An educational framework for triage nursing based on gatekeeping, timekeeping and decision-making processes

Optimizing triage education for emergency room nurses: A scoping review

AIMS

Accurate triage decisions by emergency room nurses are pivotal for patient prognosis and efficient utilization of resources. This study aimed to identify teaching methods, contents, intervention characteristics, and initial consideration of educational design for the development of triage education, targeting triage nurses.

DESIGN

A scoping review.

DATA SOURCES

PubMed, CINAHL, Web of Science, Embase, and RISS were searched for studies in either English or Korean, regardless of publication year.

REVIEW METHODS

The review was conducted according to the Joanna Briggs Institute guidelines. Studies published before November 15, 2023 were selected, based on the following index terms in each database: nurses, triage, education, and emergency services, hospital.

RESULTS

Of the 20 studies included in this review, five focused on severity classification of patients with cardiovascular diseases, one addressed infectious diseases, two examined pediatric patients, one explored patients with trauma, and the remaining eleven were not limited to specific diseases. Eleven studies (55 %) employed face-to-face (offline) education, whereas six (30 %) used non-face-to-face (online) education. The teaching methods were classified as teacher-centered learning and student-centered learning. The educational strategies included in-person lectures, online classes, demonstrations, simulations, mobile technology or web-based programs, group discussions, role-plays, and flipped learning. Outcome variables, such as triage accuracy, knowledge, performance ability, self-efficacy, satisfaction, wait time, and competency were measured as intervention effects.

CONCLUSIONS

This review demonstrates the key characteristics and contents of triage education interventions, along with key considerations in the initial design stages. Triage education covers a wide range of contents and diverse teaching methods pertinent to severity classification in triage practice. Effective educational programs hinge on the meticulous planning of objectives, optimal selection of the target population, needs assessment, and suitable teaching methods and materials. Future triage education for emergency room nurses should be tailored to specific participants while anticipating and planning all potential circumstances of implementation.

Emergency department triage decision-making by registered nurses: An instrument development study

AIM

To develop and psychometrically test the triage decision-making instrument, a tool to measure Emergency Department Registered Nurses decision-making.

DESIGN

Five phases: (1) defining the concept, (2) item generation, (3) face validity, (4) content validity and (5) pilot testing.

METHODS

Concept definition informed by a grounded theory study from which four domains emerged. Items relevant to the four domains were generated and revised. Face validity was established using three focus groups. The target population upon which the reliability and validity of the triage decision-making instrument was explored were triage registered nurses in emergency departments. Three expert judges assessed 89 items for content and domain designation using a 4-point scale. Psychometric properties were assessed by exploratory factor analysis, following which the names of the four domains were modified.

RESULTS

The triage decision-making instrument is a 22-item tool with four factors: clinical judgement, managing acuity, professional collaboration and creating space. Focus group data indicated support for the domains. Expert review resulted in 46 items with 100% agreement and 13 with 66% agreement. Fifty-nine items were distributed to a convenience sample of 204 triage nurses from six hospitals in 2019. The Kaiser-Meyer-Olkin measures indicated that the data were sufficient for exploratory factor analysis. Bartlett's test indicated patterned relationships among the items (X 2 (231) = 1156.69). An eigenvalue of >1.0 was used and four factors explained 48.64% of the variance. All factor loadings were ≥0.40. Internal consistency was demonstrated by Cronbach's alphas of .596 factor 1, .690 factor 2, .749 factor 3 and .822 for factor 4.

CONCLUSION

The triage decision-making instrument meets the criteria for face validity, content validity and internal consistency. It is suitable for further testing and refinement.

IMPACT

The instrument is a first step in quantifying triage decision-making in real-world clinical environments. The triage decision-making instrument can be used for targeted triage interventions aimed at improving throughput and staff education.

STATISTICAL SUPPORT

Dr. Tak Fung who is a member of the research team is a statistician.

STATISTICAL METHODS

Development, validation and assessment of instruments/scales. Descriptive statistics.

REPORTING METHOD

STROBE cross-sectional checklist.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

The TDI makes the complexity of triage decision-making visible. Identifying the influence of decision-making factors in addition to acuity that affect triage decisions will enable nurse managers and educators to develop targeted interventions and staff development initiatives. By extension, this will enhance patient care and safety.

Understanding triage assessment of acuity by emergency nurses at initial adult patient presentation: A qualitative systematic review

BACKGROUND

Nurses make complex triage decisions within emergency departments, which significantly affect patient outcomes. Understanding how nurses make these decisions and why they deviate from triage algorithms facilitates interventions that work with their decision-making processes, increasing acceptability and effectiveness.

AIMS

This qualitative systematic review aimed to understand decision-making processes emergency nurses use to make acuity decisions during triage assessment at initial patient presentation.

METHODOLOGY

Medline, CINAHL and Academic Search Complete were systematically searched to 15th December 2022. Data were analysed using thematic synthesis. Established themes were reviewed with GRADE-CERQual to evaluate certainty of evidence.

RESULTS

28 studies were included in the review. Data analysis uncovered three superordinate themes of holistic reasoning, situational awareness, and informed decision-making. The findings show nurses value holistic assessments over algorithms and rely on knowledge and experience. They also assess the wider situation in the emergency department.

CONCLUSIONS

This review presents new perspectives on nurses' decision-making processes about patient's acuity. Nurses holistically gather information about patients before translating that information into acuity scores. These actions are informed by their knowledge and experience; however, the wider situation also impacts their decisions. In turn, the nurses use interpretations of patients' acuity to control the wider situation.

Strategies to improve the quality of nurse triage in emergency departments: A realist review protocol

AIM

The purpose of this realist review was to assess what works, for whom and in what context, regarding strategies that influence nurses' behaviour to improve triage quality in emergency departments (ED).

DESIGN

Realist review protocol.

METHODS

This protocol follows the PRISMA-P statement and will include any type of study on strategies to improve the triage process in the ED (using recognized and validated triage scales). The included studies were examined for scientific quality using the Mixed Methods Appraisal Tool. The framework for this realist review is based on the Behaviour Change Wheel (BCW) and the context-mechanism-outcome (CMO) models.

DISCUSSION

Nurses and ED decision makers will be informed on the evidence regarding strategies to improve the quality of triage and the factors required to maximize their effectiveness. Research gaps may also be identified to guide future research projects on the adoption of best practices in ED nursing triage.

Effect of triage training on the knowledge application and practice improvement among the practicing nurses of the emergency departments of the National Referral Hospitals, 2018; a pre-post study in Asmara, Eritrea

BACKGROUND

Triage starts at the front door of the Emergency Department (ED), and repeatedly performed by the responsible duty nurses with the aim of facilitating a timely and appropriate treatment of patients. A triage system called the Orotta Triage System was implemented in the emergency settings of the selected hospitals in 2006, with the emergency nurses trained to triage using the system. Since the introduction, a majority of nurses have been replaced by new untrained nurses. This study was conducted to assess the impact of an educational intervention on the triage nurses knowledge and performance.

METHODS

A single group pre-posttest study design was performed in the adult EDs of the National Referral Eritrean Referral Hospitals, from January to July of 2018. All staff members in the ED were involved. Data collection tools utilized were, a self-administered knowledge assessing questionnaire and a practice observation checklist. Analysis was done in SPSS (version 22) using repeated measures ANOVA. Statistical significance level was set at P < 0.05.

RESULTS

The mean knowledge scores at Time 1(prior to the intervention), Time 2 (following the intervention) and Time 3 (three month follow up) were 6.23 (SD = 2.29), 10.55 (SD = 1.79), and 9.39(SD = 2.67) respectively. During the pre-intervention phase, only one (3%) nurse was determined to have adequate knowledge. Two days post training (immediate post-intervention), the percentage possessing adequate knowledge increased to 39% but dropped back to 19% three months later. Mean knowledge difference scores (95% CI) of immediate post and pre-intervention (Diff. = 4.32, 1 95%CI: 3.08-5.56), three months later and pre-intervention (Diff. = 3.16, 95%CI: 1.71-4.62) and immediate post and three months later (Diff. = 1.16, 95%CI: 0.12-2.20) were found to be statistically significant. The median score of appropriate triage practice at pre-intervention (Md = 6, IQR = 3) was not significantly different (p = 0.053) from that at post-intervention (Md = 8, IQR = 5).

CONCLUSION

The level of triage knowledge and appropriate application was low among the emergency nurses prior to training. The training provided an initial improvement in knowledge, but no significant improvement in triage nursing performance. To optimize ED triage performance, appropriate, timely in-service training is required to ensure new staff are educated and experienced staff have their knowledge and skills refreshed.

Family members' perceptions of older person discharge from emergency departments

BACKGROUND

People aged over 64 years account for approximately 20% of adult emergency presentations, with up to 60% of people discharged home from emergency departments (EDs). Many older people discharged home are supported by family.

OBJECTIVES

The objective of this study was to explore the family members' perspectives of older people's discharge from ED to inform new alternative or innovative models of care.

METHODS

The design was a descriptive exploratory study. A convenience sample of family members was recruited from three EDs across Sydney, New South Wales. Telephone interviews were conducted over a six-month period and data were analysed using statistics or thematic analysis.

RESULTS

Interviews were conducted with 133 family members of whom the majority were female (n = 80, 60%) with a median age of 70 years (IQR 91-35). Over 87% of family members were satisfied with ED care and discharge processes that were provided to the older person. The majority (n = 129, 97%) of family members reported that they understood the treatment and perceived that the older person's condition was well managed (n = 119, 86%). The majority (n = 114, 86%) of family members reported being informed of the medical diagnosis and were confident (87%, n = 115) to continue care of the older person at home. Three themes emerged from qualitative data: (a) a sense of time-moving through ED; (b) giving voice to the impact of clinician communication; and (c) the delivery of comfort and basic care.

DISCUSSION

Family members reported that they were engaged in and satisfied with the older person's ED treatment and discharge. However, family members suggested that there was opportunity to improve communication consistency for ED discharge and managing the wait.

CONCLUSION

Clinicians need to engage with family members to optimise quality and safety. Clinicians need to understand that family members considered comfort and fundamentals of care to be an important dimension of the older person's ED management plan.

Emergency care under the magnifying glass: a review of ethnographic studies in the scientific literature on hospital emergency services

The article presents a review of ethnographic studies in the scientific literature on hospital emergency services, with the objective of systematizing the studies and their principal findings, referring to the health-disease-healthcare process in hospital emergency services from an ethnographic perspective. An integrative literature review was performed of studies published in Argentine and international indexed journals and in the following electronic databases: PubMed, VHL, Scopus, Redalyc, and SciELO. The corpus of the analysis consisted of a total of 69 articles, which were submitted to content analysis, having identified the following analytical dimensions: quality of care, communication and bonds, subjectivity, application of information technologies, methodological reflection, patients' experiences and practices, decision-making, and violence. The results allowed identifying a process that differs from guidelines and protocols, in which healthcare workers' subjective aspects, communication and interpersonal relations, and working conditions shape, orient, and condition the treatment and care provided in the hospital. The article thus highlights the approach to subjective aspects in health studies, to understand not only health workers' perspectives and experiences but also the persistent barriers to providing better quality of care, complexifying a problem ignored by a large share of the analyses.

The association of the anesthesiologist’s academic and educational status with self-confidence, self-rated knowledge and objective knowledge in rational antibiotic application

Objective

This study aimed to investigate the association of anesthetists’ academic and educational status with self-confidence, self-rated knowledge and objective knowledge about rational antibiotic application. Therefore, anesthetists in Germany were asked about their self-confidence, self-rated knowledge and objective knowledge on antibiotic therapy via the Multiinstitutional Reconnaissance of practice with Multiresistant bacteria (MR2) survey. Other analysis from the survey have been published elsewhere, before.

Results

361 (52.8%) questionnaires were completed by specialists and built the study group. In overall analysis the Certification in Intensive Care (CIC) was significantly associated with self-confidence (p < 0.001), self-rated knowledge (p < 0.001) and objective knowledge (p = 0.029) about antibiotic prescription. Senior consultant status was linked to self-confidence (p < 0.001) and self-rated knowledge (p = 0.005) but not objective knowledge. Likewise, working on Intensive Care Unit (ICU) during the last 12 months was significantly associated with self-rated knowledge and self-confidence (all p < 0.001). In a logistic regression model, senior consultant status was not associated with any tested influence factor. This analysis unveiled that CIC and working on ICU were more associated with anesthesiologists’ self-confidence and self-rated knowledge than senior consultant status. However, neither of the characteristics was thoroughly associated with objective knowledge.

Triage emergency nurse decision-making: Incidental findings from a focus group study

INTRODUCTION

Emergency Department (ED) triage decision-making is a complex process. Triage scales are used to determine patient acuity level, however, they do not provide information on how nurses make triage decisions. This focus group study was part of a larger project to develop a psychometrically sound instrument to measure triage decision-making by nurses; the Triage Decision-Making Instrument. We report important incidental findings that emerged during the study that the participants identified as factors impeding triage decision-making.

METHODS

Three focus groups were conducted with 11 triage Registered Nurses. They commented on the instrument items and identified factors that influence triage decision-making. Transcripts were analyzed using thematic analysis.

RESULTS

Three powerful inter-related themes emerged central to encumbering triage decision-making: competing systems (pre-hospital versus the ED), fluctuating patient volume resulting in 'intra-Canadian Triage and Acuity Scale' triaging, and personal capacity including experience and 'triage fatigue'.

DISCUSSION

The findings demonstrate how interrelated system factors impede nurses triage decision-making. Triage nurses require support in their role and initiatives are needed to reduce the pressure they feel in relation to resolving system issues. Larger system issues and the capacity of the individual decision-makers must be accounted for within the context of increasing effectiveness and safety of ED triage.

Expanding knowledge and roles for authority and practice boundaries of Emergency Department nurses: a grounded theory study

Purpose: While emergency department nurses in Indonesia are critical to quality care, the role lacks recognition and standard practices and regulation of scope of practice are absent. This research explored the role of nurses in Indonesian EDs.

Method: The conceptual lens applied in the research was grounded theory. The main data source was 51 semi- structured interviews with 43 ED nurses, three directors of nursing, three nurse leaders and two nurse educators. Data were also generated through observations and memos.

Results: Two key categories were constructed; shifting work boundaries and lack of authority. Shifting work boundaries was symbolic of a lack of professional authority and legitimized knowledge. Lack of authority reflected the dimension of professional autonomy through the nexus of power and knowledge. The interrelationship of these two concepts constructed a core category, securing legitimate power, which underpinned the positioning of nursing in Indonesia.

Conclusions: The interconnection between political gains, tertiary knowledge, professional regulation and implementation of gender-sensitive policies was critical to the development of the ED role, the positioning of nursing within the health care system and improvement in quality of care.

Intensive Care Nurses' Belief Systems Regarding the Health Economics: A Focused Ethnography

BACKGROUND

Health care beliefs can have an effect on the efficiency and effectiveness of nursing practices. Nevertheless, how belief systems impact on the economic performance of intensive care unit (ICU) nurses is not known. This study aimed to explore the ICU nurses' beliefs and their effect on nurse's practices and behavior patterns regarding the health economics.

METHODS

In this study, a focused ethnography method was used. Twenty-four informants from ICU nurses and other professional individuals were purposively selected and interviewed. As well, 400 hours of ethnographic observations were used for data collection. Data analysis was performed using the methods described by Miles and Huberman (1994).

FINDINGS

Eight beliefs were found that gave meaning to ICU nurse's practices regarding the health economics. 1. The registration of medications and supplies disrupt the nursing care; 2.Monitoring and auditing improve consumption; 3.There is a fear of possible shortage in the future; 4.Supply and replacement of equipment is difficult; 5.Higher prices lead to more accurate consumption; 6.The quality of care precedes the costs; 7. Clinical Guidelines are abundant but useful; and 8.Patient economy has priority over hospital economy. Maintaining the quality of patient care with least attention to hospital costs was the main focus of the beliefs formed up in the ICU regarding the health economics.

CONCLUSIONS

ICU nurses' belief systems have significantly shaped in relation to providing a high-quality care. Although high quality of care can lead to a rise in the effectiveness of nursing care, cost control perspective should also be considered in planning for improve the quality of care. Therefore, it is necessary to involve the ICU nurses in decision-making about unit cost management. They must become familiar with the principles of heath care economics and productivity by applying an effective cost management program. It may be optimal to implement the reforms in various aspects, such as the hospital's strategic plan and supply chain management system.

Nonemergent Patients in the Emergency Department: An Ethnographic Study

Background

Triage in the interactive atmosphere of the emergency department (ED) has been described as complex and challenging. Nonemergent ED visits have been accompanied by ethical and legal conflicts.

Objectives

The aim of this study was to gain an understanding of ED nurses’ practice regarding triage of nonemergent patients.

Patients and Methods

Focused micro-ethnography based on Spradley’s developmental research sequence (DRS) was used. This study was conducted in an emergency department. Data was collected through complete participant observations along with formal and informal interviews, and then analyzed using DRS.

Results

Nine key informants were interviewed formally. Four main categories emerged from the nurses’ culture: nonemergent patient as an uninvited guest, nonemergent patient as an elephant in a dark room, nonemergent patient as an aggressive client, and being nonemergency unless at risk of death.

Conclusions

Providing care in the emergency department is significantly affected by nonemergent patients, as the emergency department is a place for critically ill patients thus awareness training program is recommended.

Outcomes for emergency severity index triage implementation in the emergency department

INTRODUCTION

Hospital triage scale in emergency departments needs to be valid and reliable. Lack of sufficient data exists on triage scale rigor in emergency departments of Iran. This study aimed to determine the impact of the emergency severity index (ESI) triage scale in the emergency department.

MATERIALS AND METHODS

A single-center study was conducted. Proportion of triage categories allocated to high-risk patients admitted to high-acuity departments was examined in observational period in June 2012 and May 2013. True triage score was reported based on patients` paper- based scenario questionnaire. Interrater reliability was assessed using unweighted kappa. Concordance among experts, nurses and physicians was examined. The Chi-square test and Kappa statistics was used for statistical analysis.

RESULTS

Triage decisions regarding high-risk patients before and after implementation period are independent from each other (χ2= 22.254; df=1; p<0.05) and more high-risk patients were recognized after implementation of the ESI. Overall agreement and concordance were (79%) and (κ=0.54) among nurses; (71%) and (κ=0.45) among physicians, (85%) and (κ=0.81) among experts, respectively. Correct triage decisions among clinicians were increased after implementation of the ESI.

CONCLUSION

The ESI as valid and reliable tool improving desirable outcomes` in the emergency department has been recommended but it may not reveal optimal outcomes in developing countries comparing to what have been achieved in the developed countries. In addition, patient influx in ESI level II could create considerable controversy with clinicians.

The organizational culture of emergency departments and the effect on care of older adults: a modified scoping study

How does the organizational micro culture in emergency departments (EDs) impact the care of older adults presenting with a complaint or condition perceived as non-acute? This scoping study reviews the literature and maps three levels of ED culture (artifacts, values and beliefs, and assumptions). Findings on the artifact level indicate that EDs are poorly designed for the needs of older adults. Findings on the ED value and belief level indicate that EDs are for urgent cases (not geriatric care), that older adults do not receive the care and respect they should be given, that older adults require too much time, and that the basic nursing needs of older adults are not a priority for ED nurses. Finally, finding on the assumptions level underpinning ED behaviors suggest that older adults do not belong in the ED, most older adults in the ED are not critically ill and therefore can wait, and staff need to be available for acute cases at all times. A systematic review on the effect of ED micro culture on the quality of geriatric care is warranted.

Gatekeeping access to the midwifery unit: Managing complaints by bending the rules

While poor communication between service users and front-line staff causes many service user complaints in the British National Health Service, staff rarely reflect on the causes of these complaints. We discuss findings from an action research project with midwives which suggest that the midwives struggled to fully understand complaints from women, their partners and families particularly about restricted visiting and the locked door to the midwifery unit. They responded to individual requests to visit out of hours while maintaining the general policy of restricted visiting. In this way, the door was a gatekeeping device which allowed access to the unit within certain rules. The locked door remained a barrier to women and their families and as a result was a common source of informal complaints. We argue that the locked door and restricted visiting to the midwifery unit were forms of gatekeeping and boundary making by midwives which reveals a tension between their espoused woman-centred care and contemporary midwifery practice which is increasingly constrained by institutional values.

Confidence and impact on clinical decision-making and behaviour in the emergency department

BACKGROUND

Clinical competency is underpinned by the self-confidence of nurses to act. Confidence may be critical to the understanding of how practice choices are made and not made by nurses in extended practice roles. The aim of this study was to explore how emergency nurses perceived (i) self-confidence in undertaking an extended practice role; and (ii) the factors associated with confidence within clinical practice.

METHODS

A multicentred qualitative exploratory study. Fifty two participants were included in the study. Across three sites 36 (28 females, 8 males) face to face interviews and 16 non-participant observations (13 females, 3 males) were conducted.

RESULTS

The study generated new knowledge about self-confidence, self-efficacy and the role that contextual factors have in regulating behaviour. It shows that self-confidence is an important resource that sustains a nurse's ability to problem solve and to critically think in order to determine how best to act.

CONCLUSIONS

The development of self-confidence is important if we are to promote effective clinical decision-making. Education programmes need to identify strategies that can promote and support the development of self-confidence and resilience.

The cognitive processes underpinning clinical decision in triage assessment: a theoretical conundrum?

High quality clinical decision-making (CDM) has been highlighted as a priority across the nursing profession. Triage nurses, in the Accident and Emergency (A&E) department, work in considerable levels of uncertainty and require essential skills including: critical thinking, evaluation and decision-making. The content of this paper aims to promote awareness of how triage nurses make judgements and decisions in emergency situations. By exploring relevant literature on clinical judgement and decision-making theory, this paper demonstrates the importance of high quality decision-making skills underpinning the triage nurse's role. Having an awareness of how judgements and decisions are made is argued as essential, in a time where traditional nurse boundaries and responsibilities are never more challenged. It is hoped that the paper not only raises this awareness in general but also, in particular, engages the triage nurse to look more critically at how they make their own decisions in their everyday practice.

The prevalence and triage characteristics of patients presenting with infection to one tertiary referral hospital

BACKGROUND

Globally, severe infection and or sepsis is a problem that is costing billions of dollars, using hundreds of hospital beds, and often results in patient death. Any infection can potentially develop a sepsis health trajectory if left unrecognised and unmanaged.

METHODS

We conducted a 12 month retrospective descriptive exploratory study. Our research explored the prevalence and triage characteristics of patients presenting with infection to one tertiary referral hospital. Electronic medical records were reviewed to identify patients that had a primary diagnosis related to infection.

RESULTS

The study identified that 16% (n=7756) of adult presentations had a discharge diagnosis related to infection. A significant difference (X(2)=297.83, df=4, p≤.001) in Triage Code allocation for the infection group was identified compared with the non-infection patient group. Thirty-nine percent (n=3027) of patients with infections were admitted to hospital. Of the patients (n=1930; 4%) admitted to a critical care area, 6% (n=122) had a primary diagnosis related to infection. Of the ED deaths (n=81), 12% (n=10) had a primary diagnosis related to infection.

CONCLUSION

The study provides a detailed analysis of the prevalence and triage characteristics of patients with infection presenting to one ED. Further research is needed to identify strategies to improve the triage nurse's recognition of severe infection and consistency of urgency code allocation to prevent patient deterioration.

Atividades do enfermeiro nos sistemas de triagem/classificação de risco nos serviços de urgência: revisão integrativa

Objetivou-se identificar e avaliar as evidências disponíveis na literatura sobre as atividades do enfermeiro na classificação de risco nos serviços de urgência. Realizou-se uma revisão integrativa, com busca nas bases de dados Science Direct, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medical Literature Analysis and Retrievel System Online (MEDLINE), Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS) e Scientific Electronic Library Online (SCIELO). Foram selecionados 22 artigos que atenderam aos critérios de inclusão. Os resultados evidenciaram que as principais atribuições deste profissional são a avaliação do estado de saúde do usuário e a tomada de decisão, processo que necessita de conhecimento clínico e de tempo de experiência. O enfermeiro tem a capacidade de organizar o fluxo dos usuários conforme a prioridade do atendimento e a demanda dos serviços, sendo um profissional de excelência na execução da triagem/classificação de risco nos serviços de urgência.

[Organization of clinical emergency units. Mission and environmental factors determine the organizational concept]

AIM

Mission and organization of emergency units were analysed to understand the underlying principles and concepts.

METHODS

The recent literature (2000-2007) on organizational structures and functional concepts of clinical emergency units was reviewed. An organizational portfolio based on the criteria specialization (presence of medical specialists on the emergency unit) and integration (integration of the emergency unit into the hospital structure) was established. The resulting organizational archetypes were comparatively assessed based on established efficiency criteria (efficiency of resource utilization, process efficiency, market efficiency).

RESULTS

Clinical emergency units differ with regard to autonomy (within the hospital structure), range of services and service depth (horizontal and vertical integration). The "specialization"-"integration"-portfolio enabled the definition of typical organizational patterns (so-called archetypes): profit centres primarily driven by economic objectives, service centres operating on the basis of agreements with the hospital board, functional clinical units integrated into medical specialty units (e.g., surgery, gynaecology) and modular organizations characterized by small emergency teams that would call specialists immediately after triage and initial diagnostic.

CONCLUSIONS

There is no "one fits all" concept for the organization of clinical emergency units. Instead, a number of well characterized organizational concepts are available enabling a rational choice based on a hospital's mission and demand.

Thinking strategies used by Registered Nurses during emergency department triage

AIM

This paper is a report of a study to describe and compare thinking strategies and cognitive processing in the emergency department triage process by Registered Nurses with high and low triage accuracy.

BACKGROUND

Sound clinical reasoning and accurate decision-making are integral parts of modern nursing practice and are of vital importance during triage in emergency departments. Although studies have shown that individual and contextual factors influence the decisions of Registered Nurses in the triage process, others have failed to explain the relationship between triage accuracy and clinical experience. Furthermore, no study has shown the relationship between Registered Nurses' thinking strategies and their triage accuracy.

METHOD

Using the 'think aloud' method, data were collected in 2004-2005 from 16 RNs working in Swedish emergency departments who had previously participated in a study examining triage accuracy. Content analysis of the data was performed.

FINDINGS

The Registered Nurses used a variety of thinking strategies, ranging from searching for information, generating hypotheses to stating propositions. They structured the triage process in several ways, beginning by gathering data, generating hypotheses or allocating acuity ratings. Comparison of participants' use of thinking strategies and the structure of the triage process based on their previous triage accuracy revealed only slight differences.

CONCLUSION

The wide range of thinking strategies used by Registered Nurses when performing triage indicates that triage decision-making is complex. Further research is needed to ascertain which skills are most important in triage decision-making.