Evaluating Triage Environment Influence on Mentally-Ill Clients' Care

This critical evaluation assesses a qualitative study on the impact of the emergency department (ED) triage environment on triage practices for mentally-ill clients in Australia. Published in the Australasian Emergency Nursing Journal (AENJ), the study's background and aims are thoroughly examined, focusing on the increasing number of mentally-ill clients in EDs. The research methods, including the qualitative ethnographic design, reflexivity, target population, sampling process, and data collection, are evaluated for appropriateness and rigor. The data analysis, employing the constant comparative method and theoretical coding, is scrutinized for consistency and bias. The study's findings highlight the adverse effects of the triage environment, particularly the lack of privacy and confidentiality, on triage practices. The evaluation concludes by emphasizing the relevance of the study to nursing practice, advocating for improved triage environments and ethical care for mentally-ill clients, and suggesting further research in ED triage waiting-room design and patient experience. Desklib offers this assignment solution, along with a wealth of study resources for students.

Critical Evaluation
Critical Evaluation
On
Influence of the triage environment in the emergency department on the triage
practice for mentally- ill clients: in an Australian context
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Critical Evaluation
Critical Evaluation
The critical evaluation of the qualitative study on ‘the effect of emergency
department (ED) triage environment on the triage practices for mentally-ill clients: in
Australia’ was done. This critical appraisal report will judge both the positive and
negative aspects of this study (Merriam-Webster, 2015). This article was published in
the Australasian-Emergency Nursing- Journal (AENJ) which is an official journal of the
CENA (College of Emergency- Nursing Australasia). AENJ (2017) provides the best
emergency practices available for the clients, particularly mentally-ill clients to the
emergency nurses by giving them higher-quality evidence that are relevant to their
contemporary-practice. AENJ is an international-peer reviewed journal and is a conduit
for research with impact score: 1.26, CiteScore: 1.27, Source-Normalized
Impact/Paper: 0.897 and SCImago Journal-Rank: 0.594 which has motivated me to
select an article published in this journal to critically appraise (Shaban, 2017). AENJ is
published by the Emergency-Nurse’s Association of CENA of New South-Wales:
Elsevier-Ltd. The authors Broadbent from Sunshine Coast-University; Moxham from
Wollongong-University and Dwyer from Central-Queensland’s University are the experts
in the emergency-mental health department of Australia. As they are registered nurses
in ED of regional-hospital, this study will be of higher value and hence this study has
been selected to critically appraise so as to utilize these findings in practice.
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Critical Evaluation
Background/aims
They have given an elaborate and detailed background about the study (Boswell,
n. d.). They have given a clear definition for practice environment in ED which forms the
base for their study as the environment in which the people as well as physical
architecture in a healthcare setting. They have given that there is a continuous increase
in the number of mentally- ill client in ED of Australia which suggests the importance of
determining the triage ED services to promote client care. They have given a detailed
statistics about the prevalence of mental- illness in Australia with percentage of ED
cases which is adequate.
A review of literature is a clear summary of the research-study in which the
researcher is interested (Polit, 2016). The literature review should be clear, well-
organized, concise and summarized (Houser, 2011) which is evident in the study. The
researchers have given all the literatures in a logical, systematic, organized and
sequential fashion (Greenhalgh, 2010). They have described all the related articles in
an unbiased manner by explaining the all the needed requirements appropriately. They
have quoted current, relevant and appropriate studies with correct in-text citations
except few old studies. Though the older studies may help to generalize the results,
they may increase the chance of bias.
They have mentioned about their need for the study by describing that they are
intended to explore the problems associated with practicing in an ED environment with
a clear focus on the assessment with management of mentally-ill clients is appropriate.
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Critical Evaluation
As, ED triage-nurses have a greater role in performing triage assessment, the result of
this study will help them to rule-out any discrepancies and improve their care. The ED
triage-nurses should create a therapeutic- environment to provide client care but due to
lack of appropriate studies makes them difficult to practice. Hence this study will help
them to improve quality of ED-care. The aim of this study is to investigate the influence
of triaging ED-environment on the ED-triage practice of nurses in mentally- ill clients
which is clear and achievable (Polit, 2016).
Research methods
According to Polit (2016), research-methods are the techniques that are
employed by a researcher in structuring the research-study as well as in gathering and
analysing the collected data in a systematic-fashion (Boswell, n. d.). It is evident from
their way of structuring the study by adapting appropriate research methods and
discussing in the text sequentially. A research-design is the overall-plan that is framed
to address the research question that includes specifications for promoting the integrity
of the research-study (Panneerselvam, 2014). In this study, qualitative design was
employed which involves investigating the phenomena in a holistic, sequential, and in-
depth fashion (Yin, 2015, Grossoehme, 2013). Ethnographic design was utilized to
observe as well as analyze the emergency-care practices of ED-nurses in triaging
mentally-ill clients with the analysis of the impact of triage-environment in the ED. As,
ethnography involves exploring the cultural-influences of clinical-based practice in the
practice environment, it best suits this study as it explores the emergency nursing-care
in ED environment and also adds value to the clear understanding of the ED practice
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Critical Evaluation
(Cooper, 2009). This study follows the findings of a larger (observational) ethnographic
study which has determined the relationship of the triage staff-nurses with the
specialized mental-health triage staff-nurses.
Highly consistent with the research-methodology, the time period of 8 weeks that
is spent in collecting data in ED regarding triage-practice is highly adequate. Reflexivity
is the critical self-reflection about one’s own biases, preferences as well as
preconceptions (Polit, 2016). It is evident from the study that they have clearly
introspected into their research problem and have reflected about their design
adequately to enhance the quality of study. The target-population is the entire set of
population where the researcher is collecting data and generalizing the results (Moule,
2013). In this study, they have selected appropriate group of triage ED-nurses caring
mentally-ill clients; reported in ED of a hospital in regional-Australia. A sample is a
group of population who are selected to participate in the study (Houser, 2011).
Their sampling process that involves selecting a portion of population from a
target population is adequate (Moule, 2013). They have used purposive (judgmental)
sampling which is a non-probability method that involves selecting samples based on
the researcher’s personal judgment about participants. They have selected 28 ED
triage-nurses who have been trained about triage-practices for mentally-ill clients;
assigned in shifts. The sample-size of 28 is adequate for a qualitative study in which the
sample-size is usually smaller and focused. Sample-size is calculated by power
analysis to avoid sampling-errors which is not evident in this study. The research-
setting is the physical-location with conditions where the collection of data takes. This
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Critical Evaluation
study was conducted in regional Australian-hospital that is the largest ED that receives
more than 44,000 clients/year including 4 and ½% of mentally-ill clients. They have
sufficiently described the sample and research setting.
Data-collection process is the formal procedure that is developed to guide
collection of data in a systematic fashion (Polit, 2016). In this study, data was collected
by participant observation; formal as well as informal semi-structured interviews that are
conducted with triage ED-nurses, review of case-documents with collation of the field-
notes. Participant-observation, which is a core-aspect in an ethnographic study with the
observer herself being the study-participant, clearly reflects the technique adopted in
this study. For this purpose, the researchers have interacted with the study-participants
directly in face-to-face manner to gather data. They have conducted interviews with 28
ED triage-nurses who were assigned at triage work. They have not interviewed any
clients who have presented to triage. Moreover, they have observed the nurse-patient
interaction only to rule-out the influence of the triage-environment of ED on the triage
ED-nurses practice.
Interviewing is the best method as it provides an opportunity to the researcher to
contextualize the data appropriately (Houser, 2011). Totally, they have conducted 2
individual and 10 group interviews with the triage ED-nurses. They have tape-recorded
the interviews and they transcribed verbatim before data-analysis to minimize bias.
These strategies of data collection appear to enhance trustworthiness of this study.
Overall, the data collection and recoding processes appear adequate. They have got
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Critical Evaluation
ethical clearance from two human-research ethical-committees and also obtained
written-consent from the participants.
Data-analysis
Data-analysis involves systematic and comprehensive organization and
synthesis of research-data (Polit, 2016). Thompson (2010) states that this analysis as
an eclectic-process in which the collected data were organized and interpreted to
discover underlying facts. The tape-recorded notes of interviews as well as observations
were articulated into categories in such a way that their meanings could be easily
understood. The comparative (constant) method that was given by Polit (2016) on
strategies for a qualitative study was employed to analyze the information collected at
the time of field-work. This method that was involved in analyzing the individual aspects
of the information as well as comparing these informations with other aspects of
information (data) by utilizing constant comparative method with theoretical-method of
coding was adapted by the researchers independently of each other and was also
compared to rule-out consistency and hence minimizes bias. They have drawn the
meaning from the collected information and have developed concepts with categories
which were analyzed by examining appropriate literature. Their categories include triage
environment, triage assessment and client management.
They have found that an acoustic-phenomenon (noise-creep) (Field, 2008)
reduces the ability to conduct a conversation in-spite of gathering personal details by
the clerk and triage ED-nurse. Triage environment is like a public area in which the
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Critical Evaluation
triage ED-nurses is not controlling the movement of staffs particularly in initial
assessment-area whereas the triage ED-nurses specified that there is no control in the
movement of clients; admitted for care in ED as well as the clients and families present
in the waiting area, contributes to a very-busy and noisy assessment area. In-regard to
triage assessment, it was noted that lack of privacy due to increased movement of staffs
(wards-men) makes the assessment problematic. Their field observations suggest that
the triage ED-nurses have felt to provide a separate and quite private space for
mentally- ill clients to enable appropriate client assessment. Moreover, privacy and
confidentiality should be maintained in a triage environment, which is also expected by
the mentally- ill clients. The waiting room dynamics should be effectively managed so as
provide a therapeutic landscape for the clients (Field, 2008). They also recommend
providing a calm and safe area for clients having distress, manifesting features of
agitation or clients requiring privacy. They have summarized the findings with
supporting arguments. The categories capture the meaning of data adequately and the
researchers have also conceptualized the categories clearly. Overall, the data- analysis
has yielded provocative evidence that the triage environment in the ED affects the triage
practices of mentally-ill clients adversely.
Summary & conclusion
Triage ED-nurses working in ED will be busy in assessing the clients, accessing
equipments and human-resources management in-order to enable quick decision-
making and manage waiting rooms. As, ED triage-area has a impact on the behavior of
client and the ability to provide patient-care and to perform triage assessment, they
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Critical Evaluation
have to be controlled to improve quality-of-care. This is evident from the current study
which suggests that the triage environment, particular lack of privacy and confidentiality
and busy environment affects the triage practice for mentally–ill clients in an emergency
environment which is supported by Foureur (2010) and Olsen (2008). They also
recommend that extensive studies should be proposed to study the ED-triage waiting-
room design, patients ED-triage experience and by involving the triage nurses and ED
users.
Relevance to nursing practice
Healthcare personnel should continuously work to draw solutions and find
choices for better client outcome (Douglas, 2012). Various studies should be appraised
to develop best evidences available (Aveyard, 2010). The health-care specifically for
mentally-ill clients should follow all the ethical principles as beneficence, respect,
maleficence, justice and trust-worthiness (Polit, 2016). Moreover, the healthcare
professionals who are the frontline workers should provide care by following the
contemporary practices to all the patients; irrespective of caste, creed or race; in all the
healthcare settings, to all the age without discrimination (ANA, 2010, ICN, 2010).
The triage practice in ED along with the management of patients having mental-
illness those waiting in a larger public place is of a greater challenge for all the triage
ED-nurses. This study finding will help the ED-triage nurses to understand that the ED
triage practices are greatly influenced by a number of factors such as lack of privacy,
lack of confidentiality, noisy and busy environment. This study will help to promote
patient values by disseminating that the noisy and busy triage environment affects the
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Critical Evaluation
client assessment and triage practice which will definitely in-turn make the Government
and the administration to make alterations in physical setup of ED and waiting room and
in managing external physical sources and providing a safe and private place for clients.
Strathmann (2009) stated that the caring for mentally-ill clients begins even
before a physician attends. So, it is the ED-nurses responsibility to provide safer
environment which is a routine nursing care and also in ED areas where it is regarded
as an essential skill (Andrews, 2008). Long (2011) suggested that the environment
where care is rendered has a greater impact on the outcomes with behavior of clients,
specifically in mentally-ill clients. Nurses who are considered as the therapeutic builders
have a role in restoring, rejuvenating and wellbeing (Andrews, 2009). Morphet (2012)
has also discussed about the methods of promoting the ED-triage environment that
includes providing specialized mental-health triaging-area, improving nurse-client
relationship for mentally-ill clients is appropriate. Nurses working in ED triage-area are
cognizant of the impact of environment on the client assessment. Hence, these
research-findings will make the ED nurses to understand the effect of triage
environment on ED-triage practice of mentally-ill clients and help them to modify ED
environment accordingly.
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Critical Evaluation
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