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What do adolescents want from their ED? An evaluation on the preferences and opinions of adolescents attending local EDs
  1. Anna Bryans1,
  2. Julian Camilleri-Brennan1,
  3. Lei Hua1,
  4. Nandesh Patel1,
  5. Rebecca Price1,
  6. Jen Browning2
  1. 1 University of Edinburgh, Edinburgh, UK
  2. 2 Royal Hospital for Sick Children Edinburgh, Edinburgh, UK
  1. Correspondence to Anna Bryans, University of Edinburgh, Edinburgh EH16 4SB, UK; s1201949{at}sms.ed.ac.uk

Abstract

Introduction The adolescent population comprises a significant proportion of attendances to the ED. Despite adolescent patients reporting lower levels of healthcare satisfaction compared with other age groups, their opinions are under-represented in existing literature. This prospective study investigated adolescents’ expectations and preferences regarding the ED service.

Methods A questionnaire designed by the investigators was distributed to children aged 12–16 years over a 6-month period in 2015 at two EDs in the UK. The questionnaire explored themes such as same-sex and similar-age areas, staff communication and environment. Interviews based on the questionnaire template were also conducted and guardians were permitted to accompany the participant. Verbal informed consent was obtained from both the young person and their guardian to participate in the study.

Results There were 254 respondents, which represented 8.8% of adolescent attendances in the study period. ‘Cleanliness’ was rated the most important factor within the ED setting with 94.8% of respondents selecting 4 or 5 on a 5-point Likert scale. This was followed by ‘feeling comfortable’, ‘clear explanation’ and ‘staff communication’ (91.2%, 90.8% and 90.4% rating these 4 or 5, respectively). However, when participants were asked to select a single most important factor, being ‘seen quickly’ was selected most frequently (95/206, 46.1%). ‘Entertainment’ was regarded the least important with only 17.0% selecting 4 or 5 on the Likert scale. Preference for being treated in an adult ED compared with a child ED increased with age.

Conclusions Being ‘seen quickly’ was considered the single most important factor by adolescent patients in the ED. Notably, ‘cleanliness’ and aspects of communication also rated highly, with ‘entertainment’ regarded as least important. The additional insight into the healthcare preferences of the adolescent population provides a platform on which the future ED services can be tailored to the needs of young people.

  • emergency department
  • communications
  • quality
  • paediatrics, paediatric emergency medicine

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Key messages

What is already known on this subject

  • Existing studies suggest that numerous factors including confidentiality, treatment with respect and admission to age-appropriate wards can have an impact on a young person’s experience of healthcare.

  • Lower patient satisfaction is commonly reported in adolescents; however, limited research exists regarding their experiences of ED services.

What this study adds

  • This survey of adolescents waiting for care at two EDs in the UK found that ‘cleanliness’, being ‘seen quickly’, ‘feeling comfortable’ and ‘clear explanations’ of investigation and management were the most important factors to adolescents within an ED setting.

  • Enhancing our understanding of adolescents' requirements can help to tailor ED services to the needs of young people and ultimately improve patient satisfaction.

Introduction

Adolescent emergency medicine is a complex component of a healthcare professional’s role in the ED. This age group represents a transition phase into adulthood which includes physical changes, psychological adjustments and forming a sense of identity. These circumstances may contribute to the challenges in conducting medical research in this population and adolescents report lower degrees of satisfaction compared with adults.1 Internationally, WHO recognises that the adolescent population have specific requirements which are not addressed in the care of adults or children.2 A report published in 2003 by The Royal College of Paediatrics and Child Health identified healthcare barriers for young people which included concerns regarding confidentiality, being well informed and respected, continuity of care and being accommodated in age-appropriate wards.3

Despite increasing demand for adolescent-specific services and rising rates of hospital admission,4 5 adolescent opinions regarding healthcare remain under-represented in literature. A Canadian study established that waiting times and treatment within a child or adult ED environment were factors influencing adolescents’ satisfaction6; however, similar studies in the UK have not been conducted. Lack of knowledge regarding adolescent preferences may cause discrepancies between the expectations of healthcare professionals and of adolescents themselves.7 A greater understanding of adolescents’ requirements will improve standards of care and enable EDs to tailor services for young people. This study aims to establish the aspects of emergency healthcare that are most relevant to young people to inform future provision of ED care.

Methodology

Study setting

Data collection took place between February and August 2015 at two ED sites; The Royal Hospital for Sick Children (RHSC) admits patients up until their 13th birthday and The Royal Infirmary of Edinburgh (RIE) admits those from 13 years onwards. The annual attendance rate at the RHSC ED is >50 000 patients per year. The RIE ED sees >120 000 patients per year, of which approximately 4000 are aged 13–16 years. Questionnaires were distributed to children aged 12 years at the RHSC and children aged 13–16 years at the RIE. The WHO and United Nations define an adolescent as an individual aged between 10 and 19.2 8 This study encompassed adolescents who are transitioning into adult services (12 years) and adolescents aged 13–16 who have recently started to attend the adult ED and are typically difficult to survey.

Participants

The inclusion criteria required patients to be aged 12–16 attending the ED. Patients who required immediate emergency medical attention, those who were unable to speak English and those that previously responded to the study from a prior ED attendance were excluded.

Study design

This prospective evaluation employed the use of questionnaires and interviews. A new adolescent-specific questionnaire was developed (online Supplementary appendix 1) based on existing literature which contributed to patient satisfaction.9–12 It was specifically designed to be short and simple to complete compared with previously validated questionnaires to maximise adolescent participation. The questions were presented in quantitative (5-point Likert scales; 1=low importance, 5=high importance) and qualitative formats. The questionnaires were reviewed by ED healthcare professionals prior to the study and adjusted based on their recommendations. A parallel interview template (online supplementary appendix 2) which mirrored the content of the questionnaire was developed to gain further insight into patients’ experiences of the ED with the addition of four open-ended questions and one closed question.

Supplemental material

Supplemental material

Data collection

Individuals were consecutively selected to participate on arrival at the ED reception. ED reception staff and nurses distributed and collected questionnaires.

To supplement data from the questionnaires and obtain quotes directly from adolescents, a convenience sample was selected for interview. This was restricted by interviewer availability to the first month of the study between 09:00 and 18:00 from Monday to Friday. The interview template consisted of additional open-ended free-text questions which were posed to the patient and no prompting was provided by the interviewer. The patients’ own words were documented in note form. Interviewers consisted of medical students undertaking a research module within the ED. All interviewers were provided with an identical interview structure which minimised the risk of bias and optimised inter-rater reliability. Interviews were conducted in front of guardians accompanying the adolescent. No interviewer was involved in the provision of care or associated with the hospital setting.

No further approval was deemed necessary by the Health Research Authority ‘Defining Research’ decision-making tool.13

Data handling and statistics

The study size was dependent on the number of responses obtained in the study period. Based on previous admission data, there are approximately 3000 attendances of adolescents aged 12–16 every 6 months. This study aimed for a 10% sample representation. Summary statistics for quantitative variables were calculated in Microsoft Excel 2016. Likert scale responses were treated as ordinal data without the assumption of interval-level measurement and are therefore presented with the median and frequency.14 No qualitative analysis was performed on interview responses. Missing data, and responses which selected more than one answer were excluded from final analysis. N=total number of questionnaires collected; n=total number of responses per question number or age group.

Results

In total, there were 254 respondents representing 8.8% of the adolescents attending during the study period (2904 attendances). In total, 216 responses were from questionnaires and 38 from interviews. The mean study population age was 13.8 years (range 12–16). Also, 133 (52.4%) of the 254 adolescents were male. Due to the different age distributions at the two study sites, the majority of responses were collected from the RIE (n=212, 83.5%). Respondent profiling is shown in table 1. Completion rate for each question ranged from 86.6% (online supplementary appendix 1, ‘What is the most important factor?', question 6, n=220) to 94.9% (online supplementary appendix 1, ‘Please rate the following from most important to least important’, question 5, n=241).

Table 1

Age, gender and site of recruitment of participants

Based on the proportion of respondents selecting 4 or 5 on the Likert scale, ‘cleanliness’ was rated the most important factor within an ED setting (importance proportion 94.8%). This was followed by ‘feeling comfortable’, ‘clear explanation’ and ‘staff communication’ (importance proportions 91.2%, 90.8% and 90.4%, respectively) (table 2). Being ‘treated with the same age’ and ‘entertainment’ were regarded the least important factors based on low importance proportions of 25.8% and 17.0%, respectively (table 2).

Table 2

Healthcare factors rated by importance

When asked to select a single most important factor, being ‘seen quickly’ was most frequently chosen (95/206, 46.1%). Being seen by the ‘same doctor’ was chosen the fewest times (2/206, 1.0%) (figure 1). Qualitative responses to selecting the most important factor are displayed in table 3.

Table 3

Qualitative responses regarding the most important factor in the ED

Figure 1

Single most important factor. A pie chart of the six most commonly chosen ‘single most important’ factors selected by adolescents attending the ED.

A large proportion of adolescents were impartial regarding their preference for a child or adult ED (‘don’t mind’: 110/238, 46.2%). Among those who expressed an opinion, a greater proportion of older adolescents preferred to be treated with adults (12 years: 3/17 (17.6%), 13 years: 9/44 (20.5%), 14 years: 9/33 (27.3%), 15 years: 9/22 (40.9%), 16 years: 10/12 (83.3%)). Examples of patients’ reasoning for their preferences are presented in table 4.

Table 4

Qualitative responses regarding preference for a child or adult ED

Discussion

The aim of this study was to gain a greater insight into the attitudes and perceptions of adolescents towards the ED which are poorly represented in existing literature. When asked to rate the importance of ED healthcare factors, ‘cleanliness’ was among the highest rated factors by adolescents and ‘entertainment’ was rated one of the least important factors. When asked to select the overall most important factor, being ‘seen quickly’ was the most popular consideration. Responses to being asked whether they preferred to be treated with adults or children showed that although the proportion of patients who preferred an adult ED increased with age, a large proportion did not express a specific opinion.

Cleanliness has been shown to be an important contributory factor to patient satisfaction in the adult population.15 Interestingly, the high importance ratings for ‘cleanliness’ (table 2) suggests that adolescents are aware of infection risks and also regard ‘cleanliness’ as a primary concern. Aspects of patient–staff relationships were highly rated by adolescents, including ‘feeling comfortable’, ‘clear explanation’ and ‘staff communication’. Similar results were found in another paediatric ED survey, where interpersonal communication was related to respondents’ satisfaction of the ED.16 Notably, adolescents often referred to their increased sense of safety when reasoning for their choice of ‘cleanliness’, being ‘seen quickly’ and aspects of patient-staff relationships (table 3). The overall most important factor to adolescents was being ‘seen quickly’ which corroborates findings from the Canadian study6 and suggests that reducing waiting times will greatly improve patient satisfaction.

Adolescents in this study were asked whether they would prefer to be treated with adults or children. A greater proportion of adolescents aged 15–16 preferred to be treated in an adult ED. This suggests that adolescents’ attitudes towards emergency care can be influenced by their age and maturity, reflecting increasing expectations of being treated as an adult. Previous studies suggest that adolescents report greater satisfaction in paediatric or adolescent-specific wards.17 18 Therefore, specific adolescent treatment areas may be most appropriate. The current choices of entertainment (toys, books and DVDs) were presented to the adolescents in the questionnaire and were regarded the least important. The availability of alternative forms of entertainment which are of greater interest to adolescents including access to WiFi may influence this attitude and should be explored in future studies.

A number of limitations affect the generalisability of this study. First, due to challenges in identifying the number of ineligible patients in two different centres, we are unable to estimate the response rate. Individuals from ethnic minorities represent only 8% of Edinburgh’s population19 and adolescent opinions may differ in EDs which serve a more ethnically diverse population. The cohort only included children who spoke English which further restricts the generalisability of the findings. Data collection relied on ED staff handing out questionnaires during out-of-hour periods when researchers were not present. Due to the extremely busy and time-pressured nature of the ED, it was not possible for staff to ensure completeness regarding questionnaire distribution resulting in the exclusion of data. Adolescents who attend the ED out-of-hours may have different opinions which could have impacted the results. There was the potential for guardians to influence responses to the questionnaire and no questions were related to parents or guardians. Questionnaires were distributed on presentation to the ED and completed in the waiting room. Therefore, the length of time a patient was waiting to be seen may have prompted greater concern regarding waiting times and consequentially skewed the results. The findings of this evaluation are specific to an ED service with an unusual age threshold and these adolescent preferences are not necessarily representative of the wider adolescent population. There was no adolescent involvement in constructing the questionnaire which may have benefited its design and suitability. Finally, challenging subjects such as youth-on-youth violence and potentially distressing aspects of sharing an environment with adult patients were not approached. Further adolescent-specific research in multiple centres is necessary to thoroughly establish the healthcare preferences of young people.

Despite the above limitations, this preliminary report suggests some novel areas for practice improvement and highlights several topics for further discussion in this under-represented branch of emergency medicine. Healthcare professionals must communicate effectively with young people, respect their autonomy, involve them in decision-making and ensure that they feel safe. Furthermore, modifications to staff training can raise awareness and facilitate recognition of the needs and expectations of young people. The adolescent years represent a transition phase into adulthood and with this an opportunity to apply positive healthcare interventions which will influence the health behaviour of the future generation.

Supplemental material

Acknowledgments

The authors acknowledge Mikolaj Kotts, Shaun Massie and the nurses and reception staff at RHSC Edinburgh and RIE for their valuable engagement with the study.

References

Footnotes

  • Contributors AB, JCB, LH, NP, RP and JB collectively planned the study, developed the questionnaire, collected data and prepared the manuscript. JB provided guidance and direction for the study. AB edited the final manuscript and is guarantor.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval Student Selected Component 4 programme of the University of Edinburgh College of Medicine and Veterinary Medicine.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement All available anonymised data can be obtained by contacting the corresponding author.