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Triage research in Australia: Guiding education
RESEARCH
PAPER
Triage Research in Australia: Guiding Education
Jeni E. Ritchie
Literature Review
BA, /VIA,GradDippAppSci, TNCC M. Nursing (Trauma) (Current)
Nursing as a profession has moved towards a system of integrated and interrelated specialty areas. Specialty areas are now seen as clearly separate areas which "require practitioners with specific and specialised knowledge and skills," skills that are "more specific and specialised than would effectively be obtained through an educational program for generalised practice." The demand for nurses to obtain specialist qualifications reflects the fact that the "pace of specialisation has accelerated" (ANF Editorial, Victoria, 1996).
Narelle M. Aldridge Crafter
RN, RM, A &E Cert, RemoteArea Course, TNCC Amanda E. Little
RN, GradDipCritCare, M. Nursing (Current)
ABSTRACT Emergency Department triage is emerging as a subspecialty area of emergency nursing. Literature identifies the current lack of standardised training for this role in Australia. A study of 159 triage nurses across the Australian Capital Territory (ACT) and New South Wales (NSW} regions, was conducted to identify the current preparedness of staff to perform triage and the impediments to specialist training. Respondents identified a strong need for comprehensive rapid assessment skills, and identified the specific factors which inhibit current post registration education. These aspects have been used in the development of a specialist training course called the Emergency Department Triage Assessment Course (EDTAC).
• [] [] ~ ::
Emergency nursing is widely recognised as a specialty area with new focus being placed on the subspecialty of triage nursing. Nurses generally make triage decisions inAustralian EmergencyDepartments, (Whitby, Ieraci, Johnson and Mohsin 1997) where the triage nurse's responsibility is to assess all patients presenting to the department, determine the potential severity of the clinical condition and allocate the urgency rating. Rowe (1992) extends this by stating that "determining which data to collect and deciding acuity.., is an immense responsibility and must be executed quickly and incisively." Morle and Maggs (1993) suggest, "practitioners make highly complex decisions for which there is no apparent continuing education preparation". How then do we ensure that this crucial, clinical decision- making process is standardised and accurate? Emergency dinicians recognize that the "complexity of the triage role demands experience and knowledge" (Whitby et a11997) and manyhospitals have developed internal training programs, guidelines and protocols to assist staff.
April 2002, Volume 5 Number I - Australian Emergency Nursing Journal
3 7
RESEARCH
PAPER
Researchers have attempted to identify the "clinical features which lead experienced staff to recognize the urgency of patient presentations", thereby facilitating the development of more appropriate teaching resources. Despite these efforts, Considine (2000) states "anecdotal evidence suggests wide diversity in the way that novice triage nurses are taught and oriented to the triage role".
• • •
Gerdtz and Bucknall in 2000 studied Australian triage nurses to "describe their scope of practice, educational background and explore the self-reported influences perceived to impact on their decision-making." This study identified that there was "variability in the educational requirements for nurses to triage...more than half of the participants in the study worked in emergency departments that provided no specific unitbased triage education". McNally (1996) identifies that "nurses develop triage skills through clinical experience and peer discussion in the absence of accessible and developed triage courses."
•
This study was designed to identify: • Current nursing qualifications/experience of nurses required to perform the role of triage, • Current policies, protocols or resources currently available to these nurses, • Education needs of the nurses and • Impediments to specialist training.
Methodology Research questionnaires were sent to 43 randomly selected hospitals across the ACT and NSW, that provide emergency services in metropolitan, rural and remote areas. Participation in the studywas anonymous if desired. The questionnaires consisted of 43 multiple-choice questions, which were designed to elicit the following data: • demographic data • professional qualifications/experience • professional associations
• • •
orientation to emergency/triage nursing existing policies for the triage role staffing levels, medical resources and physical work environment duties expected of the triage nurse, e.g. performing vital observations application of the Australasian Triage Scale self reported need for advanced assessment skills, and factors that would facilitate further study.
Participants in the study were asked to provide any additional comments, which would assist the researchers in understanding their triage education needs.
Results Demographic 159 nurses responded with completed questionnaires. Of these respondents, 8 were male (5%) and 151 (95%) were female. 27 nurses (16.9 %) were from hospitals designated as metropolitan, 110 nurses (69.2 %) were from rural hospitals and 22 nurses (13.8 %) were from remote area health care centers. Qualifications and Emergency Nursing Experience
104 nurses had completed a general nursing certificate course whilst 55 had completed a general nursing degree. Only 2 respondents had completed postgraduate study at master's level, however, 21 nurses had successfullycompleted three post registration certificate courses or equivalent and 31 had two. 48 nurses had not attempted any post registration qualifications. Post registration courses, as shown in Table 1, included: • Emergency nursing certificate courses from various nursing colleges/tertiary institutions • First Line Emergency Course (FLEC) • Trauma Nursing Core Course (TNCC) • Remote Emergency Care Course (RECC) • Intensive Care certificate/diploma • Midwifery certificate • Mental Health Certificate Course, and • general others (Professional Assault Response Training (PART), Education andAdministration
courses).
38
Emergency Nurses Association of NSW Inc.
RESEARCH
PAPER
Figure 1. ED experience as criterion for performing triage
Table 1. Post registration qualifications Nurses
70
Emergency Nursing Certificate
32
FLEC
40
60 50-
TNCC
28
RECC
12
20
ICU certificate/diploma
12
10
Midwifery certificate
41
0
Mental Health certificate
6
Other (PART, Education, Administration)
5
Qualification
Experience in the emergencydepartment varied widely. Table 2 indicates ED experience. Table 2. Emergency nursing experience Years in ED
Nurses
1-2
28
2-5
44
5-8
25
>8
62
//...../.X~
40- / =
30"
\\
\.
\ 0
lto6
7to12 13to24 Months
>24
Nurses are not only required to work in the difficult role of triage nurse with little or no exposure to the world of emergencymedicine but are often expected to do so without clear written policies as per Figure 2. Nurses also indicated that theywere required to perform other functions whilst working at triage, such as performing ECG without interpretation, wound dressings, taking blood specimens etc. Figure 2. Existing policies for triage and phone triage
Professional Associations
Nurses were asked to identify any professional association affiliations. The Royal College of Nursing were represented by 23 nurses, the EmergencyNursing Association of NSW also by 23 nurses, the Association of Critical Care Nurses by2, whilst 22 nurse subscribed to various journals. 89 nurses did not maintain membership with any nursing organisation except the relevant nursing union. Comments indicated that many nurses who perform the role of triage do not regularly work in an emergency department, and do not identifywith any particular emergencyassociation, particularly in the rural and remote area health care centers. Orientation to Emergency/Triage Nursing
59 % of nurses in this study perform the role of triage as general nurses in hospitals which provide emergency facilities. Many of these nurses work less than three days aweek in the emergencysetting. 41% of nurses are permanently rostered to the emergency department. Experience in the emergency department as a prerequisite for performing the role of triage varied greatly between hospitals as shown in Figure 1.
Nurses required to triage
Existing triage policy
Nurses required to do phone triage
Existing phone triage policy
The Triage Role - Professional Development
This study has found that despite many nurses having qualifications and experience relevant to the emergency department setting, there is a strong need for advanced assessment skills. Of the 159 nurses who participated in this study, 94 % of respondents indicated their belief that triage is an advanced practice role and requires advanced assessment skills. Specific advanced assessment skills sought by these triage nurses are shown in Figure 3.
April 2002, Volume 5 Number I - Australian Emergency Nursing Journal
39
RESEARCH
Figure 3. Specific advanced assessment skills sought by triage nurses
Z
PAPER
Figure 5. Preferred study mode 140 lPo
140 120 ] 100 80 60
2-3 day course
1 Z
40 20
g Study Modes
Impediments to specialist education were examined. 90 nurses believe that specialist post registration training is an expectation of employers. However, the funding that is made available for this is often negated by the lack of available staff to replace nurses on study leave, as shown in Figure 4. The goal of maintaining a skilled and responsive health workforce was cited in the National Rural Health Policy Forum (2000). Strategies to achieve this are documented as "providing opportunities to maintain and advance skills". Figure 4. Education opportunities 140 120 100
116
60
53
40 20 Expected by employer
Funding available
Study leave available
Distance education may seem the obvious solution to nurses' education needs but nurses have indicated their preference for short, locally based, interactive courses (2-3 days) as indicated in Figure 5. Questionnaire comments indicate that education facilitators must be prepared to take education programs to participants, primarily to reduce travel costs and to reduce time away from work and family.
40
Rapid assessment skills must be taught to build confidence in triage assessment. Within the rural and remote areas, this confidence enables nurses to convey information to offsite staff, thereby enabling best possible outcomes for patients. Comprehensive rapid assessment skills at triage are adaptable to any triage scale used on a national and international basis.
90
80
0
Outcomes These results reflect current research, in that there is an identified need for standardised, minimal educational preparation to be undertaken prior to performing triage. This is particularly true for nurses geographically isolated from resources. Currently there is very little consistency in education, training and orientation to the role of triage in Australia. None argue that the role is difficult and that it requires a large degree of experience, assessment skill and interpretation by those performing the role.
This identified void in the area of specialist triage education has led to the development of a comprehensive and adaptable triage training course, structured around the needs and learning styles of the participants. The Emergency Department Triage Assessment Course (EDTAC) was developed in 2000, partly based on the findings of this study. The course is suitable for all nurses who are required to perform triage in either the rural, remote or metropolitan setting.
Emergency Nurses Association of NSW Inc.
RESEARCH
PAPER
Course Focus
References
Material is presented in workshop style with supplementary lectures and is based on sound clinical
ANF Victoria. (1996) Nursing:Specialisationand credentialling. Lamp, 53(10)
principles. There is a strong emphasis on interactive participation. Participants undertake final assessment on all relevant skills, including material supplied in the pre reading manual. EDTAC numbers are limited to 12-15 people per course. Course duration is two days and runs approximately from 0830 hrs -1730 hrs. Courses are held in the ACT regularly as well as regional areas where there is an identified need.
Whitby,S., Ieraci,S., Johnson,D. and Mohsin,M. (1997)Analysis of theprocessof triage; The use and outcome of the National Triage Scale. Sydney,LiverpoolHealth Service Morle, K. and Maggs,C. (1993) Informed opinion:An exercise in gatheringthe opinions of experts to facilitatethe planning of continuingprofessionaleducation.NurseEducation Today, 13(2), 100-6 Gerdtz, M. and Bucknall, T. (2000) Australian triage nurses' decision making and scope of practice. Australian Journal of Advanced Nursing, 18(1), 24-33
Contact Details
T.R.I.A.G.E. Consultants (Triage: Resources, Instruction and Assessment Guidelines in Emergency) PMB # 44, PO Box 11, Woden ACT 2606 Tel: 02 6284 9074 Email: TRIAGE @ bigpond, corn
Rowe,J.A. (1992) Nurseeducator:Triageassessmenttool.Journal of EmergencyNursing, 18(6), 540-544 McNally, S. (1996) The triage role in emergency nursing. Developmentofan educationalprogramme.InternationalJournal of Nursipg Practice, 2(3), 122-8 Considine, J., Ung, L. and Thomas, S. (2000) Triage nursing decisionsusingthe NationalTriageScaleforAustralianemergency departments. Journal of Accident and Emergency Nursing, 8(4), 201-209
April 2002, Volume 5 Number I - Australian Emergency Nursing Journal
4 1
PAPER
Triage Research in Australia: Guiding Education
Jeni E. Ritchie
Literature Review
BA, /VIA,GradDippAppSci, TNCC M. Nursing (Trauma) (Current)
Nursing as a profession has moved towards a system of integrated and interrelated specialty areas. Specialty areas are now seen as clearly separate areas which "require practitioners with specific and specialised knowledge and skills," skills that are "more specific and specialised than would effectively be obtained through an educational program for generalised practice." The demand for nurses to obtain specialist qualifications reflects the fact that the "pace of specialisation has accelerated" (ANF Editorial, Victoria, 1996).
Narelle M. Aldridge Crafter
RN, RM, A &E Cert, RemoteArea Course, TNCC Amanda E. Little
RN, GradDipCritCare, M. Nursing (Current)
ABSTRACT Emergency Department triage is emerging as a subspecialty area of emergency nursing. Literature identifies the current lack of standardised training for this role in Australia. A study of 159 triage nurses across the Australian Capital Territory (ACT) and New South Wales (NSW} regions, was conducted to identify the current preparedness of staff to perform triage and the impediments to specialist training. Respondents identified a strong need for comprehensive rapid assessment skills, and identified the specific factors which inhibit current post registration education. These aspects have been used in the development of a specialist training course called the Emergency Department Triage Assessment Course (EDTAC).
• [] [] ~ ::
Emergency nursing is widely recognised as a specialty area with new focus being placed on the subspecialty of triage nursing. Nurses generally make triage decisions inAustralian EmergencyDepartments, (Whitby, Ieraci, Johnson and Mohsin 1997) where the triage nurse's responsibility is to assess all patients presenting to the department, determine the potential severity of the clinical condition and allocate the urgency rating. Rowe (1992) extends this by stating that "determining which data to collect and deciding acuity.., is an immense responsibility and must be executed quickly and incisively." Morle and Maggs (1993) suggest, "practitioners make highly complex decisions for which there is no apparent continuing education preparation". How then do we ensure that this crucial, clinical decision- making process is standardised and accurate? Emergency dinicians recognize that the "complexity of the triage role demands experience and knowledge" (Whitby et a11997) and manyhospitals have developed internal training programs, guidelines and protocols to assist staff.
April 2002, Volume 5 Number I - Australian Emergency Nursing Journal
3 7
RESEARCH
PAPER
Researchers have attempted to identify the "clinical features which lead experienced staff to recognize the urgency of patient presentations", thereby facilitating the development of more appropriate teaching resources. Despite these efforts, Considine (2000) states "anecdotal evidence suggests wide diversity in the way that novice triage nurses are taught and oriented to the triage role".
• • •
Gerdtz and Bucknall in 2000 studied Australian triage nurses to "describe their scope of practice, educational background and explore the self-reported influences perceived to impact on their decision-making." This study identified that there was "variability in the educational requirements for nurses to triage...more than half of the participants in the study worked in emergency departments that provided no specific unitbased triage education". McNally (1996) identifies that "nurses develop triage skills through clinical experience and peer discussion in the absence of accessible and developed triage courses."
•
This study was designed to identify: • Current nursing qualifications/experience of nurses required to perform the role of triage, • Current policies, protocols or resources currently available to these nurses, • Education needs of the nurses and • Impediments to specialist training.
Methodology Research questionnaires were sent to 43 randomly selected hospitals across the ACT and NSW, that provide emergency services in metropolitan, rural and remote areas. Participation in the studywas anonymous if desired. The questionnaires consisted of 43 multiple-choice questions, which were designed to elicit the following data: • demographic data • professional qualifications/experience • professional associations
• • •
orientation to emergency/triage nursing existing policies for the triage role staffing levels, medical resources and physical work environment duties expected of the triage nurse, e.g. performing vital observations application of the Australasian Triage Scale self reported need for advanced assessment skills, and factors that would facilitate further study.
Participants in the study were asked to provide any additional comments, which would assist the researchers in understanding their triage education needs.
Results Demographic 159 nurses responded with completed questionnaires. Of these respondents, 8 were male (5%) and 151 (95%) were female. 27 nurses (16.9 %) were from hospitals designated as metropolitan, 110 nurses (69.2 %) were from rural hospitals and 22 nurses (13.8 %) were from remote area health care centers. Qualifications and Emergency Nursing Experience
104 nurses had completed a general nursing certificate course whilst 55 had completed a general nursing degree. Only 2 respondents had completed postgraduate study at master's level, however, 21 nurses had successfullycompleted three post registration certificate courses or equivalent and 31 had two. 48 nurses had not attempted any post registration qualifications. Post registration courses, as shown in Table 1, included: • Emergency nursing certificate courses from various nursing colleges/tertiary institutions • First Line Emergency Course (FLEC) • Trauma Nursing Core Course (TNCC) • Remote Emergency Care Course (RECC) • Intensive Care certificate/diploma • Midwifery certificate • Mental Health Certificate Course, and • general others (Professional Assault Response Training (PART), Education andAdministration
courses).
38
Emergency Nurses Association of NSW Inc.
RESEARCH
PAPER
Figure 1. ED experience as criterion for performing triage
Table 1. Post registration qualifications Nurses
70
Emergency Nursing Certificate
32
FLEC
40
60 50-
TNCC
28
RECC
12
20
ICU certificate/diploma
12
10
Midwifery certificate
41
0
Mental Health certificate
6
Other (PART, Education, Administration)
5
Qualification
Experience in the emergencydepartment varied widely. Table 2 indicates ED experience. Table 2. Emergency nursing experience Years in ED
Nurses
1-2
28
2-5
44
5-8
25
>8
62
//...../.X~
40- / =
30"
\\
\.
\ 0
lto6
7to12 13to24 Months
>24
Nurses are not only required to work in the difficult role of triage nurse with little or no exposure to the world of emergencymedicine but are often expected to do so without clear written policies as per Figure 2. Nurses also indicated that theywere required to perform other functions whilst working at triage, such as performing ECG without interpretation, wound dressings, taking blood specimens etc. Figure 2. Existing policies for triage and phone triage
Professional Associations
Nurses were asked to identify any professional association affiliations. The Royal College of Nursing were represented by 23 nurses, the EmergencyNursing Association of NSW also by 23 nurses, the Association of Critical Care Nurses by2, whilst 22 nurse subscribed to various journals. 89 nurses did not maintain membership with any nursing organisation except the relevant nursing union. Comments indicated that many nurses who perform the role of triage do not regularly work in an emergency department, and do not identifywith any particular emergencyassociation, particularly in the rural and remote area health care centers. Orientation to Emergency/Triage Nursing
59 % of nurses in this study perform the role of triage as general nurses in hospitals which provide emergency facilities. Many of these nurses work less than three days aweek in the emergencysetting. 41% of nurses are permanently rostered to the emergency department. Experience in the emergency department as a prerequisite for performing the role of triage varied greatly between hospitals as shown in Figure 1.
Nurses required to triage
Existing triage policy
Nurses required to do phone triage
Existing phone triage policy
The Triage Role - Professional Development
This study has found that despite many nurses having qualifications and experience relevant to the emergency department setting, there is a strong need for advanced assessment skills. Of the 159 nurses who participated in this study, 94 % of respondents indicated their belief that triage is an advanced practice role and requires advanced assessment skills. Specific advanced assessment skills sought by these triage nurses are shown in Figure 3.
April 2002, Volume 5 Number I - Australian Emergency Nursing Journal
39
RESEARCH
Figure 3. Specific advanced assessment skills sought by triage nurses
Z
PAPER
Figure 5. Preferred study mode 140 lPo
140 120 ] 100 80 60
2-3 day course
1 Z
40 20
g Study Modes
Impediments to specialist education were examined. 90 nurses believe that specialist post registration training is an expectation of employers. However, the funding that is made available for this is often negated by the lack of available staff to replace nurses on study leave, as shown in Figure 4. The goal of maintaining a skilled and responsive health workforce was cited in the National Rural Health Policy Forum (2000). Strategies to achieve this are documented as "providing opportunities to maintain and advance skills". Figure 4. Education opportunities 140 120 100
116
60
53
40 20 Expected by employer
Funding available
Study leave available
Distance education may seem the obvious solution to nurses' education needs but nurses have indicated their preference for short, locally based, interactive courses (2-3 days) as indicated in Figure 5. Questionnaire comments indicate that education facilitators must be prepared to take education programs to participants, primarily to reduce travel costs and to reduce time away from work and family.
40
Rapid assessment skills must be taught to build confidence in triage assessment. Within the rural and remote areas, this confidence enables nurses to convey information to offsite staff, thereby enabling best possible outcomes for patients. Comprehensive rapid assessment skills at triage are adaptable to any triage scale used on a national and international basis.
90
80
0
Outcomes These results reflect current research, in that there is an identified need for standardised, minimal educational preparation to be undertaken prior to performing triage. This is particularly true for nurses geographically isolated from resources. Currently there is very little consistency in education, training and orientation to the role of triage in Australia. None argue that the role is difficult and that it requires a large degree of experience, assessment skill and interpretation by those performing the role.
This identified void in the area of specialist triage education has led to the development of a comprehensive and adaptable triage training course, structured around the needs and learning styles of the participants. The Emergency Department Triage Assessment Course (EDTAC) was developed in 2000, partly based on the findings of this study. The course is suitable for all nurses who are required to perform triage in either the rural, remote or metropolitan setting.
Emergency Nurses Association of NSW Inc.
RESEARCH
PAPER
Course Focus
References
Material is presented in workshop style with supplementary lectures and is based on sound clinical
ANF Victoria. (1996) Nursing:Specialisationand credentialling. Lamp, 53(10)
principles. There is a strong emphasis on interactive participation. Participants undertake final assessment on all relevant skills, including material supplied in the pre reading manual. EDTAC numbers are limited to 12-15 people per course. Course duration is two days and runs approximately from 0830 hrs -1730 hrs. Courses are held in the ACT regularly as well as regional areas where there is an identified need.
Whitby,S., Ieraci,S., Johnson,D. and Mohsin,M. (1997)Analysis of theprocessof triage; The use and outcome of the National Triage Scale. Sydney,LiverpoolHealth Service Morle, K. and Maggs,C. (1993) Informed opinion:An exercise in gatheringthe opinions of experts to facilitatethe planning of continuingprofessionaleducation.NurseEducation Today, 13(2), 100-6 Gerdtz, M. and Bucknall, T. (2000) Australian triage nurses' decision making and scope of practice. Australian Journal of Advanced Nursing, 18(1), 24-33
Contact Details
T.R.I.A.G.E. Consultants (Triage: Resources, Instruction and Assessment Guidelines in Emergency) PMB # 44, PO Box 11, Woden ACT 2606 Tel: 02 6284 9074 Email: TRIAGE @ bigpond, corn
Rowe,J.A. (1992) Nurseeducator:Triageassessmenttool.Journal of EmergencyNursing, 18(6), 540-544 McNally, S. (1996) The triage role in emergency nursing. Developmentofan educationalprogramme.InternationalJournal of Nursipg Practice, 2(3), 122-8 Considine, J., Ung, L. and Thomas, S. (2000) Triage nursing decisionsusingthe NationalTriageScaleforAustralianemergency departments. Journal of Accident and Emergency Nursing, 8(4), 201-209
April 2002, Volume 5 Number I - Australian Emergency Nursing Journal
4 1