BACKGROUND: An emergency department (ED) should offer timely care for acutely ill or injured persons that require the attention of specialized nurses and physicians. This study was aimed at exploring what is actually going on at an ED.

METHODS: Qualitative data was collected 2009 to 2011 at one Swedish ED (ED1) with 53.000 yearly visits serving a population of 251.000. Constant comparative analysis according to classic grounded theory was applied to both focus group interviews with ED1 staff, participant observation data, and literature data. Quantitative data from ED1 and two other Swedish EDs were later analyzed and compared with the qualitative data.

RESULTS: The main driver of the ED staff in this study was to reduce non-acceptable waiting. Signs of non-acceptable waiting are physical densification, contact seeking, and the emergence of critical situations. The staff reacts with frustration, shame, and eventually resignation when they cannot reduce non-acceptable waiting. Waiting management resolves the problems and is done either by reducing actual waiting time by increasing throughput of patient flow through structure pushing and shuffling around patients, or by changing the experience of waiting by calming patients and feinting maneuvers to cover up.

CONCLUSION: To manage non-acceptable waiting is a driving force behind much of the staff behavior at an ED. Waiting management is done either by increasing throughput of patient flow or by changing the waiting experience.