The Emergency Department (ED) is a highly challenging clinical environment. All critically ill patients should first be managed in the resuscitation room, as it is necessary to provide the optimal infrastructure, including material and personal resources, to maintain high-quality care. While a core specialist healthcare team (over multiple shifts) is essential for effective emergency care, many staff members from other parts of healthcare organizations are qualified to administer emergency care due to the requirement for basic training in such services as part of normal medical and nursing education and training, supported by recognized continued professional development and regular simulation training (Özkan et al., 2021).
Emergency settings have a more necessary focus on biomedical aspects of care due to the emergency nature of patient requirements, but patients’ families and friends are more agitated and worried, and effective communication with service users is an essential aspect of quality of care. Nurses are the main professionals interfacing with service users; thus, their communication with patients and their relatives is highly instrumental in service quality and satisfaction (Hsiao et al., 2017). A survey of 200 patients revealed that the respect and problem-solving skills of emergency nurses are highly valued (Orcajada Munoz et al., 2020).
Previous studies have indicated that training in communication skills can enhance empathy and effectiveness among emergency nurses, leading to improved care quality, higher patient satisfaction, and reduced complaints. Communication training is an essential competency for registered nurses (RNs). It should be consistently integrated into nursing education and training to ensure that all RNs possess the necessary skills to listen to their clients in any scenario (Ak et al., 2011; Bullington et al., 2019; Khodadadi et al., 2013). However, within the challenging environment of overcrowded and high-pressure emergency departments (EDs), healthcare professionals must efficiently execute complex medical tasks while prioritizing patient outcomes. Furthermore, inadequate communication can significantly impact client satisfaction, a pivotal performance metric in contemporary patient-centered healthcare systems.
Studies of client satisfaction with nursing care in Thailand indicate that most complaints concern the unethical behavior of Thai nurses (Jirapaet et al., 2020; Ramkaew & Oumtanee, 2014). One of three main motives was dissatisfaction with communication behaviors, described as impolite, indicative of unwillingness, and manifesting negligence when service users requested some service related to their needs. As individual registered nurses struggle to comprehend the feelings, requirements, and perspectives of the service recipient or others when handling difficult situations, they instinctively put patient safety first in their work, which can be perceived as insensitive. To ameliorate such misunderstanding, frameworks have been developed offering communication strategies by which nurses can deliver care and answer information requests, including the Acknowledge, Introduce, Duration, Explanation, and Thank you (AIDET) communication framework, which is applied in many Thai hospitals (Jirapaet et al., 2020). However, any keywords AIDET deployed in conversation with service users have to be adapted and designated in alignment with Thai communicative norms.
The AIDET framework was first presented by Studer Group (2005) and became widely used in training for healthcare professions over recent years. Puppala et al. (2020) demonstrated that the AIDET tool is a focused, directed structure for provider-patient communications. The evidence listed under AIDET is a shorthand for a very effective technique for talking to persons who are frequently worried, anxious, and feeling vulnerable (Palombi et al., 2015). The findings of previous studies conducted in Thailand demonstrate that AIDET increases patient satisfaction and has beneficial effects on the delivery of care in emergency departments and other critical care settings (Panchuay et al., 2022; Thangkratok et al., 2017). However, the study findings slipped short of explaining how nurses functioned or how to make personal changes.
Based on the literature review, most research described how patients and their relatives responded to emergency services but limited exploration of the issues from the service users’ perspectives. There is a dearth of research on the experiences of emergency nurses themselves when faced with the different needs and responses of service users (Panchuay et al., 2022; Sriwichai & Limprasert, 2019; Thangkratok et al., 2017). The current study seeks to address this research gap in the Thai context of emergency care by ascertaining how nurses actually function in such circumstances, asking them to describe the context of ED communication, identify barriers they experience, and note approaches they have found to be helpful regarding the AIDET global framework.
The study outcomes can help emergency nurses offer better support for patients and their relatives when encountering crucial events and increase satisfaction with ED services. The findings can help improve evidence-based practice regarding communication strategies and demonstrate the benefits of AIDET in emergency nursing care in an underexplored context.
This study aimed to explore the experience of emergency nurses in utilizing the AIDET framework for emergency patients and their relatives. A qualitative descriptive research design was selected because this study requires a comprehensive description of specific events perceived by individuals or groups (Sandelowski, 2000).
The study was conducted at the ED of Vachira Phuket Hospital, a regional hospital in southern Thailand, where the number of annual ED visits has grown dramatically over recent years, from 30,000 in 2017 to 45,000 in 2021. The ED offers full emergency care facilities, medical staff, emergency physicians (EPs), and a comprehensive range of advanced medical equipment. The number of staff nurses in each shift ranges from 7 to 10, with one nurse designated as the triage nurse, 3 or 4 placed in the emergency and resuscitation zones, and 3-5 nurses placed in the urgent and non-urgent zones. The sample was selected using purposive sampling from the RNs who had undergone staff training in the AIDET framework for communication. Fifteen nurses met the inclusion criteria and agreed to participate in this study voluntarily. Additionally, in order to achieve data saturation, all researchers evaluated the instances they had gathered that were thought to be information-rich (Lambert & Lambert, 2012).
Data were collected between September 2021 and March 2022. The researchers contacted the head of ED in the target hospital to explain the study objectives, timeframe, and general procedures of participants. After participants agreed to join the study, they were invited to sign the consent forms. Before the interview, they were asked to complete a short form covering demographic data, such as age and ED work experience. Codes were used to record and identify clinically pertinent demographic information anonymously. The 15 interviews were held via Zoom Video Communications (due to Covid-19 restrictions). All interviews were audio recorded, each taking approximately 45–60 minutes. Open-ended questions were used in the in-depth interviews to investigate participants’ experiences in using the AIDET information communication. Four questions were asked to determine the emergency nurses’ experiences applying AIDET in ED (Table 1). All questions were reviewed for the content’s accuracy and edited by three experts, two experienced in spatial research and one an expert in qualitative research.
|• Please describe your experiences using the AIDET communication with relatives of critically ill patients.
|• In your opinion, how appropriate is AIDET for communicating with relatives of critically ill patients?
|• What were the results of using AIDET communication with relatives of critically ill patients, such as a result in satisfaction? If so, to what extent?
|• Do you have any problems or obstacles in using AIDET?
Interview data were analyzed using qualitative content analysis (Sandelowski, 2000). They were transcribed, and the texts were read through in their entirety several times by all authors to achieve total data immersion. After that, meaning-bearing units addressing the aim of the study were identified, condensed, and sorted into themes. Next, themes describing the latent meaning of the data were identified. The analysis was undertaken primarily by the first author (WP), under supervision from the second author (TS). The third author (PS) verified the analysis results by relating them to the full-text interviews. The resultant triangulation ensured the accuracy of the analytical interpretation collectively produced by the researchers in this study. The point of data saturation was determined when no more categories emerged.
Credibility was established through member and peer checking and prolonged engagement (Speziale et al., 2011). The researchers tried to add credibility to the study by allocating sufficient time for investigation and following the step-by-step data analysis process. Participants received a copy of the findings for member verification. Peer reviews included the employment of two more senior professional nurses and the emergency department’s chief nurse. The analysis of emerging codes and themes was confirmed to understand the context and answer to the study’s objectives. Six months of consistent engagement were allowed to gain rich information in the field.
Permission was obtained from the Human Research Ethics Committee at Vachira Phuket Hospital (approval 10 August 2021/ number VPHREC0102021). The rights of study participants were taken into account, and strict protection was given with a consent form. When data was recorded, saved, processed, and analyzed, there was no mention of the emergency nurses’ names, surnames, or anything else that may have been used to identify the person who gave the information. In order to ensure privacy and confidentiality, access to the identity of the participants was limited to the researchers.
Participants comprised 15 emergency nurses, including 13 females and two males. Regarding their ED experience, five were advanced beginners (less than three years), five were proficient (three to five years), and five were expert nurses (more than five years). Three main themes were identified under the experiences of emergency nurses’ communication with the AIDET framework in ED: 1) Ability to follow the AIDET framework, 2) Recognizing the value of using AIDET steps for positive communication, and 3) Establishing a foundation of successful communication. These are discussed with illustrative excerpts from interview transcripts.
Theme 1: Ability to Follow the AIDET Framework
Most informants described the ability to use the AIDET framework alphabetically in terms of A and I, E and D, and T. The analysis reflects this intuitive division.
A and I (Awareness, take care, acknowledge, and Introduction) included a name-based identification and welcoming of the patients, making eye contact with them, and, if appropriate, smiling to display consideration of their feelings. Participants reflected that they commonly introduced themselves and stated their position as a nurse.
“A: Acknowledge in AIDET made me recognize that we approach patients enthusiastically to take care; if they did not feel good, they might calm down before… Talking with patients and their families so they do not get moody” (ID06: female, 3 years of experience)
“A and I come together; in all cases I start by saying ‘hi!’ and introducing myself, ‘I am an emergency nurse,’ not telling my name… and then I ask patients and also confirm with their family caregiver, for identifying patients correctly, before step E and D.” (ID05: female, 2 years of experience)
E and D (Explanation and Duration) pertain to explaining the severity of the injury and illness, the progression of the disease, and the need for necessary treatment procedures consistent with the physician’s treatment plan. Emphasis is placed on estimating the time involved in procedural care according to the context and time standards of the setting. The order of examination by a physician and the waiting period to see a specialist mainly follow the disease and management guidelines of the agency.
“We tried to emphasize providing details of the preliminary assessment… whether it is a disease suspected by an emergency physician. What should be investigated? When the doctor makes a diagnosis, the emergency nurse receives a treatment plan and comes to help, including medication information that the patient receives… gets better or has side effects, and also tells that the specialist gets consulted” (ID04: female, 2 years of experience)
“When I perform operations with patients, I frequently try to let them know where I am in the process and what I’ve accomplished so far. How many minutes do you wait for the relatives to understand that they have to wait? For some procedures, a lengthy wait may be necessary. It takes about this long.” (ID10: female, 5 years of experience)
T (Take home message/ take care) refers to awareness of empathy and concern for feedback after giving information. All conversations with service users should conclude by asking them if they have any questions or concerns or require additional help. In addition, it is not necessarily data that they need in this context, but a brief and effective conclusion that addresses essential care needs and manifests genuine concern and high-quality service provision, as in the following excerpt in which the participant emphasized the importance of ascertaining the client’s acceptance.
“T alphabet… well… In my mind, take home message… I preferred to convey my ideas through conversation, encouragement, and the use of amiable and trustworthy body language, touch, and facial expressions. The chance to ask inquiries or express aid requests is given to patients and their loved ones. Depending on the amount of anxiety, nurses will assess their listeners’ understanding of what they are saying after 2 to 20 minutes by asking them to reflect on their thoughts and give comments. When considering whether to leave the patient and their family, pay attention to the patient’s eyes and facial expressions to see if he appears to feel less anxious” (ID11: female, 9 years of experience)
Emergency nurses with AIDET communication training have a roadmap for information to those patients and relatives before providing care, and they strongly appreciate the need to pay attention to and be supportive of the needs and concerns of service users.
Theme 2: Recognizing the value of using AIDET steps for positive communication
Participants considered that junior nurses, in particular, could benefit from the AIDET framework, which they thought was fundamentally useful for self-learning to understand care requirements and practically improve their daily care practice, such as regarding monitoring data on their patients’ clinical signs. Most informants referred to the benefits of self-learning to increase expertise because they have to explain the severity of the injury and illness and the disease’s progression (i.e., in steps E and D). Although the AIDET framework is simple to memorize, the text cannot be copied and pasted to inform clients’ individual views and additional repetitions are required. Participants also noted the need to keep a positive attitude when providing care, and the AIDET framework itself was seen as promoting a happy ethos.
“An introduction to the AIDET framework as a communication tool should be provided to all junior nurses from the first day that they start work, as it gives guidelines on how to communicate more effectively and the necessary information that should be provided to patient relatives while practicing different medical procedures. Personally, I think this tool is really good. Using AIDET as a communication framework will reduce confrontation and complaints of patient relatives and patients” (ID01: female, 1 year of experience)
“Junior nurses who do not yet know the practice guideline of caring for patients of each disease need to study the information so that they can provide information, discuss and answer the family caregivers” (ID07: female, 5 years of experience)
“After adopting the AIDET framework to communicate with the patients, they appeared satisfied and more relaxed, as you could see the smile on their faces. It was mainly because they were provided with important information at each step, so they were aware of what they were waiting for and the duration of waiting time. Consequently, it decreased the incidence of confrontation dramatically” (ID02: female, 2 years of experience)
For the interaction communication process, engendering a positive atmosphere can reduce the argument/ defense/ denial of procedure and treatment plan, with the service users as receivers. When the session concludes, the nurse can provide patients with time to ask additional questions, as if it were a time for them to express their concerns.
“…the ED was extremely busy, the AIDET framework, especially the A alphabet, as a trigger that helps me be aware and concerned about taking care of myself, calming down, and attempting to control my moods before taking care of clients…” (ID13: female, 15 years of experience)
“…feel good… Thanks to the information-sharing framework like AIDET, awareness of taking care… um… helps me feel less frustrated when giving information to clients…” (ID11: female, 9 years of experience)
AIDET was found to be helpful, especially for vulnerable patients such as children, as it mitigates complaints and dissatisfaction of parents. In the past, there was no formal communication between nurses and patients or family caregivers, with nurses only focusing on reducing the patients’ biomedical symptom severity; after meeting basic medical needs, they would walk on to take care of other patients who were waiting, with no consideration of the concerns of the family caregivers, or holistic care in general.
“In the case of children with high fever and convulsions, parents are very concerned that their child may have repeated seizures. There used to be cases where the body temperature had gone down, yet the patient still had to wait an hour before blood test results came out. With AIDET, parents will understand that and cooperate without ranting… because our nurses give information clearly” (ID15: male, 20 years of experience).
“After using AIDET when practicing medical procedures with patients, I provide information to the family caregivers and explain where they are on the process, what has been done, what will be done, and the expected waiting time, which may differ slightly for each step. This is to reduce any potential problems that might occur later. Sometimes family caregivers can be assertive, but they will calm down after receiving explanations and show gratitude to us” (ID12: female, 10 years of experience).
In addition, the information provided by nurses who have applied the AIDET framework was manifested in step-by-step explanations. To avoid repeatedly giving clients the same response, the nurses expressed appreciation for working as a team.
“From my experience, communication without an AIDET framework and no detailed process or the duration of each process/treatment when provided to the family relatives will lead to the situation that they will come back with questions every 15 or 30 minutes, which is really annoying” (ID07, female, 3 years of experience)
“If we are able to communicate effectively to provide comprehensive information to the patient/ family caregivers by following the AIDET framework, they will rarely ask the nurse/ doctor for information as often as before. It also benefits other colleagues and reduces the redundant work they need to respond to family caregivers with the same questions. In the past, sometimes when I saw a patient fretting, I had to stop caring for them and offer some assistance to find out the information they wanted to know” (ID09. female, 4 years of experience)
Providing clearer information using AIDET promoted a better understanding among family caregivers. It avoided them asking further questions or asking different nurses to confirm whether they had perceived information correctly or received what they needed.
“Previously, when asked questions by the family caregivers, some nurses may respond to all or some questions or not answer any questions. The situation has improved after adopting AIDET. It also enhances responsible nurses of each shift to communicate in the same direction” (ID08, female, 4 years of experience)
“Normally, a nurse will rotate and perform different functional work alternately. During the nurse’s transition at lunch break, the informant will be rotated. Implementation of AIDET provides guidelines to everyone involved to share and get the same information among the team members and to communicate the same information with family caregivers, which results in problem reduction” (ID12: female, 10 years of experience)
Theme 3: Establishing a Foundation for Successful Communication
Following the steps of the AIDET framework is considered a foundation for successful communication. This achievement can be attributed to two key factors: informative use by emergency nurses’ experience and interpersonal relationships between emergency nurses and specialty physicians.
The informative use of emergency nurses’ experience was seen from the confidence and abilities of nurses to give accurate and precise information to patients and family caregivers that were affected by their capacity to predict the progression of the disease and patient wellbeing, as well as by their familiarity with the multidisciplinary team across departments.
“I am worried about the T [Take home message] process. Family caregivers often ask for treatment procedure information; sometimes, they disagree with the doctor and express dissatisfaction. For example, in their opinion, the patient has severe symptoms and should be admitted to the hospital rather than going home, or they will ask for the reasons why the patient should go home. I have reacted to the situation differently; I may inform them to wait to discuss their issue with their doctor and just smile” (ID01, female, 1 year of experience)
“In my opinion, junior nurses sometimes do not know specific information, such as what time the responsible specialist doctor will see the patients in the emergency room in case the patient needs surgery, whether the nurses should send the patient to the operating room directly or let the patient wait in the room, etc. Those will affect the information and waiting time that needs to be informed to the family caregivers. It is recommended that the in-charge nurse or emergency physician who directly consults the doctor specialist are the respondents to all inquiries in order to mitigate arguments and dissatisfaction” (ID14, female, 15 years of experience)
Interpersonal relationships pertain to a strong association among individuals working together in the same organization, which in healthcare contexts relates to interdisciplinary collaboration between nurses and allied healthcare professionals (particularly physicians). Employees working together should share a special bond to deliver their best level. Individuals need to be honest with each other for a healthy interpersonal relationship and, eventually, a positive ambiance at the workplace.
“Walking with specialist doctors while they visit each patient allows family caregivers, nurses, and doctors to discuss and have the same information. When family caregivers are confused when the doctor delivers the information, the nurse can explain it in spoken language that is easy to comprehend. The nurse can also provide the same information or further detail to other family caregivers” (ID03: female, 2 years of experience)
“I developed many professional communications with the specialist doctor when he consulted with patients in diseases, the progression of many diseases, and some guideline treatment. I was touched by his kindness when he taught patients. Then I could provide useful health information at this point for those who want to confirm their medical conditions” (ID09, female, 4 years of experience)
This study aimed to explore Thai nurses’ experiences in applying the AIDET framework for communications with patients and their relatives in the emergency department. Three main themes were generated: 1) Ability to follow the AIDET framework, 2) Recognizing the value of using AIDET steps for positive communication, and 3) Establishing a foundation for successful communication.
The first theme, “Ability to Follow the AIDET Framework,” sheds light on how emergency nurses skillfully utilize the AIDET framework to communicate with patients and their families. Insights emerge through participants’ accounts into integrating various AIDET components within their communication practices. In the initial stages of AIDET, Acknowledge (A) and Introduce (I), nurses emphasize the significance of making patients feel valued from the outset. Nurses warmly introduce themselves, laying the groundwork for trust between patients, families, and medical staff. Explanation (E) and Duration (D) are vital facets of communication. Nurses explain conditions, treatments, and procedures clearly, reducing anxiety and empowering patients to engage in their care. Timeframes for procedures and wait times manage expectations, giving patients a sense of control in a potentially uncertain situation. The last element, the Take-home message (T), highlights empathy and closure. Patients are encouraged to ask questions and express concerns, while nurses employ body language and touch to convey care. The narratives underline how AIDET acts as a roadmap for nurses to obtain critical information while addressing emotional needs. AIDET training equips them with structured communication that enriches patient interactions and establishes a patient-centered environment. Numerous publications recommend using the AIDET framework for staff training to enhance communication skills between healthcare providers and clients (Palombi et al., 2015; Panchuay et al., 2022; Thangkratok et al., 2017).
The second theme, “Recognizing the Value of Using AIDET Steps for Positive Communication,” illustrates participants’ perceptions of implementing the AIDET framework in emergency department communication. The findings reveal advantages, especially for junior nurses. AIDET aids self-learning, clarifying care, and enhancing daily practice, notably in Explanation (E) and Duration (D). Additionally, participants find AIDET simple yet requiring personalization. Easy to remember, AIDET needs tailoring to individual patients for positive communication. This approach acknowledges patients’ perspectives, fostering positivity.
AIDET’s adoption improves the caring atmosphere, promoting support, reducing conflicts, and elevating patient and family satisfaction. It guides content and tone, cultivating respect and empathy. It is also noted that positive interactions and patient-centered care are vital. AIDET assists nurses in staying positive while considering emotional well-being. Beyond individuals, AIDET enhances holistic care and teamwork. It ensures consistent information and efficient care delivery, easing transitions. This theme aligns with Joseph (2020) in stating that incorporating the AIDET framework played a vital role in enhancing patients’ access to required care, streamlining communication between medical professionals and patients, and ultimately boosting patient satisfaction. Howick et al. (2018) also demonstrate that empathetic provider-patient communication, directly engendered by AIDET, can lead to better outcomes, treatment adherence, and patient satisfaction.
The third theme, “Building Effective Communication Foundations,” demonstrates how the AIDET framework enhances successful communication in the emergency department. It highlights the crucial roles of nurses’ expertise and interpersonal relationships in achieving positive outcomes. Nurses’ expertise is vital, enabling clear delivery of information about conditions and treatments. Familiarity with the interdisciplinary team ensures consistent and accurate communication, minimizing confusion. Similarly, Creswick et al. (2009) stated that efficient communication and effective interpersonal interactions are vital in most organizational endeavors, and communication in EDs is complex and mainly face-to-face.
Moreover, interpersonal relationships, especially with physicians, play a pivotal role. Strong collaboration ensures clear interdisciplinary communication, enhancing patient consultations. Trust and respect in these relationships foster open and effective information exchange. Studies have revealed that a strong interpersonal relationship may directly affect professional outcomes, such as nurse-physician interactions and patient outcomes (Babiker et al., 2014; Lin et al., 2012). According to Siedlecki and Hixson (2015), 50% of the 807 nurses who responded “yes” to the question said that a medical doctor’s attitude could influence how nurses ask questions or make them unwilling to report changes in a patient’s clinical state.
Positive healthcare team relationships also matter. Effective teamwork elevates patient care and nurtures a unified work environment. Nurses’ collaboration with physicians in addressing patient inquiries showcases shared responsibility and transparent communication. Brock et al. (2013) stated that patient safety depends on efficient multidisciplinary healthcare team communication, and healthcare workers must be taught how to work in teams with maximum effectiveness. In the communication structure, how well team members interact is essential. The teamwork between physicians and nurses influences communication and patient safety (Lee & Doran, 2017).
Implications of the Study for Nursing Practice
The study yielded several implications for nursing practice. Firstly, the findings indicated a need for upskilling training among junior or new emergency registered nurses in applying AIDET communication guidelines. This training should be supplemented by mentorship from experienced emergency nurses. Secondly, the significance of the AIDET framework should be emphasized in daily practice and endorsed by ward policies. This approach will bolster positive communication, improve emergency care quality, and enhance patient satisfaction. Thirdly, registered nurses should engage in ongoing education related to the AIDET communication framework to advance emergency department operations. This education could potentially elevate the standard of care, leading to a closer alignment with client and family expectations. Fourthly, the study suggests that strong healthcare team relationships, built on effective teamwork and collaboration, are pivotal in elevating patient care and creating a harmonious work environment. Nurses and physicians can enhance patient safety and satisfaction by fostering open communication and shared responsibility. These findings could serve as a basis for nurse managers and hospital administrators to improve communication skills, enhance patient-centered care, and ultimately increase patient outcomes in emergency department settings.
Limitations of the Study
The scope of this study was limited to the emergency department of a regional hospital in southern Thailand, thus restricting the generalizability of the findings. Further studies are necessary to validate the results.
This study highlights how using the AIDET framework improves communication in emergency nursing. Nurses who skillfully apply AIDET build trust, provide clear information, and show empathy. This framework benefits junior nurses, makes communication more positive, and enhances teamwork. The study also shows that nurses' expertise and good relationships with others are vital for effective communication. Overall, AIDET can potentially improve patient care, teamwork, and patient experiences in emergency settings.