It's a battlefield! A thematic analysis of narratives shared in Cape Town emergency departments.

Background: The Emergency Department(ED) team need to make sense of an ever-changing dynamic environment. The stories people tell about everyday occurrences are central to how sense-making occurs. These stories also contribute to organisational culture, with the frequently told narratives maintaining organisational identity and shaping behaviour. By capturing stories in the ED, valuable insights can be gained into organisational culture and identity.

Methods: Non-random purposive sampling was used to recruit doctors and nurses from EDs in five hospitals in Cape Town. Data collection took place over 8 weeks between June and August 2018. Participants were asked to tell a short descriptive narrative, provide a title for their story and create a metaphor to describe working in the ED. Data were captured using the SenseMaker Collector tool, and stories were exported into a Microsoft Excel spreadsheet for analysis. An inductive thematic analysis was undertaken to discover the dominant themes.

Results: Stories were collected from 89 participants. Five did not meet the inclusion criteria and were excluded. Four themes were identified. The theme 'the usual chaos' included stories about everyday challenges, clinical situations and the difficulties in managing patients with acute behavioural disturbance and those with mental health disorders in the ED. 'There is no help' included stories about a perceived lack of support from the rest of the hospital and healthcare system, whereas 'set up to fail' referred to characteristics of the ED, including crowding and boarders. The fourth theme demonstrated a pervasive 'war-like mentality' shared among professional groups in the ED.

Conclusion: Considering the ED as a socially constructed verbal system, we identified stories that used war-like metaphors, and related staff feelings of being unsupported and disconnected. The findings are concerning from an organisational perspective. The next step is to facilitate a participative process to strategically shape future narratives.