Emergency department (ED) waiting rooms have long been a challenging area for both staff and patients, with increased demand, overcrowding and waiting times experienced in practice globally (Perera et al., 2014), resulting in poor patient outcomes and experiences (Smith, Bouchoucha, & Watt, 2016). In response to these challenges some emergency departments (EDs) in Australia have introduced a registered nurse role dedicated to care for patients in the waiting room. This initiative has moved the episode of care that previously commenced in a cubicle, to now effectively beginning on a patient’s arrival to the ED and prior to being seen by a medical officer or Nurse Practitioner. Overall, the aim of the waiting room nurse (WRN) is to commence interventions early, reassess patients during their waiting period, including for signs of any deterioration in clinical condition, and to improve communication between patients, accompanying family members and all health care professionals (Innes, Jackson, Plummer, & Elliott, 2015).
There is however currently scant literature relating to WRN roles internationally. The study aims of this research were to exploration the extent to which the role has been adopted, and ED nurses’ perceptions of the role.
Methods:
The final phase of a three-phase exploratory sequential mixed methods design study is reported here. This phase utilised an on-line survey to collect data, using the framework outlined by de Vaus (2014). First, literature relating to WRN roles and findings from the previous study phases (key informant interviews; observations of WRNs in practice) were revisited to identify broad concepts. A draft set of questions were then developed, entered into the online platform SurveyMonkey. The questions were then revised based on feedback from the research team based on functionality, clarity and interpretation. Face and content validity was then established; two emergency nurses’ familiar with the WRN role completed the online survey and provided feedback, including with some suggestions for improving the skip logic for items to improve the experience of respondents. Establishing reliability was then examined, using a pilot study of six nurses with varied familiarity with the WRN role, to ensure all aspects of the tool were tested (de Vaus, 2014). All participants viewed the survey as appropriate, with no changes required.
After human research ethics approval, purposive sampling was used to recruit respondents. The sample was Registered Nurses who were members of the College of Emergency Nurses Australasia (CENA). The CENA secretariat emailed members with details of the study, and a link to the survey site. Completion of the survey implied informed consent. The survey was open 1st June to 30th June, a 4 week period, to allow for nurses rotating through night duty. A reminder email was sent from the CENA secretariat on the 19th June, one week prior to the survey closing.
Descriptive statistics were used to analyse data using SPSS Statistics. Non-parametric tests (frequencies, percentages, median and interquartile range) were utilised as the data were not normally distributed. Additionally, Chi-Square test for independence and Kruskal-Wallis test were used to compare variables (Pallant, 2013). The validated content analysis framework by Hsieh and Shannon (2005) was used to analyse the open-ended responses.
Results:
Overall, 198 respondents completed the survey (response rate 15.9%). Approximately one quarter of the respondents were from New South Wales (n=48, 24.4%), 44% (n=87) were in Registered Nurse roles and just over a third of respondents held a Master degree (n=67, 34.2%). The median years of overall and emergency nursing experiences were 16 years (IQR 2-45) and 11 years (IQR 0.3-38), respectively.
In relation to the WRN role, 60.7% reported their ED allocated a nurse to care for patients in their waiting room. This equated to 51 different EDs across Australia. The most common name for the role was Clinical Initiative Nurse (CIN) (n=37, 39.4%). Respondents identified that key roles and responsibilities of the WRN was to expedite care and commence interventions early, reassess patients to monitor for patient deterioration, to ensure patients were safe in the waiting room and to improve communication and collaboration. Respondents indicated that the WRN was expected to assess patients within the maximum waiting time associated with their allocated Australasian Triage Scale category e.g. Category 3 has a maximum 30 minute waiting time (Australasian College for Emergency Medicine, 2013) or every hour the patient waits. The WRN played a major advocacy role for patients in the waiting room, in particular, creating a safe environment by escalating care if deterioration was detected.
Experience and preparation prior to commencing the role varied from less than one year (n=5, 11.6%) to five years (n=3, 7%), and nurses did not need to be triage prepared (n=102, 96.2%) or required any additional educational preparation (n=56, 53.3%). Respondents perceived that professional competence was more important than a minimum number of years of experience. In regards to preparation, respondents identified that a one-day workshop covering documentation, communication, skills update including patient assessment, standing orders/clinical pathways and an overview of the role with an orientation period was required prior to commencing in the role. Despite not needing to be triage prepared, the WRN was permitted to assist with the triage process if patients experienced delays at triage.
Respondents identified standing orders (n=66, 62.9%) and clinical pathways (n=30, 76.9%) were used to guide practice, with nurse initiated analgesia (n=62, 58.8%) and chest pain (n=30, 76.9%) the most common policies respectively. Paracetamol (n=98, 82.4%) was the most common medication administered, and basic first aid (n=98, 82.4%) was the most frequent intervention initiated by the WRN. Safety concerns due to potential adverse reactions was the most likely reason WRNs could not initiate particular medications and interventions
Overall, respondents perceived that the role was important, especially when demand for emergency care increased. Some challenges were identified including limited standing orders relating paediatric patients, and the WRN being reallocated during busy periods.
Conclusion:
An important finding is that the WRN contributes to patient safety, primarily through close monitoring of vital signs, in particular respiratory rate, which is key to detecting clinical deterioration (Boerma, Reijners, Hessels, & v Hooft, 2017). There was a perception that competence was more important than a minimum number of years of experience prior to commencing as the WRN. Exposure to the same or similar experiences repeatedly over time leads to the development of competence, which is crucial to the safe delivery of patient care. A feature of competence is reflection, a key component of the nursing praxis or the nurses’ ability to care (Jangland, Nyberg, & Yngman-Uhlin, 2017).
Findings from this study have clear implications for patient care and safety in ED waiting rooms with education and policy development relating to this role needing to consider competence and preparation of nurses. Internationally, implementation of this role could positively impact on patient safety in ED waiting rooms through close monitoring and escalating care if clinical deterioration is detected.
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