Australian emergency nurses' experiences of working with personal protective equipment during the COVID-19 pandemic. A qualitative study

INTRODUCTION

The COVID-19 pandemic has exposed a need to understand the challenges associated with wearing Personal protective Equipment (PPE). The aim in this study was to explore emergency nurses' experiences early in the COVID-19 pandemic in Australia and the impact of PPE use on their practice.

METHODS

An explorative descriptive qualitative study was conducted between January 2022 and April 2022. Eighteen emergency nurses and six leaders participated. Semi-structured interviews (n = 21) and one focus group were conducted. Interview transcripts were analysed using Braun and Clarke's framework.

RESULTS

Two major themes were identified. The first theme was: (1) The shifting ground of the COVID-19 pandemic response. Associated sub-themes were: i) What's the go with PPE today? ii) In the beginning we were scrambling for masks; iii) Emergency is the true frontline. The second theme was: (2) Physical and emotional impacts of emergency nursing work. Sub-themes were: (i) Facing the fear of exposure; (ii) By the end of the shift I am just absolutely spent; iii) Discomfort of wearing PPE impacts on compliance.

CONCLUSIONS

Healthcare leaders need to secure PPE supply chains and evaluate the effectiveness and side-effects of different PPE designs to minimise occupational harms associated with prolonged PPE use.

Healthcare provider perspectives on emergency department-initiated buprenorphine/naloxone: a qualitative study

BACKGROUND

Take-home buprenorphine/naloxone is an effective method of initiating opioid agonist therapy in the Emergency Department (ED) that requires ED healthcare worker buy-in for large-scale implementation. We aimed to investigate healthcare workers perceptions of ED take-home buprenorphine/naloxone, as well as barriers and facilitators from an ED healthcare worker perspective.

METHODS

In the context of a take-home buprenorphine/naloxone feasibility study at a tertiary care teaching hospital we conducted a descriptive qualitative study. We conducted one-on-one in person or telephone interviews and focus groups with ED healthcare workers who cared for patients given take-home buprenorphine/naloxone in the feasibility study at Vancouver General Hospital from July 2019 to March 2020. We conducted 37 healthcare worker interviews from December 2019 to July 2020. We audio recorded interviews and focus groups and transcribed them verbatim. We completed interviews until we reached thematic saturation.

DATA ANALYSIS

We inductively coded a sample of transcripts to generate a provisional coding structure and to identify emerging themes, which were reviewed by our multidisciplinary team. We then used the final coding structure to analyze the transcripts. We present our findings descriptively.

RESULTS

Participants identified a number of context-specific facilitators and barriers to take-home buprenorphine/naloxone provision in the ED. Participants highlighted ED conditions having either facilitative or prohibitive effects: provision of buprenorphine/naloxone was feasible when ED volume was low and space was available but became less so as ED volume increased and space decreased. Similarly, participants noted that patient-related factors could have a facilitative or prohibitive effect, such as willingness to wait (willing to stay in the ED for study-related activities and buprenorphine/naloxone initiation activities), receptiveness to buprenorphine/naloxone, and comprehension of the instructions. As for staff-related factors, time was identified as a consistent barrier. Time included time available and time required to initiate buprenorphine/naloxone (including time building rapport). Healthcare worker familiarity with buprenorphine/naloxone was noted as either a facilitating factor or a barrier, and healthcare workers indicated that ongoing training would have been advantageous. Many healthcare workers identified that the ED is an important first point of contact for the target patient population.

CONCLUSION

Integrating a buprenorphine/naloxone program into ED care requires organizational supports (e.g., for managing buprenorphine/naloxone within limitations of ED volume, space, and time), and ongoing education of healthcare workers to minimize identified barriers.

Impact of the COVID-19 pandemic on emergency department team dynamics and workforce sustainability in Australia. A qualitative study

INTRODUCTION

The COVID-19 pandemic has challenged health care professionals and changed our approach to care delivery. The aim in this study was to explore nurses' experiences providing care in the ED during the COVID-19 pandemic in Australia and the impact of this on ED team functioning.

METHODS

A qualitative explorative descriptive study was conducted using thematic analysis strategies. Participants comprised: Registered Nurses (n = 18) working in clinical roles in the Emergency Department and Leadership Registered Nurses (n = 6) within the organisation. One on one interviews (n = 21) and one focus group interview were conducted utilising semi-structured, conversational style, in-depth interviews between January 2022 and April 2022.

RESULTS

Two major themes were identified that described the impact on ED team dynamics and longer-term impacts on the ED nursing workforce. The first major theme was: 'Changed Emergency Department team identity and dynamics' and included four sub-themes: i) PPE is a barrier to team camaraderie; ii) outsiders versus insiders - ambivalence to PPE spotter role; iii) personal safety comes first in a pandemic; and iv) using PPE depersonalises the whole patient experience. The second major theme was: 'This pandemic caught everyone off guard' and had three sub-themes. The associated sub-themes were: i) People outside ED have no understanding of what it has been like; ii) COVID-19 is here to stay - Permanent changes to care delivery and nursing practice; and iii) tenacity of a true profession.

CONCLUSIONS

Study findings illuminated the dynamics and functionality of ED nursing, encompassing the unique qualities of camaraderie, autonomy, resilience and tenacity.

Evaluating the effects of triage education on triage accuracy within the emergency department: An integrative review

INTRODUCTION

Triage accuracy can affect patient outcomes. Education to ensure nurses provide the most accurate triage scores is paramount for patient safety.The objective was to investigate whether ongoing triage education increases triage accuracy, knowledge or behaviour.

METHOD

An integrative review was conducted by searching five databases to identify studies that included triage-based education. A systematic search strategy was completed followed by analysis with critical appraisal using the Critical Appraisal Skills Programme, a TIDieR Checklist and thematic analysis.

FINDINGS

Four thousand five hundred seventy-six studies were retrieved, with 34 studies selected for inclusion. Thirty-one studies were quantitative, and three were mixed methods. 18 out of 34 studies showed improvement in triage accuracy. Seven showed increased knowledge. Six studies showed no improvement in triage accuracy. Sixteen studies assessed triage behaviour and showed improvement post-intervention, with five showing no changes. Only three studies compared interventions. Fifty-three opportunities for changes to triage accuracy, knowledge or behaviour were found, 41 showed improvements.

CONCLUSION

Triage education interventions can improve accuracy, knowledge and behaviour, but whether improvements are sustained needs further research.

Implementing intimate partner violence (IPV) screening within emergency departments - Barriers, challenges and enablers experienced by intimate partner violence practice change champions

AIM

To identify the barriers, challenges, and enablers that clinical champions experience whilst implementing Intimate Partner Violence (IPV) screening within Emergency Departments (EDs).

BACKGROUND

Champions support the introduction of IPV screening within EDs. This paper shares new knowledge about IPV practice change champions: barriers, challenges and enablers they experienced in their efforts.

DESIGN

Between 2017-2019, semi structured qualitative interviews were conducted with 23 individuals who identified as champions, working to introduce routine IPV in two rural tertiary hospital Emergency Departments. An interpretive framework and process of constant comparison was used to thematically analyse data from transcribed interviews.

RESULTS

Champions identified barriers, challenges, and enablers that they experienced. Enablers included: support for the work of champions; champion leadership and collegiality; and training for the champion role. Challenges and Barriers included: resistance to a change in the focus of practice; and workflow and workload.

CONCLUSIONS AND IMPLICATIONS

Nurse champions can effectively support IPV practice change but face certain barriers, challenges and enablers. Nurse managers can use this information to support champions to undertake their role effectively in order to better meet the needs of individuals experiencing IPV.

Establishing the research priorities for major trauma in the United Kingdom: A Delphi study of nurses and allied health professionals

BACKGROUND

Research prioritisation exercises are used to determine which areas of research are important. In major trauma care, nurses and allied health professionals are central to the delivery of evidence-based care but their opinions on research priorities are under-represented in the literature. We aimed to identify the research priorities of major trauma nurses and allied health professionals in the UK.

METHODS

A three-round electronic Delphi study was conducted in the UK between November 2019 and May 2021. Round one aimed to generate research questions with rounds two and three questions in order of priority. In stages two and three responses were analysed using descriptive statistics to compute frequencies and proportions for the ranking of each question.

RESULTS

Survey rounds were completed by 180, 100 and 91 respondents respectively. The first round generated 285 statements that were condensed into 71 research questions. Analysis of rankings in subsequent rounds prioritised 54 research questions across themes of adult / children's acute care, psychological care and workforce, training and education.

DISCUSSION

Nurses and AHPs are well-positioned to determine research priorities in major trauma care. Focusing on these priorities will guide future research and help to build an evidence-base in trauma care.

Emergent care nurses' perceived self-competence in palliative care and its predictors: A cross-sectional study

AIM

To describe the prevalence of perceived self-competence in palliative care among emergent care nurses, and explore its predictors.

BACKGROUND

Emergent care nurses have a responsibility to develop palliative care competence to enhance the quality of life of dying patients and their families in the emergency department.

METHODS

With a convenience sample, a cross-sectional study was conducted among 415 emergent care nurses from 22 hospitals in China. Descriptive analysis, Spearman correlation analysis, and multivariate linear stepwise regression were performed.

RESULTS

Variables including marital status (single), emergency department not implementing palliative care, no palliative care training, and true cooperation dimension were selected as independent predictors and explained 19.9% of variation in the regression model.

CONCLUSIONS

Interventions to improve healthy work environments, offering palliative care training, advocating for policies in palliative care, and offering support to unmarried nurses can advance nurses' palliative care competence.

IMPLICATIONS FOR NURSING MANAGEMENT

This is the first study of emergent care nurses in China aimed at identifying predictors associated with palliative care self-competence. It is significant in that palliative care training and a cooperative work environment are required to encourage the development of palliative care.

The impact of an educational video about the role of an emergency nurse, viewed by emergency nurses' support systems, on emergency nurses' wellbeing

BACKGROUND

High stress daily events contribute to burnout in emergency nurses. Strong and informed support systems are essential in ensuring emergency nurses are actively dealing with their workplace-generated stress, through informal social support.

METHODS

A pre and post intervention design over a 6-month period in a single ED. A video was created by emergency nurses to orientate their support system to their role and work environment. Its impact on nurse well-being was assessed.

RESULTS

More than half of the participants considered their spouse/partner to be their main support system (n = 52, 58%). The majority of participants found their support system: (i) had a greater understanding of their everyday work (n = 79, 88%), (ii) were more engaged when talking about work (n = 72, 80%), (iii) asked more questions about work (n = 63, 70%), and (iv) reported they had an improved ability to debrief with their support system (n = 67, 74%). The median total World Health Organization wellbeing score improved by two points (7%, p < 0.001).

CONCLUSION

Emergency nurses' support systems had a greater understanding of the emergency nurse's role and work environment following exposure to the video. This in turn improved the emergency nurses' ability to debrief at home, experience of support, and ultimately their wellbeing.

Applying real-time Delphi methods: development of a pain management survey in emergency nursing

The modified Delphi technique is widely used to develop consensus on group opinion within health services research. However, digital platforms are offering researchers the capacity to undertake a real-time Delphi, which provides novel opportunities to enhance the process. The aim of this case study is to discuss and reflect on the use of a real-time Delphi method for researchers in emergency nursing and cognate areas of practice. A real-time Delphi method was used to develop a national survey examining knowledge, perceptions and factors influencing pain assessment and management practices among Australian emergency nurses. While designing and completing this real-time Delphi study, a number of areas, emerged that demanded careful consideration and provide guidance to future researchers.

Transcutaneous Pacing: An Emergency Nurse's Guide

Transcutaneous pacing is commonly performed in emergency departments to treat patients with cardiac dysrhythmias. Although emergency nurses are required to complete a standardized course that reviews components of transcutaneous pacing, such as Advanced Cardiac Life Support, performing transcutaneous pacing on patients may be done infrequently in some facilities and can lead to anxiety and fear for bedside emergency nurses, especially novice emergency nurses and nurses who infrequently care for patients requiring external pacing. This manuscript provides a practical guide for emergency nurses to care for patients who require transcutaneous pacing. Key information found in this manuscript includes indications for transcutaneous pacing, the nurse's role when performing transcutaneous pacing, and transcutaneous pacing troubleshooting information.

Ecstasy and related drug consumption and the effect on emergency department resource use

BACKGROUND

Ecstasy and other recreational related drug use and substance related presentations to the emergency department are increasing. The aim of this study was to identify, quantify, and describe the emergency department resources used to care for patients diagnosed with ecstasy and related drug use.

METHOD

A retrospective case study design.

RESULTS

Eighty-nine patients (89%) needed one to one (n=25) and/or one to two nursing care (n=83). Security presence was required for 37 patients (37%) and the Emergency Psychiatric Service team reviewed 29 patients (29%). Most patients (n=80, 80%) received an Emergency Short Stay Unit admission, but continued to receive care in the emergency department, and were not transferred to the short stay unit (n=74, 92.5%). Most patients (n=86, 86%) were discharged home, after 5hr 49mins (median) in the emergency department.

CONCLUSION

Extensive human resources were required to care for patients diagnosed with ecstasy and related drug use. Nursing staffing levels required to care for this patient cohort during times of peak presentations should be reviewed. It is important the government acknowledges the National Emergency Access Target is not suitable for all presenting patients. A dedicated model of care is recommended to support care requirements and reduce pressure on busy emergency departments.

Does electronic medical record redesign increase screening of risk for pressure injury, falls and substance use in the Emergency Department? An implementation evaluation

BACKGROUND

Following the provision of urgent care, screening for risks known to impact patient outcomes is an extension of safe emergency nursing care, in particular for falls, pressure injury and substance use. Screening is a process that primarily aims to identify people at increased risk for specific complications. This study aimed to describe and evaluate the implementation of a consolidated electronic checklist on the screening completion rates for falls, pressure injury and substance use in a regional health district.

METHODS

This pre-post study used emergency data from four Emergency Departments (EDs) in southern NSW, Australia between November 2016 and February 2019. Patient characteristics, triage category, discharge diagnosis, arrival date and time, screening completion date and time and treatment location were extracted. Descriptive statistics were used to describe the characteristics of the presentations. Z test with adjusted p-values using Bonferroni Correction method was used to compare the characteristics of the presentations and the rates of screening completion. The Theoretical Domains Framework was used to identify any deficits in the implementation.

RESULTS

There were 33,561 patients in the pre and 35,807 in the post group. There were no differences in patient characteristics between the two groups. The mean emergency department (ED) length of stay was unchanged (490.5min pre vs 489.9min post). The proportion of patients who had all three screens completed increased from 1.3% to 5.5% (p<0.001). Pressure injury risk screening increased from 46.6% (pre) to 53.1% (post) (p<0.001) as did substance use screening (1.7% vs 12.4%, p<0.001). Screening was strongly associated to which hospital the patient was admitted, their age and ED length of stay. Of the 51 mapped intervention functions, 20 (39%) were used in the implementation.

CONCLUSIONS

The introduction of a consolidated electronic checklist for use by emergency nurses to complete fall, pressure injury and substance use screening resulted in an overall increase in risk screening. However screening rates remained poor. Implementation that considers the capability, opportunity and motivation of those that need to alter their behaviour would likely improve the overall compliance.

[Development of a Triage Competency Scale for Emergency Nurses]

PURPOSE

This study aimed to develop a triage competency scale (TCS) for emergency nurses, and to evaluate its validity and reliability.

METHODS

Preliminary items were derived based on the attributes and indicators elicited from a concept analysis study on triage competency. Ten experts assessed whether the preliminary items belonged to the construct factor and determined the appropriateness of each item. A revised questionnaire was administered to 250 nurses in 18 emergency departments to evaluate the reliability and validity of the scale. Data analysis comprised item analysis, confirmatory factor analysis, contrasted group validity, and criterion-related validity, including criterion-related validity of the problem solving method using video scenarios.

RESULTS

The item analysis and confirmatory factor analysis yielded 5 factors with 30 items; the fit index of the derived model was good (χ²/df =2.46, Root Mean squared Residual=.04, Root Mean Squared Error of Approximation=.08). Additionally, contrasted group validity was assessed. Participants were classified as novice, advanced beginner, competent, and proficient, and significant differences were observed in the mean score for each group (F=6.02, p=.001). With reference to criterion-related validity, there was a positive correlation between scores on the TCS and the Clinical Decision Making in Nursing Scale (r=.48, p<.001). Further, the total score on the problem solving method using video scenarios was positively correlated with the TCS score (r=.13, p=.04). The Cronbach's α of the final model was .91.

CONCLUSION

Our TCS is useful for the objective assessment of triage competency among emergency nurses and the evaluation of triage education programs.

Emergency nurse disaster preparedness during mass gatherings: a cross-sectional survey of emergency nurses' perceptions in hospitals in Mecca, Saudi Arabia

OBJECTIVES

To assess hospital emergency nurses' self-reported knowledge, role awareness and skills in disaster response with respect to the Hajj mass gathering in Mecca.

DESIGN

Cross-sectional online survey with primary data collection and non-probabilistic purposive sample conducted in late 2014.

SETTING

All 4 public hospitals in Mecca, Saudi Arabia.

PARTICIPANTS

106 registered nurses in hospital emergency departments.

MAIN OUTCOME MEASURE

Awareness, knowledge, skills and perceptions of emergency nurses in Mecca with regard to mass gathering disaster preparedness.

RESULTS

Although emergency nurses' clinical role awareness in disaster response was reported to be high, nurses reported limited knowledge and awareness of the wider emergency and disaster preparedness plans, including key elements of their hospital strategies for managing a mass gathering disaster. Over half of the emergency nurses in Mecca's public hospitals had not thoroughly read the plan, and almost 1 in 10 were not even aware of its existence. Emergency nurses reported seeing their main role as providing timely general clinical assessment and care; however, fewer emergency nurses saw their role as providing surveillance, prevention, leadership or psychological care in a mass gathering disaster, despite all these broader roles being described in the hospitals' emergency disaster response plans. Emergency nurses' responses to topics where there are often misconceptions on appropriate disaster management indicated a significant knowledge deficit with only 1 in 3 nurses at best or 1 in 6 at worst giving correct answers. Respondents identified 3 key training initiatives as opportunities to further develop their professional skills in this area: (1) hospital education sessions, (2) the Emergency Management Saudi Course, (3) bespoke short courses in disaster management.

CONCLUSIONS

Recommendations are suggested to help enhance clinical and educational efforts in disaster preparedness.

The accuracy and consistency of rural, remote and outpost triage nurse decision making in one Western Australia Country Health Service Region

BACKGROUND

The Australasian Triage Scale aims to ensure that the triage category allocated, reflects the urgency with which the patient needs medical assistance. This is dependent on triage nurse accuracy in decision making. The Australasian Triage Scale also aims to facilitate triage decision consistency between individuals and organisations. Various studies have explored the accuracy and consistency of triage decisions throughout Australia, yet no studies have specifically focussed on triage decision making in rural health services. Further, no standard has been identified by which accuracy or consistency should be measured. Australian emergency departments are measured against a set of standard performance indicators, including time from triage to patient review, and patient length of stay. There are currently no performance indicators for triage consistency.

METHODS

An online questionnaire was developed to collect demographic data and measure triage accuracy and consistency. The questionnaire utilised previously validated triage scenarios.(1) Triage decision accuracy was measured, and consistency was compared by health site type using Fleiss' kappa.

RESULTS

Forty-six triage nurses participated in this study. The accuracy of participants' triage decision-making decreased with each less urgent triage category. Post-graduate qualifications had no bearing on triage accuracy. There was no significant difference in the consistency of decision-making between paediatric and adult scenarios. Overall inter-rater agreement using Fleiss' kappa coefficient, was 0.4. This represents a fair-to-good level of inter-rater agreement.

CONCLUSIONS

A standard definition of accuracy and consistency in triage nurse decision making is required. Inaccurate triage decisions can result in increased morbidity and mortality. It is recommended that emergency department performance indicator thresholds be utilised as a benchmark for national triage consistency.

Disaster nursing skills, knowledge and attitudes required in earthquake relief: Implications for nursing education

BACKGROUND

Globally, nurses becoming more aware of getting better prepared for disaster relief, but in China, disaster nursing knowledge, courses and research are still limited.

INTRODUCTION

China has long been prone to disasters, but disaster nursing education and training is in its infancy.

AIM

This study explored the skills, knowledge and attitudes required by registered nurses from across China who worked in the aftermath of three large earthquakes to try to determine future disaster nursing education requirements.

METHOD

The Questionnaire of Nurses' Disaster Nursing Skills at Earthquake Sites, assessing nursing skills, knowledge and attitudes, was distributed to 139 registered nurses in 38 hospitals in 13 provinces across China who had worked in one or more earthquake disaster zones. Descriptive statistics were used for quantitative data, and content analysis for qualitative data.

RESULTS

Eighty-nine questionnaires were returned, a response rate of 68.3%. No respondent had ever received specific disaster nursing training prior to their post-earthquake nursing. Skills most often used by respondents were haemostasis bandaging, fixation, manual handling, observation and monitoring, debridement and dressing, and mass casualty transportation. Respondents identified that the most important groups of skills required were cardiopulmonary resuscitation; haemostasis, bandaging, fixation, and manual handling; and emergency management. They emphasized the need for psychological care of victims as well as that of fellow health workers.

CONCLUSION

No respondent had ever received disaster nursing training prior to engagement at the earthquake disaster sites. All believed that there were important gaps in their knowledge and skills, and supported disaster nursing courses in the future.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

China urgently needs to develop disaster nursing courses, with the support of nurse leaders, educationalists and government, to implement training using an all hazards approach in accordance with international best practice and trainees' background clinical experience and knowledge.

Development of an emergency nursing training curriculum in Ghana

The formal provision of emergency health care is a developing specialty in many sub-Saharan African countries, including Ghana. While emergency medicine training programs for physicians are on the rise, there are few established training programs for emergency nurses. The results of a unique collaboration are described between a university in the United States, a Ghanaian university and a Ghanaian teaching hospital that has developed an emergency nursing diploma program. The expected outcomes of this training program include: (a) an innovative, interdisciplinary, team-based clinical training model, (b) a unique and low-resource emergency nursing curriculum and (c) a comprehensive and sustainable training program to increase in-country retention of nurses.