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Factors Affecting the Proce ss of Clinical Decision-Mak ing in Pediatric Pain Management by Emergency Department Nurses by Teresa A. Russo A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy College of Nursing University of South Florida Major Professor: Susa n C. McMillan, Ph.D. Lois O. Gonzalez, Ph.D. Janine Overcash, Ph.D. Kevin Kip, Ph.D. Date of Approval: April 14, 2010 Keywords: triage, prioritize, pediatric pain assessment, injury, children in the Emergency Department Copyright 2010, Teresa A. Russo
Dedication This dissertation is dedicated first to the many infants and children I have encountered at triage in the Emergency Depa rtment who made me aware of their needs for pain relief and compassion. Secondly, fo r my daughter Lindsay who has been my primary support throughout this endeavor; my family for supporting me, feeding me, and serving as my stress-buster team when neede d. And finally, but certain ly not last, to my late father, Pasquale, who inst illed in me a principled appr oach to life, and whatever challenges I may face along the way.
Acknowledgements I would like to thank my family for their emotional support and understanding during this long journey my daughter Lindsay, who was always there to listen and help with whatever needed to be attended to, my sisters, and my nieces who always made me laugh just when I needed some stress relief. My dissertation committee has been esp ecially helpful, even through several committee member changes. A special thank you goes out to each of you. To Dr. Lois Gonzalez for helping me conceptualize my re search and bring my thoughts to words, and a plan to move forward. To Dr. Kromrey fo r his statistical advice and kind, calm manner. Dr. Susan McMillan was especially gracious for stepping in as my committee chair and guiding me through the final stages and disse rtation defense. Dr Kevin Kip provided invaluable statistical expe rtise to get the data analyzed and guide me through understanding the logistic regression maze. And thanks to Dr. Cathy Meade for serving as my examining committee chair at the last minute. I would like to acknowledge and thank the Sigma Theta Tau International Delta Beta-at-large chapter for the research gran t award in May, 2009, which not only helped me financially, but gave me encouragement to push a little harder to get my dissertation done. Thank all of you for helping me see this through to completion.
i Table of Contents List of Tables iv List of Figures v Abstract vi Chapter One Introduction 1 Purpose 3 Research Questions 4 Significance of Study 5 Conceptual Framework 7 Assumptions 11 Definition of Terms 11 Chapter Two Review of Literature 13 Practitioners, Parents, and Discrepancies 14 Cultural Factors 15 Problems with Pediatric Emergency Care 16 Role of the Triage Nurse 18 Clinical Decision Making 19 Summary 22 Chapter Three Methods Phase One 23 Sample and Setting 24 Inclusion and Exclusion criteria 24 Instruments 25 Reliability and Validity in Qualitative Research 25 Procedures 27 Human Rights Protection 27 Data Management and Analysis 28 Chapter Four Phase I Results 30 Demographic data 32 Data Collection Process 33 Data Analysis Process 35 Themes 36 Age of the child is important 37 Behavior can tell a lot 39 Really looking at the patient 41
ii Things that help make decisions 42 Things that hinder decisions 44 Summary 44 Chapter Five Methods Phase Two 48 Sample and Setting 48 Inclusion and Exclusion criteria 49 Instruments : Pediatric Triage Pain Assessment Scale 50 Reliability and Validity 50 Procedures 51 Data Management and Analysis 52 Summary 55 Chapter Six Results Phase Two 56 Pediatric Triage Pain Assessment Scale Validity and Reliability 57 Content Validity Index 57 Reliability 59 Data Collection Process 60 Demographic Data 62 Data Analysis Process 64 Triage Vignettes 66 Logistic Regression Methods 66 Unadjusted Chi-Square Analyses 67 Logistic Regression Adjust ed Methodology and Results 70 Pain measurement methods 77 Survey comments 79 Summary 79 Chapter Seven Discussion and Implications 81 Summary of Research 81 Instrument Development 82 Pediatric Triage Pain Assessment Scale 82 Discussion 84 Phase I 84 Age of the child is important 84 Behavior can tell a lot 86 Really looking at the patient 87 Things that help make decisions 87 Things that hinder decisions 88 Phase II 89 Limitations 93 Social Desirability Response Bias 94 Implications for Nursing 96 Practice 96 Education 97 Research 98
iii References 99 Appendices 107 Appendix A: Phase One Demographic Data Form 108 Appendix B: Interview Format Guide 109 Appendix C: Morton Plant Mease Letter of Support 110 Appendix D: Tampa General Offi ce of Clinical Research Letter 111 Appendix E: Human Subject Consent Form A Phase I 112 Appendix F: Human Subject Consent Form B Phase I 115 Appendix G: Letter of Introduction for Phase I 123 Appendix H: Recruitment Flyer 124 Appendix I: Letter of Introduction for Phase II 125 Appendix J: Human Subject s Consent FormPhase II 126 Appendix K: Content Validity Index for Triage Vignettes 129 Appendix L: Triage Vignette Survey 133 About the Author End Page
iv List of Tables Table 1. Phase I Participant De mographic Characteristics 33 Table 2. Major Themes that Emerged from Data Analysis 37 Table 3. Cumulative Logit Model Contingenc y Table: Child and Nurse Variables 54 Table 4. Phase II Participant De mographic Characteristics 63 Table 5. Unadjusted Chi-Square Analys es by Vignette Clinical Condition 70 Table 6. Analysis of Maximum Likelihood Estimates and Odds Ratio Estimates 73 Table 7. Logistic Regression and Odds Ratio Estimates by Clinical Condition 76 Table 8. Pain Assessment Method by Vignette 78
v List of Figures Figure 1. Logic Model 9 Figure 2: Comparison of Conceptual Mode l to Triage Decision-making Factors 50
vi Factors Affecting the Process of Clinical Decision-Making in Pediatric Pain Management by Emergency Department Nurses Teresa A. Russo ABSTRACT The purpose of this mixed methods study was to describe the cognitive processes/knowledge sources used by Emer gency Department (ED) nurses in decisionmaking activities regarding triage and pediatric pain assessment and management. Deficiencies persist in ED pediatric pain assessment, and management methods or approaches that might help resolve these deficiencies have not been identified previously. Methodology triangulation with sequential use of qualita tivequantitative methods provided a rich description of knowledge s ources and cognitive processes used by ED nurses relative to pediatric pain assessment decisions. Based on qualitative results, a set of vignettes was developed to assess ED nurse s. Data analysis using ordinal logistic regression with a cumulative logit model identified patient and nurse variables which influence triage acuity decisions. Five common themes emerged from the qualitative data; 1) Age of the child is important, 2) Behavior can tell a lot, 3) Really looking at the patient, 4) Things that help make decisions, and 5) Things that hinder decisions. Ordinal logistic regression analysis of the quantitative data identified predictor variables of infants compared to school-age children, Hispanic ethnicity, moderate number of years of ED experience (11 -20 years) and years of education that were associated w ith higher triage levels .The implications of
vii this new knowledge include changes in ED tr iage nurse practice towa rds pain assessment, and increased awareness of the need for educ ation in use of pain assessment tools. Additional implications include education rela ted to pain management practices by ED physicians and pain medication protocols at tr iage. This information may enhance triage and care of the pediatric patient experi encing pain, expand the knowledge base of emergency nursing, identify areas in which to implement changes, assist in improving care provided to children experiencing pain, and provide direction for future education, training, and research.
1 Chapter 1 Introduction A complaint of pain has been cited as a frequent presen ting symptom to the Emergency Department (ED), for both adult a nd pediatric populations (Cordell, Keene, Giles, Jones, J. B., Jones, J.H., & Brizedine, 2002; Tanabe, & Buschmann, 1999; Drendel, Brousseau, & Gorelick, 2006). Cordel l and colleagues, (2002) reported pain as chief complaint in more than half of 1,600 medical records review ed from a one-week period. Retrospective reviews of data from the National Hospital Ambulatory Medical Care Survey identified disparities in pa in assessment documentation, particularly in children. A review of more than 24,000 ED visits found pain documentation in only 44.5% of cases (James, Bourgeois & Shannon, 2005; Drendel et al., 2006). Despite knowledge of the need for prompt and accurate triage of children experiencing acute pain, clinical evidence of ongoing disparity in assessment and documentation of pediatric pain has been reported (Drendel, et al ., 2006; Johnston, Bourna ki, Gagnon, Pepler & Bourgalt, 2005). The assessment and ED response to pain in infants and young pediatric patients has presented challenges. Children and adolescen ts up to the age of 18 are treated in the Pediatric Emergency Department of many hosp itals. Pediatric pain assessment scales have been available for a number of years, how ever there have also been discrepancies in published reports regarding th e age at which these scales provide a valid measure (Bulloch & Tenenbein, 2002; Kelly, Powell, & Williams, 2002). The age range used to
2 define a pediatric patient has varied accordi ng to the information source. American Heart Association guidelines for Pediatric Adva nced Life Support and Basic Life Support recommended that health care providers use the age range for children beginning at 1 year old, and up to the beginning of puberty (A HA, 2005); however this range pertains to physiologic parameters more than pain assessment. This wide variation in age, size, and developmental levels has added to the co mplexity of pediatric pain management. Consequently, healthcare providers must ha ve a broad knowledge base of assessment, age appropriate pain assessment scales, pain management interventions, and medication dosage ranges. Published literature indicated an enhan ced clinical knowledge base concerning pediatric pain management. A va riety of validated pediatric pain assessment tools have been made available for use in the ED and other settings. Moreover, nationally recognized pain assessment standards of pr actice have been put forth. Despite these positive changes, documented inadequacy of pediatric pain management in the ED setting has continued as a major clini cal issue (Drendel, et al., 2006). In view of these trends, research to evaluate the efficacy of alternat ive or creative approaches aimed at improving these practices has been lack ing. Additional research was indicated in order to further explicate clinical decision-making, and guide changes in practice toward pediatric pain assessment and management by the ED triage nurse. A number of factors may have compo unded problems with accurate and timely pediatric pain assessment and triage d ecision making. Emergency Departments have served as a safety net for health care for many underserved groups, and particularly uninsured children during recent years (IOM, 2006). Unintended effects of the
3 Emergency Medical Treatment and Active Labo r Act (EMTALA), as well as other health care system-wide problems have contributed to ED over-crowding and extensive waiting times for treatment (Hostetler, et al., 2007). A review of the 2001 National Hospital Ambulatory Medical Care Survey found that ED visits increased by 20% between 1992 and 2001, which reflected approximately 22 milli on visits per year for children 15 years and younger ( James, Bourgeois & Shannon, 2005). The Healthy People 2010 public health initiative included the goal of elimina ting racial and ethnic he alth disparities (US DHHS, 2000). Therefore, considering the imp act of these factors on the treatment of children in the ED, it became imperative to gain a better understanding of clinical decisions regarding pediatric pa in assessment and management. Purpose The primary purpose of this mixed methods study was to describe the cognitive processes/knowledge sources used by Emer gency Department (ED) nurses in decisionmaking regarding triage and pediatric pain assessment and management. The secondary purpose was to clarify and describe external and internal factors influencing triage decisions and pain interventions. This study consisted of two phases, including both qualitative and quantitative methods approach es. In Phase I, a qualitative method was used to describe triage decision-making. In Phase II, a quantitative component, used a triage vignette survey, designed to further veri fy the processes and factors identified from Phase I (Morse & Richards, 2002).
4 Research Questions Research questions addressed in th e first phase of this study were: 1. What are the cognitive processes/know ledge sources used by ED nurses in decision-making regarding pain a ssessment of pediatric patients? 2. What internal factors influence ED nu rses cognitive processes and clinical decisions in pediatric pain assessment? 3. What external factors influence ED nu rses cognitive processes and clinical decisions in pediatric pain assessment? Research questions for the second ph ase of the study addressed whether differences in triage level assigned for a given vignette could be predicted by nurse variables (education, year s of experience) or patient vari ables (age, ethnicity, gender, or behavior). The following research questions pertained to Phase Two: 1. What are the differences in triage le vel assigned for a given vignette, based on nurse variables of: educational background, or years of experience (grouped continuous variable)? 2. What are the differences in triage le vel assigned for a given vignette based on patient variables of: age (two categories) ethnicity (three categories), gender (two categories), or behavior (two categories)? The qualitative portion of the study will cl arify and describe decision-making processes and factors that infl uenced those decisions, as desc ribed by the triage nurses. Interviews which explored the lived experience of triage nurses that were recorded, transcribed, and analyzed, provided informatio n about patterns, processes, themes and insight into the contextual wo rld of the ED triage nurse. The second phase of the study
5 used patterns and themes that emerged, along with variables that were identified from the literature, to describe commonalities or di fferences in triage nurse decision-making through their responses to a series of triage vignette exercises. The qualitative portion allowed for describing a phenomenon, while the secondary quantitative portion of the study allowed for assessing the distribution, st rength and direction of any commonalities or differences in the phenomenon, which is tr iage decision-making concerning pediatric pain assessment (Morse & Richards, 2002). There were no published reports of rese arch using a mixed methodology approach in studying this phenomenon. The future resear ch trajectory of this work would be to develop and test an instrument that could facilitate nursi ng education and knowledge of triage assessment of pediatric pain. Howeve r, this was not the focus of the present project. Significance The significance of this study pertained to the enhancement of care of the pediatric patient experiencing pain in th e ED, through applica tion of the knowledge gained from the research findings. The methods used were intended to provide a contextual, rich description of triage clinical decision-maki ng processes, and factors that may have influenced those decisions. There was little published research regarding the nature and processes of clinical decisi on-making and knowledge sources used by ED triage nurses in pediatric pa in assessment and management (Crellin & Johnston, 2002; Drendel, et al., 2006; Johnst on, et al., 2005). A triangulated design method which used sequential qualitative inquiry, followed by quantit ative analysis of data served to capture and validate phenomena from the lived experi ences of ED triage nurses (Polit & Beck,
6 2004). The qualitative approach provided data for development of triage vignettes, which were analyzed via quantitative methods. Th is process of first describing phenomena followed by determining distribution of those phenomena had potential for enhancing the validity of findings (Morse & Roberts, 2002; Polit & Beck, 2004). Clinical experience has been recognized as a requisite for expertise in the challenging role of ED triage nurse. Triage in the ED has become a process of quickly determining the priority of car e for patients upon arrival, so that each patient can receive appropriate resources in a timely manner. Tria ge has become the point of entry to ED care, and the medical screening exam pro cess. Algorithms have provided principlesbased guidance for this decision-making proce ss. Through a set of steps, or decision tree the triage nurse can determine the correct priority level for the patient, assuming that the patients chief complaint on arriva l allowed for the corre ct choice of algorithm pathway by the nurse (Gerdtz & Bucknall, 1999). Real-life situations may challenge propositions or principles-based expectations (Benner, 1984), such as triage algorithms, necessitating quick thin king on the part of the triage nurse. Recent recommendations have suggested use of a five-level triage scale; however, there were no published validation studies w ith pediatric patients (Fernandes, Tanabe, Gilboy, Johnson, McNair, Rosenau, et al., 2005 ). An important clinical question was whether the expert nurse has made use of or followed these algorithms in the same sense as a novice, or less experienced nurse. The triage nurse has traditionally been a nurse with years of experience. Current nursing shortages and busier emergency departments across the US, have led to situations in wh ich nurses with less experience in triage decision-making have found themselves challeng ed to perform these duties, putting them
7 at risk for making inappropriate decisions. T hus, research of this nature was necessary and justified for describing the triage decisi on-making process and factors that may have influenced those decisions. Conceptual Framework A conceptual framework provided a frame of reference that guided how the researcher organized or vi ewed these phenomena. The philosophical underpinnings, research traditions and assumptions of this conceptual framework provided structure, context and linkages within the research me thods used in this study (Fawcett, 1999; Polit & Beck, 2004). The phenomenon of interest wa s gaining an understa nding of the lived experience of the triage nurse through inte rpretation of descrip tions of processes, experiences and meanings. Interpretive phenomenology from a hermeneutic tradition guided explicating the meaning embedded in the common experiences of triage nurses decision making. The lifeworld reality of the decision making experience of the triage nurse has been influenced by what is expe rienced on a daily basis (Lopez &Willis, 2004). This approach allowed for describing the meaning of being-in-the-world, and how these meanings influenced choices made by nurses (Lopez & Willis, 2004, p.729). Benner (1984) described using an inte rpretive approach for describing the meaning of nursing clinical knowledge within the context of where it is found. The subjective world of the triage nu rse was conceptualized as embedded in layers of context which influence triage decisions. To understand and grasp some meaning and understanding of this phenomeno n, the researcher was aided by previous knowledge of the context in which the phenomena occurs. Hinds, Chaves and Cypess (1992), provided a framework which they c onceptualize as four nested interactive
8 layers distinguished from each other by the extent of shared meanings, time focus, and speed of change (p. 65). In this framework the phenomenon of intere st; triage decisionmaking regarding pediatric patients complaini ng of pain, was embedded within the layers of context. These layers included: 1) the immediate context; 2) specific context; immediate past or environmental factors; 3) a general context, or general frame of reference; and 4) a broader, socially constr ucted metacontext. Pate l, Gutnik, Karlin, and Pusic (2008), developed a conceptual model of pediatric triage decision-making that included the influence of patient factors, nurse factors, guidelines and contextual factors on triage outcomes. These two models contributed to the formulation of the logic model for this study. The logic model (Figure 1) provided a visual re presentation of this framework and guided descriptiv e research regarding the re lationship between variables for this study (Evans, 1992). The logic model is explained here (Figure 1). A graphic display of the layers of context provided a conceptualization of the components in the logic model for this study, and a frame of reference for better understa nding and interpreting the qualitative data generated from triage nurse experiences. View ing the logic model from left to right depicts the contextual la yers described here. Figure 1: Logic model for triage decisi on-making and pediatric pain assessment
The immediate context included the input va riables of the child who comes to the ED, and the specific actions taken by the tria ge nurse. Child variables comprised age, gender, ethnicity, behavior, symptoms, appearance, and the intera ction of parental behavior. Any of these variables were possible presenting factor inputs in the triage decision process. Child variables such as age, gender or behavior may have influenced or mediated actions by the nurse. The nurses act ion, or triage decision was mediated or influenced by a number of factors that were viewed as components of the contextual layers of the conceptual model. These contex tual layers may be t hought of as expanding, or encompassing more factors that influenced the triage decision-making process. The specific context included a number of mediat ors that may influence triage decisionmaking including the physical setting such as the type of ED (general versus pediatric only), the population, and the vol ume of patient visits to th e ED. Also included in this 9
10 layer are the staffing patterns of the triage area, and the availability of pediatric specific equipment, assessment tools and technology. The general context consisted of a unique system of knowing; the knowledge base of the nurse, education, years of experience, rules or guidelines for conducting the triage process such as tr iage algorithms, or statutes such as the Emergency Medical Treatment and Active Labor Act (42 USC 1395dd). The broader socially constructed context included nurse characteristics (internal factors) that may mediate or influence triage decision ma king including values, attitudes, emotions, traditions, and the nurses philosophy towards the hospital or work environment. There are a number of factors which may have influenced triage decision-making process with the pediatric patient experiencing pain. A number of these factors have been conceptualized by the researcher; however data from the qualitative phase of this study ultimately determined the variables that were included in the second phase of the study. The logic model served to provide a visual representation of the in teractive layers of context in which the triage nurse makes decisi ons regarding the child who presents to the ED with a complaint of pain. The outcomes of this study were the co mmonalties and differences in triage decision making that emerged from analysis of data from the study, and can be used to enhance triage and care of the pediatric patient experiencing pain. The variables and data that are interpreted as contributing to appr opriate decisions and treatment may facilitate future evidence based research and educati on. Areas for future re search included the accuracy, timeliness, safety and effectivene ss of assessment, diagnosis, treatment and follow up care for the pediatric patient w ho comes to the ED experiencing pain.
11 Assumptions 1. Knowledge of the ED triage nurse expe rience on the part of the researcher, used with bracketing when appropriate provides a meaningful guide to inquiry. 2. Descriptions of triage process decisi on-making derived from an interpretive approach blended the outcome of meani ngs articulated from the informants and interpreted by the researcher (Lopez & Willis, 2004). Definition of Terms Algorithm A decision making tool used in triage, based on a decision-tree or diagram approach that provides step by step directions or stru cture in order to standardize decisions. Clinical decision making the outcome of cognitive processes; information processing, step-by-step consci ous thinking, use of cues, patt erns, previous experience, and practical rules or protocols to choos e a course of action for a given set of circumstances or patient symptoms. Cognitive process the thought model used by nurses to analyze and process information, which uses a blend of analytic and intuitive thinking. Nurses ways of knowing (Berragan, 1998; Carper, 1978); empiri cal, ethical, esthetic and personal could be used to describe these processes. Intuition Knowing or sensing without the use of specific processes, and insight gained from using this source of knowing.
12 Pain an unpleasant sensory and emotional experience that arises from actual or potential tissue damage and elicits various phys iological and/or psyc hological responses. Pediatric patient a child beginning at 1 year old, and up to the beginning of puberty. Triage a process of quickly determining the pr iority of care for patients as they arrive, so that each patient receives a ppropriate resources in a timely manner. Triage vignette A short descriptive literary sk etch or written case scenario designed to include specific clinical informa tion which requires a decision as to a triage score for the patient desc ribed in the vignette. Triangulation method of using multiple research approaches in the same study to answer research questions. Triangulat ion may be through either data collection, investigator, method or th eoretical approaches (Speziale & Carpenter, 2007)
13 Chapter 2 Background and Literature Review The review of literature included a synthe sis of literature regarding research articles in the domain of Emergency Depart ment (ED) decision making, and assessment and management of acute pain in children. A literature search which utilized databases such as CINAHL, Ovid, PubMed, ERIC, and an ancestral search of references from pertinent studies produced numerous studies including both qualitat ive and quantitative methods, which explored clinical decision-making in various settings; however published studies that described ED tr iage decisions with pediatri c pain were lacking. Several themes were the most prevalent in the published literature and are elucidated as follows; satisfaction and attitudes of patients and parents, pain symptom assessment, pain assessment correlation between patient and ot hers, ethnic disparity, triage assessment, and nursing interventions. Limited research involving triage deci sion-making processes had been published; however no published rese arch was located which addressed sources of knowledge ED nurses use, triage clinical decisions, or the lived experience of the pediatric ED triage nurse in respect to pediatric pain. The logic model guided the l iterature review. Relevant themes included in this review of literature include discrepancies in pain ratings between parents and healthcare practitioners, cultural factors, problems with pediat ric ED care, the role of the triage nurse, and clinical decision-making in the ED.
14 Practitioners, Parents, and Discrepancies Differences in ED nurse and physician tr iage decisions for pediatric patients, (Maldonado & Avner, 2004; Bergeron, Gouin, Bailey & Patel, 2002), and differences in pain ratings between nurses and parents (Singer, Gulla, & Thode, 2002), provided evidence that health care pract itioners, as well as parents, may underestimate pain in both adults and children in the ED setting (J ohnston, Bournaki, Gagnon, Pepler & Bourgalt, 2005). Kelly, Powell and Williams (2002), reported a tendency for parents to underestimate their childs pain when using a visual analog scale. A study from Australia that compared pain scale ratings between nurses, parents and children with either the Wong-Baker Faces pain scale or a linear numeric rating scale also found significant differences in pain scores, in that nurses repo rted pain scores lower than parents or the children themselves ( Rajasagaram, Taylor Braitberg, Pearsell, & Capp, 2009). Despite availability of validated pain assessme nt tools, and ED policies guiding pain management, discrepancies were still reported. Comparisons of ED pain management by a survey of pain management policies and actual ED chart reviews demonstrated di screpancies in pain management practices with adults and children (Probst, Lyons, Le onard, & Esposito, 2005). There were clinical accounts of discrepancies in adult pain mana gement (Todd, 2001; Tamayo-Sarver, Hinze, Cydulka, & Baker, 2003; Puntillo, Neighbor, ONeil, & Nixon, 2003), and pediatric pain management in the ED, (Petrack, Norma n, & Kriwinsky, 1997; Drendel, Brousseau & Gorelick, 2006) which require further explicati on. There was also evidence that children received less pain-relieving medication when compared to adults with similar injuries (Petrack, et al., 1997). Despite implementation of education and mandatory pain scoring
15 at triage, a retrospective comparison of pa in score documentation and administration of analgesia for children with long bone fract ures and burns found 97% compliance with documentation, but only 66% of those patients received analgesia, and only 10% received opiates for their pain (Jadav, Lloyd, McLauc hlan, & Hayes, 2009). Documentation of pediatric pain on the part of both ED nurses and physicians has been deficient despite specific requirements regarding pain assessm ent. Incorporation of a pediatric pain assessment scale into the emergency medical records form, as an intervention with ED physicians, resulted in a modest improvement in documentation of pain with pediatric patients; however no change in analgesic administration was reported (Kaplan, Sison, & Platt, 2008). In one patient satisfaction survey of both parents, and their children who had been ED patients, resolution of pain wa s a more significant indicator of satisfaction for the children than for the parents (M agaret, Clark, Warden, Magnusson, & Hedges, 2002) Cultural Factors Cultural and ethnic differences in pain e xpression and behaviors add another layer of complexity for the triage nurse. Lack of knowledge of cultural/ethnic differences in child behavior and pain expression can affect the ability to rec ognize and assess a child with a potentially emergent c ondition. Accurate triage assess ment allows for recognition of those children who present with painfu l problems or subtle, but potentially life threatening problems. The triage nurses own cu ltural or ethnic beliefs may influence the determination of pain in others. One st udy which compared ED waiting time identified that a greater number of Hispanic children were assigned triage cat egories resulting in wait times longer than 2 hours, as compared to triage categories assigned to white or
16 black children (James, et al., 2004). However, the study did not include a comparison of discharge diagnosis, or determination of th e accuracy of the triage levels assigned. Verifying that the triage nurse made accura te triage level assignments would help determine if other factors influenced the wait times. Other studies have shown disparities in analgesic use for racial or ethnic mi nority patients in the ED (Todd, Samaroo, & Hoffman, 1993; Todd, 2001). Problems with Pediatric Emergency Care Authors of The Future of Emergency Care, (IOM, 2006) reported a number of problems with pediatric emergency care, in cluding uneven distribution of resources. Emergency Departments serve as a safety net for health care for many underserved groups, especially children of minority ethn ic and cultural groups (Trzeciak & Rivers, 2003). The ED crisis has impacted access to care for everyone. Shortages of both ED nurses and physicians have further exacerbated the problem (IOM, 2006; Kellerman, 2006). The IOM reported that approximately 27% of all Emergency Department (ED) visits are for infants and children, but only about 6% of EDs in the United States are adequately equipped for pediatrics. Johnson and Rimsza (2004) found that children who had access to pediatric care used the ED less, whether they had insurance or not. Access to a regular source of ca re resulted in fewer visits to the ED. Public health care policy such as the Emergency Medical Treatment and Active Labor Act (EMTALA, 42 U.S.C. 1395dd) whic h mandated care regard less of the ability to pay, have paradoxically resulted in threats to the last remaining saf ety net in the U.S. healthcare system, specifically emergenc y care access. Since implementation of EMTALA, Emergency department use increas ed from 85 to 110 million visits yearly,
17 while 550 hospitals and 1,100 emergency depart ments closed, either due to financial difficulties, or through administrative decisi ons to terminate emergency services at specific hospitals (Bitterma n, 2002). Unintended effects of this legislation include decreased access to care and ED overcrowd ing (ENA, 2006; Hostetler, et al., 2007). The problem of overcrowding in the ED a nd the resulting impact on pediatric care was reported as another concern, in part because children vis it the ED more than any age group except those over 65 (IOM, 2006; Hostetler et al., 2007 ). Prompt and accurate triage of children who come to the ED from injury or illness has been recommended to lessen morbidity, prevent deterioration, and improve outcomes. Triage nurses faced with multiple newly arrived patients must adapt methods of rapid, accurate assessment in the face of overcrowded waiting rooms. Multiple factors may influence this process including the nurses previous experience, physical processes such as overcrowding, cultural/ethnic differences, healthcare policy, and nurses educational preparation. All of these factors were noted to affect the deci sion-making capabilities of the triage nurse (ENA, 2006). In response to increased attenti on to the state of emergency care in this country, a number of recommendations for improvement emerged recently (IOM, 2006; ENA, 2006) including system-wide changes to facilitate prompt access to treatment, and to improve resources and services for pediatri c patients. There were a number of systemwide problems in need of change in regards to pediatric emergency care, however simpler interventions, both non-pharmacologic and pha rmacologic have been recommended to help alleviate pain, particularly that which has been associated with procedures in the ED. Ramponi (2009) discussed pain relieving interventions pediatric ED nurses might consider, such as anticipation and preparation of the child for painful procedures that may
18 be experienced, use of simple explanations allowing parents to remain present during procedures, distraction, and positioning, in addition to multidisciplinary education for all ED healthcare providers to facilitate reducing pain for pediatric patients. Role of the Triage Nurse The triage nurse assesses each patient and assigns a triage category based on the perceived urgency of the presenting complaint, and has responsibility for recognizing urgent conditions and initiati ng further treatment in the ED. The triage nurse functions as the gatekeeper in some respects in the ED setting, and ideally should be an experienced nurse, able to communicate well, recognize ethni c/cultural expressions of illness and pain and initiate care for acutely i ll or injured patients. Recent efforts to standardize, or provide for some consistency in the triage process have resulted in development of several different triage acuity guidelines or algorithms in Aust ralia, Great Britain, Canada, and the United States (Atack, Ranki n, & Then, 2005; Scoble, 2004; Worster, Sardo, Eva, Fernandes, & Upadhye, 2007). The Emergency Nurses Association (ENA) and American College of Emergency Physicia ns (ACEP) worked on a joint task force toward implementation of a standardized five -level triage acuity system, in order to facilitate a uniform method of assigning tria ge acuity (Fernandes, et al., 2005). The Emergency Severity Index (ESI), 5level triage system resulted from the work of this task force and has been refined, modified and validated; however the system has had limited reliability or validity evaluation with pediatric patients. The ESI version 4(ESI v.4) has been listed on the Agency for Health care Research and Quality (AHQR) website within the Tools and Resources for Meas uring Healthcare Quality section (AHQR publication #05-0046-2), (Gilboy, Tanabe, Ro senau, & Eitel, 2005). An annotated
19 bibliography compiled by members of the ESI triage study team provided summary information from 33 literature sources related to pediatric triage. There were no reports that specifically addressed pediatric pain in the ED (Pediatric ESI Triage Study Team, 2006). The lack of pediatric validation for th e ESI has been addressed through recent reports of moderate re liability, yet with inconsistencies at the high and low ends of the 5level scale, from a multi-site study which incl uded measurement of in terrater reliability with case scenarios and actua l patient triage reports (Travers, Waller, Katznelson & Agans, 2009). Reliability of the ESI v.4 w ith pediatric patients was assessed by determination of interrater reliability and level of agreement between experienced pediatric ED physicians and triage nurses us ing training materials and patient scenarios which found 83% agreement between these experienced ED healthcare providers (Durani, Brecher, Walmsley,Attia, & Lois elle, 2009). While these approaches were intended to improve, or facilitate the decisi on-making processes for triage nurses, some authors suggested an algorithm approach c ould place restrictions on the nurse, possibly cause delays secondary to inexperience with detailed algorithms, or hinder decisionmaking abilities or growth of the triage nurse towards a more expert level of functioning (Gerdtz & Bucknall, 1999). Clinical Decision Making Decision-making theories and cognitive pro cesses have been studied for a number of years in healthcare and the social scie nces; however decision-making specific to ED triage has only recently been the subject of research, in part due to the more significant role ED care has taken in healthcare services. Gaining a better understanding of the
20 processes and knowledge sources used by tr iage nurses can contribute to improved patient outcomes and development of educa tion and training resour ces for new triage nurses. A brief summary of decision-making models suggested that methods used by triage nurses may include pattern rec ognition, hypothetico-deductive reasoning, and intuition, in addition to experience (Evans 2005). Benners (1984) early work describing knowledge sources of practical knowledge and theoretical knowle dge which contrast know-how and know-that are still releva nt today (pg. 2). Pract ical knowledge or know-how develops from clinical experience, while theoretical knowledge, or knowthat, is derived from textbook or sources more elusive to describe. Use of both knowledge sources, refinement of knowledge and learning from e xperience lead to clinical expertise. Another explanation of knowledge sources applied to ED nurses described declarative knowledge from the domain of emergency nursing, (textbook knowledge), and procedural knowledge derived from pr actical expertise an d skills. These two knowledge sources contribute to decision-ma king skills as well as being important resources for novice triage nurse training techniques such as simulation (Cioffi, 1999). The triage nurse may frequently be p hysically separated from the main ED treatment area, must keep track of patients wait ing to be seen and make contact with each new patient who arrives at th e triage area. All of thes e factors contribute to the complexity of decision-making and create a degree of uncertainty for the triage nurse. Tools that are employed include triage guideli nes or scales which sp ecify the urgency of care needed, triage algorithms, which ar e decision-making guidelines, and use of heuristics or mental rules of thumb the triage nurse acqui res with experience (Gerdtz &
21 Bucknall, 1999, p. 55). Cone and Murray (2002) used qualitative methods to describe aspects of triage decision-making important to ED nurses, who included quick decisionmaking, critical thinking, and behavioral ch aracteristics such as working well under pressure, experience, intuition, assessment skills, communication, dependability and being able to make decisions independently. Several international studies that ev aluated ED nurse triage decision-making identified variables that affect the process, such as nurse characteristics and triage training methods (Atack, et al., 2005; Gora nsson, Ehrenberg, Marklund & Ehnfas, 2005). One observational study of Aust ralian ED triage nurse decision-making in the natural environment (Gerdtz & Bucknall, 2001) provi ded a detailed description of data nurses gathered during triage of adult patients, and factors that influenced the amount of time spent with each patient. Another study which made us e of observation methods and interviews with Canadian pediatric tria ge nurses found differences in use of, and interpretation of triage guidelines based on th e nurses years of experience, and identified factors that impact decision-making in tria ge (Patel, Gutnik, Karlin, & Pusic, 2008). Research such as this is lacking in the U.S. nursing literature, especia lly so with pediatric patients. While the cognitive processes used by nurses may be much the same in other countries, there are differences in factors such as the nur ses scope of practice, and federal legislation such as the EM TALA rules in the United States. Several studies and literatur e syntheses which described clinical decision-making and cognitive processes with pediatric pain management in settings other than the ED provide some insight into pr ocesses used in general by pe diatric nurses (Estabrooks, et al., 2005; Van Hulle, Vincent, & Denyes, 2004). However; emergency department
22 patients may require different approaches to pain manageme nt relative to the factors which have been discussed in this review of literature. Summary Numerous published research or literatu re syntheses regarding pediatric pain assessment and management were located. However, due to the unique nature of the specialty of emergency nursing (ENA, 1999), findi ngs from other clinic al settings are not necessarily applicable to the ED setting. Fundamental questions persist about why deficiencies still exist in ED pediatric pain management. Me thods or new approaches that might help resolve these deficiencies remain unclear. Limited research in the area of triage d ecision-making and pediatric pain revealed findings which demonstrated discrepancies in pain assessment, deficiencies in documentation and multiple factors that impact the pediatric ED setting. Concerns with the current state of emergency services in the United States and the impact on both ED staff and patients were cited often. The study of ED nurse triage decision -making with pediatric pain from a phenomenological perspective used in this study has further explicated the lived experience of the triage nurse, added to the knowledge base of emergency nursing, identified possible areas to implement ch anges, and provided direction for future education, training, and research. Information gained from this proposed study helps to address this research gap, and enhance the knowledge base of emergency nurses.
23 Chapter 3 Methods Phase I The design for this study consisted of a mixed methods approach that included a Phase I qualitative descriptive component and a Phase II quan titative component consisting of a triage vignette exercise. Phase I comprised the qualitative component of the study. Phase II of this study which involved a quantitative analysis of responses to triage vignettes, is described in Chapter 5. Th is chapter presents methods used in Phase I. First the setting and sample are described, followed by the instruments used, procedures and data analysis methods. Sample and Setting A purposeful sample of experienced tria ge nurses who work in one of several different ED settings were recruited for interviews. Recruitment continued until when achievement of data saturation, when eviden ce of recurring content or themes emerged. Thirteen informants were interviewed. Participants who were considered best able to provide optimal data to facil itate addressing the research questions included nurses who had experienced the phenomenon being studi ed, and who were able to respond to questions concerning the phenomenon. ED triage nurses had experience with the study topic contributed meaningful data, in this case experience with pediatric patients experiencing pain (Polit & Beck, 2004). Snowball sampling was used, which allowed
24 volunteer informants to refer others interest ed in participating (Speziale & Carpenter, 2007). The settings included Emergency Depart ments from within a four-hospital system, and a large metropolitan Level One Tr auma Center Pediatri c ED. This approach allowed for recruitment from a diverse sample of ED nurses in terms of gender, age, education, ethnicity, and years of experien ce. The setting for the interviews was a conference room, or designated private area in each clinical setting to allow audio recording of the interview and protection of confidentiality for the informants. Inclusion and exclusion criteria Inclusion criteria included registered nurses who worked more than 16 hours per week in an ED, and who had more than 6 m onths experience functioning as the triage nurse in a dedicated triage area separate from the main ED. These informants had completed some orientation to the triage area or attended a triage course. Informants were limited to nurses able to read, write, and speak English. Exclusion criteria included registered nur ses, who work in the ED, but lacked experience in the role of triage nurse, i.e., had less than 6 months experience as the assigned triage nurse. Any nurse who declined to have the interview audio recorded was not eligible to participate. Instruments All informants were asked to complete a brief demographic survey (Appendix A) including age, sex, and years of ED experience, type of education, certifications, and whether they had children themselves. Individual semi-structured interviews with informants were utilized to explore the li ved experience of the triage nurse, decision-
25 making processes used, the meaning of th e experience for each informant, and any internal or external factors that influence the process. The interview questions (Appendix B) were piloted with a small sample of nurses to assess the credibi lity and dependability of the questions (Morse & Roberts, 2002). Interview questions were not changed. Interview guiding questions derived from the logic model and literature review included the following: 1) Tell me about a situation in whic h you felt very good about your triage decision for a pediatric patient in pain. 2) Tell me about a situation in whic h you did NOT feel good about your triage decision of a pedi atric patient in pain. 3) What things help you make d ecisions about pediatric pain? 4) What things hinder your ability to ma ke decisions about pediatric pain? 5) What else can you share with me ab out pediatric ED nursing and pain management of children? Reliability and Validity in Qualitative Research The constructs of reliability and validity used with quantitative methods were not applied in the same manner w ith the qualitative methods used in Phase I of this study. Rigor of qualitative methods as a means of demonstrating reliability and validity has traditionally required evidence of credibility, confirmability, transferability, and dependability of the study (B urns, 1988; Polit & Beck, 2004; Speziale & Carpenter, 2007; Whittemore, Chase & Mandle, 2001). More contemporary approaches which view more overarching efforts of demonstrating valid ity are described here. Whittemore, et al., (2001) suggested a synthesis of techniques that consisted of primary and secondary
26 validity criteria. Primary criteria consisted of credibility, authenticity, criticality and integrity, while secondary criteria consis t of explicitness, vividness, creativity, thoroughness, congruence and sensitivity. These criteria represented standards to uphold, while the qualitative methods employed repres ented techniques to diminish threats to validity of the study (Whittemore et al., 2001). Credibility and authenticity were supported by a conscious effort to represent the experience and contex t of the informants in an accurate and believable manner. In addition, authenticity was demonstrated by a trustworthy representa tion of the lived experiences and perceptions of the informants, with appreciation for the emic perspective of the nurses who partic ipated. Criticality and integrity were demonstrated by use of a systematic research design, methods to substantiate findings, clear ar ticulation and awareness or concern for potential research bias. Secondary validity criteria of exp licitness and thoroughness included careful consideration and descripti on of the study design, sampli ng, data collection methods, creating memos and journal notes, verifyi ng meanings with informants, providing an audit trail, use of bracketing and development of themes derived from data analysis to answer the research questions posed. These actio ns related to auditability of the research. Engagement with informants and inclusion of rich descriptions of the triage nurse experience were intended to eventually allo w readers to conceptualize the experience relate to vividness. Creativity was shown through the methodology triangulation approach used in the study. Congruence related to adequate linkages between research questions, methods and analysis, as well as to the practice setting. A nd finally, sensitivity of the study related to concern and respect for the informants and the context of the role
27 of the triage nurse in making decisions a nd providing care for the youngest patients who come to the ED. Procedures Human Rights Protection The proposal was submitted for approval to the Institutional Review Boards of BayCare Pasco-Pinellas Health care System, (Morton Plant Mease Health Care System letter of support, Appendix C) the University of South Florida and the Tampa General Hospital Office of Clinical Research (Tam pa General Hospital letter of support, Appendix D). Once approval was granted, the recruitment process commenced. Each potential informant was provided an inform ed consent packet (Appendix E, Appendix F )that included an information letter fully de scribing the study contact information for the investigator, a reminder that no obligation to participate existed, and assurance that the informant could withdraw at any time from the study (Appendix G). There were no known risks involved. The investigator informed participants of all measures to maintain confidentiality of information. The first phase of this study was a qualita tive descriptive exploration of the lived experience of the ED triage nurse decisionmaking process, guided by a hermeneutic phenomenology perspective. This method was in tended to facilitate explication of the thoughts, perceptions and factors that influen ce decisions and actions taken with pediatric patients who come to the ED with painful conditions. Following IRB approval from the Univers ity of South Florida, and from the proposed study sites, ED nurse s were recruited to particip ate in the study. Flyers were posted in the ED staff lounges of the resp ective sites (Appendix H) The investigator
28 contacted volunteers who met the inclusion criteria in or der to schedule a convenient meeting time to explain the study, to obtain informed cons ent, and to conduct the interviews, which were conducted in a private meeting room at the cl inical site of the informant, generally during early morni ng hours at the beginning of a shift. The interviews generally lasted less than one hour. A brief demographic survey tool was completed by each informant in order to provide nurse variables that would be included in the analysis. The interviews were audio recorded by the investig ator and field notes were written at the time of the inte rviews or immediat ely afterwards. Data Management and Analysis This section describes the qualitative data analysis for Phase I of this study. Demographic data from the informants was an alyzed using descriptiv e statistical methods first. For Phase I of this study, the research questions that were analyzed included: (1) what are the cognitive processes/knowledge sources used by ED nurses in decisionmaking regarding pain assessment of pediat ric patients, (2) what internal factors influence ED nurses cognitive processes and clinical decisions in pediatric pain assessment, and (3) what external factors influence ED nurses cognitive processes and clinical decisions in pediatric pain assessment. Willingness of the informants to participate was verbally reaffirmed at the time of the interviews. Demographic data was obtained before beginning the interviews. Individual interviews with informants were audio recorded and kept on a digital recorder until transcribed and stored on a password protected computer by the investigator. Once transcription and reviewing wa s completed, then recordings were erased. Data analysis began as the first interviews began. Sampling and interviews continued until data
29 saturation was achieved (Speziale & Carpenter, 2007). Data saturation was reached after 13 interviews. All names and identifying information was removed to protect confidentiality of informants. A qualitative descriptive approach, from the perspective of interpretive phenomenology, was used to describe triage decision-making in order to elicit a more holistic, rich description of the meaning of nurses intentions, thoughts, and actions. Constant comparison and analysis of the text of each informants interviews, followed by coding and reflective reviewing of journal no tes allowed for identification of shared meanings. Following Benners (1984) approach, re flective analysis of descriptions of the triage decision-making process facilitated id entification and descri ption of domains and competencies of the triage nurse. The factors and meanings derived from this qualitative process were incorporated into a series of triage vignettes which were used in Phase II of this study. Methodology triangulation with a two-phase design allowed for a first phase qualita tive exploration of the lived experience of the ED triage nur se decision-making process, followed by a second quantitative component of decision-making verifica tion, using a triage vignette exercise which allowed for describing rela tionships, commonalities and differences in triage decision-making process variables as well as direction a nd strength of those relationships.
30 Chapter 4 Phase I Results This chapter addresses the data and results of Phase I of this research, including a description of the development and pilo ting of the interview guiding questions, a summary report of the demographic characteris tics of the participants and the analysis and interpretation of 13 interviews conducted with ED nurses. The influence of Phase I results on the development of Phase II of this study are addressed as well. These interviews were conducted to obta in data relative to the first three research questions, that of describing the cognitive processes/knowle dge sources used by ED nurses in decisionmaking regarding pain assessment of pediatric patients, as well as describing the internal and external factors that influence ED nurses cognitive processes and clinical decisions in pediatric pain assessment. The data analys is in Phase I was structured relative to the first three research questions and the conceptual framework of the study. Information provided insight and understandi ng about the thinking processes the triage nurses used in making decisions with pediatric patients who come to the ED with painful conditions or injuries. Additional responses from the interviews provided insight towards factors that might influence the decision-making process. Interview guiding questions (Appendix B) derived from the literature review and the study logic model, were p iloted with four nurses with extensive ED experience. The nurses were asked to consider whether the questions were pertinent and suitable to elicit
31 responses from ED nurses about their expe riences with triage decision-making for children experiencing pain. Each nurse was aske d to think as if she were actually being interviewed, and to consider whether or not the questions posed were understandable and pertinent to elicit responses from nurses who participate in the study. The nurses were in agreement that the proposed questions were pertinent and suitable for eliciting the experience of participants. All the original questions were retained for the interview guide, which was used for semi-structured interviews with ED nurses. Piloting the interview guiding questions in this manne r contributed to the dependability and credibility of the interview format (Mor se & Roberts, 2002). This process also contributed to the validity of qualitative data, as demonstrated by the criteria of credibility and authenticity, or the usefulness (trustworthine ss) of the interview guiding questions to elicit responses that reflect th e experience of the participants (Whittemore, Chase & Mandle, 2001). Once IRB approval was obtained, telephone or e-mail contact with participating ED nurse managers was established to make them aware of the study, to provide a copy of the recruitment flyer and to verify th e contact person who should be contacted for follow-up and to arrange ED visits. In all instances, the researcher was referred to the ED nurse educator as the contact person. Recru itment flyers were posted in the ED staff break room. The ED nurse educators volunteere d to send e-mail notices to the staff as well. Participants were also recruited by vi siting the ED and being available during early morning hours when the ED generally tends to be less busy.
32 Demographic Data A demographic profile of the interview participants provided a summary of the age, gender, ethnicity, education, years of ED experience, and a dvanced certification (Table 1) of the nurses who participated in this study. Demographics of the participants contributed to the frame of re ference and general contextual layer of the subjective world of the triage nurse describe d in the conceptual model for this study (Figure 1). The general contextual layer of the model encompassed the knowledge base of the nurse, education, and years of experience, that may mediate triage decisionmaking. This contextual layer included general rules and triage guidelines that may mediate the triage process as well. Following the demographi c summary the researcher described the interview and data collection process. The nurses who agreed to par ticipate in the interviews worked in either the ED triage area that covers both adult and pediatri c patients or in the pe diatric ED patient care area specifically. The nurse informants range d in age from 26 to 48 years (table 1). Informants were predominantly females and all were White (84.6%). No participants were from different ethnic backgrounds, (i .e. all non-Hispanic white), as had been anticipated. Educational prep aration in nursing included A ssociate Degree in Nursing (ADN), Bachelors Degree in Nursing (BSN) and Diploma School graduates. Years of ED nursing experience ranged from 2 to 29 years (mean 9.5 years). All informants reported advanced certification such as Advanced Cardiac Life Support Provider or Pediatric Advanced Life Support Provider; how ever these courses ar e typically required of all ED nurses. The informants held a mean of 6 advanced certifications.
Table 1. Phase I Participant Demographics Variable freq. (%) Mean Range Age 40 26 to 48 years Gender Female Male 11 2 (84.6) (15.4) Ethnicity White 13 (100) Education ADN BSN Diploma 7 4 2 (53.8) (30.8) (15.4) Years of Experience (grouped) 1-10 yrs 11-20 yrs 21-30 yrs 7 4 1 (58.3) (33.3) (8.3) 9.5 years 2 to 29 years Adv. Certifications held 6 N = 13 Data Collection Process 33 Each of the 13 interviews lasted appr oximately 30 minutes and was conducted in a quiet room adjacent to the ED. Each nur se informant was provided the informed consent form to review and sign as well as the demographic data form to complete (Appendix A). As the interview began the in formant was asked to verify consent to participate. Each one seemed eager to part icipate, although one nurse stated her reason
34 for participating was peer pressure. She was offered the opportunity to withdraw if she really did not want to par ticipate; however she agreed to. Two nurses were former students of the investigator who stated they wanted to help out. The interviews were conducted using the semi-structured interview guide (Appendix B) previously developed, and were audio-taped for transcription and analysis. Interviews were adapted to follow the participants responses or additional comments. Brief anecdotal or field notes were written by the investigator during each interview for later reflection and analysis along with th e interview transcriptions. Preliminary interpretation of responses from participants began as the interviews were conducted, and were facilitated by asking fo r clarification of responses and further discussion. The researcher also reflected upon the interacti on with each participant, both during the interviews and afterwards. The researcher consciously sought to bracket thoughts and feelings, in order to avoid influencing re sponses. Self-awareness by the researcher of previous triage experience contributed towards a shared understanding of the processes involved in triage decision-making with chil dren who come to the ED with a painful problem. Observation of the physical settings of th e ED and triage area after completion of each interview provided the researcher some understanding of the environment in which the triage nurses worked, represented by th e specific contextual layer of the study conceptual model. All of the interviews were conducted during the early morning hours, when the ED generally tends to be less busy. This quiet time allo wed for observation of the pediatric ED, the main triage area and th e ED entrance, initial sign-in area for arriving patients and the waiting room. The previous tria ge experience of the researcher facilitated
35 an understanding of the typical flow of pa tients from arrival to the ED, triage and placement of patients in treatment rooms. Data Analysis Process Analysis of the data utilized a descrip tive qualitative approach with a perspective guided by phenomenology and by comparison to the logic model.. The following process of analysis was followed in order to elucid ate the emic view of the triage nurses experience with children who come to the ED with a painful condition: 1. Each recorded interview was transcribed verbatim by the investigator and saved on a password protected computer and read in entirety to begin the process of interpreting experi ences of the triage nurses. 2. Field notes were written during, or immediately afte r the interviews were conducted. Interview transcripts and field notes were numbered sequentially for la ter comparison. 3. Interview transcriptions were saved as primary documents in the Atlas.ti program. Each primary document was revi ewed and relevant or interesting comments were highlighted. 4. As additional interviews were conducted, additional field notes were made when common ideas or comments were made by the nurses. Each subsequent interview was compared for the same or similar comments. 5. As repetitive key words or phrases we re identified, the investigator began assigning preliminary codes. Short pa ssages related to key ideas were identified and saved as quotes. Me mos were written that described the investigators thoughts about these passa ges. The Atlas.ti program used a
36 system of relating memos, quotes and primary documents for comparison and further interpretation. 6. Emerging themes began to unfold and were given tentative names. The frequency of each code within the a ccumulated interviews was counted to verify the significance of each theme. 7. The emerging themes were compared to the conceptual model which guided this study. The themes mapped to the contextual layers of the conceptual model. 8. The experiences, descriptions a nd thoughts across informants were integrated and synthesized into a descriptive structure of the lived experience of the triage nurse who makes decisions for children experiencing pain. The patterns, themes and context that emer ged from data analysis were compared to the Phase I research questions and the conceptual model for the study to assess for congruence or differences. The theoretical contextual laye rs of the logic model did provide a good fit for the themes that emer ged. The data was also analyzed for any potential new variables that should be included in the Phase II triage survey development. Themes Five major themes which emerged from the data analysis (Table 2) are discussed in this section, and in the Chapter 7 discussi on and results section. Themes were coded as follows: 1) Age of the child is important, 2) Be havior can tell a lot, 3) Really looking at
the patient, 4) Things that help make decisions, and 5) Things that hinder decisions. Each theme is discussed in this section. Table 2: Major Themes that Emerged from Data Analysis Themes Age of the child is important Behavior can tell a lot Really looking at the patient. Things that help make decisions Things that hinder decisions Times coded 17 25 18 17 33 Age of the child is important The age of the child was frequently menti oned as an important factor in assessing pain and making triage decisions, especially for infants and with a nonEnglish speaking family. The age range of patients seen in a Pediatric ED may range from infancy to 21 years. Infants and young children make pain assessment and triage more challenging for the triage nurse due to limited verbal sk ills however, school age and older children are able to rate their pain with several differ ent validated pain scales. Several informants mentioned how challenging it can be to asse ss pain in infants. Eliciting the chief complaint from the parents, gathering a dditional assessment data, noting physiologic signs, and assessing the interaction between the infant and parents all emerged as important indicators. Two nurses mentioned using the Faces, Legs, Activity, Cry, and Consolability Pain Scale (FLACC) which has been validated for use with infant pain 37
38 assessment. Several others mentioned obser vations which are components of the FLACC scale without actually naming it. The challenge of assessing pain in infants was described by the comments of one informant: Asking parents what thei r baseline is what ha s changed; whether they are crying or withdrawn. How much attention they pay to you, depending on their age whether they are playful or just sitting there; whether they are consolable or hysterical. A lot depends on their ages. Another informant expressed these same concerns: its difficult to differentiate pain w ith babies. I try to incorporate what the mother says about how the baby is different than the norm; if the crying is different. Try to generate th at it could be from pain, according to how the baby hasnt been eating, acting irritable, so I try to prioritize whether that patient may need to go back before some others. Informants expressed concerns about assessing pain with young children which appeared to be related to inexperience with using some pain scales or in judging the childs ability to understand the pain scal e. This corresponds to published literature indicating the youngest age at which children can compre hend and use pain scales. Children as young as 5 years have been documen ted as being able to use the Faces pain scale with simple explanations (Bulloch & Tenenbein, 2002). One informant explained how it might be necessary to improvise pain assessment: Depends on their age; their understanding. We have the Faces (pain scale), or we kind of gauge what level they are at. Asking them if a little
39 owie or big owie, or whatever, can give you an idea of how much pain they are having. Sometimes if they dont understand the Faces scale you have to ad hoc Informants described observati ons they would employ in dete rmining pain in infants and young children, and problems that may be en countered, such as communication with parents or the child. Informants most often referred to the smiley face scale which is posted in every treatment room, or using a numeric rating scale of 0 to 10. The younger the child, the more difficult assessing pain becomes, and greater the need for more assessment data, visual cues and information from the parents. Several nurses expressed concerns about the efficiency of the tria ge system when the ED becomes busy and pediatric patients have to wait to be see n. Concern was expressed about the accuracy of triage decisions, and the difficulties in keep ing track of, and re-assessing patients who are in the waiting room. Behavior can tell a lot Behavior of the child, behavior of the pa rents, and observation of interactions with the child and parent were factors men tioned that provide insi ght relative to pain assessment. Nurses expressed a range of atti tudes toward their perceptions of parents. Some parents were seen as helpful and as providing useful information about the childs problem. Other parents were described as bei ng too emotional, over-reacting, or not able to provide helpful information. Previous stud ies have provided eviden ce of discrepancies in pediatric pain level determination between parents, nurses and physicians, as well as differences in ED triage cat egories assigned to pediatric patients by nurses and physicians
40 (Maldonado & Avner, 2004; Singer et al., 2002 ). Other nurses expressed reliance on the information from parents, particularly in reporting differences in infant behavior. The concept of the child or infant be ing inconsolable was mentioned by the participants several times, in the context of observing behavior indicative of pain. One nurse said the following: ...related to orthopedic t ype injuries. They are so painful and theyre so unable to describe the pain, but you k now that it hurts because they are crying so much and they are inconsolable My point is if the pedi patient is inconsolable even by the parents within a short period of time, then something is really wrong. An infant or childs behavior that is reported as being unusual by the parent, or observations of behavior such as wincing, crying or prot ecting a body part from being touched or examined were indicat ors of pain. Behavioral indicat ors of pain or visual cues included obvious behaviors a ssociated with pain: facial grimace, crying, when you do thei r initial vital signs, their vital signs can be elevated like their pulse or respiratory rate. These are factors that indicate that there is definitely pain or discomfort Informants were also concerned with the school age child who seemed very stoic and attempted to remain quiet. Several informants suggested that the very quiet child could actually be tense or fearful and concerned about what painful procedures they might have to endure. Fear of the need for an injection was mentioned as a source of the tense, quiet childs behavior. Some nurses expressed c oncern about missing visual cues with the
41 quiet, stoic child and thereby delay treating a painful condition such as a non-displaced fracture: Children are afraid that if they admit they are in pain because they are afraid something bad will happen to th em. So you have to; 1) listen to their parents to understand how the child expresses pain. Another example of the quiet, stoic child included the following statement: Based on his behavior I could tell he was in pain, just being stoic about, even at that age. So even though he didnt have an obvious deformity I followed through to the pedi ED advoca ting for a hep lock to be started and to give him some pain medicatio n despite the fact that we had not done the x-ray yet because it was just so obvious there was a lot of tension in the child. It tu rns out he did have a fracture of the arm.The behavior of a child or infant experi encing pain was mentioned frequently as an important indicator, but informants frequently corre lated recognizing behavior with their ow n years of experience. Really looking at the patient Looking at the child or infant, in the c ontext of gathering assessment data and attention to detail, was mentioned frequent ly as a component of the decision-making process. Using good assessment skills, and focu sing on the appearance of the infant or child and connecting this data with the verbal information provided was another important aspect of pain assessment. Eyeballing the patient is, of cour se, the first concern, so your first encounter with the patient you can kind of tell, just by looking at them if
42 they are in any acute distress, just by looking at them, and that comes from years of experience. Informants indicated that looking at the patient encompassed more than just observing behavior, although the two themes ar e linked. Other important indicators of pain included visual cues and physiologic da ta such as respiratory rate, body positioning and skin color. As previously noted, obser ving the interaction between the patient and parents was cited as an importa nt indicator. Another nurse e xplained this in her comment: Learn to assess a patient without speaking to them When you walk into the room you look, observe, you see, you watch and then as the patient is speaking or the family is talking you try to put the tw o together. Dont make a judgment, because you will be wrong one day, and that will bite you in the butt one day. But get really in tune with looking, touching, and observing without being judgmental. Things that help make decisions Parents who were informative a nd knowledgeable about their childs normal behavior were viewed as decision-ma king helpers. This comment was an example of expectations of parents; ...the parents should be re liable. You need to listen to them, if they say this is not normal for the child. Interestingly, parents were also frequently described as a hindran ce to decision-making. Another experienced triage nurse stated that nurses must be cautious in listening to the parents, and instead rely on the nurses own experience.
43 The most often mentioned helping factor was the amount of experience of each individual nurse in terms of assessing the patient, asking appropriate questions, making decisions and initiating treatment. As this nurse stated: Ive had enough experience in my b ackground to know that not all pain presents the same way. That people react to pain differently, even children react to pain differently varies grea tly from hysteria to stoicism, like that one child. A lot of that is just based on years of experience. Other factors mentioned as helping in clinical decision-making were good communication between staff in different areas of the ED. The entrance to one ED, as well as the waiting room, triage area and tr eatment areas were physically separated. To facilitate patient flow, the entrance area wa s staffed with an experienced paramedic or licensed practical nurse, who serves as the meeter-greet er, who greets the patient (which in reality equates to a cursory check for life threatening problems), who then communicated verbally or via computerized syst ems with the triage nurse or the Pediatric ED charge nurse as to the patients arrival and chief complaint. This system was discussed as being helpful when everything is going well, but as a hindrance when the ED is very busy or comm unication was interrupted. Only one of the informants interviewed mentioned triage algorithms, or any sort of guidelines followed. An ED policy repeated by several informants was that pediatric patients were taken directly to a treatment room on arrival and a triage level was assigned at the bedside. Years of experience was fre quently mentioned in that it helped with recognition of signs, symptoms and indica tors of pain. One younger informant did mention training which was helpful:
44 the training we have, the certificat ions like ENPC, PALS, the pediatric focused training helped to ki nd of reinforce the concepts Things that hinder decisions Hindrances to decision-maki ng concerning the pediatric patient experiencing pain included language barriers, and a crowde d, busy, noisy environment in the ED. Physicians were mentioned often as a hindrance; however this seemed to be related to not giving orders for pain medication when the nurse felt a patient needed medication, not in the process of assigning a triage level. Lack of appropriate analgesia for pediatric patients by physicians has been reported in previous studies (Petrack, et al., 1997; Jadav, 2009). One informant mentioned that a hindrance to initiating treatment for pain may occur when nurses differ in assessment of pain, or when the patient situ ation changed as the patient was transferred from the tr iage area to a treatment room: Sometime it is difficult if you assess or triage the patient and then you try to give report to the nurse who is going to take care of the patient, and you have a meeting of the minds. Because kids can be very distraught at one point and then be quiet. I think a lot of times the nurse assumes that if the baby is not crying that they are good, and that is so not so. Summary Variables of interest for this study and a conceptual model were developed from the literature review a nd general experience of the resear cher. The interviews in Phase I o explored the perceptions and lived experience of ED triage nurses who interact with, make decisions about, and initiate treatment for pediatric patients who experience painful conditions or injuries. Research questions fo r Phase I obtained information about sources
45 of knowledge ED triage nurses use in ma king decisions about pediatric patients experiencing pain and any factors that might influence those decisions. The data analyzed from the interviews assisted the researcher in the choice of factors included in a series of triage vignettes depicting pe diatric patients brought to th e ED with painful conditions. These vignettes were used in Phase II of this study. The basic question of interest was: How does the ED triage nurse assess pain with the very young pediat ric patient, and what actions are taken? The themes indentified from the data analysis corresponded to the conceptual model for the study and the first three research questions (Table 3). The everyday world of the triage nurse appeared to be embedded within contextual laye rs of an immediate context including the child or infant who comes to the ED experiencing pain and the actions of the triage nurse in response to the patient and/or parents. Themes that related to this contextual layer included the age of th e child and behaviors of the child. The next contextual layer was described as the specifi c context, or immediate past, and current environment (Hinds, Chaves & Cypess, 1992). In cluded in this contextual layer are the physical setting of the ED, the population of patients, volume of patients waiting, and the staffing of the triage. This level is represented by the themes of things that hinder or things that help make triage decisions. The third la yer represented the general context, represented by a general frame of reference, or nurses ways of knowing, their education, experience, and rules or heuris tics they use in deci sion-making. Finally the fourth layer, or Metacontext, was described as a socially constructed layer re presented by internal factors, nurses attitudes, values and beliefs, which also relate to triage nurse perceptions of things that hinder or help triage decision-making.
46 Emergency department pain assessment and management of the very youngest patients continues to be an elusive and probl ematic area (Drendel, et al., 2006). For this study, the data from Phase I was used to de velop triage vignettes depicting pediatric patients with painful conditions for Phase II of the study. The depende nt variable for the vignettes was the triage level assigned to each vignette and was intended to serve as a reflection or proxy for recognition of the degree of pain each patient in the vignette might be experiencing. The initial child and nurse variables conceptualized by the researcher were validated as important mediators to be incorporated into the triage vignettes. While the ED nurses who were interviewe d were able to describe the behaviors they considered indicators of pain in children and infants, particularly the concept of the infant being inconsolable, most of the nurses did not name pediatric pain scales others than the faces scale and the numbers scal e. This observation led to the decision to include in the Phase II triage vignettes, a question regardi ng which pain scale would be appropriate to use for pain assessment for the child or infant descri bed in the vignette. Analysis of the Phase I data supported in clusion of the child and nurse variables from the literature review and the logic model (Figure 1), childrens age, ethnicity, gender and behavior, and nurses education and years of ED work experience. Five predominant themes were identified in the qua litative data analysis and were found to be congruent with the conceptual model of the study. These variables were used to construct 24 triage vignettes described in Chapter 5. An additional question with each vignette asks what pain scale or method would have been used to assess pain for the patient in each vignette. The re sults of Phase II are discussed in Chapter 6.
47 Figure 2: Comparison of Conceptual Mode l to Triage Decision-making Factors Conceptual model: Immediate context (child variables nurse actions) Theme: Age of the child is important Behavior can tell a lot Conceptual model: Specific context (External factors; phy sical setting, ED environm ent, volume of patients) Theme: Things that help make decisions Things that hinder decisions Conceptual model: General context (Nurse knowledge, years of experience, education) Theme: Really looking at the patient Conceptual model: Metacontext (Internal factors; Atti tudes, values of the nurse) Theme: Things that help make decisions Things that hinder decisions
48 Chapter 5 Methods Phase II This chapter presents methods used in Phase II of this study. The setting and sample are described, followed by a descri ption of the instru ment development, evaluation of validity and reliability, the procedure for data collection and the data management and analysis. The second phase of the study used a quantitatively measured triage vignette exercise designe d to further clarify and valid ate the factors and meanings identified in the first phase. A series of tr iage vignettes were de veloped to incorporate variables from the logic model and those derived from the qualitative analysis in Phase I. Research questions in Phase II addressed whet her a triage level for a given vignette can be predicted by child variables of age, gender, ethnicity or behavior, or by nurse variables of education or years of experience. St atistical methods to determine the most parsimonious set of predictor variables are discussed. Sample and Setting The quantitative component of the study, utilized a convenience sample (N= 384) recruited from a population of ED nurses who responded to an announcement e-mailed to members of the Emergency Nurses Asso ciation (ENA). The study was originally designed with a sample size of 384 subjects in order to detect modest to large effects for factors associated with triage level ratings. However, this initial calculati on did not take into account the rep eated measures design whereby the 118 subjects with full data rated
49 each of 24 vignettes. Thus, in actuality, there were 2,832 observations (118 x 24) included in the logistic regres sion analysis. Conservatively considering a binary outcome variable framework (rather than ordinal le vel which affords greater power) and binary predictor, within-subject co rrelation of 0.50, and 2-sided type I error rate of 0.005, the final sample analyzed provided 80% power to detect modest-to-large odds ratios of 1.78 and 1.62 assuming a predictor of interest with proportions of high triage ratings of 0.4 or 0.5, respectively. The sampling procedure followed the pr ocess recommended by Schaefer and Dillman (1998), which consisted of a pr e-letter notice (Appendix I) e-mailed to individual ED nurses. This was followed by an e-mail 2 to 3 days later with a link to the survey and the consent form for an Internet-based survey (Appendix J). A reminder email was sent 3 to 5 days later. Finally, a re placement link to the survey and a thank you e-mail was followed in 3 to 5 days to any ED nurses who had not responded. The use of multiple e-mail contacts, personalized to each potential participant, reassurances of confidentiality and a convenient survey format were all methods recommended to enhance the response rate. Inclusion and Excl usion criteria Inclusion criteria included ED nurses who ha d at least 6 months experience as the assigned triage nurse and experience with pe diatric triage. These participants had all completed some orientation to the triage area or had attended a triage course. Informants were limited to nurses able to read, write, and speak English and those who had the ability to access the in ternet-based survey.
50 Exclusion criteria included ED nurses who lacked experience in the role of triage nurse, had less than 6 months experience as the assigned triage nurse, or lacked experience with triage of the pediatric patient. Instrument: Pediatric Tri age Pain Assessment Scale A series of 24 vignettes were create d for this study, incorporating factors identified from the literature review and th e qualitative data analysis. Each of the 24 vignettes included variables derived from factors identified from the Phase I data analysis, randomly positioned in each vignett e (i.e. age of child, gender, ethnicity, behavior), which depicted an infant or chil d with a painful conditi on or injury who had just arrived at triage. Each vi gnette was scored by assigning a triage level ranked from (1) emergent, to (5) non-urgent. The ranked score, or triage level for each vignette indicated the degree of urgency for initiating eval uation and treatment. A second question following each vignette asked the participan t to choose a pain assessment method or instrument that might be used for that patient. A space for additional comments was included at the end of the survey. A short de mographic form was included in the survey so that nurse characteristics of years of experience and educat ion could be incorporated in the data analysis. Reliability and validity The reliability of the triage vignette survey was estimated by measuring the stability and equivalence of the instrument (Polit & Beck, 2004). Stability was measured using a test-retest procedure to calculate a re liability coefficient. A sample of six ED nurses were recruited to complete the triage vi gnette survey and to repeat it in two weeks. A Pearson reliability coefficient was calculate d between the two sets of scores. The ideal
51 coefficient should be greater than .70. E quivalence can be assessed by examining the interrater reliability of responses to each item on the survey. The validity of the survey was estimated by assessing the cont ent validity and a content validity index (CVI). A panel of five ED nurse experts was recruited to review the triage vignette survey. Four of the nurses completed and returned the CVI which rated each vignette based on the following two questions: 1). the relevance of information in each vignette, and 2). the adequacy of information in each vignette. 1. Is this question relevant to measuring so me aspect of triage clinical decisionmaking and pediatric pain assessment? Plea se rate this vignette on a 4-point scale from not relevant (1) to very relevant (4). 2. Is there sufficient information in this vi gnette to make a triage decision? Please rate this vignette rating it from not sufficient (1) to very sufficient (4), (Appendix K). The proportions of vignettes rated with a sc ore of 3 or 4 were calculated for each question. These two scores represented the CV I for content relevan ce and adequacy of information respectively (Polit & Beck, 2004). Procedures An Internet notice which consisted of a br ief explanation and brief description of the survey, components of informed consent, assurances of confiden tiality, directions for completing the survey, and a link to the survey website was sent to ENA members. Return of a completed survey and demographic form via the Checkbox 4.6 program, a web-based data management system maintain ed by the University of South Florida, served as consent to participate. Use of a four-phase sampling procedure, which included
52 an emailed pre-notice, the notice with link to the survey, a reminder e-mail, and a final e-mail reminder and thank you optimized responses. The Phase II component of the study c onsisted of a convenience sample of ED nurses who were asked to respond to a series of vignettes which asked for a triage level assignment based on the 5-level triage system recommended by ENA and ACEP (Fernandes, et al., 2005). The vignettes were c onstructed using factors from the literature review and those that emerged from analysis of the qualitative data. The responses to vignettes enabled the in vestigator to further explore the significance of those factors. The quantitative phase of the st udy allowed for describing the distribution, commonalities and differences in responses as well as the strength or direction of any patterns or relationship in responses. At the end of the survey a comment box was included as an option for the participant to write in additional comments and thus further validate the outcomes of the data from Phase I of this study. Also, this opportunity for personal input provided an opportunity to identify additional factors not previously identified. Any comments listed were analyzed using quantitative methods for content, frequency, and similarity. Data Management and Analysis The first step of data management was to analyze the reliability and validity data for the triage vignette survey pr ior to uploading the su rvey to the internet website so that any necessary revisions could be made. Res ponses from the expert panel of reviewers were entered into a database for analysis of responses and calculation of a CVI. Descriptive statistics for each item and summary statistics across items were calculated for interrater agreement, as well as a CV I (Polit & Beck, 2004). This data analysis provided a basis for the cont ent validity of the survey.
53 Following the validity and reliability evaluation of the scale the final format was entered into the Checkbox 4.6 program sy stem, and the four-step e-mail process initiated. Responses from returned, completed surveys were entered into a database for analysis with SPSS 17.0 Graduate Pack (SPSS Inc., Chicago, IL) and/or SAS 9.1.3 (SAS Institute Inc., Cary, NC) software programs. Demographic data from surveys were analyzed using descriptive statistical me thods. Any additional comments written by participants in reference to the vignettes were analyzed using descriptive methods as well. The data set was examined for meas ures of central tendency, dispersion and distribution. Two research questions pertained to Phas e II; (a) what were the differences in triage level assigned for a give n vignette based on nurse vari ables, and (b) what were the differences in triage level assigned for a gi ven vignette based on patient variables? The set of variables that had been proposed for the research questions were retained in the final scale. The nurse variables and child variables previously stated in this research proposal remained as stated, so that all the variables or predictors were incorporated to create a 2X2X3X2X5 contingenc y table with one continuous variable design (Table 3). Analysis of the triage vignette response s and demographic variables with SPSS and/or SAS statistics programs, with ordinal logistic regression and cumulative logit model data methods allowed for analysis of the directi on, and strength of rela tionships between the categorical and continuous predictor variab les and an ordinal, categorical dependent variable (i.e. five triage levels).
Table 3. Cumulative Logit Model Contingenc y Table: Child and Nurse Variables Child Variables : Age Infant School age Gender Male Female Male Female Ethnicity Black White Hispanic Black White Hispanic Behavior Crying Quiet Crying Quiet Nurse Variables Education ADN Diploma BSN MSN Other Years of ED experience Grouped Continuous Variable (1-10 yrs, 11-20 yrs, 21-30 yrs, 31-41 yrs) Triage Level (Dependent Variable) 1Immediate 2Emergent 3-Urge nt 4-Semi-urgent 5-Non-urgent Note: ADN = Associate Degree in Nursing, BSN= Bachelors Degree in Nursing, MSN =Masters Degree in Nursing, Other =Doctoral Degree or other. Thus, adjusted odds ratios could be estimated for various predictors of interest by use of ordinal logistic regression methods. Th e effective sample size of 118 participants with full data provided 80% power to detect a significant increasing trend (2-sided type I error rate of 0.05) in outcome for a binary predictor such as age, gender, or child behavior, and average outcome proportion of 0.20 (e.g. prevalence rates of 0.10, 0.15, 54
55 0.20, 0.25, 0.30 across all 5 levels of the dependent variable). The 118 participants with full data for all 24 vignettes provided adequa te power to detect modest differences in levels of the dependent variables fo r various predictors of interest. Summary In summary, the study consisted of two phases; quantitative semi-structured interviews with experienced ED triage nur ses who described the experience of triaging pediatric patients who come to the ED e xperiencing pain and secondly, a quantitatively measured triage vignette exercise, designed to further clarify and va lidate the factors and meanings identified in the first phase. For Phase II of this study the Pediatric Triage Pain Assessment Scale was developed, validity and reliability was evaluated and the survey was uploaded to the Checkbox 4.6 program internet site. A four-step process for soliciting participants was implemented. Data analysis and results are discussed in Chapter 6.
56 Chapter 6 Phase Two Results This chapter addresses the data and results of Phase II of this research, including a description of the development of the vignettes estimates of validity and reliability of the triage vignettes, and development and testing the survey for the Internet environment. This phase of the study was conducted to obtai n data relative to the last two research questions; the first question asked whether ther e are differences in triage level assigned for a given vignette, based on nurse variables of: educational backgr ound, (four levels) or years of experience (continuous variable). The second res earch question asked whether there were differences in triage level assi gned for a given vignette based on patient variables of: age (two categorie s), ethnicity (three categories) gender (two categories), or behavior (two categories). The purpose of these two research questions was to describe commonalities and differences in triage decision-making processes through analysis of responses to a series of triage vignette s. A summary report of the demographic characteristics of the participants, data an alysis of the triage vignette responses and descriptive analysis of the pain asse ssment method is included as well.
57 Pediatric Triage Pain Assessmen t Scale Validity and Reliability Content Validity Index Twenty four triage vignettes were created based on information from the literature review, the Phase I data results and previous ED nurse experience of the researcher. An estimate of the content validity was the next st ep in the process. The vignettes were typed in a table format with columns (Appendix K) to allow for the reviewers to rate the vignettes on a 4-point scale fo r the two following questions: 1. Is this question relevant to measuring so me aspect of triage clinical decisionmaking and pediatric pain assessment? 2. Is there sufficient information in this vignette to make a triage decision? Four of the five ED nurse experts who we re requested to participate completed and returned the survey so that a CVI could be calculated, based on the number of vignettes rated with a score of 3 or 4 for each of the two questions. Responses to the first question concerning relevance of the question resulted in a CVI of 0.92. Responses to the second question concerning sufficiency of inform ation resulted in a CVI of 0.46, which was lower than anticipated. Two of the reviewers contact ed the researcher to express concerns that many of the vignettes did not provide sufficient info rmation to make a triage decision. This problem reflected one of the issues related to the triage decision-making process; the amount and quality of data needed to assign an appropriate triage category while working in a fast-paced, crowded ED. The original inte nt with development of the vignettes was to provide enough information to facilitate participant response s, without including extraneous information that could make anal ysis of responses diffi cult. After reviewing
58 responses from the reviewers, the researcher revised the vignettes to include addition contextual detail in each vignette. The de tails, such as a brief statement about the mechanism of injury were randomly repeated in subsequent vignettes. A group of injuries representing painful conditions (obvious fr acture, bruising, head injury, abdominalthoracic pain, lacerations and burns) were al so randomly repeated in the vignettes. These additional details added to the vignettes were incorporated such that the original child predictor variables were preserved and each vignette was enhanced to more closely represent a real-life situation. The final vignettes used in the study included a minimum amount of contextual detail in addition to th e original child predic tor variables of age, gender, ethnicity and behavior. The additional details added to the vignettes were derived from contextual details that emerged from th e Phase I interviews, and from the previous triage experience of the researcher. To supplement the triage vignette scale and gain some additional information from participants relative to pediatric pa in assessment, each vignette was followed by a question which asked the survey participant to indicate whic h pain assessment technique or tool would have been used with that vignette. Answer choices included; observations, FLACC scale, Faces pain scale, numeric rating scale, ask the parent, and other. The final survey consisted of a short series of dem ographic questions, 24 vignettes, and 24 pain assessment questions. The researcher was concerned about the participant response burden if the survey was perceived to be too long. None of the content validity reviewers commented on the length of the survey.
59 Reliability Once the triage vignettes were finalized the content validity process was not repeated. The researcher expected the CVI for the question concerned with sufficiency of information to remain low to moderate; how ever for the purposes of this study it was necessary to limit the contextual information in each vignette. The next step in the process involved creating the survey on the inte rnet and then estimating the reliability of the survey by evaluation in the same presenta tion which would be viewed by participants on the Survey website. Creating a visually app ealing survey that was accessible and easy to follow was an important aspect relevant to influence on response rates (Dillman & Bowker, 2001). The Checkbox 4.6 program was used, which allowed creation of the survey with an appealing blue background and easy to read text and font. The demographic questions appeared on the first page, followed by directions for responding to the vignettes. The actual vignettes and pain assessment questions followed. Several page breaks were inserted to create a visual and mental pau se for the participant as he or she progressed through th e survey. The page breaks were required for the Checkbox 4.6 program to progress correctly, and we re thought to help ease any participant fatigue. Reliability of the triage vignette survey was estimated by assessing the stability of the instrument with a test retest procedur e to calculate a reliability coefficient. A sample of six ED nurses were recruited to co mplete the survey and to repeat the survey again in one week. Due to technical probl ems with the Checkbox 4.6 program survey site program, the test retest procedure had to be repeated. The final sample resulted in completed sets of test and retest data from three participants. The Pearson reliability
60 coefficient for the two sets of scores was 0.90, a very good indication of the stability of the instrument; however, this was an extrem ely small pilot sample (Polit and Beck, 2004). The test retest reviewer s did not express any concerns about the survey length or amount of time required. The summary data from the Checkbox 4.6 program program indicated the length of time for completion of the survey was approximately 20 minutes. A measure of internal consistency was al so calculated using Cronbachs alpha. The resultant score was 0.95, which is also a good in dicator of the instruments reliability. This preparation and testing of the survey provided so me assurance of a reliable instrument so that Phase II data collection could begin. Data Collection Process E-mail addresses to invite participan ts were obtained from a list of ENA members. A pre-notice e-mail was sent to each potential partic ipant (Appendix I) to explain the study and to alert each person that a subsequent e-mail with a link to the actual survey would be sent in several da ys. This pre-notice e-mail also provided an opportunity to verify whether each e-mail address was still active and correct. Approximately 25 nurses responded to the prenotice e-mail to indi cate interest in participating. A second e-mail invitation which incl uded the Phase II informed consent document (Appendix J) and a direct link to the survey was sent directly from the Checkbox 4.6 program. A total of 686 e-mail inv itations to participat e were sent over a four to five day period. By coincidence, the 2009 ENA national conference was occurring during the same time frame, so a number of nurses from the e-mail address list were attending the conference. Seve ral of them actually sent an e-mail while attending the
61 general assembly proceedings, with offers to participate when the conference was over. One person sent an e-mail to say that several ENA state council members had submitted a motion to discuss and adopt a position st atement concerning ED pediatric pain management. This incident reflects the importance of the purpose of this study. A reminder e-mail invitation and a thank you note were sent several days later, which generated additional survey responses. Over a three week period, 170 participants accessed the survey; however 33 of them did not enter any responses. These empty responses were deleted. The remaining 137 su rveys were recorded, which represented a 20% response rate. There were 18 incomple te surveys missing at least half of the vignettes, which were retained in the final response set. The final sample size consisted of 137 surveys. Reasons for the incomplete su rveys include possible Internet system failures, participant fatigue or unknown r easons. Forty three participants wrote in comments with the survey; 13 of the comment s indicated they felt there was not enough information in the triage vignettes to make a triage decision. The demographic data for completed surveys was compared to the incomplete surveys to determine if there were any differences, such as years of experi ence. The Checkbox 4.6 program was set to only allow one response per person, so if the In ternet connection was lost for any reason, that person could not co mplete the survey. The internet-based survey was accessible for approximately four weeks to allow time for ED nurses who had been sent an e-mail invitation an opportunity to respond. When responses fell to zero for several days and following a second e-mail reminder, the completed surveys were downloaded into a pa ssword protected computer for analysis using the SPSS 17.0 Graduate Package software program and/or SA S software program.
62 All responses returned to the Checkbox 4.6 program system were anonymous, which provided confidentiality for the participants. Demographic Data Demographic data for Phase II participants followed the same guide as that for Phase I. Participants were asked to provide their age, gender, ethnicity, education, years of ED experience, and advanced certification (Table 4). Th e participants ranged in age from 26 to 72 years. They were predominantly White females with a mean of 20 years of ED nursing experience. More than half reported either a BSN (30%) or MSN (34%) education degree. A larger pr oportion of ADN participants (79%) reported less than 20 years ED work experience, however BS N and MSN participants (46% and 60% respectively) reported greater than 20 years of ED work experience. Eighty percent of the participants held at least five advanced certificates such as Advanced Life Support Provider, which are frequently required to wo rk in the ED. Certification in Emergency Nursing (CEN) was reported by 77% of partic ipants. This sample was obtained from an e-mail address list of ED nur ses who had attended the Emer gency Nurses Association National Scientific Assembly, and were members of their respective state delegation to the assembly.
Table 4. Phase II Participant Demographics Variable Mean Freq. (%) Age Range 26 72 years 50 years 137 (100%) Variable Mean Freq. (%) Gender Female Male 121 15 (89%) (11%) Ethnicity White Black Hispanic Asian Other 128 0 2 3 2 (93%) 0 (1.5%) (2%) (1.5%) Education ADN Diploma BSN MSN Other 23 12 41 47 13 (17%) (9%) (30%) (34%) (9.5%) 63
Table 4. Phase II Participant Demographics continued Variable Mean Freq. (%) Years of Experience (grouped) 1-10 yrs 11-20 yrs 21-30 yrs 31-41 yrs 50 years 28 41 45 22 (21%) (30%) (33%) (16%) Advanced Certification CEN ACLS TNCC ENPC PALS Other N=137 106 126 109 89 96 50 (77%) (92%) (80%) (65%) (70%) (37%) Data Analysis Process Triage vignettes The data were analyzed with descrip tive statistical methods to assess for independence of responses, normality of the di stribution and homogene ity of variance by assessment of frequencies, overall mean and mode for categorical variables, standard deviation, variance, skewness and kurtosis. Gra phical representations using stem and leaf 64
65 plots, box and whisker plots and histograms were also assessed to observe the distribution of scores of variables. The additional su rvey comments added by participants were analyzed for content and are discussed below. Responses to the triage vignettes (dep endent variable) provided categorical ordinal ranked data which were analyzed for frequency, distribution, measures of dispersion and central tendency, skewness and kurtosis. A 5-level triage response model had been created based on recent recommenda tions in the literature by ACEP and the ENA (Fernandes, et al., 2005); however the di stribution of responses to the triage vignettes resulted in a skewed distribution and a large number of cross tabulation cells with zero responses. To addre ss this problem, the low and hi gh endpoint triage levels (1= immediate, and 5= non-urgent) were re-coded into the next adjacent level so the data could be analyzed with three tr iage levels (level 2 = emerge nt, level 3 = urgent, level 4 = semi-urgent). The triage level is ranked in re verse numerical order; level 2 represents the highest acuity (patient needs to be seen prom ptly), while level 4 represents the lowest acuity (patient is stable enough to wait a short period of time to be seen). The continuous predictor variable, years of ED experience was also problematic in that the scores ranged from one year to more than 40 years (range =46) which made response tables very long and cumbersome and caused a large number of zero response cells. To minimize this problem the continuous variable was re-coded into groups based on the mean score, one and two standard deviations above and below the mean. This resulted in a grouped con tinuous variable with 4 cutpoi nts (1-10 years, 11-20 years, 21-30 years, and 31-41 years).
66 Logistic Regression Methods To address the research questions for Phase II an ordinal logistic regression approach with a cumulative logit model was us ed to measure the stre ngth and direction of relationships between predicto r variables on the dependent variable of triage level assigned for each vignette (logistic regressi on procedure was done using SAS software program). Logistic regression methods are robust to the distribu tion assumptions that apply to linear regression and therefore are the method of analysis recommended for data with non-linear relationships between predictor and dependent variables; in this instance, use of categorical and conti nuous predictor variables and an ordinal ranked dependent variable. A logit is described as the natural l ogarithm of an odds ratio, or the ratio of two probabilities. Use of a logit or log-odds approximates a linear function with a predictor and represents the amount of change seen in the logit w ith a 1-unit change in the predictor (Agresti, 1984; Pedhazer, 1997; Zu mbo & Ochieng, 2002). Two assumptions of ordinal logistic regr ession with a cumulative logit model are: 1) Cumulative information along the pr edictor variables e ffects the outcome variable so that the odds of Y< 1 rather than > 1and the odds of Y< 2 rather than > 2. 2) At any given point on the X-axis th e orders of the logistic curves have a common slope (Zumbo & Ochieng, 2002). For the first step of data analysis, chi-square test s were used to assess the association between individual predictor variables and the pr oportion of triage level of the dependent variable (level 2 = emergent level 3 = urgent, level 4 = semi-urgent) across all 24 vignettes (Mantel-Haenszel 2 for ordinal measures of association were reported). The nurse characteristic variables of education and year s of experience were
67 found to be highly correlated. Pa rticipants who assigned higher triage levels for a given vignette were more likely to do the same for every vignette (i.e. correlated rather than independent observations). While this design of multiple ratings of vignettes by the same participants would not necessarily bias resultant odds ratio estimates, the w ithin-subject correlation would be expected to bias standa rd error estimates (smaller than expected) thereby increasing the possibility of Type I errors at the conventional significance level of p < 0.05. Therefore, to be conservative, a modified p-value of < 0.005 was used to determine statistical significance throughout the data analysis. Unadjusted Chi-Square Analyses Ethnicity predictor variable categories were White, Black and Hispanic. In chisquare analyses, whereas Black versus non-Bl ack race was not associated with vignette triage levels, vignettes with Hispanic ethnicity were associ ated with higher triage level 2 (1, N= 118) =34.934, p<.0001. Vignettes with male gender were also associated with a higher acuity level 2 (1, N=118) = 24.588, p<.0001. Similarly, vignettes with an infant were associated with a higher acuity 2 (1, N= 118) = 172.91, p<.0001, whereas vignettes with crying compared to quiet behavior resu lted in no statistical difference in acuity levels assigned. Nurse predictor variables of years of experience and education, were associated across all levels with a higher propor tions of level 3 triage scores compared to level 4; however there were no sign ificant differences noted. The second step of data analysis involv ed classifying the vignettes grouped by clinical condition to evaluate fo r associations with acuity levels (i.e. subgroup of analyses of the vignettes by clinical condition). As the data results were examined, it seemed logical that the survey participants might tend to view various clinical conditions
68 differently in terms of acuity. The clinic al condition categories included the following proportions of the total number of vignettes: soft tissue in jury 16.7% (bruises, burns, and lacerations); abdomen/thoracic injuries 29% neurological/head injury 25%, and orthopedic injury 29%. Predictor variables were evaluated for any associations or trends towards higher acuity levels within each clinical grouping (Table 6). Within the soft tissue injury grouping, and like the overall results, the ethnicity category of Hispanic compared to non-Hispanic was associated with a higher acuity 2 (1, N=118) =31.057, p<.0001. Female gender was also associat ed with a higher triage level 2 (1, N=118) =11.765, p =.0006, as was the variable age of infant: 2 (1, N=118) =33.839, p<.0001. Neither nurse characteristic variables of education or years of experience were associated with triage leve l assigned to soft ti ssue injury vignettes. The next clinical conditi on grouping analyzed was abdomen/thoracic injury which accounted for 29% of the vignettes. The ethnicity categories of Black 2 (1, N=118) =14.915, p<.0001 and Hispanic 2 (1, N=118) =38.306, p<.0001 were associated with a higher acuity, however the Hispanic categor y had a higher proportion of vignettes rated more serious (60%) compared to the Black category (42%). The gender category was not associated with triage level ratings. Both the infant 2 (1, N=118) =61.559, p<.0001, and crying 2 (1, N=118) =32.577, p<.0001 variables were associat ed with higher acuity in this clinical condition grouping. Once again, the nurse characteristic variables of education and years of experi ence were not associated w ith triage level ratings. The third clinical condition group anal yzed included vignettes simulating neurological/head injury problems which repr esented 25% of the vignettes. The variable of ethnicity was not associat ed with higher acuity levels in this clinical condition
69 grouping. Gender also was not associated with any ratings of acuity. In contrast, the variable of infant compared to school aged child was associated with a higher acuity level 2 (1, N=118) =38.111, p<.0001, as was the variable of quiet compared to crying 2 (1, N=118) =14.841, p<.0001. Several participants wrote comments to say the vignettes which included the combined variables of a qui et infant with a bruise on the head would have caused concern as to whether the infant was sleeping or had a decreased level of consciousness, and therefore warranted a highe r acuity level to allow the patient to be evaluated by a physician soone r. The nurse years of experience variable was also associated with higher triage level ra tings as years of experience increased 2 (1, N=118) =11.361, p=.0008, but education levels were not. The final clinical condi tion grouping analyzed incl uded vignettes simulating orthopedic injuries which represented 29% of the vignettes. The category of non-Black compared to Black ethnicity was associated with a higher triage level 2 (1, N=118) =120.219, p<.0001, and Hispanic ethnicity was also a ssociated with higher acuity levels 2 (1, N=118) =32.105, p<.0001. Similarly male gender 2 (1, N=118) =145.288, p<.0001, and infants 2 (1, N=118) =81.571, p<.0001, were both associated with higher acuity levels for orthopedic in jury vignettes, however behavi or (crying or quiet) was not associated with higher acuity. Neither nurse variables of experience or education were associated with higher acuity triage levels. Written comments from participants mentioned the possibility of concern for ch ild abuse for vignettes with infants with orthopedic injuries, which may have contributed to the trend towards higher acuity triage levels.
Table 5. Unadjusted Chi-Square Analyses by Vignette Clinical Condition Clinical Condition Df Wald 2 Pr>ChiSq Soft tissue injury Hispanic: ethnicity Female: gender Age: Infant 1 1 1 31.057 11.765 33.839 < .0001 .0006 < .0001 Abdomen/Thoracic injury Ethnicity: Black Ethnicity: Hispanic Age: Infant Behavior: crying 1 1 1 1 14.915 38.306 61.559 32.577 < .0001 < .0001 < .0001 < .0001 Neurological/Head injury Age: Infant Behavior: Quiet Nurse: Yrs. Exp. 1 1 1 38.111 14.841 11.361 < .0001 < .0001 .0008 Orthopedic injury Ethnicity: non-Black Ethnicity: Hispanic Gender: Male 1 1 1 120.219 32.105 145.288 < .0001 < .0001 < .0001 Logistic Regression Adjusted Methodology and Results An ordinal logistic regression (OLR) approach was used to simultaneously analyze multiple variables across all 24 vignettes, followed by OLR with the vignettes 70
71 sub-divided by similar clinical condition as previously described, and analyzed separately. A cumulative logit model was used to evaluate the independent effect of the predictor variables on the probabi lities of triage level assigned for a given vignette, which are reported as adjusted odds ratios. A Wald 2 test with an alpha significance value of p < .005 was used to identify the best combination of predictor variab les associated with the dependent variable; triage level. A response profile of descending order values was designated such that a positive coefficient was associated with an increased triage acuity score (ordered value 1 = triage level 2, or emergent; a value of 2 = triage level 3, or urgent; and a value of 3 = triage level 4, or semi-urgent. Taking into account multiple ratings per participant, the total numbers of triage level ratings acr oss all vignettes were as follows: value = 1; 933 observations, value =2; 1160 observations and value =3; 576 observations, (hence 933+1160+576=2669 observations for analysis). A test for the proportional odds assumption that the regressi on lines for cumulativ e logits ar e parallel 2 (12, N=118) =68. 861, p<.0001 was rejected. The globa l null hypothesis test of BETA=0 was rejected; likelihood ratio 2 (12, N=118) =328.316, p < .0001, which indicates that at least one of the predictor vari able regression coefficients is not equal to zero, and the model is significant. Analysis of maximum likelihood estimates calculated the ordered logit regression coefficients and tested whether each individual predictor in the model is different than zero, given the othe r predictor variables in the model, using a Wald 2 and alpha of .005 for significance (Table 6) Predictor variables with significant Wald statistical values have a significant eff ect on the dependent variable. For the logits, a one unit increase in a predictor variable is expected to result in a change of the logit by
72 its respective regression coefficient while othe r variables are held c onstant (UCLA, ATS, 2010). The estimates or logits (regression coe fficients) for the Hispanic ethnic category compared to non-Hispanic did have a significan t effect on the probabi lity of higher triage scores, Wald 2 (1, N=118) =36.7916, p< .0001. For the gender variable, the female category compared to males had a significant negative effect (estimate of -0.3763) Wald 2 (1, N=118) =25.9576, p< .0001, or a decline in the probabi lity of a higher triage level for females compared to males. Infants compar ed to school-age children had a significant effect on the probability of higher triage scores Wald 2 ( 1, N=118)186.988, p< .0001; however the behavior variable (crying compared to quiet) had no effect on overall triage levels across vignettes. For the nurse characteristic variables, the grouped vari able years of experience (11-20 years) was related with a decline in the probability of higher triage scores compared to more years of experience (Wald 2 16.412, p< .0001). Associate Degree Nurses (ADN) (Wald 2 49.138, p< .0001), as well as those with a Masters Degree (MSN) (Wald 2 10.687, p=.001), and other education category (Wald 2 13.345, p=.0003), all had a significant effect on the probab ility of higher triage scores compared to Bachelors Degree (BSN) and Diploma nurses. The other category is unclear as to the nature of the educational pr eparation of the participant.
Table 6. Analysis of Maximum Likelihood Estimates and Odds Ratio Estimates Parameter df Est. (logit) St. Error Wald Chi-Sq Pr> ChiSq Point est. 99.5% Wald CI Intercept 2 Intercept 3 Black Hispanic Female Infant Crying Years exp: 11-20yrs 21-30yrs 31-41yrs ADN DIPL MSN Other 1 1 1 1 1 1 1 1 1 1 1 1 1 1 -1.5345 0.5725 0.1324 0.5509 -0.3763 1.0351 0.1432 -0.4230 0.0886 0.1377 0.7974 0.2148 0.3099 0.4827 0.1264 0.1229 0.0896 0.0908 0.0379 0.0757 0.0737 0.1044 0.1089 0.1297 0.1138 0.1500 0.0948 0.1321 147.3281 21.7169 2.1833 36.7916 25.9576 186.9884 3.7777 16.4121 0.6632 1.1276 49.1379 2.0506 10.6873 13.3447 <.0001 <.0001 0.1395 <.0001 <.0001 <.0001 0.0519 <.0001 0.4154 0.2883 <.0001 0.1521 0.0011 0.0003 1.142 1.735 0.686 2.815 1.154 0.655 1.093 1.148 2.220 1.240 1.363 1.620 0.888 1.468 1.344 2.239 0.558 0.845 2.277 3.482 0.938 1.419 0.489 0.878 0.805 1.483 0.797 1.652 1.613 3.055 0.814 1.889 1.045 1.779 1.118 2.348 The effect of the predictor variables was assessed by examining the Odds Ratio (OR) point estimates (Table 6) which compar ed the odds of a vignette having been rated a triage level of 2 compared to a level of 3 or 4. Hispanic ethnicity was 1.74 times more likely to have a higher triage acuity rating th an non-Hispanic in th e vignettes (CI 99.5%; 73
74 1.344 and 2.239). Females compared to males were 0.69 times less likely to have a triage level of 2 or 3 assigned (CI 99.5%; 0.558 and 0.845). Infants compared to school-age children were 2.815(CI 99.5%; 2.277 and 3.482) times more likely to have a higher triage level assigned. Nurses with 11 20 y ears of experience were 0.66 times less likely to rate a given vignette a triage level of 2 or 3, compared to a triage level of 4. ADN nurses were 2.2 times more likely to rate vignettes with a hi gher triage level, as were MSN (OR: 1.363, CI 99.5%; 1.613 and 3.055) an d other (OR: 1.62, CI 99.5%; 1.118 and 2.348). Vignettes were sorted by clinical conditi on as previously desc ribed and evaluated with logistic regression using a cumulativ e logit model again to identify factors associated with triage level ratings (Table 7). The same logistic regression procedure was used as in the full OLR. The first clinical condition explored was so ft tissue injuries. For these vignettes, both Black (Wald 2 9.7437, p= .001) and Hispanic (Wald 2 33.9645, p< .0001) ethnicity had a significant effect on th e probability of higher triage scores, however the magnitude for vignettes with Hi spanic ethnicity was larger (OR: 4.87, CI 99.5%; 2.273 and 10.452) compared to the vigne ttes with Black ethnicity (OR: 2.220, CI 99.5%; 1.084 and 4.549). For the gender variable in these vignettes, the female category compared to males had a significant effect (Wald 2 8.350, p= .004), on the probability of a higher triage level. The next clinical condition examined were the vignettes with simulated abdomen/thoracic pain. In these vignettes predictor variables which had significant effects on the probability of higher triage scores included Hispanic ethnicity compared to non-Hispanic (Wald 2 89.602, p< .0001), infant compared to school-age child, (Wald 2
75 55.2473, p<.0001) crying compared to quiet behavior, (Wald 2 21.4227, p< .0001) and ADN education (Wald 2 14.3989, p< .0001). OR for these predictors were quiet impressive; Hispanic ethnicity was 11.76 times more likely to have been rated a higher triage level (CI 99.5%; 5.662 and 24.424). Infa nts were 4.4 times more likely than school-age children to have a higher triage le vel, as well as crying compared to quiet behavior (OR 2.48, CI 99.5%; 1.43 and 4.31). ADN education was also 2.36 times more likely to be associated with rating highe r triage levels fo r these vignettes. For vignettes with simulated neurological /head injury problems, infants compared to school-age children had a sign ificant effect on the probability of higher triage scores, (Wald 2 28.276, p< .0001) with an OR of 4.02 (CI 99.5%; 1.93 and 8.37). The only other predictor with a significant effect was ADN edu cation compared to other categories (Wald 2 32.828, p< .0001) and an OR of 4.01. Orthopedic injury vignettes, both Black compared to non-Black ethnicity, (Wald 2 23. 552, p< .0001), and female compared to male gender (Wald 2 45.366, p< .0001) had a decline in the probabil ity of higher triage levels. Black ethnicity was 0.197 times less likely to have higher triage levels, a nd females were 0.243 times less likely to have higher triage levels assigned. These results demonstrated a wide range of responses to triage vignettes. Sorting the vignettes by clinical conditi on revealed contrasting areas of difference. Participants may have made triage choices with the vignettes based on overall concern for clinical condition, rather than considera tion of how much pain the infa nt or child in the vignette might be experiencing.
Table 7. Logistic Regression and Odds Ratio Estimates by Clinical Condition Clinical Condition Df Wald 2 Pr>ChiSq OR 99.5% CI Soft tissue injury Ethnicity: Black Hispanic Gender Female 1 1 1 9.7437 33.9645 8.3501 .001 <.0001 .003 2.220 4.874 2.046 1.084 4.549 2.273 10.452 1.021 4.102 Abd/Thoracic injury Ethnicity: Hispanic Age: Infant Behavior: crying Nurse Educ: ADN 1 1 1 1 89.602 55,2473 32.577 14.3989 < .0001 < .0001 < .0001 < .0001 11.76 4.422 2.484 2.364 5.662 24.424 2.522 7.753 1.431 4.314 1.241 4.466 Neuro/Head injury Ethnicity: Hispanic Age: Infant Nurse Educ. ADN: 1 1 1 .6892 28.2756 32.8284 .003 < .0001 <.0001 2.118 4.016 4.010 1.036 4.326 1.928 8.366 2.031 7.920 Orthopedic injury Ethnicity: Black Gender: Male 1 1 23.5520 43.3656 < .0001 < .0001 0.197 0.243 0.077 0.504 0.125 0.428 76
77 Pain measurement methods Following analysis of the Phase I data it appeared that informants were not able to clearly articulate the differe nt pediatric pain scales av ailable. The most commonly mentioned scale was the smiley face. Th e FLACC scale was mentioned only twice during the interviews by name; however most of the informants described assessing infants for behaviors which are in fact, components of the FLACC scale. One behavior in particular, being inconsolable, was mentioned frequently as an indicator of pain. Based on the discussions about pain scales with th e Phase I informants, for the Phase II survey, a question was added following each vignette wh ich asked for a choice of pain scale or method of pain assessment that would be most appropriate to use with the patient in each survey vignette. The response choices incl uded: 1) ask parents, 2) 0-10 rating, 3) observation, 4) faces scale, 5) FLACC scale, and 6) other. Frequency and percentages of responses for each vignette were calculated (table 7). The responses were also assessed for appropriate methods, based on whether the vignette portrayed an infant or school-age child. A number of participants wrote comments at the end of the survey indicating a need for specifying an age range for school-age child. Some felt the range included ages from 5 to 18 years old.
Table 8. Pain Assessment Method by Vignette Vignette/ Age Pain Assessment Method f (%) f (%) f (%) f (%) f (%) f (%) Ask parent 0 -10 Rating Observation Faces scale FLACC scale Other V1/Infant 3 (2%) 0 34 (25%) 15 (11%) 63 (46%) 3 (2%) V2/Infant 1 (.7%) 0 38 (28%) 19 (14%) 57 (42%) 3 (2%) V3/ School age 0 42 (31%) 3 (2%) 69 (50%) 3 (2% ) 1 (.7%) V4/School age 0 51 (37%) 2 (2%) 63 (46%) 1 (.7% ) 1 (.7%) V5/ Infant 1 (.7%) 0 34 (25%) 15 (11%) 65 (47%) 2 (2%) V6/Infant 1 (.7) 1 (.7%) 33 (24%) 17 (12%) 63 (46%) 3 (2%) V7/Infant 2 (2%) 0 31 (23%) 19 (14%) 59 (43%) 3 (2%) V8/School age 0 48 (35%) 3 (2%) 65 (47%) 1 (.7%) 1 (.7%) V9/School age 0 48 (35%) 6 (4%) 58 (42%) 2 (2%) 0 V10/Infant 1 (.7%) 1 (.7%) 29 (21%) 15 (11%) 64 (47%) 3 (2%) V11/School age 0 55 (40%) 3 (2%) 53 (39%) 1 (.7%) 0 V12/Infant 3 (2%) 1 (.7%) 30 (22%) 11 (8%) 63 (46%) 3 (2%) V13/School age 0 47 (34%) 6 (4%) 58 (42%) 1 (.7%) 0 V14/Infant 3 (2%) 0 35 (26%) 8 (6%) 64 (47%) 1 (.7%) V15/Infant 2 (2%) 0 31 (23%) 12 (8%) 64 (47%) 2 (2%) V16/School age 0 43 (31%) 8 (6%) 54 (39%) 6 (4%) 0 V17/Infant 3 (2%) 2 (2%) 28 (20%) 11 (8%) 58 (42%) 2 (2%) V18/School age 0 48 (35%) 5 (4%) 50 (37%) 2 (2%) 0 V19/School age 1 (.7%) 49 (36%) 3 (2%) 48 (35%) 3 (2%) 1 (.7%) V20/Infant 2 (2%) 3 (2%) 31 (23%) 14 (10%) 54 (39%) 1 (.7%) V21/School age 0 55 (40%) 1 (.7%) 48 (35%) 1 (.7%) 0 V22/School age 0 52 (38%) 2 (2%) 49 (36%) 1 (.7%) 0 V23/Infant 2 (2%) 0 33 (24%) 10 (7%) 58 (42%) 1 (.7%) V24/School age 0 52 (38%) 1(.7%) 50 (37%) 1(.7%) 0 Approx. 15% of questions had no response 78
79 Survey comments The Phase II survey included a final comment box for participants to write in comments about the survey. These comments were read verbatim, compared for similarity and are summarized here. These comments provided useful feedback and some criticism of the study. Thirty ni ne participants (28 %) wrote in comments at the end of the triage survey. The most frequent comme nts entered indicated there was not enough information to accurately make a triage deci sion. Use of the category school aged child was problematic for some participants who cons idered the range of s chool-aged to be 5 years to 18 years. Vignettes with sleeping or quiet infants or child ren, and bruises brought to mind concerns of neurological status and possible signs of child abuse. Several participants were concerned w ith, or insulted by the inclusi on of ethnicity as a variable. One participant wrote the comment, level of pain seldom factors in when deciding a triage level. Comments as to which pain scale would be appropriate for a given child varied between a faces scale and nurse rated 10 numbers scale. These comments further validate the complexity of the lived experience of the triage nurse when making triage decisions, as well as the need for in creasing awareness of th e disparity of pain assessment and management for the youngest patients who use ED services. Summary Phase II of this study involved preparing for, obtaining and analyzing quantitative data relative to the last two research questi ons; the first question as ked whether there are differences in triage level assigned for a given vignette, based on nurse variables of: educational background, (four levels) or years of e xperience (grouped continuous
80 variable). The second research question was in tended to describe differences in triage level assigned for a given vignette based on patient variables of: age (two categories), ethnicity (three categories), gender (two cat egories), or behavior (two categories). Qualitative data from Phase I identified themes which were congruent with the conceptual model of the study and validated th e predictor variables to be included in the study. One additional question was added along with each vignette to ask which method of pain assessment would have been us ed with the patient in the vignette. A triage vignette survey was developed, evaluated for validity and reliability with appropriate methods and made available to ED nurses via the Internet using the Checkbox 4.6 program. Responses from 137 ED nurses were analyzed for demographic data. Further statistical analyses of the tria ge vignettes were conducted using descriptive methods, followed by logistic regression. Th e pain assessment methods question and post-survey comments were analyzed using de scriptive methods. Results are discussed in Chapter 7.
81 Chapter 7 Discussion and Implications The final chapter of this study offers a summary of the research including the conception process, instrument development, data gathering, analysis methods, and a discussion of results, limitations, and implications for nursing. Summary This was a mixed-methods study that blended a qualitative-d escriptive inquiry guided by phenomenological methods with quan titative methods to describe processes, knowledge sources and factors that influen ce triage decisions with infants and young children who come to the ED with painfu l problems or injuries. This study was conceptualized as a unique approach to study ED triage nurse decision-making for pediatric patients experienci ng pain. Both Phases of this study revealed outcomes consistent with other reported research as well as some outcomes that were not consistent. Phase I informants were recruited from several area hospitals through a convenience sample and snowball technique in an effort to enroll participants. Thirteen interviews were completed for the study w ith nurses who were predominantly White females with ED experience ranging from 2 to 29 years. Ultimately all of the informants came from one large ED study si te. Participants for Phase II were recruited from an email address list of ENA members from across the United States. The final sample size
82 for Phase II was 137 participants. Neither of the samples for this study achieved the diversity in gender or ethni city that had been sought. Instrument Development Pediatric Triage Pain Assessment Scale In order to begin Phase II of the stud y a series of 24 triage vignettes were designed to further clarify a nd validate the factors and processes identified in the first phase. The intent of the vignette survey was to determine associations or differences in recognition and assessment of painful c onditions based on child and/or nurse characteristics, and a triage score rated for each vignette. Including 24 vignettes allowed for each category of each variable to be includ ed in a balanced manner, in an effort to reduce variance error. For example; there wa s a vignette with a cr ying White, Black and Hispanic infant as well as a vignette a quiet White, Black and Hispanic infant and so forth (Appendix L). Each vignette was scored by assigning a triage level ranked from (1) emergent, to (5) non-urgent. In this study th e triage scores were compared across all vignettes and participants using logistic regression methods to evaluate which variables or set of variables were more likely to be associated with or predict triage scores. The validity of the survey was estimat ed by assessing a CVI with a panel of experts. Relevance of the vignettes resulted in an index of 0.92, how ever; sufficiency of information resulted in an index score of 0.46, which was lower than anticipated. The reliability of the triage vignette survey was estimated by measuring the stability and equivalence of the instrument (Polit & Bec k, 2004). A test-retest procedure estimated a Pearson reliability coefficient of 0.90; however the pilot samp le size of participants was
83 very small so the reliability coefficient is not dependable. A measure of internal consistency was also calculated using Cronbachs alpha (0.95). For future use as a teaching tool, the vigne ttes could be expanded and an ideal or correct answer for triage level indicated. This scale had potential for use as a research or ED triage teaching tool with further valida tion and refinement. Validity and reliability estimates would need to be conducted with a la rger sample size. Further refinement of the vignettes may be achieved by piloting the vignettes in a different format such as comparing responses between paired particip ants, or a comparison of matched vignettes with and without painful conditions to comp are pain score or triage level responses. Piloting the scale with an onsite group of pa rticipants rather than an internet based format may allow discussion and clarif ication of participant responses. The scale included a questi on concerning participant choice of pain assessment scale or method that would have been used with the patient in each vignette. This question provided some information about participant knowledge of pediatric pain assessment scales. Responses for vignettes that depicted infants revealed knowledge deficits as to which pain scale would be more appropriate. The FLACC scale was reported more than 40% of the time; however the Faces pain scale was reported as often as 14% of the time, and observation of the in fant was reported up to 28% of the time. A very small number of participants in dicated they would ask the parent.
84 Discussion Phase I The study was guided by a conceptual model developed from the literature review and ED experience of the researcher. The first phase of this study consisted of a qualitative descriptive explor ation of ED triage nurse t houghts, perceptions and factors that influence decisions and actions taken w ith pediatric patients who come to the ED with painful conditions. Thirteen semi-struc tured interviews were conducted with ED nurses. The interviews were limited in depth due in part to the novi ce researcher, and to the lack of informants who were willing to meet for a longer period of time. Despite the brevity of interviews the researcher was able to gain insight into th e lived experience of the pediatric triage nurse. Five themes were identified from analysis and interpretation of the interviews: 1) Age of the child is important, 2) Behavior can tell a lot, 3) Really looking at the patient, 4) Things that help make decisions and 5) Things that hinder decisions. Data analysis from the interviews, and the concep tual model guided the variables that were included in Phase II of the study. The them es are discussed in this section. Age of the child is important Interviews with these informants provide d insight into the daily complexity of triage in the ED. All of the informants e xpressed concern with assessment of pain and assigning triage levels for infants and the ve ry youngest patients. The policy of the ED was that all infants and children were take n directly to an exam room and triage completed at the bedside. Therefore, in ma ny instances, the pediatric patient bypassed the triage nurse. When the ED was busier or all rooms were occupied, th e triage nurse would
85 bring the patient into the tr iage room to begin an assessment. During busier hours the triage nurse needed to be vi gilant for any patients who a rrived and were waiting to be taken to an exam room in the Pediatric ED Several informants expressed concern, or a need to scan the waiting room periodically to make sure no patients had been overlooked. The need for good communication between the m eeter-greeter, triage nurse and charge nurse was important to facilitate the flow of patients and accommodate any newly arrived pediatric patients with higher acuity problems. The infant who was brought to triage required more indepth assessment to determine if the infant was experiencing pain. Important indi cators discussed by informants included obtaining an adequate history from the parents, assessing physiologic signs, and the intera ction between the parents a nd the patient. Parents who reported symptoms that were no longer eviden t or who changed the story seemed to raise concerns. Only two informants discussed using the FLACC infant pain scale. For infants in particular there seemed to be limited knowledge of pain assessment scales. Others mentioned observation of the infant for crying, and efforts to gather information from the parents as to the infants ba seline activity. They wanted to know how the infant had changed, what was different that prompted th e parents to come to the ED. There was a general concern among the informants about the re liability of the parents to give adequate information. The reliability of parents was mentioned frequently and is a common element of all five themes. Informants were sharply divided in their attitudes towards parents. Parents who were emotional, crying, or othe rwise unable to provide an adequate history were viewed as unreliable, causing the nurse to call upon good assessment skills in order
86 to formulate an idea of the clinical problem Calm, informative parents who could explain the problem were viewed as reliable and helpful. An assessment of the parental credibility seemed necessary as a component of the triage pr ocess. Previous research had reported discrepancies in pain ratings be tween patients, nurses and physicians which supported this issue as a common concern in the ED setting. This therefore is an area for further research in order to gain a better unde rstanding of why this occurs (Singer, et al., 2002; Rajasagaram et al., 2009). Behavior can tell a lot Pain scales proved to be challenging with young children. Informants discussed improvising use of pain scales by estimating a pain score through observation of behavior. Observation of the child and inte raction between the ch ild and parents were important indicators. Another potential s ource of concern was being observant for possible signs of child abuse. Several informants expressed that the in consolable infant or child was a definite sign of distress that n eeded further assessment. If the patient was inconsolable, even by the parent after seve ral minutes, this was considered an obvious indicator of pain. Other beha viors noted as signs of pa in included facial grimacing, wincing, protecting or withdraw al of body parts from the nurse or the parent. While these informants could clearly articulate these behaviors as signs of pa in, only two of them identified them as the FLACC scale or mentioned using this pain scale. The other type of behavior that was si gnificant was the quiet stoic child who may or may not have had an obvious injury. Visual cues could be missed and allow a child to wait when there might have been an injury. One informant expressed regret about a child who was very quiet on arrival and was sitti ng in the waiting room or had been bypassed
87 somehow and, once the child was evaluated, was found to have a fractured arm. Recognition of behavioral indicators of pain we re related to experience with recognizing symptoms gained after a number of years working in the ED setting. Really looking at the patient The first initial contact w ith the patient involved looki ng at the patient and asking the initial question about the reason for coming to the ED. Scanning the patient for obvious signs of distress or obvious injuries such as displaced extremity fractures would allow for quick intervention. Th is initial observation was linke d to nurse experience. The informants believed that years of experience gave them an intuitive skill You just know by eyeballing the pati ent and that comes from years of experience. Another informant discussed observing the pati ent before ever touching the patient by looking, observing, taking in all the detail s possible, but also avoiding becoming judgmental and jumping to conclusions about th e patient. Informants talked about really looking at the patient in the c ontext of close assessment of physiologic signs such as respiratory rate, skin color, body positioning and the reactivity or response of the patient. This assessment encompasses more than using a pain assessment scale and was meant to focus in closely and observe the patient. It seemed that a number of these informants may have used these types of observati on skills rather than a specific pain assessment scale. Things that help make decisions These informants had internalized the practical and theoretical knowledge needed to make sound decisions regarding young children and infants experiencing pain. While
88 none of the informants specifically mentione d the other elusive knowledge source nurses use intuition, it was implied a number of times during the interviews. For example: It seems that if you do pediatrics long enough you come to realize who the sick kids are just by looking at them. A chance to be said, by them walking by you face to face, its lik e you know, something isnt right. Reliability of parents was viewed from two different perspectives. Those who were calm, able to provide a c oherent history and interacted appropriately with the infant or child were viewed as reli able and trustworthy to give information about the patient. Parents who were emotional, crying, angry or who could not give an adequate account of events that led to the ED visit, or who provi ded a description of the patient that did not match the appearance at the time of arriva l ,were viewed as less dependable. The researcher did not ascertain from these informants what efforts were made to help improve the reliability of those parents who were viewed less favorably. While there may have been evidence for the need for health teaching, infant or child care, not many opportunities for exist in the fast pace of the ED. Things that hinder decisions Things that hinder triage d ecisions seemed to be sources of frustration for the informants. The only indication of concerns towards patient and parents of different ethnicity was relative to language barriers. Communica tions with non-English speaking families were described as sources of frustration. New guidelines that require professional telephone translators were de scribed as time consuming and sometimes difficult.
89 One frequently mentioned problem area was a situation in which the nurse recognized a patient was experiencing pain but the physician w ould not order pain medication except possibly ibuprofen or aceta minophen. Another concern, especially in a teaching hospital setting was whether or not new residents were familiar with pediatric dosage ranges. The analysis, interpretation and description of themes identified from the Phase I data and comparison to the c onceptual model supported develo pment of the variables and factors used in Phase II. Devel opment of the triage vignettes allowed further validating of the significant factors relative to triage d ecision-making and pediatric pain assessment. Phase II The second phase of the study was conducted to obtain data rela tive to the last two research questions; 1) what are the diffe rences in triage level assigned for a given vignette, based on nurse variables of: educational background, (five levels) or years of experience (grouped continuous variable), and 2) what are differen ces in triage level assigned for a given vignette based on patie nt variables of: age (two categories ), ethnicity (three categories), ge nder (two categories), or beha vior (two categories). The Pediatric Triage Pain Assessment Scale (PTP AS) was developed based on these variables for use in an internet-based survey. Chi-square tests for frequency trends evaluated the association between individual predictor variables and the proportion of triage le vel of the dependent variable (level 2 = emergent, level 3 = urgent, leve l 4 = semi-urgent) across all 24 vignettes. Hispanic ethnicity, infants compared to sc hool-age children, and ma le gender compared
90 to female were all associated with higher tria ge levels. The vignettes were then sorted by similar clinical condition and evaluated again with chi-square test for association between predictors and higher acuity (triage level) The researcher noted comments from participants who indicated c oncern about symptoms other than pain, and the need for additional information to make an accurate triage decision. This concern prompted exploring the vignettes subdivided by the clin ical symptoms (contex tual details) which had been added to the vignettes. There were in teresting differences based on the nature of the injury or problem in the subsets. W ith the neurological/head injury vignettes the predictors infant compared to school age child, and quiet compared to crying were associated with higher triage levels. Several participants wrote comments indicating concern that a quiet infant w ith a bruise on the head would need further evaluation to assess level of consciousness and therefore wa rranted a higher triage level. In this instance the higher triage level assigned was not related to pa in assessment but rather due to concern for neurological status. Full analysis across all vigne ttes with ordinal logistic regressi on methods and a cumulative logit model, Hispanic ethnic category compared to non-Hispanic did have a significant effect on the probability of higher triage scores. Reported in terms of odds ratios, Hispanic ethnicity was 1.74 times more likely to have a higher triage acuity rating than non-Hispanic in the vignettes. The da ta from this study failed to demonstrate disparity in triage level as that reported in previous re search (James, et al., 2004). For the gender variable, the female category compared to males had a significant negative effect (estimate of -0.3763), ( 2 25.9576, p< .0001), or a decline in the probability of a higher triage level for females compared to males. Infants compared to school-age
91 children had a significant effect on the probabi lity of higher triage scores; however the behavior variable (crying compared to quiet) had no effect on overall triage levels across vignettes. This observation supported the overa ll theme of the challenges triage nurses face with evaluating infants. Crying, inconsolable infants were obviously in distress while the concern with a quiet infant in some instances raised the question of decreased level of consciousness as opposed to just sleeping. Other predictors with significant effect s on the probabilities of higher triage levels included nurse characteristics of AD N and MSN education. U pon further review of participant demographic data the researcher noted that for the part icipants who reported ADN education, 79% of them also reported le ss that 20 years experience, while 46% of participants who held a BSN degree and 60% of those with an MSN degree reported more than 20 years experience. The higher triage levels based on education may have been a reflection of years of experience or simply erring on the side of caution with triage scores. A secondary logistic regression with th e separated clinical condition grouping revealed different predictors with significan t effects on probabilities with each different clinical condition group. For the abdomen/thor acic injury, Hispanic ethnicity was 11.76 times more likely to have been rated a higher triage level (CI 99.5%; 5.662 and 24.424). Infants were 4.4 times more likely than school-age children to have a higher triage level, as well as crying compared to quiet behavior (OR 2.48, CI 99.5%; 1.43 and 4.31). ADN education was also 2.36 times more likely to be associated with rating higher triage levels for these vignettes. It is unclear why this clinical condition groupi ng resulted in these higher odds ratios. Perhaps the clinical picture of a Hispanic crying infant with indicators
92 of abdominal pain was viewed differently th an other vignettes. Part icipants who reported ADN education also had a much higher pe rcentage (79%) who reported less than 20 years experience while the BSN and MSN prep ared participants re ported (46% and 60% respectively) more than 20 years of ED experience. It is unclear whether those participants were more or less conf ident with their triage decisions. The predictor variables that were more li kely to have been rated higher triage levels overall were Hispanic ethnicity compar ed to non-Hispanic and infant compared to school-age children. In the full OLR, female gender was less likely than male to have higher triage levels, and nurse years of experience (11 20 y ears) was also less likely to be associated with higher triage levels. Comparison of the outcomes from Phase I to Phase II provided evidence and validation of variables that impact ED nurse triage decision-making with pediatric patients experiencing pain. Infants were found to be a significant predictor of higher triage scores. Whether this finding is directly related to pain assessment or other assessment parameters was unclear. Crying infant s, particularly those who were Hispanic were more likely to have a higher triage level assigned. The PTPAS was designed with balanced vignettes, to avoid introducing bias with any of the child predictor variables, such as ethnicity. Why a vignette which depict ed a crying Hispanic infant resulted in much higher odds of a higher triage level than other crying infant vignettes is of interest. For this study which used patient vignette s there was no evidence of ethnic disparity. Some participants wrote comments at the end of the survey to indicate dissatisfaction with ethnicity having been included as a vari able. Different clini cal conditions in the
93 vignettes resulted in varying differences of significant predictors; however these differences appeared to be related to the clinical condition more so than to a pain score. Limitations Limitations of this study related to sm all sample size and the limited ability to generalize the findings. The researcher t ook necessary precautions to bracket all presuppositions and opinions towards the tria ge decision-making process, which resulted from more than 14 years of emergency nursing experience. However, from the perspective of interpretive phenomenology, the experience and knowledge of the researcher as an ED nurse can be a valuable guide to the research (Lopez & Willis, 2004). LeVasseur (2003) suggested a different perspective towards bracketing. She recommended rather than setting aside the perspective and assumptions of researcher experience, bracketing could be employed as a temporary suspe nding of knowledge and experience to allow a fresh view of the t opic of interest; desc ribed as persistent curiosity (p. 419). Sampling procedures used for both components of the study may limit generalizability of the resu lts. Use of a convenience sample could introduce sampling bias. Sampling bias for Phase II may have occurred due to the large percentage of participants with advanced education, membership in a professional organization, and active participation in the orga nization at the state and/or national level. ED nurses who actively participate in a professional orga nization may have been more willing to participate in a research study. Use of an internet based survey allo ws for convenience wi th participation by participants, however there are limitations in controlling access to the survey, and
94 whether the participant completed the survey independently. Potent ial sources of error related to use of an internet -based survey which can limit results of this study include coverage and sampling error, and nonrespons e error. Recommendations and principles for design of internet based surveys that pr ovided approaches to limit these sources of error were incorporated in the procedur es for this study (Dillman & Bowker, 2001). Social desirability response bias One source of bias that may affect the outcomes of this research is the concept of social desirability response bias (SDRB) which is de scribed as the tendency of participants to answer questions in a manner th at is more socially desirable, particularly when the subject or context of the survey que stion is of a sensitive nature (Polit & Beck, 2004; Streiner & Norman, 2003). SDRB can have an impact on the validity of a study. In the context of this study; tr iage decision-making of childre n with painful conditions who come to the ED, responses that would give the impression of taking actions that would alleviate the painful problem more quickly coul d be viewed as more socially acceptable. During the Phase I interviews informants frequently commented that pediatric patients are taken directly to a treatment room where the initial assessment and triage level are assigned. This response seemed almost automatic, or as if following a script, or this may have been an example of SDRB. D ecreasing patient wait times in the ED is an important patient satisfaction factor; however, th e reality of ED care is that the treatment area may be filled quickly during high volume times and pediatric patients may wait for treatment longer than desirable. The triage nurse is responsible for re-evaluating any patients waiting to be seen a nd take action when needed.
95 Responses from participants who complete d the internet-based survey may also have demonstrated evidence of SDRB, particular ly with respect to the ethnicity variable that was included in the vignettes. Research related to ED triage and treatment has previously reported some evidence of et hnic disparity with pain assessment and management (James, et al., 2004) however; ev idence of ethnic disp arity was not observed in this study. The variable of Hispanic ethnicity was consiste ntly associated with higher triage levels and several participants wr ote comments expressing dissatisfaction with inclusion of ethnicity as a vari able in the survey. Due to the sensitive nature of the issue of ethnic disparity in ED patient care, it is possible higher triage levels assigned for Hispanic patients in the survey vignett es and the negative comments from some participants were both evidence of SDRB. Par ticipants may have wanted to be viewed favorably in their responses for vignettes that portrayed ethnic minority patients. The reasons for higher triage levels assigned for Hispanic infant vignettes compared to similar vignettes with White or Black infants were not clear, but it was possible evidence of SDRB. Internet-based survey vignettes that requi re assessing pain in pediatric patients and assigning a triage level could potentially elicit SDRB th rough the participants desire to choose a triage level that would result in a shorter time un til the patient is moved to the ED treatment area. Any of the triage vignettes in this study could have been a potential source of SDRB, and resulted in a higher ac uity triage level assignment for a given vignette. SDRB is not considered to be an inte ntional choice, but rather an unconscious desire to be perceived favorab ly. Many factors may contribute to this type of bias; the
96 participant responding to a survey, the cont ext and setting, whet her the survey is administered in a live face-to-face or a nonymous survey (Streiner & Norman, 2003). The rational choice theory provides a framework to explain SDRB, described as cognitive incentives, based on the need for social appr oval which increases as the need for approval rises, and when the interviewer is able to recognize the behavior according to the explanation offered by Stocke and Hunkler (2007). These authors suggest the One Point Measure developed by Edwards in 1957 as th e most parsimonious method for measuring incentives that cont ribute to SDRB. Another potential source of SDRB has been suggested with the method of personalizing invitations to participate in in ternet-based surveys. While personalization or use of individual e-mail addresses to invite su rvey participants has been recommended to increase response rates, ther e is a potential unintended e ffect of causing SDRB due to a perceived decrease in anonymity of part icipants. Heerwegh and Loosveldt (2006) explored this hypothesis in a mixed-me thods study which compared face-to-face interviews contrasted with non-personalized and personalized internet surveys. Specific surveys items did show evidence of SDRB when comparing face-to-face interviews with non-personalized internet surveys; howe ver comparisons of personalized and nonpersonalized surveys did not reveal any significant differences in responses. Implications for Nursing Practice Assessing pain in infants and young child ren who present to the ED is a challenging component of triage assessment. In this study, choosing a triage level for a given vignette which portrayed an infant or school-aged child with a painful condition
97 has been used as proxy for assigning a pain measurement for the patient in each vignette. Use of the triage level as a proxy for pain assessment is problematic for several reasons. Assigning a triage level involves a more comp rehensive assessment of the patient including physiologic measurem ents, appearance, and interac tion with parents, a brief history and chief complaint in addition to pain assessment. It is very likely that triage survey responses were based on the clinical condition portrayed in a given vignette rather than being focused on how much pain the in fant or child might be experiencing. This observation is another indicator of the difficulty in eval uating nursing practice towards pain assessment in the clin ical setting. Comments from a small number of survey participants indicated that pain is not neces sarily a consideration in triage decisions. Another concern for nursing practice that was made evident in the Phase I interviews was lack of physician support for pa in management. Nurses must act as patient advocates to facilitate pain management fo r the youngest patients who do not have the ability to ask for pain medication. Education One implication of the outcomes of this re search is the need for further education for ED nurses as to the various pediatric pain measurement scales available, and updates in the application of different scales periodically. This researcher searched the Internet recently for pain assessment scales and found seventeen diff erent pain scales listed on Wikipedia.org. While this site is not an information source for scholarly work, many people, nurses included may use it for a qui ck reference. Pain scale competency validation could be incorpor ated into hospital based y early updates. The pain measurement method question included with the triage vignette survey in this study
98 provided some evidence that up to 28% of nurses who responded may not have a clear understanding of infant pa in assessment scales. There are implications fo r increasing education for ED physicians as well as nurses as to pain assessment and mana gement practices. Long standing myths and misconceptions towards pediatric pain mana gement may still exist in the ED setting. Incorporating pain related info rmation and research articles into evidence-based practice models may increase awareness. Increasing pharmacologic knowledge in regard to safe pediatric analgesics, opioid analgesics and safe dosages would help dispel misconceptions towards pediatric pain mana gement. The goal of any education program concerning pediatric pain is to improve patient care and outcomes. Research The outcomes of this research indicate th at more research in the area of ED pediatric pain management could add to the knowledge base of ED nurses, it is equally important to support ED nurses as consumers of research. Efforts to increase awareness of the evidence that exists, such as the info rmation included in the literature review for this study are needed. Activities such as j ournal clubs, participat ion in professional organizations, and other means for disse minating research evidence can increase awareness, generate interest in participating in research, and lead to changes in practice. Activities that promote interest in research and dissemination of information will in turn, promote better patient care, better pain management and improved patient outcomes. Further research to refine and validate the Pediatric Triage Pain Assessment Scale would make this new scale available for additional research and education of triage nurses and physicians.
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105 Schaefer, D. R. & Dillman, D. A. ( 1998). Development of a standard e-mail methodology: Results of an experiment. Public Opinion Quarterly, 62 378-397. Retrieved January 30, 2009 from: http:// www.sesrc.wsu.edu/dillman/papers.htm. Simons, J., Franck, L. & Roberson, E. (2001). Parent involvement in childrens pain care: Views of parents and nurses. Journal of Advanced Nursing, 36 (4), 591-599. Singer, A. J., Gulla, J. & Thode, H. C. (2002) Parents and practiti oners are poor judges of young childrens pain severity. Academic Emergency Medicine, 9(6), 609-612. Stock, V., & Hunkler, C. (2007). Measures of desirability beliefs and their validity as indicators for socially desirable responding. Field methods, 19 (3), 313-336. Streiner, D. L., & Norman, G. R. (2003). Hea lth Measurement Scales a practical guide to their development and use. 3rd Ed., New York: Oxford University Press, Inc. Tamayo-Sarver, J. H., Hinze, S. W., Cydulka, R. K., & Baker, D. W. (2003). Racial and ethnic disparities in emergency de partment analgesic prescription. American Journal of Public Health, 93 (12), 2067-2073. Tanabe, P., and Buschmann, M. (1999). A pr ospective study of ED pain management practices and the patients perspective. Journal of Emergency Nursing, 25 (X), 171-177. Todd, K. H. (2001). Influence of ethnicity on emergency department pain management. Emergency Medicine, 13 274-278. Todd, K. H., Samaroo, N., & Hoffman, J. R. (1993). Ethnicity as a risk factor for inadequate emergency department analgesia. Journal of the American Medical Association, 269, 1537-1539.
106 Trzeciak S, and Rivers E. (2003). Emergenc y Department overcrowding in the United States: An emerging threat to pa tient safety and public health. Emergency Medicine Journal, 20 (5), 402-405. Retrieved November 5, 2005 from: http://emj.bmjjournals.com/c gi/contents/full/20/5/402 UCLA: Academic Technology Services, Stat istical Consulting Group. Introduction to SAS. from:http://www.ats.ucla.edu/stat/s as/notes2/ (accessed March 15, 2010). Van Hulle, Vincent, C., & Denyes, M. (2004). Relieving childrens pain : Nurses abilities and analgesic administration practices. Journal of Pediatric Nursing, 19 (1), 4050. Whittemore, R., Chase, S., & Mandle, C. L. (2001). Validity in qualitative research. Qualitative Health Research, 11( 4), 522-537. Zumbo, B. D., & Ochieng, C. O. (2002). The eff ects of various configurations of likert, ordered categorical, or rati ng scale data on the ordinal logistic regression pseudo R-squared measure of fit: The case of the cumulative logit model. Paper presented at the Annual Meeting of the American Educational Research Association (New Orleans, LA, April 1-5, 2002)
Appendix A DEMOGRAPHIC DATA FORM Demographic Data Form Phase I Date __________ Subject # _____________ Interview #_______ Age: _________ Sex: Male _____ Female _____ Racial/Ethnic Identification: _____White (not of Hispanic origin) _____Black/African-American (not of Hispanic origin) _____Hispanic (including Black individuals whose origins are Hispanic) _____Chinese/Chinese-American _____Japanese/Japanese-American _____Filipino/Philipino _____Other Asian _________________________________ _____American Indi an/Alaskan Native _____Mexican/Mexican-American _____Latin-American/Latino _____Other Spanish/Spanish-American ___________________ _____ Other__________________________________________ Nursing Education: Associate in Nursing Degree ________________ Bachelor of Science in Nursing Degree__________________ Other_____________________________________________ Years of Emergency Nursing Experience___________________ Advanced certification__________________________________ Are you a parent yourself? Yes__________ No___________ 108
109 Appendix B INTERVIEW GUIDING QUESTION S (QUALITATIVE COMPONENT) You were recently asked to participate in a research study to describe the cognitive processes Emergency Departme nt (ED) nurses use in decision-making regarding triage and pediatric pain assessmen t and management, as well as the external and internal factors influencing tria ge decisions and pain interventions. 1) Did you agree to participate? If yes : 2) On what did you base your decision to participate? If no: On what did you base your d ecision not to participate? 3) What was your understanding of the study? 4) Tell me about a situation in which you felt very good about your triage decision for a pediatric patient in pain? 5) Tell me about a situation in whic h you did NOT feel good about your triage decision of a pediatric patient in pain? 6) What things help make decisions? 7) What things hinder making decisions? 8) What else can you tell me about pedi atric ED nursing and pain management of children?
Appendix C Morton Plant Mease Baycare Health System Letter of Support 110
Appendix D Tampa General Hospital Office of Clinical Research Letter 111
Appendix E Human Subject Consent Form A Phase I 112
Appendix F Human Subjects Consent Form B Phase I 115
123 Appendix G Letter of introduction for Phase I interviews Dear Emergency Nurse, I would like to invite you to participate in a resear ch study that will describe triage decision-making and pediatric pain assessment by emergency nurses. I am a doctoral student at the University of S outh Florida, conducting this study for my dissertation. I obtained your name from your response to an announcement posted at your hospital. I will not use your information for any other purpose, nor share your confidential information, as explained in the enclosed informed consent section. Please read everything carefully. If you choose to participate, please sign the consent form, complete the demographic page and we will begin the interview. I will be audio recording the interview. If you have any concerns or change your mind, even as we begin the interview, do not hesitate to stop. If you have any ques tions about this study, you can call me at 813-468-0508. Sincerely, Teresa Russo MSN, RN Research Resident/ Ph.D. candidate University of South Florida College of Nursing, Ph.D. Program Tampa, FL
Appendix H Recruitment Flyer 124
125 Appendix I Letter of Introduction for Ph ase II Internet-based survey Dear Emergency Nurse, I would like to invite you to participate in a research study that will describe triage decisionmaking and pediatric pain assessment by emergency nurses. I am a doctoral student at the University of South Florida, conducting this study for my dissertation. I obtained your name from an e-mail list of members of the Emergency Nurses Association. I will not use your information for any other purpose, nor share your confidential information. We are asking you to take part in a research study that is called: Factors Affecting the Process of Clinical Decision-Making in Pediatric Pain Management by Emergency Department Nurses. If you agree to participate in the e-mailed survey, you will be able to complete it in your home, at your convenience. There will be a consent form to read, a short demographic form and a series of 48 case vignettes in which you would be asked one question about the vignettes. Your consent to participate is implied by your completion of the survey. Completed surveys will be retrieved by the principle investigator, stored on a password protected computer and entered into a data base for analysis Your information would be kept confidential once received by the principle investigator. Please read everything carefully. If you choose to participate, please follow the electronic link to the survey, complete the demographic page and begin the survey. If you have any concerns or change your mind, do not hesitate to stop. If you have any questions about this study, you can call me at 813-468-0508. Sincerely, Teresa Russo RN, MSN, Doctoral Candidate University of South Florida College of Nursing, Doctoral Program Tampa, FL
Appendix J Human Subjects Consent FormPhase II Informed Consent to Participate in Research Information to Consider Before Taking Part in this Research Study IRB Study # 107869I Researchers at the University of South Florida (USF) study many topi cs. To do this, we need the help of people who agree to take pa rt in a research study. This form tells you about this research study. We are asking you to take part in a research study that is called: Factors Affecting the Process of Clinical Decision-making in Pediatric Pain Management by Emergency Department Nurses The person who is in charge of this research study is Teresa A. Russo RN, MSN. This person is called the Prin cipal Investigator. The research will be done by analyzing responses to an internet-based survey. This research is being paid for, in part by a research award from Sigma Theta Tau, Delta Beta at-large Chapter. Purpose of the study The purpose of this study is to: Describe the cognitive pr ocesses/knowledge sources Emergency Department (ED) nurses use in decision-making re garding triage and pediatric pain assessment and management, as well as the external and internal factors influencing triage decision s and pain interventions. This study is being conducted by a doctoral student as part of the requirements for a dissertation. Study Procedures If you take part in this study, you will be asked to: 126
127 Complete a survey on an internet we bsite. If you choose to complete the survey, you will be asked to follow the electronic link provided in the e-mail inviting you to participate. o The survey should take no more than 1 hour of your time. o The survey includes a short demographic form and a series of 48 case vignettes in which you would be asked one question about the vignettes. o Choosing to participate w ill serve as your consent to participate in the study. You can stop at any time if you do not wish to continue. o Your information would be kept confidential once received by the principle investigator. Alternatives You have the alternative to choose not to participate in this research study. Benefits We dont know if you will get any benef its by taking part in this study. Risks or Discomfort This research is considered to be minimal risk. That means that the risks associated with this study are the same as what you face every day. There are no known additional risks to those who take part in this study. Compensation We will not pay you for the time you vol unteer while being in this study. Conflict of Interest Statement There are no known conflicts of inte rest involved with this study Confidentiality We must keep your study records as confid ential as possible. However, certain people may need to see your study records. By law, anyone who looks at your records must keep them completely confidential. The only people who will be allowed to see these records are: The research team, including the Principa l Investigator, and all other research staff Certain government and university people who need to know more about the study. For example, individuals who provi de oversight on this study may need to look at your records. This is done to make sure that we are doing the study in the
128 right way. They also need to make sure that we are protec ting your rights and your safety. These include: o The University of South Florida Ins titutional Review Board (IRB) and the staff that work for the IRB. Other individuals who work for USF that provide other kinds of oversight may also need to look at your records. o The Department of Health and Human Services (DHHS). We may publish what we learn from this study. If we do, we will not let anyone know your name. We will not publish anything else that would let people know who you are. Voluntary Participation / Withdrawal You should only take part in this study if you want to volunteer. Y ou should not feel that there is any pressure to take part in the st udy, to please the investig ator or the research staff. You are free to participate in this res earch or withdraw at any time. There will be no penalty or loss of benefits you are entitled to receive if you stop taking part in this study. Your decision to participat e or not to participate will not affect your student status (if you are a student), or job status. Questions, concerns, or complaints If you have any questions, concerns or compla ints about this study, call Teresa Russo at 813-468-0508. If you have questions about your rights as a pa rticipant in this study, general questions, or have complaints, concerns or issues you want to discuss with someone outside the research, call the Division of Research In tegrity and Compliance of the University of South Florida at (813) 974-9343. If you experience an unanticipated problem rela ted to the research call Teresa Russo at 813-468-0508. Consent to Take Part in this Research Study It is up to you to decide whether you want to take part in this study. If you want to take part, please follow the directions to the survey below, if the following statements are true. I freely give my consent to take part in this study. I understand that by completing the survey I am agreeing to take part in research. I have received a copy of this form to take with me.
129 Appendix K Content Validity Index Surve y for Triage Vignettes Please read each of the followi ng triage vignettes and respond to the 2 questio ns about the vignettes. Please enter an X under the column that corresponds to your answer choice, save the file and return to me via email (firstname.lastname@example.org) Triage Vignettes 1. Is this question relevant to measuring some aspect of triage clinical decisionmaking? Please rate each vign ette on a the 4-point scale below by placing an X in one of the boxes: 1 2 3 4 not slightly relevant very relevant relevant relevant 2. Is there sufficient information in this vignette to make a triage decision? Please rate this vigne tte information on the 4 point scale below by placing an X in one of the boxes: 1 2 3 4 not slightly sufficient very sufficient sufficient sufficient 1. A woman enters the ED ca rrying a white male infant who has an obvious deformity of his left forearm. The infant is asleep in her ar ms, and the woman is quietly asking for help. 2. The ED is extremely busy when a woman enters the ED entrance carrying a crying Hispanic male infant, who has an obvious deformity of his right forearm. 3. A man walks in the ED entrance with a Black schoolaged boy crying and walking behind him. The child has a large bloody bandag e on his left arm. 4. A school-aged Hispanic girl walks into the ED with a woman who asks for help with her child who fell from a tree and is complaining of stomach pain. 5. A woman comes to triage carrying a black male infant who is screaming, with his legs and arms drawn tightly to his body 6. A man and woman run into the ED entrance carrying a Black female infant who is crying and has a bloody towel wrapped around her leg 7. A white female infant who is quiet and alert, and has
130 Triage Vignettes 1. Is this question relevant to measuring some aspect of triage clinical decisionmaking? Please rate each vign ette on a the 4-point scale below by placing an X in one of the boxes: 1 2 3 4 not slightly relevant very relevant relevant relevant 2. Is there sufficient information in this vignette to make a triage decision? Please rate this vigne tte information on the 4 point scale below by placing an X in one of the boxes: 1 2 3 4 not slightly sufficient very sufficient sufficient sufficient a large swollen bruised area on her left leg is carried to triage by her parents. 8. The ED is very busy when a white school age boy comes to triage with his mother crying and complaining of a headache. 9. A black school age female walks to triage with her mother, bent over holding her stomach and crying. 10. A woman comes to triage carrying a white male infant who is crying and has a large bruise on his head from falling out of bed. 11. A school age white male who is quiet, holding his hand over his lower abdome n and bent over slightly, comes to triage with his mother. 12. A Hispanic infant sleep ing in an infant carrier is brought to triage. The infant has an obvious deformity of the right forearm. 13. A Hispanic school age boy who is crying and complaining of a headache comes to the ED during a very busy evening shift. 14. A woman carrying a sleeping Black male infant in an infant carrier comes to the ED. The infant has a large bruise on his forehead. 15. A woman carries a scream ing white female infant to triage in an infant carrier, with a large bruise on her forehead.
131 Triage Vignettes 1. Is this question relevant to measuring some aspect of triage clinical decisionmaking? Please rate each vign ette on a the 4-point scale below by placing an X in one of the boxes: 1 2 3 4 not slightly relevant very relevant relevant relevant 2. Is there sufficient information in this vignette to make a triage decision? Please rate this vigne tte information on the 4 point scale below by placing an X in one of the boxes: 1 2 3 4 not slightly sufficient very sufficient sufficient sufficient 16. A school age Hispanic boy is carried to triage by a crying woman. The child is very quiet and has an obvious deformity of his left ankle. 17. A woman carries a Black female infant to triage, who is quiet but lying with her arms and legs drawn tightly to her body. 18. A woman walks into the ED with a school aged Black male who is quiet, walking slowly with his hand holding his left ribs tightly. 19. A school age Hispanic female is crying and being carried into the ED with a large bruise on her right thigh, following a bicycle accident. 20. A man and woman carry a Hispanic female infant into the ED who is crying and has large reddened blister area on her left thigh. 21. A Black school age female who is very quiet comes to the ED with her mother limping on her left foot after playing volleyball. 22. A White school age female who is crying and has a large red blistered area on her left arm comes to the ED with a woman. 23. A man and woman come to the ED with a Hispanic female infant who is lying qu ietly in an infant carrier, with a large bruise on her forehead. 24. A woman comes to triage with a White school age female who is quietly walk ing with her left forearm
132 Triage Vignettes 1. Is this question relevant to measuring some aspect of triage clinical decisionmaking? Please rate each vign ette on a the 4-point scale below by placing an X in one of the boxes: 1 2 3 4 not slightly relevant very relevant relevant relevant 2. Is there sufficient information in this vignette to make a triage decision? Please rate this vigne tte information on the 4 point scale below by placing an X in one of the boxes: 1 2 3 4 not slightly sufficient very sufficient sufficient sufficient supported with her right hand.
Appendix L Pediatric Triage Pa in Assessment Scale 133
About the Author Teresa Russo received a Bachelors Degr ee in Nursing from the University Of South Florida College Of Nursing in 1976; the second graduating class from the college. During the ensuing years she worked in the hos pital-based clinical setting, primarily in Emergency Nursing, and was active with the local Emergency Nurses Association. She received an MSN from the University of Florida in 1993. Her nursing experience gradually moved towards nursing education, incl uding specific required nursing courses, emergency department nurse educator and full time nursing faculty positions. In 2004 she began Ph.D. coursework at th e University Of So uth Florida College Of Nursing and accepted a Nursing Faculty position with Hillsborough Community College Nursing Program. While in the Ph.D. pr ogram she served as a Research Resident and Graduate Teaching Assistant. She is cu rrently an Assistant Professor at South University College of Nursing.
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Factors affecting the process of clinical decision-making in pediatric pain management by emergency department nurses
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by Teresa Russo.
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Dissertation (Ph.D.)--University of South Florida, 2010.
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ABSTRACT: The purpose of this mixed methods study was to describe the cognitive processes/knowledge sources used by Emergency Department (ED) nurses in decision-making activities regarding triage and pediatric pain assessment and management. Deficiencies persist in ED pediatric pain assessment, and management methods or approaches that might help resolve these deficiencies have not been identified previously. Methodology triangulation with sequential use of qualitative- quantitative methods provided a rich description of knowledge sources and cognitive processes used by ED nurses relative to pediatric pain assessment decisions. Based on qualitative results, a set of vignettes was developed to assess ED nurses. Data analysis using ordinal logistic regression with a cumulative logit model identified patient and nurse variables which influence triage acuity decisions. Five common themes emerged from the qualitative data; 1) Age of the child is important, 2) Behavior can tell a lot, 3) Really looking at the patient, 4) Things that help make decisions, and 5) Things that hinder decisions. Ordinal logistic regression analysis of the quantitative data identified predictor variables of infants compared to school-age children, Hispanic ethnicity, moderate number of years of ED experience (11 -20 years) and years of education that were associated with higher triage levels .The implications of this new knowledge include changes in ED triage nurse practice towards pain assessment, and increased awareness of the need for education in use of pain assessment tools. Additional implications include education related to pain management practices by ED physicians and pain medication protocols at triage. This information may enhance triage and care of the pediatric patient experiencing pain, expand the knowledge base of emergency nursing, identify areas in which to implement changes, assist in improving care provided to children experiencing pain, and provide direction for future education, training, and research.
Advisor: Susan C. McMillan, Ph.D.
Pediatric triage emergency nursing pain
t USF Electronic Theses and Dissertations.