2.1 Participants

Participants for this study (N = 65, age range = 25-75 years; 76.9% female) included individuals who had visited the ED at one of the two study sites (details below) in the past 12 months either as patients or as carers/relatives, aged ≥18 years, living in the community (not inpatient) and having conversational English language skills; staff members including ED doctors and nurses, HSCPs working in the ED or in the hospital, and pre-hospital staff (advanced paramedics or emergency medical technicians) in full- or part-time employment in the hospital for at least 12 months (thus, familiar with the ED/hospital procedures).

We recruited participants through purposive sampling, informed by the inclusion criteria described above. Participants’ selection was conducted by research team members (DR and RQ) who acted as gatekeepers at the hospital sites, providing prospective participants with information sheets and organizing in-hospital advertisement through flyers and screen display. Prospective participants contacted one member of the research team (MC) who provided further details about the study, asked to read and sign the consent form and arranged participation either in one of the focus groups or in an individual interview. Seven out of 72 prospective participants refused to take part. The gatekeepers were blinded to participants’ recruitment and data collection (ie not informed on whether prospective participants agreed or not to take part, and not involved in data collection) to maintain confidentiality and to ensure voluntary participation.

In order to boost recruitment, we also employed snowball sampling and open advertisements through social media and flyers distributed in the local community (eg community centres, GPs, supermarkets). Recruitment occurred iteratively until data saturation was agreed by two authors (MC and KR).32

This multisite study adheres to the Declaration of Helsinki and received ethical approval from the Health Service Executive (HSE) Mid-Western Regional Hospital Research Ethics Committee (reference number: 040/18) and from the HSE North East Area Research Ethics Committee (reference number: 3/9/18).

2.2 Settings

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

2.3 World Cafés

While we were interested in several aspects of a HSCP team model of care (implementation process, impact), we opted for broad questions in line with the World Café guidelines to enable participants to generate ideas and views freely. Participants were asked to focus on five HSCP professions: clinical pharmacists (CPs); medical social workers (MSWs); occupational therapists (OTs); physiotherapists (PTs); and speech and language therapists (SLTs). These five disciplines were chosen based on the evidence on extended scope of practice for HSCPs in the ED.7, 8

At the end of the focus group, participants completed a short demographic survey collecting data on their sex, age and stakeholder type.

2.4 Individual interviews

The individual semi-structured interviews (n = 12; 67% users, 33% providers) explored the same questions investigated in the World Café focus groups with the addition of prompts and follow-up questions (Interview schedule in File S3); participants completed the demographic survey at the end of the interview. Interviews lasted 20-40 minutes. No repeat interviews were held.

2.5 Data analysis

The participants’ responses in the group and individual interviews were audio-recorded electronically and transcribed in full; we also took pictures of the paper sheets of each World Café table discussion to include in the transcript; recordings and paper sheets from the World Café’ were matched for each table discussion, checked for consistency and analysed as one document including both transcript and paper sheet picture. Participants did not check transcripts after data collection. While the study questions were developed and agreed by consensus by the research team to ensure relevance to both service users and providers, two female authors (MC and KR) with expertise in the area of health and health service delivery conducted data transcription, analysis, interpretation and write-up; MC has experience in quantitative and qualitative methods in the area of health; and KR has extensive expertise and experience in qualitative research in the area of health and health service delivery. In keeping with guidelines on reflexivity, the researchers (MC and KR) critically evaluated the impact of their position (personal characteristics, beliefs and relevant experiences; having no professional ED experience and single ED attendances each as service users/relatives of service users) on the research process.33 The researchers (MC and KR) strove to avoid leading language during data collection or sharing personal experiences while maintaining an empathetic attitude. The research team reviewed the data analysis to ensure that multiple perspectives were considered.

Transcribed recordings and pictures of paper sheets were entered into the qualitative data analysis software NVivo 11 Pro (QSR International Pty Ltd). Data saturation was determined by two researchers (MC and KR).32 A descriptive inductive approach to data analysis was employed to provide a rich and detailed account of the data, adhering to the six-stage guide to thematic analysis described by Braun and Clark34, 35: (a) familiarization with the data through repeated reading; (b) identification of initial codes; (c) sorting of codes into potential themes; (d) review and discussion of themes by the two researchers (MC and KR) to ensure internal homogeneity and external heterogeneity; (e) naming and definition of themes; and (f) final analysis and generation of underlying story linking the themes. The Results section includes anonymized extracts of transcripts to support the identified themes, with an indication of the stakeholder type (user or provider) and whether quotes come from interviews (IV) or World Cafés (WC). Both authors selected quotes that exemplified each theme and then agreed on the quotes to include by consensus.

3.1 HSCP teams working in the ED could improve quality and integration of care and staff experience

From a user's perspective, timely and multidisciplinary care was associated with increased satisfaction, reduced carer's anxiety and, to a lesser extent, improved patient education (eg advice on available services in primary care) and fewer ED returns.

Staff member also described interdisciplinary teamwork as an opportunity for upskilling and for the promotion of networking/support and job satisfaction.

3.2 HSCP teams have a role in the ED mainly for non-urgent complaints

Given the focus of this study on team care, both users and providers discussed how different HSCPs could collaborate; an example of this discussion is illustrated in Figure 1.

HSCPs working as team were perceived as increasing patient safety in a holistic manner; a HSCP team could for instance provide mobility assessment, treatment and education (PT and OT), together with safe discharges through linkage with community services (MSW, OT, PT and CP), particularly for older patients and frequent users. Other index complaints that could be addressed by the team included the management of chronic disease and treatment of acute injuries.

While considering HSCPs in teams, participants engaged in an in-depth discussion about the competencies of specific HSCPs. OTs were designated as providing functional assessment and appraising the need for aids and equipment, particularly for older frail patients. PTs were described as crucial to optimize care for managing musculoskeletal conditions and orthopaedics. CPs were frequently associated with enhanced medication management and education. SLTs were seen as crucial for communication and swallow assessment/management, especially for stroke patients. Most participants agreed that MSWs were instrumental to safeguard vulnerable people, particularly older individuals and children. Some participants discussed also the role of other HSCPs, particularly dieticians, who have specialized skills to provide dietary and weight assessment. Both service users and providers described the roles of MSWs, SLTs and PTs, whereas inputs on OTs and CPs were provided by staff members only, and some service users were not aware of what their role might be in the ED.

3.3 Concerns about operational and relational challenges for HSCPs working in the ED

When asked how they felt about HSCPs working in the ED, concerns were expressed alongside positive expectations. Participants discussed potential barriers to successful implementation in terms of the ED physical space, operational and relational aspects, the community and the broader health-care system.

3.4 Changes in processes and culture needed for HSCPs to work successfully in the ED

3.5 Users’ concerns about their ED experience centring on communication and feeling that they are in good hands

Participants also provided suggestions on issues that were not necessarily related to the HSCP model of care but would improve the ED experience; many suggestions related to the need for improved staff/patient communication, staffing resources and the quality of ED non-clinical services.

Other suggestions included improving hot food services for patients on trollies on the corridor, providing refreshments for carers, improving pre-hospital resources (ie number of ambulances) and introducing ED waiting time monitors.

4.1 Summary of findings

This study used a participatory approach to understand the views of a variety of stakeholders on introducing team-based HSCP services in the ED. Overall, HSCPs working in the ED were seen as having the potential to enhance the quality, timeliness and safety of care and promote integrated care for patients, facilitate lighter workload for existing staff members and potentially lower costs for the hospital. Participants agreed that ED patients with non-urgent complaints and with complex needs, particularly frail older adults, would benefit the most from having a HSCP team. Despite identifying multiple benefits, concerns were raised about barriers to feasibility, including limited ED physical space, working hours, care protocols, communication and acceptability. Given the novelty of ED-based HSCP services in the Irish context, our findings have policy and practice implications in that changes in the scope of ED practice and a more interdisciplinary culture of care would be necessary for HSCPs to work successfully in the ED. Service users in particular highlighted the need to improve relational staff/patient dynamics in the ED and the quality of non-clinical services. Borrowing from one participant, an appropriate summary of stakeholders’ views is that the introduction of ED-based HSCP teams is ‘positive with challenges’.

Notably, in our analysis we found that service users focused mainly on relational aspects, whereas service providers discussed more operational issues. One reason for this diversity may lie in the fact that service users appeared to be less aware of the operational aspects of an ED as well as the competencies of HSCPs. Furthermore, users brought up issues with their ED experience that might not necessarily apply to HSCPs specifically, but which they felt would have a significant impact on how future patients might accept having more professionals in the ED.

4.2 Results in the context of the current literature

In line with a systematic review of ED stakeholders’ perceptions of HSCPs,36 our study showed overall acceptability both among service users and providers, with similar benefits reported in terms of timely, safe and integrated care, particularly for older patients with complex needs. In line with our findings, qualitative studies in Australia and Sweden have suggested comprehensive, integrated and interdisciplinary care as key to promote better health-care services across acute and primary settings, especially for older patients.5, 29

On the other hand, in line with the Theoretical Domains Framework,11 participants raised concerns about potential operational and relational influences on implementation: feasibility issues related to space, time resources and cost-effectiveness, as well as challenges in optimizing teamwork and care pathways, were consistent with the international literature.18, 21, 36, 37 Also in line with previous studies,21, 36 patients and staff feared the negative impact of limited working hours on quality and continuity of care; hospital HSCP services in Ireland are conventionally within business hours, but this may not fit well with the 24/7 ED opening hours. These issues should be carefully considered both at policy and practice levels to ensure successful changes in models of emergency care.

The discussed need to optimize care protocols and team communication for the HSCP team to enhance quality of care resonate with findings of previous studies suggesting the need for improved communication, teamwork and operations when caring for patients with complex needs, especially if older.22, 38 Importantly, our finding that ED service users and providers attached different values to relational and operational aspects, which aligns with the extant literature,18, 20, 39 shows that individuals’ perspectives depend strongly on their specific roles and experiences, thus supporting the importance of engaging multiple stakeholders in order to understand factors of implementation.

4.3 Strengths and limitations

While in keeping with previous literature, our study is, to the best of our knowledge, the first to investigate views on HSCP teams working in the ED through the engagement of multiple stakeholders. Employing a World Café format enabled the creation of an inclusive space for inquiry where different stakeholders had an opportunity to sit together and discuss issues relevant to them. On the other hand, individual interviews provided an additional space for participants who were unable or unwilling to be in the focus groups; the interviews offered deep insights about individuals’ experiences in the ED, thus providing a richer understanding of the reasons behind the perspectives that had emerged during the focus groups.

Our study is not without limitations. Although we collected data in two separate sites in Ireland, generalizability of findings might be limited given the specific contextual characteristics of health-care systems in different countries; nonetheless, our results are in line with those of the existing international literature.18, 21, 36 Despite its many benefits, the World Café format has some disadvantages: Firstly, as for other qualitative investigations, social desirability may have influenced the participants’ contributions. Furthermore, the World Café notes were more difficult to contextualize and interpret than audio-recorded data, although we matched notes and transcripts where possible. As the World Café table membership rotated, we were not always able to identify specific respondents in the recordings; also, although all the five relevant HSCP disciplines were represented in our sample, we did not record how many participants from each HSCP discipline were present. While we involved different stakeholders, our sample did not include policy-makers or members of the hospital Executive, who could have contributed further insights on factors of implementation; lastly, more service users participated in interviews than focus groups; thus, it is possible that group discussions could have been different if more users were present.