Consensus-based clinical research priorities for emergency nursing in Australia

Abstract

Introduction

Research is vital to responding to contemporary challenges of providing safe, high quality emergency nursing care, yet the research priorities for emergency nursing practice in Australia are unknown. This study aimed to establish research priorities for emergency nursing in Australia.

Methods

A two-stage descriptive, exploratory study was conducted. First, research themes were identified through a survey of 232 emergency nurses the Delphi Technique (2 rounds) was used to rank and prioritise the research themes.

Results

There were five research themes with a CVI ≥ 0.90: (i) recognising and responding to deteriorating ED patients; (ii) effect of access block on clinical care of admitted ICU patients; (iii) effects of ED overcrowding on clinical care; (iv) scope of practice of specialist emergency nurses; and (v) effect of access block on clinical care of admitted ward patients. These are reflected in four broad research priority areas: professional issues, patient safety, emergency care of vulnerable populations, and healthcare system issues.

Conclusion

Future research should focus on these priority areas in partnership with other emergency disciplines to enable safe, high quality emergency care, and, to inform the practice of emergency nursing in Australia.

Introduction

Emergency departments are core to Australian healthcare. In 2016–17 there were 7.8 million emergency department (ED) presentations to public hospitals across Australia [1], and the demand for emergency services is increasing by 3.4% per year [2]. On average, 30% of ED presentations result in hospital admission, equating to 2.6 million public hospital admissions. Emergency nurses play a key role in these processes and the delivery of this healthcare, as the first hospital-based clinicians to have patient contact when a patient attends an ED. Despite this, emergency nursing in Australia is comparatively a young professional specialty. The first documented specialist emergency nursing courses were post-registration courses in the 1970s [3]. To support emergency nurses, organisations such as Emergency Nurses Associations (ENA) were formally established in the Australia in 1983 [4] and in 2002, a number of state based associations amalgamated to become the College of Emergency Nursing Australasia (CENA) [5]. Similarly, emergency medicine is also comparatively a young professional specialty with the appointment of the first full-time director in the ‘Casualty Department’ in Geelong, Victoria in 1967. This was followed by the formation of the Australasian Society for Emergency Medicine in 1981 and the Australasian College for Emergency Medicine in 1984.

The ED is a uniquely challenging healthcare environment. The role of the emergency nurse is starkly different to that of other nursing specialities. Emergency nurses assess, and initiate care for patients of all ages and with varying degrees of clinical urgency and illness or injury severity, most of whom are undiagnosed and undifferentiated [4]. Typically, assessment and care provision by emergency nurses occurs independently from, and prior to, medical assessment. Emergency nurses are responsible for the ongoing assessment, symptom management, monitoring, and, if needed, escalation of care of all patients in the ED. Emergency nurses make autonomous and complex decisions for critically ill patients, including the management of mechanical ventilation [6]; titrating inotropic and vasopressor medications, sedation and analgesia [7]; and managing advanced respiratory and haemodynamic monitoring, all which carry a high level of clinical risk [8]. Accordingly, the model of care is unique to the context. The workload in EDs is unpredictable with demand routinely exceeding capacity. EDs are routinely overcrowded, more so than any other clinical area, which is a well-established and documented risk to patient safety and the quality of their care [9], [10], [11], [12].

Key to responding to these and other challenges in practice is research that yields new knowledge, insights and solutions. Research and the generation of new knowledge is key to providing safe, high quality and safe emergency nursing care. The sibling professions to emergency nursing in Australia, namely emergency medicine and paramedicine (pre-hospital care), have to a varying extent established research priorities to guide and support the professional practice needs of emergency physicians and emergency paramedics respectively. How the research priorities of these disciplines is presented varies with priority research themes, research objectives and formal research questions reported for emergency care in general [13], [14], [15], [16], emergency medicine specifically [17], [18], [19], [20], and emergency nursing in the United States [21].

Some of the key clinical practice research priority areas identified across emergency medicine and prehospital care literature includes resuscitation [14], [16], [18]; emergency care of patients with trauma [16], [18], cardiac emergencies [16], [18], mental health emergencies [18], [22], and cancer; [23] prehospital paediatric emergencies; [24] and diagnostic methods [16]. The emergency medicine community also report systems-based research priorities including quality and safety indicators for EDs [25], resource management [25], emergency health systems structure and functioning [13], and patient safety. Research priorities for emergency nursing in the United States has included staff-to-patient ratios, human resource management, ED overcrowding and patients waiting in the ED for hospital beds, and education strategies [21]. Further, a narrative review of the international literature has been used to determine the best methodological approach for setting research priorities for paramedicine practice [26].

Beyond this, there is a dearth of Australian literature or evidence on specific emergency nursing research priorities established by and for emergency nurses to meet the contemporary challenges of emergency care. In Australia, there is an evidence-base informing the research priorities to meet the professional and practice needs of emergency physicians, including the International Federation for Emergency Medicine [20], [25], and Australasian College for Emergency Medicine [16], and rural nurses [27] and critical care nurses [28], [29], but not for emergency nurses. In fact, emergency nursing is conspicuously absent from the Australian literature associated with emergency care [16], [20], [25] despite the importance of their role and the fact that they make up the majority of health professionals in this sector. The aim of this study was to establish research priorities to meet the needs of the profession and practice of emergency nursing in Australia.