Navigating the unknown: A qualitative analysis exploring patient experience in the Emergency Department

Navigating the unknown: A qualitative analysis exploring patient experience in the Emergency Department | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Navigating the unknown: A qualitative analysis exploring patient experience in the Emergency Department Moriah Carmel, Navneet Kaur, Christian Strachan, Andreia Alexander This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5045716/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background: Patient experience within healthcare is an increasingly pivotal area of exploration. The objective of this study was to use qualitative methods to elucidate the primary drivers shaping patients' ED experience and to discern how these factors diverge between the UAC and RCH environments. Methods: Qualitative, semi-structured individual interviews with ED patients were conducted across two EDs, an urban academic center (UAC) and a rural community hospital (RCH). An inductive thematic analysis approach was used. Results: Fifty-six participants were interviewed. Four major themes (attitudes of staff, showing concern, patient-centered communication, and frequent updates) emerged across six subthemes: what mattered most, wait time, rushed, end of visit, discrimination, and intent to return ; with an overarching theme which encompasses all four major themes – empathy. Overall, positive experiences were associated with positive and empathetic attitudes of all staff, frequent updates along the spectrum of their ED visit, patient-centered communication particularly during the discharge process, and having the ability to ask questions without feeling rushed. A primary distinguishing feature between the UAC vs the RCH included confidence in care received and differences in the ED environment. Regardless of the patient’s experience, showing empathy, even in unfavorable situations, was identified as the most impactful part of their visit. Conclusion: Patients’ perceptions of healthcare staff empathy is a critical driver in influencing overall ED patient experience. Future studies should include further characterization of patients’ perceptions of healthcare provider empathy and its impact on ED patient experience. Emergency Department Patient Experience Empathy Figures Figure 1 1 Introduction Patient experience within healthcare is an increasingly pivotal area of exploration, bearing significant implications for patient outcomes, financial performance, and physician satisfaction. The correlation between elevated patient experience levels and favorable outcomes [1], enhanced profitability [2], and heightened physician job satisfaction [3] underscores its significance as a quality-of-care metric. As healthcare systems progressively integrate patient experience assessments into their quality evaluations, understanding the factors shaping patient experiences becomes crucial. However, existing literature predominantly adopts a quantitative lens, leaving a dearth of qualitative investigations into patient experiences [4], particularly within the Emergency Department (ED) context [5]. Qualitative methodologies offer a nuanced understanding of patients' emotions and perspectives during ED visits, serving as invaluable tools for pinpointing areas of improvement. While prior qualitative studies have explored individual facets such as care coordination [6] and wait times [7] in the ED, few have delved into comprehensive portrayals across diverse ED settings [8-9]. Our study addresses this gap by conducting a qualitative inquiry into the ED experiences of patients, encompassing both a large tertiary Urban Academic Center (UAC) and a rural community hospital (RCH). By leveraging a relatively large sample size, our research aims to elucidate the primary drivers shaping patients' ED experience and to discern how these factors diverge between the UAC and RCH environments. 2 Methods This was an exploratory study utilizing cross-sectional semi-structured one-on-one interviews based on a constructivism approach [10-11]. This study, which took place from April 2021 through February 2022, was approved by the Institutional Review Board at the authors’ institution (Indiana University) on 7/19/2021. The study approval number is 12251. Participants received written and verbal information about the study, including the purpose of the study, and were informed that participation was voluntary and that they could withdraw from the study at any time. Verbal consent was obtained from participants. Each participant was given a $25 gift card for participation. 2.1 Study Setting and Recruitment Participants were recruited from the EDs at a UAC and a RCH. The UAC, a Level 1 trauma center, sees about 90,000 patients per year and is staffed by Emergency Medicine (EM) faculty/residents, residents from other services, students, and advance practice providers (APPs). The RCH is a Level 3 trauma center that sees approximately 60,000 patients per year and is staffed by EM faculty and APPs, with intermittent medical students and Family Medicine/Internal Medicine residents. As a standard procedure, after discharge from the ED patients are contacted to complete patient experience surveys at which time they can opt-in to be contacted for additional feedback. Participants for this study were recruited from this opt-in pool. Patients were eligible to participate if they were able to speak and comprehend English, were 18 years of age or older, and were discharged from the ED. Initial recruitment emails and three reminder emails were sent to all eligible patients. Interviews were held on a rolling basis until theoretical saturation, the point at which no new information was being reported for at least 3 interviews, was reached. Individual interviews were held virtually over Zoom, lasting 45-60 minutes. 2.2 Data Collection and Analysis Three study team members (authors AA and MC, along with research assistant NK) conducted semi-structured interviews. All three interviewers/facilitators are female, and none of them had relationship with any of the participants prior to the interview. AA, a physician faculty in the Department of EM with a PhD in Health Behavior specializing in qualitative research, led training sessions attended by MC and NK. Following training, MC and NK conducted practice interviews with EM residents under AA's supervision, receiving real-time feedback. AA also reviewed and provided feedback on the first three patient interview recordings conducted by MC and NK. MC was a medical student at the time that the interviews were conducted, and NK was a staff member for the Department of EM. Other than being and Emergency Physician, AA did not have a particular interest in the topic of patient experience and was called upon by the Department of Emergency Medicine at her institution to conduct this study as a neutral party with an expertise in qualitative research. Interviews focused on the participants’ experiences during their most recent ED visit (Interview Guide, Appendix 1). Interviews were recorded and transcribed, and an audit trail was created [12]. Transcripts were not returned to participants for comment and/or correction. No interviews were repeated. Throughout the participant recruitment, data collection, and data analysis process the researchers kept a field journal. This journal was used to document important ideas regarding study procedures, preliminary analyses, lessons learned, new patient experience related data, and patient experience related efforts. Data was analyzed using inductive content analysis [13]. Each member of the research team openly coded the first five transcripts, identifying preliminary codes used in subsequent rounds of coding. The remaining transcripts were divided among MC and NK for coding. Throughout the analysis process the team met several times to discuss findings and codes. As a quality check, AA coded five random transcripts coded by MC and NK. Disagreement between researchers was resolved through discussion. Participants did not provide feedback on the findings. 3. Results We contacted 228 patients. Fifty-six patients agreed to participate in this study (UAC = 30, RCH = 26). No participants withdrew from the study. Most participants were female (n = 36, 64.2%) and White (n = 44, 78.6%). Participants were 24 to 75 years old. Demographics by site can be found in Table 1. Table 1: Demographics by Site Urban Academic Center Rural Community Hospital N = 30 N = 26 Sex * n % n % Female 20 66.7 16 61.5 Male 10 33.3 10 38.4 Race/Ethnicity + n % n % Asian 1 3.3 1 3.8 Black 6 20.0 4 15.4 White 23 76.7 21 80.8 Age Min Max Min Max Range 24 75 26 73 *This information was obtained from the information documented in the patient’s chart. At this time these EDs did not collect self-reported gender identity data, therefore only male and female were the only options. + This information was obtained from the information documented in the patient’s chart. These are the only race/ethnicities with at least 1 participant. All other races/ethnicities had zero participants, so those were left out of the chart. We identified four major themes (attitudes of staff, showing concern, patient-centered communication, and frequent updates) that appeared across six subthemes: what mattered most (WMM), wait time, rushed, end of visit, discrimination, and intent to return ; and an overarching theme which encompasses all four major themes – empathy. Figure 1 depicts how subthemes, major themes, and the overarching theme relate to each other. 3.1 Theme: Attitudes of Staff Four sub-themes underpin this major theme: WMM, Rushed, Discrimination, and Intent to Return. A t titudes of Staff included behaviors/actions of staff perceived by participants as reflecting positive or negative feelings about them as patients or staffs’ feelings about working in the ED. Some participants described staff displaying positive attitudes such as being “pleasant,” “friendly,” “respectful,” “courteous,” “polite,” and “kind.” Other participants described staff displaying negative attitudes such as being “apathetic,” “impatient,” and “rude.” Participants expressed that the attitude of all members of their healthcare team mattered, from the front desk staff to technicians to cleaning staff, not only providers and nurses. Moreover, participants discussed the importance of perceived attitudes of staff not only towards themselves but also towards the loved ones accompanying them. 3.1.1 Subtheme: WMM Participants frequently reported that attitudes of their healthcare team mattered most to them during their ED visit. Some participants described positive attitudes in terms of receiving kind, reassuring words from their healthcare team. One participant described this as relating to them on a personal level, stating: “Being able to talk to somebody who was willing to share that and say, ‘hey, here's kind of what I personally experienced, it sounds like it's pretty close to what you're experiencing’ was reassuring.” (RCH8) Though participants could not always remember specific actions that their healthcare team took, they remembered how their healthcare team made them feel. For example, a participant recounted a story in which she came into the ED for a mental health concern. She recalled feeling anxious prior to being seen but that the attitudes of her physicians and nurses put her “at ease.” 3.1.2 Subtheme: Rushed In the subtheme “Rushed,” participants discussed not wanting to feel as though they were a burden to staff. Additionally, participants expressed the importance of treating patients as individuals rather than another "cog in the wheel.” For example, one participant stated: “[Some of the staff] look so annoyed with what you're saying and the fact that you're even there...There was a lot of whispering and giggling. A couple of them curled their nose and rolled their eyes...The nurse seemed really irritated and kept looking around the room, like, ‘ if you'll shut up now, I can go get the doctor.’” (RCH21) In contrast, another participant stated: “They genuinely would stop and listen to me. I could tell they were busy...But they gave me the time that I felt like I deserved or needed. [They] addressed me by name...They never made [me] feel unworthy.” (RCH8) 3.1.3 Subtheme: Discrimination Participants described discriminatory attitudes as staff displaying judgmental and assumptive behaviors or actions. Negative attitudes were perceived through the actions, communication from, and body language of staff. For some, this was explicit, such as one participant who stated: “You would just kind of see whispering over to the side while you were being treated and you're just sitting there like, ‘well, I wonder what they're saying.’ Sometimes you could hear them saying different things like, ‘well, you know, she's got diabetes or whatever.’ And made it seem like that your pre-existing conditions should make a difference on what's happening to you.” (UAC26). Some participants could not provide specific examples of discrimination but remembered feeling that something was “off.” 3.1.4 Subtheme: Intent to Return “Attitudes of Staff” often influenced the likelihood that participants would return that ED in the future, with positive attitudes motivating them to return and negative attitudes dissuading them from returning. For example, one participant described their intent to return to the same ED because “it left a positive feeling.” In contrast, participants often cited experiences with staff being “rude” or “unprofessional” as being a primary driver dissuading them from returning. For example, one participant described an experience where she fell off her chair in the waiting room: “The triage nurse was so rude to me. She was like, you know, basically, “get off the floor”...It was her whole demeanor.” (UAC1) 3.2 Theme: Showing Concern Five subthemes underpin this major theme: WMM, Wait Time, Rushed, End of Visit, and Discrimination. Participants described “showing concern” as being treated like a unique individual rather than a medical condition or checkbox, feeling that their healthcare team took their symptoms seriously, and that their healthcare team valued their expertise and knowledge of their own bodies and medical conditions. Participants who perceived their healthcare team showing concern were more likely to have confidence in the care they received. Conversely, those who felt that their healthcare team did not show concern expressed feeling dehumanized and that their expectations were not met. For example, one participant shared: "I was brought in by an ambulance. It was a very busy day for the emergency department...No one even looked at me or touched me. When they brought me in, I didn’t have clothes [or shoes] on. I had to go sit in the waiting room in a sheet. It was very degrading." (UAC9) Participants also appreciated small gestures from their healthcare team that showed concern such as offering them a warm blanket or asking if the participant wanted the lights on or off. Participants viewed these gestures as their healthcare team caring about and valuing them. 3.2.1 Subtheme: Wait Time When discussing their experiences with waiting during their ED visit, participants discussed not wanting to “feel alone,” such as one participant who stated that they, “spent a lot of time alone just wondering what's going on” (RCH 10). Another participant discussed an experience where they were forgotten about for 3-4 hours and when the nurse finally came, said, “I didn't even know you were down here.” Participants who felt alone while waiting also described feeling as though they were not important to their healthcare team and that their healthcare team was not concerned about their well-being. 3.2.2 Subtheme: Rushed & End of Visit Within this subtheme, participants discussed their experiences feeling rushed by their healthcare team, particularly during discharge. Participants felt that their providers cared about their well-being when they were given adequate time to ask questions, such as one participant who stated: “They showed interest. I wasn’t dismissed or felt like they had more important things to do or get back to, or that it was a minor concern and that I was over exaggerating it. I was taken seriously, and I felt like I was an equal part of my care team.” (UAC21) On the other hand, when rushed, participants reported feeling frustrated, confused, unimportant or as an inconvenience to staff, or that their providers simply saw them as an item on their “to do” list rather than an individual. For example, one participant when asked about the time they spent with the provider stated: “I think they were in a hurry...[It made me feel] disappointed. I mean, I'm like, “okay, I came here for help, and I get nothing. So, then what's the point of me coming?&rdquo (UAC10) 3.2.3 Subtheme: Discrimination This subtheme included validation of participants concerns, dismissive language or actions, and thoroughness of clinical care. Participants discussed experiences where their symptoms were not taken seriously, which participants attributed to factors including race/ethnicity, age, physical appearance, and medical history. Participants often perceived this as their providers not trusting, listening to, or disregarding their concerns. For example, one participant felt that her symptoms were not taken seriously because she “didn’t look sick” when she was having an adrenal crisis. “A lot of times, people just assume because I'm young and I look fine, I am fine. Because I was younger, I was put on the backburner for several hours.” (RCH16) Participants often discussed experiences in which they felt discriminated against based on their history of chronic pain. Participants felt that their healthcare team did not care about their pain or assumed that they were exaggerating or “faking” their pain. When this happened, participants felt “dehumanized.” For example, several participants discussed feeling as though they were labeled as “drug seeking” and because of this were not given adequate pain management. One participant stated that they felt that healthcare professionals often forget that “they are people, too” and encouraged healthcare professionals to remember that “regardless of whether they're addicted or not, it's still real pain.” 3.3 Theme: Patient-Centered Communication The major theme Patient-Centered Communication includes subthemes: WMM, Wait Time, Rushed, and End of Visit . Participants described Patient-Centered Communication as 1) using patient-entered language, 2) providing opportunities to ask questions to solidify patient understanding of their care plan, diagnosis, discharge instructions, and follow-up plan, 3) providing rationale for medical decision making, and 4) providing reasons for extended periods of waiting. 3.3.1 Subtheme: WMM When asked WMM to them during their ED visit, the most frequent response was that “their reason for coming in was addressed.” Participants felt this expectation was met when they were informed about their care plan and included in making this plan. Participants felt that this was achieved when their provider actively listened to their concern, considered their input, and explained medical decision-making. When this did not happen, participants felt confused and anxious. For instance, the participant discussed her experience not receiving the rationale for certain medical procedures being performed: “They started doing the EKG on me with no explanation. So, I was like, ‘Hey, why are you doing that?’” (UAC35) 3.3.2 Subtheme: Wait Time Within this subtheme, participants discussed the importance of providing explanations for any extended period of wait and ensuring patients understand their plan of care, so they don’t feel “left in the dark.” Participants felt that this could be best achieved by explaining their care plan and an estimated wait time at the beginning of their visit. Participants expressed understanding that the ED is an unpredictable environment and that sicker patients that take precedence could walk in the door at any time; however, participants explained the importance of “keeping patients in the loop” about any potential delays in care. “I think it would make it easier to wait when you actually know. At least if it's not happening right away, you know.” (RCH11) Participants felt “seen” when their healthcare team communicated delays. One participant gave an example of how healthcare providers can communicate empathy when there are delays in care: “I see you; you’re going to be seen, and we’ll get to you as fast as we can. I think that would go a long way.” (UAC9) 3.3.3 Subtheme: Rushed & End of Visit In this sub-theme, participants discussed their experiences with staff explaining discharge instructions and diagnosis, citing the importance of explaining concepts “using patient terms.” and avoiding using medical jargon whenever possible. Moreover, participants expressed the importance of confirming that patients understand what is being told to them and providing them with the space to ask clarifying questions without feeling rushed. When this happened, participants felt more prepared to leave the ED and confident in the care they received. For example, one participant discussed receiving ample information not only about her discharge instructions but also insights into how to manage her chronic medical condition once she left the ED: “They went in depth on my condition. Like they knew the ins and outs of it... They told me what to do when I have those flare ups again.... So, I trust them a lot.” (UAC1) Conversely, when participants received either limited, inadequate, or poorly explained information, they were left with a sense of frustration, confusion, and felt that their needs and expectations had not been met. For example, one participant described how she was told “they couldn’t do anything” for her son after they presented with severe abdominal pain, and that he needed a colonoscopy. However, it was not explained to her what the next steps should be and why they were not able to complete the colonoscopy during that ED visit. As a result, the participant was visibly frustrated to the point of tears during her interview, as she felt that the healthcare team did not care about her son and dismissed his pain. 3.4 Theme: Frequent Updates The major theme Frequent Updates includes the subthemes: WMM, Wait Time, and Intent to Return. Participants described Frequent Updates as being consistently updated on their care plan and estimated wait times during any part of their visit. Receiving limited updates contributed to feelings of anxiety and fear over the seriousness of their condition, as well as feeling forgotten about, alone, and overwhelmed. For several participants, their healthcare team served as their only companionship. One participant stated: “Even if you're a healthcare professional, it’s kind of a scary place. I was nervous and I was alone. I didn't have any family members or anything.” (UAC24) Participants felt their healthcare team could provide a sense of companionship by introducing themselves at the start of the visit. As one participant explained: “Once we established contact, it was lot less being alone.” (UAC14) Receiving frequent updates made participants feel “seen” by their healthcare team, which participants defined as showing sympathy and care. 3.4.1 Subtheme: WMM Many participants indicated that being consistently updated and informed about their care mattered most to them during their ED visit. Receiving updates made them feel they were receiving the attention they needed and increased confidence in the care received. For one participant, she discussed that being updated mattered most to her because she had her young son with her and needed to coordinate his care. 3.4.2 Subtheme: Wait Time & Intent to Return Within this sub-theme, participants discussed their experiences waiting during any point of their ED visit. Having a long wait during any point in their ED visit was “frustrating.” Negative feelings associated with long periods without updates (anywhere between 30-120 minutes) contributed to participants' overall feelings towards their ED visit. However, despite being frustrated, most participants understood that the ED is a busy environment and that there are often other patients of higher acuity who are being looked after. Participants revealed that rather than caring about the actual length of their wait, they cared about how often they were updated on how long their wait would be. When participants were updated on delays in care, they felt that they were getting the attention they needed. Many participants indicated that long waits and the level of attention they received during periods of waiting affected their intent to return to that ED in the future. 3.5 Overarching Theme: Empathy Though themes such as attitudes of staff and frequent updates may appear as distant concepts from a surface level view, patients’ thoughts and feelings about their experiences were linked across the 6 subthemes and 4 major themes through the overarching theme, empathy. This theme connects participants’ experiences to the emotion behind these experiences. Table 2 contains quotes which illustrate how the overarching theme “empathy” fits within the four major themes. Major Themes Exemplar quotes from participant interviews Attitudes of Staff “I always pay attention to doctors, nonverbals. I think what they're saying is extremely important, but I think even more important is how they say it. I thought the staff always was very calm. [They] didn’t seem stressed or worried even if it would have been something that caused them some worry...I think just overall like the cadence in which they spoke. Obviously, they're all brilliant people. I'd imagine they were very accurate with what they were saying, but it was how they said it. And also that they were really nice to my wife who was there with me. That was really important to me.” (UAC27) Showing Concern “[The doctor] was very kindhearted. She's a very sweet lady, and I would just like to say that when I told her I was hurting, she held my hand.” (UAC29) Patient-centered Communication “The staff were really responsive in terms of just letting me know what they were going to do, who they were, what their jobs were, and describing what came next. I was pretty scared at the time, so it was really helpful to me for them to communicate so well... [It made me feel] a lot calmer. It helps to have information. I'm not a person who looks freaked out, and people tend to misread that. They're just like, “Oh, she's calm, she's just fine.” But inside, there's a lot going on, and it really helped me. I didn't have to tell them I'm freaking out; they just did that. And I'm assuming they do that with everybody." (UAC22) Frequent Updates “The staff were both professional and clearly showed a sense of caring despite the fact that they were busy... while I knew I was one of many patients, they did a really good job of making me feel like I was one of only a few patients that they were actually tending to. They made me feel like I was getting the attention that I needed and kept me informed.” (RCH5) Table 2: Exemplar Empathy Quotes 3.6 Urban Academic Center vs Rural Community Hospital Overall, the subthemes and major themes were similar across both the UAC and the RCH. However, the primary differences between the UAC and the RCH included confidence in care and the ED environment . Most participants indicated that they would return to the UAC in the future because they trusted the care they received. Some commented that the physicians at the UAC were smart, trusted, and dedicated. Participants also remarked that the UAC is an established “cutting edge” facility. There was a distinction between how participants described the ED environment of the UAC versus the RCH. As opposed to the RCH where participants described the ED environment as “calm” and “quiet,” participants described the UAC as being “noisy” and “chaotic.” A participant described a “chaotic” experience where police were called into the ED, which left them feeling “unsettled.” Another major difference between the UAC and the RCH was the use of hallway beds at the UAC. Participants expressed negative feelings seeing other patients in hallway beds and when they were placed in a hallway bed. Participants felt that the presence and use of hallway beds contributed to feeling that the ED was “busy” and “crowded.” When placed in a hallway bed during their visit patients felt “degraded,” saying that it made them feel as though they weren’t “important enough to even be in a room.” Participants felt “exposed” and that their privacy was compromised. “[It made me feel] uncomfortable, a little bit unsafe, a tiny bit sort of threatened.” (UAC20) Those who were not placed in hallway beds still had negative feelings surrounding this, such as one participant who stated: “I saw lots of elderly in a hallway bed. I felt terrible that I had a room and they didn’t.” (UAC6) At the heart of the issue was not actually being placed in hallway beds but the lack of communication from staff regarding why patients were placed in hallway beds. Though most participants did not like being placed in a hallway bed, they understood why this happens. Patients said they felt that if it was explained why they were placed in a hallway bed, this would have relieved some anxiety. “I think that it would alleviate some discomfort and anxiety if they just had a couple sentences -- the ER is really busy right now and we need to put you in the hallway at the moment until a bed opens up.” (UAC20) 4. Discussion This study explored adult patient experiences at two large, yet different, EDs – a UAC and an RCH. Participants in the study articulated the importance of the patient-staff relationship. The major themes of attitudes of staff, showing concern, patient-centered communication, and frequent updates align with the concept of patient-centered care previously discussed in the literature [9,14-16]. Throughout our study, we found that regardless of the questions asked, participants’ answers were encompassed within one or more of the four major themes, which collectively aligned with an overarching theme of empathy. Viewing the major themes as being nested within a single overarching theme allows us to understand participants responses from a holistic perspective. Moreover, viewing the data from this perspective helps us understand how and why certain behaviors evoked certain emotions in participants. Rather than specific behaviors and actions from staff being important, it’s the perception of empathy related to these behaviors and actions which mattered most to participants. While previous research has discussed empathy [15-18], none have identified empathy as a connecting thread across themes in patient ED experience. Hajot et al [19] describes empathy in the context of patient care as “a predominantly cognitive attribute that involves an understanding of experiences, concerns, and perspectives of the patient, combined with a capacity to communicate this understanding, and an intention to help.” By understanding patients’ experiences and stories, we are not only able to better understand how empathy functions within a clinical setting but may also be able to better determine quality improvement measures to improve patient experiences. For example, our study found that small gestures showing concern from the healthcare team improved patients’ experiences. These actions can be coached and audited to improve patient experience. Studies have found that empathic engagement in patient care leads to improved patient outcomes [20-21]. Moreover, research has shown that empathy may be a protective factor of physician burnout [22]. Wait time is a common theme within ED patient experience literature [5,15-16,18]. In our data, wait time is reframed when it encompasses empathy . This idea is reinforced by prior studies that show the actual length of a patient’s wait time is less important than perceived quality of health interaction and interpersonal communication [23]. Furthermore, modifiable factors, such as proactively informing patients of delays and explicitly apologizing for delays, affect patients’ perception of wait time and have a greater impact on patient experience than actual wait times [24]. New AI technology is currently being developed and implemented to provide real-time updates to patients. This software may address wait times, however, given that this takes the personal touch out of the interaction, effects on patient experience using this technology should be studied further. Perceived empathetic interactions between healthcare providers and patients are seen within the subtheme discrimination. Consistent with previous literature, participants in our study attributed experiences of discrimination, microaggressions, and harassment while in the ED to factors that not only included race and gender but also age, physical appearance, and types of chief complaints, especially those related to pain (chronic and acute) and mental health [25-27]. Furthermore, many participants discussed previous experiences of discrimination that extended beyond their ED visit, such as experiences with primary care physicians or previous ED visits. As discussed by Punches BE et al. [25], “previous experiences of discrimination may have lasting effects on patient perceptions of current healthcare,” which makes understanding patients' feelings and emotions regarding experiences of discrimination and microaggressions important and should be further studied. It is important to note that fixating on empathy as a “catch all” cure for eliminating discrimination is problematic and misguided. Internal and external bias are core components of discrimination. For example, participants also described systematic issues outside the control of their healthcare team, such as patient forms not being gender inclusive or chairs not being big enough for plus sized patients to sit in. Therefore, we must also go beyond the individual patient-healthcare team interaction when addressing discrimination in the healthcare setting. Moreover, although it is not necessary to share the same experiences as another to be empathetic, lived experiences can limit our ability to grasp how another person feels and internalized bias towards certain populations can influence if/how someone chooses to display empathy. Understanding patients’ perceptions of discrimination and understanding how perceived empathetic interactions between patients and their healthcare team are a component of patients’ perceptions of discrimination can inform efforts to reduce disparities in clinical care and improve patient experience. Though research has shown the importance of empathy in clinical care, understanding how empathy functions within the patient-physician relationship is less known. Current measures of empathy fail to reflect patients’ views about the healthcare team’s ability to offer empathy. If patients can perceive the amount of empathy in helping relationships, they can provide valuable insights as to how professionals can offer empathy [28]. Knowledge about empathy has mostly originated from physicians’ perspectives, often using self-assessment tools. However, there is a lack of correlation between physician self-assessed empathy levels and patients’ perception of empathy [29]. On the other hand, patients’ perceptions of therapist empathy predicted outcomes better than therapist self-perceptions of their own empathy [30]. This suggests that patients should be included in the process of empathy evaluation, and further research should be conducted in this area. When comparing the data from the UAC to the RCH, a primary difference between the environment at the UAC and RCH was the use of hallway beds. Participants don’t like hallway beds. However, experience improved when the patient felt they were important, and their privacy would be respected. Our findings are consistent with available literature showing that satisfaction among patients treated in hallways appeared to be mainly dictated by caring/empathetic interactions with staff and communication variables of understanding ED procedures [17]. Though hospitals may not be able to reconfigure the structure or environment of their ED, our results illustrate how efforts such as explaining to patients why they are being placed in a hallway bed can alleviate negative feelings associated with them. 4.1 Study Limitations Several limitations should be considered when evaluating the results of this study. As with any qualitative study, the results are not generalizable. While we do not consider this to be a limitation, it is important to remind the readers of this fact. The goal of this qualitative study was to provide in-depth explanations rather than generalized findings. Participants were all self-selected, creating self-selection bias. Though this study included a larger sample size than many existing qualitative studies on ED patient experience, the sample size is still small, as is characteristic of qualitative studies. Some of the patients included in this study visited the ED during the COVID-19 pandemic, both during times when patient volumes were high and times in which volumes were low. The timing of their ED could have influenced their perspective on many of the themes discussed in this paper. Finally, this was an unfunded study, and, as a result, interpretation services were not available for this study. Therefore, the perspectives of non-English speaking patients are not represented in this study. Future studies should look to include non-English speaking patients as this is a very important perspective that is missing from the literature. Conclusions The patient-staff relationship is a critical component of patient experience in the ED. Specifically, our findings show that a patient’s perceptions of healthcare staff empathy is a critical driver in influencing overall ED patient experience. Future studies should include further characterization of patients’ perceptions of healthcare provider empathy and its impact on ED patient experience. Abbreviations Emergency Department (ED) Rural Community Hospital (RCH) Urban Academic Center (UAC) Emergency Medicine (EM) Advance Practice Providers (APPs) What Mattered Most (WMM) Declarations Ethics approval and consent to participate: this study, which took place from April 2021 through February 2022, was approved by the Institutional Review Board at the authors’ institution (Indiana University) on 7/19/2021. The study approval number is 12251. The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Participants received written and verbal information about the study and were informed that participation was voluntary and that they could withdraw from the study at any time. Verbal consent was obtained from participants. Consent for publication: n/a Availability of data and materials: data collected and analyzed in this study is available on request from the authors. Competing interests: no competing interests to report. Funding: no funding sources to report. Authors’ contributions: All authors read and approved the final version of this manuscript. Criteria Author Initials Made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; MC NK SC AA Involved in drafting the manuscript or revising it critically for important intellectual content; MC CS AA Given final approval of the version to be published. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content; MC NK SC AA Agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. MC NK SC AA Acknowledgments: no acknowledgments to add. References Kelley JM, Kraft-Todd G, Schapira L, Kossowsky J, Riess H. The influence of the patient-clinician relationship on healthcare outcomes: a systematic review and meta-analysis of randomized controlled trials. PLoS ONE. 2014;9(4):e94207. Richter JP, Muhlestein DB. Patient experience and hospital profitability: Is there a link? Health Care Manage Rev. 2017;42(3):247–57. Zgierska A, Rabago D, Miller MM. Impact of patient satisfaction ratings on physicians and clinical care. Patient Prefer Adherence. 2014;8:437–46. Nairn S, Whotton E, Marshal C, Roberts M, Swann G. The patient experience in emergency departments: a review of the literature. Accid Emerg Nurs. 2004;12(3):159–65. Bull C, Latimer S, Crilly J, Gillespie BM. A systematic mixed studies review of patient experiences in the ED. Emerg Med J. 2021;38(8):643–49. Chang L, Wanner KJ, Kovalsky D, Smith KL, Rhodes KV. It's Really Overwhelming: Patient Perspectives on Care Coordination. J Am Board Fam Med. 2018;31(5):682–90. Cross E, Goodacre S, O'Cathain A, Arnold J. Rationing in the emergency department: the good, the bad, and the unacceptable. Emerg Med J. 2005;22(3):171–6. Aleksandrovskiy I, Ganti L, Simmons S. The emergency department patient experience: in their own words. J Patient Experience. 2022;9:23743735221102455. Bull C, Latimer S, Crilly J, Spain D, Gillespie BM. I knew I'd be taken care of': Exploring patient experiences in the Emergency Department. J Adv Nurs. 2022;78(10):3330–44. Mills J, Bonner A, Francis K. Adopting a constructivist approach to grounded theory: Implications for research design. Int J Nurs Pract. 2006;12(1):8–13. Mogashoa T. Applicability of constructivist theory in qualitative educational research. Am Int J Contemp Res. 2014;4(7):51–9. Rodgers BL, Cowles K. The qualitative research trail: A complex collection of documentation. Res Nurs Health. 1993;16(3):216–26. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77–101. McConnell D, McCance T, Melby V. Exploring person-centeredness in emergency departments: A literature review. Int Emerg Nurs. 2016;26:38–46. Gordon J, Sheppard LA, Anaf S. The patient experience in the emergency department: A systematic synthesis of qualitative research. Int Emerg Nurs. 2010;18(2):80–8. Graham B, Endacott R, Smith JE, Latour JM. They do not care how much you know until they know how much you care': a qualitative meta-synthesis of patient experience in the emergency department. Emerg Med J. 2019;36(6):355–63. Villalona S, Cervantes C, Boxtha C, Webb WA, Wilson JW. I Felt Invisible Most of the Time: Communication and satisfaction among patients treated in emergency department hallway beds. Am J Emerg Med. 2020;38(12):2742–44. Sonis JD, Aaronson EL, Lee RY, Philpotts LL, White BA. Emergency Department Patient Experience: A Systematic Review of the Literature. J Patient Exp. 2018;5(2):101–06. Hojat M. Empathy and patient outcomes. In: Hojat M. Empathy in health professions education and patient care. 1st edition. New York City, NY: Springer Publishing; 2016. pp. 189–201. Hojat M, Louis DZ, Maio V, Gonnella JS. Empathy and health care quality. Am J Med Qual. 2013;28(1):6–7. Del Canale S, Louis DZ, Maio V, et al. The relationship between physician empathy and disease complications: an empirical study of primary care physicians and their diabetic patients in Parma, Italy. Acad Med. 2012;87(9):1243–9. Thirioux B, Birault F, Jaafari N. Empathy Is a Protective Factor of Burnout in Physicians: New Neuro-Phenomenological Hypotheses Regarding Empathy and Sympathy in Care Relationship. Front Psychol. 2016;7:763. Locke R, Stefano M, Koster A, Taylor B, Greenspan J. Optimizing patient/caregiver satisfaction through quality. Pediatr Emerg Care. 2011;27(11):1016–21. Maister DH. The psychology of waiting lines. Harvard Business School Background Note 684 – 064, April 1984. (Revised May 1984.). Punches BE, Osuji E, Bischof JJ, et al. Patient perceptions of microaggressions and discrimination toward patients during emergency department care. Acad Emerg Med. 2023;30(12):1192–200. Punches BE, Brown JL, Soliman S, et al. Patient Pain Experiences and the Emergency Department Encounter: A Qualitative Analysis. Pain Manag Nurs. 2022;23(4):391–96. MacDonald S, Sampson C, Turley R, et al. Patients' Experiences of Emergency Hospital Care Following Self-Harm: Systematic Review and Thematic Synthesis of Qualitative Research. Qual Health Res. 2020;30(3):471–85. Reynolds WJ, Scott B, Jessiman WC. Empathy has not been measured in clients' terms or effectively taught: a review of the literature. J Adv Nurs. 1999;30(5):1177–85. Bernardo MO, Cecilio-Fernandes D, Costa P, et al. Physicians' self-assessed empathy levels do not correlate with patients' assessments. PLoS ONE. 2018;13(5):e0198488. Elliot R, Bohart A, Watson JC, Greenburg LS. Empathy Psychother. 2011;48(1):43–9. Additional Declarations No competing interests reported. Supplementary Files SupplementalFileAppendix.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 17 Sep, 2024 Editor assigned by journal 17 Sep, 2024 Submission checks completed at journal 17 Sep, 2024 First submitted to journal 06 Sep, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5045716","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":355099666,"identity":"3a3907d4-d8ed-43c2-bb86-c8d1a37a596d","order_by":0,"name":"Moriah Carmel","email":"","orcid":"","institution":"Indiana University","correspondingAuthor":false,"prefix":"","firstName":"Moriah","middleName":"","lastName":"Carmel","suffix":""},{"id":355099668,"identity":"63a86b93-6314-4469-a0d1-fc12d6cead42","order_by":1,"name":"Navneet Kaur","email":"","orcid":"","institution":"Indiana University","correspondingAuthor":false,"prefix":"","firstName":"Navneet","middleName":"","lastName":"Kaur","suffix":""},{"id":355099669,"identity":"9e4070e5-9d81-4d40-9d1e-9754ee842e72","order_by":2,"name":"Christian Strachan","email":"","orcid":"","institution":"Indiana University","correspondingAuthor":false,"prefix":"","firstName":"Christian","middleName":"","lastName":"Strachan","suffix":""},{"id":355099670,"identity":"612066e2-c2d8-4dc9-ae3a-cd2eef98e569","order_by":3,"name":"Andreia Alexander","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAuUlEQVRIiWNgGAWjYDACCQbGAyCanxlEshGnhQGsRbKZZC0GB4jVwj+7+cGBj212ecbHeQwYPpQdJsKSO8cMDs44k1xsdpjHgHHGOSK0MNxIMDjMU8GcuA2ohZm3jQgt8jfSPxz+Y1CfuLkZqOUvMVoMbuQYHGaoOJy4gRmohZEYLYZ3zhQc7DlzPHHGYTYg41w6YS1yt9s3PvjZVp3Y339444MfZdaEtaCAAySqHwWjYBSMglGACwAANSY/KYSE7rUAAAAASUVORK5CYII=","orcid":"","institution":"Indiana University","correspondingAuthor":true,"prefix":"","firstName":"Andreia","middleName":"","lastName":"Alexander","suffix":""}],"badges":[],"createdAt":"2024-09-06 18:04:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5045716/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5045716/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":71473184,"identity":"25c02c57-f99f-4242-8007-7cf0a3e78210","added_by":"auto","created_at":"2024-12-16 04:36:54","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":59156,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eModel of Emergency Department patient experience and interaction of overall theme\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure12.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5045716/v1/eb590d2b322777df0c2b36a2.jpg"},{"id":71474272,"identity":"ff2f149b-e873-40ec-9be7-fa61d0009ae2","added_by":"auto","created_at":"2024-12-16 04:44:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":664362,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5045716/v1/b44218dd-2bce-4f1c-925b-40aab2b22e05.pdf"},{"id":71473185,"identity":"708a86f5-64a6-4972-816b-55bce27a679b","added_by":"auto","created_at":"2024-12-16 04:36:55","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":16911,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalFileAppendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-5045716/v1/0ae125a4539fbcdf6c95f7f5.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eNavigating the unknown: A qualitative analysis exploring patient experience in the Emergency Department\u003c/p\u003e","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003ePatient experience within healthcare is an increasingly pivotal area of exploration, bearing significant implications for patient outcomes, financial performance, and physician satisfaction. The correlation between elevated patient experience levels and favorable outcomes [1], enhanced profitability [2], and heightened physician job satisfaction [3] underscores its significance as a quality-of-care metric. As healthcare systems progressively integrate patient experience assessments into their quality evaluations, understanding the factors shaping patient experiences becomes crucial.\u003c/p\u003e\n\u003cp\u003eHowever, existing literature predominantly adopts a quantitative lens, leaving a dearth of qualitative investigations into patient experiences [4], particularly within the Emergency Department (ED) context [5]. Qualitative methodologies offer a nuanced understanding of patients\u0026apos; emotions and perspectives during ED visits, serving as invaluable tools for pinpointing areas of improvement. While prior qualitative studies have explored individual facets such as care coordination [6] and wait times [7] in the ED, few have delved into comprehensive portrayals across diverse ED settings [8-9].\u003c/p\u003e\n\u003cp\u003eOur study addresses this gap by conducting a qualitative inquiry into the ED experiences of patients, encompassing both a large tertiary Urban Academic Center (UAC) and a rural community hospital (RCH). By leveraging a relatively large sample size, our research aims to elucidate the primary drivers shaping patients\u0026apos; ED experience and to discern how these factors diverge between the UAC and RCH environments.\u003c/p\u003e"},{"header":"2 Methods","content":"\u003cp\u003eThis was an exploratory study utilizing cross-sectional semi-structured one-on-one interviews based on a constructivism approach [10-11]. This study, which took place from April 2021 through February 2022, was approved by the Institutional Review Board at the authors\u0026rsquo; institution (Indiana University) on 7/19/2021. The study approval number is 12251. Participants received written and verbal information about the study, including the purpose of the study, and were informed that participation was voluntary and that they could withdraw from the study at any time. Verbal consent was obtained from participants. Each participant was given a $25 gift card for participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.1 Study Setting and Recruitment\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants were recruited from the EDs at a UAC and a RCH. The UAC, a Level 1 trauma center, sees about 90,000 patients per year and is staffed by Emergency Medicine (EM) faculty/residents, residents from other services, students, and advance practice providers (APPs). The RCH is a Level 3 trauma center that sees approximately 60,000 patients per year and is staffed by EM faculty and APPs, with intermittent medical students and Family Medicine/Internal Medicine residents. As a standard procedure, after discharge from the ED patients are contacted to complete patient experience surveys at which time they can opt-in to be contacted for additional feedback. Participants for this study were recruited from this opt-in pool. Patients were eligible to participate if they were able to speak and comprehend English, were 18 years of age or older, and were discharged from the ED. Initial recruitment emails and three reminder emails were sent to all eligible patients. Interviews were held on a rolling basis until theoretical saturation, the point at which no new information was being reported for at least 3 interviews, was reached. Individual interviews were held virtually over Zoom, lasting 45-60 minutes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2 Data Collection and Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThree study team members (authors AA and MC, along with research assistant NK) conducted semi-structured interviews. All three interviewers/facilitators are female, and none of them had relationship with any of the participants prior to the interview. AA, a physician faculty in the Department of EM with a PhD in Health Behavior specializing in qualitative research, led training sessions attended by MC and NK. Following training, MC and NK conducted practice interviews with EM residents under AA\u0026apos;s supervision, receiving real-time feedback. AA also reviewed and provided feedback on the first three patient interview recordings conducted by MC and NK. MC was a medical student at the time that the interviews were conducted, and NK was a staff member for the Department of EM. Other than being and Emergency Physician, AA did not have a particular interest in the topic of patient experience and was called upon by the Department of Emergency Medicine at her institution to conduct this study as a neutral party with an expertise in qualitative research.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInterviews focused on the participants\u0026rsquo; experiences during their most recent ED visit (Interview Guide, Appendix 1). Interviews were recorded and transcribed, and an audit trail was created [12].\u0026nbsp;Transcripts were not returned to participants for comment and/or correction. No interviews were repeated.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThroughout the participant recruitment, data collection, and data analysis process the researchers kept a field journal. This journal was used to document important ideas regarding study procedures, preliminary analyses, lessons learned, new patient experience related data, and patient experience related efforts.\u003c/p\u003e\n\u003cp\u003eData was analyzed using inductive content\u0026nbsp;analysis [13]. Each member of the research team openly coded the first five transcripts, identifying preliminary codes used in subsequent rounds of coding. The remaining transcripts were divided among MC and NK for coding. Throughout the analysis process the team met several times to discuss findings and codes. As a quality check, AA coded five random transcripts coded by\u0026nbsp;MC and NK. Disagreement between researchers was resolved through discussion. Participants did not provide feedback on the findings.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003eWe contacted 228 patients. Fifty-six patients agreed to participate in this study (UAC = 30, RCH = 26). No participants withdrew from the study. Most participants were female (n = 36, 64.2%) and White (n = 44, 78.6%). Participants were 24 to 75 years old. Demographics by site can be found in Table 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Demographics by Site\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 206px;\"\u003e\n \u003cp\u003eUrban Academic Center\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 209px;\"\u003e\n \u003cp\u003eRural Community Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 206px;\"\u003e\n \u003cp\u003eN = 30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 209px;\"\u003e\n \u003cp\u003eN = 26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"bottom\" style=\"width: 518px;\"\u003e\n \u003cp\u003eSex\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 105px;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 105px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e66.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 105px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 105px;\"\u003e\n \u003cp\u003e61.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e33.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 105px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 105px;\"\u003e\n \u003cp\u003e38.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"bottom\" style=\"width: 518px;\"\u003e\n \u003cp\u003eRace/Ethnicity\u003csup\u003e+\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 105px;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 105px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003eAsian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 105px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 105px;\"\u003e\n \u003cp\u003e3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003eBlack\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e20.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 105px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 105px;\"\u003e\n \u003cp\u003e15.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003eWhite\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e76.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 105px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 105px;\"\u003e\n \u003cp\u003e80.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"bottom\" style=\"width: 518px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003eMin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003eMax\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 105px;\"\u003e\n \u003cp\u003eMin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 105px;\"\u003e\n \u003cp\u003eMax\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 105px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 105px;\"\u003e\n \u003cp\u003e73\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"bottom\" style=\"width: 518px;\"\u003e\n \u003cp\u003e*This information was obtained from the information documented in the patient\u0026rsquo;s chart. At this time these EDs did not collect self-reported gender identity data, therefore only male and female were the only options.\u003c/p\u003e\n \u003cp\u003e\u003csup\u003e+\u003c/sup\u003eThis information was obtained from the information documented in the patient\u0026rsquo;s chart. These are the only race/ethnicities with at least 1 participant. All other races/ethnicities had zero participants, so those were left out of the chart. \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eWe identified four major themes (attitudes of staff, showing concern, patient-centered communication, and frequent updates) that appeared across six subthemes: what mattered most (WMM), wait time, rushed, end of visit, discrimination, and intent to return\u003cem\u003e;\u0026nbsp;\u003c/em\u003eand an overarching theme which encompasses all four major themes \u0026ndash; empathy. Figure 1 depicts how subthemes, major themes, and the overarching theme relate to each other.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.1 Theme: Attitudes of Staff\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFour sub-themes underpin this major theme: \u003cem\u003eWMM, Rushed, Discrimination, and Intent to Return. A\u003c/em\u003et\u003cem\u003etitudes of Staff\u0026nbsp;\u003c/em\u003eincluded behaviors/actions of staff perceived by participants as reflecting positive or negative feelings about them as patients or staffs\u0026rsquo; feelings about working in the ED. Some participants described staff displaying positive attitudes such as being \u0026ldquo;pleasant,\u0026rdquo; \u0026ldquo;friendly,\u0026rdquo; \u0026ldquo;respectful,\u0026rdquo; \u0026ldquo;courteous,\u0026rdquo; \u0026ldquo;polite,\u0026rdquo; and \u0026ldquo;kind.\u0026rdquo; Other participants described staff displaying negative attitudes such as being \u0026ldquo;apathetic,\u0026rdquo; \u0026ldquo;impatient,\u0026rdquo; and \u0026ldquo;rude.\u0026rdquo; Participants expressed that the attitude of all members of their healthcare team mattered, from the front desk staff to technicians to cleaning staff, not only providers and nurses. Moreover, participants discussed the importance of perceived attitudes of staff not only towards themselves but also towards the loved ones accompanying them.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.1.1 Subtheme: WMM\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants frequently reported that attitudes of their healthcare team mattered most to them during their ED visit. Some participants described positive attitudes in terms of receiving kind, reassuring words from their healthcare team. One participant described this as relating to them on a personal level, stating:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Being able to talk to somebody who was willing to share that and say, \u0026lsquo;hey, here\u0026apos;s kind\u0026nbsp;\u003c/em\u003e\u0026nbsp; \u003cem\u003eof what I personally experienced, it sounds like it\u0026apos;s pretty close to what you\u0026apos;re\u0026nbsp;\u003c/em\u003e\u003cem\u003eexperiencing\u0026rsquo; was reassuring.\u0026rdquo; (RCH8)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThough participants could not always remember specific actions that their healthcare team took, they remembered how their healthcare team made them feel. For example, a participant recounted a story in which she came into the ED for a mental health concern. She recalled feeling anxious prior to being seen but that the attitudes of her physicians and nurses put her \u0026ldquo;at ease.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.1.2 Subtheme: Rushed\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the subtheme \u0026ldquo;Rushed,\u0026rdquo; participants discussed not wanting to feel as though they were a burden to staff. Additionally, participants expressed the importance of treating patients as individuals rather than another \u0026quot;cog in the wheel.\u0026rdquo; For example, one participant stated:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;[Some of the staff] look so annoyed with what you\u0026apos;re saying and the fact that you\u0026apos;re\u0026nbsp;\u003c/em\u003e \u003cem\u003eeven there...There was a lot of whispering and giggling. A couple of them curled their\u0026nbsp;\u003c/em\u003e\u0026nbsp; \u0026nbsp;\u003cem\u003enose and rolled their eyes...The nurse seemed really irritated and kept looking around\u0026nbsp;\u003c/em\u003e\u003cem\u003ethe room, like, \u0026lsquo;\u003c/em\u003eif you\u0026apos;ll shut up now, I can go get the doctor.\u0026rsquo;\u0026rdquo; \u003cem\u003e(RCH21)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn contrast, another participant stated:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;They genuinely would stop and listen to me. I could tell they were busy...But they gave\u0026nbsp;\u003c/em\u003e\u0026nbsp; \u0026nbsp;\u003cem\u003eme the time that I felt like I deserved or needed. [They] addressed me by name...They\u0026nbsp;\u003c/em\u003e\u0026nbsp; \u0026nbsp;\u003cem\u003enever made [me] feel unworthy.\u0026rdquo; (RCH8)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.1.3 Subtheme: Discrimination\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants described discriminatory attitudes as staff displaying judgmental and assumptive behaviors or actions. Negative attitudes were perceived through the actions, communication from, and body language of staff. For some, this was explicit, such as one participant who stated:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;You would just kind of see whispering over to the side while you were being treated and you\u0026apos;re just sitting there like, \u0026lsquo;well, I wonder what they\u0026apos;re saying.\u0026rsquo; Sometimes you could hear them saying different things like, \u0026lsquo;well, you know, she\u0026apos;s got diabetes or whatever.\u0026rsquo; And made it seem like that your pre-existing conditions should make a difference on what\u0026apos;s happening to you.\u0026rdquo; (UAC26).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome participants could not provide specific examples of discrimination but remembered feeling that something was \u0026ldquo;off.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.1.4 Subtheme: Intent to Return\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Attitudes of Staff\u0026rdquo; often influenced the likelihood that participants would return that ED in the future, with positive attitudes motivating them to return and negative attitudes dissuading them from returning. For example, one participant described their intent to return to the same ED because \u0026ldquo;it left a positive feeling.\u0026rdquo; In contrast, participants often cited experiences with staff being \u0026ldquo;rude\u0026rdquo; or \u0026ldquo;unprofessional\u0026rdquo; as being a primary driver dissuading them from returning. For example, one participant described an experience where she fell off her chair in the waiting room:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The triage nurse was so rude to me. She was like, you know, basically, \u0026ldquo;get off the\u0026nbsp;\u003c/em\u003e\u003cem\u003efloor\u0026rdquo;...It was her whole demeanor.\u0026rdquo; (UAC1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2 Theme: Showing Concern\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFive subthemes underpin this major theme: \u003cem\u003eWMM, Wait Time, Rushed, End of Visit, and Discrimination. \u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants described \u0026ldquo;showing concern\u0026rdquo; as being treated like a unique individual rather than a medical condition or checkbox, feeling that their healthcare team took their symptoms seriously, and that their healthcare team valued their expertise and knowledge of their own bodies and medical conditions. Participants who perceived their healthcare team showing concern were more likely to have confidence in the care they received. Conversely, those who felt that their healthcare team did not show concern expressed feeling dehumanized and that their expectations were not met. For example, one participant shared:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I was brought in by an ambulance. It was a very busy day for the emergency\u0026nbsp;\u003c/em\u003e \u003cem\u003edepartment...No one even looked at me or touched me. When they brought me in, I\u0026nbsp;\u003c/em\u003e \u003cem\u003edidn\u0026rsquo;t have clothes [or shoes] on. I had to go sit in the waiting room in a sheet. It was\u0026nbsp;\u003c/em\u003e \u003cem\u003every degrading.\u0026quot; (UAC9)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants also appreciated small gestures from their healthcare team that showed concern such as offering them a warm blanket or asking if the participant wanted the lights on or off. Participants viewed these gestures as their healthcare team caring about and valuing them.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2.1 Subtheme: Wait Time\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhen discussing their experiences with waiting during their ED visit, participants discussed not wanting to \u0026ldquo;feel alone,\u0026rdquo; such as one participant who stated that they, \u0026ldquo;spent a lot of time alone\u0026nbsp;just wondering what\u0026apos;s going on\u0026rdquo; (RCH 10). Another participant discussed an experience where they were forgotten about for 3-4 hours and when the nurse finally came, said, \u0026ldquo;I didn\u0026apos;t even know you were down here.\u0026rdquo; Participants who felt alone while waiting also described feeling as though they were not important to their healthcare team and that their healthcare team was not concerned about their well-being.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2.2 Subtheme: Rushed \u0026amp; End of Visit\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWithin this subtheme, participants discussed their experiences feeling rushed by their healthcare team, particularly during discharge. Participants felt that their providers cared about their well-being when they were given adequate time to ask questions, such as one participant who stated: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;They showed interest. I wasn\u0026rsquo;t dismissed or felt like they had more important things to\u0026nbsp;\u003c/em\u003e\u0026nbsp; \u0026nbsp;\u003cem\u003edo or get back to, or that it was a minor concern and that I was over exaggerating it. I\u0026nbsp;\u003c/em\u003e\u003cem\u003ewas taken seriously, and I felt like I was an equal part of my care team.\u0026rdquo; (UAC21)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOn the other hand, when rushed, participants reported feeling frustrated, confused, unimportant or as an inconvenience to staff, or that their providers simply saw them as an item on their \u0026ldquo;to do\u0026rdquo; list rather than an individual. For example, one participant when asked about the time they spent with the provider stated:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think they were in a hurry...[It made me feel] disappointed. I mean, I\u0026apos;m like, \u0026ldquo;okay, I\u0026nbsp;\u003c/em\u003e\u0026nbsp; \u0026nbsp;\u003cem\u003ecame here for\u003c/em\u003e \u003cem\u003ehelp, and I get nothing. So, then what\u0026apos;s the point of me coming?\u0026rdquo\u003c/em\u003e\u003cem\u003e(UAC10)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2.3 Subtheme: Discrimination\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis subtheme included validation of participants concerns, dismissive language or actions, and thoroughness of clinical care.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants discussed experiences where their symptoms were not taken seriously, which participants attributed to factors including race/ethnicity, age, physical appearance, and medical history. Participants often perceived this as their providers not trusting, listening to, or disregarding their concerns. For example, one participant felt that her symptoms were not taken seriously because she \u0026ldquo;didn\u0026rsquo;t look sick\u0026rdquo; when she was having an adrenal crisis.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;A lot of times, people just assume because I\u0026apos;m young and I look fine, I am fine. Because\u0026nbsp;\u003c/em\u003e \u003cem\u003eI was younger, I was put on the backburner for several hours.\u0026rdquo; (RCH16)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants often discussed experiences in which they felt discriminated against based on their history of chronic pain. Participants felt that their healthcare team did not care about their pain or assumed that they were exaggerating or \u0026ldquo;faking\u0026rdquo; their pain. When this happened, participants felt \u0026ldquo;dehumanized.\u0026rdquo; For example, several participants discussed feeling as though they were labeled as \u0026ldquo;drug seeking\u0026rdquo; and because of this were not given adequate pain management. One participant stated that they felt that healthcare professionals often forget that \u0026ldquo;they are people, too\u0026rdquo; and encouraged healthcare professionals to remember that \u0026ldquo;regardless of whether they\u0026apos;re addicted or not, it\u0026apos;s still real pain.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.3 Theme: Patient-Centered Communication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe major theme\u003cem\u003e\u0026nbsp;Patient-Centered Communication\u0026nbsp;\u003c/em\u003eincludes subthemes: \u003cem\u003eWMM, Wait Time, Rushed, and End of Visit\u003c/em\u003e. Participants described Patient-Centered Communication as 1) using patient-entered language, 2) providing opportunities to ask questions to solidify patient understanding of their care plan, diagnosis, discharge instructions, and follow-up plan, 3) providing rationale for medical decision making, and 4) providing reasons for extended periods of waiting.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.3.1 Subtheme: WMM\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhen asked WMM to them during their ED visit, the most frequent response was that \u0026ldquo;their reason for coming in was addressed.\u0026rdquo; Participants felt this expectation was met when they were informed about their care plan and included in making this plan. Participants felt that this was achieved when their provider actively listened to their concern, considered their input, and explained medical decision-making. When this did not happen, participants felt confused and anxious. For instance, the participant discussed her experience not receiving the rationale for certain medical procedures being performed:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;They started doing the EKG on me with no explanation. So, I was like, \u0026lsquo;Hey, why are\u0026nbsp;\u003c/em\u003e\u0026nbsp; \u003cem\u003eyou doing that?\u0026rsquo;\u0026rdquo; (UAC35)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.3.2 Subtheme: Wait Time\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWithin this subtheme, participants discussed the importance of providing explanations for any extended period of wait and ensuring patients understand their plan of care, so they don\u0026rsquo;t feel \u0026ldquo;left in the dark.\u0026rdquo; Participants felt that this could be best achieved by explaining their care plan and an estimated wait time at the beginning of their visit.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants expressed understanding that the ED is an unpredictable environment and that sicker patients that take precedence could walk in the door at any time; however, participants explained the importance of \u0026ldquo;keeping patients in the loop\u0026rdquo; about any potential delays in care.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think it would make it easier to wait when you actually know. At least if it\u0026apos;s\u0026nbsp;\u003c/em\u003e\u003cem\u003enot\u0026nbsp;happening right away, you know.\u0026rdquo; (RCH11)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants felt \u0026ldquo;seen\u0026rdquo; when their healthcare team communicated delays. One participant gave an example of how healthcare providers can communicate empathy when there are delays in care: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I see you; you\u0026rsquo;re going to be seen, and we\u0026rsquo;ll get to you as fast as we can. I think that\u0026nbsp;\u003c/em\u003e\u003cem\u003ewould go a long way.\u0026rdquo; (UAC9)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.3.3 Subtheme: Rushed \u0026amp; End of Visit\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this sub-theme, participants discussed their experiences with staff explaining discharge instructions and diagnosis, citing the importance of explaining concepts \u0026ldquo;using patient terms.\u0026rdquo; and avoiding using medical jargon whenever possible.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMoreover, participants expressed the importance of confirming that patients understand what is being told to them and providing them with the space to ask clarifying questions without feeling rushed. When this happened, participants felt more prepared to leave the ED and confident in the care they received. For example, one participant discussed receiving ample information not only about her discharge instructions but also insights into how to manage her chronic medical condition once she left the ED:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;They went in depth on my condition. Like they knew the ins and outs of it... They told me\u0026nbsp;\u003c/em\u003e\u003cem\u003ewhat to do when I have those flare ups again.... So, I trust them a lot.\u0026rdquo; (UAC1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eConversely, when participants received either limited, inadequate, or poorly explained information, they were left with a sense of frustration, confusion, and felt that their needs and expectations had not been met. For example, one participant described how she was told \u0026ldquo;they couldn\u0026rsquo;t do anything\u0026rdquo; for her son after they presented with severe abdominal pain, and that he needed a colonoscopy. However, it was not explained to her what the next steps should be and why they were not able to complete the colonoscopy during that ED visit. As a result, the participant was visibly frustrated to the point of tears during her interview, as she felt that the healthcare team did not care about her son and dismissed his pain.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.4 Theme: Frequent Updates\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe major theme \u003cem\u003eFrequent Updates\u003c/em\u003e includes the subthemes: \u003cem\u003eWMM, Wait Time, and Intent to Return.\u003c/em\u003e Participants described \u003cem\u003eFrequent Updates\u0026nbsp;\u003c/em\u003eas being consistently updated on their care plan and estimated wait times during any part of their visit.\u003c/p\u003e\n\u003cp\u003eReceiving limited updates contributed to feelings of anxiety and fear over the seriousness of their condition, as well as feeling forgotten about, alone, and overwhelmed. For several participants, their healthcare team served as their only companionship. One participant stated:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Even if you\u0026apos;re a healthcare professional, it\u0026rsquo;s kind of a scary place. I was nervous and\u0026nbsp;\u003c/em\u003e\u003cem\u003eI was alone. I didn\u0026apos;t have any family members or anything.\u0026rdquo; (UAC24)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants felt their healthcare team could provide a sense of companionship by introducing themselves at the start of the visit. As one participant explained: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Once we established contact, it was lot less being alone.\u0026rdquo; (UAC14)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eReceiving frequent updates made participants feel \u0026ldquo;seen\u0026rdquo; by their healthcare team, which participants defined as showing sympathy and care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.4.1 Subtheme: WMM\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMany participants indicated that being consistently updated and informed about their care mattered most to them during their ED visit. Receiving updates made them feel they were receiving the attention they needed and increased confidence in the care received. For one participant, she discussed that being updated mattered most to her because she had her young son with her and needed to coordinate his care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.4.2 Subtheme: Wait Time \u0026amp; Intent to Return\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWithin this sub-theme, participants discussed their experiences waiting during any point of their ED visit. Having a long wait during any point in their ED visit was \u0026ldquo;frustrating.\u0026rdquo; Negative feelings associated with long periods without updates (anywhere between 30-120 minutes) contributed to participants\u0026apos; overall feelings towards their ED visit. However, despite being frustrated, most participants understood that the ED is a busy environment and that there are often other patients of higher acuity who are being looked after. Participants revealed that rather than caring about the actual length of their wait, they cared about how often they were updated on how long their wait would be. When participants were updated on delays in care, they felt that they were getting the attention they needed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMany participants indicated that long waits and the level of attention they received during periods of waiting affected their intent to return to that ED in the future.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.5 Overarching Theme: Empathy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThough themes such as attitudes of staff and frequent updates may appear as distant concepts from a surface level view, patients\u0026rsquo; thoughts and feelings about their experiences were linked across the 6 subthemes and 4 major themes through the overarching theme, empathy. This theme connects participants\u0026rsquo; experiences to the emotion behind these experiences.\u003c/p\u003e\n\u003cp\u003eTable 2 contains quotes which illustrate how the overarching theme \u0026ldquo;empathy\u0026rdquo; fits within the four major themes.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 183px;\"\u003e\n \u003cp\u003eMajor Themes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 423px;\"\u003e\n \u003cp\u003eExemplar quotes from participant interviews\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 183px;\"\u003e\n \u003cp\u003eAttitudes of Staff\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 423px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I always pay\u0026nbsp;attention to doctors, nonverbals.\u0026nbsp;I think what they\u0026apos;re\u0026nbsp;saying is extremely important,\u0026nbsp;but I think even more\u0026nbsp;important is how they say it.\u0026nbsp;I thought the staff\u0026nbsp;always was very calm.\u0026nbsp;[They] didn\u0026rsquo;t seem stressed\u0026nbsp;or worried even if it would have\u0026nbsp;been something that caused them some worry...I think just overall\u0026nbsp;like the cadence in which they spoke.\u0026nbsp;Obviously, they\u0026apos;re all brilliant people. I\u0026apos;d imagine they\u0026nbsp;were very accurate with\u0026nbsp;what they were saying,\u0026nbsp;but it was how they said\u0026nbsp;it. And also that they were really nice to\u0026nbsp;my wife who was there with me.\u0026nbsp;That was really important to me.\u0026rdquo; (UAC27)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 183px;\"\u003e\n \u003cp\u003eShowing Concern\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 423px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;[The doctor] was very kindhearted. She\u0026apos;s a very sweet lady, and I would just like to say that when I told her I was hurting, she held my hand.\u0026rdquo; (UAC29)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 183px;\"\u003e\n \u003cp\u003ePatient-centered Communication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 423px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The staff were really responsive in terms of just letting me know what they were going to do, who they were, what their jobs were, and describing what came next. I was pretty scared at the time, so it was really helpful to me for them to communicate so well... [It made me feel] a lot calmer. It helps to have information. I\u0026apos;m not a person who looks freaked out, and people tend to misread that. They\u0026apos;re just like, \u0026ldquo;Oh, she\u0026apos;s calm, she\u0026apos;s just fine.\u0026rdquo; But inside, there\u0026apos;s a lot going on, and it really helped me. I didn\u0026apos;t have to tell them I\u0026apos;m freaking out; they just did that. And I\u0026apos;m assuming they do that with everybody.\u0026quot; (UAC22)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 183px;\"\u003e\n \u003cp\u003eFrequent Updates\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 423px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The staff were both professional and clearly showed\u0026nbsp;a sense of caring\u0026nbsp;despite the fact that they\u0026nbsp;were busy...\u0026nbsp;while I knew I was one of many patients,\u0026nbsp;they did a really good job\u0026nbsp;of making me feel like I was one of\u0026nbsp;only a few patients\u0026nbsp;that they were actually tending to.\u0026nbsp;They made me feel like I was getting the attention that I needed and kept me informed.\u0026rdquo; (RCH5)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Exemplar Empathy Quotes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.6 Urban Academic Center vs Rural Community Hospital\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOverall, the subthemes and major themes were similar across both the UAC and the RCH. However, the primary differences between the UAC and the RCH included \u003cem\u003econfidence in care\u0026nbsp;\u003c/em\u003eand the \u003cem\u003eED environment\u003c/em\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMost participants indicated that they would return to the UAC in the future because they trusted the care they received. Some commented that the physicians at the UAC were smart, trusted, and dedicated. Participants also remarked that the UAC is an established \u0026ldquo;cutting edge\u0026rdquo; facility.\u003c/p\u003e\n\u003cp\u003eThere was a distinction between how participants described the ED environment of the UAC versus the RCH. As opposed to the RCH where participants described the ED environment as \u0026ldquo;calm\u0026rdquo; and \u0026ldquo;quiet,\u0026rdquo; participants described the UAC as being \u0026ldquo;noisy\u0026rdquo; and \u0026ldquo;chaotic.\u0026rdquo; A participant described a \u0026ldquo;chaotic\u0026rdquo; experience where police were called into the ED, which left them feeling \u0026ldquo;unsettled.\u0026rdquo;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnother major difference between the UAC and the RCH was the use of hallway beds at the UAC. Participants expressed negative feelings seeing other patients in hallway beds and when they were placed in a hallway bed. Participants felt that the presence and use of hallway beds contributed to feeling that the ED was \u0026ldquo;busy\u0026rdquo; and \u0026ldquo;crowded.\u0026rdquo;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhen placed in a hallway bed during their visit patients felt \u0026ldquo;degraded,\u0026rdquo; saying that it made them feel as though they weren\u0026rsquo;t \u0026ldquo;important enough to even be in a room.\u0026rdquo; Participants felt \u0026ldquo;exposed\u0026rdquo; and that their privacy was compromised.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;[It made me feel] uncomfortable, a little bit unsafe, a tiny bit sort of\u003c/em\u003e \u003cem\u003ethreatened.\u0026rdquo; (UAC20)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThose who were not placed in hallway beds still had negative feelings surrounding this, such as one participant who stated:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I saw lots of elderly in a hallway bed. I felt terrible that I had a room and they didn\u0026rsquo;t.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u0026nbsp; \u003cem\u003e(UAC6)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAt the heart of the issue was not actually being placed in hallway beds but the lack of communication from staff regarding why patients were placed in hallway beds. Though most participants did not like being placed in a hallway bed, they understood why this happens. Patients said they felt that if it was explained why they were placed in a hallway bed, this would have relieved some anxiety.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think that it would alleviate some discomfort and anxiety if they just had a couple\u0026nbsp;\u003c/em\u003e\u003cem\u003esentences -- the ER is really busy right now and we need to put you in the hallway at the\u0026nbsp;\u003c/em\u003e\u0026nbsp; \u003cem\u003emoment until a bed opens up.\u0026rdquo; (UAC20)\u003c/em\u003e\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study explored adult patient experiences at two large, yet different, EDs \u0026ndash; a UAC and an RCH.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants in the study articulated the importance of the patient-staff relationship. The major themes of \u003cem\u003eattitudes of staff, showing concern, patient-centered communication, and frequent updates\u0026nbsp;\u003c/em\u003ealign with the concept of patient-centered care previously discussed in the literature [9,14-16].\u003c/p\u003e\n\u003cp\u003eThroughout our study, we found that regardless of the questions asked, participants\u0026rsquo; answers were encompassed within one or more of the four major themes, which collectively aligned with an overarching theme of empathy. Viewing the major themes as being nested within a single overarching theme allows us to understand participants responses from a holistic perspective. Moreover, viewing the data from this perspective helps us understand how and why certain behaviors evoked certain emotions in participants. Rather than specific behaviors and actions from staff being important, it\u0026rsquo;s the perception of empathy related to these behaviors and actions which mattered most to participants. While previous research has discussed empathy [15-18], none have identified empathy as a connecting thread across themes in patient ED experience.\u003c/p\u003e\n\u003cp\u003eHajot et al [19] describes empathy in the context of patient care as \u0026ldquo;a predominantly \u003cem\u003ecognitive\u003c/em\u003e attribute that involves an \u003cem\u003eunderstanding\u003c/em\u003e of experiences, concerns, and perspectives of the patient, combined with a capacity to \u003cem\u003ecommunicate\u003c/em\u003e this understanding, and an \u003cem\u003eintention to help.\u0026rdquo;\u0026nbsp;\u003c/em\u003eBy understanding patients\u0026rsquo; experiences and stories, we are not only able to better understand how empathy functions within a clinical setting but may also be able to better determine quality improvement measures to improve patient experiences. For example, our study found that small gestures showing concern from the healthcare team improved patients\u0026rsquo; experiences. These actions can be coached and audited to improve patient experience. Studies have found that empathic engagement in patient care leads to improved patient outcomes [20-21]. Moreover, research has shown that empathy may be a protective factor of physician burnout [22].\u003c/p\u003e\n\u003cp\u003eWait time is a common theme within ED patient experience literature [5,15-16,18]. In our data, wait time is reframed when it encompasses \u003cem\u003eempathy\u003c/em\u003e. This idea is reinforced by prior studies that show the actual length of a patient\u0026rsquo;s wait time is less important than perceived quality of health interaction and interpersonal communication [23]. Furthermore, modifiable factors, such as proactively informing patients of delays and explicitly apologizing for delays, affect patients\u0026rsquo; perception of wait time and have a greater impact on patient experience than actual wait times [24]. New AI technology is currently being developed and implemented to provide real-time updates to patients. This software may address wait times, however, given that this takes the personal touch out of the interaction, effects on patient experience using this technology should be studied further.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePerceived empathetic interactions between healthcare providers and patients are seen within the subtheme \u003cem\u003ediscrimination.\u0026nbsp;\u003c/em\u003eConsistent with previous literature, participants in our study attributed experiences of discrimination, microaggressions, and harassment while in the ED to factors that not only included race and gender but also age, physical appearance, and types of chief complaints, especially those related to pain (chronic and acute) and mental health [25-27]. Furthermore, many participants discussed previous experiences of discrimination that extended beyond their ED visit, such as experiences with primary care physicians or previous ED visits. As discussed by Punches BE et al. [25], \u0026ldquo;previous experiences of discrimination may have lasting effects on patient perceptions of current healthcare,\u0026rdquo; which makes understanding patients\u0026apos; feelings and emotions regarding experiences of discrimination and microaggressions important and should be further studied.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIt is important to note that fixating on empathy as a \u0026ldquo;catch all\u0026rdquo; cure for eliminating discrimination is problematic and misguided. Internal and external bias are core components of discrimination. For example, participants also described systematic issues outside the control of their healthcare team, such as patient forms not being gender inclusive or chairs not being big enough for plus sized patients to sit in. Therefore, we must also go beyond the individual patient-healthcare team interaction when addressing discrimination in the healthcare setting. Moreover, although it is not necessary to share the same experiences as another to be empathetic, lived experiences can limit our ability to grasp how another person feels and internalized bias towards certain populations can influence if/how someone chooses to display empathy. Understanding patients\u0026rsquo; perceptions of discrimination and understanding how perceived empathetic interactions between patients and their healthcare team are a component of patients\u0026rsquo; perceptions of discrimination can inform efforts to reduce disparities in clinical care and improve patient experience.\u003c/p\u003e\n\u003cp\u003eThough research has shown the importance of empathy in clinical care, understanding how empathy functions within the patient-physician relationship is less known. Current measures of empathy fail to reflect patients\u0026rsquo; views about the healthcare team\u0026rsquo;s ability to offer empathy. If patients can perceive the amount of empathy in helping relationships, they can provide valuable insights as to how professionals can offer empathy [28]. Knowledge about empathy has mostly originated from physicians\u0026rsquo; perspectives, often using self-assessment tools. However, there is a lack of correlation between physician self-assessed empathy levels and patients\u0026rsquo; perception of empathy [29]. On the other hand, patients\u0026rsquo; perceptions of therapist empathy predicted outcomes better than therapist self-perceptions of their own empathy [30]. This suggests that patients should be included in the process of empathy evaluation, and further research should be conducted in this area.\u003c/p\u003e\n\u003cp\u003eWhen comparing the data from the UAC to the RCH, a primary difference between the environment at the UAC and RCH was the use of hallway beds. Participants don\u0026rsquo;t like hallway beds. However, experience improved when the patient felt they were important, and their privacy would be respected. Our findings are consistent with available literature showing that satisfaction among patients treated in hallways appeared to be mainly dictated by caring/empathetic interactions with staff and communication variables of understanding ED procedures [17]. Though hospitals may not be able to reconfigure the structure or environment of their ED, our results illustrate how efforts such as explaining to patients why they are being placed in a hallway bed can alleviate negative feelings associated with them.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.1 Study Limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeveral limitations should be considered when evaluating the results of this study. As with any qualitative study, the results are not generalizable. While we do not consider this to be a limitation, it is important to remind the readers of this fact. The goal of this qualitative study was to provide in-depth explanations rather than generalized findings. Participants were all self-selected, creating self-selection bias. Though this study included a larger sample size than many existing qualitative studies on ED patient experience, the sample size is still small, as is characteristic of qualitative studies. Some of the patients included in this study visited the ED during the COVID-19 pandemic, both during times when patient volumes were high and times in which volumes were low. The timing of their ED could have influenced their perspective on many of the themes discussed in this paper. Finally, this was an unfunded study, and, as a result, interpretation services were not available for this study. Therefore, the perspectives of non-English speaking patients are not represented in this study. Future studies should look to include non-English speaking patients as this is a very important perspective that is missing from the literature.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe patient-staff relationship is a critical component of patient experience in the ED. Specifically, our findings show that a patient\u0026rsquo;s perceptions of healthcare staff empathy is a critical driver in influencing overall ED patient experience. Future studies should include further characterization of patients\u0026rsquo; perceptions of healthcare provider empathy and its impact on ED patient experience.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eEmergency Department (ED)\u003c/p\u003e\n\u003cp\u003eRural Community Hospital (RCH)\u003c/p\u003e\n\u003cp\u003eUrban Academic Center (UAC)\u003c/p\u003e\n\u003cp\u003eEmergency Medicine (EM)\u003c/p\u003e\n\u003cp\u003eAdvance Practice Providers (APPs)\u003c/p\u003e\n\u003cp\u003eWhat Mattered Most (WMM)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e this study, which took place from April 2021 through February 2022, was approved by the Institutional Review Board at the authors\u0026rsquo; institution (Indiana University) on 7/19/2021. The study approval number is 12251. The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.\u003c/p\u003e\n\u003cp\u003eParticipants received written and verbal information about the study and were informed that participation was voluntary and that they could withdraw from the study at any time. Verbal consent was obtained from participants. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003en/a\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003edata collected and analyzed in this study is available on request from the authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e no competing interests to report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e no funding sources to report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final version of this manuscript.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCriteria\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAuthor Initials\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003eMade substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003eMC\u003c/p\u003e\n \u003cp\u003eNK\u003c/p\u003e\n \u003cp\u003eSC\u003c/p\u003e\n \u003cp\u003eAA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003eInvolved in drafting the manuscript or revising it critically for important intellectual content;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003eMC\u003c/p\u003e\n \u003cp\u003eCS\u003c/p\u003e\n \u003cp\u003eAA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003eGiven final approval of the version to be published. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003eMC\u003c/p\u003e\n \u003cp\u003eNK\u003c/p\u003e\n \u003cp\u003eSC\u003c/p\u003e\n \u003cp\u003eAA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 396px;\"\u003e\n \u003cp\u003eAgreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 204px;\"\u003e\n \u003cp\u003e\u0026nbsp;MC\u003c/p\u003e\n \u003cp\u003eNK\u003c/p\u003e\n \u003cp\u003eSC\u003c/p\u003e\n \u003cp\u003eAA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u0026nbsp;\u003c/strong\u003eno acknowledgments to add.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKelley JM, Kraft-Todd G, Schapira L, Kossowsky J, Riess H. The influence of the patient-clinician relationship on healthcare outcomes: a systematic review and meta-analysis of randomized controlled trials. PLoS ONE. 2014;9(4):e94207.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRichter JP, Muhlestein DB. Patient experience and hospital profitability: Is there a link? Health Care Manage Rev. 2017;42(3):247\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZgierska A, Rabago D, Miller MM. Impact of patient satisfaction ratings on physicians and clinical care. Patient Prefer Adherence. 2014;8:437\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNairn S, Whotton E, Marshal C, Roberts M, Swann G. The patient experience in emergency departments: a review of the literature. Accid Emerg Nurs. 2004;12(3):159\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBull C, Latimer S, Crilly J, Gillespie BM. A systematic mixed studies review of patient experiences in the ED. Emerg Med J. 2021;38(8):643\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChang L, Wanner KJ, Kovalsky D, Smith KL, Rhodes KV. It's Really Overwhelming: Patient Perspectives on Care Coordination. J Am Board Fam Med. 2018;31(5):682\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCross E, Goodacre S, O'Cathain A, Arnold J. Rationing in the emergency department: the good, the bad, and the unacceptable. Emerg Med J. 2005;22(3):171\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAleksandrovskiy I, Ganti L, Simmons S. The emergency department patient experience: in their own words. J Patient Experience. 2022;9:23743735221102455.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBull C, Latimer S, Crilly J, Spain D, Gillespie BM. I knew I'd be taken care of': Exploring patient experiences in the Emergency Department. J Adv Nurs. 2022;78(10):3330\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMills J, Bonner A, Francis K. Adopting a constructivist approach to grounded theory: Implications for research design. Int J Nurs Pract. 2006;12(1):8\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMogashoa T. Applicability of constructivist theory in qualitative educational research. Am Int J Contemp Res. 2014;4(7):51\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRodgers BL, Cowles K. The qualitative research trail: A complex collection of documentation. Res Nurs Health. 1993;16(3):216\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77\u0026ndash;101.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcConnell D, McCance T, Melby V. Exploring person-centeredness in emergency departments: A literature review. Int Emerg Nurs. 2016;26:38\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGordon J, Sheppard LA, Anaf S. The patient experience in the emergency department: A systematic synthesis of qualitative research. Int Emerg Nurs. 2010;18(2):80\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGraham B, Endacott R, Smith JE, Latour JM. They do not care how much you know until they know how much you care': a qualitative meta-synthesis of patient experience in the emergency department. Emerg Med J. 2019;36(6):355\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVillalona S, Cervantes C, Boxtha C, Webb WA, Wilson JW. I Felt Invisible Most of the Time: Communication and satisfaction among patients treated in emergency department hallway beds. Am J Emerg Med. 2020;38(12):2742\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSonis JD, Aaronson EL, Lee RY, Philpotts LL, White BA. Emergency Department Patient Experience: A Systematic Review of the Literature. J Patient Exp. 2018;5(2):101\u0026ndash;06.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHojat M. Empathy and patient outcomes. In: Hojat M. Empathy in health professions education and patient care. 1st edition. New York City, NY: Springer Publishing; 2016. pp. 189\u0026ndash;201.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHojat M, Louis DZ, Maio V, Gonnella JS. Empathy and health care quality. Am J Med Qual. 2013;28(1):6\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDel Canale S, Louis DZ, Maio V, et al. The relationship between physician empathy and disease complications: an empirical study of primary care physicians and their diabetic patients in Parma, Italy. Acad Med. 2012;87(9):1243\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThirioux B, Birault F, Jaafari N. Empathy Is a Protective Factor of Burnout in Physicians: New Neuro-Phenomenological Hypotheses Regarding Empathy and Sympathy in Care Relationship. Front Psychol. 2016;7:763.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLocke R, Stefano M, Koster A, Taylor B, Greenspan J. Optimizing patient/caregiver satisfaction through quality. Pediatr Emerg Care. 2011;27(11):1016\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaister DH. The psychology of waiting lines. Harvard Business School Background Note 684\u0026thinsp;\u0026ndash;\u0026thinsp;064, April 1984. (Revised May 1984.).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePunches BE, Osuji E, Bischof JJ, et al. Patient perceptions of microaggressions and discrimination toward patients during emergency department care. Acad Emerg Med. 2023;30(12):1192\u0026ndash;200.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePunches BE, Brown JL, Soliman S, et al. Patient Pain Experiences and the Emergency Department Encounter: A Qualitative Analysis. Pain Manag Nurs. 2022;23(4):391\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacDonald S, Sampson C, Turley R, et al. Patients' Experiences of Emergency Hospital Care Following Self-Harm: Systematic Review and Thematic Synthesis of Qualitative Research. Qual Health Res. 2020;30(3):471\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReynolds WJ, Scott B, Jessiman WC. Empathy has not been measured in clients' terms or effectively taught: a review of the literature. J Adv Nurs. 1999;30(5):1177\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBernardo MO, Cecilio-Fernandes D, Costa P, et al. Physicians' self-assessed empathy levels do not correlate with patients' assessments. PLoS ONE. 2018;13(5):e0198488.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElliot R, Bohart A, Watson JC, Greenburg LS. Empathy Psychother. 2011;48(1):43\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Emergency Department, Patient Experience, Empathy","lastPublishedDoi":"10.21203/rs.3.rs-5045716/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5045716/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003ePatient experience within healthcare is an increasingly pivotal area of exploration. The objective of this study was to use qualitative methods to elucidate the primary drivers shaping patients' ED experience and to discern how these factors diverge between the UAC and RCH environments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eQualitative, semi-structured individual interviews with ED patients were conducted across two EDs, an urban academic center (UAC) and a rural community hospital (RCH). An inductive thematic analysis approach was used.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Fifty-six participants were interviewed. Four major themes (attitudes of staff, showing concern, patient-centered communication, and frequent updates) emerged across six subthemes: what mattered most, wait time, rushed, end of visit, discrimination, and intent to return\u003cem\u003e; \u003c/em\u003ewith an overarching theme which encompasses all four major themes – empathy. Overall, positive experiences were associated with positive and empathetic attitudes of all staff, frequent updates along the spectrum of their ED visit, patient-centered communication particularly during the discharge process, and having the ability to ask questions without feeling rushed. A primary distinguishing feature between the UAC vs the RCH included confidence in care received and differences in the ED environment. Regardless of the patient’s experience, showing empathy, even in unfavorable situations, was identified as the most impactful part of their visit.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Patients’ perceptions of healthcare staff empathy is a critical driver in influencing overall ED patient experience. Future studies should include further characterization of patients’ perceptions of healthcare provider empathy and its impact on ED patient experience.\u003c/p\u003e","manuscriptTitle":"Navigating the unknown: A qualitative analysis exploring patient experience in the Emergency Department","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-16 04:36:49","doi":"10.21203/rs.3.rs-5045716/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-17T08:46:23+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-09-17T05:58:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-09-17T05:56:15+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2024-09-06T18:00:25+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"648e143f-8381-441f-abde-68f264a82d57","owner":[],"postedDate":"December 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-04-07T05:38:21+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-16 04:36:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5045716","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5045716","identity":"rs-5045716","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}