Emergency Department Triage: A Critical Ethnography

The assignment focuses on conducting a critical ethnography study of triage practices within emergency departments. Students are expected to analyze existing literature on emergency department overcrowding, mortality rates, and the 4-hour rule in Australia. Further, they will investigate nurses' thinking strategies during triage and their experiences with mental health patients presenting in the ED. The assignment emphasizes understanding the complexities of triage through the lived experiences of nurses and the impact of various factors on patient flow and outcomes.

Running head: CRITICAL ANALYSIS
CRITICAL ANALYSIS
Name of the Student
Name of the university
Author’s note

1CRITICAL ANALYSIS
Introduction
Emergency department across the world follow a triage system in order to manage the
overcrowding in the department. An emergency triage basically improves the emergency care
and to sort out the cases on the basis of urgency. This qualitative paper provides with an
observational ethnographic approach to examine the problems faced in assessing mental health
patients in the triages of the emergency department.
It is a moderately regarded journal having the cite score 0.15.
This journal has been published in Australia. The journal provides us with an insight of the usual
problems that are faced in emergency tried for accessing the mental health patient, which would
help to develop the evidence based nursing interventions that has to be conducted to mitigate the
problems faced by the triage nurses.
The authors of this article are Marc Broadbent, who is a registered nurse and contains a
PhD in nursing from the school of nursing and Midwifery, Australia. Second author is Lorna
Moxham, who is a mental health nurse and holds a PhD degree and belongs to the School of
nursing, Midwifery and Indigenous health, NSW and Trudy Dwyer, who is also an RN having a
PhD degree and belongs to the School of Nursing and Midwifery, Central Queensland
University, Australia.
Background
The key points described to give the background of this paper are that the Australian
emergency departments are the main centre for the clients having mental health illness in order
to access acute health care. Although the exact number of the mental health presentations in the

2CRITICAL ANALYSIS
emergency departments is not known for sure, but the patients often have to wait in the ED
waiting room till the physicians arrive which becomes difficult for the triage nurse of the
emergency departments. The following paper also describes the disadvantages of the
architectural set up of the triage room that makes the environment extremely noisy and
undisciplined (Geelhoed & de Klerk, 2012). Other factors that were focused upon were the lack
of privacy (Fitzgerald et al., 2010). As per the interview taken by the ethnographer, the triage
nurses desires for private rooms to deal with the mental health patients. The paper also focuses
on the architectural design of the triage rooms that enhance the problem between the client nurse
communications.
Thus this study was important as it would help to shed light on the difficulties faced by
the triage nurses and to understand how the provision of quality care is balanced with the
requirement to maintain the efficiency of the organization. This study also provides with the
information that the there are certain important points that has to be enlisted for an ED triage that
is accessibility, proper access to the examination areas, provision of modern equipments, control
measure for infections, safety and confidentiality for the clients (Fitzgerald et al., 2010). A
literature review was provided which focuses on the management of the patients in the waiting
room of the triage and indicates that it is becoming an important area for evaluating the service
delivery.
Aims of research: The aim of this research is to provide information regarding the environments
associated to the triage practice and mainly focuses on the management of the clients with
mental health illness.

3CRITICAL ANALYSIS
Methods
This research study has been done in an ethnographic framework for observing the
nursing practice emergency. This type of study is suitable for getting a deeper understanding
regarding the emergency department. This paper also helps to draw attention on the
interdisciplinary relationship between the specialist mental health nurse and the ED triage nurse.
It can be seen that data depending on 8 weeks have been taken, which can be thought as enough
time to understand the trend of a clinical setting. One emergency nurse was appointed to triage in
the morning shift, two for the afternoon shift and one for the night shift. The sample population
used in this design was well identified. Informal as well as formal interviews were taken from 28
triage nurses, who have received triage training and were entitled to work at the triage. The
clients were never interviewed. 2 individuals and 10 group interviews were conducted with the
triage nurses. Informations were tape recorded and documented which helped to strengthen the
observational field data and which reflects reflexivity in the design. Recording of the interview
sessions strengthened the trust worthiness of the survey. The data collection method would have
been bias-free as the interviews were organized depending upon the availability of the nurses on
the shift (Fitzgerald et al., 2010). The interviews taken were sufficiently trained. Face to face
interaction with the participants helped to further analyze the researches. There were sufficient
amount of data to evaluate the condition of the clinical setting. The participants recruited for the
study was appropriate to the aims of the research. The data was collected exactly in the way that
is appropriate to address the aims of the research. The relationship amongst the participants and
the researcher had been adequately considered in this study. The ethical issue like maintaining of
confidentiality had been addressed in this paper (Geelhoed & de Klerk, 2012).

4CRITICAL ANALYSIS
This type of study can be regarded as the best possible method of sampling as it not only
provided with the observational field data but also provided with the information gathered from
the face to face interview taken It had helped the Ethnographer to contextualize what they are
visualizing and hearing. The interview had helped the researcher to confirm the records obtained
from gather observations and give a deeper understanding of the methods.
The sample and the setting have been described appropriately which describes the
architectural designs of the clinical setting. It helped to provide an idea regarding the different
fallacies of the settings that contributed to the chaos in the ED.
Results
Data analysis
A systematic and comprehensive approach was taken for analyzing the data. During
conducting the field study, an eclectic process was undertaken. Intuitions and ideas were
documented during the field study. Extensive notes were jotted down from the taped interviews
and critically analyzed to get the relevant findings. Each element of the data was analyzed and
then compared with the other pieces of the data. During the conduction of the field study the
ethical issues were considered. Throughout the research the four pillars of ethics have been kept
in mind (Lowthian et al., 2010). All the triage nurses were imparted with prior information
regarding their participation in the field study. The acknowledgement had been taken verbally
and well as in fact sheets. Prior approval from the ethical committee had been obtained to
continue the field study, Therefore it can be said that all the ethical perception has been
addressed (Christ et al., 2010).

5CRITICAL ANALYSIS
The findings from the observational study and the interviews were relevant to the key issues. The
findings were explicit and provided with a vivid description about the triage environment. It
provided with supported evidences both for and against the arguments of research. It can be
known from the paper that there was a glass barrier which separated the client from the nurses
and the small gap in the glass were the portals of the client- nurse communication. According to,
the triage area becomes noisy and chaotic as the staffs have to raise their voices to overcome the
surrounding noises. The article further focused on the requirements of the nurses for giving an
appropriate care to the mental patients.
Mental patients should be given special attention and should be provided with a holistic
care of approach. The articles could provide how lack of confidentiality and privacy hampered
the decision making process of the triage nurses. According to (Farrohknia et al., 2011) ED
nurses are capable of managing to the mental health patients prior to their assessment by the
doctor. According to (Christ et al., 2010) environment has immense impact on the health
outcomes of the patients. Therefore the wish of the triage nurses for a private space is valid and
should be addressed. According to (Christ et al., 2010) that would help to increase the safety of
the mental health patients as well as the clients waiting in the waiting room.
Limitations - The clients were never interviewed in the study. Interaction with the clients
could have been useful for the ethnographer as that would have been an unbiased statement in
part of the customer. Knowing the grievances of the customers would have enhanced the
knowledge regarding the difficulties faced by the nurses in dealing with mental health patients
(Lowthian et al., 2010). The perceptions of the participants reflected the social, cultural and
historical context at the time of the field study. Therefore those aspects should also be considered
before the analysis.

6CRITICAL ANALYSIS
Summary and conclusion
Triage nurses are usually at the first point of clinical contact with the patient and play a
crucial role while dealing with a patient having a mental illness. They have to evaluate the type
of illness, the vital signs and the patient’s explanation of emergency and the vital signs
(Lowthian et al., 2010). They often face with the urgent requirements for quick decision making.
Things become adverse when the client behavior changes due to the poor delivery of the care to
the patients (Ganley & Gloster, 2011). Recent researches have highlighted several factors that
were responsible for disrupting the effective communication to the patients. This paper had
rightly identified the various fallacies of the Australian triage design and the field study and the
interviews has also helped to understand the possible strategies that can mitigate these problems
and provides with the strategies how a mental patient can be handled with care in an emergency
triage (Gorransson et al., 2008) This article indicates towards the broader scope of researches
regarding the ED triage design, client and nurses experience.
Relevance to nursing practice
In the emergency department triage, adverse conditions are sometimes found like delay in
providing the appropriate care, lack of confidentiality, failing to take decisions as whose life to
save at first. These give rise to ethical challenges in the department (Geelhoed & de Klerk,
2012). As per the four ethical principles of the bioethics that is respect for the autonomy, non
maleficience, beneficience and Justice determines that starting point and helps one to detect the
ethical challenges faced by the triage of the emergency department (Ganley & Gloster, 2011).
For addressing the ethical issues of the emergency department, one needs to have a more
comprehensive ethical view. Additional insights are required to address a more comprehensive
ethical view.

7CRITICAL ANALYSIS
The goal of the nurses should be to reduce delay and overcrowding in the EDS. In order to
alleviate with the problems are different solutions proposed by the researchers like input-
throughput-output process of ED crowding, lean thinking, operation research, units for observing
chest pain, clinical decision units, rapid assessment zone (Wolf, 2008).
As per this paper which focuses about dealing with mental health patients, it is evident
that the architectural design of the triage waiting room is not enough warm, cosy or confidential
for patients with mental illness. It becomes very difficult for them to communicate with the
clients through the glass which makes the surrounding noisy (Wolf, 2008).
Specific units should be there for attending the patients with mental illness. A separate
quite space should to attend these special people. As per the study, the triage is often crowded
with people like staffs, wards men and ambulance officers, which compromise the confidentiality
of the patients. It should be rightly said that the triage nurse often provides appropriate care to
the patient before being assessed by the doctor, in order to accomplish that a calm and peaceful
environment is required (Geelhoed & de Klerk, 2012). The architectural design of the health care
setting makes it a very noisy environment which jeopardizes the rapid decision making and
patient assessment. It is evident from the paper that there is only one main work space for the
triage nurses. During heavy patient load, two triage nurses can create separate work space just by
sitting next to each other, but there are no barriers between each clients and each can over hear
each other, which can bring about adverse effects in the mental health patients. There should be
sound attenuating tiles in the ceiling in order to prevent the outside noise to come inside and it
becomes easy for them to communicate with the clients (Geelhoed & de Klerk, 2012).

8CRITICAL ANALYSIS
There can be telephone triage system in order to provide after hours care to the patient
(Purc‐Stephenson & Thrasher, 2010). Reverse triage system can be organized for enabling safe
and rapid early discharge of the inpatients to promote additional capacity of the inpatients. MH
client have discussed several ways that can improve the environment conducive for the mental
health patient, like improving the communication between client and the staffs, using singe
rooms, regarding the term “MH” with ‘ Well being’(Geelhoed & de Klerk, 2012).

9CRITICAL ANALYSIS
References
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emergency department. Deutsches Ärzteblatt International, 107(50), 892.
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Göransson, K. E., Ehnfors, M., Fonteyn, M. E., & Ehrenberg, A. (2008). Thinking strategies
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