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Contents lists available at ScienceDirect

Australasian Emergency Care

journal homepage: www.elsevier.com/locate/auec

Research paper

The implementation and usability of HIRAID, a structured approach to

emergency nursing assessment
Kate Curtis a,b,c,d , Belinda Munroe b , Connie Van a , Tiana-Lee Elphick b,∗
a
Susan Wakil School of Nursing and Midwifery, Sydney Nursing School, Faculty of Health and Medicine, The University of Sydney, 88 Mallett Street,
Camperdown, NSW 2006, Australia
b
Illawarra Shoalhaven Local Health District, Wollongong Hospital, Loftus Street, Wollongong, NSW 2500, Australia
c
Illawarra Health and Medical Research Institute, Building 32, University of Wollongong, Northfields Avenue, Wollongong, NSW 2522, Australia
d
The George Institute for Global Health, Level 5, 1 King Street, Newtown, NSW 2042, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Background: Emergency nurses are responsible for the initial assessment, management and safety of
Received 27 March 2019 critically ill patients. HIRAID, an evidence-informed emergency nursing assessment framework, is known
Received in revised form 23 August 2019 to improve emergency nursing patient-assessment in the simulated environment however has not been
Accepted 2 October 2019
evaluated in the clinical setting.
Methods: A pre-post design was used to assess the usability and impact of HIRAID on emergency nurses
Keywords:
self-efficacy in the emergency department (ED). Nursing and medical staff from three Australian EDs
Framework
were surveyed. Descriptive and optimal pooled sample t-tests statistics were conducted.
Patient assessment
Emergency
Results: One hundred and two emergency nurses completed the pre-intervention self-efficacy survey
Nursing and 63 completed the post-intervention self-efficacy and satisfaction survey. Forty-two and 17 medical
Self-efficacy officers completed the pre- and post-intervention satisfaction surveys, respectively. Nursing staff self-
efficacy levels were unchanged pre- and post-HIRAID implementation (Mean (SD): 8.8 (0.21) vs. 8.7
(0.20)) as was medical staff satisfaction (Mean (SD):7.5 (1.43) vs. 7.8 (1.07)), although there was a trend
towards improved communication.
Conclusion: The HIRAID structured approach to patient assessment is acceptable, feasible, practical and
appropriate for use in the clinical environment. Further research will demonstrate the direct effects of
HIRAID on clinical performance.
© 2019 Published by Elsevier Ltd on behalf of College of Emergency Nursing Australasia.

1. Introduction safe patient care challenging [3]. A structured approach to patient

Emergency Departments (ED) are critical components of
Australia’s health care system and provide care for all ages at nearly
300 hospitals. ED presentations have increased to more than 8 mil-
lion/year in 2017–18, about 22,000 patients per day [1]. The role
of emergency nurses is starkly different to that of other special-
ties. Emergency nurses assess and initiate care for patients of all
ages, with varying degrees of clinical urgency and severity, most of
whom are undiagnosed and undifferentiated [2]. This complexity,
ambiguity and sometimes urgency require a structured approach
to patient-assessment to ensure the delivery of safe patient care.
The exposure to a hectic, diverse and unpredictable work pat-
terns makes performing quality patient assessments and delivering
∗ Corresponding author at: Illawarra Shoalhaven Local Health District, Wollon-
gong Hospital, Research Central, Loftus St, Wollongong, NSW 2500, Australia.
E-mail address: Kate.Curtis@sydney.edu.au (T.-L. Elphick).
assessment has been shown to enhance clinician performance and
has the potential to improve the delivery of care and subsequent
patient outcomes in nurses and medical officers in other spe-
cialty areas including medical, surgical and intensive care units. Yet
there is no standardised emergency nursing assessment framework
reported in use [4]. Improved clinical assessment is recognised as
an area of need by the Australian Commission on Safety and Quality
in Health Care (ACSQHC) [5]. Evaluating interventions to improve
clinical care is an Australian emergency research priority [6,7].
The expectation to care for multiple patients at once within
severe time constraints often present in the ED environment and
can result in emergency nurses experiencing higher levels of stress
compared to other nursing specialties [8]. Self-efficacy, belief in
one’s capability to perform a given behaviour or course of action,
acts as a coping mechanism in response to stress [9] with higher
levels of self-efficacy reported to positively influence clinical per-
formance [10]. Heavy workloads, high presentation rates and high

https://doi.org/10.1016/j.auec.2019.10.001
2588-994X/© 2019 Published by Elsevier Ltd on behalf of College of Emergency Nursing Australasia.

Please cite this article in press as: Curtis K, et al. The implementation and usability of HIRAID, a structured approach to emergency
nursing assessment. Australasian Emergency Care (2019), https://doi.org/10.1016/j.auec.2019.10.001
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Fig. 1. HIRAID: An evidence-informed emergency nursing assessment framework.

patient acuity common to the ED workplace can threaten the self-
confidence of emergency nurses [11].
To address this gap in emergency clinical practice, an emer-
gency nursing assessment framework ‘HIRAID’ (History, Identify
Red flags, Assessment, Interventions, Diagnostics, communication
and reassessment) (Fig. 1) was developed in 2015, based on the best
available research evidence [12]. HIRAID builds on existing frame-
works such as the A–G assessment. The A–G structure is a way
to conduct physical assessment, however it is solely limited to the
physical assessment of the patient and does not consider the fusion
of patient history, indicators of urgency, assessment, intervention,
monitoring, reassessment, communication and definitive care. All
of these components are essential for safe, quality nursing care
in the emergency practice environment [12]. The cyclical HIRAID
framework is the first known system designed to teach emer-
gency nurses how to systematically assess and manage Emergency
patients after the triage process [4]. In the simulated environment,
HIRAID improved emergency quality of patient assessment [13], as
well as reduced anxiety and increased self-efficacy in assessment
performance [14] which are closely associated with clinical perfor-
mance [15,16]. However, HIRAID has not been tested for usability
and efficacy in real life clinical situations.

Please cite this article in press as: Curtis K, et al. The implementation and usability of HIRAID, a structured approach to emergency
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Fig. 2. Overall study design evaluating the usability and impact of HIRAID in the
clinical environment.
The aim of this study was to 1) evaluate the usability of HIRAID
in the clinical environment, and the impact on emergency nurses’
self-efficacy when conducting an initial comprehensive patient
assessment and 2) determine the satisfaction of emergency nurses
and medical staff with the utility of the HIRAID framework in actual
clinical practice
2. Methods
2.1. Study design
This study used a pre-post design to assess the usability and
impact of a structured assessment framework (intervention) on
emergency nurses ability to assess and manage patients with com-
mon presentations to the ED. This study is part of a larger study
testing the efficacy of HIRAID (Fig. 2). Research conducted as part
of this study adhered to the National Statement on the Conduct
of Human Research by the Australian National Health and Med-
ical Research Council, and has been approved by the UOW and
ISLHD Health and Medical Human Research Ethics Committee
(LNR/16/WGONG/249).
2.2. Sample
An email invitation was sent to all permanently employed emer-
gency nurses and senior medical officers in three geographically
diverse Australian EDs inviting them to participate in the study:
Wollongong (regional: 62,130 presentations); Shoalhaven (district:
36,829 presentations) and; Milton Ulladulla (rural: 13,309 presen-
tations). One hundred and sixty-six nurses and 59 senior medical
officers (staff specialists, registrars and casualty medical officers)
across the three sites were eligible to participate. Pre-intervention
data were collected from January to March 2017, and all eligible
staff were invited via email to participate. Post-intervention data
were collected from May to June 2018 via their managers. All per-
manently employed nursing staff were again invited to participate,
as they had all received HIRAID training. Only medical staff who
were employed in the pre period were invited to participate, to
ensure a sample exposed to both pre and post intervention. Sur-
veyRPower calculations were performed using G*Power 3.1.3 [17].
A paired sample size of 34 was needed to provide 80% power to
detect statistically significant differences between pre and post
self-efficacy, with 2-tailed alpha <.05 and a medium (0.5) effect
size.
Please cite this article in press as: Curtis K, et al. The implementation and usability of HIRAID, a structured approach to emergency
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3
2.3. Intervention
HIRAID is an evidence-informed emergency nursing assessment
framework developed to provide emergency nurses with a struc-
tured approach to the initial assessment of patients presenting to
the ED following triage (Fig. 1) [18]. This framework was originally
developed to provide novice emergency nurses with a systematic
approach to patient assessment as part of a university post grad-
uate curricula [19] and was revised and re-developed in 2015 to
reflect current research evidence [18].
2.4. Implementation of the intervention
As recommended by the Knowledge to Action Cycle, barriers and
facilitators to knowledge use were determined prior to implemen-
tation [20]. Central to the success of any intervention is collective
and individual clinician behavior [21]. Changing behaviour also
requires an understanding of the contextual influences on behav-
ior [22]. As part of the implementation strategy development
for HIRAID, a behavioural analysis was conducted using a con-
vergent parallel mixed-methods study [23] described in detail
elsewhere [24] and summarised in Table 1. The recommended
interventions and techniques from this study were assessed using
the APEASE criteria (Affordability, Practicability, Effectiveness and
cost-effectiveness, Acceptability, Side-effects/safety and Equity) by
the site senior emergency nursing team to select strategies most
likely be most successful at the site context [25]. For example, one
of the interventions identified was education of all nursing staff in
the application of HIRAID. To ensure the education developed was
affordable (not requiring one person to deliver all education), prac-
tical to shift workers, effective (an education delivery mode known
to work that didn’t require every nurse to attend a full day work-
shop), acceptable to management and staff, and equitable (ensure
no nurse was excluded), A series of educational strategies were
designed, such as eLearning, train the trainer and simulation, A mul-
timodal strategy was developed based on the behavioural analysis
and is detailed in Table 1.
Following the engagement of and endorsement from nursing
executive and departmental nursing leadership, implementation
of HIRAID commenced across the health district in November
2017. Six intervention functions were selected to optimise the
implementation of the HIRAID assessment framework: ‘training’;
‘education’; ‘environmental restructuring’; ‘enablement’; ‘persua-
sion’ and; ‘modelling’. Behaviour change techniques and modes of
delivery selected to implement HIRAID are presented in Table 1.
These include: the development and compulsory completion of
an eLearning module; attendance at a half day HIRAID work-
shop; integration of HIRAID into ED orientation programs and
specialty training programs; mandated quarterly random audits of
10 episodes of initial nursing documentation at all sites; introduc-
tion of cues within the workplace such as posters and reference
cards; development of a brief video outlining what HIRAID is and
that it has executive support; development and mandated use of a
documentation template based on the assessment structure (Fig. 3).
2.5. Instruments
Participants completed an electronic survey to collect demo-
graphic, usability and self-efficacy while performing the patient
assessment. Emergency nurses’ pre-post self-efficacy in assess-
ment performance was measured using a 14 item previously
validated instrument [14]. Participants were asked to indicate their
level of confidence on an 11-point Likert scale where ‘0’ indicated
no confidence and ‘10’ complete confidence. For example, ‘As of
today, I am confident that I am able to identify when reassessment
of the patient is indicated’.
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Table 1
Summary of intervention functions, policy and behaviour change techniques selected for implementing the HIRAID assessment framework into the clinical setting using the
Behaviour Change Wheel.

Intervention functions(techniques) Policy categories Selected modes of delivery

Training (Imparting skill, increasing Guidelines (Creating documents Provide instruction on the application of the HIRAID assessment framework
knowledge or understanding) and that recommend or mandate through:
Education practice)
- Instructs how to perform behaviour - Develop interactive e-learning program

- Demonstration of behaviour - Integrate e-learning program and practical training into ED nursing
orientation

- Feedback on behaviour - Include research evidence on the effectiveness of the HIRAID assessment
framework in improving the quality of patient assessments

- Education Regulation (Establishing rules or - ‘train-the-trainer’ model for ED nurse educators

principles of behaviour or practice)
Environmental restructuring - all staff mandated to attend group practical training using
(Changing physical or social context) simulation exercises, communication strategies

- Adding objects to the environment - individual teaching at the bedside (a check list of each staff members name
held by educator)

- Prompts/cues - Educational resources freely available to EDs (including online learning

package, facilitator manual, participant workbooks)

Service provision (Delivering a

Enablement(increasing means/reducing
barriers to increase capability)
- Social support
- Action planning
service)
Communicating/marketing Communicate
(Using print, electronic, telephonic
or broadcast media)
- Posters in clinical workplace (including bathrooms at eye
level) to advertise education and remind clinicians to use
HIRAID in clinical practice

Persuasion (Using communication to - Nurse educators / preceptors provide ongoing feedback clinical performance
induce positive or negative feelings or using HIRAID
stimulate action)
- Information about consequences - Video of senior leadership explaining and endorsing HIRAID

- Feedback on behaviour Demonstration of behaviour

- Video demonstrating application of HIRAID in clinical scenario

Environmental/social planning Restructure environment

(Designing and /or controlling the
physical or social environment)
Modelling (Providing an example for - HIRAID documentation templates created for general adult
people to aspire to or imitate) and paediatric assessment, mental health, trauma, rapid
assessment and reassessment (Fig. 3)

- Mandated use of documentation template

- Nursing documentation audits built in to hospital governance system

Reinforcement
Senior nurses, educators and preceptors provide praise to nurses when seen to
be using the HIRAID assessment framework in their clinical practice

Emergency medical and nursing staff were surveyed on their
satisfaction with the HIRAID tool in clinical practice. Medical staff
satisfaction was measured using 9 items and nursing staff satis-
faction was measured using 12 items on an 11-point Likert scale
where ‘0’ indicated no satisfaction and ‘10’ indicated complete
satisfaction. For example: ‘In the last week whilst working in the
emergency department, how satisfied were you with the relevance of
historical information collected and reported to you by nursing staff’
(medical staff survey); ‘How satisfied were you with the usefulness of
the HIRAID framework for collecting a patient history’ (nursing staff
survey). Open-ended questions were also used enabling free text
responses. The opinion of permanently employed senior medical
officers was sought as the HIRAID intervention includes a compo-
nent of communication with medical staff, as a group of clinicians
working in a fast paced, highly stressful environment, there is vast
interdependence. It is essential that emergency nurses and doctors
are able to exchange information in a coherent, comprehensive way
for patient safety, and to maintain collaborative relationships [26].
2.6. Survey administration
Staff surveys were administered using REDCap (Research Elec-
tronic Data Capture), a secure web-based application for data
management and survey tool. To enable pre-post pairing, the email
addresses of all eligible staff were uploaded to RedCap. RedCap then
allocates an individual ID for each person and an individualised
email link is sent to each person. The data entered by the partic-
ipant are linked with their participant ID, but stored separately,

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HIRAID EMERGENCY NURSING ASSESSMENT (ADULT)

HISTORY (include historical red flags)

Presenting Problem
(Aggravating/relieving factors, related symptoms, severity, timing etc.)

Individual Health History

Pertinent Medications:
Pertinent medical/surgical:
Social history:

ASSESSMENT (include physiological red flags)

Airway (patent/protected):
Breathing (RR/WOB/O2/air entry):
Circulation (HR/BP/rhythm/pulses/capillary refill/colour):
Disability (GCS/pain):
Exposure (temp/skin):
Fluids (in):
Fluids (out):
Glucose (if Indicated):
Relevant focused assessments (look/listen/feel):

INTERVENTIONS, DIAGNOSTICS & COMMUNICATIONS

(What was done and what was the outcome. Who was contacted and when)

PLAN:

**don't forget to complete the mandatory nursing assessment forms

(allergies, falls, pressure injury, patient belongings, substance use)**

Fig. 3. Example of application of HIRAID framework through mandatory nursing documentation template.

and not visible to or identifiable by investigators. The automated
reminder email function was activated within REDCap to send a
reminder every six weeks until the closing of the survey (maximum
3 reminders). When a participant completes the survey, REDCap
records this as a completion and will not send out any further emails
to contact participants. This controls and minimises the amount of
emails sent to participants.
2.7. Analysis
Descriptive statistics including tabulations of frequencies and
percentages or mean and standard deviations for characteristic
variables were performed using Stata/IC 14.2. Pre-post data that
contained partially paired continuous data for both nursing and
medical participants were compared using optimal pooled t-tests
[35]. Wilcoxon signed rank test statistics were run separately for
continuous data that only included paired pre-post data. A p-value
< 0.05 was considered statistically significant.
3. Results
3.1. Nursing participant demographic profile
a 29% response rate with 5 matched cases that completed both the
pre and post survey). The mean (SD) age of nurse respondents was
38.2 years (11.96). 91.2% of nurse respondents had more than 3
years nursing experience, and 77.8% had more than 3 years emer-
gency nursing experience. Characteristics of the pre-intervention
survey respondents are summarised in Table 2. Twenty-nine nurses
completed both the pre- and post-intervention survey, and 71.4%
had more than 3 years emergency experience. Of the respondents
who completed the pre-intervention survey, 65 (73%) indicated
they currently use a pre-planned structure to determine the order
in which they perform tasks when managing patients in the ED. The
most commonly cited structure used was the A–G assessment tool
(68%).
3.2. Pre- and post-HIRAID intervention self-efficacy
Self-efficacy levels were unchanged pre- and post-intervention
(Table 3). The mean overall self-efficacy levels were high (Mean
(SD): 8.8 (0.21)). When comparing only the 28 participants who
completed both pre- and post-intervention surveys, the overall
self-efficacy score remained unchanged (Mean (SD): 8.79(1.12) vs
9.03 (0.85), t = 0.91, p = 0.365).

A total 136 emergency nurses participated in the study (102
pre-intervention for a 61% response rate, 63 post-intervention
for a 38% response rate with 29 matched cases that completed
both the pre and post survey) and 54 medical officers (42 pre-
intervention for a 63% response rate and 17 post-intervention for
3.3. Usability
Of those that completed the usability component of the post-
survey, 96% of respondents (49/51) indicated they were using
HIRAID. The most commonly given reason for using HIRAID was

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Table 2 ED nurse. Many respondents felt HIRAID assisted them in their roles
Characteristics of pre-intervention nursing and medical survey respondents.
by providing a structured framework for practice:
Nursing Characteristic Number (%) (n = 102)
“My responsibilities as an ED nurse are to accurately assess the
Gender patient, initiate appropriate treatment, escalate where required
Female 77 (75.5)
and communicate effectively. HIRAID provides a vehicle to facil-
Male 25 (24.5)
Current position itate all these aspects of patient care” (nurse 5)
Enrolled Nurse 1 (1.0) “It is our responsibility as any emergency nurse to maintain a
Registered Nurse 79 (77.5) systematic approach, HIRAID is concise way to maintain vigi-
Clinical Nurse Specialist 13 (12.8) lant documentation for patient safety/best practice and nursing
Nurse Practitioner 3 (2.9)
Other 6 (5.9)
legalities” (nurse 65)
Location
The most frequently cited barrier to HIRAID uptake was a lack of
Wollongong 67 (62.8)
Shellharbour 7 (6.9) time, followed by perceiving HIRAID to be too complicated, how-
Shoalhaven 31 (30.4) ever there were also a handful of respondents who reported no
Employment Status barriers to HIRAID uptake. When respondents were asked what
Permanent full-time 67 (65.7) would make it easier for them to use HIRAID in their clinical prac-
Permanent part-time 28 (27.5)
tice, many suggested simplifying the HIRAID template and ensuring
Temporary contract 3 (2.9)
Casual 4 (3.9) there are computers available for use at the bedside.
Years of experience working as a nurse While most respondents did not identify any negative outcomes
<1 3 (2.9) of using HIRAID in their practice, a couple of respondents thought
1–2 6 (5.9)
that there could “possibly [be a] false sense that if you tick all those
3–5 22 (21.6)
6–10 15 (14.7) boxes you don’t need to expand or think clinically out of the box” (nurse
>10 56 (54.9) 7) and that “any model that has an element of repetitiveness may lead
Years of experience working in ED users to become complacent” (nurse 13).
<1 11 (10.8) HIRAID was believed to benefit junior or new staff most:
1–2 12 (11.8)
3–5 19 (18.6) “Great prompts for junior nursing staff who have not worked
6–10 21 (20.6) out systematic assessment yet” (nurse 12)
>10 39 (38.2)
Age
“Works for new nurses who are unsure what to document”
<25 11 (12.4) (nurse 8)
25–34 32 (36.0)
35–44 24 (27.0) However it was also beneficial to more experienced staff mem-
45–54 12 (13.5) bers as “for more senior staff, it reinforces to them to use this consistent
>54 10 (11.2) process” (nurse 45).
Medical Officer Characteristic Number (%) (n = 42) In terms of implementation resources for HIRAID, respondents
Gender
believed HIRAID documentation templates, formal training such as
Female 12 (28.6)
Male 30 (71.4) workshops and training at the bedside whilst caring for patients to
Current position be most helpful in assisting them apply HIRAID in their clinical prac-
Staff specialist 15 (35.7) tice (Table 4). In relation to satisfaction with the HIRAID framework
Registrar 12 (28.6)
components, respondents reported that HIRAID was most useful
Resident 3 (7.1)
Intern 4 (9.5)
in assisting them document a patient’s medical record, collect a
VMO 1 (2.4) patient history and structuring a physical assessment (Mean (SD)
CMO 7 (16.7) scores 7.69 (1.9), 7.41 (2.1) and 7.41 (2.2), respectively, where ‘0’
Location indicates no satisfaction and ‘10’ indicates complete satisfaction).
Wollongong 34 (58.6)
Shellharbour 8 (13.8)
Shoalhaven 16 (27.6) 3.4. Medical staff
Years of experience working as a medical officer
0–2 6 (14.3)
3–5 5 (11.9) A total of 59 surveys were completed, 42 medical officers
6–10 2 (4.8) completed the pre-intervention survey and 17 completed the post-
>10 29 (69.1) intervention survey. Only five medical officers completed both the
Years of experience working in ED
pre- and post-intervention survey so matched analysis was not pos-
0–2 9 (21.4)
3–5 7 (16.7)
sible. Respondents were experienced. 78.6% had more than 3 years
6–10 10 (23.8) emergency medicine experience.
>10 16 (38.1) The overall medical staff satisfaction with the HIRAID assess-
Age ment was moderate to high (post mean (SD): 7.8 (1.07)), and the
<25 1 (2.6)
improvements shown did not reach significance (Table 5). Overall
25–34 10 (25.6)
35–44 15 (38.5) medical staff spoke highly of the nursing staff they worked with:
45–54 10 (25.6)
>54 3 (7.7)
“I feel very privileged to be part of the ED team at SDMH. The
senior nursing staff are outstanding and a huge part of the reason
I wish to stay and work here” (Medical 7)
because it was a mandatory requirement of the hospital. Other
Comments from medical officers prior to the introduction of
reasons included because it was a useful assessment and documen-
HIRAID were most often around communication and reflective of
tation tool, was easy to use and provided clinical consistency. The
the low satisfaction score (6.5/10). For example:
reason given for not using HIRAID was because the respondent had
their own method and template. The majority of respondents (88%, “There is a tendency to be vague and thus make questions unan-
44/50) believed HIRAID is reflective of their responsibilities as an swerable” (Medical 30)

Please cite this article in press as: Curtis K, et al. The implementation and usability of HIRAID, a structured approach to emergency
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Table 3
Nursing staff self-efficacy scores pre- and post-intervention.

Variable Pre-intervention (n = 94) Post-intervention Comparison of means pre

(n = 63) and post-intervention

Mean* SD Mean* SD p value t value

Overall 8.8 0.21 8.7 0.20 -** –

History
1. Take adequate history 8.9 1.27 8.8 1.28 0.748 −0.32
2. Recognise historical indicators of deterioration 8.7 1.41 8.6 1.33 0.746 −0.33
Red flags
1. Recognise potential/actual deterioration 8.6 1.32 8.4 1.70 0.228 −1.23
2. Recognise physiological indicators of deterioration 8.7 1.25 8.4 1.70 0.860 0.18
3. Respond to indicators of deterioration 8.7 1.24 8.5 1.65 0.799 −0.26
Assessment
1. Perform comprehensive physical assessment 8.6 1.25 8.4 1.49 0.539 −0.62
2. Perform physical assessment in order of urgency 8.8 1.16 8.5 1.76 0.535 −0.63
Interventions
1. Identify and perform appropriate interventions 8.9 1.09 8.7 1.65 0.149 −1.48
Reassessment
1. Identify when reassessment is indicated 9.0 0.99 8.7 1.61 0.906 0.12
Communication
1. Identify need for escalation of care 9.1 0.98 8.9 1.24 0.863 0.17
2. Communicate concerns to medical officer 9.2 1.07 9.1 1.11 0.679 0.42
3. Communicate using ISBAR mnemonic 8.5 1.43 8.8 1.11 0.135 −1.52
4. Perform accurate nursing handovers 8.6 1.38 8.7 1.14 0.640 −0.47
5. Document assessment and care 8.7 1.49 8.7 1.26 0.396 −0.86
*
Where ‘0’ indicates no confidence and ‘10’ indicates complete confidence.
**
Comparison not tested as summary of means.

Table 4 “There is a lot of room for improvement i.e. more of an ISBAR

Perceived helpfulness of educational resources for HIRAID.
structure” (Medical 10)
Educational resource Number agree/ “Less experienced nurses don’t escalate well and get intimi-
strongly agree it dated by hierachy. The older nurses are much better because
is helpful (%)
of experience” (Medical 54)
HIRAID posters in the ED (n = 54) 13 (24)
HIRAID reference cards (n = 54) 21 (39) The HIRAID tool was viewed as “certainly an improvement from
Formal training e.g. workshops (n = 54) 38 (70) previous clinical handover tools” (Medical10) however respondents
Training at the bedside whilst caring for patients (n = 54) 35 (65) believed it also depended largely on the nurse who utilised it and
Written resources e.g. ED orientation manual (n = 53) 26 (49) resource levels:
Online learning module (n = 53) 29 (55)
HIRAID documentation templates (n = 52) 42 (81) “Insufficient nursing staff in subacute to adequately monitor the
number of potentially unstable patients in area” (Medical 13)

“Common to get requests like here is an ECG to sign - no infor- 4. Discussion

mation re obs relayed or documented on it is common here is
a medication chart to write up meds but dont know if allergies Following the implementation of HIRAID in three EDs, this expe-
and not documented on eMR” (Medical 24) rienced group of emergency nurses did not report any change in

Table 5
Medical staff satisfaction scores pre- and post-intervention.

Variable Pre-intervention (n = 42) Post-intervention Comparison of means pre

(n = 17) and post-intervention

Mean* SD Mean* SD p value t value

History
1. Relevance of history collected by nurses 6.6 1.91 7.3 1.49 0.153 −1.53
Red flags
1. Nurse recognition and response to red flags 7.4 1.54 7.4 1.37 0.750 −0.32
Assessment
1. Relevance of physical assessment items performed 6.5 1.98 7.2 1.42 0.228 −1.24
Interventions
1. Appropriateness of nurse initiated treatments 7.2 1.66 7.2 1.60 0.723 −0.36
Investigations
1. Appropriateness of nurse initiated investigations 6.5 2.10 7.1 1.64 0.069 −2.11
Reassessment
1. Level of monitoring and reassessment of patients 6.7 1.81 6.5 1.84 0.244 −1.30
Communication
1. Relevance of nursing clinical handover information 6.5 1.90 7.1 1.22 0.204 −1.32
2. Quality of nursing clinical documentation 7.2 1.66 7.1 1.76 0.969 0.04
Overall
Overall satisfaction 7.5 1.43 7.8 1.07 0.267 −1.14
*
Where ‘0’ indicates no satisfaction and ‘10’ indicates complete satisfaction.

Please cite this article in press as: Curtis K, et al. The implementation and usability of HIRAID, a structured approach to emergency
nursing assessment. Australasian Emergency Care (2019), https://doi.org/10.1016/j.auec.2019.10.001
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self-efficacy in assessing and commencing nursing care for patients
presenting to the ED. Nursing and medical participants reported
high levels of satisfaction and relevance to clinical practice, partic-
ularly around structure, consistency, prompts and communication.
It is plausible that a change in self-efficacy levels was not
seen because the participants already reported high levels of self-
efficacy. This is in contrast to the findings of the study evaluating
HIRAID in the simulated environment with a group of inexperi-
enced emergency nurses (<3 years) [14]. The majority of nurse
participants in this study had more than three years of emer-
gency experience, and comments indicated while they found the
structure useful, it would be of greater benefit to early career
nurses. Early career nurses have been observed to lack confidence in
their clinical practice and ability to make decisions [27]. Strategies
should perhaps be focussed to enhance novice emergency nurses’
self-efficacy in patient assessment, as an increasing number of new
graduate nurses are seeking and gaining direct entry to ED [27,28],
with minimal prior experience in performing patient assessments.
Of the respondents who completed the pre-intervention sur-
vey, 65 (73%) indicated they currently use a pre-planned structure
to determine the order in which they perform tasks when man-
aging patients in the ED. The most commonly cited structure used
was the A–G assessment tool, which does not consider the fusion
of patient history, indicators of urgency, assessment, intervention,
monitoring, reassessment, communication and definitive care. All
of these components are essential for safe, quality nursing care
in the emergency practice environment [12]. Emergency nurses
are responsible for the initial assessment, management and safety
of critically ill patients. They are the first clinicians that patients
see, so the quality of their initial assessment and treatment is vital
[29]. This assessment underpins clinical decisions and safe care by
detecting and acting upon deterioration. The quality of this assess-
ment is also crucial as emergency patients often have extended
wait times for medical officer review. Across Australia, only 64%
of urgent patients were seen within 30 min of arrival to the ED in
2017-18, a decline since 2013–14 [1]. HIRAID provides a universal
system to structure comprehensive patient assessment.
In 2018 the Australian Institute of Health and Welfare
reported increased in-hospital adverse event rates, particularly
for emergency admissions which were more than double that of
non-emergency admissions [30]. Between 36% and 71% of adverse
events in the ED are preventable [3]. Clinical deterioration has been
reported to occur undetected by emergency clinicians in as many
as one in seven patients in Australian EDs [31]. Failure to recog-
nise and respond to clinical deterioration increases the incidence
of high-mortality adverse events [32,33]. Nation-wide intervention
in our EDs is required to: improve emergency nursing assessment;
reduce unwarranted variation in care; recognise and respond to
clinical deterioration; reduce time to treatment and; escalate care
to medical officers as needed.
The HIRAID assessment framework addresses each of these
priorities, and in this study is demonstrated to be an acceptable
tool for clinical application. Prior to this study there had been no
reports of the usability of a structured approach to the compre-
hensive assessment of patients performed by emergency nurses.
The impact of the implementation of HIRAID in the clinical envi-
ronment requires evaluation, in particular, on emergency nurse
recognition and response to clinical deterioration, time to appropri-
ate treatment and the incidence of adverse events. This evaluation
is underway at the study sites.
Nursing and medical staff alluded to the impact of resourcing
on the ability of nursing staff to conduct a high quality assessment.
The most effective intervention strategy appeared to be mandatory
use which was achieved through environmental remodelling (elec-
tronic medical record templates). Prior to the implementation of
any intervention that requires clinicians to alter their behaviour, a
Please cite this article in press as: Curtis K, et al. The implementation and usability of HIRAID, a structured approach to emergency
nursing assessment. Australasian Emergency Care (2019), https://doi.org/10.1016/j.auec.2019.10.001
detailed diagnostic process should be undertaken to identify facili-
tators and barriers to successful uptake. The theoretical domains
framework is an ideal tool to achieve this as it considers all 14
domains known to influence human behaviour, and can be reli-
ably mapped to interventions to address each domain using the
Behaviour Change Technique Taxonomy (BCTT) [34].
4.1. Limitations
This intervention was tested on a purposeful and convenience
sample of emergency nurses using a context specific implemen-
tation strategy. Implementation elsewhere will required tailored,
context specific strategy. There was limited examination of the
reliability and validity of the medical tool due to the small sample.
The sample size required to determine power was not reached
for the self-efficacy levels, although it is unlikely a difference would
have been demonstrated given the existing high levels of self-
efficacy reported. Sub analysis of the less experienced emergency
nurses would have been beneficial, however was not possible as
demographic data were not collected in the post sample.
5. Conclusions
The HIRAID structured approach to patient assessment is
acceptable, feasible, practical and appropriate for use in the clinical
environment. Further research will demonstrate the direct effects
of HIRAID on clinical performance.
Provenance and conflict of interest
No authors have a conflict of interest. Kate Curtis is Associate
Editor (Trauma) forAustralasian Emergency Care but had no role to
play in the peer review or editorial decision-making of this paper
whatsoever.
Funding
This work was funded by the Agency for Clinical Innovation (ACI)
and the Australian College of Nursing (ACN).
Authorship
BM & KC conceived and designed the study. KC & BM & CV
secured funding. BM developed the study protocol. BM tested the
study instruments. KC & BM supervised data collection. TE analysed
the data. KC prepared the manuscript. All authors approved of the
final manuscript.
Acknowledgements
The authors would like to thank the educators, nursing and med-
ical staff who participated in this study.
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