Background/aim
The report provides a critique of a qualitative research article by Broadbent, Moxham & Dwyer, (2014) to find out the best practice available to address the environmental challenges and challenges faced by staffs in attending to client with mental illness. The research article is published in the Australasian Emergency Nursing Journal which is an official journal of the College of Emergency Nursing Australia. The main advantage that college members and others subscribers get from this journal is that it provides high quality and thought provoking knowledge related emergency nursing practice in Australia, New Zealand and overseas. The impact factor of the journal is high as its accepts original research work and double-blind peer review process is used to enhance the quality and trustworthiness of the evidence (Australasian Emergency Nursing Journal, 2017). In addition, the credibility of the article is also understood from the research interest and professional background of the researchers. Dr. Marc Broadbent’s main research interest is emergency care, management of vulnerable people in the emergency department (Dr Marc Broadbent, 2017). Secondly, Lorna Moxham is a professor of Mental Health nursing with research interest in the same field and Trudy Dwyer has research interest in rapid response system and clinical teaching (Dwyer, 2017). With years of experience in their professional field and publication of past research work, it is confirmed that the research would offer high quality of data for ED nursing.
Broadbent, Moxham & Dwyer, (2014) used ethnographic research design to investigate about the challenges associated with working in a triage environment and identifying about the impact of triage practice environment on the role of triage nurse in conducting triage assessment in clients coming to mental illness in emergency department (ED). The reason for such research is understood from the case scenario that maximum client with mental illness attend ED first to access care and lack of appropriate triage environment affect patient safety and privacy. The motivation for the research on this topic is also understood from the problem statement in the research article that flow of clients with mental illness to the Australian ED has increased due to mainstreaming of mental health service into general health service (Shafiei, Gaynor, & Farrell, 2011). Although the Australian government has responded to this issue by introducing specialist mental health triage scales and specialist mental health clinicians within ED, the research emphasized that management of such patients remains the core responsibility of triage nurse (Ebrahimi et al., 2016). Hence, as there is lack of evidence regarding the impact of triage environment on triage assessment process done by nurse, this research became important.
Methods
The review of literature related to the topics has also helped Broadbent, Moxham & Dwyer, (2014) to engage in decision making and plan research design. For example, literature review of recent research work mainly discussed about the ED design in Australia and the provision needed in ED triage design according to the policy documents in Australia (Ebrahimi et al., 2016). Research evidence regarding use of space in ED and mental health setting was also found (Nugus & Forero, 2011). However, the author identified the gap in past research work by the statement that studies has been done regarding the role of triage nurse in ED, however there is lack of research on evaluation of the architectural environment of triage. Hence, this gap in study informed the research design as well as the study objective.
Broadbent, Moxham & Dwyer, (2014) has mainly used ethnographic research design to extend knowledge regarding the impact of triage environment on the role and performance of triage nurse in ED. Such research design is appropriate when the focus of any study is to find or explore impact of any process on participants. Hence, ethnographic research design facilitates observation and interaction with participants to understand the problem facing them in real setting (Hammersley, 2016). Congruent with the ethnographic research design, the decision regarding collecting data by means of participant observation and interview with participants is a right approach by the researcher. The reflexivity in the design was also seen by the collation of document and field notes to gain understanding regarding triage environment and triage nurse performance. However, one important point in research design is that enough time is not spent with study participants as this research only evaluated one element from a wider study on interdisciplinary relationship between ED triage nurse and specialist mental health triage nurse.
Although Broadbent, Moxham & Dwyer, (2014) had analyzed one element of broader study to investigate on the research topic, however sample population and setting has been described in detail. The research setting included a large emergency hospital in regional Australia with about 4.5% client presentation for mental illness and the study participants included emergency nurse rostered in morning shift, afternoon shift and day shift. In addition, emphasis on richness was also seen because purposive sampling method was used to conduct interview with the triage nurse. In qualitative research, purposive sampling is mainly done to ensure that a sample is selected that represent the population of interest (Etikan, Musa & Alkassim, 2016). As Broadbent, Moxham & Dwyer, (2014) focused mainly on evaluating the experience of triage nurse in ED, the validity of the data was enhanced by taking 28 ED triage nurse who were trained in triage practice and has been rostered to work at triage.
Results
The method of collecting data is found to be effective in the article as the researchers tried to achieve triangulation through two or more method of data collection. Triangulation is a process of using multiple data in research to better understand the topic and it ensures that rich, robust and well developed data is presented. Hussein (2015) achieved triangulation by collecting data using documents and field notes, participant observation and interview method. This reflects that sufficient amount of data was there to explore the triage environment in depth and explore the challenges of nurse in triage assessment.
The richness in collecting data has been already proved by use of different data collection method to achieve triangulation. In addition, during the data collection process for each method too, face to face interaction with study participant and observation related to triage practice environment on ED triage nurse is considered to be effective. The effort to minimize biasness in collection and interpretation of data is also seen because the researcher themselves were involved in face to face interaction and observation and all of them had great professional experience in mental health and ED nursing practice. The biasness in research data is also done by blinding the investigators and this is evident from the research by Jordi et al., (2015) which used this approach to collect survey data and keep nurse response anonymous.
The credibility and substantiality of any research become evident if the eminent and renowned researchers are involved in conducting the research. With evidence regarding publication of innovative research work on emergency and mental health nursing by all three writers, any reviewer can develop confidence in the finding. Moreover, trustworthiness and fairness of the data is also seen by the compliance with ethical considerations in qualitative research such as taking informed consent, right to withdraw from research and taking ethical approval (Silverman, 2016).
The use of thematic approach in data analysis justified the compatibility of the process with the type of data collected. As the data was huge, using any other approach would have made the analysis process very complex. However, thematic analysis ensure that multiple data could be effectively presented under specific themes relevant to the research objective (Broadbent, Moxham & Dwyer, 2014). In addition, use of systematic inductive method through constant comparison and theoretical coding by different authors independently and then comparing them reduced all possibility of biases too.
As multiple methods were used to collect and analyse the data, interpretability of the study result was enhanced by categorizing the data into different themes. Use of thematic approach in presentation of result is found to be beneficial because despite getting huge data, individual theme made it easier to understand the triage environment and its impact on triage nurse (Vaismoradi,Turunen, & Bondas, 2013). The meaning of the data was captured well with the use of specific themes. For example, in the context of triage environment, the results revealed that presence of high activity staff, free movement of public, non sound attenuating ceiling and no barrier for interacting with client seriously challenge work of triage nurse. For the themes of triage assessment, the nurses excerpts revealed that their triage practice was seriously affected by inappropriate practice environment and lack of privacy for client (Broadbent, Moxham & Dwyer, 2014). Hence, the study was successful in giving insight regarding environmental barrier in triage assessment and the need for serving the best interest of patients by building a separate ED triage environment. The research by Opiro, Wallis & Ogwang, (2017) presented variation in triage protocols, absence of administrative support and shortage of staff on duty as barrier to development of triage system and there is need to work in these areas in the future.
The research by Broadbent, Moxham & Dwyer, (2014) gave the idea that architectural environment of an ED triage area is factor that challenges triage nurse in triage assessment and their ability to provide optimal care. The analysis of data by multiple methods shows that environmental characteristics of a triage area comes in the way of building a therapeutic environment and this results is considered trustworthy and reliable as different researchers have evaluated the data and then compared it to come to this conclusion. The only limitation that may affect the transferability of the research in real setting is that the sample size was small and there was social, cultural and historical links to the study site understood from student’s comment. Despite this limitation, the study gives useful knowledge to improve nursing practice in the triage area and find the factors needed to build an ideal triage area.
The critical appraisal of Broadbent, Moxham & Dwyer, (2014) article was done in this report mainly to solve the dilemma in the case study. The case study presented the issue that ED is a busy area and people with mental illness first approach ED as first point of access to care. However, the dilemma in the case scenario was that mental health clinicians are not rostered to ED normally and such practice affected the patient safety and privacy significantly. In relevance with issues, it is found that the article by Broadbent, Moxham & Dwyer, (2014) is most suitable to address the dilemma. The study presented that specialist triage nurse should be present in ED to assess and screen clients attending ED with mental illness. The study gave the idea about how triage nurse engage in rapid decision making and obtaining the best possible data for the optimal care of clients. In this context, it can be said that the article is informing nursing practice regarding the preparedness for triage assessment. Ebrahimi et al., (2016) also affirmed that triage nursing is a relatively new role of nurses and they need comprehensive educational program as well as organizational support to increase efficiency in the triage process. The article is an effort towards extending knowledge and skills regarding the new role of triage practice for nurse.
The findings of results pointed out that patient’s privacy and right to therapeutic environment is seriously violated by the free movement and noise near the triage desk. In this context, it reflects about the need to preserve patient value in care and the recommendation from the study was to modify the architectural environment of triage so that clients do not face issues during assessment. However, there is a need for future research in studying about the experience of client in ED triage area as client’s perspective were not evaluated in the study. The research is also significant because it also points out to ways clinical expertise in triage can be enhanced and this included both organizational support as well as environmental modification of triage area. The study supported their results with many arguments. The clinical practice in the triage area for nurses is also informed by other available evidence. For example, Ebrahimi et al., (2016) which gives detail results regarding the role description of triage nurse in the ED.
Reference
Australasian Emergency Nursing Journal. (2017). Aenj.com.au. [online] Available at: https://www.aenj.com.au/ [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.
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].
Dwyer, T. (2017). Staff Profile. [online] My.cqu.edu.au. Available at: https://my.cqu.edu.au/documents/10165/5667933/Trudy+Dwyer+Staff+profile+2013.pdf/35f2f9e1-2d53-4eb8-8c56-224e394bd9aa [Accessed 9 Oct. 2017].
Ebrahimi, M., Mirhaghi, A., Mazlom, R., Heydari, A., Nassehi, A., & Jafari, M. (2016). The role descriptions of triage nurse in emergency department: a Delphi study. Scientifica, 2016.
Ebrahimi, M., Mirhaghi, A., Mazlom, R., Heydari, A., Nassehi, A., & Jafari, M. (2016). The role descriptions of triage nurse in emergency department: a Delphi study. Scientifica, 2016.
Etikan, I., Musa, S. A., & Alkassim, R. S. (2016). Comparison of convenience sampling and purposive sampling. American Journal of Theoretical and Applied Statistics, 5(1), 1-4.
Hammersley, M. (2016). Reading ethnographic research. Routledge.
Hussein, A. (2015). The use of triangulation in social sciences research: Can qualitative and quantitative methods be combined?. Journal of Comparative Social Work, 4(1).
Jordi, K., Grossmann, F., Gaddis, G. M., Cignacco, E., Denhaerynck, K., Schwendimann, R., & Nickel, C. H. (2015). Nurses’ accuracy and self-perceived ability using the Emergency Severity Index triage tool: a cross-sectional study in four Swiss hospitals. Scandinavian journal of trauma, resuscitation and emergency medicine, 23(1), 62.
Nugus, P., & Forero, R. (2011). Understanding interdepartmental and organizational work in the emergency department: an ethnographic approach. International Emergency Nursing, 19(2), 69-74.
Shafiei, T., Gaynor, N., & Farrell, G. (2011). The characteristics, management and outcomes of people identified with mental health issues in an emergency department, Melbourne, Australia. Journal of psychiatric and mental health nursing, 18(1), 9-16. Opiro, K., Wallis, L., & Ogwang, M. (2017). Assessment of hospital-based adult triage at emergency receiving areas in hospitals in Northern Uganda. African Health Sciences, 17(2), 481-490.
Silverman, D. (Ed.). (2016). Qualitative research. Sage. Vaismoradi, M., Turunen, H., & Bondas, T. (2013). Content analysis and thematic analysis: Implications for conducting a qualitative descriptive study. Nursing & health sciences, 15(3), 398-405.
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