Table 4 Categories, subcategories and quotes from the qualitative content analysis

Salience of reflection

Self-awareness to scrutinize oneself

IP 19: “The demands increase. You have higher expectations of yourself. Okay, I must know this, I must check this. So, for something that might happen in the ED – I feel I should know how to deal with it, especially if I am working alone”. (registered nurse)

IP 18: “Yes, I was very numb, as I thought it was very difficult situation. I disliked attending emergency calls for a while afterwards. It was probably because we didn’t get to process it properly with debriefing afterwards because that never happened… It was more that one witnessed this person die. Observing that person going from being talkative and alive one minute to being dead the next”. (nurse assistant)

Team reflection as a way of interprofessional learning

IP 7: “So, she stands there and massages his heart [cut open thorax] and you see how the blood is just spurting out, and then the thoracic surgeon comes over and starts to stitch. And there I am standing with blood all over the place, and everyone wades in the patient’s blood. His blood, you know. […] Yes, I never forget that boy. We can’t even go and sit down somewhere as we are so few. If we who attended the trauma alarm leave, then the staff would disappear out onto the floor. So we have to [deep sigh] you know, change our scrubs and clean our shoes and blow our noses [emotional snorting].[…] We try [to talk] whilst cleaning but we know that we must soon go out again. In the worst case, there will be a new trauma alarm. So you have to act quickly. And when we got out [from the trauma room] it felt crazy”. (nurse assistant)

Professional experience makes a difference

Experience is a crucial component of professional practice

IP 6: “The team did signal but I didn’t really listen and as a result it became really stressful. A super-stressful situation […] But they had actually already informed me that I should go see the patient, since it is so much easier for me than for the intern to look at the patient and assess their need for further care. It is crucial to act sooner rather than later […] In any case, I think that the others in the team acted properly […]. I consider that I was relatively inexperienced as the medically responsible physician and that I was stressed because of that”. (physician)

Expectation of professional experience

IP 19: “‘Is there any physician here’?! And a resident comes running and says ‘I have not handled any acute situations, so this will be my first.’ And I look at her and say ‘Oh my God, I haven’t responded to a call either, so this will also be my first acute situation.’ So both of us were slightly panicked but we thought ‘Okay, we will simply do the best we can.’ […] Both of us were new and didn’t want to miss anything. So, we double-checked with each other all the time: ‘Okay, you want me to give this now, I will give this now’. And you don’t want to make any mistakes. So it wasn’t that she [the physician] had any expectations that I would do things according to a certain routine, in the way it should be, but rather we talked to each other: ‘Take this, do that’. I think if you are a trauma-trained registered nurse, then you already know what to do without the physician really needing to say much […] It was very calm and nice [giggle], which was good. So it felt good in any case to have experienced an acute situation that was handled successfully”. (registered nurse)

Need for continuous development and training

IP 18: “I am convinced that training is the ‘A to Z’ actually. You talk a lot about what you do, and there is a lot of simulation training. In addition, you already have a structure, so that with these cases or whatever the situation you should know what to do”. (nurse assistant)

IP 21: “I did not have any introduction. I only had 1 h, then I was directed to the changing room [ready to start work]”. (physician)

Demanding physical and psychosocial work environment

The physical work environment

IP 6: “We must behave in such a way that we have space to move and think. So, what I have done several times after them [the patients] becoming ill in small rooms, is to move to an acute emergency room. Because it is also that this has a signal value for the staff”. (physician)

IP 9: “There is too much squawking and fuss and unnecessary twaddle about things that concern the clinical work […]. Because a quiet work environment is much better than a loud screeching one. It would make a difference. It should be organized so that the environment becomes more discrete and calmer. I don’t think that it is possible do so, therefore the focus of the work should be in getting patients out of the ED or not even transferring them into this small ED”. (registered nurse)

Dealing with emotions related to stress

IP 2: “[…] I know that bad things happen. Partly [because of] the choice of profession, I would never have chosen to be in the ED if I could not accept that it was possible to do something wrong. So it is probably a personality trait. […] I think it’s very sad [describing patient hazard] but I know that it happens and that one must learn from it and move on, because it is part of the job”. (physician)

Balancing communication demands

Applying communication (tools, climate, and attitudes)

IP 11: “For my part, I am active in communicating, in that I am listening to what they are saying and keeping up with what is going on. Therefore, there doesn’t need to be chat all the time because you have an overall picture of the situation”. (administrator)

IP 8 “There was an overall bad atmosphere. The whole team failed to function. We who were working in the ED were doing great whilst for those working with anesthesia, it was not working. We didn’t get the teamwork to function at all. There was no communication, and there were no closed loops. Nothing worked”. (registered nurse)

Art of concise and clear information

IP 15: “Well, had I not been speaking aloud and the nurse not been speaking aloud, then I think the diagnosis would have been delayed, because we would have thought it was a stroke instead”. (physician)

Silent communication

IP 17: “My experience is that the patient [low heart rate of 17 beats/min] is in need of this treatment, so I start connecting the patient to be ready if the decision comes. So I look up at our experienced physician and we make eye contact directly and I don’t know who said it but the decision is to perform external pacing [transcutaneous pacing]!”. (registered nurse)

Lacking management support, structure, and planning

ED considered an unsuitable place of care

IP 9: “The blood gas results improved after a couple of hours and we saw that we were doing a good job, whereas we were all in agreement that she needed to be hospitalized because she was not well [in need of advanced breathing assistance] […]. From the management via the overall responsible physician on call, down to the resident physician on call I was informed that ‘the patient will return to her home’. And I was just thunderstruck. Amazed!” (physician)

Mismatch of available resources and excessive workload

IP 16: “It had been a terrible day for the daytime staff with a high number of patients and many severely ill patients, so they felt that they hadn’t realized that he was as wheezy as he was [non-invasive ventilator assistance]. It is possible that feeding the patients had not been prioritized. In this case, receiving food could have been beneficial [patient with diabetes and asthma] […]. He could have been assisted to inhale better, and maybe not be so oxygen-dependent. Finally, the patient ended up in the ICU, where he was intubated”. (registered nurse)

IP 27: “Well, you don’t have time to communicate properly […]. You don’t have time to have these great briefings within the team: As a result, you know partially how we think (nursing staff) and how the physician thinks, and we can…well, talk to each other, I think”. (nurse assistant)

Discordant views on strategies of care

IP 5: “Yes, but this is the way it is. It’s not worth being annoyed about this [nurse assistant]”. Right or wrong, but they have gotten used to the situation […]. Neurologists, in this case, don’t need to inform [the interprofessional team] about where they go, if no one cares. (registered nurse)

IP 24: “But sometimes I think that people are a little stressed about that [statistical numbers] and maybe care a little more about the fact that everything appears to be in place, while under the blanket there is a full diaper [the situation is much worse than it appears on the surface]”. (registered nurse)

Tensions between professional role and responsibility

Gender roles and hierarchies of expertise

IP 1: “I didn’t get to have any contact with the patient because this patient turned to the male nurse all the time. Moreover, this was a rather dominant male nurse who didn’t pass the ball to me but just kept on talking. So I had a great difficulty to break into the conversation […]. (physician)

Violation of personal and professional integrity

IP 2: “The staff could give a damn to push for the patient to get discharged. One didn’t have to put pressure on the physician from the viewpoints of the hospital bed occupational coordinator and the registered nurses.”. (physician)

Different views on interprofessional teamwork

Inadequate involvement/intrusion by the patient

IP 6:”[Oxygen] Saturation went down, down, down and I hate it when the discussion about the level of care takes place above the patients head. “Well, what is this patient actually capable of? What is their usual condition? Do they have dementia?” And then you see that the patient hears everything”. (physician)

Personal relations and favoritism

IP 25: “He is kind of her favorite nurse. And all of us who work here know that [laughter] […]. It felt like you didn’t have any competence at all to do anything, it was just him, him, him”. (registered nurse)

Perspective on teamwork attributes

IP 15: “There was no specific [person] who took the lead in the situation, because the cardiologist on-call, who should lead the situation, received no response to her suggestions. […] So, they didn’t listen to her or allow her to direct the care. Suggestions were discarded and directives were issued that really did not have any [receiver]. […] There was no structure in the room”. (physician)

IP 25: “[…] But the fact that you work in the same [way] direction, I think can be important, that there is some kind of structure in how you think”. (registered nurse)

Confidence in interprofessional team members

Joint team assessments

IP 12: “It is difficult to be a nurse without a physician and it is extremely difficult to be a physician without a nurse. I think you also realize it when it becomes like this, you sort of help each other”. (registered nurse)

Mutual need for interprofessional support

IP 7: “He said, ‘This is not ok. I will never get used to this. Never. A young beautiful human being who is executed like this. I will never get used to this’. And I thought, Wow! Well, not wow like that, of course he is human too, but this is the first time I have seen a physician stand up and be so emotionally moved that the tears just flowed.” (nurse assistant)

IP 14: “So, it has been great…it has been good, but it has also been damn irritating that it is not always like that. One gets frustrated that it can work like this but then no one does it”. (nurse assistant)

IP 21: “The patient wanted help. He wanted to be hospitalized. And then I walked out and told the nurses: ‘you have to go in and treat the wounds until I have spoken to the medically responsible physician’. And everyone passed on this problem to…in other words the nurses assigned it to other nurses to handle, as no one wanted to treat this patient because of the strong smell, and they didn’t really want to help him”. (physician)