Symposium 19 Nursing research in the Emergency Department
Symposium lead and chair:
Cara Bailey, PhD Postgraduate Student and Phillip Miller, School of Nursing, University of Nottingham, Nottingham, United Kingdom ntxcb4@nottingham.ac.uk
Symposia focus:
Research in the Emergency Department (ED) is limited and consequently very little attention has been paid to the methodological and professional challenges that researchers face when conducting research in an acute, fast paced and task orientated area of the healthcare system. Despite the drive for evidence based practice in research, there is a significant lack of research experience amongst ED nurses. Ferns et al (2005) believes that this is partly due to a research hierarchy that exists within the research world and as the symposium illustrates nurses are frequently forced to adopt methodologies from other disciplines in the social sciences that are open to criticisms of credibility, trustworthiness and reliability. Restrictions on access and processes of informed consent are often seen as impracticable in an area of unpredictability and unexpected emergency presentations. Whilst, the Mental Capacity Act (Department of Health, 2005) sets out the provisions of informed consent for practitioners, it leaves much more to be consolidated for the researcher conducting research within the ED.
The symposium presents four papers associated with conducting research in the ED. It discusses the role of the researcher in a familiar clinical area, looks at the processes of recruitment, consent and the problems associated with patients presenting to the department unable to make informed decisions. It tackles the ethical and moral dilemmas of researching those who are colleagues and explores the problems of including patients presenting with a life threatening condition or at a time of trauma.
Despite the difficulties involved in planning, implementing and assessing research in the ED, research in the emergency care setting is crucial to the development of healthcare strategies and improvement of patient services. The symposium offers evidence from research in a large ED tackling problems of role, recruitment and consent and presents strategies to protect both the researcher and potential researched.
References:
- Department of Health. (2005) Mental Health Capacity. Department of Health, UK. Ferns, T. (2006) Violence and aggression in the emergency department: Factors impinging on nursing research. Accident and Emergency Nursing.14(1): 49-55
Source of Funding: Centre Social Research in Health and Healthcare. The Burdett Fund for Nursing
Level of Funding: N/A
Abstract 1: Conducting End of Life Care Research in the Emergency Department.
Cara Bailey RGN MN PhD Postgraduate Student, The University of Nottingham.
Introduction:
Despite recent strategies to improve end of life care across all areas of healthcare, very little attention has been paid to the Emergency environment. Conducting research in an Emergency Department (ED) is complex and consequently it is limited. From a qualitative study exploring end of life care in the ED, the paper draws on the dilemmas associated with conducting such research and offers a defined role in which to observe and explore sensitive issues in a fast paced, unpredictable environment.
Methods:
Informed observation was used to explore the daily practices of caring for the dying and the bereaved. Interviews with staff, patients and the bereaved accompany the observational data and provide an in depth insight into care when end of life becomes an emergency. Preliminary sensitising is crucial in order to overcome problems previously associated with observational healthcare research.
Findings:
Preliminary sensitising identified problems with education, societal barriers to end of life and avoidance of the bereaved, a disparity between the technological opportunities to save life and reality of imminence and an ambiguity over resuscitation efforts and prognosis. Through informed observation, the researcher was then able to explore these issues more deeply with the staff involved on a daily basis at the time of the emergency occurring.
Conclusion:
The paper draws on the experiences of conducting research in the Emergency Department and identifies problems of access, recruitment and the role of the researcher with the researched. The paper presents the role of the Informed Observer where the researcher is able to use previous knowledge and understanding of the emergency environment to gain an in depth understanding of end of life care in the emergency department. The role resolves previous dilemmas associated with practitioner research in an acute clinical setting.
Abstract 2: Postal Questionnaire Data Collection After Discharge From the Emergency
Phillip Miller RGN, Research Nurse Emergency Department. PhD Postgraduate Student, The University of Nottingham.
Introduction:
Unscheduled and emergency care present specific difficulties for researchers. Though emergency departments (ED) allow for complete capture of cases in injury research, making contact and recruiting patients in this setting poses practical challenges. Follow-up rates have been low in published studies. The following presentation reports the methods used to collect data from ED attendees including tactics designed to boost response rates.
Methods:
A postal questionnaire study was conducted in a large urban ED (148 000 new patient attendances). Cyclists involved in accidents and brought in for assessment and treatment received questionnaires sent out 2 weeks after discharge. A personalised covering letter from a consultant acted as the ‘first approach’ by clinical staff rather than a researcher as required by ethical guidelines. Consent was taken as implied by questionnaire completion. A reminder letter was triggered if no response was received within one month. A further questionnaire was sent at 6 months. Participants could request a results summary by tick box.
Results:
During the study period 138 baseline and 37 follow-up questionnaires were posted along with 90 reminders. Respectively 51% (n=71) and 49% (n=18) were returned with 5% (n=7) opting out. The mean age of respondents was significantly higher than non-responders although gender split and disposal were similar. Responders were representative of injury severity in other similar studies.
Discussion:
Reminder letters and personalised letters have both been shown to increase response rates. The response rate reported here is broadly equivalent to other more resource-intensive methods from the literature. Response rates should always be fully reported. Bias introduced by voluntary participation can be evaluated by comparison with non-responders and other cohorts to assess validity.
Conclusion:
Follow-up rates in ED research are often low with a potential for bias. This should be reported and evaluated. There may be an acceptable trade-off when resource considerations are important.
Abstract 3: On The Scene’ Crash Study Loughborough University’s Vehicle Safety Research Centre and The Emergency Department QMC, Nottingham
Introduction:
Injuries to ‘vulnerable road users’ (VRU; Cyclists, Motorcyclists and Pedestrians) in road accidents are a significant problem in the UK (DFT, 2005). The ‘On The Scene’ crash study run by Loughborough University’s Vehicle Safety Research Centre (VSRC) conducts detailed investigations of crashes in Nottinghamshire. In 2005 the study was extended to collect data on VRUs with the help of staff in the emergency department (ED) at the Queens Medical Centre in Nottingham.
Methods:
The VSRC crash team, alerted by Nottinghamshire Constabulary are conveyed to the scenes of accidents under blue lights, attending before much volatile data are disturbed. They collect video, eye witness and environmental data regarding the incident and for VRUs it is necessary to collect body measurements, details of clothing and external injury details to establish body/vehicle and body/environment impact points to reconstruct accident progression. This information can often only be collected once the casualty has been assessed and stabilised in the ED. Hospital staff are sent a pack of study documentation to complete when research staff are not available.
Discussion:
Data has been successfully collected by a research nurse in the department, trained to gain consent and collect the required data once alerted by pager. Despite considerable effort in communicating the study aims to other medical and nursing staff little usable data has been collected by them. Problems have stemmed from the intermittent nature of presentations leading to unfamiliarity with procedures, the requirement to gain written consent and difficulty in undertaking research activity in between clinical responsibilities.
Conclusion:
Dedicated research staff are vital to ensure that research activity can be conducted in emergency settings. Clinical staff are rarely able to undertake such non-clinical activities and despite training the quality of data collected may be poor. DFT (2005) Road Casualties in Great Britain 2004: Annual Report. Department of Transport, London.
Abstract 4: The UK Burden of Injury Project (BOI)
Introduction:
The UK Burden of Injury Project (BOI) is a multi-centre study investigating the longer term effects of accidental injury on a cohort of over a thousand people attending emergency departments (ED). The study uses questionnaires completed over a follow-up period of one year. Participants are identified and recruited in emergency departments using a quota system to ensure adequate sampling of different injury locations and age groups.
Methods & results:
Under guidance for Good Clinical Practice for research projects NHS patients should not be approached to participate in research by research staff directly. A member of staff with responsibility for care should identify eligible patients and check with the patient that they are willing to discuss participation with a researcher; the ‘first approach’. For the BOI, research assistants worked in shifts in relevant areas of the hospital. They built a rapport with staff explaining the study aims and in particular the quota system so that potential participants were accurately identified. Despite this many potential patients were ‘missed’ as staff failed to identify them or make an approach. Because of low recruitment a request to allow invitation letters to be sent out to eligible patients after discharge was submitted to the Main Research Ethics Committee who had reviewed the study. Permission was refused. The MREC was concerned that confidentiality could be compromised if another member of the patient’s household discovered that the patient had attended the ED. Some quotas for injury categories and age groups were not filled potentially reducing the validity of the sample.
Discussion:
Recruitment of ED patients is vital to injury research. Ethical protection of potential participants is important. Requirements for a ‘first approach’ only by clinical staff and a restrictive interpretation of ethical principles may threaten research studies despite honourable intentions.