Person-centered fundamental care in the emergency room : Patient and registered nurse perspectives

Sammanfattning: Patients who suffer from life-threatening illness or injury – experiencing conditions such as cardiac arrest, breathing problems, or trauma – are cared for at designated emergency rooms within the emergency department. In the emergency room, the registered nurse is responsible for those who are exposed and vulnerable and have complex needs. In these rooms, the biomedical focus may reinforce a culture that values the medical-technical aspects of nursing. Meeting patients’ fundamental care needs, such as respect, information, and toileting, in a person-centered way seems challenging in emergency rooms. When care is not provided correctly, the consequences for the patient’s health can be serious, for instance resulting in physical complications in the form of pressure injuries from breathing masks and spine boards or psychological complications such as worry, anxiety, or post-traumatic stress syndrome. Little is known about how person-centered fundamental care is made visible and valued both for and by patients in emergency rooms. In this thesis the understanding of fundamental care is guided by the Fundamentals of Care framework, in order  to maintain an optimal person-centered care that considers the patient’s fundamental care needs with a holistic view of the patient. The overall aim of this thesis is to explore how person-centered fundamental care needs are met for life-threateningly ill patients in emergency rooms, from both patient and registered nurse perspectives.Study I explored how fundamental care needs of life-threateningly ill or injured patients were met by observing the daily activities of registered nurses in the emergency room, through 108 observations. The results showed that registered nurses were initially engaged and active in meeting patients’ needs, but that this decreased over the duration of the care. Registered nurses met the patients’ physical needs to a greater extent than their psychosocial and relational ones. The environment affected the registered nurses’ ability to meet the patients’ fundamental care needs.To describe fundamental care needs in the emergency room, based on life-threateningly ill patients’ experiences, an interview study (Study II) was conducted with 15 persons who had been cared for in an emergency room. The interviews were analyzed using deductive content analysis based on the Fundamentals of Care framework. The results showed that relationship, timely and personalized information, and existential needs were identified as essential fundamental care needs, which were not (or only partly) met. The physical environment limited patients in having their fundamental care needs met, and they adopted a “patient role” to avoid adding to healthcare professionals’ stress.Study III described registered nurses’ work approach and prerequisites for meeting life-threateningly ill patients’ care needs from the perspective of a person-centered fundamental care framework, through 14 interviews. The results revealed that registered nurses structure their work approach in meeting patients’ fundamental care needs based on prevailing organizational and personal prerequisites.In Study IV the content of guidelines governing the registered nurses’ work in the emergency room was investigated. The results revealed that the registered nurses’ work in Swedish emergency rooms was guided by an instrumental and task-oriented approach to care. The guidelines lacked guidance in providing for patients’ fundamental care needs, and did not support the registered nurses in conducting holistic, comprehensive patient assessments and interventions.The organizational prerequisites contribute to a task-oriented and instrumental way of working, and patients are not having their fundamental care needs fully met. Fundamental care is not being promoted or prioritized, as the organization and responsibilities for providing person-centered fundamental care are unclear, unspecified, and lacking in direction for how it is to be performed – neither the organization nor the culture supports the registered nurses’ work and profession.