Barriers and enablers to nurse-initiated care in emergency departments: An embedded mixed methods survey study

BACKGROUND

Increased demand, wait times and length of stay have seen many emergency departments implement nurse-initiated protocols In New South Wales, Australia, 74 nurse-initiated protocols have been developed for implementation. The aim of this paper is to identify the barriers and enablers to nurses' use of these protocols to inform and maximise future implementation.

METHODS

Data were collected via surveys informed by the theoretical domains' framework and the Practice Environment Scale of the Nursing Work Index (PES-NWI). Descriptive statistics summarised quantitative data and content analysis was performed on qualitative data. Results were integrated and classified as barriers or enablers to nurses' use of protocols.

RESULTS

The nurses' response rate was 82 % (n = 76) and doctors 72 % (n = 34) Six categories were generated; one barrier (lack of resources), three enablers (patient and organisational benefits, nurses' motivation, nurses' desire to develop their practice) and two were both a barrier and enabler ( nurse confidence and the work environment).

CONCLUSION

Emergency nurses are highly motivated to use nurse-initiated protocols to positively impact patient outcomes. However, a lack of resources, time, access to education and confidence are barriers to use that need to be addressed when designing implementation.

Identifying Barriers and Enablers for Nurse-Initiated Care for Designing Implementation at Scale in Australian Emergency Departments: A Mixed Methods Study

AIM

The aim of this study was to (i) identify barriers and enablers and (ii) inform mitigating or strengthening strategies for implementing nurse-initiated care protocols at scale in emergency departments (EDs).

DESIGN

Embedded mixed methods.

METHODS

The study included four clusters with a total 29 EDs in NSW, Australia. Concurrent quantitative and qualitative data were collected via electronic nursing and medical staff surveys and analysed. Barriers and enablers to implementation were identified and mapped to the domains of the Theoretical Domains Framework (TDF). Selection of intervention functions and behaviour change techniques (BCTs) enabled development of implementation strategies.

RESULTS

In total, 847 responses from nursing and medical staff (43%) reported four enablers for use and implementation: (i) knowing or being able to learn to use simple nurse-initiated care; (ii) protocols help staff remember care; (iii) carefully considered education programme with protected time to attend training; and (iv) benefits of nurse-initiated care. Nine barriers were identified: (i) lack of knowledge; (ii) lack of skills to initiate complex care (paediatric patients, high-risk medications and imaging); (iii) risk for inappropriate care from influence of cognitive bias on decision-making; (iv) punitive re-enforcement; (v) protocols that are too limited, complex or lack clarity; (vi) perceived lack of support from medical or management; (vii) perception that tasks are outside nursing role; (viii) concern nurse-initiated care may increase the already high workload of medical and nursing staff; and (ix) context. The barriers and enablers were mapped to nine TDF domains, five intervention functions and 18 BCTs informing implementation using strategies, including an education programme, pre-existing videos, audit and feedback, clinical champions and an implementation plan.

CONCLUSION

A rigorous, systematic process generated a multifaceted implementation strategy for optimising nurse-initiated care in rural, regional and metropolitan EDs.

IMPLICATIONS

Staff wanted safe interventions that did not lead to increased workload. Staff also wanted support from management and medical teams. Common barriers included a lack of knowledge and skill in advanced practice. Clinicians and policymakers can consider these barriers and enablers globally when implementing in the ED and other high-acuity areas. Successful strategies targeting barriers to advanced practice by emergency nurses can be addressed at the local, state and national levels.

IMPACT

Implementation of new clinical practices in the ED is complex and presents challenges. Key barriers and enablers, including those related to initiating care and workloads in the ED were identified in this study. This research broadly impacts ED staff and policymakers globally.

REPORTING METHOD

Mixed Methods Reporting in Rehabilitation & Health Sciences (MMR-RHS).

PATIENT OR PUBLIC CONTRIBUTION

Site senior nurse researchers for each cluster worked closely with site stakeholders, including local consumer groups. Consumer councils were engaged at all the sites. Site visits by the research nurses have been an important strategy for discussing the study with key stakeholders.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trial: ACTRN12622001480774p.

The effectiveness of nurse-initiated interventions in the Emergency Department: A systematic review

BACKGROUND

Nurse-initiated interventions potentially provide an opportunity for earlier response for time sensitive presentations to the Emergency Department, and may improve time-to-treatment, symptomatic relief and patient flow through the department.

OBJECTIVE

To determine the effectiveness of nurse-initiated interventions on patient outcomes in the Emergency Department.

METHOD

The review followed the JBI methodology for reviews of quantitative evidence. Each study was assessed by two independent reviewers and data were extracted from included papers using standardized data extraction tools. Outcomes of interest included time-to-treatment, relief of acute symptoms, waiting times and admission rates.

RESULTS

Twenty-six studies were included in the final review, with a total of 9144 participants. Nine were randomized control trials, 17 had a quasi-experimental design. Twelve of the studies involved pediatric patients only and 14 included adult patients only. Interventions, protocols and outcomes were heterogeneous across studies. Overall, nurse-initiated interventions were effective in reducing time-to-analgesia, time-to-treatment for acute respiratory distress as well as improved pain relief and decreased admission rates.

CONCLUSION

To achieve early intervention and timely relief of acute symptoms, nurses should seek to consistently implement nurse-initiated interventions into their care of patients in the Emergency Department. Several findings are made to inform practice, however future high-quality research with locally specific strategies is required to improve certainty and quality of findings.

Pain assessment and interventions by nurses in the emergency department: A national survey

AIM

The aim of this study was to examine the knowledge, perceptions and factors influencing pain assessment and management practices among Australian emergency nurses.

BACKGROUND

Pain is the most commonly reported symptom in patients presenting to the emergency department, with over half rating their pain as moderate-to-severe. Patients unable to communicate, such as critically ill intubated patients, are at greater risk of inadequate pain management.

DESIGN

This cross-sectional exploratory study used survey methodology to explore knowledge, perceptions and factors influencing pain management practices among Australian emergency nurses.

METHODS

Australian emergency nurses were invited to complete an online survey comprising 91 items. The response rate was 450 of 1,488 (30.2%). STROBE guidelines were used in reporting this study.

RESULTS

Variations in level of acute pain management knowledge, especially in older, cognitively impaired or mechanically ventilated patients were identified. Poor interprofessional communication, workload and staffing negatively impacted on nurses' intention to administer analgesia. For intubated patients, validated observation pain assessment instruments were rarely used, although respondents recognised the importance of pain management in critically ill patients.

CONCLUSIONS

Emergency nurses recognise the importance of pain relief. The ability to nurse-initiate analgesia, education and training in pain management education is variable. Little education is provided on assessing and managing acute pain in elderly, cognitively impaired or mechanically ventilated patients. Use of validated pain assessment instruments to assess pain in critically ill patients is poor.

RELEVANCE TO CLINICAL PRACTICE

While pain management is the responsibility of all healthcare professionals, in the emergency department, it is a core role of emergency nursing. This study highlights the variation in ability to nurse-initiate analgesia, level of acute pain knowledge, education and training, and use of validated pain assessment instruments to guide pain management in critically ill intubated patients.