The next longish illustration of some characteristics of ED nurses’ work is borrowed from Schriver et al. (2003) because of its appropriateness, and is presented as follows: 1) There are no limits to ED’s clinical patient load, especially in the university, central and district hospitals; 2) Its’ patients are from both sexes and represent all age groups (with some solitary exceptions); 3) Patients present with virtually all diseases (either undiagnosed or in acute phase of their natural history); 4) Patient diagnosis and treatment is unscheduled; 5) All ED personnel perform their professional responsibilities in each others’ constant presence; 6) The performances are observed by a variety of other persons with reason to be present - patient’s family and other relatives, fire-fighters, paramedics, and police, to name a few; 7) In the centre of this environment ED nurses play an essential role, spending more time with the patients than other ED personnel, including physicians; 8) Increasingly, ED nurses, as well as physicians, spend more than half of their clinical time on indirect patient care tasks; 9) The nursing assessment of ED patients demands advanced skills, as does ongoing patient monitoring; 10) Nursing documentation is ongoing, requiring computer entry skills; 11) None of the nursing educational pathways adequately prepare the emergency nurse for clinical practice; 12) The emergency nursing practice is continuously becoming more complex, requiring more formal and longer orientation periods for those newly recruited; 13) A worldwide shortage of nurses is predicted by 2010, and a severe shortage by 2020; 14) In this ever-changing world, one thing that is not changing is the expectation by patients and their families that their emergency nurses will be caring, supportive and informative caregivers, who value the patients as individuals. As mentioned previously, it most likely is futile to even attempt to deny any of these characterisations when considering the work of Finnish ED nurses.
The purpose of all nursing is to support human beings’ own resources in order to enable their recovery from the emergency that has afflicted them (MacPhall 1992, Ministry of Education 2006). Within the ED, the primary aims of ED nursing are the assessment of patient’ s need of
care, establishing a working hypothesis, adequate response according to the patient’ s needs, and outlining the need for continuing treatment. (Koponen and Sillanpää 2005.) These aims are commonly pursued conforming to the following scheme: triage primary assessment -resuscitation or immediate care - secondary assessment - focused assessment - diagnostic procedures or data - setting a diagnosis - transfer to continued treatment or home (Twedell 2000). A typical clinical workflow of an ED is described in Figure 2.
FIGURE 2. Illustration of clinical workflow in the ED (modified by the researcher from:
Göransson 2006, Ruohonen 2007).
The factors that regulate the process of ED work are the inflow, throughflow and outflow of patients (Figure 3). ED crowding occurs when inflow is greater than outflow. ED crowding, in turn, is associated with adverse effects as poor patient outcomes, long waits to be seen, and patent dissatisfaction. (Patel and Vinson 2005, Hoot et al. 2008.) Thus, the throughflow time is of paramount importance, and inadequate staffing appeared to be one factor being in the position of possibly causing crowding (Hoot and Aronsky 2008).
FIGURE 3. Factors regulating ED working process according to Koponen and Sillanpää (2005, modified by the researcher).
Numerous definitions and descriptions exist for the concept of a profession. According to one of them, professions are such compilations of expertise to which an established and distinguished status has gradually been formed (Tolppi 2001). From this standpoint there probably is no hindrance to defining ED nursing as a genuine profession. On the other hand, one of the most prominent features of a profession is the requirement for the possession of formal knowledge, and a profession without formal knowledge is an impossibility as a definition (Tolppi 2001). Furthermore, formal knowledge is usually acquired within education, which frequently is institutional and aims especially at a certain profession. This, for the time being, is lacking in Finland in terms of special qualifications available to ED nursing. The nurse-paramedic (Bachelor of Health Care) educationl programmes of Finnish Universities of applied sciences are approaching this aim (Ministry of Education 2006), but still we do not have the established, distinguished and officially approved concept and scope of practice for ED nurse and nursing.
During the through-flow phase of the ED working process, one of the most demanding and clinical skill-consuming fields of action is the triage- phase. The concept of triage is attributable to a French word trier, which stands for sorting, and patient sorting actually is what ED triage is all about. The concept of triage goes back to 19th century French wartime surgery, within which, as far as is known, there was initiated the sorting of wounded soldiers according to the severity of their injuries, and to focus the treatment first to the most severely injured. During the next century this policy was begun to be applied within armies around the world. During World War I evidence was developed that triage was concerned with the improved prognosis of certain war injuries. Thus, triage can be regarded as one of the first implementations of medicine after first aid (Derlet 2002).
Triage in the ED settings relates back to the early part of the 20th century, where in certain overburdened North-American EDs some kind of patient sorting began to be implemented rather by chance than as a consequence of systematic consideration. It was not until the latter half of the 20th century that triage began to be implemented more systematically in hospital EDs, where continuously on-call physicians became a national standard (Derlet 2002).
Within specialised medical care in-hospital, triage means a swift assessment of every patient entering an ED. The triage role, being predominantly a nursing role, is especially characteristic for ED nursing, and differentiates ED nursing from other nursing specialities (Considine et al. 2000). Triage is implemented by a nurse specifically assigned for this
purpose (the triage nurse), utilising predetermined criteria and with the objectives being as follows: 1) Promptly identifying patients requiring immediate, definitive care; 2) Define the appropriate area for treatment (i.e. medical, surgical, neurological areas, or fast track/urgent care clinics); 3) Facilitate patient flow through the ED, and avoid unnecessary congestion; 4) Provide information and referrals to patients and families; and 5) Alleviate patient and family anxiety and enhance favourable public perceptions of and experiences with emergency services (Tipsord-Klinkhammer 1998). In addition to the aforementioned, a variety of tasks and duties may, depending on a hospital’s policy, be added to the scope of a triage nurse’s practice, e.g. initiation of diagnostic tests, including laboratory studies and radiographs, making an immediate diagnosis, and even prescription of certain medicines (Williams and Sen 2000, Zimmerman 2002).
It seems reasonable to postulate that the most important aim of ED triage is to find, among the continuously growing flows of patients, especially those whose clinical condition is obviously severe or whose condition may deteriorate critically as a function of time. Detecting an impending high-risk event, which has the potency of leading to catastrophic collapse of the patient’s clinical state, is one of the most demanding and difficult areas of ED nursing’s domain and which requires such special expertise, which is called clinical skill in this study.
At its best it can save a patients’ life, but at its worst it’s deficiencies can jeopardise the patient and lead to catastrophic deterioration of their clinical condition, or even to death, without anyone even knowing what is going on in the ED (ENA 1997, Zimmerman 2002, Tippins 2005).
All in all, the phenomena of preventable critical illness and death have received considerable scientific and clinical interest recently, especially at acute care hospitals. With reference to several scientific reports, tendencies seem to prevail as described next: 1) Patients suffering unanticipated critical events often exhibit signs of physiological deterioration, even hours before the collapse; 2) In some cases the deterioration is well documented, but with little evidence of appropriate intervention; 3) In other cases the monitoring and recording of vital signs turns out to be infrequent or incomplete; 4) There may be indications to assume that the understanding of the mechanisms that lead to clinical crises may not always be sufficient to enable adequate clinical action; 5) The findings may suggest that an algorithm-based system is needed for guaranteeing a suitable clinical response to a deteriorating patient. (Vincent et
al. 2001, Chellel et al. 2002, Angus and Black 2004, Bion and Heffner 2004, Ryan et al. 2004, Skrifvars 2004, Nurmi 2005, Smith et al. 2006.)
However, these studies mainly concern hospitalised patients on general wards. The pathology leading to unanticipated adverse events with these patients is related to long-lasting insufficient tissue perfusion and oxygenation and, when assessed retrospectively, might still have been anticipated provided that the nursing personnel had had enough time, knowledge and skills as well as an unambiguous protocol for monitoring patients and reacting to what might have been discovered. Out-of-hospital, non-traumatic, cardiac arrests are known to be mainly cardiac arrests connected with malignant arrhythmias induced by coronary disease (Nurmi 2005, Arntz et al 2008). EDs could be described as corridors between out-of-hospital and in-hospital circumstances. To what extent the unanticipated deterioration of patients’
clinical condition in ED have similarities with these different kinds of phenomena remains unclear to the researcher. In a study by Ruiz-Bailơn and Morante-Valle (2006), according to echocardiographic findings during on-going CPR in 32 patients brought to the ED or intensive care unit without a previous diagnosis, the following features were observed:
Cardiac tamponade in four patients; two type-A aortic aneurysms; one papillary rupture; two patients had dynamic hypertrophic obstructive cardiomyopathy; six patients with dilated cardiomyopathy; one patient with spongiform cardiomyopathy; three patients with aortic disease; twelve pulmonary embolisms; and one patient with a cardiac mass (rhabdomyosarcoma) (Ruiz-Bailơn and Morante-Valle 2006).
This innovative study does not yet, however, reveal the whole picture as, like the authors also state, a prospective, controlled study with larger populations is needed (Ruiz-Bailơn and Morante-Valle 2006). It also seems unlikely that these findings, albeit important, would be sufficient to explain unanticipated adverse events occurring in EDs. All in all there seems to be a tendency, according to which the risk of adverse events is higher for patients admitted to EDs and general medical wards than for those admitted for elective surgery. Clinically important adverse effects most commonly affect the elderly, who also account for the majority of emergency admissions (Leape et al. 1991, Bion and Heffner 2004) The aetiology of intra-hospital cardiac arrest is poorly described (Nurmi 2005). However, although most of the adverse events with hospitalised patients turn out to be less malignant, a cavalier attitude towards these events can hardly be tolerated, as patient safety has to be the focus of all health
care pursuits (International Council of Nurses 2002). There seems to be a call for a systematic approach for the prevention of these events (Bion and Heffner 2004).
The key role of professional nurses in preventing cardiac arrest has been strongly emphasised.
The decreased availability of highly skilled professional nurses translates into lower patient-to-nurse ratios and higher incidence of death (Aiken et al. 2002, Needleman et al. 2002).
Unfavourable patient-nurse ratios may also hinder early recognition of warning signs, and therefore the prevention of imminent cardiac arrest (Weil and Fries 2005). With reference to the aforementioned, and possibly due to its clinical importance, the accuracy and reliability of triage performed by ED nurses has also recently been the object of intensive research (e.g.
Cooke and Jinks 1999, Fernandes et al. 1999, Travers 1999, Washington et al. 2000, Wuerz et al. 2000, Considine et al. 2001, Parenti et al. 2006).
Despite the fact that triage only covers one area of the through-flow phase for an ED patient, it requires such clinical skill that is constantly needed when repeatedly assessing and re-assessing the clinical condition of ED patients. Furthermore, it is reasonable to claim that the skill required to make a rapid and reliable assessment and re-assessment is a fundamental attribute of and a prerequisite for an ED nurse. Thus, the predominant attention paid to this isolated area of compilation of theoretical knowledge and clinical experience conceivably turns out to be justified in this research report.