title: Patient Experiences in the Emergency Department: A Multi-Methods Study
Creators: name: Bull, Claudia F
Publisher: name: Griffith University
Year: 2022
Subjects: subject: Emergency Department
subject: Patient Experiences
subject: Australian public hospital

description: Introduction: Measuring and evaluating patient experiences of care is critical to improving the delivery of high quality, safe, value-based healthcare; monitoring service and system performance; and enacting person-centred care. However, few psychometrically robust and parsimonious patient-reported experience measures (PREMs) are available for use in hospital Emergency Departments (EDs), and none are specifically designed for the Australian healthcare context. The overarching aim of this research was to develop and psychometrically evaluate a new ED PREM that can be used across Australian public hospital EDs. Methods: This research used a three-phase, sequential multi-methods design where each phase informed the next. Phase one involved undertaking two systematic literature reviews. The first review sought to identify, describe and critically appraise the psychometric properties of published PREMs. The second review sought to identify and describe adult ED patient experiences from the patient perspective, as described in published studies. Phase one also involved semi-structured telephone interviews with adult patients purposively recruited across two southeast Queensland public hospital EDs. Phase two comprised the development of items for the ED PREM and established its content validity from the patient perspective using a two-round online reactive Delphi method. Phase three involved psychometrically evaluating the new ED PREM in a sample of adult patients recruited from one southeast Queensland public hospital ED. Multi-modal ED PREM administration was used, where recruited patients could choose to complete the ED PREM online, via telephone or post. The structural validity, internal consistency reliability and discriminant validity of the ED PREM was then assessed. Results: In phase one, the first review included 109 studies describing 88 published PREMs of variable validity and reliability. The most frequently reported validity and reliability statistics included internal consistency reliability (65.2%), structural validity (55.1%) and content validity (38.2%). The second review included 54 published studies highlighting inter-related themes of adult ED patient experience: (i) Relationships between ED patients and care providers and (ii) Spending time in the ED environment. These findings were supported by semi-structured interviews with 30 adult ED patients. Four themes were inductively identified and included: (i) Caring relationships between patients and ED care providers; (ii) Being in the ED environment; (iii) Variations in waiting for care and (iv) Having a companion in the ED. Collectively, the phase one findings informed the development of a conceptual model of patient experience in the ED and subsequent ED PREM item development. In phase two, 37 items were developed and assessed for clarity, relevance and importance using a Content Validity Index by 15 patient participants (83.3%). After round one of the Delphi process, 22 items were retained for the final ED PREM, two items were dropped and 13 items were revised and included in round two. In the second round, a total of 35 items reached consensus for clarity, relevance and importance, and were retained for the final ED PREM. In phase three, the 35 item ED PREM was psychometrically evaluated using the responses of 349 (68.4%) adult ED patients. All items indicated ceiling effects ranging between 34.4-79.7%. Exploratory factor analysis revealed a four-factor solution, comprising 26 items that explained 55% of the model variance. Factors included: (i) Person-centred relationships between patients and ED care providers; (ii) Receiving timely ED care; (iii) Patient engagement in ED care and (iv) Privacy and comfort in the ED environment. Internal consistency reliability (Cronbach’s α) for all factors ranged between 0.84-0.97. Using the known-groups technique, the ED PREM demonstrated good discriminant validity in its ability to differentiate ED experiences based on gender, age and self-reported ED length of stay. Conclusions: This research contributes to new knowledge through the development of a conceptual model of patient experience in the ED, published guidance for establishing PREM content validity and the development of a new ED PREM. With further psychometric testing, the ED PREM could be used to capture adult patient experiences across Australian public hospital EDs. These findings have important research, clinical practice and policy implications for building capacity in service and system-level performance measurement, benchmarking and quality improvement.