Examining Emergency Department Communication Through a Staff-Based Participatory Research Method: Identifying Barriers and Solutions to Meaningful Change

Article Outline

• Abstract
• Introduction
  • Background and Importance
  • Goals of This Investigation
• Materials and Methods
  • Study Design
  • Setting and Selection of Participants
  • Methods of Measurement
  • Primary Data Analysis
• Results
• Limitations
• Discussion
• References
• Copyright

Study objective

We test an initiative with the staff-based participatory research (SBPR) method to elicit communication barriers and engage staff in identifying strategies to improve communication within our emergency department (ED).

Methods

ED staff at an urban hospital with 85,000 ED visits per year participated in a 3.5-hour multidisciplinary workshop. The workshop was offered 6 times and involved: (1) large group discussion to review the importance of communication within the ED and discuss findings from a recent survey of patient perceptions of ED-team communication; (2) small group discussions eliciting staff perceptions of communication barriers and best practices/strategies to address these challenges; and (3) large group discussions sharing and refining emergent themes and suggested strategies. Three coders analyzed summaries from group discussions by using latent content and constant comparative analysis to identify focal themes.

Results

A total of 127 staff members, including attending physicians, residents, nurses, ED assistants, and secretaries, participated in the workshop (overall participation rate 59.6%; range 46.7% to 73.3% by staff type). Coders identified a framework of 4 themes describing barriers and proposed interventions: (1) greeting and initial interaction, (2) setting realistic expectations, (3) team communication and respect, and (4) information provision and delivery. The majority of participants (81.4%) reported that their participation would cause them to make changes in their clinical practice.

Conclusion

Involving staff in discussing barriers and facilitators to communication within the ED can result in a meaningful process of empowerment, as well as the identification of feasible strategies and solutions at both the individual and system levels.

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Introduction 

Background and Importance 

Communication failure has been cited by The Joint Commission as the most common reason for sentinel patient safety events that result in medical error.¹ The high-stakes, fast-paced nature of the emergency department (ED) environment poses significant challenges to effective communication. ED staff attempt to focus on rapid recognition and response to imminent life threats while also meeting other important patient needs, such as compassion, comfort, and provision of detailed information. Additional stresses, such as crowding, interruptions, and shift changes, may further complicate relationships and communication between the patient and the ED health care team.², ³

No one “silver bullet” can address patient safety and fix the multitude of communication challenges faced by ED staff.⁴ Existing research provides insight into patient satisfaction,⁵, ⁶, ⁷, ⁸, ⁹, ¹⁰, ¹¹ patient knowledge of or adherence to discharge instructions,¹², ¹³, ¹⁴, ¹⁵ and efforts to explore how communication practices may affect patient care and safety in the ED setting.², ⁶, ¹⁶, ¹⁷, ¹⁸, ¹⁹ However, such studies often fail to embrace the “team” approach of the ED environment by focusing on only one group of individuals (eg, physicians or patients),², ⁵, ⁸, ¹², ¹⁹ with some notable exceptions.³, ⁶, ²⁰

At our institution, physician and nursing leadership previously implemented the Team version of the Communication Assessment Tool to measure patient perceptions of the extent to which ED medical teams accomplished key communication tasks.⁵, ²¹ Although scores were low in comparison to encounters in outpatient settings, results indicated that patients gave the ED team the highest ratings for treating patients with respect, paying attention to the patient, and showing care and concern. Lowest ratings were given in the areas of greeting patients appropriately, encouraging patients to ask questions, showing interest in patients' ideas about their health, and involving patients in decisions as much as they wanted.⁵ Given this information from patients, we sought to create a culture of engagement and develop situational awareness among ED team members,⁴, ²² using the novel approach of staff-based participatory research (SBPR).²³, ²⁴

Goals of This Investigation 

To build on the results of our previous work identifying patient perceptions,⁵ the objective of this study was to engage and empower the ED staff by identifying their perceptions of current communication barriers and elicit their strategies to improve communication within the ED.

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Materials and Methods 

Study Design 

This qualitative study used a prospective SBPR method to identify staff perceptions arising from communication challenges informed by previous patient surveys and to develop solutions to improve communication in the ED setting. SBPR is developed from the tenets of community-based participatory research, a collaborative research approach designed to ensure and establish structures for participation by communities affected by the issue being studied.²⁵, ²⁶ In community-based participatory research, a colearning and empowerment process is promoted, facilitating the reciprocal transfer of knowledge, skills, capacity, and power among participants.²⁵, ²⁷ SBPR views the staff as the community and focuses on ensuring that varied, and sometimes divergent, voices are given the opportunity to provide knowledge and personal experience when working together to address the identified issue or challenge. SBPR has been used successfully to address ED crowding issues.²³, ²⁴ All study procedures were approved by the institutional review board, with a waiver of written documentation of consent. However, a recruitment letter sent to all ED staff and clinicians indicated that attendance at the voluntary workshops constituted participants' consent.

Setting and Selection of Participants 

This study was conducted from April through May 2008 at a large, urban, tertiary academic medical center with 85,000 ED visits per year. All ED nurses, ED assistants, unit secretaries, residents, and attending physicians were invited to participate in staff workshops composed of ED team members from all ranks and positions. Announcements were made at faculty, resident, and staff meetings; a recruitment letter was sent to all ED staff. At the time of the study, the ED employed 218 total staff: 105 nurses, 30 ED assistants, 15 unit secretaries, 45 residents, and 23 attending physicians. Three attending physicians and 2 nurses were members of the core study team and served as facilitators and were thus ineligible to participate. This study was supported by ED leadership; participants were compensated for their time at their normal hourly rate.

Participants attended one of 6 workshops (3.5 hours each) consisting of 3 parts. The first portion, lasting approximately 45 minutes, included introductions to discussion leaders and orientation to the goals and expectations for the workshop. A brief didactic presentation reviewed the importance of communication within the ED, highlighted previous research, and provided, as a starting point, the results of the earlier assessment of patient perceptions of communication in our ED.⁵

During the second portion, which lasted approximately 90 minutes, participants were assigned to small, mixed-provider groups for focused discussion of communication issues within the ED. The composition of the small groups ranged from 7 to 11 participants; types of providers were split as evenly as possible among groups. Each small group session included 2 facilitators, one who led the discussion and another who took extensive field notes and asked probes when needed. The lead facilitator recorded key themes on large paper posted on the walls, visible to all participants. Small group facilitators included attending physicians, nurses, and communication scholars.

This discussion used a semistructured focus group protocol that asked for feedback on the large group discussion (the first portion), participant identification of challenges and barriers to good communication within the ED, and suggestions of “communication best practices.”

During the small-group discussions, participants were asked to focus both on identifying their own perceived barriers and facilitators to communication within the ED and on discussing areas of improvement previously identified by patients.⁵ These areas included greeting patients in a way that made them feel comfortable, showing interest in patients' ideas about their health, giving patients as much information as they want, encouraging patients to ask questions, and involving patients in decisions as much as they want. Participants shared their own perceptions of communication barriers in the ED setting, ensuring that strategies proposed by participants encompassed both patient-perceived barriers and barriers identified according to the staff's own experience.

Each small group was tasked with generating a list of communication barriers identified by participants and providing consensus on proposed best practices/strategies to present to the larger group. Throughout these small-group sessions, probes were used when needed to clarify responses or engage less vocal participants. For clarity, participants were asked to identify their responses as examples of challenges/barriers or solutions/strategies. As the small group progressed, the lead facilitator encouraged participants to summarize the emergent ideas; this summary was also written on large paper visible to all participants.

The third portion, lasting approximately 45 minutes, brought all participants back together into a large group, in which each of the smaller groups reported on their session, including their identification of communication barriers and proposals for strategies or solutions. Similarities and differences of barriers identified in each of the small groups were explored, and the large group as a whole discussed and refined proposed strategies or solutions by eliciting input from participants from all ranks and positions. At the end of each workshop, participants completed a brief survey.

Methods of Measurement 

After completion of each workshop, both the detailed field notes and the large paper from each small group discussion were collected and transcribed and returned to the original note takers and facilitators to ensure accuracy. No personal identification was included in any of the data. These transcriptions, which included both the field notes and electronic versions of the large paper summaries, were collated and distributed to 3 independent coders (K.A.C., K.G.E., D.M.M.).

The participant survey, collected at the end of each workshop, included demographic data and 7 items to evaluate the workshop. These items were presented on a Likert scale (1=strongly disagree, 5=strongly agree) and assessed both the format of the workshop (eg, “I felt comfortable participating in the large group sessions”) and participants' perception of their experience (eg, “The workshop was meaningful and relevant to my clinical practice in the ED”). Participants also provided open-ended responses to 2 items: “Please comment on any aspect of your experience today that you found particularly meaningful or helpful” and “Please comment on any aspect of your experience today that you found challenging or frustrating.”

Primary Data Analysis 

To emerge with tangible outcomes from this SBPR process, we coded the discussions from the workgroup sessions. Hence, 3 authors (a communication scholar, an attending physician, and a resident) used the inductive approach of latent content and constant comparative analysis on the detailed field notes to organize the content into operational categories.²⁸ Multiple coders are often used in the development of such categorical systems to control for the subjective bias each coder brings to the analytic process.²⁹, ³⁰, ³¹ The 3 coders independently reviewed the field notes of all small-group sessions multiple times to familiarize themselves with the data, initially identifying individual focal and then overarching themes that emerged from participant responses. Reviews were done with paper and pen highlighting. The coders then convened to compare and compile findings and create a preliminary list of categories and major themes. They met repeatedly to discuss the identified themes, alternating group meetings with independent review of the field notes, until consensus was obtained and all coders believed that saturation of themes had been reached; specifically, that the overarching categorical system derived from the data described all challenges/barriers and related solutions/strategies identified by participants. The coders then returned to the data independently to assess the exhaustiveness and adequacy of the created system. Any discrepancies were resolved through discussion. There were no cases in which the coders were unable to reach consensus. These identified themes were brought to the research group as a whole, which included nurses, residents, attending physicians, and social scientists, for final presentation and discussion. Descriptive statistics were used to analyze participant surveys.

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Results 

A total of 127 of the total 213 eligible staff members, including attending physicians (13/20), residents (23/45), nurses (66/103), ED assistants (14/30), and unit secretaries (11/15), participated in 6 workshop sessions, for an overall participation rate of 59.6% (range 46.7% to 73.3% by staff type; ED assistants were least likely to participate). Participant characteristics are reported in Table 1.

Table 1. Participant characteristics.

Characteristic	Results, No. (%)
Current role (% within each specialty)⁎
Attending	13(10.2)
ED assistants	14(11.0)
RN	66(52.0)
Resident	23(18.1)
Unit secretary	11(8.7)
Years in position, n (% within in each category)†
<1	12(11.8)
1–5	50(49.0)
6–10	22(21.6)
11–15	7(6.9)
≥16	11(10.8)
Female†	68(66.7)
Race/ethnicity†
Black	11(10.8)
Asian/Pacific Islander	9(8.8)
White	71(69.6)
Hispanic/Latino	10(9.8)
Other	2(2.0)
Age, y†
18–29	32(31.4)
30–39	40(39.2)
40–49	15(14.7)
50–59	11(10.8)
≥60	4(3.9)

Coders identified a framework of 4 core themes describing both identified barriers/challenges to communication and solutions/strategies participants proposed. The themes included (1) greeting and initial interaction, (2) setting realistic expectations, (3) team communication and respect, and (4) information provision and delivery. Within this framework, coders further identified 2 broad categories to describe the proposed solutions and strategies: individual behavioral interventions and system-based interventions. Individual behavioral interventions are defined as those actions or behaviors a staff member personally may incorporate into practice to improve communication with patients, families, and other ED staff. System-based interventions describe operational changes or strategies that occur on a department level that may facilitate communication among individuals within the ED (eg, provider-patient or provider-provider).

The 4 identified themes represent those areas participants identified as vital to improving communication with patients, families, and other ED staff. Descriptions of each theme are provided, along with examples of related communication challenges and barriers pertinent to each theme, as well as selected examples of individual behavioral and system-based interventions relevant to each theme. A summary of selected individual behavioral and system-based interventions proposed by participants and categorized by emergent themes is provided in Table 2.

Table 2. Identified individual behavioral and system-level interventions by theme.

PCP, Primary care provider.

Greeting and initial interaction emphasizes the staff's perception of the critical role of the patient's (and family's) first impressions on the resulting communication process. The nature and quality of initial interactions with the ED team establish a foundation for the patient's entire visit and are acknowledged by staff as vitally important for facilitating effective communication with patients and families. The sheer number of ED team members and their varied roles (nurse, resident, attending, etc) were identified as challenges to the greeting process, particularly in an academic setting. Participants also cited wait times in triage as an important factor influencing patients' perceptions of the greeting process. Staff believed that most patients do not understand the concept of triage and the reasons for their wait and therefore have increased frustration during their initial interaction in the ED. Participants identified individual behavior interventions to address these issues, including repeating introductions at each new interaction and reinforcing names and titles of other clinicians to help patients understand the composition and coordinated efforts of their ED team. A related system-based intervention involved the development of a sign to be posted in the waiting room to acknowledge patient wait times, as well as to explain the triage process.

Setting realistic expectations was identified as a second theme reflecting the significant focus on this aspect of the communication process in our discussion groups. Staff noted frequent unrealistic patient expectations, such as patients' belief that they would be seen immediately because their primary care provider had “called ahead.” Efforts to help patients and family members set realistic expectations for all aspects of their visit were recognized as a crucial aspect of the communication process. An example of a system-based intervention proposed for this category is: “Display posters in patient rooms with approximate times for tests to be performed.” An associated individual behavioral intervention was for ED staff to monitor their use of everyday phrases such as “someone will be in to see you in a few minutes” because such a colloquialism may give patients and their families unrealistic expectations.

The third theme, team communication and respect, addresses the close link between team communication and patient-provider communication. Effective communication and positive interactions between ED team members were recognized as having an important influence on the overall communication process with patients, patients' families, and other ED staff. Conversely, negative interactions caused by a failure to acknowledge, inform, or support team members were identified as potential barriers to effective team communication. Participants observed that frequent turnover of ED staff, both because of staff assignment changes and daily shift changes, was perceived as an impediment to team communication. Moreover, it was recognized that the high volume of patients, rapid decisionmaking, and complex patient care plans in the ED serve to hinder and delay communication between team members. A means of asynchronous communication between providers by using checklists was proposed as a system-based intervention to facilitate team communication. This intervention facilitates information exchange around a patient's care plan and, in turn, supports individual behavioral interventions focused on efforts to respect all ED colleagues and their roles on the team and to acknowledge other ED staff who assist.

The final theme identified by our discussion groups was information provision and delivery. This topic incorporates the overall approach to how information is delivered to patients and emphasizes the importance of content, as well as timing and nonverbal cues. The primary challenge addressed was the fact that patients and families are often provided with substantial amounts of complex information during their ED visit. Additional barriers to the communication process were identified as the loud and chaotic environment of the ED, patients' physical symptoms and anxiety, and significant time constraints that most often limit patients to brief interactions with their providers during an ED visit. Participants suggested as an individual behavioral intervention that, whenever possible, the timing of information delivery to patients be delayed to avoid its coinciding with other events that may be drawing the patient's attention (eg, intravenous line insertion, ECG). Related system-based interventions for this category were aimed at ensuring that critical information is thoroughly reviewed with patients at discharge (“Redefine staff roles to incorporate a position of discharge RN or discharge planner”) and that patients have an information resource to help address any questions that may arise once they go home (“provide diagnosis-specific discharge sheet, available in multiple languages”).

As implied by the numerous themes identified in these multidisciplinary group sessions, the staff were engaged throughout the workshop and provided a great deal of insight about their own perceptions of communication challenges and ideas for addressing those challenges. We received very positive feedback from our study participants about the format and content of the workshop sessions, with an 80.3% survey response rate. The majority of respondents indicated that they were comfortable participating in both the small (89.2%) and large (80.4%) group discussion sessions. A considerable majority also indicated they had gained ideas and new ways of thinking about clinical practice in the ED (81.4%) and that their experience would cause them to make changes in their clinical practice (81.4%). The survey asked for respondents to provide open-ended comments about any aspects of the experience that they found particularly “meaningful or helpful” and “challenging or frustrating.” A resounding theme in these comments included favorable responses to the multidisciplinary aspect of these groups: multiple individuals indicated that they thought the group discussions were informative, occurred in a “nonstressful environment,” and that “everyone had an equal voice.” Participants indicated that they enjoyed the opportunity to talk and share ideas with colleagues from provider groups outside of the ED setting. Participants were excited about thinking of ways to work better as a team in improving interactions with each other and patients. Challenges and frustrations cited by participants included concerns about disparate levels of involvement from different members of the small group and uncertainty about administrative support for ideas and changes.

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Limitations 

The specific interventions proposed by staff in this study may be limited in their external validity. We view this limitation as acceptable because different EDs are likely to vary significantly in their organization and operation and also have unique communication and organizational norms. Administration of the Communication Assessment Tool–Team followed by an SBPR process as outlined here could be of benefit to other EDs to generate ideas and strategies that are department specific.²³ A second limitation relates to workshop participation being voluntary and thus susceptible to selection bias. Our lowest participation rate was among ED assistants, which may have been because our department employs numerous part-time ED assistants whose schedules make participation more difficult. We attempted to minimize this issue by compensating all participants at their hourly rate and by scheduling workshops at times convenient for ED shift times. Workshops were held half an hour after shift change for all shifts. Participants included individuals from all provider/administrative groups within the ED, allowing us to obtain feedback about all positions and types of interactions within the ED (eg, attending physician to nurse, unit secretary to nurse). The format of these mixed-provider groups may raise the question of whether power differentials may have influenced the discussions. Of the open-ended responses received, none indicated such concerns, and the majority of participants indicated that they were comfortable participating in the mixed-provider groups. A final limitation observed by some of our participants is that we did not include ancillary staff such as security guards and ambulance crews. The perceptions of these individuals could enhance proposed system-based interventions, particularly those related to patient and work flow.

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Discussion 

Because health care in the ED is delivered by integrated teams, high fidelity and robust communication are essential. In addition to attending to known patient perceptions of communication weaknesses, it is critical to identify the staff's perception of ED communication barriers and facilitators. We believe that an effective way to address these challenges is to involve the team charged with delivering ED care; hence, we involved this multidisciplinary team in proposing and refining solutions to identified and perceived communication barriers. The value of using an SBPR approach allows us to draw on this wealth of experience of the staff and engage them in the process, which empowers the staff to effect change and ensures that the people most affected by the proposed interventions endorse them.²³, ²⁴, ²⁵, ²⁷

As has been observed in other contexts, there is often a lack of intersection between physician and patient viewpoints.³² Using previous research related to patient perceptions of communication within our ED,⁵ we broadened our understanding of communication challenges by providing a venue for discussion among multidisciplinary groups of ED staff. This process allowed staff to work together to shape identified strategies to increase their likelihood of success. This process shares some similarity with the tenets of action research, which has been used in studies to describe both the ideal and the real narrative about challenges faced by an individual ED, giving voice to staff who may not always be heard.³ The SBPR process allows for similar feedback from the staff, a valuable component when striving for improvement. As evidenced both by the wealth of challenges and proposed solutions identified, as well as by overwhelmingly positive responses to the sessions and participants' intentions to make individual changes in their clinical practice according to their experiences, such involvement of staff can result in a meaningful process of colearning and empowerment, leading to the identification of feasible strategies and solutions at both the individual and system levels.

The process of coding individual and overarching themes, and related proposed individual and system interventions, allowed us to present tangible outcomes of the workshops to staff and ED and hospital administration. Table 2 also identifies system changes already made within our ED, as well as other changes currently in process. The 4 overarching themes that emerged from the coding of the field notes from the multidisciplinary groups augment results of previous studies. In particular, a great deal of literature related to communication in health care settings, both provider-patient and team communication, has focused on contexts other than the ED.³³, ³⁴, ³⁵ Studies have shown the importance of greetings and initial interactions, with a majority of patients reporting they would like physicians to shake their hand, introduce themselves, and greet them.³⁶ Although the ED is a different environment, the importance of greeting patients in the ED has been identified by patients themselves⁵, ¹⁴ and, in our study, by ED staff. Studies such as ours, when added to the current body of research, show the power of engaging staff in both describing and addressing existing challenges. For example, by implementing strategies that set more realistic patient expectations, a need we heard repeatedly from our participants, we can begin to address the common issue of violation of such expectations in the ED setting.³, ³⁷ Future research will allow us to link patient and staff perceptions and explore effects on outcomes such as patient satisfaction and adherence.

The ED team works in a fast-paced, intense environment that calls for quick action and offers little time for extensive discussions. Cognizant of these constraints, participants acknowledged the importance of recognizing and respecting each other's efforts and roles in taking care of the patient. Aspects of teamwork include ensuring that critical information is not lost during handoffs³⁸ and recognizing and respecting the value of all team members in caring for the patient.³⁹ Numerous studies have observed the frequency and negative consequences of interruptions within ED settings.¹⁷, ¹⁸, ³⁸, ⁴⁰ A specific example identified in our study was a seemingly common occurrence of an attending physician entering a room and initiating a conversation with a patient (eg, about test results or discharge instructions) while an ED assistant or nurse was in the midst of administering medications. In such an instance, by default, we are essentially forcing the patient to multitask and may also be contributing to communication multitasking by ED staff. Communication multitasking occurs approximately 15% of the time both in ED and hospital inpatient settings⁴¹, ⁴² and has the potential to incur threats to patient safety.⁴³, ⁴⁴

Although many proposed interventions may be institution specific, this categorization provides an overview of staff-derived suggested improvements to the communication lacuna between providers and patients in the ED. Other institutions can use a SBPR process to identify relevant challenges, as well as strategies and solutions.

In conclusion, the SBPR process, accompanied by qualitative analysis of the findings, demonstrates a commitment to and respect for perceptions of ED staff, who are themselves at the front lines of these daily communication exchanges between patients, families, and other ED staff of all ranks and positions. Commitment to implement some of these proposed strategies by individual ED staff and administration may affect patient satisfaction, outcomes, and adherence to discharge instructions.

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References 

1. In:  Smith IJ editors. The Joint Commission Guide to Improving Staff Communication. Oakbrook Terrace, IL: Joint Commission Resources; 2005;
   • View In Article
2. Chisholm CD, Collison EK, Nelson DR, et al. Emergency department workplace interruptions: are emergency physicians “interrupt-driven” and “multitasking”?. Acad Emerg Med. 2000;7:1239–1243
   • View In Article
   • MEDLINE
   • CrossRef
3. Eisenberg EM, Baglia J, Pynes JE. Transforming emergency medicine through narrative: qualitative action research at a community hospital. Health Commun. 2006;19:197–208
   • View In Article
   • MEDLINE
   • CrossRef
4. Nemeth CP, Wears RL. A healthcare team communication research agenda. In:  Nemeth CP editors. Improving Healthcare Team Communication: Building on Lessons From Aviation and Aerospace. Hampshire, England: Ashgate; 2008;p. 245–250
   • View In Article
5. Mercer LM, Tanabe P, Pang PS, et al. Patient perspectives on communication with the medical team: pilot study using the Communication Assessment Tool-Team (CAT-T). Patient Educ Couns. 2008;73:220–223
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (129 KB)
   • CrossRef
6. Mayer TA, Cates RJ, Mastorovich MJ, et al. Emergency department patient satisfaction: customer service training improves patient satisfaction and ratings of physician and nurse skill. J Healthc Manag. 1998;43:427–470
   • View In Article
   • MEDLINE
7. Boudreaux ED, Cruz BL, Baumann BM. The use of performance improvement methods to enhance emergency department patient satisfaction in the United States: a critical review of the literature and suggestions for future research. Acad Emerg Med. 2006;13:795–802
   • View In Article
   • CrossRef
8. Lau FL. Can communication skills workshops for emergency department doctors improve patient satisfaction?. J Accid Emerg Med. 2000;17:251–253
   • View In Article
   • MEDLINE
9. Sun BC, Adams J, Orav EJ, et al. Determinants of patient satisfaction and willingness to return with emergency care. Ann Emerg Med. 2000;35:426–434
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (841 KB)
   • CrossRef
10. Thompson DA, Yarnold PR, Williams DR, et al. Effects of actual waiting time, perceived waiting time, information delivery, and expressive quality on patient satisfaction in the emergency department. Ann Emerg Med. 1996;28:657–665
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (884 KB)
    • CrossRef
11. Trout A, Magnusson AR, Hedges JR. Patient satisfaction investigations and the emergency department: what does the literature say?. Acad Emerg Med. 2000;7:695–709
    • View In Article
    • MEDLINE
    • CrossRef
12. Engel KG, Heisler M, Smith DM, et al. Patient comprehension of emergency department care and instructions: are patients aware of when they do not understand. Ann Emerg Med. 2009;53:454–461
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (661 KB)
    • CrossRef
13. Logan PD, Schwab RA, Salomone JA, et al. Patient understanding of emergency department discharge instructions. South Med J. 1996;89:770–774
    • View In Article
    • MEDLINE
    • CrossRef
14. Spandorfer JM, Karras DJ, Hughes LA, et al. Comprehension of discharge instructions by patients in an urban emergency department. Ann Emerg Med. 1995;25:71–74
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (371 KB)
    • CrossRef
15. Crane JA. Patient comprehension of doctor-patient communication on discharge from the emergency department. J Emerg Med. 1997;15:1–7
    • View In Article
    • Abstract
    • Full-Text PDF (760 KB)
    • CrossRef
16. Nemeth CP, Cook RI, Wears RL. Studying the technical work of emergency care. Ann Emerg Med. 2007;50:384–386
    • View In Article
    • Full Text
    • Full-Text PDF (67 KB)
    • CrossRef
17. Chisholm CD, Dornfeld AM, Nelson DR, et al. Work interrupted: a comparison of workplace interruptions in emergency departments and primary care offices. Ann Emerg Med. 2001;38:146–151
    • View In Article
    • Abstract
    • Full Text
    • CrossRef
18. Coiera EW, Jayasuriya RA, Hardy J, et al. Communication loads on clinical staff in the emergency department. Med J Aust. 2002;176:415–418
    • View In Article
19. Apker J, Mallak LA, Applegate EB, et al. Exploring emergency physician-hospitalist handoff interactions: development of the Handoff Communication Assessment. Ann Emerg Med. 2010;55:161–170
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (258 KB)
    • CrossRef
20. Eisenberg EM, Murphy AG, Sutcliffe K, et al. Communication in emergency medicine: implications for patient safety. Commun Monogr. 2005;72:390–413
    • View In Article
21. Makoul G, Krupat E, Chang CH. Measuring patient views of physician communication skills: development and testing of the Communication Assessment Tool. Patient Educ Couns. 2007;67:333–342
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (934 KB)
    • CrossRef
22. Eisenberg EM. The social construction of healthcare teams. In:  Nemeth CP editors. Improving Healthcare Team Communication: Building on Lessons From Aviation and Aerospace. Hampshire, England: Ashgate; 2008;p. 9–20
    • View In Article
23. Tanabe P, Gisondi MA, Medendorp S, et al. Should you close your waiting room? (addressing ED overcrowding through education and staff-based participatory research). J Emerg Nurs. 2008;34:285–289
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (133 KB)
    • CrossRef
24. Tanabe P, Gisondi M, Barnard C, et al. Can education and staff-based participatory research change nursing practice in an era of ED overcrowding? (a focus group study). J Emerg Nurs. 2009;35:290–298
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (747 KB)
    • CrossRef
25. Israel B, Eng E, Schulz A, et al. Methods in Community-Based Participatory Research for Health. San Francisco, CA: Jossey-Bass; 2005;
    • View In Article
26. O'Toole TP, Aaron KF, Chin MH, et al. Community-based participatory research: opportunities, challenges, and the need for a common language. J Gen Intern Med. 2003;18:592–594
    • View In Article
    • MEDLINE
    • CrossRef
27. Israel BA, Schulz AJ, Parker EA, et al. Review of community-based research: assessing partnership approaches to improve public health. Annu Rev Public Health. 1998;19:173–202
    • View In Article
    • MEDLINE
    • CrossRef
28. Neuendorf KA. The Content Analysis Guidebook. Thousand Oaks, CA: Sage; 2002;
    • View In Article
29. Lincoln YS, Guba EG. Naturalistic Inquiry. Beverley Hills, CA: Sage; 1985;
    • View In Article
30. Cameron KA, Rintamaki LS, Kamanda-Kosseh M, et al. Using theoretical constructs to identify key issues for targeted message design: African American seniors' perceptions about influenza and influenza vaccination. Health Commun. 2009;24:316–326
    • View In Article
    • CrossRef
31. Brashers DE, Neidig JL, Haas SM, et al. Communication in the management of uncertainty: the casse of persons living with HIV or AIDS. Commun Monogr. 2000;67:63–84
    • View In Article
32. Haidet P, O'Malley KJ, Sharf BF, et al. Characterizing explanatory models of illness in healthcare: development and validation of the CONNECT instrument. Patient Educ Couns. 2008;73:232–239
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (640 KB)
    • CrossRef
33. Street RL, Gordon HS. The clinical context and patient participation in post-diagnostic consultations. Patient Educ Couns. 2006;64:217–224
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (124 KB)
    • CrossRef
34. Street RL, Gordon HS, Ward MM, et al. Patient participation in medical consultations: why some patients are more involved than others. Med Care. 2005;43:960–969
    • View In Article
    • MEDLINE
    • CrossRef
35. Cegala DJ, McClure L, Marinelli TM, et al. The effects of communication skills training on patients' participation during medical interviews. Patient Educ Couns. 2000;41:209–222
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (101 KB)
    • CrossRef
36. Makoul G, Zick A, Green M. An evidence-based perspective on greetings in medical encounters. Arch Intern Med. 2007;167:1172–1176
    • View In Article
    • MEDLINE
    • CrossRef
37. Toma G, Triner W, McNutt LA. Patient satisfaction as a function of emergency department previsit expectations. Ann Emerg Med. 2009;54:360–367e6
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (1126 KB)
    • CrossRef
38. Magid DJ, Sullivan AF, Cleary PD, et al. The safety of emergency care systems: results of a survey of clinicians in 65 US emergency departments. Ann Emerg Med. 2009;53:715–723e1
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (368 KB)
    • CrossRef
39. Freeth D, Ayida G, Berridge EJ, et al. Multidisciplinary obstetric simulated emergency scenarios (MOSES): promoting patient safety in obstetrics with teamwork-focused interprofessional simulations. J Contin Educ Health Prof. 2009;29:98–104
    • View In Article
    • CrossRef
40. Fairbanks RJ, Bisantz AM, Sunm M. Emergency department communication links and patterns. Ann Emerg Med. 2007;50:396–406
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (649 KB)
    • CrossRef
41. Woloshynowych M, Davis R, Brown R, et al. Communication patterns in a UK emergency department. Ann Emerg Med. 2007;50:407–413
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (105 KB)
    • CrossRef
42. Edwards A, Fitzpatrick LA, Augustine S, et al. Synchronous communication facilitates interruptive workflow for attending physicians and nurses in clinical settings. Int J Med Inform. 2009;78:629–637
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (1372 KB)
    • CrossRef
43. Weigl M, Muller A, Zupanc A, et al. Participant observation of time allocation, direct patient contact and simultaneous activities in hospital physicians. BMC Health Serv Res. 2009;9:110
    • View In Article
    • CrossRef
44. Parker J, Coiera E. Improving clinical communication: a view from psychology. J Am Med Inform Assoc. 2000;7:453–461
    • View In Article
    • MEDLINE
    • CrossRef