Key words: discretion, emergency care, emergency department, health care, health
care administration, nurses, nursing care, qualitative, targets, work environment
Authors: Louise Hoyle, PhD, MSc, RN, Lecturer, School of Nurs- Correspondence: Aimee Grant, Research Fellow, Institute of Pri-
ing Midwifery and Social Care, Edinburgh Napier University, Edin- mary Care and Public Health, School of Medicine, Cardiff Univer-
burgh; Aimee Grant, PhD, MSc, BSc (Econ), Research Fellow, sity, 5th Floor, Neuadd Meirionnydd, Heath Park, Cardiff CF14
Institute of Primary Care and Public Health, School of Medicine, 4YS, UK. Telephone: +44 02920 687250.
Cardiff University, Cardiff, UK E-mail: GrantA2@cardiff.ac.uk
see a clinician had not decreased (Freeman et al. 2010). this impacts clinical decision-making throughout acute sec-
Research within England found that of all clinicians, nurses ondary care hospitals.
were most actively involved in attempting to meet the tar-
get, although interviewees reported that the organisation of
Participants
the hospital, which nurses have little control over, was cen-
tral to being able to meet the target (Weber et al. 2012). We used a flexible approach for gaining access to and
During 2013, the four-hour ED target was brought to recruiting participants, as is often the case when recruiting
the UK publics attention as a result of serious concerns professionals (Feldman et al. 2003), including health profes-
regarding treatment at the Mid Staffordshire Hospital sionals (author 2, self citation, 2013), into qualitative
Trust, which was investigated by a Public Inquiry. Within research. This meant some participants were recruited by us
the inquirys report (Francis 2013), it was suggested that approaching individuals on the wards and asking for partic-
patients within the ED were prioritised by the nurse in ipation. In other areas, the ward manager disseminated
charge according to the amount of time they had been information sheets and then provided us with the details of
waiting, as opposed to their clinical need, to avoid those willing to participate. The clinical areas included in
breaching the four-hour target within a considerably the study were acute medical and surgical wards along with
understaffed and high pressured environment. Significant ED, surgical receiving and acute medical receiving.
problems were reported within the ED, where staff All 31 participants were front-line nursing staff based in
reported being asked to inaccurately record the time that five departments with a large inner city hospital in Scot-
patients were within the department, or to subsequently land, UK. Interviewees were registered nursing staff who
alter the paperwork, if the patient had breached the four- were employed as nurses on the Agenda for Change pay
hour target. The Francis report highlighted that there was scale between Band 5 (the lowest role exclusively available
generally a lack of evidence of appreciation of the poten- to qualified nurses) and Band 7 (a role including significant
tial unintended consequences for individual patients of managerial duties, e.g. managing a ward). Table 1 shows
implementing policies, for instance in relation to targets participant demographics.
(Francis 2013: 20.17).
The Francis report in its recommendations for nurses
Data collection
focused on the training of nursing staff and leadership. It
suggested that there needed to be a focus on caring, com- We used a case study approach (Yin 2013) to understand
passionate and considerate nursing. However, there was no relationships between managers, staff and patients in acute
mention of the impact of targets or management decisions
on the workloads of the nursing staff. In the UK Nursing
Table 1 Participant demographics
and Midwifery Council response to the Francis report, the
issues of workload pressures and meeting targets within the Characteristic Group Count
workplace were also not reported (NMC 2013). The gov- Gender Male 6
ernment response stated that: Targets or finance must Female 25
never again be allowed to come before the quality of care. Age 2130 10
(Department of Health 2014: 7, emphasis original). How- 3140 9
4150 6
ever, the report did not consider removing the four-hour
5165 6
target, but instead sets a requirement for reporting of staff Length qualified 12 years 1
levels and a further target for undertaking appraisals with 35 years 11
staff. The Nuffield Trust (2014) reports that in the year 610 years 6
since the Francis report, little progress has been made in 1115 years 0
>15 years 13
changing the culture within UK hospitals.
Nursing grade Band 5 20
Band 6 4
Design/methods Band 7 7
Area: Emergency Emergency departments 5
Area: Nonemergency Medical assessment 4
Aims Surgical receiving 2
Medical wards 9
To explore nurses views and experiences of four-hour
Surgical wards 11
treatment targets in the emergency department and how
hospital settings. The case study method allows investiga- based on the literature and author 1s analytical memo-
tors to focus on a case and retain a holistic and real- randa. Initially, the themes were quite broad and required
world perspective. . . (Yin 2013: 4). Thus in our research, further refinement; also further themes were identified
the case was a single hospital in Scotland, from which we through the analysis process as we became more familiar
generated empirical insights which can be tested in other with the data. This meant that development of thematic cat-
hospitals around the world in which a treatment time target egories was an emergent and iterative process, which
has been adopted. A semi-structured interview guide was allowed first insight into connections between themes. NVIVO
developed and used during the face-to-face individual inter- version 8 (QSR International, Doncaster, Victoria, Austra-
views. Topics of interest were focused around six key lia) was used by author 1 as a data management tool at this
themes identified from the literature on health policy, man- stage of analysis. Data relating specifically to the code tar-
agerial practices and the sociology of work: the role of gets were then subjected to more detailed thematic analysis
nursing and relationships with management; financial by author 1 and author 2, within the context of the intervie-
accountability; efficiency; impact of targets and monitoring; wees accounts of their work behaviour. Themes relating to
policies; working conditions and consumerism. The ques- the literature were used to inform a coding framework. In
tions asked in relation to targets were: addition to this, further codes were added as appropriate
Can you think of any targets that have been introduced during analysis, allowing an inductive and deductive
in your work areas? approach to be used. During this stage of analysis, coding
In what ways can targets in your work environment be was agreed by both authors to ensure validity. To facilitate
a positive thing? this, ATLAS.TI version 7 was used as a data management tool.
In what ways can targets in your work environment be
a negative thing?
The four-hour target was not specifically asked about to Results
remove the possibility of bias for nurses who did not feel Findings will be discussed in relation to pressure on nurses,
that the target impacted on their clinical practice, but was the impact on patient care and the use of alternative treat-
a salient theme which was discussed by the majority of par- ment areas. The emotional impact on nurses is described
ticipants, and at length by those working in the ED. throughout. Inconsistencies between nurses working in dif-
Staff were interviewed by author 1 at the hospital site ferent departments will be described. Approximately, half
during a three-month period in 2010. Interviews varied in (medical n = 5; surgical n = 5) of the nonemergency depart-
length from 20 minute to one hour, generally lasting ment nurses did not discuss the four-hour target at all in
around 45 minutes. Written consent was obtained once their interview. This shows the low importance of the four-
staff had been provided with full information on the pro- hour target in their work. Instead, these nurses discussed
ject. Interviews were either audio recorded or comprehen- infection control, hand hygiene and discharge times. For
sive notes were taken at time of interview (if consent for the other half of nonemergency department nurses, there
recording was not given, as occurred in three interviews). was variation in the importance given to the four-hour tar-
In keeping with legal requirements, audio recordings were gets in their descriptions, and this will be outlined in more
stored on a secure encrypted database. Transcripts were detail below.
anonymised, and a code system was used to identify the
participants. Ethical approval was obtained from both a
university ethics committee and the UK NHS Research Eth- Pressure
ics Committee (ref: 09/S0709/75) and had all appropriate Nurses from all departments described various ways in
UK NHS governance clearances. Within this article, all par- which the four-hour target put pressure on their work. This
ticipants will be referred to as female to protect anonymity. theme was encountered more than any other during analy-
sis, and was particularly salient in accounts from ED
Data analysis nurses. The ED nurses noted that they felt pressured by a
demanding work load and inadequate levels of staff to meet
Data were analysed using thematic analysis (Braun & the target:
Clarke 2006). A preliminary analysis of the data was inte-
grated within the data collection process as part of a process . . . we work as fast as we can . . . were like working our socks off
of continual reflection by author 1. Once fieldwork had and trying to get them coming in as quickly as possible, and its
been completed, a set of thematic categories were developed just not enough its never enough, you know . . . (ED nurse 5)
In addition to this, all five of the ED nurses reported con- fited patients who were not acutely ill, who would be seen
sistent pressure from monitoring of their performance, such more quickly than they would have been prior to the intro-
as reporting to senior nurses on the ward and regular phone duction of the target. Many nurses contrasted the benefits
calls from managers. Two of the nurses explicitly related and costs of the target for patients, including three who
this to the managerial structure that was in place, which directly compared the costs and benefits:
required serious breaches of the four-hour target to be
I mean, if I was a user and you were in ED then aye definitely.
relayed to the Scottish Government.
When youre coming in it might be positive, but if youre sitting
While four of the ED nurses were concerned about the
there and youre maybe not ready to go home yet theyre maybe
consequences of breaching the target, ED nurse 4 reported
pushing you, so it can be negative at the other side of it kind of
that she was not concerned about the impact if the patient
thing. (medical nurse 6)
did breach the target because of a sound clinical reasoning
or a lack of resources. This approach of acknowledging but Despite the benefits for nonacute patients, ED nurses
refusing to be panicked by the pressure was more common report having less time to support the sickest patients. One
among nurses who worked in departments that received ED nurse stated that patient care did have to be compro-
patients but were not ED (AMU and surgical receiving). mised sometimes to meet the target, although she reported
These nurses also reported being under consistent pressure that she ensured the most ill patients did not have their care
to help contribute towards meeting four-hour targets, compromised:
including moving their patients to other wards as soon as
And the thing is, as much as I think we do compromise some
possible.
patients care, but I dont think we compromise it. . . I think that ill
Only four of the 20 nurses who did not work in EDs
people, the people that are really acutely unwell we do recognise,
reported feeling pressure to ensure patients were discharged
and I think that we do take care of (them). (ED nurse 5)
quickly, including receiving telephone calls from ED staff
to request beds, routinely planning surgical discharges on Moreover, despite the pressure reported above, ED
the day of admission and attempting to discharge patients nurses noted that they would resist moving unstable
as quickly as possible: patients or those for whom a suitable bed could not be
found, regardless of if they would breach the four-hour tar-
Sometimes we have people coming in fasted that day for proce-
get:
dures as well and youre trying to get a bed available for them. So
youre trying to discharge somebody and then youre getting them you shouldnt rush the decision making because that can be impor-
in admitting and them in and its quite hard sometimes [laugh]. tant, and if somebody is unstable they shouldnt be moved anyway
And before you know it you turn around and the porters are stand- whether its four hours or six or eight hours, if theyre not fit to
ing there with a trolley and youre like Im not ready. So its very be moved, theyre not fit to be moved. (ED nurse 1)
stressful [laugh]. (surgical nurse 10)
. . . because theres a bed in Ward (x), why can he not go to the
An emotional burden was explicitly reported from this bed in Ward (x)? But to me thats downstream and theres no back
pressure to move or discharge patients earlier than desired up medical care down there except for the Junior House Officer
by one medical receiving nurse and one surgical nurse. By and he aint suitable. Hes not going there . . . (ED nurse 3)
contrast, one medical nurse did not appear to experience
pressure to contribute towards meeting the four-hour tar-
get: Use of Clinical Decision Units (CDUs) and other
assessment areas
I dont really know much to do with, like, the four hour waiting
time or anything like that, but they always kind of talk about To meet the target, ED nurses noted that patients were rou-
theyve breached and all that down in casualty and all that sort of tinely moved to assessment units for further investigations.
thing . . . (medical nurse 4) Three of the ED nurses were critical of the practice, which
was not seen as beneficial for patient care, but simply a
way of meeting a target that was not realistic:
Impact on patient care
theyre trying to avoid breaching these four hour targets, but
Participants described the impact of attempting to meet theyre just trying to find. . . its more just finding a way about the
four-hour targets for patient care at considerable length. four hour targets, thats the whole point of the new department, is
The majority of interviewees reported that the target bene- theyre building it because the four hour targets are unrealistic
anyway. So theyre trying to avoid it by splitting up the department target, where nurses refused to move patients who were not
almost so they can try to deal with it, which is the best way, I sup- seen as clinically ready to leave the ED. This resistance
pose, you can deal with it, because theyre so unrealistic, thats the aligns with the existing literature which has found strong
only way that you can deal with it is to get patients in separately support for nurses rejecting targets that did not fit with
and to try and reduce the times. (ED nurse 5) their beliefs (Wells 1997, Provis & Stack 2004, Bergen &
While 2005, Kramer et al. 2007), and thus contrasts Hunt-
In addition to this, the use of assessment units was criti-
ers (2003). However, the research was based on interviews
cised by a medical nurse, as she stated that it did not make
with nurses, and it may be that a more ethnographic
patient care any more efficient:
approach, including observations of practice within the ED,
It was things like we had an assessment unit, so patients would would have uncovered further insights, as has occurred in
come into A&E and as long as they got up onto the assessment research on nurses professional relationships (Allen 1997).
unit within the four hours then the paperwork looks good. But Accordingly, to truly understand the impact of these targets
then that patient could be sitting in the assessment unit for any- on nurses, there is a need for ethnographic research within
thing. The worse case scenario, anything up to seven or eight EDs, including ways in which nurses behave to meet the
hours, to be seen. So its like it didnt actually improve patient care majority of targets, and minor and major acts of resistance
but it improved the figures. (medical nurse 2) to the target.
In nonemergency areas, staff were aware of the four-hour
target, but half did not consider it to be a target that
Discussion
affected them, and those who did reported experiencing less
Our research found that nurses working in one hospital in direct pressure than their ED colleagues. Moreover, the
Scotland stated that they worked hard to attempt to meet majority of nurses from nonemergency areas did not appear
the four-hour target, showing that a national target was to understand the impact of their discharge decisions on the
affecting clinical practice (Som 2009). In trying to meet the four-hour target. Accordingly, if ED treatment targets are
target, nurses carried a considerable burden, as highlighted to remain, there is a need for considerable health service
by the Francis Report (2013). This was evident in two reform to optimise systems and approaches throughout hos-
ways: an inability to meet demand because of high numbers pitals. This should aim to redistribute pressure to meet tar-
of patients compared to nursing staff, and pressure from gets more evenly throughout all hospital wards.
senior staff to meet the four-hour target. This burden was
most apparent among those working in emergency arenas
Conclusion
(including the ED, and other departments that received
patients). Lipskys (1980) research on the use of discretion For the last 30 years, many western health services have
among front-line workers highlights these challenges as cen- become increasingly monitored on their ability to meet tar-
tral to public organisations, as inadequate resources are gets. As health service budgets in developed countries fail
available to meet demand. However, Wells (1997) research to keep pace with demand, the way in which nurses behave
on community mental health nurses found that compliance to prima facie meet targets is of considerable interest. To
with targets was lower when they were inadequately re- date, the way in which targets for waiting times in ED are
sourced, showing a continuum of inadequacy. It may be managed by nurses has been an under-researched area. Our
that the pressure to meet the target from managers, very study of Scottish nurses found that while the four-hour wait
clear guidance (Bergen & While 2005) and reporting target in ED was met in the majority of cases, this was
directly to the Scottish Government for serious breaches often as a result of considerable pressure being placed on
mitigated this factor. ED staff. Moreover, the spirit of the target was sometimes
For interviewees, the main reported impact of the target lost, with ED nurses reporting that assessment areas were
was on patient care. It was noted that nonemergency cases used to move patients who were not ready to be moved to
were dealt with more quickly than prior to the introduction a ward. Nurses reported that they felt able to maintain an
of the target. However, ED nurses reported having less time acceptably high standard of patient care, although ethno-
to spend with patients, including those who were very sick, graphic insight would be valuable to independently verify
showing that clinical priorities were distorted by targets. the effects on patient care. Additional research should be
This could lead to a further, emotional, burden which had undertaken in other countries in which treatment time tar-
not previously been explored in the literature on nurses and gets are in place, to understand their effects internationally.
discretion. Some ED nurses reported active resistance to the Moreover, investigation should be undertaken in hospitals
which are funded in ways which are different to the UK sure in ED, which may contribute to staff burnout and
NHS, which is funded through taxation and free at the long-term sickness absence. In countries in which treatment
point of use. time targets have not yet been introduced, consideration of
how to reduce the negative impacts of such targets within
local or national contexts should be undertaken before pol-
Relevance to clinical practice
icy is implemented.
Within the UK Francis inquiry, no mention of the impact More generally, there needs to be further consideration
of targets of management decisions on workloads of nurs- of the workload pressures that are faced by nursing staff in
ing staff was made. Likewise, the NMC response to the their daily work and how targets impact on these work-
Francis Report (NMC 2013) did not focus on workload loads. Ensuring that there is a balance and that targets are
pressures or meeting targets within the workplace. The UK appropriate and do not detract from good quality care is
Government response stated that quality of care needed to essential to reduce staff sickness and to retain a highly
come before targets and finances, but then proposed further motivated workforce.
reporting requirements and targets alongside additional
training with an aim to make nurses more compassionate.
Disclosure
This has not offered solutions to the high workload pres-
sures felt by staff in trying to achieve the four-hour treat- The authors have confirmed that all authors meet the
ment targets. Health care professionals within EDs should ICMJE criteria for authorship credit (www.icmje.org/ethical_
to be able to make the most appropriate decision for their 1author.html), as follows: (1) substantial contributions to
patients, regardless of targets. This would ensure that conception and design of, or acquisition of data or analysis
patients are not moved inappropriately to meet targets and interpretation of data, (2) drafting the article or revising
which lack an empirical basis. it critically for important intellectual content and (3) final
We suggest that governments that have introduced treat- approval of the version to be published.
ment time targets (UK, Australia, New Zealand, Canada)
should pool their experiences to develop an understanding
Funding
of best practice. Moreover, wherever treatment targets are
in place, senior nurses should have the authority to breach This research was made possible as a result of an ESRC
the target whenever clinically appropriate without fear of PhD studentship (Ref: ES/F023278/1).
negative consequences to ensure accurate reporting. More
generally, to meet treatment time targets, hospital systems
Conflict of interest
should be designed in such a way to redistribute pressure
more evenly around hospital departments, to reduce pres- The authors declare no potential conflicts of interest.
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