A Delphi Study on Research Priorities for Emergency Nurses in Western Australia

RESEARCH TOPIC: VIOLENCE IN EMERGENCY DEPARTMENTS 

A survey of violence (both physical and verbal) in emergency departments will be undertaken. The number of reported incidences (nature and outcome) will be collated, followed by a survey of nurses to determine the number of unreported incidences.

AIM 

To determine the actual number and nature of violent incidents taking place in emergency departments, then to create a plan to protect staff and reduce the level of violence towards staff.

SIGNIFICANCE 

Anecdotal evidence suggests that violence (both verbal and physical) is increasing in emergency departments. The management of aggressive patients, especially adolescents, is an ongoing concern for ED nurses. It is also perceived that management is not supportive enough regarding violence-related issues. Appropriate levels of security and control measures need to be determined. The development of a policy on formal charges toward offenders and video evidence also needs to be addressed.

The ENAWA members were asked to rank the entire list of research questions (1 to 25) according to priority, with 1 being the greatest priority and 25 being the lowest priority. Forty-six ENAWA members responded in the second round (40%); all responses were usable. According to Lindeman,7 a sample of 30% of the respondents is sufficient to generate a useful set of priorities. Calculating which question had the most responses attributed to it at each level enabled the research team to tabulate the results. A cumulative score was tabulated for each question beneath the higher ranked question until all 25 questions had been ranked according to the respondents' desired level of priority.

The research team believe that this research study is both reliable and valid, having met the following prerequisites of a Delphi study, being: (1) formulation and structure of the initial questions; (2) transcription of individual responses by the researchers; (3) response rates over successive rounds of the survey; and (4) an understanding of the meaning of consensus.4., 8.

The second round of research questions was broad enough to incorporate a range of issues, adding depth to each response. Each member of the research team cross-analyzed each response to reduce bias, resulting in a true reflection of the intent of the participant's response.

Table 3 contains the abbreviated title (space constraints prohibit including the entire topic, such as in the topic previously illustrated on ED violence) for each research question ranked in order of priority determined by the respondents in the second round.

TABLE 3. Research questions ranked according to the priority allocated in the second round

	Rank	Research question
	1	Nurse-initiated analgesia in the emergency department
	2	ED staffing levels
	3	Violence in emergency departments
	4	Nurse iniated x-rays in the emergency department
	5	Common policies, procedures, and protocols across emergency departments
	6	The community perception of the emergency department's role
	7	Stress evoking issues of ED nurses
	8	The presence of relatives during patient resuscitation
	9	Psychiatric assessment time period (following referral) and the relationship to levels of agitation and violence
	10	Levels of nurses' skills in resuscitation
	11	Accuracy of ED nurses' initial judgment triage code allocation, compared with final diagnosis
	12	Pediatric resuscitation protocols, drug standards, and intravenous fluid therapy regimes
	13	ED nurses' attitude toward suicide
	14	Perception of relatives (and significant friends) of their management following the sudden death of a significant other in the emergency department
	15	The effect of postgraduate emergency nursing education on patient outcomes
	16	Nonhospital telephone triage advice (managed by an independent agency) and its effects on inappropriate patient presentation
	17	Effectiveness of ED staff development
	18	Length of shift time related to accuracy of triage decision-making skills
	19	Pediatric requirements in the emergency department
	20	Adequacy of ED feedback to referring agency or agent
	21	Critical Incident Stress Management in rural and remote emergency departments
	22	RN and non-RN ambulance officers and paramedics assessment and patient management skills
	23	Non-nursing ED health team members' perceptions of the emergency department nurses' role
	24	Use of educational videos in the emergency department of the role of the emergency department, aimed at patients and visitors
	25	Alternative and diversion therapies in pediatric emergency care

1. NURSE-INITIATED ANALGESIA IN THE EMERGENCY DEPARTMENT 

Pain management is often a contentious issue in emergency departments, with patients and nurses often concerned about the time a patient waits for analgesia. Nurse-led drug administration in emergency departments may improve this situation. Safety concerns and the effect on initial diagnosis need to be taken into consideration. How rural and remote nurses deal with patients' analgesic needs requires exploration.

2. ED STAFFING 

There is a perception of increasing levels of stress and job dissatisfaction within emergency nursing. Issues such as the night shift generally having less staff but often being as busy if not busier than other shifts, with less resources available, are of concern. The retention of emergency nurses in high-volume emergency departments may be linked to appropriate skill mix and staff numbers. Alternative models such as team-based models need to be sought and examined.

3. VIOLENCE IN EMERGENCY DEPARTMENTS 

Anecdotal evidence suggests that violence (both verbal and physical) is increasing in emergency departments. The management of aggressive patients, especially adolescents, is an ongoing concern for ED nurses. It also is perceived that management are not supportive enough regarding violence-related issues. Appropriate levels of security and control measures need to be determined. The development of a policy on formal charges toward offenders and video evidence also needs to be addressed.

4. NURSE-INITIATED X-RAYS IN THE EMERGENCY DEPARTMENT 

There is some resistance in Western Australia to the practice of nurses initiating x-rays in emergency departments. Research needs to ascertain whether nurse-initiated x-rays are accurate and a valid process to adopt in order to fast-track patients through the emergency department. Whether this initiative would increase the number of x-rays obtained needs to be determined during a trial period.

5. COMMON POLICIES, PROCEDURES, AND PROTOCOLS ACROSS EMERGENCY DEPARTMENTS 

There is a perception amongst emergency department nurses that there is a lack of uniform protocols and procedures between emergency departments. This situation may be a result of inadequate communication and unwillingness to share information or problems and difficulties in interdepartmental cooperation. Statewide standardization of clinical practice is perceived to be particularly useful for nonmetropolitan emergency departments when treating and preparing a patient for transport to an inner-city emergency department. Uniform procedure protocols are perceived as benefiting all of the stakeholders, saving time and money, and improving patient care. This issue is especially pertinent for nurses who work for a metropolitan health region and work in different emergency departments within the region.

6. THE COMMUNITY PERCEPTION OF THE EMERGENCY DEPARTMENT'S ROLE 

There is a perception that the general community has a poor understanding of the role of emergency departments because of poor public relations and poor communication with the general community. ED clinicians believe they need to become more skilled at communicating the emergency department's role to the general community and become more involved in preventive health education. The use of general practice clinics linked to the emergency department also may relieve the pressure of overloaded emergency departments.

7. STRESS EVOKING ISSUES OF ED NURSES 

The issue of ongoing stress related to working in an emergency department needs to be assessed. How well do emergency nurses look after themselves? How do they deal with psychological distress compared with the public? Is the incidence of such issues as sexual abuse, domestic violence, depression, and drug and alcohol abuse amongst emergency department nurses higher compared with the general Australian population?

8. THE PRESENCE OF RELATIVES DURING PATIENT RESUSCITATION 

The level of involvement of relatives and friends in the resuscitation of their significant other has been the subject of debate in emergency departments for many years, with increasing numbers of emergency departments now allowing the presence of relatives and friends during the resuscitation of their significant other. Research needs to be undertaken to determine the impact this experience has on the relatives and friends as well as the staff involved.

9. PSYCHIATRIC ASSESSMENT PERIOD (FOLLOWING REFERRAL) AND THE RELATIONSHIP TO LEVELS OF AGITATION AND VIOLENCE 

There is a perception that mental health patients are not managed effectively and expediently while in emergency departments. It is assumed that there is an escalation in levels of agitation and violent behavior exhibited in mental health patients who wait for long periods in emergency departments for psychiatric review, treatment, and admission. This situation has an impact on both staff and resources in emergency departments.

10. LEVELS OF NURSES' SKILLS IN RESUSCITATION 

Resuscitation is a major part of emergency nursing practice. There is a perception that nurses may not be properly prepared for the role, especially in smaller emergency departments. What is the standard of training, and how is it benchmarked? Issues such as an accredited standard that is accepted by all the emergency departments in both the metropolitan and nonmetropolitan area need to be determined.

11. ACCURACY OF ED NURSES' INITIAL JUDGMENT TRIAGE CODE ALLOCATION COMPARED WITH FINAL DIAGNOSIS 

Triage education is based on collecting objective data to make decisions using a triage score. ED nurses are concerned that much of the decision is based on tacit (and subjective) knowledge that overrides objective information. Comparing the eventual patient diagnosis and the initial triage nurse assessment is important to validate the role of the triage nurse.

12. PEDIATRIC RESUSCITATION PROTOCOLS, DRUG STANDARDS, AND INTRAVENOUS FLUID THERAPY REGIMES 

Concern exists that there are significant differences between emergency departments when treating children with life-threatening conditions. These differences make it difficult for nurses who work between emergency departments and those who work in mixed-age emergency departments.

13. ED NURSES' ATTITUDE REGARDING SUICIDE 

There is a perception amongst ED nurses that people who deliberately attempt to kill themselves are wasting the ED staff's time and that there is very little the ED nurse can do in terms of psychosocial support for such patients. These attitudes need to be explored in terms of the impact on both patients and staff.

14. THE PERCEPTION OF RELATIVES (AND SIGNIFICANT FRIENDS) OF THEIR MANAGEMENT FOLLOWING THE SUDDEN DEATH OF A SIGNIFICANT OTHER IN THE EMERGENCY DEPARTMENT 

There is a perception among the general public and ED staff that “death telling” is often performed inadequately in terms of immediacy, accuracy, and empathy. Determining the right mix of staff seniority and skill mix is often compromised by the demands of the emergency department at the time. Whether a staff member (eg, a social worker) from outside the emergency department should assist in this process will be explored.

15. THE EFFECT OF POSTGRADUATE EMERGENCY NURSING EDUCATION ON PATIENT OUTCOMES 

Research to compare the practice of nurses who have postgraduate education with the practice of nurses who do not have postgraduate education was perceived to be important to validate whether the expense and effort that is required to gain postgraduate emergency nursing education is worthwhile.

16. NONHOSPITAL TELEPHONE TRIAGE ADVICE (MANAGED BY AN INDEPENDENT AGENCY) AND ITS EFFECTS ON INAPPROPRIATE PATIENT PRESENTATION 

Since the introduction of “Health Direct,” an initiative funded by the Health Department of Western Australia in which experienced emergency nurses give health-related advice to callers by telephone, there is a perception that patients are unnecessarily being sent to emergency departments. There is anecdotal evidence that many people who present to emergency departments following a call to “Health Direct” say that they were told to present immediately, and on assessment by triage nurses, their complaints are generally deemed to be of a minor nature.

17. EFFECTIVENESS OF ED STAFF DEVELOPMENT 

There is a perception amongst ED nursing clinicians that there is a lack of incentive for continuing education and development amongst the aging workforce. It is indicated that local staff development is not adequate, and this is particularly the case in nonteaching hospitals, where management often limit funds and time available for staff development.

18. LENGTH OF SHIFT TIME RELATED TO ACCURACY OF TRIAGE DECISION-MAKING SKILLS 

There is no standard time that a nurse is allocated to triage. Some emergency departments allow their nurses to be at the triage desk for the duration of the entire shift (up to 12 hours), whereas others break the shift into segments of various periods. Is there a minimum time span that provides effective triage management? Conversely, what is the maximum time a nurse should be at triage before decision making and care is affected?

19. PEDIATRIC REQUIREMENTS IN THE EMERGENCY DEPARTMENT 

Pediatric patients have unique needs. Pediatric patients present differently than do adults and have different psychosocial and developmental needs that require specific approaches by the ED nurse. How effectively pediatric patients are cared for in adult-orientated emergency departments is questionable. Does Western Australia need more specialist pediatric emergency departments other than the one it currently has? What training do ED nurses have in pediatric care? To what extent does resource allocation have an impact on the special needs of pediatric patients?

20. ADEQUACY OF ED FEEDBACK TO REFERRING AGENCY OR AGENT 

Feedback regarding patient outcomes would assist the referring emergency department in providing improved service and nursing care. Referring ED clinicians have the perception that patients presently transferred to tertiary hospitals just “disappear” into the system and that the referring ED clinicians only find out about the patients' progress by following them up themselves or via a more informal communication route (which is often inaccurate). Documentation is needed that includes such things as the management of patients with spinal and head injuries, burns, and obstetric and gynecologic problems, which have been identified as being important areas for feedback to the referring emergency department. Feedback would enable the referring ED clinicians who may not deal with these emergencies very frequently to offer best practice for these patients.

Staff at rural and remote emergency departments believe that the tertiary receiving centers do not understand the situation of staff and facilities in the referring rural and remote emergency departments. With increased communication between the referring and receiving emergency departments, there may be a lessening of what is currently perceived as judgement and critical attitudes to staff in rural and remote emergency departments. It is perceived that there is a need for greater appreciation from inner-city and metropolitan emergency departments of the rural and remote emergency departments' staffing numbers, skill mix, equipment levels, and the amount of effort involved in transferring a patient to a tertiary setting.

21. CRITICAL INCIDENT STRESS MANAGEMENT IN RURAL AND REMOTE EMERGENCY DEPARTMENTS 

In rural and remote areas, staff involved in critical incidents often are left to debrief themselves, either informally with other staff, or outside of work with friends and relatives. Given the small populations in these areas, the staff member may know the patient involved in a critical incident, which compounds and complicates the staff member's response. Exploration of policies and procedures that are used to care for staff in this situation need to be explored to establish common best practice.

22. RN AND NON-RN AMBULANCE OFFICER'S AND PARAMEDICS' ASSESSMENT AND PATIENT MANAGEMENT SKILLS 

There is a need to examine the strengths and weaknesses in skills of the 2 groups to identify differences and similarities in training to ascertain the best outcomes for ambulance officers and paramedics.

23. NON-NURSING ED HEALTH TEAM MEMBERS' PERCEPTIONS OF THE ED NURSES' ROLE 

The actual role of the ED nurse may vary depending on whether it is a nurse's opinion or that of a doctor. Whether ED nurses are practitioners in their own right or totally dependent on the medical system to fulfill their function is an area in need of research. This is especially pertinent now that nurse practitioners are being educated in Western Australia.

24. USE OF EDUCATIONAL VIDEOS IN THE EMERGENCY DEPARTMENT REGARDING THE ROLE OF THE EMERGENCY DEPARTMENT, AIMED AT PATIENTS AND VISITORS 

Research is needed to determine whether passive parent/patient education has any long-term effect on repeat presentations such as fevers, gastroenteritis, asthma, and other common childhood illnesses.

Many ED nurses believe that a significant number of ED pediatric presentations could be avoided if parental education had been more thorough. Do parents receive enough education regarding childhood illnesses and how to manage them? Also, parenting skills are perceived as an area that needs to be researched.

25. ALTERNATIVE AND DIVERSION THERAPIES IN PEDIATRIC EMERGENCY CARE 

Diversion therapy during procedures involving pediatric patients has been used extensively in ward and specialist unit environments but often has been underutilized in emergency departments. The use of play therapy in pediatric emergency departments and the use of distractions during procedures such as intravenous line insertion and plaster application needs to be explored and developed to improve client comfort, safety, and patient outcomes.