Stakeholders’ perspectives on models of care in the emergency department and the introduction of health and social care professional teams: A qualitative analysis using World Cafés and interviews

Abstract Background There is some evidence that health and social care professional (HSCP) teams contribute to enhanced patient and process outcomes in increasingly crowded emergency departments (EDs), but the views of service users and providers on this model of care need investigation to optimize implementation. Objective This qualitative study investigated the perspectives of key ED stakeholders about HSCP teams working in the ED. Methods Using a participatory design, we conducted World Café focus groups and individual interviews in two Irish hospital sites with 65 participants (purposive sampling) including ED patients and carers/relatives, ED doctors and nurses, HSCPs and pre‐hospital staff. Data were thematically analysed using NVivo software. Results Participants reported that ED‐based HSCP teams could improve quality and integration of care and staff experience (Theme 1) and would be appropriate for older adults with complex needs and non‐urgent complaints (Theme 2). Concerns were raised about operational and relational barriers to implementation (Theme 3), and changes in processes and culture were considered necessary for HSCPs to work successfully in the ED (Theme 4). In contrast to service providers, service users’ concerns centred on the importance of positive communication and relations (Theme 5). Conclusions Our study indicates potential acceptability of HSCP teams working in the ED, especially to care for older adults; however, operational and relational aspects, particularly developing interdisciplinary and integrated care, need addressing to ensure successful implementation. Differences in priorities between service users and providers (relational vs operational) highlighted the usefulness of gathering views from multiple stakeholders to understand ED processes.


| BACKG ROU N D
Emergency departments (EDs) worldwide are experiencing increasing numbers of attendances due to population ageing, multimorbidity and limited resources in primary and acute care, which impact negatively on patient flow and outcomes. 1,2 Calls for ED quality improvement strategies have highlighted the need to identify cost-effective models of care in terms of optimization of workforce (eg skill mix) or operations (eg fast-track systems). 3,4 Encouraging evidence suggests the potential benefits of diversifying the ED workforce in terms of both promoting interdisciplinary work 5,6 and extending the scope of practice of health and social care professionals (HSCPs), as their specialized skills can enhance decision making and quality of care, particularly when working within a multidisciplinary team. 7,8 ED-based HSCP teams are common in some countries, such as Australia, 9 where they have demonstrated some level of effectiveness in improving patient outcomes 8 ; however, this type of service is in its infancy elsewhere, and there is limited evidence of the factors that may influence its implementation. 4 Introducing new models of care to settings with well-established organizational structures is a complex process, particularly if involving workforce changes. 10 The Theoretical Domains Framework of behavioural change 11 suggests that the implementation of new practice may require modifications at multiple levels, including individuals, organizations, services and systems. Engaging stakeholders who receive or provide health care has become increasingly instrumental to identify factors of implementation based on experiences of care, [12][13][14][15] as well as understanding pathways to safer and more effective patient care. 16 Studies of users' ED experiences suggest that patients value integrated and competent care and empathetic communication. [17][18][19] Similarly, ED service providers perceive positive communication and interactions as key enablers of health-care change, 10,[20][21][22] although organizational aspects that may impact their daily operations are also valued, such as receiving appropriate education about new processes and adequacy of resources. 23 Building on the Medical Research Council's Framework for the development and evaluation of complex interventions 24 and on the findings of a recent systematic review on HSCP teams in the ED, 8 the present study aimed to explore the views of various ED stakeholders (service users and providers) on the role and impact of HSCP teams working in the ED, including the perceived value of HSCPs' extended scope of practice, 25,26 potential concerns about feasibility and acceptability, 10,26 and the needs of specific patient populations. 27 To this end, we employed a World Café focus group format (http://www.thewo rldca fe.com/), which has been used successfully to investigate mechanisms of change in health-care settings. 28,29 This participatory approach promotes the engagement of different stakeholders in an inclusive, equitable environment 30 where diverse perspectives are encouraged and valued, thus providing rich insights on the complex dynamics and processes that may enable or hinder the introduction of an ED HSCP team.

| ME THODS
This qualitative study using a participatory design adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) 31 guidelines. A full checklist is included in File S1.

| Participants
Participants for this study (N = 65, age range = 25-75 years; 76.9% female) included individuals who had visited the ED at one of the two study sites (details below) in the past 12 months either as patients or as carers/relatives, aged ≥18 years, living in the community (not inpatient) and having conversational English language skills; staff members including ED doctors and nurses, HSCPs working in the ED or in the hospital, and pre-hospital staff (advanced paramedics or emergency medical technicians) in full-or part-time employment in the hospital for at least 12 months (thus, familiar with the ED/hospital procedures).
We recruited participants through purposive sampling, informed by the inclusion criteria described above. Participants' selection was conducted by research team members (DR and RQ) who acted as gatekeepers at the hospital sites, providing prospective participants with information sheets and organizing in-hospital advertisement through flyers and screen display.
Prospective participants contacted one member of the research team (MC) who provided further details about the study, asked to ensure successful implementation. Differences in priorities between service users and providers (relational vs operational) highlighted the usefulness of gathering views from multiple stakeholders to understand ED processes.

K E Y W O R D S
emergency department, health and social care professionals, implementation, interdisciplinary care, participatory research, World Café to read and sign the consent form and arranged participation either in one of the focus groups or in an individual interview.
Seven out of 72 prospective participants refused to take part.
The gatekeepers were blinded to participants' recruitment and data collection (ie not informed on whether prospective participants agreed or not to take part, and not involved in data collection) to maintain confidentiality and to ensure voluntary participation.
In order to boost recruitment, we also employed snowball sampling and open advertisements through social media and flyers distributed in the local community (eg community centres, GPs, supermarkets

| Settings
Four World Café' focus groups (n = 53) were held in two separate Irish hospital sites in the Mid-West and North-East regions (with similar patient populations). At both sites, the ED did not have a dedicated HSCP team at time of data collection, with HSCP services provided mainly in the ward or on-call in the ED at the discretion of the medical team. Three focus groups took place in a meeting room on the hospital campus, hosting between 10 and 15 participants each. One focus group took place in a meeting room at a hotel venue near the hospital (n = 13). Participants unable to take part in the focus groups completed individual interviews (n = 12) either over the phone or in person.

| World Cafés
The World Café procedure followed in this study is described in While we were interested in several aspects of a HSCP team model of care (implementation process, impact), we opted for broad questions in line with the World Café guidelines to enable participants to generate ideas and views freely. Participants were asked to focus on five HSCP professions: clinical pharmacists (CPs); medical social workers (MSWs); occupational therapists (OTs); physiotherapists (PTs); and speech and language therapists (SLTs). These five disciplines were chosen based on the evidence on extended scope of practice for HSCPs in the ED. 7,8 At the end of the focus group, participants completed a short demographic survey collecting data on their sex, age and stakeholder type.

| Individual interviews
The individual semi-structured interviews (n = 12; 67% users, 33% providers) explored the same questions investigated in the World Café focus groups with the addition of prompts and follow-up questions (Interview schedule in File S3); participants completed the demographic survey at the end of the interview. Interviews lasted 20-40 minutes. No repeat interviews were held. The Results section includes anonymized extracts of transcripts to support the identified themes, with an indication of the stakeholder type (user or provider) and whether quotes come from interviews (IV) or World Cafés (WC). Both authors selected quotes that exemplified each theme and then agreed on the quotes to include by consensus.

| RE SULTS
The characteristics of our sample are provided in File S4, with details about participant distribution across focus groups and interviews.
We identified five themes related to the two study questions, described hereafter.

| HSCP teams working in the ED could improve quality and integration of care and staff experience
Overall, both service users and providers expressed positive views about HSCPs working in the ED, with benefits highlighted for patients, staff and the hospital more broadly:

I think it would be a massive benefit to everybody's experience for there to be an Allied Health team down here (User-IV2)
Considering benefits for patients, both users and providers described having the HSCP team in the ED rather than the ward as contributing to timely assessment/treatment (eg reduced ED length of stay) thanks to their specialized skills. Providers also highlighted the potential for improved quality and safety of care and a more integrated service through multidisciplinary decision making and better linkages with community services, leading to safer discharges home and reduced risk of secondary conditions: Another benefit for staff was shared decision making and enhanced multidisciplinary team working, thus the ability to integrate different perspectives in order to make effective decisions: The collective brain on everybody. So, putting them all together (Provider1-WC3) Staff member also described interdisciplinary teamwork as an opportunity for upskilling and for the promotion of networking/support and job satisfaction.
Lastly, service providers mentioned the potential cost-effectiveness of having specialized workforce in the ED:

| HSCP teams have a role in the ED mainly for non-urgent complaints
Given the focus of this study on team care, both users and providers discussed how different HSCPs could collaborate; an example of this discussion is illustrated in Figure 1.
Users and providers agreed on the relevance of an interdisciplinary HSCP team for patients with non-urgent complaints but complex demands, especially older patients with frailty issues or fall risk: Physiotherapists and Occupational Therapists would be very important to assess an older patient who has experienced a fall

| Concerns about operational and relational challenges for HSCPs working in the ED
When asked how they felt about HSCPs working in the ED, concerns were expressed alongside positive expectations. Participants discussed potential barriers to successful implementation in terms of the ED physical space, operational and relational aspects, the community and the broader health-care system.
Considering the physical space, both service users and providers felt that limited space and crowding in the ED would limit the ability of HSCPs to conduct an assessment efficiently and maintain the patient's privacy: You are not going to be able to spend a half an hour or an hour with a patient. You might need to see them for ten minutes and basically assess them within their tiny ED cubicle and make a decision on their function, their cognition, their consciousness, and decide 'Well, they should be safe enough to go home'

(Provider-IV5)
At an operational level, HSCPs' absence from the ED outside business hours (ie night, weekend) was seen by both users and providers as potentially leading to a two-tier care service for patients, as well as increasing pressure on existing ED staff who work out of hours.

| Changes in processes and culture needed for HSCPs to work successfully in the ED
The concerns raised in theme three were discussed in the context of changes in processes and culture needed for HSCPs to work successfully in the ED; these included strategies to positively integrate the HSCP team within the ED team, such as promoting acceptability through staff education and defining the appropriate competencies for the team:

| Users' concerns about their ED experience centring on communication and feeling that they are in good hands
Participants also provided suggestions on issues that were not nec-

| Summary of findings
This study used a participatory approach to understand the views of a variety of stakeholders on introducing team-based HSCP services in the ED. Overall, HSCPs working in the ED were seen as having the potential to enhance the quality, timeliness and safety of care and promote integrated care for patients, facilitate lighter workload for existing staff members and potentially lower costs for the hospital. Participants agreed that ED patients with nonurgent complaints and with complex needs, particularly frail older adults, would benefit the most from having a HSCP team. Despite identifying multiple benefits, concerns were raised about barriers to feasibility, including limited ED physical space, working hours, care protocols, communication and acceptability. Given the novelty of ED-based HSCP services in the Irish context, our findings have policy and practice implications in that changes in the scope of ED practice and a more interdisciplinary culture of care would be necessary for HSCPs to work successfully in the ED. Service users in particular highlighted the need to improve relational staff/ patient dynamics in the ED and the quality of non-clinical services.
Borrowing from one participant, an appropriate summary of stakeholders' views is that the introduction of ED-based HSCP teams is 'positive with challenges'.
Notably, in our analysis we found that service users focused mainly on relational aspects, whereas service providers discussed more operational issues. One reason for this diversity may lie in the fact that service users appeared to be less aware of the operational aspects of an ED as well as the competencies of HSCPs.
Furthermore, users brought up issues with their ED experience that might not necessarily apply to HSCPs specifically, but which they felt would have a significant impact on how future patients might accept having more professionals in the ED.

| Results in the context of the current literature
In line with a systematic review of ED stakeholders' perceptions of HSCPs, 36 our study showed overall acceptability both among service users and providers, with similar benefits reported in terms of timely, safe and integrated care, particularly for older patients with complex needs. In line with our findings, qualitative studies in Australia and Sweden have suggested comprehensive, integrated and interdisciplinary care as key to promote better health-care services across acute and primary settings, especially for older patients. 5,29 On the other hand, in line with the Theoretical Domains Framework, 11 participants raised concerns about potential operational and relational influences on implementation: feasibility issues related to space, time resources and cost-effectiveness, as well as challenges in optimizing teamwork and care pathways, were consistent with the international literature. 18,21,36,37 Also in line with previous studies, 21,36 patients and staff feared the negative impact of limited working hours on quality and continuity of care; hospital HSCP services in Ireland are conventionally within business hours, but this may not fit well with the 24/7 ED opening hours. These issues should be carefully considered both at policy and practice levels to ensure successful changes in models of emergency care.
The discussed need to optimize care protocols and team communication for the HSCP team to enhance quality of care resonate with findings of previous studies suggesting the need for improved communication, teamwork and operations when caring for patients with complex needs, especially if older. 22,38 Importantly, our finding that ED service users and providers attached different values to relational and operational aspects, which aligns with the extant literature, 18,20,39 shows that individuals' perspectives depend strongly on their specific roles and experiences, thus supporting the importance of engaging multiple stakeholders in order to understand factors of implementation.

| Strengths and limitations
While in keeping with previous literature, our study is, to the best of our knowledge, the first to investigate views on HSCP teams working in the ED through the engagement of multiple stakeholders. Employing a World Café format enabled the creation of an inclusive space for inquiry where different stakeholders had an opportunity to sit together and discuss issues relevant to them.
On the other hand, individual interviews provided an additional space for participants who were unable or unwilling to be in the focus groups; the interviews offered deep insights about individuals' experiences in the ED, thus providing a richer understanding of the reasons behind the perspectives that had emerged during the focus groups.
Our study is not without limitations. Although we collected data in two separate sites in Ireland, generalizability of findings might be limited given the specific contextual characteristics of health-care systems in different countries; nonetheless, our results are in line with those of the existing international literature. 18,21,36 Despite its many benefits, the World Café format has some disadvantages: Firstly, as for other qualitative investigations, social desirability may have influenced the participants' contributions. Furthermore, the World Café notes were more difficult to contextualize and interpret than audio-recorded data, although we matched notes and transcripts where possible. As the World Café table membership rotated, we were not always able to identify specific respondents in the recordings; also, although all the five relevant HSCP disciplines were represented in our sample, we did not record how many participants from each HSCP discipline were present. While we involved different stakeholders, our sample did not include policy-makers or members of the hospital Executive, who could have contributed further insights on factors of implementation; lastly, more service users participated in interviews than focus groups; thus, it is possible that group discussions could have been different if more users were present.

| CON CLUS IONS
In this qualitative participatory study, ED service users and providers highlighted potential benefits of having HSCP teams working in the ED, particularly for enhancing the care of patients with complex needs; however, several factors including communication, acceptability, physical space, interdisciplinary work and community resources arose as issues to be carefully considered in order to optimize the implementation of this model of care. The study has practical implications for the implementation of HSCP teams in EDs and for future research on ED-based interdisciplinary work, which have both been suggested as potential cost-effective strategies to improve ED care.