Using a theory to understand triage decision making

Decision-making in nursing research and practice-Application of the Cognitive Continuum Theory: A meta-aggregative systematic review

AIM

To explore how the Cognitive Continuum Theory has been used in qualitative nursing research and to what extent it has been integrated in the research process using the Qualitative Network for Theory Use and Methodology (QUANTUM).

BACKGROUND

Theory, research and nursing are intrinsically linked, as are decision-making and nursing practice. With increasing pressure on nurses to improve patient outcomes, systematic knowledge regarding decision-making is critical and urgent.

DESIGN

A meta-aggregative systematic review.

METHODS

DATABASES: CINAHL, Medline, PsycINFO, Embase and PubMed were searched from inception until May 2022 for peer-reviewed research published in English. Seven studies were included and assessed for methodological quality using the Joanna Briggs Institute checklist for qualitative research. A meta-aggregative synthesis was conducted using Joanna Briggs methodology. The QUANTUM typology was used to evaluate the visibility of the Cognitive Continuum Theory in the research process.

RESULTS

The review identified five synthesised findings, namely: 1. the decision-making capacity of the individual nurse, 2. nurses' level of experience, 3. availability of decision support tools, 4. the availability of resources and 5. access to senior staff and peers. Only two of seven studies rigorously applied the theory. The included studies were mainly descriptive-exploratory in nature.

CONCLUSION

The transferability of the Cognitive Continuum Theory was demonstrated; however, evolution or critique was absent. A gap in the provision of a patient-centric approach to decision-making was identified. Education, support and research is needed to assist decision-making. A new Person-Centred Nursing Model of the Cognitive Continuum Theory has been proposed to guide future research in clinical decision-making.

RELEVANCE TO CLINICAL PRACTICE

Nurses make numerous decisions every day that directly impact patient care, therefore development and testing of new theories, modification and revision of older theories to reflect advances in knowledge and technology in contemporary health care are essential.

Cognitive biases regarding utilization of emergency severity index among emergency nurses

AIM

The study aimed to measure emergency nurses' prevalence of cognitive biases when utilizing Emergency Severity Index (ESI). Moreover, the study aimed to measure the differences between cognitive biases and demographic variables.

BACKGROUND

Nurses use Emergency Severity Index (ESI) to prioritize the patients. Cognitive biases could compromise the clinical decisions of nurses in triage. Consequently, this hinders the delivery of safe and quality patient care.

METHODS

A cross-sectional analytical approach invited 208 emergency nurses from four tertiary care hospitals. Institutional review board approval and permission from institutional heads were obtained. Informed consent was attained before data collection. Data was collected through a structured scenario-based questionnaire to measure cognitive biases at five levels of ESI. Descriptive and inferential statistics were obtained through v25.0 of SPSS.

RESULTS

Among the 86.6% response rate, 56.2% of nurses were male. 62.90% had nursing diplomas. Cognitive biases were present at all ESI levels one to five, in order 51%, 45%, 90%, 89%, and 91% among nurses. Premature closure 22%, tolerance to risk 12%, satisfying bias 25%, framing effect 22%, and blind obedience 34% from level one to five consecutively. Demographic variables, including males, experience between 2 and 5 years, general nursing as qualification, and without emergency severity index certification, were identified to encounter more cognitive biases when making triage decisions.

CONCLUSION

Numerous cognitive biases are considerably existing among emergency nurses when prioritizing patients. Cognitive de-biasing measures can improve triage decisions among nurses that could enhance quality care and patient safety.

Factors contributing to patient safety during triage process in the emergency department: A systematic review

BACKGROUND

Triage is a dynamic environment in which large numbers of people can present. It presents a vulnerable assessment point, as a triage nurse must assess a patient's urgency level and analyse their health status and expected resource needs. Given the critical nature of triage, it is necessary to understand the factors contributing to patient safety.

OBJECTIVES

To identify and examine the factors contributing to patient safety during the triage process.

METHODS

A systematic review of the literature was undertaken, and a thematic analysis of the factors contributing to patient safety during the triage process. PubMed, CINAHL, Web of Sciences, Science Direct, SAGE, EMBASE and reference lists of relevant studies published in English until March 2022 were searched for relevant studies. The search protocol has been registered at the PROSPERO (CRD42019146616), and the review was conducted using the PRISMA criteria.

RESULTS

Out of 5366 records, we included 11 papers for thematic synthesis. Identified factors contributing to patient safety in triage are related to the emergency's work environment, such as patient assessment, high workload, frequent interruptions and staffing, and personal factors such as nurse traits, experience, knowledge, triage fatigue and work schedule.

CONCLUSIONS

This review shows that patient safety is influenced by the attitude, capabilities and experiences of triage nurses, the time when nurses can dedicate themselves to the patient and triage the patient without disruption. It is necessary to raise awareness among nursing administrators and healthcare professionals to provide a safe triage environment for patients.

RELEVANCE TO CLINICAL PRACTICE

This review highlights the evidence on the factors contributing to patient safety in the triage process. Further research is needed for this cohort of triage nurses in the emergency department concerning ensuring patient safety.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution was required to design or undertake this review.

Exploring Primary Care Streaming Pathway in Emergency Departments in Saudi Arabia: A Qualitative Study

Background

Due to significant emergency department overcrowding, some hospitals implemented a system of directing certain patients who were deemed not in need of emergency care to other facilities called triage away. Pathways were developed as ways to stream patient from emergency departments to primary healthcare who is presenting with less urgent or nonurgent conditions. Thus, the purpose of this study was to explore the pathways (process) for streaming patients from emergency department to primary healthcare at three different sites across Western Region of Saudi Arabia and to identify the streaming criteria and guidance.

Materials and Methods

This study used a qualitative observational design. Data were collected through an unstructured observational approach, with an in-depth case study observation involving three emergency departments in the Western Region. Data were collected over three months until data saturated and recorded in the form of filed notes.

Results

The results of this study explored that all CTAS-5 were streamed away either (off-site) or (on-site) from emergency department. The average of the sorting/triage cases were around 200 to 250 per shift, and about third to half of them were streamed to Primary Health Centre or Urgent Care Clinic. The total streamed patients were ranging from 50 to 60 per shift, which mean 15-20 case per hour. The study highlighted many factors that influence the practice and decision of streaming.

Conclusions

In general, the term "streaming" was not as widely known among emergency clinicians, as was the term "triage." However, streaming was performed as an evidence-based practice, and clinicians routinely acted to direct patients based on hospital policies. Although, in one hospital, some nurses hack the system to manage the flow of patients based on their intuition. In contrast, the nurses in another hospital emphasised the importance of experience and confidence in streaming improvement.

The effectiveness of primary care streaming in emergency departments on decision-making and patient flow and safety - A realist evaluation

Primary care streaming was implemented in UK Emergency Departments (EDs) to manage an increasing demand for urgent care. We aimed to explore its effectiveness in EDs with different primary care models and identify contexts and mechanisms that influenced outcomes: streaming patients to the most appropriate clinician or service, ED flow and patient safety.

METHOD

We observed streaming and interviewed ED and primary care staff during case study visits to 10 EDs in England. We used realist methodology, synthesising a middle-range theory with our qualitative data to refine and create a set of theories that explain relationships between contexts, mechanisms and outcomes.

RESULTS

Mechanisms contributing to the effectiveness of primary care streaming were: quality of decision-making, patient flow, redeploying staff, managing patients across streams, the implementation of governance protocols, guidance, training, service evaluation and quality improvement efforts. Experienced nurses and good teamworking and strategic and operational management were key contextual factors.

CONCLUSION

We recommend service improvement strategies, operational management, monitoring, evaluation and training to ensure that ED nurses stream patients presenting at an ED seeking urgent care to the most appropriate clinicians for their needs in a safe and efficient manner.

Responsibility-Evading Performance: The Experiences of Healthcare Staff about Triage in Emergency Departments: A Qualitative Study

Background:

Correct triage is one of the most important issues in delivering proper healthcare in the emergency department. Despite the availability of various triage guidelines, triage is not still appropriately implemented. Therefore, this study was conducted to investigate the role of different underlying factors in triaging emergency patients through a qualitative approach.

Materials and Methods:

This study was conducted by conventional content analysis. For this purpose, 30 interviews were conducted with 25 participants. The participants included triage nurses, emergency general physicians, emergency medicine specialists, and expert managers at different position rankings in hospitals and educational and administrative centers in Yazd, selected by purposeful sampling. Data were collected through in-depth and unstructured interviews from April 2017 to January 2018, and then analyzed by inductive content analysis.

Results:

Four categories of profit triage, exhibitive triage, enigmatic, and tentative performance triage were drawn from the data, collectively comprising the main theme of responsibility-evading performance.

Conclusions:

The dominant approach to the triage in the emergency departments in a central city of Iran is responsibility evasion; however, the triage is performed tentatively, especially in critical cases. To achieve a better implementation of triage, consideration of the underlying factors and prevention of their involvement in triage decision-making is necessary.

Triage education in rural remote settings: A scoping review

BACKGROUND

Triage is a complex nursing task to prioritise patient care, based on acuity. Triage decisions can affect patient safety and must employ critical thinking. Graduate registered nurses are expected to triage in rural facilities, which is in contrast to current guidelines. The purpose of this review was; to discover how effective education support programs were in developing clinical decision-making skills for graduates at triage; and to determine what is known about triage education support programs for graduate or novice registered nurses undertaking triage in rural and remote settings.

METHOD

A scoping review was undertaken to identify and analyse primary research articles following PRISMA guidelines, sourced from four electronic databases.

RESULTS

6158 retrieved articles were found, after duplicate removal and screening against inclusion/exclusion criteria; fourteen articles were included. Themes included 'variability of triage accuracy and assessment'; 'education qualifications and experience'; and 'training and supervision'.

CONCLUSION

This review demonstrates significant gaps in the literature reporting on this topic area, particularly in the rural context. Common recommendations include standardised triage education strategies, and strategies that account for differences in resourcing levels. Further research is required to attempt to link education strategies in rural contexts to acceptable triage outcomes like triage accuracy.

Reliability analysis of the Manchester Triage System: inter-observer and intra-observer agreement

Objective:

To analyze the reliability of the Manchester Triage System to determine the priority of patients in emergency services.

Method:

This is a reliability study with a sample of 361 nurses. The data were collected in three stages and the questionnaires were applied using the electronic software. The agreement was measured by the evaluation of clinical cases. The outcomes evaluated were agreement with the gold standard and intra-observer in the indication of the flowchart, discriminator, and level of risk. Data were submitted to univariate and bivariate analyses. The agreement was measured by the Kappa index.

Results:

The external and internal reliability of the protocol ranged from moderate to substantial (Kappa: 0.55-0.78). The time of professional experience as a nurse, in emergency services and in the classification of risk were associated with external and internal reliability. The correct choice of the discriminator influenced the correct indication of the risk level (R² = 0.77, p <0.0001) more than the correct choice of the flowchart (R² = 0.16, p <0.0001).

Conclusion:

The reliability of the Manchester Triage System ranged from moderate to substantial and it was influenced by the clinical experience of the nurse. The protocol is safe for defining clinical priorities using different classification flowcharts.

Embracing the wild profusion: A Foucauldian analysis of the impact of healthcare standardization on nursing knowledge and practice

Standardization has emerged as the dominant principle guiding the organization and provision of healthcare, with standards resultantly shaping how nurses conceptualize and deliver patient care. Standardization has been critiqued as homogenizing diverse patient experiences and diminishing nurses' skills and critical thinking; however, there has been limited examination of the philosophical implications of standardization for nursing knowledge and practice. In this manuscript, I draw on Foucault's philosophy of order and categorization to inform an analysis of the consequences of healthcare standardization for the profession of nursing. I utilize three exemplars to illustrate the impact of the primacy of standardized thinking and practices on nurses, patients and families: pain assessments using the 0-10 pain scale; patient triage emergency departments through the Canadian Triage and Acuity Scale; and determination of cause of death within the context of the current opioid crisis. Through each exemplar, I demonstrate that standardization reductively constrains nursing knowledge and the health and healthcare experiences of patients and populations. I argue that the centrality of standardization must be re-envisioned to embrace the complexity of health and more effectively and meaningfully frame nursing knowledge and practice within healthcare systems.