Research| Volume 45, ISSUE 1, P46-53, January 2019

Download started.


Use of Group Concept Mapping to Identify Patient Domains of Uncertainty That Contribute to Emergency Department Use



      Prior research suggests that uncertainty related to symptoms is a driver of emergency department (ED) use, and that patients often leave the ED with uncertainty not being addressed. Our objective was to engage patients to identify domains that contribute to feelings of uncertainty and decisions to use the ED.


      We used Group Concept Mapping, a quasi-qualitative/quasi-quantitative method, to elicit patients’ views on how uncertainty related to experiencing symptoms contributes to decisions to access the ED. Purposive sampling was used to recruit participants who either sought treatment at the ED twice within a 30-day period, or visited both the ED and a primary care provider at least once within the past year.


      Thirty-four participants engaged in two rounds of Group Concept Mapping during which participants participated in structured brainstorming of ideas, followed by ranking and clustering of ideas into domains. The first round generated 47 idea statements reflecting uncertainty about consequences, severity, emergency room services, primary care options, finances, and psychologic concerns. The second round generated 52 idea statements reflecting uncertainty about self-management, causation, diagnosis and treatment plan, trust in the provider and institution, accessibility, and alternative care options.


      Factors that contribute to uncertainty and decision-making about ED use are both intrinsic (ie, cause, symptom severity) and extrinsic (ie, finances, accessibility). These domains can inform approaches to measure the uncertainty that patients experience, and to design and test interventions for nurses and other providers to help manage patient uncertainty during acute illness.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Emergency Nursing
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Morganti K.G.
        • Bauhoff S.
        • Blanchard J.C.
        • et al.
        The Evolving Role of Emergency Departments in the United States.
        (Santa Monica, CA: RAND Corporation)2013
        • Uscher-Pines L.
        • Pines J.
        • Kellermann A.
        • Gillen E.
        • Mehrotra A.
        Emergency department visits for nonurgent conditions: systematic literature review.
        Am J Manag Care. 2013; 19: 47-59
        • Raven M.C.
        • Billings J.C.
        • Goldfrank L.R.
        • Manheimer E.D.
        • Gourevitch M.N.
        Medicaid patients at high risk for frequent hospital admission: real-time identification and remediable risks.
        J Urban Health. 2009; 86: 230-241
        • Hunt K.A.
        • Weber E.J.
        • Showstack J.A.
        • Colby D.C.
        • Callaham M.L.
        Characteristics of frequent users of emergency departments.
        Ann Emerg Med. 2006; 48: 1-8
        • Mautner D.
        • Peterson B.
        • Cunningham A.
        • Ku B.
        • Scott K.
        • LaNoue M.
        How multidimensional health locus of control predicts utilization of emergency and inpatient hospital services.
        J Health Psychol. 2017; 22: 314-323
        • Pines J.M.
        • Lotrecchiano G.R.
        • Zocchi M.S.
        • et al.
        A conceptual model for episodes of acute, unscheduled care.
        Ann Emerg Med. 2016; 68: 484-491.e3
        • Rising K.L.
        • Hudgins A.
        • Reigle M.
        • Hollander J.E.
        • Carr B.G.
        “I’m just a patient”: fear and uncertainty as drivers of emergency department use in patients with chronic disease.
        Ann Emerg Med. 2016; 68: 536-543
        • Rising K.L.
        • Padrez K.A.
        • O’Brien M.
        • Hollander J.E.
        • Carr B.G.
        • Shea J.A.
        Return visits to the emergency department: the patient perspective.
        Ann Emerg Med. 2015; 65: 377-383.e3
        • LaNoue M.D.
        • Gerolamo A.M.
        • Powell R.
        • Nord G.
        • Doty A.M.
        • Rising K.L.
        Development and preliminary validation of a scale to measure patient uncertainty: the “uncertainty scale”.
        J Health Psychol. 2018; (Epub Ahead of Print)
        • Trochim W.
        • Kane M.
        Concept mapping: an introduction to structured conceptualization in health care.
        Int J Qual Healthc. 2005; 17: 187-191
        • Anderson L.A.
        • Day K.L.
        • Vandenberg A.E.
        Using a concept map as a tool for strategic planning: the healthy brain initiative.
        Prev Chron Dis. 2011; 8: A117
        • Waltz T.J.
        • Powell B.J.
        • Chinman M.J.
        • et al.
        Expert recommendations for implementing change (ERIC): protocol for a mixed methods study.
        Implement Sci. 2014; 9: 39
        • de Vries G.
        • Hees H.L.
        • Koeter M.W.J.
        • Lagerveld S.E.
        • Schene A.H.
        Perceived impeding factors for return-to-work after long-term sickness absence due to major depressive disorder: a concept mapping approach.
        PLoS One. 2014; 9e85038
        • Schiller C.
        • Winters M.
        • Hanson H.M.
        • Ashe M.C.
        A framework for stakeholder identification in concept mapping and health research: a novel process and its application to older adult mobility and the built environment.
        BMC Public Health. 2013; 13: 428
        • Alafaireet P.
        • Bouras A.
        • Houghton H.H.
        • et al.
        Applying concept mapping to solving in-patient mental health recidivism.
        Mo Med. 2015; 112: 63-66
        • Hynes H.
        • Stoyanov S.
        • Drachsler H.
        • et al.
        Designing learning outcomes for handoff teaching of medical students using group concept mapping: findings from a multicountry European study.
        Acad Med. 2015; 7: 988-994
        • LaNoue M.
        • Mills G.
        • Cunningham A.
        • Sharbaugh A.
        Concept mapping as a method to engage patients in clinical quality improvement.
        Ann Fam Med. 2016; 14: 370-376
        • Polit D.
        • Beck C.
        Nursing Research: Generating and Assessing Evidence for Nursing Practice.
        10th ed. Wolters Kluwer Health/Lippincott Williams & Wilkins, Philadelphia, PA2017
        • Kane M.
        • Trochim W.M.K.
        Concept Mapping for Planning and Evaluation.
        Sage Publications, Thousand Oaks, CA2007
        • Ogden K.
        • Barr J.
        • Greenfield D.
        Determining requirements for patient-centred care: a participatory concept mapping study.
        BMC Health Serv Res. 2017; 17: 780
        • Windsor L.C.
        Using concept mapping in community-based participatory research: a mixed methods approach.
        J Mix Methods Res. 2013; 7: 274-293
        • Concept Systems Incorporated
        Concept Systems Global MAXTM.
        • US Census Bureau
        • US Census Bureau QuickFacts
        US Census Bureau Quickfacts.
        • Mishel M.H.
        Uncertainty in chronic illness.
        Annu Rev Nurs Res. 1999; 17 (0739-6686 (Print)): 269-294
        • Mishel M.H.
        Perceived uncertainty and stress in illness.
        Res Nurs Health. 1984; 7: 163-171
        • Mishel M.H.
        Uncertainty in Illness.
        Image J Nurs Sch. 1988; 20: 225-232


      Kristin L. Rising is Associate Professor and Director of Acute Care Transitions, Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA.


      Shannon K. Doyle is in the Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA.


      Rhea E. Powell is Assistant Professor, Department of Internal Medicine, Thomas Jefferson University, Philadelphia, PA.


      Amanda M.B. Doty is in the Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA.


      Marianna LaNoue is Research Associate Professor, Department of Family and Community Medicine, Thomas Jefferson University, Philadelphia, PA.


      Angela M. Gerolamo is Associate Professor, College of Nursing, Thomas Jefferson University, Philadelphia, PA.