Hospital A
Hospital B
Hospital C
Hospital D
Hospital E
Two nurses work in tandem in two different rooms
One nurse works with an assistant in nursing (AIN) or junior ‘runner’
Nurses work in pairs in one space; queues can be lengthy at times
Two or three nurses work in one space; very busy
Nurses work in pairs, one in ambulance bay, the other at window; very small room
3.2.1 Waiting Room
Our observations of goings-on in the waiting room were similar across the five emergency departments we visited. At peak times (between 11 am and 11 pm), many of the seats were taken. At other times (for example, 8 am–9 am), the waiting rooms were virtually empty. In most cases, signs directed patients to the triage nurse for assessment. More urgent cases were taken straight into the emergency department. The rest were asked to register their details (name, date of birth, marital status, etc.) with the clerical staff outside in the waiting room, and then to take a seat until a doctor could see them.
The amount of written information available to inform patients about the emergency department process, particularly the triage system and how long it could take before they were admitted for emergency department care, was variable across the five emergency departments. However, on the whole very little information was provided. In all emergency departments, patients tended to return to the triage nurse to get updates on waiting times . Some patients were extremely nervous about entering the ‘visual space’ of the triage nurse; triage nurses themselves were frequently so busy that they chose not to (or did not) ‘see’ the patients or carers who reapproached them.
Observation Field Notes in a Waiting Room, 2 pm
Over 30 people are in the waiting room. One person with a suspected deep vein thrombosis (DVT) goes up to the window at 14.05. She says she has been waiting for 4 hrs. She wants to go home, her husband says, ‘No, we are not going home’. An emergency department (ED) doctor brings out a letter and gives it to a patient. People are reading absentmindedly, turning pages. Hospital staff walks through. One man returns to the waiting room from an outside call at 14.10. Someone drops a radio, checks it is still working. A wheelchair is wheeled through at 14.14. A sleeping elderly woman wakes up when a trolley is banged next door. A man in a wheelchair is wheeled through. Another man is trying to sleep on a wheelchair. At 14.18 a new person is called in to the ED. A man with his arm in a sling, accompanied by two people, walks through. A woman on crutches walks through. At 14.27 someone places a blanket on a girl in a wheelchair. People pick up books, babies are squealing; the ED doctor calls in a new person to see at 14.37. One woman is on a mobile phone; some are flipping through magazines; some are just looking; one young man is balancing on crutches; a patient exits from fast track. The carer with the woman who has suspected DVT goes up to the window at 15.08 to say ‘We are not going to wait’.
Some patients and carers exhibited high levels of anxiety and frustration in the waiting room, particularly after they had been left unattended in the waiting room for a considerable amount of time. Occasionally, a nurse ventured out to let the patients know how long they would be waiting, or to administer an analgesic. These interventions when they occurred were very warmly received. Triage nurses, however, were frequently limited in the amount of information they gave patients about waiting times, and what would happen in the next stage of their journey. The exchange below exemplifies this. It took place at 11.24 am on a particularly busy day.
The triage nurse had just ventured out of the consultation room to conduct observations of patients in the waiting room. One patient, Jack (MS, feeling unwell, weak), had been waiting for admission to the emergency department since 9 am. When the triage nurse approached Jack, she immediately advised Jack that because more sick people had presented to the emergency department since he had arrived, he would have to wait longer before seeing a doctor:
Nurse 1: Yes, so we have just had a couple of people who have come in.
Patient: Okay.
Nurse 1: So a little bit more urgent at this point.
Patient: No worries.
Nurse 1: But it’s churning along, it’s always this time.
Patient: Yeah, no worries. We …
Nurse 1: How are you feeling right now?
Patient: Oh, still lousy but …
Nurse 1: Yeah. Worse?
Patient: Oh, about the same. [Pause in talking, distant background noises, approx one minute while N1 does obs]
Patient: Okay? Can I just …?
Nurse 1: That’s all.
Patient: Oh, good. Thank = = you for that.
Nurse 1: = = Fine, looks good. And so, yeah, we’ll just let you know how it’s going = = I guess.
Patient: = = Yeah. You see, no—no time frame? You don’t …?
Nurse 1: No, sorry.
Patient: That’s alright. Thank you.
This interaction illustrates how difficult it is for triage nurses to give time frames for waiting patients. It also shows, after the explanation, Jack’s willingness to accept this reality: ‘That’s alright. Thank you’.
3.2.2 Ambulance Bays
Patients who arrived at the emergency department by ambulance were triaged while they were still on the ambulance trolley. The ambulance officer would give medical details of the presentation to the triage nurse, who would then categorise the patient for treatment, following the same uniform set of criteria used for walk-in patients. Triage nurses occasionally initiated treatment (in the form of pain relief, for example) to patients while they were waiting in the ambulance bay. Ambulance bays could get extremely hectic, as the following observation notes show:
Observation Field Notes from the Ambulance Bay, 1.30 pm
There is a very elderly, frail patient on a trolley. A female ambulance officer is handing over to the triage nurse. The patient has recently increased medication to help with cramping and is not able to communicate normally. His elderly wife (hunched with a walking stick) is with him. Two male ambulance officers are standing by. The triage nurse knows the patient and the ambulance officers. We can hear a baby crying from one of the cubicles. The patient is taken to bed 6. The baby is still crying. A man is wheeled into Triage, speaking to the triage nurse who is taking ‘obs’. An elderly female patient is wheeled from bed 19 to? There is laughter from the ‘station’. Another male at Triage is being given ‘obs’ and he then goes back to waiting room. A woman with a baby arrives at the triage window who then comes through into Triage; we overhear the word ‘diarrhoea’. The male patient on a wheelchair leaves Triage to return to the waiting room. A male patient, 54 years, is brought in by male and female ambulance officers. They check his pulse and blood pressure. They hand over to the triage nurse—suspected anaphylactic reaction to medication (penicillin) . The patient has previously had pleurisy and pneumonia . The patient has had shaking, shortness of breath and redness to body. The triage nurse says, ‘We will get you seen to straight away’. The patient is taken to bed 4.
Another ambulance arrives and then another. An elderly female patient had a fall at the hostel this morning and then came over all hot and clammy. She felt fine to go out for lunch at the RSL with her husband where she took a turn for the worse. She appear to be very disorientated. The triage nurse asks her what month it is which she knows but not what year it is. The ambulance officers are told to take her to bed 16 but someone is already there. She is wheeled to the corridor. She smells as if she has defecated.
An elderly male patient, Sam, aged 99, arrives. He lives at home alone; had a fall this morning and cut his head. The triage nurse feels his arm, ‘you are cold darling’. Sam does not take any medication except two lite beers a day. The triage nurse, ‘You are amazing, you have got ages to go yet’. Sam used to be a butcher.
Now there are seven ambulance officers standing around laughing and joking. There seems to be a real camaraderie with the ED staff.
Another ambulance arrives with a 61-year-old man who dropped his hands into 90° hot wax.
Another ambulance arrives with an elderly male in a wheelchair. All the ambulance officers know him; he seems to be a regular to the ED. A drinker. Apparently he had rung an ambulance several times the previous night; it seems they only pick him up if they are not too busy.
3.2.3 Communication in the Triage Stage
In the triage stage, the major communicative responsibilities fall to the triage nurse who will interview patients about their symptoms and medical history, in order to assess the patients accurately and subsequently assign them an appropriate triage category. The importance of the triage nurse in the emergency department communication network is highlighted by the following comment from a member of the clerical team:
Good communication is when the triage nurse and us are on the same wavelength. If the triage nurse is happy then we’re happy, then the doctor’s happy. Everything’s running smoothly. (Communication supervisor)
Clinicians we interviewed frequently remarked that if there were misunderstandings or errors of communication between the patient and the triage nurse, this would have a ripple effect throughout the patient’s journey.
The triage stage is characteristically brief and the role of the triage nurse is clearly prescribed. The triage nurse must balance a number of competing priorities during his or her assessment process, including the medical priority of patient care, the organisational priority of allocating the correct category and the most appropriate assessment/treatment area, and the professional priority of performing discipline-specific practice, which includes being accountable for these decisions. In Australia, triage nurses are senior nurses who are specially trained to assess patients. As an advanced practice nurse described, one of the main communication challenges for triage nurses is to sift out the clinically relevant information from patient descriptions of their symptoms and what led them to seek care in the emergency department, ‘because often what the patient says to triage and what they have actually got wrong with them are two totally different things’ (advanced practice nurse).
The interview between the nurse and the patient during the triage assessment is framed by a uniform set of criteria designed to make the process both thorough and efficient. During the brief encounter, patients are asked to provide limited information in response to a very specific series of questions and are not encouraged to ask questions of their own. Patients are invited to tell their story succinctly and coherently. If they do not do this, the triage nurse intervenes to achieve the goals of the triage consultation. An excerpt from one triage consultation with Natasha (post-op infection due to a breast augmentation), demonstrates how the nurse elicits crucial information:
Patient: And then today I started to really feel unwell and I feel like it’s a heart attack actually. Just really sharp pains in my chest and my left breast is swollen () fever, gone down my arm, you know …
Nurse: Okay, so it’s particularly the left one.
Patient: It’s the = = right one …
Nurse: And = = () swollen, or …
Patient: Yep, yep, and that’s where all the pain is.
Nurse: Okay. And how long has that been like that for?
Patient: The pain has been since I had the op, but it’s …
Nurse: Okay, but the swelling and the …
The overall structure of the interactions we found in most triage consultations was very similar, despite differences in the levels of medical complexity of patient presentations. The agenda was clearly set by the triage nurse, and interactions were characteristically short. For example, in Jean’s case (Jean presented with minor leg trauma) the triage nurse asked nine questions: four were about the patient’s presenting condition and five related to the organisational processes of the emergency department (we refer to this as the ‘hospital system’ from this point). The nurse also made three statements during the assessment process, all related to the hospital system. Jean asked no questions, and her contribution was limited to providing short, concise responses to the nurse’s questions.
As stated above, the information patients receive is usually limited to what they can expect to happen until they are moved from the waiting room to a bed inside the emergency department. In other words, patients are generally not given an outline of what they can expect to happen during their overall emergency department journey. It is likely that patients initially find the triage/emergency department context bewildering, especially if they are in distress. The information triage nurses provide usually relates to approximate waiting times or refers, in general terms, to the staff members who will follow.
There is often little time in the triage stage for the nurse to establish a relationship with the patient. However, we noted that sometimes they managed to convey a positive friendly attitude by using a few simple strategies. They would, for example, establish rapport with the patient by introducing themselves informally and describing their role, use inclusive language and occasionally terms of endearment, and further give supportive or empathetic feedback to patients when they describe their pain or anxiety.
3.2.4 Communication in the Triage Stage: Summary
Language is constrained by a uniform set of criteria and a clearly defined process.
A limited number of prescribed questions are designed to achieve correct triage allocation.
Patients are not encouraged to ask questions of their own.
Patients rarely ask questions about what is going to happen to them beyond triage.
The information patients receive is generally limited to what they can expect to happen until the end of this particular stage.
The information triage nurses provide relates to approximate waiting times or to the staff members who will follow.
There is limited opportunity to establish an interpersonal relationship.
The important aspects of language and communication in triage are those that recognise the patient’s unfamiliarity with the emergency department process and those that address their vulnerability in presenting to the emergency department. Actions which do this include clinicians greeting the patient and introducing themselves and their roles, allowing the patient to tell their story, normalising the patient’s concerns, and explaining what will be happening next, including providing information about the entire process of the emergency department.
3.3 Nursing Admission
Following triage, patients will typically be asked to sit in the waiting room until they are admitted into the emergency department. Their admission, when it eventually takes place, will be handled by nurses who are allocated to patient beds in teams. The teams will usually consist of junior and senior nurses, with the former supervised by the latter as part of the process of situational learning. The nurses perform their own discipline-specific practice and are answerable to the hierarchy within their own discipline. Nurses responsible for the admission of patients have a clearly defined role. First, they perform the task of admitting patients in the emergency department, which involves getting patients changed into hospital gowns and recording their personal details. Second, they make sure that patients are medically stable by doing basic observations, recording information in patient notes and administering pain relief to patients when necessary. Handover to consecutive nursing staff is both written (patient notes) and spoken.
Throughout this stage, nurses need to balance the competing priorities of the organisation of the emergency department with the priority of patient care. Depending on the urgency of each patient’s condition and the number of people the emergency department is dealing with, a number of different clinicians (nurses and junior and senior doctors) may surround the patient at the same time—or may simply pass by—during this stage. This can create a hectic, noisy atmosphere around the patient’s bedside.
Observation Field Notes from Bed 3 in Acute, 3 pm
On this day 36 people have walked past the bed in a space of fifteen minutes, the fire alarms have been tested twice; on 24 occasions the noise was so high as to interfere with audible communication with the patient; there were 10 overhead announcements and/or code calls; and 180 patients have fronted up to the ED in the previous 24 hrs resulting in a very stressed set of interactions for all the clinicians concerned as well as for the patient. People going past the bed one after the other include one team leader, one carer, one person in a bed, one person in a wheelchair, two staff nurses, four doctors and two people with IV drips.
3.3.1 Communication in the Nursing Admission Stage
Communication in the nursing admission stage is challenged by three requirements: the need for nursing staff to manage and adapt their priorities according to changing demands, particularly in very busy times; the need for all clinicians to communicate effectively with the multidisciplinary team; and the need for nursing staff to attend to the disorientation patients experience in the emergency department. One senior nurse we interviewed summed up the priority for the nursing teams in the admission process:
I like to package people to a degree. I like to get all their observations done and make sure they are settled, and their pain’s under control, and all the pieces of paper that go along with it and my documentation. And then I can sort of think … I know everything that I could possibly know right now, until something [else happens]. I like to sort of go right; I know if I walk away for the next 10 min, it is all kind of sorted for you. (Clinical nurse specialist)
It is through nursing admission that patients enter the main clinical areas of the emergency department and become part of the hospital system, and many are highly anxious and feel a loss of personal control. Pain and distress contribute to the feeling of powerlessness, and this can be magnified by other factors such as gender, age and socioeconomic circumstances. Most clinicians we interviewed were aware of the emotional impact of hospitalisation on patients:
No one wants to come to an emergency department so you’re dealing with consumers who are distressed. So every single patient that we deal with has some form of stress and so that makes it a particularly different area to work in. (Nursing unit manager)
I think it can be a very daunting experience. I think it can be quite scary sometimes … because they come in to what can be a foreign environment … so what concerns me is how they perceive how we treat other patients sometimes because, especially with our mental health patients who might need to be sedated and that sort of thing, I quite often think about what other patients may think what we’re doing to these patients. (Staff nurse)
One way in which nurses can reduce patient anxiety is to keep them informed in terms of their treatment and also a propos the emergency department processes they will become involved in or will see around them. Patients may not always be well enough or confident enough to ask questions, or understand information provided.
The amount of time that nurses have with patients is a major limitation. A number of nurses we interviewed described how the interpersonal dimensions of providing care were frequently compromised by high patient loads . When the department is under pressure, nurses described having to prioritise their work differently, as they spread themselves across the needs of several patients simultaneously:
Often there is a time factor where if the department’s really busy and we’re short staffed or you know the level of staffing isn’t as it should be, then you start to run into problems where you need to just do the basics for one person and then move on to the next one because there just isn’t time and if you sort of get three new patients all at once, you have to prioritise what your duties are. So I personally just go back to my basic nursing, make sure they’ve got observations, electrocardiogram (ECG) and you know make sure they’re stable for the moment, then I’ll move on and then come back, if there is time to do the more, you know, the higher skills, I guess. (Staff nurse)
The need to work at maximum pace meant that patients were given less time to ask and respond to questions. Many also got less information than they wanted about what would happen to them next, and when it would happen.
Sometimes it’s very organised and things go well. Sometimes I think we try to rush our patients through and not that we miss things, but sometimes I don’t think we take a holistic approach. I think we just hone in [home in] on what’s wrong with them, get them in, get them out and let someone else do the definitive care. I think sometimes we forget that we do actually complete definite care here sometimes. (Transitional nurse practitioner)
The language patterns we found during the admission stage of all patient journeys showed clear similarities and reflected the nurse’s practice described above. We used a move analysis1 (where we analyse the number and type of questions, statements and acknowledgements made by the nurses and patients) to examine the kinds of utterances made by nurses and patients in this stage. This analysis showed that the exchange of information between nurse and patient was often limited to a brief review of the presenting medical condition, and that the nurse would typically provide a series of statements to the patient concerning the emergency department processes associated with the admission stage. The patient’s main contribution was through their answers to the nurse’s questions. The overall emphasis in most patient admissions was on orienting patients about what they should expect to happen during admission, and preparing them for seeing a doctor in the next stage. Most often they announce the (pending) arrival of the doctor
Related posts:
Effective Clinician–Patient Communication: Strategies for Communicating Medical Knowledge
Effective Clinician–Patient Communication: Strategies for Bridging the Interpersonal Gap
Communication Risk in Clinician–Patient Consultations
The Context of Communication in Emergency Departments
The Role of Communication in Safe and Effective Health Care
Action Strategies for Implementing Change
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
