Perceptions and experiences of emergency department staff during the implementation of the four-hour rule/national emergency access target policy in Australia: a qualitative social dynamic perspective

Abstract

BackgroundThe Four-Hour Rule or National Emergency Access Target policy (4HR/NEAT) was implemented by Australian State and Federal Governments between 2009 and 2014 to address increased demand, overcrowding and access block (boarding) in Emergency Departments (EDs). This qualitative study aimed to assess the impact of 4HR/NEAT on ED staff attitudes and perceptions. This article is part of a series of manuscripts reporting the results of this project.MethodsThe methodology has been published in this journal. As discussed in the methods paper, we interviewed 119 participants from 16 EDs across New South Wales (NSW), Queensland (QLD), Western Australia (WA) and the Australian Capital Territory (ACT), in 2015–2016. Interviews were recorded, transcribed, imported to NVivo 11 and analysed using content and thematic analysis.ResultsThree key themes emerged: Stress and morale, Intergroup dynamics, and Interaction with patients. These provided insight into the psycho-social dimensions and organisational structure of EDs at the individual, peer-to-peer, inter-departmental, and staff-patient levels.ConclusionFindings provide information on the social interactions associated with the introduction of the 4HR/NEAT policy and the intended and unintended consequences of its implementation across Australia. These themes allowed us to develop several hypotheses about the driving forces behind the social impact of this policy on ED staff and will allow for development of interventions that are rooted in the rich context of the staff’s experiences.

When a health policy cuts both ways: Impact of the National Emergency Access Target policy on staff and emergency department performance

“…We identified four main themes (i.e. social factors, ED management, ED outcomes and 4HR/NEAT compliance) and subthemes from the QUAL analysis described elsewhere …”

“…social factors, ED management, ED outcomes and 4HR/NEAT compliance) and subthemes from the QUAL analysis described elsewhere. [21][22][23]28 Quantitative Standardised quantitative measures of performance and aggregate score based on three methods for quantifying access block and % EDLOS ≤4 h were used to measure overall ED performance. Table 1 shows the classification based on the overall measures of access block and the proportion of ED patients with EDLOS ≤4.…”

Training in the era of time‐based targets: Balancing service provision with education

“…Some EM clinicians have experienced an increase in conflict and fracturing of professional relationships. Implementation of the Australian NEAT increased tension and resistance between ED staff members, in particular between doctors and nurses, with both groups feeling increased pressure to focus on compliance . The relationship between EM clinicians and other departments varies considerably and probably depends on the methods used to implement the targets, as well as the hospital culture.…”

“…Some EM clinicians said these relationships had improved because of positive changes resulting from a whole‐hospital approach to improving access block. Others said there was increased resentment and frustration arising from pressure to move patients before either team was ready . This frustration is seen as difficult referral processes and leads to a ‘Us versus Them’ mentality and even toxic tribalism.…”

“…Although some EDs are reportedly less congested as a result of improvement in access block and overcrowding, the administrative burden has increased. Also, some jurisdictions have taken a punitive approach to compliance, which leads to an overwhelming focus on meeting performance indicators . High rates of absenteeism and resignation during NEAT implementation illustrates the increase in ED staff burnout …”