A structured patient assessment framework improves the clinical performance and communication skills of emergency nurses

Belinda Munroe1,2, Kate Curtis1-3, Margaret Murphy 1,4, Luke Strachan5, Julie Considine6,7, Jennifer Hardy1, Mark Wilson7, Kate Ruperto8, Judith Fethney1 & Thomas Buckley

1 Sydney Nursing School, University of Sydney, Camperdown, NSW, 2050
2 Emergency Department, Wollongong Hospital, Wollongong NSW, 2500
3 Trauma Service, St George Hospital, Kogarah, NSW, 2217
4 Emergency Department, Westmead Hospital, Westmead, NSW, 2145
5 Emergency Department, Blacktown Hospital, Blacktown, NSW, 2148
6 Deakin University, School of Nursing and Midwifery, Geelong, NSW, 3220
7 Eastern Health, Box Hill, VIC, 3128
8 Emergency Department, Shellharbour Hospital, Shellharbour, NSW, 2529
9 Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong, NSW, 2500

Introduction: Emergency nurses are at the forefront of the Emergency Department (ED) and frequently assess patients and commence investigations and treatment, before patients are seen by a medical officer. Inadequate assessment is known to result in a large proportion of ED clinical incidents 1. A structured approach to patient assessment has the potential to improve clinical performance, yet there is no validated system used to teach new nurses to the ED how to perform accurate and complete comprehensive assessments post triage 2. The evidence-informed assessment framework HIRAID (History, Identify Red flags, Assessment, Interventions, Diagnostics, reassessment and communication) (Figure 1) was designed to provide emergency nurses with a structured approach to the comprehensive assessment of emergency patients 3.

Aims: To evaluate the effect of HIRAID on the quality of patient assessment, non-technical skills and anxiety, self-efficacy and perceived control in assessment performance, in addition to determine factors influencing the future successful implementation of HIRAID into clinical practice.

Methods: A convergent mixed methods design was used. The performance of thirty eight early career emergency nurses from five Australian Hospitals, were evaluated performing assessments of simulated patients with common presentations to the ED, before and after completing education in the application of HIRAID. Participants completed surveys, interviews and focus groups. Changes from pre to post intervention were assessed using paired parametric and non-parametric tests as appropriate. Inductive content analysis was used to analyse qualitative data. The two data sets were analysed separately prior to integration.

Results: Increases were observed in the percentage of patient history elements collected (p=0.02), critical indicators identified (p=0.02) and reported to medical officers (<0.01) and reassessments performed (p=0.01), from pre to post intervention. Improvements were seen in all four non-technical skill categories: communication, decision-making, task management and situational awareness (p<0.01). Anxiety levels decreased (p<0.01) and self-efficacy in assessment performance increased (p<0.01). The majority of participants reported a high level of satisfaction with the usefulness of HIRAID and recommended HIRAID be introduced before or within three months of commencing work in the Emergency Department. A range of behaviours and beliefs were identified to enhance or impeded on the implementation of HIRAID into clinical practice.

Conclusion: HIRAID has the potential to improve patient safety and should be considered for implementation into clinical practice. Behaviours and beliefs identified to influence the uptake of HIRAID should be enhanced or modified to optimise the uptake of HIRAID in the clinical setting.


  1. NSW Emergency Care Institute (ECI) and NSW Agency of Clinical Innovation, ECI Incident Advisory Committee (IAC) Report to CRAG 2015.
  2. Munroe, B., K. Curtis, J. Considine, and T. Buckley, The impact structured patient assessment frameworks have on patient care: An integrative review. Journal of clinical nursing 2013; 22: 2991-3005.
  3. Munroe, B., K. Curtis, M. Murphy, L. Strachan, and T. Buckley, HIRAID: An evidence-informed emergency nursing assessment framework. Australasian Emergency Nursing Journal. 2015; 18: 83-97.


Belinda Munroe specialises in emergency nursing care and has experience working as a clinician in emergency, trauma and intensive care. She is employed part time as a Clinical Nurse Specialist at Wollongong Hospital Emergency Department and is currently completing a Doctor of Philosophy degree in Nursing, full-time through Sydney Nursing School, University of Sydney. Munroe’s career ambitions are to apply her skills in clinical education and research to promote the translation of research evidence into clinical practice to enhance the delivery of safe emergency nursing care.