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Influence Triage Environment In Emergency

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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. 



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. 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 (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 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 ethical clearance from two human-research ethical-committees and also obtained written-consent from the participants.



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 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 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 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.



AENJ. (2017). Australasian Emergency Nursing Journal: College of Emergency Nursing Australasia. Retrieved from

ANA. (2010). Nursing: Scope and Standards of Practice. American Nurses Association. Silver Spring, Maryland.

Andrews, G & Shaw, D. (2008). Clinical geography: nursing practice and the (re) making of space: J Nurs Manag. 16:463—73.

Aveyard, H. (2010). Doing a literature review in health and social care: a practical guide (second edition). Open University Press: Berkshire, England.

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Cooper, S et al. (2009). Qualitative research: specific designs for qualitative research in emergency care: Emerg MedJ. 26:773—6.21

Field, C. (2008). Acoustic design in green buildings. ASHRAE J. 50(9):60—70.28
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Foureur, M et al. (2010). The relationship between birth unit design and a safe,satisfying birth: developing a hypothetical model: Midwifery. 26(5):520—5.35.

Greenhalgh, T. (2010). How to read a paper: the basics of evidence-based medicine. (4th ed.). Wiley-Blackwell/BMJ Books: Oxford.

Grossoehme, D.H et al. (2013). "I honestly believe God keeps me healthy so I can take care of my child: Parental use of faith related to treatment adherence: Journal of Health Care Chaplaincy. 19(2):66–78. doi: 10.1080/08854726.2013.779540. 

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