality varies significantly worldwide, and treatments may be ineffective or even harmful. More people die from poor-quality care than from lack of access to health services [5].

Emergency departments are considered as the backbone of acute hospital care, with their primary mission being to promptly respond to urgent, life-critical or function-critical needs. However, this high-pressure environment, combined with heavy workloads and other challenges, can raise concerns about the quality of care and the commitment to humanistic principles.

In light of these challenges, we chose to carry out this study with two main objectives: first, to describe healthcare professionals’ perceptions of quality of care and humanist concepts in Tunisia; secondly, to assess how the primary challenges faced by emergency departments in Tunisia impact these fundamental values.

Our survey involved 130 healthcare professionals, with the majority being females (70%) and more than half being young adults aged between 20-30. The largest proportion of respondents (56.9%) were nurses, while teaching hospitals were home to a significant number of these caregivers at around 60%, and many of the respondents had been in their workplace for less than five years (63.9%).

Quality of care

Regarding quality of care, our survey found that most respondents agreed with the Institute of Medicine’s definition which states that quality of care encompasses all the principles of safety, efficiency, effectiveness, timeliness, fairness and being patient-centric. However, around 40% of caregivers disagreed and omitted certain principles to varying degrees. Indeed, while over 98% of respondents agreed with the principle of effective care, only 75% felt that care should be delivered in a timely manner. These proportions varied among different caregiver groups – including age, gender, profession, and years in practice – but they were not statistically significant.

These differences however can be attributed to several factors. The main one being the absence of a clear, agreed-upon definition of the concept of quality of care. Indeed, several definitions have emerged to try and describe this concept:

– That of Allen-Duck et al, who described quality of care as the assessment and delivery of safe, effective care that achieves an optimal or desired state of health [6].

– That of the Institute of Medicine which describes it as the measures by which health services in populations increase the likelihood of achieving desired health objectives [4].

– That of the WHO, which implies the notions of effective, safe, evidence-based and patient-centered care [7].

This lack of precision in the definition of “quality” has been exacerbated by the fact that different stakeholders have distinct interpretations of what constitutes quality care [6]. Specifically, patients, healthcare professionals, and health structures/organizations each possess their own understanding of quality, further complicating efforts to establish a clear and universally accepted definition.

In our study, the concept of quality of care seems to differ, proportionally, between different healthcare professionals, without being significant. These described differences aligns with previous research by Swart et al which demonstrated varying perceptions among nurses with different qualifications and academic backgrounds [8].

However, other studies did not find such differences [9,10]. For instance, Abdul Rahman et al investigation on university hospital wards showed that differences in caregivers’ academic backgrounds did not impact the quality of care provided, as long as these professionals had equivalent training and experience [10].

Furthermore, in addition to the principles of efficiency, promptness and safety of care, Ryan et al’s research highlighted additional characteristics essential to good quality of care, including clinical skills, collaboration, autonomy, sufficient staffing, and mastery of nursing practice, which are particularly crucial in a clinical setting [11].

Humanist concept

The definition of humanist concept of care among caregivers was found to be subjective and varied from one individual to another. Only 30% of respondents agreed that compassion, listening, support, collaboration, and engagement with patients all encompassed the humanist concept.

Most caregivers believed that listening was a crucial aspect of this concept (90% of respondents) and as many as 85.4% considered support essential. Compassion, however, was only chosen by less than 50% of respondents These proportions differed between healthcare professionals groups – including age, gender, profession, and years in practice; however, they were not statistically significant.

This difference in perception in our study could be attributed to the unique context of practice in the emergency department where caregivers face high patient volumes, making it challenging to balance patient satisfaction with efficiency [12].

However, there appears to be a disconnect between patients’ and healthcare professionals’ views the humanist concept and the notion of Caring. On one hand, healthcare professionals emphasize the interpersonal aspect rather than the technical aspect of the care-giver-patient relationship [13]. In their view, this relationship is based on the use of good communication techniques to establish a trust-based relationship with patients [14], thereby facilitating the treatment process and enhancing their physical, emotional and mental recovery [14]. But on the other hand, several studies have shown that patients’ expectations are more closely linked to the knowledge and skills displayed in the care they receive [15,16]. This was most evident in Baldursdottir and Jonsdottir’s study, which found that emergency department patients place a higher priority on healthcare professionals’ professional attitude and technical expertise [17].

Emergency department challenges

More than 70% of healthcare professionals considered their workload, according to the Workload Score (WLS), to be heavy (36.2% of respondents) or overwhelming (36.2% of respondents), while less than 10% of respondents described it as light.

For the majority of respondents in our study, the main constraints that had an impact on the quality of care and the humanist concept were work overload in the department (90.8% of respondents) and staff shortages (84.7% of respondents)

The majority of respondents identified work overload in the department (90.8%) and staff shortages (84.7%) as significant challenges having an impact on the quality of care and humanist concept. However, the lack of time to interact with each patient was reported as a challenges by only 52.3% of respondents.

Emergency departments are typically the busiest hospital wards in terms of both throughput and patient numbers [18,19]. This often leads to overcrowding where urgent cases are mixed together with less or non-urgent cases, which, in some cases, account for the majority of visits [20].

This imbalance in the visits is often attributed to patients’ perception of emergency care. Indeed, Research by Northington et al found that patients’ perception their condition’s urgency and the easy and immediate access to emergency care were ones of the main reasons for spontaneous use of the emergency department, along with the perception of better treatment and diagnostic capabilities in said departments [21]. As a result, these patients face longer wait times for either examination or treatment, potentially delaying or limiting caregiver attention per patient [22,23].

Moreover, from healthcare professionals’ perspectives, emergency departments often struggle with staffing issues – ranging from absolute shortages due to manpower gaps [24] to relative understaffing caused by shifting workloads [25,26].

Impact of challenges

A significant majority (78.5%) of healthcare professionals reported that workplace challenges negatively impacted both the quality of care provided and the humanist aspect of their work, whereas only 3.9% believed these challenges had no effect on either concept.

This finding is consistent with previous research studies by Jones et al, Dewa et al, and Eriksson et al, which found a link between the decline in emergency department quality of care and factors such as overcrowding, increased workload, and stress/fatigue among healthcare professionals [27–29].

The cumulative effect of these factors can lead to emotional exhaustion and burnout among healthcare professionals, compromising their ability to provide high-quality patient care [30,31]. As they themselves become overwhelmed and in need of help [32,33], this state of distress can also compromise their own health and well-being, as the increased workload particularly in the context of long work hours, quick rotations, can ultimately hinder their capacity to perform their roles effectively and safely [34,35] which leads to a decline in the quality of patient care.

Furthermore, our study found that when facing these challenges, 50% of healthcare professionals reported maintaining their professional behavior and 30% demonstrated seriousness in their work. This dedication stems from workers’ sense of responsibility and respect for their professions, driving them to prioritize thoroughness, humanism, duty, integrity, and putting patients’ needs before their own [36]. This is particularly evident as patients form trust-based relationships with providers based on their presentability [37] and attitude [38].

Notably, many respondents adopted a negative attitude towards the challenges they faced, with 15.4% reporting low efficiency and 13.9% exhibiting poor interpersonal skills, often only answering questions posed by patients or taking less time to talk or explain the care processes.

This finding highlights communication barriers between caregivers and patients. Research by Norouzinia et al found that healthcare workers’ lack of time and high workload were primary factors contributing to poor communication [39]; a conclusion corroborated by the study of Al Kalaldeh et al, which also identified staff shortages, overwork, and limited time for care as key barriers to effective patient-provider interaction [40].

Limitations

The main limitation of our study is the low sample size in certain categories. Unfortunately, we could not control the distribution of staff within each department. Obtaining consent and using a self-administered questionnaire meant that this disparity in numbers was accentuated by the lack of motivation of some workers to participate and complete the questionnaire.

RECOMMENDATION

In light of our findings, we propose several feasible solutions to enhance care quality in emergency departments and emphasize humanist concept of care:

1. Establishing a unified definition for both quality of care and humanist concept across all healthcare workers which will rationalize behavior and promote professionalism.
2. Intensifying continuing education programs to help caregivers to better understand the importance of professional relationships with patients, aligning their actions with their humanitarian message.
3. Creating an environment that fosters commitment to training aimed at improving care quality and promoting patient-centered care approaches.
4. Strengthening human and material resources in emergency departments which will address work overload and improve shortcomings that hinder the development of a patient-friendly attitude.

CONCLUSION

Our study revealed that there is a significant variation among healthcare providers regarding the definitions of quality care and the humanist concept, which are often subject to personal interpretation.

We identified key challenges faced by healthcare workers in emergency departments, which included workload overload, staff shortages, lack of time for patient care, and unfavorable working environments. These challenges can lead to fatigue, exhaustion, and negative impacts on both care quality and patient outcomes.

In parallel, we assessed the impact of these challenges on healthcare workers’ performance in the emergency department where we found that although some staff reported adopting a negative attitude, the majority said they continued to act with seriousness and professionalism.

Our results were corroborated by other studies. When it comes to quality of care, these studies highlighted not only the importance of fairness, efficiency, safety in patient care but also that clinical competence, collaboration, and caregiver autonomy are paramount in ensuring high-quality care. With regard to the humanist concept, a divergence of opinion was reported between healthcare providers’ emphasis on benevolence and humanism and patients’ prioritization of technical expertise.

To address these challenges, we proposed several interventions aimed at improving quality of care and the humanist concept. These interventions essentially involve adopting a unified definition for both quality of care and the humanist concept, reinforcing continuing education programs and opportunities for all healthcare workers to promote a better understanding of caregiver-patient relationships and professional behavior, and finally reducing stress factors and improving working conditions within emergency departments.

In conclusion, we believe that high-quality care rooted in a shared humanist concept is achievable through collaborative efforts among all stakeholders responsible for the smooth operation of emergency department services.

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