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Background and importance

Crowded emergency departments (EDs) and long waiting times may lead to delayed care for acute conditions and increased mortality in patients leaving without being seen by a physician (LWBS).

Objectives

The aim of this study was to characterize patients LWBS from the ED at a Swedish university hospital and report their mortality.Design, setting, and participantsA cohort study was conducted. Data from electronic medical records of patients LWBS (exposure) were compared with those who stayed through completion of treatment. Data were gathered from 151 228 patients making 363 308 visits to the Uppsala University Hospital ED from 1 January 2010 to 30 June 2017.

Outcome measures and analysis

Short- and long-term mortality of patients LWBS were studied using Cox regression analysis. Sex, age, triage level, arrival mode, length of stay, presenting complaint, crowding, and time of day were assessed as regards effect on the probability of LWBS and as covariates in the mortality analysis.

Results

In our dataset, 9058 patient visits to the ED (2.5% of all ED visits) ended in LWBS. These patients were younger than average and had lower triage levels. No significant difference was found between males and females. The highest rates were seen in patients presenting with a psychiatric disorder (12.8%), victims of physical assault (11.7%), or alcohol/drug withdrawal (9.9%). The likelihood of LWBS was highest in the evening and lowest in the early morning. Short-term mortality at 28 days was not significantly affected by LWBS, but a 34% lower long-term mortality risk was seen for patients LWBS (hazard ratio 0.66, 95% confidence interval 0.45-0.95, P = 0.028) in median follow-up of 3.5 years.

Conclusion

Patients LWBS were younger, had lower triage levels, and more frequently presented with psychiatric or substance use-related complaints. They had lower short- and long-term mortality compared with those who completed treatment. This observation does not imply a causal relationship but highlights differences in patient characteristics.

Aim

To explore how frail older patients experience their stay and nursing care during boarding time at the emergency department.

Design

A qualitative explorative interview study.

Method

Purposive sampling was used, with a two-step selection process: (1) Patients 65 years or older spending at least 4 h at the emergency department waiting for a hospital bed, referred to as boarding time, were (2) screened for frailty using the FRail Elderly Support researcH group screening instrument. If screening identified a patient as frail, they were eligible for an interview. Individual semi-structured interviews (n = 19) were conducted during patients' boarding time at the emergency department. Data was collected between March and April 2019. The theoretical Fundamentals of Care framework shaped the interview guide. Interviews were transcribed and an inductive latent content analysis was performed.

Results

The findings resulted in four main categories: Frail older patients felt disregarded, defenceless, and resigned during boarding time at the emergency department, yet also hopeful. The experience of hope resulted from confidence in the nurses, good nursing care, patience towards one's situation, and hope in emergency care.

Conclusion

The frail older patient experienced boarding time in the emergency department through an overarching theme: ‘being left in no-man's land in the emergency department but still feeling hopeful’. A trusting nurse–patient relationship, integrating the provision of fundamental care, is a favourable factor for the well-being of the frail older patient.

Impact

The study addressed the increased number of older adults with complex health needs, coupled with overcrowded emergency departments. Frail older patients perceive the boarding time as being left in a ‘no-man's-land’, addressing unclear information and lack of caregiver responsibility. This highlights the need for tailored guidelines and care practices that promote person-centred care and ensure safety for this vulnerable group in emergency settings.

Patient or Public Contribution

Not applicable.

Background: Emergency rooms prioritize rapid, life-saving interventions, often at the expense of patients ' psychosocial and existential needs. Patients in these settings are particularly vulnerable, yet such needs are frequently overlooked. Despite growing emphasis on person-centered care, knowledge of how existential needs (e.g. fear, anxiety, vulnerability) are expressed and addressed in emergency rooms remains limited.This study aims to describe how existential needs are expressed in the emergency room context.

Methods: A qualitative secondary analysis was conducted using 108 field notes, 14 registered nurse interviews, and 15 patient interviews viewing emergency room care through a Fundamentals of Care framework lens. An inductive approach was inspired by key existential concepts described in a review and relevant to acute care. Reflexive thematic analysis was applied to each dataset, followed by cross-data comparison to identify patterns of existential needs.

Results: The secondary analysis resulted in four themes; Existential vulnerability in a technical environment, Ensuring trust through presence and communication, Violations ofprivacyand dignity, and Moments of meaning-making through connection showing that existential needs in the emergency room are widespread and closely connected to both patients' experiences and registered nurses' care practices. Patients faced sudden transitions, fear, and emotional vulnerability, while registered nurses balanced these needs with organizational constraints. Existential concerns were expressed verbally and non-verbally and shaped by the environment, communication, and presence. Even brief, attentive encounters were experienced as meaningful and created a sense of safety in the stressful clinical setting.

Conclusions: Addressing existential needs is integral to emergency care. Recognition and responsive care can mitigate patients'emotional isolation and enhance safety, despite organizational constraints, highlighting the importance of integrating existential support with medical treatment.The organization should enable healthcare professionals to recognize and respond to existential needs as an integrated part of patient assessment and care interventions, supporting a more person-centered and holistic care in acute environments.This study highlights the importance of addressing existential needs within the emergency room, for both patients and registered nurses. Organizational constraints and ethical tensions challenge person-centered fundamental care, while underscoring safety as a crucial condition for meaningful and compassionate encounters. The findings offer guidance for emergency care professionals on integrating existential and relational awareness into practice, education, and policy.

  Aim

To describe how the Fundamentals of Care framework was applied within a postgraduate nursing programme facilitated by a pedagogical project for educators.

Design

A discursive paper approach was used.

Data Sources

The paper draws on the authors' experiences from a pedagogical project that included a book circle, an education retreat, and a mini-conference and identified learning activities applied in the programme.

Findings

The Fundamentals of Care framework was integrated into learning activities, such as assignments, seminars, and exams, within a diversity of specialties: anaesthesia, intensive care, emergency care, operation theatre, psychiatric care, prehospital care, and surgical care. In this paper, we provide an overview and examples of how the learning activities were applied.

Conclusion

This pedagogical project in a post-graduate nursing programme illustrated that the Fundamentals of Care framework is applicable to learning activities in education at the post-graduate level. Application of the framework at the post-graduate level could facilitate students' understanding of the importance of fundamental care for patients with complex care needs requiring advanced nursing interventions. It can also help students understand how to use theory in clinical practice. However, further research could focus on conducting interviews with students to understand their experiences and whether their views on nursing have changed.

Background: Identifying factors predictive of hospital admission can be useful to prospectively inform bed management and patient flow strategies and decrease emergency department (ED) crowding. It is largely unknown if admission rate or factors predictive of admission vary based on the population to which the ED served (i.e., children only, or both adults and children). This study aimed to describe the profile and identify factors predictive of hospital admission for children who presented to four EDs in Australia and one ED in Sweden.

Methods: A multi-site observational cross-sectional study using routinely collected data pertaining to ED presentations made by children < 18 years of age between July 1, 2011 and October 31, 2012. Univariate and multivariate analysis were undertaken to determine factors predictive of hospital admission.

Results: Of the 151,647 ED presentations made during the study period, 22% resulted in hospital admission. Admission rate varied by site; the children's EDs in Australia had higher admission rates (South Australia: 26%, Queensland: 23%) than the mixed (adult and children's) EDs (South Australia: 13%, Queensland: 17%, Sweden: 18%). Factors most predictive of hospital admission for children, after controlling for triage category, included hospital type (children's only) adjusted odds ratio (aOR):2.3 (95%CI: 2.2-2.4), arrival by ambulance aOR:2.8 (95%CI: 2.7-2.9), referral from primary health aOR:1.5 (95%CI: 1.4-1.6) and presentation with a respiratory or gastrointestinal condition (aOR:2.6, 95%CI: 2.5-2.8 and aOR:1.5, 95%CI: 1.4-1.6, respectively). Predictors were similar when each site was considered separately.

Conclusions: Although the characteristics of children varied by site, factors predictive of hospital admission were mostly similar. The awareness of these factors predicting the need for hospital admission can support the development of clinical pathways.

Background

Persons who become life-threateningly ill or injured (due to for example trauma or cardiac arrest) are cared for in hospitals’ designated emergency rooms at the emergency department (ED). In these rooms, the life-threatening condition and biomedical focus may reinforce a culture that value the medical-technical care. Meeting patients fundamental care needs (integrating physical, psychosocial and relational care needs) in a person-centred way might hence be challenging in emergency rooms. Little is known about how person-centred fundamental care is experienced and valued by vulnerable and exposed patients in emergency rooms. This study aims to describe fundamental care needs experienced by patients with a life-threating condition in the emergency room.

Methods

A descriptive deductive qualitative study with individual interviews were carried out with 15 patients who had been life-threateningly ill or injured and admitted in an emergency room, in Sweden. Data collection was conducted during 2022. Transcribed interviews were analyzed with deductive content analysis, based on the Fundamentals of Care framework.

Results

Despite being life-threateningly ill or injured, patients were still able to describe their unique needs—which were not only related to biomedical care. A relationship was established between healthcare professionals and the patient in the initial stage, but not maintained during their stay at the emergency room. Patients felt their physical needs were met to a greater extent than psychosocial and relational needs, despite their prioritizing the latter. Patients preferred personalized care but described care as task oriented. The physical environment limited patients from having their fundamental care needs met, and they adopted to a “patient role” to avoid adding to staff stress. The emergency room situation evoked existential thoughts.

Conclusions

This paper provides unique insights into patients’ experiences of being cared for in an emergency room. From the patient perspective, physical care was not enough. Relationship, timely and personalized information, and existential needs were identified as essential fundamental care needs, which were not, or only partly met. The finding highlights the need to embed and prioritize fundamental care in practice also for patients who are life-threateningly ill or injured, which in turn calls for focus on organizational prerequisites to enable person-centred fundamental care.

Introduction:

Guidelines are important for guiding clinical practice and governing registered nurses' work in an emergency room to enable them to secure quality of care and patient safety in a life-saving situation. However, guidelines are not always systematically prepared, or evidence based. This study aimed to map and describe the content of Swedish guidelines governing the registered nurses' work in emergency rooms.

Methods:

A descriptive cross-sectional design, together with a thematic synthesis of content of the submitted guidelines. The data were analyzed with descriptive statistics and a thematic synthesis. Quality of the guidelines was measured using a modified version of the AGREE II instrument.

Results:

The result is based on 190 included guidelines, collected from 37 participating emergency departments. The registered nurses' work in emergency rooms was guided by an instrumental and task-oriented approach to care, with a wide variation in how the registered nurses' work was described in the guidelines. The quality of the guidelines was poor. The registered nurse was reported as target user in 15 % (n = 29) of the guidelines. None of the guidelines described the population to whom they were meant to apply. In 17 % (n = 32) there was an explicit link between recommendations and supporting evidence.

Conclusions:

There is a need to improve guidelines to support registered nurses in assessing, treating, and providing fundamental care for patients with life-threatening illnesses in an equal, evidence-based, and personcentered way. Registered nurses should play an active role in the development of the guidelines governing their work.

Background: A changing nursing workforce and an increase in demands for care together with more complex care, raise arguments that leading and guiding nursing practice is more challenging than ever. Therefore, nurses need to have a shared agenda and a common language to show the importance of nursing care and the consequences of not addressing this in an appropriate way. In response to this the Fundamentals of Care framework was developed to also contribute to the delivery of person-centred care in an integrated way. However, to gain acceptance and applicability we need to ensure the framework's relevance to clinical practice from bedside nurses' perspectives.

Objective: To describe bedside nurses' perspectives on the Fundamentals of Care framework and how it can be applied in clinical practice.

Design: A descriptive qualitative design informed by the Fundamentals of Care framework.

Setting(s): The study was undertaken at seven hospitals in Sweden, Denmark and the Netherlands during 2019.ParticipantsA total sample of 53 registered nurses working at the bedside participated.

Participants: had a wide variety of clinical experience and represented a range of different nursing practice areas.

Methods: Twelve focus group interviews were used to collect data and analysed with a deductive content analysis approach.

Results: Bedside nurses perceived that the Fundamentals of Care framework was adequate, easy to understand and recognised as representative for the core of nursing care. The definition for fundamental care covered many aspects of nursing care, but was also perceived as too general and too idealistic in relation to the registered nurses' work. The participants recognised the elements within the framework, but appeared not to be using this to articulate their practice. Three main categories emerged for implications for clinical practice; guiding reflection on one's work; ensuring person-centred fundamental care and reinforcing nursing leadership.

Conclusions: The Fundamentals of Care framework is perceived by bedside nurses as a modern framework describing the core of nursing. The framework was recognised as having clinical relevance and provides bedside nurses with a common language to articulate the complexity of nursing practice. This knowledge is crucial for bedside nurses both in clinical practice and in leadership roles to be able to speak up for the need to integrate all dimensions of care to achieve person-centred fundamental care. Various activities for reflection, person-centred care and leadership to apply the framework in clinical practice were presented, together with minor suggestions for development of the framework.

Tweetable abstract: Bedside nurses recognise their clinical practice within the Fundamentals of Care framework, showing the core of modern nursing.

Aims To map how frailty among older people is assessed at Swedish emergency departments and to describe fundamental nursing care actions for these patients.

Design Descriptive national survey and a qualitative analysis of text.

Methods A majority (82%, n = 54) of the Swedish hospital-based emergency departments for adults were included, representing all six healthcare regions. An online survey was used to collect data, together with submitted local practice guidelines for older people at the emergency departments. Data were collected during February-October 2021. Descriptive and comparative statistics were performed together with a deductive content analysis framed by the Fundamentals of Care framework.

Results Sixty-five per cent (35 of 54) of the emergency departments identified frailty, with less than half of them using an established assessment instrument. Twenty-eight (52%) of the emergency departments have practice guidelines containing fundamental nursing actions for the care of frail older people. The majority of nursing actions in the practice guidelines were related to patients' physical care needs (91%), followed by psychosocial care needs (9%). No actions could be identified as relational actions (0%) according to the Fundamentals of Care framework.

Conclusion Many Swedish emergency departments identify frail older people, but they use a range of different assessment instruments. While practice guidelines directing fundamental nursing actions for frail older people are often in place, a holistic, person-centred view addressing the patient's physical, psychosocial and relational care needs is missing.

Impact The population is growing older, and more people are needing more complex hospital care. Frail older people have an increased risk of negative outcomes. The use of a variety of assessment instruments for frailty may pose a challenge to equal care. To ensure a holistic, person-centred view of frail older people, the Fundamentals of Care framework can be used in developing and reviewing practice guidelines.