The triage and management of pregnant women in a Queensland hospital emergency department: a participatory action research study
Harvey, Nichole Racheal (2012) The triage and management of pregnant women in a Queensland hospital emergency department: a participatory action research study. PhD thesis, James Cook University.
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Abstract
This study was born out of anecdotal evidence from midwives and nurses involved with the care of pregnant women, who claimed that the management of pregnant women in a Queensland Emergency Department (ED) could be significantly improved. Anecdotal examples were provided which demonstrated that care was often inconsistent and not woman-centred when a pregnant woman attended the ED. The ED is a demanding and sometimes chaotic place, with staff having to triage and manage the most life threatening and urgent cases on a priority basis. As evidenced by the literature and study results, the main reason for pregnant women attending an ED is threatened miscarriage; this can be a devastating event in the life of a woman and her family. Nevertheless, it is generally triaged as semi-urgent, since the woman's physical condition is stable. This particular scenario has led to many emotive media reports, uncorroborated by clinicians, such as, 'birth in toilet in hospital without care', as well as governments and hospital administrators advocating changes to practice, with little or no consultation or planning. Anecdotal evidence by both the ED staff and the maternity staff at the research hospital confirmed that such impulsive changes in this particular health district were considered inappropriate and unsustainable and would do little to address the problem and improve the care of pregnant women in the ED.
This study therefore endeavoured to employ a participatory strategy to improve the triage and management of pregnant women when they attended the ED. To achieve this the following research questions were formulated, with a view to conducting a participatory action research study: what is/are the current problem/s with the triage and management of pregnant women in the ED?; why does this problem exist?; how can the situation be improved?; and, how effective is the plan that has been developed and implemented in improving the situation for pregnant women who attend the ED?.
Action Research methodology underpins this study. Action research is a form of collective self-reflective enquiry undertaken by a group of people to understand and improve practices to real life problems (Kemmis & McTaggart, 1988). A key purpose of action research is to produce strategies and practical knowledge which are useful to people in everyday life (Reason & Bradbury, 2006). A multi-disciplinary Participatory Action Research Group (PARG) made it possible to explore and assess the triage and management of pregnant women in the ED from the perspectives of nurses, doctors and midwives. Throughout each stage of the research process a critical theory standpoint informed the analysis, with particular reference to Habermas' theories of knowledge-constitutive interests and communicative action. The study's design promoted a collaborative working relationship with expert clinicians that created opportunities whereby the participants involved in the research were empowered to bring about positive change for pregnant women and themselves.
The PARG reached consensus on identifying three main themes in the data. These themes concerned communication, knowledge and care. The first theme, communication, was highlighted as an important area that staff could improve upon in order to provide more humanistic care to women, especially with the concept of language use. It was also identified that interdisciplinary communication was problematic as the different clinical areas had limited understanding of the everyday difficulties that each experienced, which caused tension and ineffective interactions. The second theme, knowledge, was also very important in understanding the reasons for inconsistency in the triage and management of pregnant women in the ED. Once the PARG identified the main areas of knowledge concern for both staff and women, they were able to formulate and implement strategies to help improve the situation. The final theme, care, represented the paucity of psychological care compared to physiological care in the ED and a deeper appreciation among the ED staff of the impact a miscarriage can have on a woman and her family. In addition, the PARG recognised situations where woman-centred care was in the background and health-professional centred-care was in the foreground, and the possible reasons for this occurring.
This research resulted in the implementation and the evaluation of a number of strategies that directly improved the triage and management of pregnant women in the ED. Strategies included, but are not limited to: new triage flow chart for bleeding in early pregnancy; advice sheet for women with bleeding in early pregnancy; revised policies; development of two pamphlets to distribute to women concerning miscarriage and available support options; education sessions for the ED staff on common pregnancy related conditions; new furniture and renovations to the gynaecology room in the ED; and a resource book for the ED staff containing information from the Stillbirth and Neonatal Death Society (SANDS). Further significant outcomes of the research included an increased awareness and understanding by staff in both the ED and the maternity areas of the problems, and the improved networking and collaborative relationships that were established as a result of the PARG. This alone had significant impact on how women were triaged and managed in the ED. However, the most significant outcome is that even though the research is completed, the collaborative relationships that were established by undertaking this research continue to develop, grow and create a positive influence on the care that pregnant women receive when they attend this ED.
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