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Back to basics—Essential nursing care in the ED

Part One

      Summary

      Emergency nurses are expected to work under pressure to many standards, guidelines and protocols related to patient care, and often in an advanced practice role. These expectations can sometimes take priority over basic nursing care once emergency/resuscitative intervention has occurred. However, posing the question ‘How would I want this patient to be cared for if they were my grandmother/father/child?’ sets a benchmark for nursing practice [Fulbrook P, Grealy B. Essential nursing care of the critically ill patient. In: Elliot D, Aitken L, Cheboyer W, editors. ACCCN critical care nursing. Sydney: Elsevier; 2006]. How well patients are cared for has a direct effect on their sense of well-being and their recovery. Effective communication is essential to good nursing care and patient outcomes. The length of stay of the patient in the ED may be extended, and the use of “holding” wards while waiting for investigation results of patients for probable discharge necessitates the ED nurse to consider basic but essential aspects of nursing care that will be discussed. Other essential aspects of care such as psychosocial; including culture, pain management and infection control are beyond the scope of this paper.

      Keywords

      Introduction

      This is a two part series on essential but basic aspects of nursing care in the ED. Part 1 discusses the vital roles of communication and caring in relation to the patient, family, and other staff members. Part 2 describes the importance of physical aspects of care such as hygiene, posturing and nutrition. While these are essentially core nursing roles, they have a significant impact on patient outcomes and satisfaction.
      • O’Mara A.
      Communicating with other health care professionals.
      Designated EDs began in the early 1970s. Since then increasing demand for emergency care, advances in technology, and improvements in resuscitation procedures have led to a need to expand services and create a specialty area for the delivery of emergency care.
      • Fry M.
      Overview of emergency nursing in Curtis.
      By 1985 these changes raised the expectation that both nursing and medical staff needed to become highly trained, specialised and permanently based in ED. Emergency nurses require in-depth knowledge and clinical expertise to provide care across the lifespan and to manage situational events such as patient overcrowding and the use of complex technology.
      • Fry M.
      Overview of emergency nursing in Curtis.
      This has resulted in ED nurses spending more that 50% of their clinical time on indirect patient care tasks, and a resultant decrease in time to perform basic nursing care.

      Schriver J, Talmage R, Chuong R, Hedges J. Emergency nursing: historical, current and future roles. J Emerg Nurs, 29 (5): 431–439.

      Overcrowding is the result of ‘Access block’, which is defined as a patient who is ready for transfer to the ward but remains in the ED for longer than 8 h because of the lack of an inpatient bed.
      • Australasian Council of Emergency Medicine (ACEM)
      Policy document: standard terminology.
      There is an association between overcrowding, increased hospital length of stay and mortality in Australian hospitals.
      • Sprivulis P.C.
      • Da Silva J.
      • Jacobs I.G.
      • Razer A.R.L.
      • Jelinek G.A.
      The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments.
      • Richardson D.
      The access-block effect: relationship between delay to reaching an inpatient bed and inpatient length of stay.
      Known effects of overcrowding include delays in patient management, poor hospital processes, poor infection control and patients not being placed on the appropriate ward.
      • Cameron P.A.
      Hospital overcrowding: a threat to patient safety?.
      There is extensive evidence to demonstrate that low levels of hospital nurse staffing and deficiencies in the working environment are associated with poor patient outcomes, including excess deaths.
      • Hayes L.
      • O’Brien-Pallas L.
      • Duffield C.
      • Shamian J.
      • Buchan J.
      • Hughes F.
      • et al.
      Nurse turnover: a literature review.
      • Clarke S.
      • Aiken L.H.
      More nursing, fewer deaths.
      These factors can make it difficult to provide emergency care for patients just arriving in the ED as well as ward patients of high acuity. Dealing with obstacles such as these inhibit the provision of good patient care and results in a decrease in staff satisfaction as they are too busy to provide the care they know the patient requires.
      • Ruggiero J.
      Health, work variable, and job satisfaction among nurses.
      Several practice models have been trialled in the emergency setting, such as the clinical initiative, rapid assessment and advanced practice nurse. Some of the features of the practice environment that have the potential to make a large, positive impact on nurse, patient and organizational outcomes are: promoting and maintaining improvements in nurse managers’ ability to lead and support nursing staff; improving nurses’ participation in hospital affairs; ensuring adequate staffing and other needed resources for patient care; and promoting stronger interdisciplinary collaboration.
      • Tourangeau A.
      • Coghlan A.
      • Shamian J.
      • Evans S.
      Registered nurse and registered practical nurse evaluation of their hospital practice environments and their responses to these environments.
      Further discussion of how to adjust the health care team structure to ensure these basic duties are being attended is beyond the scope of this paper.
      The following discussion outlines the rationale and importance of each aspect of basic but essential nursing care.

      Communication

      Working with others effectively in health care is challenging, and communication and human relationships with all those involved in the patient's care impact on nursing practice, patient care and how nurses feel about themselves.
      • O’Mara A.
      Communicating with other health care professionals.
      • Brereton M.L.
      Communication in nursing: in theory and practice.
      • Sweet S.J.
      • Norman I.J.
      The nurse–doctor relationship: a selective literature review.
      Harmonious relationships with patients, between healthcare providers, the organization, and the community are dependent on effective communication.
      • Kelly A.E.
      Relationships in emergency care: communication and impact.
      Although ED nurses are extremely busy and a large proportion of their time is spent communicating, good communication is an essential aspect of care.

      Principles of communication

      Communication is made up of a sender, receiver and a message sent within a particular context. The sender intends to convey a particular message however the way in which the message is sent and/or received may be numerous as a result of paralinguistic features, body language and psychological factors. Factors which impact on communication, both sending and receiving messages are listed in Table 1, and it is important that the ED nurse is familiar with these to avoid hidden messages, misunderstandings and misinterpretations.
      • Ellis R.B.
      • Gates R.J.
      • Kenworthy N.
      Interpersonal communication in nursing. Theory and practice.
      Table 1Factors impacting on communication
      • Brereton M.L.
      Communication in nursing: in theory and practice.
      Type of language usedJargon, dialect, social linguistics
      Paralinguistic featuresPitch, tone, pace, emphasis and volume
      Body languagePosture, touch, eye contact, proximity, facial expression, gestures
      SocialAge, gender, ethnicity, power, social status, relationship
      PsychologicalAttitudes and beliefs, prejudices, perceptual distortions, defence mechanisms, frame of mind/mood, stress, trust
      EnvironmentalPrivacy, lay out of room, odours, lighting, colour

      Communication in the ED

      Studies of human cognition and analysis of high-reliability organizations predict that despite excellent training, human error is unavoidable.
      • Hobgood C.
      • Hevia A.
      • Hinchey P.
      Profiles in patient safety: when an error occurs.
      However, the high rate of poor communication causing error can be improved. Communication in the ED occurs verbally and physically, using written or computerised documentation. Brereton
      • Brereton M.L.
      Communication in nursing: in theory and practice.
      (1995) explains that there are several basic principles to effective communication in the workplace, including:
      • An appropriate knowledge base;
      • A range of behavioural skills that are essential to effective performance, such as authenticity, empathy, active listening and respect for others;
      • A positive attitude towards communicating;
      • The availability of opportunities to communicate.
      A positive attitude towards communicating can be hindered by aspects of organisational behaviours and opportunities to communicate can be thwarted by lack of resources and heavy workloads. ED nursing and medical staff experience barriers to communication such as stress and interruptions. Senior medical and nursing staff experience higher rates of interruption than junior medical staff and registered nurses with an allocated patient load.
      • Spencer R.
      • Coiera E.
      • Logan P.
      Variation in communication loads on clinical staff in the emergency department.
      Effective strategies to promote good communication with patients include: ensuring patients know your name when you are caring for them.
      • Fulbrook P.
      • Grealy B.
      Essential nursing care of the critically ill patient.
      Maintaining eye contact in a non-threatening manner,
      • Travaline J.M.
      Communication in the ICU: an essential component of patient care.
      which conveys a sense of the importance the health professional is placing on the interaction by taking time to ensure they understand each other. Codes may also be developed by the nurse and patient, with facial expression, head nods and eye blinks used to respond to questions. These codes should be passed on to the next nurse and recorded in the patient's notes to promote continuity of care. Communication can also occur through physical contact; touch often communicates empathy and provides spiritual comfort.
      • Nussbaum G.B.
      Spirituality in critical care: patient comfort and satisfaction.
      Spiritual needs may further be met by providing comfort, reassurance and respect for privacy, and by helping patients relate to others.
      • Narayanasamy A.
      • Clissett P.
      • Parumal L.
      • Thompson D.
      • Annasamy S.
      • Edge R.
      Response to the spiritual needs of older people.
      Language barriers may necessitate the assistance of a healthcare interpreter to ensure the content is adequately translated. This ensures that the patient receives the message in its entirety from the health professional.
      • Travaline J.M.
      Communication in the ICU: an essential component of patient care.

      Communication and patient outcomes

      It is important to discuss the relationship between communication, sub-optimal care and patient outcomes, as there is a direct correlation.
      • Hindle D.
      • Braithwaite J.
      • Iedema R.
      • Travaglia J.
      Patient safety: a review of key international enquiries.
      • Menadue J.
      Reforms in NSW to include casemix, three year budgets and a metropolitan plan.
      The most common characteristics of international crisis-prompted healthcare inquiries are that: care is not delivered in multidisciplinary teams, people do not communicate well across the clinical divides, and care is not delivered in a coordinated, organised way. The variety of health care areas investigated demonstrates that no single specialty is immune from error if poor communication exists.
      • Hindle D.
      • Braithwaite J.
      • Iedema R.
      • Travaglia J.
      Patient safety: a review of key international enquiries.
      While patients may be satisfied with individual health professionals, they recognise that the overall episode of care is often poorly coordinated or managed and potential distortions of information regarding patient care leads to patients perceiving that care could be sub-optimal.
      • Anderson M.
      • Tredway C.A.
      Communication: an outcome of case management.
      • Schoenbaum S.
      Implementation: it's the way care is organised that counts.
      Poor communication causes up to 30% of adverse events in the ED specifically.
      • White A.A.
      • Wright S.W.
      • Blanco R.
      • Lemonds B.
      • Sisco J.
      • Bledsoe S.
      • et al.
      Cause-and-effect analysis of risk management files to assess patient care in the emergency department.
      In addition, poor communication can lead to delays in transfer from the ED, and there is a correlation between increased hospital LOS and increased LOS in the ED, especially on weekends when patients are not reviewed by specialist teams and are often placed on “outlying wards”, or wards that are not related to the condition of the patient, due to the unavailability of appropriate beds.
      • Sprivulis P.C.
      • Da Silva J.
      • Jacobs I.G.
      • Razer A.R.L.
      • Jelinek G.A.
      The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments.
      • Richardson D.
      The access-block effect: relationship between delay to reaching an inpatient bed and inpatient length of stay.
      Poor communication is also one of the most common elements of frustration and stress amongst health care professionals.
      • Perry L.
      Critical incidents, crucial issues: insights into the working lives of registered nurses.
      • Curtis K.
      Current issues in trauma nursing, an Australian perspective.
      • Sutton K.
      Registered nurse turnover.
      Stress placed on critical care nurses’ decreases enthusiasm and impairs problem-solving capabilities.
      • Erlen J.A.
      • Sereika S.M.
      Critical care nurses, ethical decision-making and stress.
      In our current health care system where the majority of media portrayal of Emergency Departments is negative,
      • Kennedy J.F.
      • Trethewy C.
      • Anderson K.
      Content analysis of Australian newspaper portrayals of emergency medicine.
      and the availability and retention of nursing staff is of great concern, stress remains a problem.

      Communication and patient satisfaction

      Common public expectations of emergency department care include staff communication with patients, appropriate waiting times, the triage process, information management, and good quality of care.
      • Watt D.
      • Wertzler W.
      • Brannan G.
      Patient expectations of emergency department care: phase I—a focus group study.
      While the ED nurse cannot control all of these elements, effective communication is achievable. The way in which communication is conducted is closely related to ED patient satisfaction,
      • Saunders K.
      A creative new approach to patient satisfaction.
      in particular relating to interpersonal skills and staff attitudes.
      • Taylor C.
      • Benger J.R.
      Patient satisfaction in emergency medicine.
      Patients and their families need provision of information on a consistent basis, especially on arrival and particularly for waiting room patients.
      • Taylor C.
      • Benger J.R.
      Patient satisfaction in emergency medicine.
      • Nielsen D.
      Improving ED patient satisfaction when triage nurses routinely communicate with patients as to reasons for waits: one rural hospital's experience.
      • Lee G.
      • Endacott R.
      • Flett K.
      • Bushnell R.
      Characteristics of patients who did not wait for treatment in the emergency department: a follow up survey.
      Areas in which communication is particularly important include, cause of delays, patient management plans, and how to get to other locations within the hospital.
      • Saunders K.
      A creative new approach to patient satisfaction.

      Needs of the family

      In light of the various definitions of family and regulations regarding the release of information, how people define themselves has implications for ED nurses. It is important to ask the patient who is to be considered family, receive information and be allowed in the treatment area. When that is not possible the nurse must be guided by good judgment, policy and regulations, and ethics.
      • Kamienski M.C.
      Emergency: family-centered care in the ED.
      Although ED nurses are usually very busy, it can be crucial to conduct a brief family assessment, and determine if social work intervention may be required.
      • Leahey M.
      • Wright L.
      Maximizing time, minimizing suffering. The 15-minute (or less) family interview.
      There are several ways to begin a dialogue with families and develop a relationship that will meet their needs, as outlined in Table 2.
      Table 2Developing rapport and meeting family needs
      • Saunders K.
      A creative new approach to patient satisfaction.
      • Kamienski M.C.
      Emergency: family-centered care in the ED.
      • Lee L.
      • Lau Y.
      Immediate needs of adult family members of adult intensive care patients in Hong Kong.
      • Frank A.
      Just listening. Narrative and deep illness.
      • Mitchell M.
      • Wilson D.
      • Wade V.
      Psychosocial and cultural care of the critically ill.
      • Introduce yourself to the patient and the family and involve them early
      • Ask about people at the bedside and determine their relationship to the patient
      • Call patients by name, after enquiring how they wish to be addressed
      • Explain procedures and equipment, and be honest about the anticipated waiting length
      • Repeat information; the anxiety of being in the ED, even in non-urgent situations, decreases the ability to remember what is said
      • Regularly take the time to update the patient and family especially when the situation changes. This may include calling them at home if necessary
      • Listen compassionately and acknowledge their difficult experience. Compliment them on their patience
      • Demonstrate a caring attitude (offer a chair or a cup of tea or coffee)
      • After any explanation, always ask if anyone has questions. If you do not know an answer, say so, and then find out the answer
      Encountering a family in the initial stages of a life-changing event, ED nurses often treat family members who feel despair, fear, anger, guilt, or helplessness, or who are in states of disbelief or denial. Family members coming to the ED with a loved one nearing the end of a long and debilitating illness may be fatigued, frustrated or ambivalent. ED nurses may be the first to recognize a family that is bordering on crisis. Further assessment may determine whether the family needs a referral for services such as home care, hospice, or counselling.
      • Kamienski M.C.
      Emergency: family-centered care in the ED.

      Caring

      Caring is a core characteristic of nursing. In the ED, lifesaving procedures in such situations are, of course, the priority, but it is important not to forget to meet the patients’ psychological needs as well.
      • Nussbaum G.B.
      Spirituality in critical care: patient comfort and satisfaction.
      • Wiman E.
      • Wikblad K.
      Caring and uncaring encounters in nursing in an emergency department.
      Professional caring consists of three essential elements: competence, caring and connection. Competence involves empowering, connecting and educating people, making clinical judgments and being able to do tasks and take action on behalf of people. Aspects of caring are outlined below and involve being dedicated and appropriately involved as a professional nurse. Initiating professional connection requires both the patient and nurse to reach out and respond. A bridge is built when patients realize the connection and feel free to ask for help. An uncaring encounter consists of incompetence and indifference, lack of trust, mutual avoidance and disconnection between the nurse and the patient.

      Aspects of caring in emergency nursing

      • Being open to and perceptive of others: patients in the ED are often affected by the acute event as they have abruptly lost control of their own situation and are in a position of dependence. A caring nurse has to be sensitive to such patients and capable of interpreting or predicting their needs. This requires an open attitude and should communicate openly with the patient.
      • Being genuinely concerned for the patient: nurses with this caring quality displayed genuine feelings of goodwill towards patients and a holistic view of caring.
      • Being morally responsible: from the patients’ perspective, visits to the ED are not planned. Suddenly, they become dependent on others to fulfil their needs. Nurses have to act to maintain and strengthen the patients’ dignity in this serious situation.
      • Being truly present: this means that nurses have to be attentive to the present moment, and be present in dialogue, in listening and responding. This involves both the physical and emotional aspects. In order to be truly present in the dialogue, nurses require good communication skills.
        • Wiman E.
        • Wikblad K.
        Caring and uncaring encounters in nursing in an emergency department.

      Privacy and dignity

      Respect, autonomy, empowerment and communication have been identified within literature as being the defining attributes of dignity. In the busy ED, maintenance of dignity may be unintentionally overlooked. Patients can be nursed in a corridor or other patients and relatives may over hear the handover, which does not lend itself to upholding the dignity, privacy and confidentiality of the patient.
      • Ball J.
      • Dixon M.
      • Dolan B.
      • Holt L.
      • Wilkinson R.
      Why are we waiting?.
      Discretion should be used if updating relatives in a crowded waiting room, triage assessment should be conducted in a safe and private location and the patients’ dignity should be maintained at all times.
      • Griffin-Heslin V.L.
      An analysis of the concept dignity.

      Care of emergency nurses

      ED nurses also require care. Providing thorough and effective care for emergency patients is emotionally draining and highly demanding of the busy emergency nurse, who often fails to notice or acknowledge their own needs.
      • Stockbridge J.
      Care for the careers.
      Nurses have been extensively studied as groups experiencing high levels of stress and burnout. Critical care nurses may feel they are acting unprofessionally if they show overt signs of grief following an adverse event or traumatic situation. Being aware of the signs of stress and developing and implementing coping mechanisms is essential.

      Barkway P. Stress and adaptation. In: Brown H, Edwards D, editors. Lewis’ medical and surgical nursing. Sydney: Elsevier.

      Nurses depend on colleagues and friends for support and value debriefing sessions, whether it is simply an opportunity to share feelings or a procedural clinical review of events. The effectiveness of sessions should be evaluated and staff health and welfare monitored by ED managers and colleagues.
      • Mitchell M.
      • Wilson D.
      • Wade V.
      Psychosocial and cultural care of the critically ill.

      Conclusion

      Effective communication between health care providers, the patient and their family is instrumental in patient outcomes and satisfaction. There is also a relationship between the practice environment, staff satisfaction, relationships with other staff and effective communication. While the ED nurse can be extremely busy, it is essential that effective communication between staff members and patients and family be maintained.

      Competing Interests

      Adapted from: Farnsworth L and Curtis K. Patient assessment and essential nursing care (Chapter 10). In: Curtis K, Ramsden C and Friendship J. Emergency & Trauma Nursing. 1st ed. Sydney: Mosby Elsevier; 2007. p. 92–110.

      Funding

      None.

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