Literature Review

The report provides a critical examination of a quantitative research article from the Australasian Emergency Nursing Journal. It is an official journal of the College of Emergency Nursing Australasia (CENA) which provides new knowledge and insight regarding professional practice needs of emergency nurses. The credibility of the journal is high as it is an international peer-reviewed journal publishing innovative work in emergency nursing and it employs double blinding as peer review process (Australasian Journal (2017). The article used for the critical review is work by Broadbent, Moxham & Dwyer, (2014) which investigated about the implications of emergency department triage environment on triage practice for clients with mental illness. All the three authors are PhD qualified from different School of Nursing and Midwifery in Australia.  Lorna Moxham has research interest in mental health nursing, nursing education and therapeutic recreation in mental health and other two areas also research interest in the area of emergency care and mental illness (Dr Marc Broadbent, 2017). Hence, they are likely to provided innovative information through their experience in mental illness research.

Broadbent, Moxham & Dwyer, (2014) focused on examining the impact of emergency triage environment on triage practice of nurse who care for clients with mental illness. The rationale for this research is understood by reviewing the introduction and literature review section of the article. The authors presented the problem that due to the increased presentation of clients with mental illness, having specialist mental health triage scale is necessary to facilitate decision making. Clarke et al., (2015) also pointed to the fact that Emergency Department (ED) is the first place where patients seek assistance in mental health crisis, however emergency staffs are often ill-prepared to manage complexities in patient. It also suggested that as triage nurse face challenges in making consistent and accurate decision making, they must be given evidence informed training to increase their accuracy in decision making.  Hence, an appropriate triage environment is likely to provide better positions to ED triage nurse to manage clients from point of presentation to handover to client. Therefore, with the aim of improving care for clients with mental illness coming to ED, (Broadbent, Moxham & Dwyer, (2014) aimed to investigate about the impact of ED triage environment on triage assessment and delivery of care.

To make the research more specific and identify new information related to triage assessment, literature review of past research work was presented. It mainly focused on the ED triage design area and the use of space for ED care in mental health setting. Several dilemmas in conducting operational task for triage was presented and triage desk was regarded as the main epicenter for managing client presenting with mental illness (Goode, Melby & Ryan, 2014). However, the limitation in this section was that no gap in research work was presented and challenges were only discussed. However, it formed the basis for framing the research objective which was to explore the issues surrounding triage assessment and environment needed to manage it.

Methods

For a research on exploring the triage environment in ED, observational research method is most suitable. Hence, congruent with the study objective, the researcher selected the ethnographic research design and this is most appropriate for the study because ethnographic research is designed in a way to observe and interact with study participants in their real-life environment. The research design support researcher’s goal and process to get answer to the research question. The use of ethnography  improves data collection process because such design also considers the cultural influence on clinical practice and reflexivity is possible with such study design (Creswell & Poth, 2017). . As patients from diverse background come to ED for mental illness treatment, Broadbent, Moxham & Dwyer, (2014) using ethnography is beneficial. However, no time is spent with the participant because the article mainly explored  one element from the findings of a larger observational ethnographic study and that element include triage practice environment and its effect on ED triage practice nurse.

Broadbent, Moxham & Dwyer, (2014) explored one element from the findings of broader observation ethnographic study and the research setting was a regional hospital in Australia with a large emergency department and about 4.5% of clients came with mental health issues. The main participants for the study included 45 qualified staff and one emergency nurse for morning and night shift. Another two nurses were triage for the afternoon shift. Hence, it can be said that the sample and setting has been described well by the researcher. However, the limitation is that the hospital has only 4.5 patients presenting with mental illness and a greater flow of mentally ill patient could have enhanced the validity of the study. Despite this, the sample size is appropriate to get enough data, but the information regarding method used to recruit participants is missing. In addition, study used more than two methods collecting data and purposive sampling technique was used for conducting interview with triage nurse as they are likely to give realistic insight about challenges in ED triage assessment.

In a qualitative research, the validity of the study is established by analyzing the research data from multiple perspectives. This helps to identify consistencies or inconsistencies across the data. Two or three methods of triangulation was also used by Broadbent, Moxham & Dwyer, (2014) as data was collected using participant observation, formal and informal semi-structure interview, document examination and collection of field notes. Several modes of data collection ensure that sufficient data is available and richness and depth in information is maintained.

Results

The main strength of Broadbent, Moxham & Dwyer, (2014) is that they have focused a lot on enhancing the richness and depth of the data. For instance, the participant observation and interview method for data collection was most appropriate for the goal of the research. The participant observation helped in collecting data related to impact of triage practice environment on triage nurse and the interview method gave the opportunity to contextualize the data and understand the real concern of triage nurse during triage assessment for clients with mental illness. The involvement of qualified staff to conduct triage during data collection and the use of multiple methods for data collection is commendable as it helped to assess inconsistencies and minimize biasness in the study.

 The trustworthiness in the data collection is understood from the focus on operational efficiency and the triage nurses response to organizational pressure. This gave integrity to the research work as such approach helped in identifying specific patient group that might challenge the nurse in managing optimal organizational flow in the triage area. In addition, use of both participant observation and interview method for data collection ensured that researcher could easily compared discrepancies or inconsistency in research data. The confidence and reliability in research finding is strengthened because all the three authors have a research interest in the field of Mental Health Nursing and Emergency department and they must have extensive knowledge regarding the issues taking place in such setting. Hence, their research work is likely to provide the most innovative solution to triage nurse and reviewers will have the confidence that the findings can be trustworthy and reliable enough to be applied in real setting.

Broadbent, Moxham & Dwyer, (2014) mainly used ethnographic research design for getting insight regarding the impact of ED triage environment on triage practice for triage nurses and the data is analyzed in such case by means of different ways of coding or using narrative to explain the interview outcome (Flick, 2014). The review of data analysis section has revealed that narrative review process was mainly followed to analyze the data. The notes collected from participant observation and taped interviews were categorized into different themes. In addition the data generated during fieldwork was analysed by Glaser and Strauss comparative method which facilitated systematic inductive analysis of data (Glaser, 2017). . Hence, it can be said that the data analysis method adapted for this research is compatible with the ethnography research design and the use of thematic pattern ensured that full meaning was given to the study outcome. However, there is possibility of biasness on thematic pattern of analysis as this based on the understanding of researcher and individual interpretation may differ (Elo et al., 2014).

Data Analysis

The study was summarized according to different themes like the triage environment, triage assessment and client management. Categorizing the study finding into these three themes is effective as it is relevant to the research objective and for reviewers, it becomes easy to interpret the results for each findings. In terms of efficiency of the results in capturing meaning of the data, it can be said that detailed summary of experience of triage nurse were provided with good use of excerpts to add further meaning to the research aim.  For example, in the context of triage environment, it was found that non-sound attenuating ceiling in the triage area decreased the ability to have private conversation and no control over movement of clients in the area affect their decision making process. As triage assessment is a rapid process, this result provides insight regarding modifying the triage environment so that noise and privacy barrier could be addressed (Broadbent, Moxham & Dwyer, 2014). The reliability of this result is evident from the work of Craig et al., (2016) which showed that environmental context and resource makes affects the triage nurse act of documenting screening results and restructuring behavioral change is the best approach to address this barrier in ED triage practice.  In addition, the practice environment was found to affect ED triage assessment process in nurses. In short, it can said that the research gave the idea that practice environment and architectural environment in triage area affects the triage assessment process and this areas must be addressed in clinical setting. However one limitation is that although authentic and real picture of triage process in ED was presented, however provocative argument were not presented to defend or support the study outcome.

Summary Assessment and Conclusion

The truth value of the study is high because the results have been generated based on real experience of triage nurse, observation and field notes. However, the only factors that limits the transferability or applicability of the research data in other EDs is that participants comment reflected social, cultural and historical context behind challenges in triage assessment and this may differ across different setting. Despite this, it informs areas of change in triage environment and triage practice for ED triage nurse. The research mainly pointed out to the provision of building secure and private environment for triage nurses and gives triage nurse enough space to interact and deal with mental health clients. This can be a systematic approach to address barrier in complex care environment Craig et al., (2017). This is meaningful evidence that can be applied to build a triage area, however as the focus is on triage assessment for mental illness client, future research should also focus on analyzing the experience of mental illness client in triage area.

Discussion and Conclusion

The article by Broadbent, Moxham & Dwyer, (2014) was mainly reviewed to solve the personal problem faced according to the case scenario. The case scenario is related to the problem that people with mental illness mainly use ED as the first point of access to care, however the ED does not have MH clinician to rostered in ED to handle such patients. In this scenario, the main problem was related to the safety and privacy of client with mental illness presenting to the ED. In this context, the work by Broadbent, Moxham & Dwyer, (2014) is considered most appropriate to solve the problem as it mainly gives the idea that there should be triage nurse in the ED specifically for clients with mental illness. The main implication of the result for the nursing practice was that it gave the idea that appropriate triage environment is the solution to both safety and privacy issues of client. The focus on triage area free from noise and movement barrier is likely to enhance patient values because triage nurse can closely communicate with patient and their clinical expertise in dealing with such client will also be enhanced as private space will increase their concentration and enhance decision making and screening procedures (Martin & Eckert, 2016). However, the study results cannot be used to inform evidence based practice in the case scenario because it has not investigated about experience of patient and triage nurse were only the main participants for the study. Future research work with client’s experience in triage area is likely to provide holistic solution to enhance ED triage assessment. Despite this, the challenges of triage nurse and impact of environment of triage practice for nurses is supported by many other research work (Craig et al., 2017).  

Reference

Australasian Journal (2017). Australasian Emergency Nursing Journal. [online] Journals.elsevier.com. Available at: https://www.journals.elsevier.com/australasian-emergency-nursing-journal [Accessed 9 Oct. 2017].

Broadbent, M., Moxham, L., & Dwyer, T. (2014). Implications of the emergency department triage environment on triage practice for clients with a mental illness at triage in an Australian context. Australasian Emergency Nursing Journal, 17(1), 23-29.

Clarke, D. E., Boyce-Gaudreau, K., Sanderson, A., & Baker, J. A. (2015). ED triage decision-making with mental health presentations: A “think aloud” study. Journal of emergency nursing, 41(6), 496-502.

Craig, L. E., McInnes, E., Taylor, N., Grimley, R., Cadilhac, D. A., Considine, J., & Middleton, S. (2016). Identifying the barriers and enablers for a triage, treatment, and transfer clinical intervention to manage acute stroke patients in the emergency department: a systematic review using the theoretical domains framework (TDF). Implementation Science, 11(1), 157.

Craig, L. E., Taylor, N., Grimley, R., Cadilhac, D. A., McInnes, E., Phillips, R., … & Considine, J. (2017). Development of a theory-informed implementation intervention to improve the triage, treatment and transfer of stroke patients in emergency departments using the Theoretical Domains Framework (TDF): the T 3 Trial. Implementation Science, 12(1), 88.

Craig, L.E., Churilov, L., Olenko, L., Cadilhac, D.A., Grimley, R., Dale, S., Martinez-Garduno, C., McInnes, E., Considine, J., Grimshaw, J.M. and Middleton, S., 2017. Testing a systematic approach to identify and prioritise barriers to successful implementation of a complex healthcare intervention. BMC medical research methodology, 17(1), p.24.

Creswell, J. W., & Poth, C. N. (2017). Qualitative inquiry and research design: Choosing among five approaches. Sage publications.

 Dr Marc Broadbent. (2017).  Usc.edu.au.  [online] Available at: https://www.usc.edu.au/explore/structure/faculty-of-science-health-education-and-engineering/staff/dr-marc-broadbent [Accessed 9 Oct. 2017].

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Flick, U. (2014). An introduction to qualitative research. Sage.

Glaser, B. (2017). Discovery of grounded theory: Strategies for qualitative research. Routledge.

Goode, D., Melby, V., & Ryan, A. (2014). Management of patients with mental health needs: Debbie Goode and colleagues assess whether staff are prepared to offer person-centred care to all people who present to emergency departments. Emergency Nurse, 22(5), 32-37.

Martin, M. J., & Eckert, M. J. (2016). Difficult Triage Decisions in the Combat or Austere Environment. In Surgery During Natural Disasters, Combat, Terrorist Attacks, and Crisis Situations (pp. 47-55). Springer International Publishing.