Effect of HIRAID® intervention on emergency nurses' confidence in assessment, communication and escalation: A modified stepped-wedge cluster randomised controlled trial

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BACKGROUND: The nurse's ability to communicate clinical information effectively can optimise patient safety and is related in part to confidence. Confidence underpins a nurse's capacity and motivation to undertake patient assessment and communication. AIM: To determine the effect of the HIRAID® (History including Infection risk, Red flags, Assessment, Interventions, Diagnostics, reassessment and communication) intervention on emergency nurses' confidence with clinical assessment, professional communication and escalation of care. DESIGN: A modified stepped-wedge cluster randomised control trial across 29 Australian rural, regional and metropolitan emergency departments. METHODS: A theory-informed implementation strategy was used to implement HIRAID® drawing on behaviour change, implementation science and educational pedagogy. Online surveys (pre and post intervention) were distributed to eligible nurses (n = 1377). Multiple regression was used to examine differences in nurses' confidence in patient assessment, communication and escalation of care pre and post HIRAID® implementation, adjusted for nurse years of experience and the practice environment. Qualitative data were analysed using inductive content analysis. RESULTS: Across 29 sites, 671 pre and 534 post intervention respondents completed the survey. Overall, nurses had a median of 5 years of emergency nursing experience. There was a significant difference between pre-and-post HIRAID® implementation in confidence in communication. After adjusting for potential confounding variables, the average communication score significantly increased after HIRAID® implementation. Three themes were generated from qualitative analysis: (i) HIRAID® enables more consistent and high-quality comprehensive assessment and communication; (ii) HIRAID® enables more appropriate prioritisation of care in emergency clinical practice; and (iii) role modelling and expert clinical education support is needed to develop confidence. CONCLUSION: Confidence underpins a nurse's ability to act and influences their capacity and motivation to communicate effectively and acquire and retain clinical information. HIRAID® implementation strengthened nurse confidence in communication and escalation of assessment findings, particularly for emergency nurses with <2 years' experience.

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