The reason behind the arbitrary 4‐hour target, as opposed to 3 hours or 5 hours, is unclear. It appears to be founded on the basis that the public perceive speed to be synonymous with quality,⁷ and that there is a correlation between patient waiting times and staff satisfaction.⁸ The DH⁴ claim that the 4‐hour target was based on work by Cooke et al,⁹ but in fact this work was based in a different context and setting, finding that patient streaming (“see and treat”) in a trauma unit could reduce waiting times by 30% when experienced nurse practitioners and consultants were present.

Concerns over the lack of consultation, planning and communication prior to the implementation of the target have been expressed concisely by Hayes'¹⁰ statement that “Change is often managed less effectively than it might be because those responsible for managing it fail to attend to some of the critical aspects of the change process”. The focus on targets as opposed to improving emergency care overall has also been widely criticised.¹¹ Many patients are rushed out of departments in the last 20 minutes of the 4‐hour period,¹² which has an effect on receiving teams¹³ and it has been said that EDs are becoming “a queue processing machine”.¹⁴ In fact, a survey of consultant staff by the British Medical Association (BMA)¹⁵ showed that during a monitoring week, most departments directed their efforts towards achieving the target at the expense of clinical quality and staff well‐being. A later survey¹⁶ found that it was not the target itself but the way in which the target was implemented that caused so much tension. To quote Donald MacKenzie, Chairman of the BMA Accident and Emergency Committee, “It is absolutely right that patients visiting A&E are seen and treated as quickly as possible but not if staff are being forced to make inappropriate decisions…I am appalled to hear that some A&E staff are being put under intolerable pressure, even bullied, by their trusts as they attempt to treat and discharge their patients within four hours”.¹⁷

From a positive stance, however, Munro et al¹⁸ found that waiting times are being reduced by increasing nurses' and doctors' hours, improved access to emergency beds and triage by senior staff, as long as staff remain focused. They also found that the morale of staff improved when measures were taken to improve waiting times. Others argue that nurses now concede that trusts would never have addressed some of the difficult issues surrounding emergency care (unnecessary delays and gridlocked systems) without the pressure of the 4‐hour target.¹⁹

In this study we focus specifically on views about the 4‐hour wait, and the target's emotional and personal effect on the working lives of nurses in the ED. The aim of the study was to explore nurses' views and to identify the perceived advantages and disadvantages of the 4‐hour target.

A stratified sample of nine nurses was recruited from the ED at a UK District General Hospital (three healthcare assistants, three staff nurses and three sisters/charge nurses). Respondents were required to have worked in an ED for >5 years, to ensure that they had experience of waiting times prior to the implementation of the 4‐hour target,³ resulting in a population of 19 staff members. Data was collected via audiotaped semi‐structured interviews. As the lead author (AM) was the departmental manager, hence, it was a condition of the approval from the local research ethics committee (LREC) that the interviews and transcription were performed by an independent interviewer to maintain anonymity.

To ensure validity, copies of the transcripts were returned to respondents to see if, on reflection, the elements described were essential to the experience.²¹ Secondly, emergent themes in a proportion of the transcripts were co‐verified by a second researcher.

Findings from this small study suggest that the 4‐hour target was considered an overall success with regard to improvements in patient care and patient satisfaction. Life in emergency care was better now than it had been previously. Government findings support this claim, with the announcement that in the period April 2005 to March 2006, 18.7 million patients had attended EDs, with 98% waiting <4 hours.²⁷

These benefits, however, have come at a cost: negative attitudes about the imposed and unsupported criteria for the target, workload issues, concerns over the quality of care, pressure on support systems and training, and increased staff turnover. There is still support for the target but with the caveat that links within the hospital and between primary and secondary care must be improved.

Our recommendations are that representatives from all the care pathways should be brought together to develop shared guidelines, ensuring, for example, diagnostic and pharmacy cover and admissions procedures from primary care.

This study is limited by its sample size and its focus on a single department. However, it has produced a unique perspective within the literature and is a baseline for future research in the area.