Contextual factors interfacing with quality of care in the emergency department: A micro-ethnographic study

Introduction: Triage in the interactive atmosphere of the emergency department (ED) has been described as complex and challenging. The influence of nurses’ belief systems on triage decision making has not to the authors’ knowledge been addressed. This study attempted to gain an understanding of the ED nurses’ culture of practice with respect to contextual factors that affect triage decision making. Methods: A focused micro-ethnographic study based on Spradley’s developmental research sequence (DRS) has been conducted in the emergency department of the Mashhad University hospital, Iran, from February 2014 to February 2015. Data were collected during 300 hours of participant observations that were accompanied by formal and informal interviews, then analyzed based on Spradley’s DRS. Results: Nine study participants were formally interviewed. From these interviews, eight core beliefs emerged related to nurses’ culture of practice: namely, triage decision making is arbitrary; the facility/locale of the emergency medicine department is the pivotal contextual factor affecting decision making; not every nurse can be assigned to triage; each patient assumes the existence of an emergency condition; the on-duty physician must be known; triage decision making must be considered plausible by colleagues; “they” tell us something, we should do something else; and triage guidelines are not practical. Conclusion: Contextual factors have a strong tendency to guide triage decision making and violate the principle of patient acuity (that is, that patients with the most acute medical conditions should be prioritized). In response, triage guidelines need to integrate the priorities of patients, nurses, physicians, and administrators.