33 healthcare professionals working in the ED were interviewed (15 men and 18 women), reaching data saturation, indicating that no new information came up in the last three interviews. Mean age of the respondents was 43,2 years (range 29–63), median age was 41,5 years. Mean work experience was 8 years (range 0–30). Interviews ranged from 30 min to little over 60 min. A distribution of professions over the different hospitals is presented in Table 1.
All respondents felt an increase in perceived workload. The results are presented in three major themes; causes of workload, consequences and proposed solutions. These are further divided in subthemes. Table 2 describes the themes and subthemes.
Causes of workloadIncreasing inflow
According to all respondents, patient inflow is increasing due to the aging population and the increased possibilities in healthcare. A group of patients seek the ED for non-urgent care, due to the increasing crowd in the hospital or the GP practice. Additionally, participants noticed ED presentations are rising after the visitation rounds of general practitioners, leading to peak moments at the ED and risk of patient stops. Also, they felt there is a lack of advance care planning which causes patients to come to the ED unnecessary and respondents question if all treatments should be offered to every patient, considering the quality of life and limited financial resources. Participants also stated seeing a changing attitude among patients, becoming more demanding and having unrealistic expectations of the ED services. “Whether people are here through self-referral, or whether general practitioners are more likely to refer patients because they are also too busy and can no longer manage the care, and that’s why they refer patients to us. But I do see a significant increase in inflow of patients. (Participant A28, female, nurse, age range 45–54 years)”. “In this case, supply also creates demand. The fact that specialized help is available 24/7 also creates demand. I think part of the focus should be on curbing that demand and keeping that supply available only for care that truly cannot wait. (Participant A5, female, physician, age range 45–54 years)”.
Barriers affecting efficient throughput and output
Many respondents mentioned slow throughput of patients due to a lack of hospital beds, insufficient knowledge and skills for (diagnostic) treatment of vulnerable patient groups and coordination with other healthcare professionals within the hospital. Throughput is defined as the process of patient treatment in the ED. Increasing technical possibilities cause the diagnostic process to take longer, and several respondents had doubts about the added value. Also mentioned was defensive care due to the fear of being liable for mistakes, resulting in unnecessary diagnostics. Direct transfer to home care, nursing homes and care homes from the ED were often mentioned as bottlenecks which hinders the output. “What creates stress is when we have too many patients for too few beds — having to place people in the hallway. When there is no admission capacity in the ED, we will put those people in the hallway when I still need to keep an eye on them. (Participant A4, male, nurse, age range 55–64 years)”. “Someone who presents themselves at the ED, an elderly person whose home situation is no longer tenable, and we admit them, we cannot have them placed in a nursing home today or tomorrow because the system works three-dimensionally. There are bottlenecks in all layers of care, including home care and nursing homes. (Participant A25, male, nurse, age range 35–44 years)”.
Staff shortage
Generally, respondents perceived their workload as high, but some found it difficult to describe their workload because of its subjectivity and its daily variation, due to peak days and times. Where most ED professionals saw the workload as high, few viewed it as a challenge as it is part of their profession. Respondents experienced an increasing workload due to long-term absence of personnel and perceived challenges with finding sufficient personnel. “I think that the staff shortage definitely plays a role as well. We often have too few assistants, too few doctors, too few nurses. I work 28 hours a week myself, and I think that just in the first quarter alone, I’ve already accumulated around 73 hours of overtime. (Participant A29, female, physician assistant, age range 35–44 years)”. “In terms of workload or staff shortage, I think the workload is fine, but you can definitely feel the shortage. We almost always have a bit of a staff shortage. (Participant A22, male, nurse, age range 25–34 years)”.
ConsequencesIncreased time demand
Due to high workload, respondents noted little time to speak with patients. The administrative burden was perceived high, which creates time pressure when performing tasks. For ED nurses, this created a feeling of falling short on patient care as patient contact is of great importance for them. In addition, there was not enough time for them to take breaks or unwind. ED physicians experienced interruptions, mainly phone calls disrupting their work process. “On those days when you have too many sick patients, and you have so much work that you are constantly playing catch-up, and therefore cannot provide the care. I find it awful when I cannot provide the care I want to give simply because I have too much work. (Participant A20, female, nurse, age range 25–34 years)”. “When you have a coordinating and supervising role, you sometimes feel completely overwhelmed because everyone wants to discuss something with you or wants to know your opinion, and I experience that as an increased workload. Once, I counted. I have a shift that lasts about 10 hours, and during those 10 hours, I received 254 phone calls. That is on top of everyone on the floor asking, ‘may I do this, can I do this, what do you want me to do?’ (Participant A5, female, physician, age range 35–44 years)”.
Increased mental and psychological demand
Respondents experienced an increase in patient complexity, with physical, mental, and social problems. This intensified their mental effort needed to perform tasks, making it more demanding. In addition to more complexity, medical procedures have also become more complex, which challenges their cognitive skills.
Respondents experienced psychological demand due to high numbers of incoming and more demanding patients. As the workload is increasing and there is a delay in throughput and output, patients have to be treated in the hallways. Some respondents experienced this as unsafe, affecting the privacy of patients, and contributing to a higher psychological demand. Shortage of personnel also increased feelings of stress. Many respondents expressed concerns about future personnel problems. “People will start to drop out. Working hard is not a problem, and it will not kill you. But if you are constantly under this kind of stress, as is often the case, it is not sustainable for a longer period. And I am not talking about just a few months, but six months, a year, people will inevitably start to collapse, I think. (Participant A28, female, nurse, age range 45–54 years)”. “Somehow, we have become so good in providing acute care that even non-emergency cases find it appealing to come here. And that actually creates an additional workload, but also a bit of frustration among colleagues (Participant A18, male, nurse, age range 45–54 years)”.
Job satisfaction
Respondents mentioned several aspects of workload affecting their job satisfaction. Respondents emphasized the importance of conducting research and educational activities being beneficial to job satisfaction. Increased workload and tight staffing limits opportunities for training and career development, and subsequently their job satisfaction. Secondly, respondents emphasized the impact of the workload and irregular shifts on their private life. Lastly, respondents all emphasized the importance of a diverse, good team within the ED, and open and efficient collaboration with other medical specialists. “When talking about job satisfaction, and things necessary to keep people in the field of healthcare or acute care, offering people prospects of extracurricular activities or career development or growth opportunities, those things are important (Participant A7, male, physician, age range 45–54 years)”. “Another difficult thing is that, sometimes, there is so much academic nitpicking, which makes me incredibly tired. You think we have covered everything now. No, there is another doctor who thinks…, and they want to have it said before the patient can leave. It is something we struggle with. It diminishes your job satisfaction. (Participant A9, male, nurse, age range 55–64 years)”.
General solutions to increase job satisfaction
The human connection was seen by the respondents as a key element of the profession, both amongst the team and in patient interaction. There was fear of losing that due to reorganization and innovations. In general, respondents saw collaboration within hospital and between hospitals, as a solution to improve job satisfaction. Respondents suggested that exchange of personnel could enhance collaboration. They suggested more involvement in other activities, such as scientific research and creating leadership roles for ED nurses to increase job satisfaction. According to ED nurses, job satisfaction might be improved by offering better secondary working conditions, such as free childcare. Creating more efficiency through innovation, such as AI solutions for automatic transcription of conversations to the electronic health record system (EHR-system), could also aid job satisfaction. “A friend of mine works in Norway, where all of central Norway is connected to the same electronic health record system (EHR-system), and by central Norway, I do not just mean the hospitals but also the general practitioners, the public health services, the ambulances, everything, and everyone. That would be a blessing! (Participant A5, female, physician, age range 35–44 years)”. “Things can be more efficient, and technology will definitely play a role in making many things more efficient or faster, but I do hope that the human relationship remains. (Participant A17, female, nurse, age range 25–34 years)”.
Proposed solutions
Respondents recognized the importance of organizational change to maintain adequate staffing, high quality of care and accessibility.
Input
Educating the public on how to prevent emergencies, when to visit the ED, and the costs of non-urgent or unnecessary visitations and advance care planning might help to decrease patient inflow.
According to some respondents, closer collaboration with the General Physician Cooperatives (GPCs) could reduce input and subsequently workload. A respondent had experienced that an emergency physician consultation in the GPC prevents referral.
A planned ED visit to avoid peak presentation moments is mentioned by respondents, as some patients do need emergency care but do not have a time critical problem. By planning these patients, for example in the evening, peak hour workload can be reduced. Another solution mentioned to reduce input and peak presentation is training GPs in acute care delivery and telemonitoring. It could be especially helpful for small injuries and for some elderly patient groups as they can be treated in the GP practice and at home. On an organizational level in the ED department, some respondents suggested that efficiency and anticipation on subsequent staff planning can be achieved by developing flexible schedules with shifts with different hours. Lastly, many respondents believed that a uniform EHR system will improve information transfer between hospitals and other actors in the acute care chain which might prevent unnecessary care and referrals. “What we came up with is offering the option to the general practitioner that they can ask us [ED physicians] to take a quick look. The patient stays in the consultation room; I take a quick look and say, ‘Yes, I would do this and this,’ or ‘Refer the patient.’ We have researched this over the past year for about three months. In that time, we have seen about 30 patients; 85% were not referred. (Participant A21, male, physician, age range 25–34 years)”. “Maybe through those public service videos, aimed at when to go to the general practitioner, the General Physician Cooperative in the hospital, or the emergency department, that people already have much more information, that should be emphasized (Participant A24, female, nurse, age range 45–54 years)”.
Throughput
Exchanges and collaboration between ED professionals could improve mutual understanding and deployment of ED professionals within and among different hospitals. Some respondents mentioned that stricter compliance with protocols might help to increase efficient throughput of patients. Others suggested opportunities to increase personnel capacity include greater deployment of physician-assistants and combined functions with, for example, the ambulance services or ICU. ED physicians having more autonomy to admit or discharge patients would benefit throughput of patients and lower the workload for ED professionals. Other solutions mentioned were more involvement of family through informal care or family rooms, which could aid ED nurses in their tasks. “Perhaps you could very well say, we will book you in at that time in the emergency department. That already could be somewhat of a solution, distributing the workload” (Participant A4, male, nurse, age range 55–64 years)”. “So, then we can look to the ICU or the Cardiac Emergency Unit to see if their workload is lower and if they can possibly help out, for example, by taking lab samples or performing an ECG. Just the basic support tasks. That way, things can run more smoothly again, and you get a better throughput. (Participant A14, female, physician, age range 35–44 years)”.
Output
Optimizing cooperation with local nursing homes and home care are important to optimize outplacement. Concepts like the ‘care hotel’, where patients stay temporarily until a place in a nursing or care home is available, and creating a lounge where people can wait to be discharged, are mentioned. Finally, a better cooperation and optimizing protocols with other hospital facilities such as the acute admission ward could benefit output. “A better discharge process to nursing homes and home care, so that you can discharge people more quickly. (Participant A31, female, physician, age range 25–34 years)”. “Space is not the problem, but staffing is. If we can address that, it will greatly improve output issues, not just from the emergency department but also for admitted patients who need to go home. If the output process is streamlined, so patients can quickly move from the ward to a nursing home, it will automatically allow more patients from the emergency department to move to the ward. (Participant A32, male, physician, age range 45–54 years)”.