The Accident and Emergency - Case Study Example

Introduction: Many patients present to the Accident and Emergency with minor lacerations. These small wounds frequently require suturing for appropriate wound care. This is a very common presentation in the emergency departments of almost all hospitals, may it be tertiary, regional, or rural emergency departments. In many hospitals, due to huge work load in the Accident and Emergency, attending emergency physicians can hardly find time on a priority basis to attend these patients. Quite often, with training, Advanced Clinical Nurses are capable of doing these minor dermal repairs very efficiently. Studies have been made that demonstrate that nurses who complete a standardized training programme in wound management and repair are capable of providing high-quality, definitive care for patients who present to the emergency department with dermal lacerations. The emergency department nurse practitioner will provide healthcare to a range of patients remaining within the guidelines of advanced practice nursing (Australasian College of Emergency Medicine. 2000). An advanced nurse practitioner is a registered nurse with advanced knowledge, skills, and clinical competence and is authorized to deploy her clinical skills in the emergency department. In the emergency department, she is called the emergency nurse practitioner, and she is a recognised expert nurse with specific knowledge, qualification, and authorization to provide trauma care. While minor acute lacerations are minor in extent, to the patient, it is an urgent situation. Therefore, the needs of the service would be to provide a speedy triage, minimal waiting time, and rapid intervention. In these given situations, management at triage would be the goal for any healthcare delivery system, and when emergency physicians are not available due to other serious patients, Advanced Clinical Nurses may be the most appropriate expert to deal with such presenting patients. As per guidelines, treatment and appropriate interventions are needed to be delivered within the scope of the practice, preferably as a part of a multidisciplinary team (Barr et al, 2000, 144-147). In this work, a research article will be critically reviewed that deals with implementation of a programme that enabled clinical nurse specialists to suture minor lacerations in the emergency department of a hospital in Australia. This original research article was published in Accident and Emergency Nursing in the year 1999, and it was titled, “Suturing of Minor Lacerations by Clinical Nurse Specialists in the Emergency Department” and was authored by Charles and coworkers. This study compared the outcomes of such management on two groups of patients, one by the Clinical Nurse Specialists and the other by the Emergency Department Physicians (Charles, Le Vasseur, Castle, 1999, 34). In this work, this writer aims to critically review this article of research to extract new knowledge following evaluation of this study, so that the learning from this can be utilized in clinical decision making and if applicable, to change practice from the reflections on and evaluation of this study. Moreover, since it is important to deliver highest quality of care in practice depending on the most current evidence from research and the gradually increasing requirement of the time if to be involved in nursing research, this critical review may serve as a way to learn the methodology of research activity that can be applied in a future research (Baldwin & Nail,. 2000, 163-166). Research has been traditionally defined as a systematic enquiry that uses organized methods to answer questions or solve problems on a particular issue with the ultimate goal being development, refinement, and expansion of the body of knowledge. Although the term nursing research indicates a systematic enquiry to develop knowledge about issues on nursing profession, practice, education, administration, and informatics, virtually all research has some link with clinical nursing, and therefore, these may be termed as clinical nursing research with the goal being development of a sound base of knowledge based on research to guide the way to practice (Polit, Beck, Hungler, 2001). This is possible by generation of new knowledge to influence change in practice to improve the health and quality of life of the clients. Therefore nursing research and its evaluations are necessary to incorporate high-quality evidence from research into practice that would modify decisions, actions, and interactions with the clients. This also helps nurses to understand the varied dimensions of nursing as a profession. Reviewing a research enables the nurse to describe and understand the characteristics of a specific clinical situation in nursing practice about which little is known. Critical analysis of a research may be of great utility, provided the quality of the research is high, to explain phenomena, and reflection on those would enable a better planning of nursing care in an identical clinical scenario. The nurse would be better equipped to predict the outcomes of clinical decisions, to control the occurrence of undesired outcomes, and most importantly, to initiate activities to promote desired client behaviour (Parahoo, 1997). To be able to understand and analyse this study, few baseline definitions should be dealt with for the reader’s benefit. Laceration is an injury to the skin and underlying structures that has caused loss of skin integrity. The delay in management of even minor lacerations incurs considerable cost to the individuals in terms of morbidity and consumables required for repair. The cost to human and physical resources has been traditionally representative of a considerable burden to the patients and the health services. For managing and repairing these lacerations, it is important that a detailed assessment of the laceration happens, and followed by this, the Advanced Clinical Nurse would treat these minor wounds and would manage the patients through discharge including followup, education, and advise to return to the Emergency Department if the patient deteriorates. The targeted outcomes of care of such patients are that the patient would be free of complications and pain and complete and successful wound healing without complications, infections, or preventable scarring (Bonadio, Carrey, Gustafson, 1994, 1144-1146). At the end of the care, the patient would have reasonable understanding of the wound care requirements. The care process would be documented. The practice nurse would refer the patient to appropriate person in time if such a need is felt necessary, and the patient would be satisfied with care. This research, “Suturing of Minor Lacerations by Clinical Nurse Specialists in the Emergency Department” will be reviewed to find out the strengths and weaknesses of this study through analysis and critique of different parameters of this article, to find out whether and how any new knowledge has been generated to fortify practice (Commonwealth, 1997). This article has been chosen by this author because management of lacerations is a burning issue in the practice area of emergency department. Many patients present to the Emergency Department of any hospital with injuries and lacerations arising out of them. However, the Emergency Department is a very crowded place where patients with different serious life-threatening disorders often present, and triage system classifies these patients at a lower category due to the fact that these lacerations are minor. Nevertheless, the perspectives of the patients are different, and for them waiting following the triage is long, frustrating, and annoying (Baldwin & Nail, 2000, 163-166). Due to the policies involving triage and shortage of competent care manpower, this problem can be avoided in the triage itself, if the Advanced Practice Nurses assess and repair these minor wounds. However, despite this being a policy and guideline in all emergency departments, this can be criticized that the outcomes may be different if the repair of these minor lacerations would have been undertaken by attending emergency department physicians. This is a very important and delicate issue and practically a very important problem very frequently encountered in emergency department nursing (Beales, 1997, 71-75). To find out evidence as to which confers better care and to answer the question whether the quality of the care is inferior if delivered by the advanced practice nurses, this article is “the article” to review, since the findings from this review may serve as evidence to change practice. From the title, it is apparent that the authors of this article are performing a research with a descriptive design involving eighty patients. The authors have called this as “descriptive comparative design” to evaluate the minor laceration repair by advanced practice nurses. Descriptive research encompasses a broad range of nursing research, and the majority of the nursing research is of descriptive design. This springs from the paradigm of naturalistic enquiry of qualitative nature. This places heavy emphasis on understanding the human experience as it is lived, and this is usually done through the careful collection and analysis of the qualitative information that are narrative as well as subjective. There has been ongoing debate as to which research method is right, but for this particular topic, the experiences of the patients receiving repair of minor lacerations hold a graver significance, and therefore, a reductionist approach involving reduction of these human experiences to few concepts under investigation would not be wise, rather it would be reasonable to allow these experiences to emerge as concepts that are essentially dynamic, holistic, and individual, and capturing those in the context of experiences would be the goal of this study (Carey, 1997, 345-354). There is a chance, however, that since the nature of such studies are subjective, the conclusions may turn out to be idiosyncratic. The sample size often is very small limiting the generalizability of the findings. Although this seems to be an appropriate design, since evidence suggests that there has been little if any research done in this area. Therefore, such a study would clarify and define new concepts or phenomena in order to better understand the phenomenon from another perspective of experience. The reader can have expectations that this study would describe and analyze the surveys and interviews of the patients (Cormack, 1991). This research article has been published in the Accident and Emergency Nursing Journal. This is a widely publicized nursing journal acclaimed for quality research publications that have been known to shape up today’s nursing practice. Therefore, depending on its reputations, it is likely to have wide audience. The title of the article, “Suturing of Minor Lacerations by Clinical Nurse Specialists in the Emergency Department” is precise, concise, and informative in the sense that by reading the title, the reader becomes immediately interested to read the treatise and can have a rough idea about the topic. By looking at the title, the reader will understand that this is a descriptive study to indicate the performance of the clinical nurse specialists in the emergency department, and he may question himself whether the author is attempting to demonstrate their abilities to repair minor lacerations in comparison to the standards of care. Therefore, the title draws the reader’s attention to the specific area of the study, and the reader can understand that the author is going to perform the study on a population of patients presenting in the emergency department with minor lacerations. The authors of the study are Ms. Amanda Charles, RN, Coronary Care Certified, A and E Certfied, BAppSci., and she is the lecturer of Emergency Nursing in the Centre for Graduate Studies in the Clinical Nursing Faculty of Medicine at Monash Medical Centre at Monash University, Victoria, Australia and Ms. Sandra A. Le Vasseur, RN, MGer, BSc, (Nursing), who is a research fellow in the same institute as above and Dr. Craig Castle, MBBS, FACCM, who is the deputy director of the Emergency Department of Monash Medical Centre at Victoria, Australia. This demonstrates that the authors of the reviewed article sound academic and appropriate professional qualifications along with seniority and experience to handle such research. These credentials are in conformity to maintenance of consumer-producer continuum in nursing research in that it qualifies the authors to be producers in that designed and implemented the research studies, with them being teachers, faculty, researchers, and practitioners. This also confirms the authenticity of the analysis and findings, and the consumers can use this research to update their practice norms and standards, and intelligent consumer has the opportunity to extract findings to improve their effectiveness and enhance their professional lives (Parahoo, 1997). This study has an abstract, and it identifies the research problem in a succinct manner. It also identifies the methodology and comprises of a short description of the method. "A programme enabling the clinical nurse specialists (CNS) to suture minor lacerations in the emergency department (ED) was implemented at Monash Medical Centre (MMC), Melbourne, Australia. A descriptive comparative design was used to evaluate the programme." The authors also provide hints as to how different patients with lacerations were randomised to receive care from CNS and Medical groups, and in a few short sentences, they present the findings, so the reader is able to prepare the mind to analyse the study in that light. Therefore, the abstract of this article also present the major findings. According to research theorists, an abstract is a short summary of the study in that it should briefly mention the aim, hypothesis, decision, methodology, sample type and size, analysis of data, and the main findings. The reader, while going through the abstract will have an idea what this research is about, how it is carried out, what were the findings, and over all, whether these are at all in the area of the reader’s interest, so he can read the study with greater detail and with a more intense analytic approach (LoBiondo-Wood. & Haber, 1994). The authors have labelled a section of introduction, and with ample and exhaustive reference from literature, they have established the problem pertaining to this particular area of nursing. The authors have mentioned the implication of triage scale in the care of the patients, and the effect due to increased work load in the ED has been mentioned by the authors as “patients with simple lacerations generally will receive a low priority and therefore may wait for prolonged periods” and in line with practice in the USA and UK, “advanced practice roles” of trained nurses “can increase the job satisfaction of the nurses” as well as improve care. In the introduction, the authors also establish the necessity of such a study by a needs assessment programme that incorporated the nurses’ expectations to this new role (Barr et al, 2000, 144-147). All the CNS were approached to complete a questionnaire, and this group was targeted for implementation of the advanced practice role since it was expected that this group has clinical expertise and time management skills to fit into the advanced practice role that was planned to be studied. Apart from collecting comments of the CNS group such as "extended nursing role" for those "with expertise and levels of "satisfactory skill" that "will save time" and will "increase nursing skill and knowledge", educational sessions were conducted prior to the implementation of the programme that was facilitated by one of the staff specialists in the ED. In this introduction, the authors have successfully pointed out at the research problem and have been able to format the prelude to the research question. The reader has a fair idea about the hypothesis of the research in that conducting this research would establish the author’s hypothesis that advanced clinical nursing by the clinical nurse specialists would help reduce the waiting time for the patients with minor lacerations in the ED (Donaldson, 2000, 247-311). The design and purpose of the study was to observe and study the effects of ED interventions by clinical nurse specialists whose skills and knowledge regarding minor lacerations and their repairs were increased by educational sessions even before the study. The educational programme comprised of all necessary training that would be needed for a successful repair of the minor lacerations, and practical skill development comprised of at least 5 suturing sessions supervised by a senior medical staff. Obviously, the researchers wanted to develop a rich, context-bound, and comprehensive understanding of the problem of repair of minor lacerations in the ED in an attempt to reduce the triage and waiting time of the patients. From this, it is evident also that the researchers clearly articulated the nature of the problem and the justification of a new study. In this phenomenological study, these statements note the need to know more about the people’s experiences with the changed plan of care in the ED. Like may qualitative studies, in this study, the problem statement has appeared in the introduction interwoven with the review of literature, for which there are no separate sections, although this successfully provides a context by documenting the knowledge gaps. The literature review has been done under the section heading introduction, immediately following the abstract. In this article, this section has been well written but brief, and it serves to orient the reader about what is known and what is unknown about the enquiry, and it leaves the reader convinced about the need of this research to contribute to the existing base of knowledge (Polit, Beck, Hungler, 2001). At the end of the study, the researchers have provided a reference list indicating the extent and depth of studies necessary to undertake this research. The reference list considers that the study was published in the year 1999. At the outset of the study, there are experiential descriptions of the phenomenon being studied. The section of the literature review is more conceptual than data based, and it identifies the underlying conceptual framework (Cormack, 2000). Studies included in the literature review section of this research are conceptually similar, and they highlight the basis of reasons in support of this current study. The patients’ perception of care in the ED has been supported to be enhanced by reduced waiting time and decreased length of stay in the ED. The study of Bonadio et al. has demonstrated that nurses could undertake responsibilities to reduce cost of care in the ED by augmentation of physician efficiency by undertaking other works outside their usual lists of responsibilities (Bonadio, Carrey, Gustafson, 1994, 1144-1146). This literature review, henceforth, gives an indirect explanation about the need for this study. From the critical but brief review of previous (Couchman & Dawson, 1996) literature, the authors have identified and established the central phenomena, concepts, and variables under this study in order to earmark the problem area under study. In this study, the authors have delineated the current knowledge relating to the study problem in a brief and focused manner so the readers can identify and understand the linkage between the previous findings and the present study question, and he gets a clue to assess the contribution of the new study, and this is important for knowledge development in nursing (Parahoo, 1997). The methodology section begins with the inclusion criteria, and the authors clearly mentions the research design to be a descriptive comparative design. This is a qualitative research design with a sample size if eighty. Conforming to the criteria of a qualitative design, the authors provide more information about the research setting and the context of the study (French, 1999, 72-78). The sampling methods have been elaborated by prominent mention of the inclusion criteria that includes one ethical point and five other points that classify the laceration to be a minor laceration. Therefore, although indirect, there is a description of the population under the study. The authors have not used a separate heading for the procedure of the study, but they clearly describe the steps of the procedures that were employed in each case. This description increases the trustworthiness of the data collected and analysed. The qualitative and descriptive design indicates that within the study setting, the investigators collected data through participant observation and unstructured interviews, and the data would be naturally analyzed through thematic content analysis (Donaldson, 2000, 247-311). It can be commented that this is an accepted scientific approach that complements knowledge through positivist enquiry. Therefore, it can be expected that this study would attempt to generate a new theory about care in the ED that will reflect and explain the data collected, although qualitative designs are not concerned with the control of extraneous variables. The full context of the phenomenon is considered an important factor in understanding how it plays out in the lives of people experiencing it, and authors do not demonstrate any intent to control or identify any extraneous variables other than cursory mention. The reader may get interested in performing a research to know the role of such variables as waiting time in the triage that may be a denominator of many unknown factors (Parahoo, 1997). As mentioned earlier, the subjects of the research have been clearly identified by mention of the inclusion criteria. These are patients who would present to the ED with simple lacerations. These patients would be 16 years or older in age. Their lacerations would be superficial enough not to include bony involvement or involvement of neurovascular structures. There would be no facial or perineal involvement with the laceration, and the patients would be having no preexisting medical problems associated. Ethical considerations have been taken into account by including the criterion of informed and written patient consent in the inclusion criteria. Sampling is a process in which the researchers select representative part of the population of interest so that making valid inferences and generalizations is easily feasible. A sample has the benefit of decreasing the likelihood of nonsampling errors, such as measurement errors, biases, recording, or coding errors. Sampling is viewed by the academia as important for accurately representing the population and to determine the external validity or generalization of the research findings. It can be argued that since the researchers never knows the true population values; it is always difficult to determine if any given sample is truly representative of the population (Polit, Beck, Hungler, 2001). In this research, all the patients were initially assessed by the triage nurse, and initial assessment was done to identify patients who met inclusion criteria, and this was corroborated by a senior emergency physician, who assessed the severity of the wound. The suitability was assessed, and the triage nurse explained the procedure and sought and recorded written informed consent. Following this, the patients were randomly allocated two the groups mentioned before, and all the participants were followed up for recovery and outcomes. The outcomes of the study were mentioned as aims of the project, and they serve as the end points of this research. The outcomes in both the groups were compared to observe whether the waiting times differed, the patient perceptions of waiting time differed, whether the patient satisfaction differed between the groups, and whether the healing outcomes were different. Selecting the method of investigation is not a neutral phenomenon, rather it reflects the particular beliefs and the values of the researchers. In this study, the researchers apart from explaining the methodology in detail, did not mention the method of data collection or the questionnaires that were used to this end (Polgar & Thomas, 1995). This is apparently a drawback of this study since it is important for the readers to have such information so they can evaluate the authenticity and appropriateness of the data collection method and its relevance to the research question. The choice of method is a logical exercise that points to the researchers’ intents. From the description of the method, however, it seems clear that for the area of the research, the authors have selected the appropriate methodology (Parahoo, 1997). Thus study involves human subjects, therefore, it would have needed research ethics committee approval, but apart from written informed consent, there is no other reference to ethical clearance from any ethical body or committee. The patients were verbally explained about the study and its utility, and after they clearly understood what would be done to them, they signed the informed consent, and then only the study proceeded. Polgar & Thomas (1995) illustrates that researchers apply the principles which protect the participants in the research from harm or risk and follow professional and legal rules which are laid down in the code of Professional Conduct (NMC 2002) and research guidelines (Polgar & Thomas, 1995). The results of this research are well described, disciplined, and consolidated. The presentations of the results are also concise, but there are no graphics. The authors have used labeled tables to present the results, and the tables have been arranged according to the subsections of the research questions. This makes the journey of the reader easier through the study, since these tables contain the aims of this project according to the serial presented in the text. The data presented in the tables do not repeat in the text and vise versa, and rather the authors have presented their inferences from the data in the text (Sterling, 2001, 44-47). The frequency distribution of the demographics indicates that the patients belong to the age group of 16-92 with the mean age group of 38.6, indicating the average population attending any ED. This representative population had minor lacerations in the upper extremity, followed by head and lower extremities, in that frequency. Although no questionnaire was detailed, the authors have been right to analyze the data by nonparametric statistic in this ordinal or maldistributed data to demonstrate that both groups did not demonstrate any major differences in waiting time, wound healing. However, the patients were very satisfied with the care provided by the nurses. The discussion section was well presented, and this draws upon previous researches in this area. The works of Strange, 1994 has been sited to support the introduction of the advanced practice nurses and their roles in reduction of patient waiting time. The authors, however, has derived from these that reduction of waiting time influences patient satisfaction with the ED service (Strange, 1994, 20-23). The authors have slightly tackled the research of Bonadio et al., 1994 to deduce the satisfaction of these patients for such care (Bonadio, Carrey, Gustafson, 1994, 1144-1146), and the support to this finding has been found from the literature of Carney, 1994 and Covington et al., 1992 (Carney, 1994, 517-520) (Convington, Erwin, Sellars, 1992, 124-131). The authors derive data from table 4 results and support it again from the findings of Strange 1994 study (Strange, 1994, 20-23). This way of supporting data increases authenticity and external validity of the results, and it is important that to contribute to the pool of knowledge, results should be compared with findings from other studies and when these are different, possible explanations should be offered (Parahoo, 1997). The discussion is also balanced because the author mentioned the significance and relevance of the data. One of the first tasks of a critical reader is to find out if the research questions, objectives or hypotheses set at the start of the study have been addressed, and if not, reasons should be provided. Sometimes researchers only discuss results in which they are interested and/or support their particular views. As much as possible all results, positive or negative, should be discussed (Parahoo, 1997). In this research there were no negative findings that were reported in this study, but the reader is convinced that there is a very low probability of having a negative factor demonstrated in the study. This writer concludes that there is enough evidence to support that the implemented project in MMC CNS suturing programme is capable of reducing patient waiting time, producing similar wound outcomes, and improving patient satisfaction when minor lacerations are considered, and this may indicate a change in practice in order to provide quality care to the patients. There are no recommendations for further research. The research was well presented but the use of Triangulation Method could also be applied on the said research. Triangulation means combining more than one approach to research by using variety of approaches and or methods to provide different perspectives on the same phenomenon. It has also been mentioned that nurse researchers are increasingly combining qualitative and quantitative methods in order to understand more fully the world of research objects. In this study, the authors have converted the themes into quantitative data and have analyzed them (Stetler & Marram, 1976, 559-563). The statistical analysis has further strengthened the foothold of the logic and findings of this study. A structured interview may help to extract data more efficiently. These interviews are different from casual conversations in that they have a clearer agenda, often prepared in advance and a specific purpose, and are limited in duration. With clinical interviews, the aim is not only to obtain valuable information, but also build trust between the professional and the client (Parahoo, 1997). During in-depths interviews with participants it may become apparent that those assumptions were incorrect, thus demonstrating that the triangulation of data in that instance assisted in decreasing the researchers biasing influence on data interpretation (Begley, 1996). It is implied that in this study, the authors have used questionnaire, but the reader does have no clue as to what were the questions that were used to record findings. The research finding can be used in future for nurses and doctors, this is a good and interesting research and guide for the medical professionals. However, this writer suggests that more research is required to enable practitioners to rapidly identify which patients may be better treated by the nurses in the ED. If there would be another research coming regarding the same topic, this writer would be very willing to participate because this is one of the most interesting cases in Accident and Emergency where the author works. Reference List Australasian College of Emergency Medicine. 2000. The Australian Triage Scale. Carlton Vic.: Australasian College of Emergency Medicine. Baldwin, K. M., & Nail, L. M. (2000). Opportunities and challenges in clinical nursing research. Journal of Nursing Scholarship, 32, 163–166. Barr, M et al (2000) Patient satisfaction with a new nurse practitioner service. Accident & Emergency Nursing, 8, March, pp.144-147. Beales, J. (1997) Innovation in Accident and Emergency management: establishing a nurse practitioner-run minor injuries/primary care unit. Accident and Emergency Nursing, 5, January, pp.71-75. Begley, C.M. (1996) Using Triangulation in Nursing Research Journal of Advanced Nursing Vol 24 (1) pp 122-128 Bonadio, W., Carrey, M., Gustafson, D., (1994). 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