Nursing Scholarship Symposium Event Posters.https://scholarlycommons.libraryinfo.bhs.org/nurs_presentations/1011/thumbnail.jp

LeBlanc, Raeanna, PhD

Marquard, Jenna, PhD

Smithline, Ellen, RN

Walker, Rachel K

English

Scholarly Commons @ Baystate Health

Baystate Health Scholarly Commons @ Baystate Health Nursing Research and Scholarship 2022 Presentations and Posters 2022 Perseverance: The Decision-Making Process of the Emergency Triage Nurse Ellen Smithline RN Baystate Health Rachel K. Walker University of Massachusetts Amherst Raeanna LeBlanc PhD University of Massachusetts Amherst Jenna Marquard PhD Follow this and additional works at: https://scholarlycommons.libraryinfo.bhs.org/nurs_presentations  Part of the Medicine and Health Sciences Commons Recommended Citation Smithline, Ellen RN; Walker, Rachel K.; LeBlanc, Raeanna PhD; and Marquard, Jenna PhD, "Perseverance: The Decision-Making Process of the Emergency Triage Nurse" (2022). Nursing Research and Scholarship 2022. 4. https://scholarlycommons.libraryinfo.bhs.org/nurs_presentations/4 This Book is brought to you for free and open access by the Presentations and Posters at Scholarly Commons @ Baystate Health. It has been accepted for inclusion in Nursing Research and Scholarship 2022 by an authorized administrator of Scholarly Commons @ Baystate Health. Perseverance: The Decision-Making Process of the Emergency Triage NurseEllen Smithline, PhD, MS, RN, CENRachel (Rae) Walker, PhD, RN, FAAN, University of Massachusetts Amherst, Elaine Marieb College of NursingRaeanne LeBlanc, PhD, DNP, AGPCNP, CPHN, University of Massachusetts Amherst, Elain Marieb College of NursingJenna Marquard, PhD, University of Minnesota School of NursingIntroduction• Introduction: The emergency triage process is not meeting the needs of the patient or the healthcare team. Current and past research has focused primarily on the emergency triage nurse’s ability to accurately designate the triage acuity score, while largely ignoring the impacts of the complex and dynamic environment in which they are immersed. Therefore, the purpose of this study wasto describe the factors that influence the decision-making process of the emergency triage nurse (ETN).• Method: This was a focused ethnographic study that included four phases. Phase 1 was the grand tour of the emergency triage and waiting room area. Phase 2 was the focused observations of the ETN during triage encounters. Instruments used included demographics, pre- and post-measurements of the National Aerospace and Science Administration Task-Load Index (NASA-TLX), and Fatigue Likert score. Phase 3 included the preliminary analysis of field notes to create a framework for the semistructured questions for focus groups to validate findings. Phase 4 involved focus groups of ETNs with field notes and audio transcribed verbatim. The researcher kept field notes on Phases 1, 2, & 4.• Results: Perseverance was a theme for both the ETN and the Team Patient (patient and their accompanying advocate). The model, Perseverance of the Emergency Triage Nurse was developed based on recurring themes involving the personal, interpersonal, organizational, environmental, and temporal factors during the decision-making process. Interruptions remained the biggest distractor. An incidental finding was noted related to the role of Team Patient in the triage process. Although Team Patient was the main contributor of interruptions, they also became an extension of the ETN in monitoring and notifying them of changes.• Discussion: Results of this study illustrated the factors that continue to influence the ETN’s ability to function in their role. It also demonstrated the complexity of the triage process, including interruptions and reprioritizing within a dynamic environment. Although Team Patient was the originator of many of these interruptions, Team Patient remained the patient’s person – their advocate – their voice. Team Patient’s absence during the COVID-19 pandemic has silenced them, thereby creating a gap in care. • The emergency triage process is not meeting the needs of the patients or the healthcare team. • The emergency triage nurse (ETN) is often the first healthcare provider a patient encounters upon entering the emergency department (ED). • The ETN determines an acuity score on how sick patients are and what resources might be needed (triage)• One of the most popular and widely used forms is the Emergency Severity Index (ESI). • Over 70% of U.S. hospitals use the Emergency Severity Index (ESI), a 5-point scale with 1 as emergent, 2 as unstable, 3–5 as stable and based on number of anticipated resources.1,2• In 2007, 117 million patients were seen in the US EDs with an increase to 139 million patients in 2017, of which an estimated 113 million were triaged by an ETN.3,4• Increase volume has resulted in higher patient acuity5 and increased nurse-to-patient ratio,6-8 contributing to to longer patient wait times, and delays in care.1,9-13• 60% accuracy of triage scores.14-16• This may be a result of assessment practices that focus on triaging to the ED (i.e., high volume, high acuity, boarding of patients) and not the individual patient.17• Acuity score that underestimates the patient’s needs (undertriaging). • Overtriaging leads to increased wait times and use of resources, all of which can result in higher mortality and morbidity.5,17-18• ETN role is also patient greeter, crisis manager, guide, consoler, waiting room steward, and monitor of all that might arrive through the ED door. 5,18-20• The purpose of this study was to describe the constellation of factors, including environmental influences, that impact nursebehavior and decision-making during the emergency triage process. Methodology ResultsAbstract• Triage is not simple• The triage acuity score may be the “end game”, but these competing measures of quality cannot be divorced from the context from which the score is generated. • The triage acuity scores works when there are enough resources for both the ED Team and Patients.  Realistically this is a dailychallenge • Reevaluation of the ESI acuity score to reflect the changes in care and wait times. • ETN requires: • Ability to work within a high temporal and mental demand• Possess communication skills to gather critical information, listen, and see potential possibilities• Situational awareness• Right nurse for the right position – right resources – right education• Interruption management (note that not every interruption is a bad one) - presence of support staff (patient advocates/OAs/Tas) can decrease interruptions of the ETN and Team Patient• Team Patient (Triage Patient + Their Person/advocate):• Communication with the patient and/or team patient should be without barriers, distractions including interruptions in order to obtain the most accurate information• Team Patient (virtual or in person) should be considered as one unit that will remain together throughout their hospital stay asthey are “their person”, their voice, their advocate• Organizational:• Ability to flex up to meet the needs of volume and acuity• Assigning the right nurse for the role (years of experience does not make the expert)• Environmental:• Nursing should be an integral member of the architectural team when developing new buildings, redesigning current spaces• Nursing Perseverance - to get the ultimate outcome nurse wants for patient• Patient and Team Patient Perseverance - to get the ultimate outcome they needThe Perseverance of the Emergency Triage Nurse Model offers a different lens into the daily challenges about what triage nurses do…as this study demonstrated, it is not just triage.ConclusionPerseverance of the Emergency Triage Nurse Model©Emergency Triage Nurse: • Perseverance of the ETN & interruptions• Knowing• Listen, acknowledge, & apologize• Negotiate• “Why was this the day?”• Trying to be constantly awareTriage Patient:• Alone/Isolated • Independent• Physical and Invisible Disabilities• English as a Second Language• Undocumented immigrants• OlderTeam patient:• Their person• Virtual Team Patient• Community Team PatientInterpersonal:• Interruptions• Permission to interrupt• Follow-the-leader• Not all interruptions are badOrganizational:• The right person for the right job• Being the buffer• Just the facts• Just in time chartingEnvironmental• Hearing all – seeing all• Know the drill• Overhead paging• Layered UpDesign & Setting:• Focused ethnographic design. • Single nurse researcher with specific knowledge regarding the triage process performed episodic observations of the nursing triage process over a 5-day period. • Study focused emergency nursing triage in the ED of an urban Level 1 trauma academic hospital with an average of 120,000 visits annually. Sample & Recruitment: • Data were generated between October and December 2019.• Email was distributed to all triage nursing staff to invite them to participate in observation, focus group, or both. • Eligibility: completed triage training and were currently working in the triage position • Purposeful sampling of the ETNs was used for the observation and focus group phase• All ETN who agreed to participate, provided informed consent prior to the initiation of data collection.Data Collection & Analysis• Data collected in 4 phases – see illustrationData: 20 nurses (15 observational phase/5 in focus group sessions) participated with 142 triage cases observedThemesPerseverance: Continued effort to do or achieve something despite difficulties, failure, or opposition (Merriam Webster)*This study was funded by the University of Massachusetts Amherst Graduate School Research Dissertation Grant Award©Ellen C. Smithline, March 2021

Perseverance: The Decision-Making Process of the Emergency Triage Nurse

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Perseverance: The Decision-Making Process of the Emergency Triage Nurse

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