Introduction . We aimed to describe perceptions of Australian emergency clinicians of differences in management of mental health patients in rural and remote Australia compared with metropolitan hospitals, and what could be improved. Methods . Descriptive exploratory study using semi-structured telephone interviews of doctors and nurses in Australian emergency departments (EDs), stratified to represent states and territories and rural or metropolitan location. Content analysis of responses developed themes and sub-themes. Results . Of 39 doctors and 32 nurses responding to email invitation, 20 doctors and 16 nurses were interviewed. Major themes were resources/environment, staff and patient issues. Clinicians noted lack of access in rural areas to psychiatric support services, especially alcohol and drug services, limited referral options, and a lack of knowledge, understanding and acceptance of mental health issues. The clinicians suggested resource, education and guideline improvements, wanting better access to mental health experts in rural areas, better support networks and visiting specialist coverage, and educational courses tailored to the needs of rural clinicians. Conclusion . Clinicians managing mental health patients in rural and remote Australian EDs lack resources, support services and referral capacity, and access to appropriate education and training. Improvements would better enable access to support and referral services, and educational opportunities.
Triage is a process that is critical to the effective management of modern emergency departments. Triage systems aim, not only to ensure clinical justice for the patient, but also to provide an effective tool for departmental organisation, monitoring and evaluation. Over the last 20 years, triage systems have been standardised in a number of countries and efforts made to ensure consistency of application. However, the ongoing crowding of emergency departments resulting from access block and increased demand has led to calls for a review of systems of triage. In addition, international variance in triage systems limits the capacity for benchmarking. The aim of this paper is to provide a critical review of the literature pertaining to emergency department triage in order to inform the direction for future research. While education, guidelines and algorithms have been shown to reduce triage variation, there remains significant inconsistency in triage assessment arising from the diversity of factors determining the urgency of any individual patient. It is timely to accept this diversity, what is agreed, and what may be agreeable. It is time to develop and test an International Triage Scale (ITS) which is supported by an international collaborative approach towards a triage research agenda. This agenda would seek to further develop application and moderating tools and to utilise the scales for international benchmarking and research programmes.
Aim This study presents a critique of a new model of minimum nurse-to- patient ratio and considers its utility alongside established Patient Dependency Systems. Background Since 2001 legislation mandating minimum nurse-to-patient ratios has been enacted throughout large public hospitals in the state of Victoria, Australia. The Victorian model mandates minimum staffing of five nurses to 20 patients in acute medical and surgical wards. In conjunction with this approach, Patient Dependency Systems are employed to anticipate short-term resource needs. Key issues Although this legislation has been successful in attracting nurses back into the public sector workforce, no published empirical evidence exists to support specific ratios. In addition, neither ratio nor Patient Dependency Systems approaches account for the critical influence of skill mix on hospital, employee, or patient outcomes. Conclusion There is an urgent need for further research that specifically examines relationships between models of staffing, skill mix and quality outcomes.
This paper examines the communication strategies that nurses, doctors, pharmacists and patients use when managing medications.Patient-centred medication management is best accomplished through interdisciplinary practice. Effective communication about managing medications between clinicians and patients has a direct influence on patient outcomes. There is a lack of research that adopts a multidisciplinary approach and involves critical in-depth analysis of medication interactions among nurses, doctors, pharmacists and patients.A critical ethnographic approach with video reflexivity was adopted to capture communication strategies during medication activities in two general medical wards of an acute care hospital in Melbourne, Australia.A mixed ethnographic approach combining participant observations, field interviews, video recordings and video reflexive focus groups and interviews was employed. Seventy-six nurses, 31 doctors, 1 pharmacist and 27 patients gave written consent to participate in the study. Data analysis was informed by Fairclough's critical discourse analytic framework.Clinicians' use of communication strategies was demonstrated in their interpersonal, authoritative and instructive talk with patients. Doctors adopted the language discourse of normalisation to standardise patients' illness experiences. Nurses and pharmacists employed the language discourses of preparedness and scrutiny to ensure that patient safety was maintained. Patients took up the discourse of politeness to raise medication concerns and question treatment decisions made by doctors, in their attempts to challenge decision-making about their health care treatment. In addition, the video method revealed clinicians' extensive use of body language in communication processes for medication management.The use of communication strategies by nurses, doctors, pharmacists and patients created opportunities for improved interdisciplinary collaboration and patient-centred medication management in an acute hospital setting. Language discourses shaped and were shaped by complex power relations between patients and clinicians and among clinicians themselves.Clinicians need to be encouraged to have regular conversations to talk about and challenge each other's practices. More emphasis should be placed on ensuring that patients are given opportunities to voice their concerns about how their medications are managed.
Background: Whilst there is a sense of holism existing within palliative care practice, what is not clear is the extent to which holism, as applied in recent palliative care practice, has been adequately researched. Currently, no reviews on this topic were identified through systematic and scoping review registries. Aim: To identify and describe the available published evidence on the key features of holism and the core domains underpinning the application of holism in relation to recent palliative care practice. Design: Scoping review using the Johanna Briggs Institute design. Data sources: MEDLINE, EMCARE, and CINAHL (Ovid), PsycINFO, SocINDEX, SCOPUS and Web of Science. (International, peer-reviewed, published papers in the English language from January 2010to December 2020). Results: Five studies met inclusion criteria. Two studies used qualitative methods, one used mixed-methods, and two were randomised controlled trials. The research investigated (1) frameworks for holistic care and (2) assessment tools applied in palliative care settings. Conclusions: The results from the review led to identifying key features of palliative care that were presented as interconnected aspects of holistic care domains in both assessments and interventions. The literature revealed a focus on curative and biomedical approaches to disease management with holistic aspects acknowledged, but not in the forefront of core service delivery. Holism was generally conceptualised as an overarching theoretical framework to palliative care service provision and positioned as an adjunct to palliative models of care. These findings point to a gap in research that links the concept of holism to applied palliative care practices.
Abstract Title. Influence of task properties and subjectivity on consistency of triage: a simulation study Aim. This paper reports a study to determine nurses’ levels of agreement using a standard 5‐point triage scale and to explore the influence of task properties and subjectivity on decision‐making consistency. Background. Triage scales are used to define time‐to‐treatment in hospital emergency departments. Studies of the inter‐rater reliability of these scales using paper‐based simulation methods report varying levels of consistency. Understanding how various components of the decision task and individual perceptions of the case influence agreement is critical to the development of strategies to improve consistency of triage. Method. Simulations were constructed from naturalistic observation, cue types and frequencies were classified. Data collection was conducted in 2002, and the final response rate was 41·3%. Participants were asked to allocate an urgency code for 12 scenarios using the Australasian Triage Scale, and provide estimates of case complexity, levels of certainty and available information. Data were analysed descriptively, agreement between raters was calculated using kappa. The influence of task properties and participants’ subjective estimates of case complexity, levels of certainty and available information on agreement were explored using a general linear model. Findings. Agreement among raters varied from moderate to poor ( κ = 0·18–0·64). Participants’ subjective estimates of levels of available information were found to influence consistency of triage by statistically significant amounts ( F 5·68; ≤0·01). Conclusions. Strategies employed to optimize consistency of triage should focus on improving the quality of the simulations that are used. In particular, attention should be paid to the development of interactive simulations that will accommodate individual differences in information‐seeking behaviour.
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