Handheld ultrasound versus standard machines for placement of peripheral IV catheters: A randomized, non-inferiority study.

INTRODUCTION: Ultrasound guided IV catheter (USGIV) access occurs frequently in Emergency Departments (EDs). This task is often performed using large, expensive, cart-based ultrasound systems (CBUS) which are frequently needed for other ED ultrasound functions and can be cumbersome to use and store. Handheld ultrasounds (HHUs) may be able to meet this need, but it is unknown if they function interchangeably with CBUS for USGIV placement. We performed a prospective, randomized, noninferiority study to compare the success rate of HHUs to CBUSs for placing USGIVs. METHODS: ED patients 18 and older needing an USGIV were approached for enrollment and randomized to receive an USGIV placed by CBUS or HHU. USGIVs were placed by any ED physician or nurse trained in placement. A placement was considered attempted upon needle entry into the skin. An USGIV was successful if it was immediately flushable with saline. Data was collected on the success of IV placement, number of attempts, IV and provider characteristics, patient demographics, and length of time the USGIV lasted. Demographics and operator and IV characteristics were analyzed using Pearson's Chi square, Fischer's Exact test, or Wilcoxon rank sum tests. Non-inferiority was assessed using the Farrington-Manning test. Results were approached per protocol and analyzed in R. RESULTS: 312 patients were enrolled. Patient and IV characteristics were similar between groups. There was no difference in the number of successful USGIVs placed in either group (p≥0.9) with 146 in the CBUS group and 145 in the HHU group. There was no difference in the first attempt success rate between groups (p = 0.8) and HHU was noninferior to CBUS for successful USGIV placement (p = 0.0001). The rate of premature USGIV failure was similar between HHU and CBUS (4.0 % and 6.7 %). CONCLUSION: HHU was noninferior to CBUS for successful USGIV placement. There was no difference in the rate of first attempt success at placement or USGIV survival to a patient's ED disposition between groups. No significant additional training was required for ED providers of all levels to use the HHUs.

Healthcare provider perspectives on emergency department-initiated buprenorphine/naloxone: a qualitative study.

BACKGROUND: Take-home buprenorphine/naloxone is an effective method of initiating opioid agonist therapy in the Emergency Department (ED) that requires ED healthcare worker buy-in for large-scale implementation. We aimed to investigate healthcare workers perceptions of ED take-home buprenorphine/naloxone, as well as barriers and facilitators from an ED healthcare worker perspective. METHODS: In the context of a take-home buprenorphine/naloxone feasibility study at a tertiary care teaching hospital we conducted a descriptive qualitative study. We conducted one-on-one in person or telephone interviews and focus groups with ED healthcare workers who cared for patients given take-home buprenorphine/naloxone in the feasibility study at Vancouver General Hospital from July 2019 to March 2020. We conducted 37 healthcare worker interviews from December 2019 to July 2020. We audio recorded interviews and focus groups and transcribed them verbatim. We completed interviews until we reached thematic saturation. DATA ANALYSIS: We inductively coded a sample of transcripts to generate a provisional coding structure and to identify emerging themes, which were reviewed by our multidisciplinary team. We then used the final coding structure to analyze the transcripts. We present our findings descriptively. RESULTS: Participants identified a number of context-specific facilitators and barriers to take-home buprenorphine/naloxone provision in the ED. Participants highlighted ED conditions having either facilitative or prohibitive effects: provision of buprenorphine/naloxone was feasible when ED volume was low and space was available but became less so as ED volume increased and space decreased. Similarly, participants noted that patient-related factors could have a facilitative or prohibitive effect, such as willingness to wait (willing to stay in the ED for study-related activities and buprenorphine/naloxone initiation activities), receptiveness to buprenorphine/naloxone, and comprehension of the instructions. As for staff-related factors, time was identified as a consistent barrier. Time included time available and time required to initiate buprenorphine/naloxone (including time building rapport). Healthcare worker familiarity with buprenorphine/naloxone was noted as either a facilitating factor or a barrier, and healthcare workers indicated that ongoing training would have been advantageous. Many healthcare workers identified that the ED is an important first point of contact for the target patient population. CONCLUSION: Integrating a buprenorphine/naloxone program into ED care requires organizational supports (e.g., for managing buprenorphine/naloxone within limitations of ED volume, space, and time), and ongoing education of healthcare workers to minimize identified barriers.

Effects of Using Virtual Reality Technology on Pain and Hemodynamic Variables in Patients Receiving Hand Laceration Repair in an Emergency Department: A Randomized Controlled Trial.

BACKGROUND: Pain and altered hemodynamic variables are among the most common complications in patients undergoing hand laceration repair in an Emergency Department. AIM: This study aimed to evaluate the effects of using virtual reality (VR) technology on pain and hemodynamic variables in patients receiving hand laceration repair in an Emergency Department. METHOD: This nonblinded randomized clinical trial included 160 patients undergoing laceration repair to their hands under local anesthetics from November 2020 to May 2021. The participants were randomly allocated to the experimental and control groups. Patients in the control group received routine care (such as ambient noise reduction, providing explanations about the surgery, and Lidocaine injection before the surgery). In the experimental group, a video containing natural landscapes and sounds was played using a semi-immersive VR headset during the surgery. Pain level and hemodynamic variables were measured immediately before and after the intervention. The pain was measured using the Critical Care Pain Observation Tool and Visual Analog Scale. RESULTS: Immediately after the intervention, systolic blood pressure (BP), respiration rate, and pain intensity were significantly lower in the intervention group compared with the control group (p < .05). There were no significant differences between the intervention and control groups regarding diastolic BP, mean BP, SPO2, heart rate, and muscular tension (p > .05). CONCLUSIONS: Semi-immersive VR is effective in managing pain and hemodynamic variables during hand laceration repair. The nurses could use the semi-immersive VR to better control of pain and hemodynamic variables during hand laceration repair.

Emergency department triage decision-making by registered nurses: An instrument development study.

AIM: To develop and psychometrically test the triage decision-making instrument, a tool to measure Emergency Department Registered Nurses decision-making. DESIGN: Five phases: (1) defining the concept, (2) item generation, (3) face validity, (4) content validity and (5) pilot testing. METHODS: Concept definition informed by a grounded theory study from which four domains emerged. Items relevant to the four domains were generated and revised. Face validity was established using three focus groups. The target population upon which the reliability and validity of the triage decision-making instrument was explored were triage registered nurses in emergency departments. Three expert judges assessed 89 items for content and domain designation using a 4-point scale. Psychometric properties were assessed by exploratory factor analysis, following which the names of the four domains were modified. RESULTS: The triage decision-making instrument is a 22-item tool with four factors: clinical judgement, managing acuity, professional collaboration and creating space. Focus group data indicated support for the domains. Expert review resulted in 46 items with 100% agreement and 13 with 66% agreement. Fifty-nine items were distributed to a convenience sample of 204 triage nurses from six hospitals in 2019. The Kaiser-Meyer-Olkin measures indicated that the data were sufficient for exploratory factor analysis. Bartlett's test indicated patterned relationships among the items (X 2 (231) = 1156.69). An eigenvalue of >1.0 was used and four factors explained 48.64% of the variance. All factor loadings were ≥0.40. Internal consistency was demonstrated by Cronbach's alphas of .596 factor 1, .690 factor 2, .749 factor 3 and .822 for factor 4. CONCLUSION: The triage decision-making instrument meets the criteria for face validity, content validity and internal consistency. It is suitable for further testing and refinement. IMPACT: The instrument is a first step in quantifying triage decision-making in real-world clinical environments. The triage decision-making instrument can be used for targeted triage interventions aimed at improving throughput and staff education. STATISTICAL SUPPORT: Dr. Tak Fung who is a member of the research team is a statistician. STATISTICAL METHODS: Development, validation and assessment of instruments/scales. Descriptive statistics. REPORTING METHOD: STROBE cross-sectional checklist. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: The TDI makes the complexity of triage decision-making visible. Identifying the influence of decision-making factors in addition to acuity that affect triage decisions will enable nurse managers and educators to develop targeted interventions and staff development initiatives. By extension, this will enhance patient care and safety.

Emergency department staff experiences of the Bröset Violence Checklist.

AIM: Work-related violence is a significant problem in healthcare settings and emergency departments are one of the highest at-risk locations. There have been significant challenges in identifying successful risk-mitigation strategies to reduce the incidence and impact of work-related violence in this setting. This research explores the perspectives of clinical staff who routinely use violence risk assessment to provide recommendations for improvements. DESIGN: This qualitative research used interviews of staff who routinely use of the Bröset Violence Checklist in an emergency department. The study was conducted in April 2022. METHOD: Interview transcripts were subjected to Thematic Analysis to explore participants' clinical experiences and judgements about the utility of the Bröset Violence Checklist. RESULTS: Eleven staff participated in semi-structured interviews. Participants described themes about the benefits of routine violence risk assessment and the influence of the subjective opinion of the scorer with respect to the emergency department patient cohort. Four categories of violence risk factors were identified: historical, clinical, behavioural and situational. Situational risks were considered important for tailoring the tool for context-specificity. Limitations of the BVC were identified, with recommendations for context-specific indicators. CONCLUSION: Routine violence risk assessment using the Bröset Violence Checklist was deemed useful for emergency departments, however, it has limitations. IMPACT: This study's findings offer potential solutions to reduce violence affecting front-line workers and practical processes that organizations can apply to increase staff safety. IMPLICATIONS: The findings produced recommendations for future research and development to enhance utility of the Bröset Violence Checklist. REPORTING METHOD: EQUATOR guidelines were adhered to and COREQ was used. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution was involved in this study.

Emergency nurses' experiences of caring for brought-in-dead persons and their relatives-a qualitative study.

AIM: To explore how emergency nurses experienced caring for brought-in-dead persons and their relatives, and what hindered or facilitated this care in an emergency setting. DESIGN: A qualitative study using Interpretive Description. METHODS: Data were collected as individual interviews with 13 nurses at seven Danish emergency departments from February to June 2023. FINDINGS: Our analysis revealed the overarching theme 'Navigating the complexities of providing holistic care in a constrained environment', covering five sub-themes: (1) An important yet not recognized nursing task; (2) Pending care needs of the living and the dead; (3) No physical or mental room for the brought-in-dead persons; (4) Utilizing personal experiences in the absence of formal education and training and (5) Navigating professionalism and empathy. CONCLUSION: Emergency departments posed unique challenges in providing care to brought-in-dead persons and their relatives. IMPLICATIONS FOR THE PROFESSION: The unrecognized nature of caring for brought-in-dead persons and their relatives suggests a universal undervaluation of this care in emergency departments. IMPACT: Care for brought-in-dead persons and their relatives is neither recognized nor evidence-based. This study initiates a discussion of the circumstances for delivering care for persons brought-in-dead and has an impact on nurses and nursing leaders employed in emergency departments. REPORTING METHOD: The Consolidated Criteria for Reporting Qualitative Research (COREQ). PATIENT OR PUBLIC CONTRIBUTION: None.

Data-Driven Implementation Strategy to Optimise Clinician Behaviour Change at Scale in Complex Clinical Environments: A Multicentre Emergency Care Study.

AIM: To develop an evidence-driven, behaviour change focused strategy to maximise implementation and uptake of HIRAID (History including Infection risk, Red flags, Assessment, Interventions, Diagnostics, communication and reassessment) in 30 Australian rural, regional and metropolitan emergency departments. DESIGN: An embedded, mixed-methods study. METHODS: This study is the first phase of a step-wedge cluster randomised control trial of HIRAID involving over 1300 emergency nurses. Concurrent quantitative and qualitative data were collected via an electronic survey sent to all nurses to identify preliminary barriers and enablers to HIRAID implementation. The survey was informed by the Theoretical Domains Framework, which is a synthesis of behavioural change theories that applies the science of intervention implementation in health care to effect change. Quantitative data were analysed using descriptive statistics and qualitative data with inductive content analysis. Data were then integrated to generate barriers and enablers to HIRAID implementation which were mapped to the Theoretical Domains Framework. Corresponding intervention functions and Behaviour Change techniques were selected and an overarching implementation strategy was developed through stakeholder consultation and application of the APEASE criteria (Affordability, Practicability, Effectiveness and cost-effectiveness, Acceptability, Side-effects/safety and Equity). RESULTS: Six barriers to HIRAID implementation were identified by 670 respondents (response rate ~58%) representing all 30 sites: (i) lack of knowledge about HIRAID; (ii) high workload, (iii) lack of belief anything would change; (iv) not suitable for workplace; (v), uncertainty about what to do and (vi) lack of support or time for education. The three enablers were as follows: (i) willingness to learn and adopt something new; (ii) recognition of the need for something new and (iii) wanting to do what is best for patient care. The 10 corresponding domains were mapped to seven intervention functions, 21 behaviour change techniques and 45 mechanisms. The major components of the implementation strategy were a scaffolded education programme, clinical support and environmental modifications. CONCLUSIONS: A systematic process guided by the behaviour change wheel resulted in the generation of a multifaceted implementation strategy to implement HIRAID across rural, regional and metropolitan emergency departments. Implementation fidelity, reach and impact now require evaluation. IMPACT: HIRAID emergency nursing assessment framework reduced clinical deterioration relating to emergency care and improved self-confidence and documentation in emergency departments in pilot studies. Successful implementation of any intervention in the emergency department is notoriously difficult due to workload unpredictability, the undifferentiated nature of patients and high staff turnover. Key barriers and enablers were identified, and a successful implementation strategy was developed. This study uses theoretical frameworks to identify barriers and enablers to develop a data-driven, behavioural-focused implementation strategy to optimise the uptake of HIRAID in geographically diverse emergency departments which can be used to inform future implementation efforts involving emergency nurses. REPORTING METHOD: The CROSS reporting method (Supporting Information S3) was used to adhere to EQUATOR guidelines. PATIENT OR PUBLIC CONTRIBUTION: No Patient or Public Contribution. TRIAL REGISTRATION: Australian New Zealand; Clinical Trials Registry (ANZCTR) number: ACTRN12621001456842, registered 25/10/2021.

Nurses under fire: Insights from testimonies of community nurses and midwives in nonhospital settings in the southern Israel conflict zone.

Nurses-with or without prehospital care training-may find themselves delivering immediate care to injured individuals outside a healthcare facility, sometimes even in situations where their own life is at risk. This study explores the experiences of community nurses and midwives who provided immediate care during the Hamas militant movement's attack in southern Israel. The researchers collected and analyzed eight nurse and midwife survivors' testimonies published in digital media to gain a deeper understanding of their perspectives. Through qualitative content analysis, common themes, patterns, and insights were identified. The study aimed to contribute valuable knowledge in this field and followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist for methodological rigor. Two themes emerged from the testimonies, focusing on the nurses' swift realization of necessary action under fire and resilience and ingenuity in practice. Despite lacking training and resources, the nurses professionally assessed the situation and improvised creative solutions to care for the wounded. Although they had no prehospital emergency care background, community nurses and midwives were able to respond effectively, providing lifesaving care. The findings highlight the nurses' resilience, adaptability, and dedication in unprecedented situations. However, the study also emphasizes the importance of providing all nurses with baseline prehospital care training and structured planning of this care to empower them to deliver optimal patient care in uncertain and dangerous conditions, especially in and around conflict and disaster zones.

Interventions to improve nurse-family communication in the emergency department: A scoping review.

AIM: To determine and describe what interventions exist to improve nurse-family communication during the waiting period of an emergency department visit. BACKGROUND: Communication between nurses and families is an area needing improvement. Good communication can improve patient outcomes, satisfaction with care and decrease patient and family anxiety. DESIGN: Scoping Review. METHODS: A scoping review was conducted following the Joanna Briggs Institution methodology: (1) identify the research question, (2) define the inclusion criteria, (3) use a search strategy to identify relevant studies using a three-step approach, (4) select studies using a team approach, (5) data extraction, (6) data analysis, and (7) presentation of results. DATA SOURCES: Medline, CINAHL, EMBASE, PsychInfo and grey literature were searched on 3 August 2022. RESULTS: The search yielded 1771 articles from the databases, of which 20 were included. An additional seven articles were included from the grey literature. Paediatric and adult interventions were found targeting staff and family of which the general recommendations were summarised into communication models. CONCLUSION: Future research should focus on evaluating the effectiveness of interventions using a standardised scale, understanding the specific needs of families, and exploring the communication models developed in this review. IMPLICATIONS FOR CLINICAL PRACTICE: Communication models for triage nurses and all emergency department nurses were developed. These may guide nurses to improve their communication which will contribute to improving family satisfaction. REPORTING METHOD: PRISMA-ScR. TRIAL AND PROTOCOL REGISTRATION: Protocol has been registered with the Open Science Framework, registration number 10.17605/OSF.IO/ETSYB. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

"Working in the emergency department is not a job; it's like a war" A narrative inquiry and interpretive phenomenology of the violence experienced by emergency nurses in Turkey.

AIMS: This study aims to reveal the violent experiences of nurses working in the emergency department and the meanings they attribute to them. METHODS: This research was conducted as narrative inquiry and interpretive phenomenology and recruited 15 nurses. Interviews with nurses actively working in the emergency department and who had been exposed to violence by patients or their relatives were conducted with a semi-structured interview form. The consolidated criteria for reporting qualitative research (COREQ) checklist was used. RESULTS: In the study, three themes were determined (1) Unpredictable event, (2) Interminable effects of violence, and (3) Like a bottomless pit. With seven sub-themes. CONCLUSIONS: This study underlined that violence applied to nurses by patients or relatives of patients in the emergency department is an unexpected situation that causes negative emotions. Violence affects all aspects of life and limits communication with the patient. Coping with a violent situation is challenging for nurses, and they demand support from the management.

Triage-clinical reasoning on emergency nursing competency: a multiple linear mediation effect.

BACKGROUND: Triage is the first step in providing prompt and appropriate emergency nursing and addressing diagnostic issues. Rapid clinical reasoning skills of emergency nurses are essential for prompt decision-making and emergency care. Nurses experience limitations in emergency nursing that begin with triage. This cross-sectional study explored the mediating effect of perceived triage competency and clinical reasoning skills on the association between Korean Triage and Acuity Scale (KTAS) proficiency and emergency nursing competency. METHODS: A web-based survey was conducted with 157 emergency nurses working in 20 hospitals in South Korea between mid-May and mid-July 2022. Data were collected utilizing self-administered questionnaires to measure KTAS proficiency (48 tasks), perceived triage competency (30 items), clinical reasoning skills (26 items), and emergency nursing competency (78 items). Data were analyzed using the PROCESS macro (Model 6). RESULTS: Perceived triage competency indirectly mediate the relationship between KTAS proficiency and emergency nursing competency. Perceived triage competency and clinical reasoning skills were significant predictors of emergency nursing competency with a multiple linear mediating effect. The model was found have a good fit (F = 8.990, P <.001) with, a statistical power of 15.0% (R² = 0.150). CONCLUSIONS: This study indicates that improving emergency nursing competency requires enhancing triage proficiency as well as perceived triage competency, which should be followed by developing clinical reasoning skills, starting with triage of emergency nurses.

Patient trust in nurses: exploring the relationship with care quality and communication skills in emergency departments.

BACKGROUND: Patient trust in medical staff is an important ethical issue that can influence various patient behaviors and attitudes, such as seeking healthcare, sharing confidential information, accepting treatment, and adhering to recommendations. This study aimed to assess patient trust in nurses and its relationship to the quality of care and communication skills of nurses in emergency departments. METHODS: This descriptive correlational study was conducted in 2023 in the emergency departments of medical training centers of Ardabil University of Medical Sciences, Iran. A total of 378 patients was selected using a quota sampling method. Data were collected using three valid and reliable tools: the Quality Patient Care (QUALPAC) scale, the Health Communication Feedback Questionnaire (HCFQ), and the Trust in Nurses Scale (TNS).The data were analyzed using independent t-tests, one-way analysis of variance, and Pearson's correlation coefficient tests using SPSS version 24. RESULTS: The majority of patients (99.2%) rated nurses' communication skills as moderate, with none rating them as poor. The average scores were 27.59 ± 2.76 for patient trust in nurses, 72.43 ± 3.30 for nurses' communication skills, and 198.30 ± 14.60 for the quality of nursing care. A significant correlation was found between patient trust in nurses and the overall quality of nursing care (r = 0.256, P < 0.001) as well as its dimensions. However, there was no significant relationship between patient trust in nurses and patient's perception of the nurses' communication skills (r = 0.046, P = 0.369). CONCLUSIONS: The findings indicate that patient trust in nurses is positively and significantly associated with the perceived quality of nursing care. As the quality of care improves, patient trust in nurses also increases. Therefore, nurses should focus on providing high-quality care to enhance patient trust.

Perceived academic anxiety and procrastination among emergency nursing students: the mediating role of cognitive emotion regulation.

AIM: Explore the mediating role of cognitive emotion regulation strategies used by nursing students between academic anxiety and procrastination. DESIGN: A descriptive correlational design was used. SETTING: This study was carried out in the faculty of nursing at the University of Alexandria. SAMPLE: The participants in this study were all students enrolled in emergency nursing during the second semester of the academic year 2021-2022 and a convenience sampling of 654 nursing students. The Sobel test was used as a statistical method to determine the significance of a mediation effect by assessing whether the relationship between perceived academic anxiety and procrastination was significantly reduced when cognitive emotion regulation was included, using coefficients and standard errors from regression models to calculate the test statistic. TOOLS: Academic Anxiety Scale, Academic Procrastination Scale, and Cognitive Emotion Regulation Questionnaire were used to collect data. RESULTS: The study found that 46.5% of students reported high anxiety levels, with 40.1% perceiving moderate anxiety and only 11.3% experiencing low anxiety. Moreover, 80.4% of nursing students showed moderate academic procrastination. There is a positive correlation between procrastination and academic anxiety, with Adaptive and maladaptive coping strategies mediating this relationship, according to the Sobel test. CONCLUSION: Based on the results, it can be concluded that there is a complex causal and effect relationship between academic anxiety and procrastination. Nursing students may resort to academic procrastination as a means of coping. Therefore, reducing anxiety, correcting maladaptive behaviors, and enhancing adaptive cognitive and emotional regulation strategies could effectively reduce academic procrastination.

Frailty means falling between the cracks: A qualitative study exploring emergency nurses' understanding of frailty and its use in informing clinical decision-making related to acuity, care, and disposition.

THE PURPOSE: Of this study was to understand emergency nurses' use of frailty to inform care, disposition decision-making, and further assessment. METHODS: A qualitative, descriptive, exploratory approach was used. Field notes from group discussions held during a conference presession on frailty and post-session evaluation data were analyzed. RESULTS: Two common ideas threaded these discussions: frailty as vulnerability to "falling through the cracks" and that of an iceberg. Participants stressed the broad and expansive ramifications of frailty, and lack of structure/process to accurately describe, quantify, and utilize the concept. Participants described issues of physical and emotional/social fragility, including being unable to complete activities of daily living independently; also of concern were the patients' social determinants of health and financial challenges. CONCLUSION: The conceptual understanding of frailty encompassed physical, social, cognitive, and access deficits. Emergency nurses are aware of this concept and would conduct formal frailty screening if provided with training, time, and resources.

NICHE in the geriatric emergency department (GED): The pivotal role of geriatric nurse champions and leaders in interprofessional GED care excellence.

Older adults need specialized care in the emergency department (ED) setting. Geriatric ED (GED) guidelines and the Geriatric ED Accreditation (GEDA) program address these unique needs with specific recommendations and requirements. These recommendations and requirements align with the Nurses Improving Care for Healthsystem Elders (NICHE) practice model. NICHE program evidence-based nursing practice protocols, education for nurses and other clinicians, and patient and family educational resources facilitate organizations' implementation of the recommendations and requirements to achieve improved outcomes for older adults requiring emergency care. NICHE, the GED guidelines, and the GEDA program provide standards and resources that prepare and equip ED geriatric nurse champions.

Moral courage of emergency nurses in care-limited environments: A mixed-methods study.

BACKGROUND: Professional ethics in nursing exist to guide care and allow for decision-making to be patient-centered. In the current medicolegal landscape post-Roe and in light of bans on gender-affirming care, the decision-making processes of emergency nurses in the clinical environment of care as informed by both professional and personal ethics are an important area of inquiry. AIM: The aim of this study was to examine the contribution of moral courage to decision-making by emergency nurses. RESEARCH DESIGN: A mixed-methods exploratory sequential approach was used, using a standard demographics form and the Nurses Moral Courage Scale to collect quantitative data. These data were used to inform an interview guide for qualitative data collection. Situational analysis was used to analyze the interview data. ETHICAL CONSIDERATIONS: Prior to recruitment, this study was reviewed and approved by the University of Massachusetts IRB (#00003909). Participants were provided with an informed consent document at the time of registration and at the time of interview; participants provided both signed consent and verbal assent. Participants were assigned study codes to maintain anonymity and data were maintained in a secure University cloud. PARTICIPANTS AND RESEARCH CONTEXT: US-based emergency nurses working in environments with care limitations. RESULTS: 70% of respondents reported that they would speak up if they were aware of a situation that was ethically challenging. Respondents reported that it was fairly easy or very easy to defend their values when addressing ancillary staff, coworkers, authorities outside the organization, patients, and patient families. Respondents reported challenges in defending their professional values to charge nurses, physicians, or administrators. In response to a serious ethical problem, 65.8% of respondents answered that they would bring up the problem for discussion, 21.1% would file an internal report, and 13.2% would report externally. Interview participants reported significant social and professional barriers to acting in response to an ethical violation. Willingness to act centered on personal values and not professional codes of ethics. CONCLUSIONS: While emergency nurses in this study reported high perceived levels of moral courage, they also reported low willingness to act directly, citing burnout and significant social and professional barriers. Adherence to professional codes of ethics is not the primary driver of moral courage.

The Effect of Mandatory Triage Questions on Triage Processes: A Qualitative Exploratory Study.

INTRODUCTION: The study purpose was to obtain an understanding of both the types of questions mandated for the triage encounter in emergency departments across the United States and how emergency nurses perceive the relevance of these questions to the triage process. METHODS: A qualitative descriptive exploratory study using focus group data was used. Data were collected at an in-person emergency nursing conference held in September 2022. Data were analyzed using Mayring's 8-step process. RESULTS: Participants (n = 35) voiced concerns about a lack of expertise at all points in the triage process. The overarching problem is reported as data required by regulatory agencies are conflated with triage assessment information. Participants in this study reported that the conflation of the triage assessment with regulatory compliance is causing significant issues in the ability of emergency nurses to appropriately evaluate patient presentations. Thematic categories were identified as who's assessing the patients? assessment or compliance? important questions, situationally important questions, questions asked before discharge, and the lack of emergency nurse input. DISCUSSION: The conflation of regulatory data collection with patient assessment at the initial triage encounter challenges the ability of the emergency nurse to rapidly and accurately identify patients at risk of deterioration. We recommend that initial triage processes encompass questions that focus on establishing the stability of the patient and the safety of the waiting room and include inquiry relevant to the patient presentation.

Emergency Management and Nursing Considerations of Carotid Blowout Syndrome.

INTRODUCTION: Carotid blowout syndrome is a rare but fatal complication often witnessed secondary to treating patients with head and neck cancer. It occurs when damage and necrosis lead to the carotid artery wall rupture. The symptoms encountered in these patients range from asymptomatic to cardiac arrest. Here, we present 5 cases of carotid blowout syndrome in the emergency department. CASE PRESENTATIONS: Patients demonstrated symptoms ranging from subtle bleeding to hemodynamic instability, highlighting the diverse nature of carotid blowout syndrome in this population. Notably, while all patients had a history of radiotherapy, some had additional risk factors for carotid blowout syndrome, including prior surgery (n = 2), malnutrition (n = 3), and tracheostomies (n = 2). Definitive diagnoses were established through clinical evaluation and computed tomography angiography. Immediate interventions included bleeding control, resuscitation, and consultations with relevant specialties. Four patients underwent interventional radiology procedures, and 1 patient received otolaryngology care. While 2 patients recovered completely, 1 died in the emergency department, and 1 in the intensive care unit. One patient's clinical course was complicated by a stroke. CONCLUSION: The approach to the carotid blowout syndrome patient includes complex steps that proceed in a multidisciplinary manner, starting from triage until discharge. Emergency nurses play crucial roles at every stage. They should be aware of carotid blowout syndrome when evaluating patients with head and neck cancer presenting with bleeding. When treating these patients, emergency nurses should be ready for airway interventions, bleeding control, and massive transfusion protocol. In this context, the multifaceted approaches made by nurses contribute significantly to carotid blowout syndrome management in the emergency department.

Using a Behavior Assessment Tool to Decrease Restraint Use in the Emergency Department.

INTRODUCTION: Behavioral health visits to emergency departments have increased, increasing the risk of patient violent agitation that may require restraints to control. Our objective was to determine whether using the Behavioral Activity Rating Scale and treatment recommendations matched to patient scores would affect the number of patients who required physical restraints during their stay in the emergency department. METHODS: In this quality improvement project, nursing performed Behavioral Activity Rating Scale assessments on all behavioral health patients who presented to the emergency department, occurring during triage and at regular intervals with vital signs. Data were collected for a period before implementation and compared with data collected after implementing the Behavioral Activity Rating Scale workflow. Patients who required restraints during their stay, patients who required 2 or more restraints during their stay, and timing of restraint application were analyzed. RESULTS: Results show a decrease in the number of patients who required restraints during their ED stay, decreasing from a rate of 8.7% to 7.0% (P = .02). There was also a decrease in the number of patients who required multiple restraints, from a rate of 82.2% to 27.2% (P < .001). There was no difference in the number of patients who required restraints 1 hour after their arrival before versus after intervention (P = .40). DISCUSSION: Early recognition of patient agitation is essential in appropriate treatment of that agitation. The Behavioral Activity Rating Scale assessment is an effective tool to quantify a patient's agitation level. When coupled with treatment recommendations or protocols, it may decrease restraint use in the emergency department.

Establishing Triage Competencies and Verification Processes: A Survey Study.

INTRODUCTION: Although the ED triage function is a critical means of ensuring patient safety, core competencies for ED triage are not well defined in the literature. The purpose of the study was to identify and validate emergency triage nursing competencies and to develop a competency verification process. METHODS: A sample of 1181 emergency nurses evenly divided between roles with oversight of triage training and competency assessment (manager-level and staff nurses performing triage) completed an online survey evaluating competency elements that comprised the following in terms of frequency and importance, training modalities, and evaluation methods: expert assessment, clinical judgment, management of medical resources, communication, and timely decisions. RESULTS: Both manager-level and triage nurses agreed on the importance of the identified competencies. Gaps in training and evaluation were reported by both staff nurses and manager-level nurses. Triage nurses reported less training offered and less competency evaluation compared with manager-level nurses. Triage nurses reported performing all competencies more frequently and at higher level of competency than manager-level nurses reporting on triage nurse performance. DISCUSSION: This study provides both a standard set of triage competencies and a method by which to evaluate them. Managers and educators might consider this standard to establish initial triage role competency and periodic competency assessment per institutional guidelines. The gap in perceived education and evaluation suggests that standard education and evaluation processes be adopted across emergency departments.