“We are left with nothing to work with”; challenges of nurses working in the emergency unit at a secondary referral hospital: A descriptive qualitative study

Introduction In recent times, there has been an increasing burden in traumatic, medical, and surgical emergency conditions, placing more emphasis on the need for quality emergency care. This study aimed to explore the challenges experienced by nurses working in the emergency unit of a secondary referral hospital. Methods The study used an exploratory qualitative research design with a constructivist approach and a grounded theory method. Data were collected through in-depth interviews lasting between 30 to 45 minutes using a semi-structured interview guide. Inductive content analysis was used to analyse data. Results Eleven (11) participants were interviewed. The majority were female (9), aged between 31–40 years. From the inductive content analysis, four themes emerged. These were; 1) overcrowding in the emergency unit, 2) understaffing at the emergency unit, 3) lack of emergency equipment, 4) inadequate managerial support. Conclusion The study identified several major challenges confronting nurses working in the emergency unit which are linked with managerial processes and inadequate managerial support. These challenges need to be addressed to promote quality emergency nursing care. To foster a positive working environment, hospital management should validate and address the aforementioned concerns of the Emergency Department nurses.


Introduction
In recent times, there has been an increasing burden in traumatic, medical, and surgical emergency conditions, placing more emphasis on the need for quality emergency care. This study aimed to explore the challenges experienced by nurses working in the emergency unit of a secondary referral hospital.

Methods
The study used an exploratory qualitative research design with a constructivist approach and a grounded theory method. Data were collected through semi-structured in-depth interviews lasting between 30 to 45 minutes using an interview guide. Inductive content analysis was used to analyse data because there were no preempted themes that were used to guide the study.

Results
Eleven (11) participants were interviewed and the majority were female (9), aged between 31-40 years. From the inductive content analysis, four themes emerged from the data and were; 1) overcrowding in the emergency unit, 2) understaffing at the emergency unit, 3) lack of emergency equipment, 4) Inadequate managerial support

Conclusion
The study identified several major challenges confronting nurses working in the emergency which are linked with managerial processes and inadequate managerial support. These challenges need to be addressed to promote quality emergency nursing care delivery. It is important for the government, and hospital management to invest attention and resources into emergency departments to reduce the situation of lack of resources for the emergency team to work with. Management that validates the expressions of concern from ED nurses will foster a positive working environment.   Permission was sought from the hospital management and unit manager before the commencement of data collection. Participants were informed about the purpose of the study and those that consented to participate in the study were included. Participants were informed about their right to withdraw from the study at any particular point in time. Confidentiality, privacy, and anonymity were assured. Random codes were given to participants to maintain anonymity.

Introduction
Emergency care is an important component of every health system. In recent times, there has been an increasing burden in traumatic, medical, and surgical emergency conditions across the globe, placing more emphasis on the need for quality emergency care [1]. The World Health Organization (WHO) identified sub-Saharan Africa (SSA) with 1.3% of the world's health care workers and 25% of the global disease burden [2]. Unfortunately, this burden of emergency care is high in lowresource countries compared with the developed world, with developing countries having deficiencies in organisational planning, shortage of trained healthcare personnel and resources to treat emergency conditions [1,3,4,5]. It is estimated that more than 90% of injury-related deaths occur in low-resource countries [6] where the burden of injury in SSA represents a major public health threat and highlights the need for skilled health care personnel in the emergency departments to help avert preventable deaths.
Emergency care is important for the immediate management and stabilisation of critically ill patients. Although long overlooked as an essential component of healthcare in SSA, emergency health services are now growing across many countries. Emergency nursing is a specialty within professional nursing whereby the nurse provides care for patients requiring immediate medical attention to avoid long-term disability or death [2]. The emergency nurse plays a critical role in the identification and management of patients with life-threatening conditions, prioritizes emergency care through triaging, performs resuscitation with appropriate management within a supportive health care setting [2,7]. The emergency nurse also provides information and emotional support to families or relatives of the ill person [7]. 4 Due to the shortage of nursing staff, limited specialty training, overwhelming patient volumes, and high stressful working environments, the emergency nursing role especially in Africa is particularly challenging [8,9].
In the provision of quality health care across Africa, nurses play a central role. Therefore, it is imperative to increase the skilled nursing workforce and provide specialty emergency nursing training across the sub-region. In response to these, the international community has made efforts in low and middle-income countries to develop capacity and quality improvement programs for emergency care [1,10] and Ghana is not an exception. Most recent studies have called for increased attention to trauma and emergency care, but the health sector in Ghana currently has limited training institutions for these areas, resulting in delays in emergency care, and associated with poor clinical outcomes [7]. In 2012, Ghana started a degree programme in emergency nursing to help breach the gap of lack of specialist emergency care nurses in the country. Since the introduction of the Emergency nursing programme in Ghana, there has been an increase in the number of emergency nurses in the country, however, most emergency units in hospitals across the country continue to have inadequate or no specialist emergency care nurses. Studies conducted within some emergency centres in Ghana identified some challenges confronting nurses working in the ED [11]. It is therefore prudent to explore the challenges of ED nurses in order to provide recommendations to improve the emergency care system in Ghana. The key to responding to these challenges in emergency practice is research that produces discoveries, knowledge, and solutions that will contribute to providing safe and high-quality emergency nursing care. This study aimed to explore the challenges experienced by nurses working in the emergency unit of a secondary referral hospital.

Study design
The study used an exploratory qualitative research design with a constructivist grounded theory approach [12]. An interpretative approach [13] was employed to gain an in-depth understanding of the challenges that the nurses face during emergency care delivery. A grounded theory method was used to provide explicit, sequential guidelines for conducting this qualitative research, which offered specific strategies for handling the analytic phase of inquiry, streamlined and integrated data collection, and analysis with an advanced conceptual analysis of data [12]. In undertaking a constructivist survey the researchers adopted a position of mutuality where there was a relationship with participants that enables a mutual construction of meaning during interviews and a meaningful reconstruction of their stories into a grounded theory model [12,14].

Study setting and population
This research was conducted at the emergency unit of a secondary referral hospital in the Ho municipality. It is one of the Ghana Health Services' (GHS) facilities situated in the heart of the Volta Regional Capital, Ho. The facility provides healthcare services to people living within the Ho Municipality and beyond. The hospital has a total bed capacity of one hundred and forty (140).
The emergency unit is a small unit attached to the outpatient department (OPD) that runs twentyfour-hour emergency care services to clients. It admits and detains patients for not more than twenty-four hours. The emergency unit had two beds. The unit also utilized a couch and five stretchers as beds.
The participants for this study were registered general nurses and clinical nurse assistants with an active professional identification number (PIN) and axillary identification number (AIN) respectively who have been working in the emergency unit for a period not less than six (6) months. 6 At the time of the study, the emergency unit had no emergency nurse specialist, there were 2 senior nursing officers, a nursing officer, a senior staff nurse, 4 staff nurses, and 4 clinical nurse assistants working in the unit. The nurses in the ED had an eight-hour shift system for day duty while the night duty went for 12 hours.

Sampling and data collection procedure
Participants for the study were selected through purposive sampling method. In qualitative research, purposeful sampling is a technique that is widely used for the identification and selection of information-rich cases for the most effective use of limited resources [15]. This involves identifying and selecting participants that are available and willing to participate and should be able to communicate their experiences and opinions in an expressive, articulate, and reflective manner [16,17,18]. Data were collected through in-depth semi-structured interviews lasting up to 30 to 45 minutes using an interview guide. Face to face individual interviews was conducted at the emergency unit of the study hospital in a secluded office. Due to the busy nature of the unit, the authors had to arrange a convenient time with participants that were willing to participate in the study. Questions were asked about emergency care delivery and the challenges experienced during care delivery in the unit. Prompt and probing questions were used for further information and explanation following participants' responses. Each interview session was carried out by AA., and GK. During the interview sessions, the researchers ensured a conducive atmosphere where participants expressed themselves freely without interferences, and leading questions were avoided to ensure that participants' experiences remained intact. Data saturation was reached on the eleventh participant when no new information was obtained. All interviews were recorded by a digital sound recorder and transcribed verbatim by GKK, DANZ, DKT, and SA. During interviews some field notes were taken about the atmosphere, and some personal observations were made 7 afterward about the ward environment. All audio files and transcripts were stored anonymously in a secured protected digital storage system.

Data analysis
The study employed qualitative content analysis to analyse data as described by Padgett [19]. The appropriate form of analysis was inductive content analysis because there were no pre-empted themes to guide the study. The researchers read and reread the transcripts several times to make meaning of participants' views/challenges. Transcripts were coded after reading word by word and individual sentences carefully to identify words or phrases that spelled out the meaning of the sentences. During the coding process and before the start of coding AA and GKK coded the same interviews to identify and discuss the differences in coding to check for intercoder reliability.
Similar codes were categorized to form themes and to ensure that they were representative of participants' views, the researchers met and discussed thoroughly the themes and agreed on the themes after several deliberations.

Trustworthiness
To ensure the trustworthiness, the researchers applied the principles of credibility, dependability, confirmability, and transferability [20]. Member checks were done at the end of each interview to ensure participants' views were well presented ensuring credibility. The researchers provided a detailed description of the study setting, methodology (COREQ criteria were used) [21], and background of the study sample to allow for the transferability of the findings in a similar context and setting. To ensure confirmability, an audit trail was kept for other researchers to validate the processes undertaken in the study. Dependability of findings was tested by re-reading the data to determine the depth of evidence available for each of the final themes and subthemes analysed by the research team. 8

Ethical consideration
Ethics approval to conduct this study was obtained from the University of Health and Allied Sciences Research Ethics Committee (UHAS-REC A.9 [5] 18-19) Ho, Ghana. Permission was sought from the hospital management and unit manager before the commencement of data collection. Participants were informed about the purpose of the study and those that consented to participate in the study were included. Participants were informed about their right to withdraw from the study at any particular point in time. Confidentiality, privacy, and anonymity were assured. Random codes were given to participants to maintain anonymity.

Socio-Demographic Characteristics of Participants
A total of eleven (11) participants were interviewed including 8 registered general nurses and 3 clinical nurse assistants. The majority of the participants were women (9) and aged between 31-40 years. Most of the participants (7) had more than 3 years of working experience in the emergency unit (table 1). From the inductive content analysis, four themes emerged from the data which were; 1) overcrowding in the emergency unit, 2) understaffing at the emergency unit, 3) lack of emergency equipment, 4) inadequate managerial support.

Theme 1; Overcrowding in the emergency unit
Overcrowding in the emergency unit was a great concern for participants. Participants expressed that inadequate space in the unit hinders quality nursing care delivery. Participants described the emergency unit as a 'chamber' meaning it is too small to be used as an emergency ward. Some participants also described the ward as very hot due to poor ventilation.

Theme 4; Inadequate Managerial Support
To deliver quality emergency care, overwhelmingly all participants pointed to the need to be supported and given the needed attention by management. The participants enunciated at length about the lack of support by management and how this contributes negatively to their ability to provide quality care for their clients. Some nurses singled out their unit head (in-charge) as being a supportive and motivating figure for them but seeing the nursing administration not to support their course. Most of the administrative issues were about the ineffectiveness of nursing administration-lack of effective listening and response to nurses' plight, lack of motivation, demotivating actions, and utterances. Lack of motivation from the hospital's general administration and lack of proactive effort by the hospital to continuously supply emergency drugs and other vital equipment for emergency care was a major challenge to quality emergency care delivery. All participants awaited management to validate their work-related concerns and find appropriate solutions to improve quality emergency care in the unit. Narratives below were the most pervasive among the participants Most participants after working in the emergency unit for many years believe that the hospital has no plans for nurses to go for further training in emergency care nursing, and to them, this will enhance their knowledge and skill in caring for emergency cases. They bemoaned that currently, the emergency unit has no trained emergency nurse specialist which is a major concern for all 15 participants. Lack of continuing professional education was seen to be endangering the future of emergency nursing practice in the hospital.
"… I'm not aware of any policy of the hospital concerning the upgrading of nurses and nurses working at the emergency unit. Sometimes colleague nurses may do presentations on conditions and whoever is asked to do this presentation, research, and come and present. This is not effective; we need specialist training in emergency care nursing…" (Participant 129)

Discussion
The findings of this study highlight various forms of challenges confronting nurses working in the emergency unit. Amid these challenges, emergency department (ED) nurses continued to deliver emergency care whiles calling for their concerns to be heard and addressed to enhance quality emergency care delivery.
Overcrowding in the emergency unit was one of the major challenges expressed by nurses working in the ED, making healthcare delivery tedious and unbearable. Nurses could not perform the full iterative circle of the nursing process due to the unconducive working environment and this affects the quality of emergency care delivery leading to poor patient outcomes. The current study finding is consistent with previous studies conducted across the globe identifying overcrowding in the emergency department as a major challenge to quality emergency care delivery [22,23,24,25,26,27,28,29]. Overcrowding in the ED may occur as a result of the shortage of nursing staff, the number of patients waiting to be seen, bed shortage, delays in treating or assessing patients already in the ED, or impediments to treated patients leaving the ED [22,28,30,31]. Therefore, if the global crisis [32] of ED crowding is to be solved, interventions designed to address the problem 16 must be tailored towards identified specific causes. We recommend that hospital management should provide a spacious ED and also increase the bed capacity to contain the in-flux of patients.
Also, the ED should further strengthen their triaging system by providing a triaging room at the ED as this will help identify acutely ill patients needing emergency care from non-critically ill patients who could be referred to the general ward. This will further prevent delays in referring and discharging of patients from the ED to ease crowding.  [11]. Our study finding is consistent with a study conducted in Ghana by Atakro et al., [22] where nurses complained of lack of material resources to work with. Another study by Hines, Fraze, and Stocks [39] also found that ED nurses were confronted with several challenges which included inadequate resources to work with due to decreased reimbursement by insurers. Participants in the current study expressed their dissatisfaction when they lack adequate resources to work with. Currently, the provision of high-quality emergency care nurses in Ghana are an underdeveloped resource and can be improved with support from the government, hospital management, and NGOs [11]. As the ED is most often the first point of call for patients, resourcing it has an implication for quality care, quick recovery and discharge, client and relative satisfaction, good hospital image, and reducing overcrowding.
In order to deliver quality emergency care, overwhelmingly all participants pointed to the need to be supported and given the needed attention by management. The participants enunciated at length about management's lack of support and how this contributes negatively on their ability to provide quality care for their clients. This finding is consistent with a study conducted in Canada by Enns and Sawatzky [33]. It was also observed in both studies that participants yearned for management to validate their work-related concerns and find appropriate solutions to improve quality emergency care in the unit.
Nurses in Ghana are trained in emergency care largely as general nurses with limited emergency care knowledge and skills. Participants in the current study have inadequate specialist training in emergency nursing. Participants cautioned that lack of professional continuing education in emergency nursing for nurses in the unit will endanger the future of emergency nursing practice in the hospital and the country as a whole. It is therefore imperative to develop career path or progression policies that reward increasing clinical competency, knowledge, education, and professional development for nurses.

Limitations
The findings of this study are limited to the participants interviewed and to their challenges experienced in the emergency unit. Nonetheless, the rich exploration of the challenges affecting emergency care provides an opportunity for stakeholders to find solutions to address these concerns raised by ED nurses to improve quality emergency care.

19
The study identified several major challenges confronting nurses working in the emergency unit such as overcrowding, understaffing, lack of resources, and limited managerial support. These challenges if not managed and resolved will endanger quality emergency nursing care delivery.
It is important for the government, and hospital management to invest attention and resources into EDs to reduce the situation of lack of resources for the emergency team to work with. There is a need for hospital/ED managers to develop innovative strategies and policies that will support the working environment of ED nurses to provide quality emergency care for patients. Management that validates the expressions of concern from ED nurses will foster a positive working environment.