Table 5 Content analysis of nursing survey responses around HIRAID^® use, subthemes and exemplar quotes

Quality care and documentation

83

The structure

35

Consistency and continuity of documentation

23

Documentation is easier, especially with prompts

13

Because it is mandatory

12

▪ “I use them all of the time I think it gives a great summary of the patient from the initial presentation right through to the assessment and plan” (Participant 69 Cluster 1)

▪ “Because I am supposed to. I did have a previous template that I felt was sufficient, but best not to rock the boat” (Participant 327 Cluster 2)”

Prefer own or old ways of documenting

33

Takes the clinical thinking skills away from nursing staff

1

Prefer my own way

13

▪ “what I witness is new / junior diligently filling out hiraid while not attending to the patient's immediate needs. I think it's helpful to have a good template to help junior nurses organise their notes and hopefully direct their care, but the template alone is not going to change practice. What we really need is safe staffing and skill mix so that senior nurses have the time to model and teach excellent assessment, and educators that work and teach "at the elbow" where the learning happens” (Participant 358, Cluster 2)

Not appropriate for the clinical situation

19

▪ “If in resus, to many things changing quickly so a note works better. Hi raid can then come later” (Participant 572, Cluster 4)

▪ “not every presentation needs an assessment eg. a splinter in a finger.” (Participant 102 Cluster 1)

Prioritising direct clinical care

33

Workload and patient acuity

22

Not enough staff

11

▪ “We don't have the time! 1 nurse and up to 10 patients It's often IMPOSSIBLE” (Participant 47 Cluster 1)

Why does/does not HIRAID^® support nurses to assess and manage ED patients

721 Codes

Prompts and structure for consistency

391

Prompts help assessment and reminds

192

Offers structure and guidance

83

Takes too long

38

Reduces anxiety

9

Comprehensive and consistent

69

▪ “HIRAID doesn't leave room for forgetting / missing parts of an assessment. It is very busy in ED and sometimes I will forget to assess something in my re-assessment of my patient, and when I begin documenting, the HIRAID template reminds me to go back to the patient and assess what I missed” (participant 149, Cluster 3)

▪ “It does prompt me to ask questions of the patient when I am documenting, especially when it is busy, or the patient is very complex, and I am documenting in retrospect” (participant 67, Cluster 1)

▪ “HIRAID in a way breaks down doing an assessment. I know I initially got overwhelmed with trying to gather information, but when HIRAID was introduced it simplified it for me” (participant 175, Cluster 4)

Structure enables consistent identification of potential problems and communication

187

Higher quality assessment and communication

65

Quality of documentation and assessment

91

Documentation improves assessment quality and communication

31

▪ “Promotes systematic assessment and good documentation. Especially important at our ED as our ICU is 2 h away by road. HIRAID is a valuable tool for communicating with distant sites” (Participant 24 Cluster 1)

▪ “Helps promote BTF and identification of potential issues for the pt that a new may nurse may not have been aware off or experienced before” (Participant 49 Cluster 1)

▪ “Hiraid helps to determine the severity of pt's clinical presentation, helps to identify red flags and to do focused assessment based on their situation” (Participant 155, Cluster 3)

Impacts learning, education and training needs

45

HIRAID is a structure, nurses still need to build knowledge through other sources

▪ “What I witness is new / junior diligently filling out hiraid while not attending to the patient's immediate needs. I think it's helpful to have a good template to help junior nurses organise their notes and hopefully direct their care, but the template alone is not going to change practice. What we really need is safe staffing and skill mix so that senior nurses have the time to model and teach excellent assessment, and educators that work and teach "at the elbow" where the learning happens” (Participant 358, Cluster 2)

▪ “I agree the HIRAID does help junior nurses to think about their assessment and interventions. I don't think it "teaches"—that is the job of the educator and other more senior nurses” (Participant 324, Cluster 2)

Impacts current work practice

98

Nothing new and the process is time consuming

27

Document system and structure takes too long

71

▪ “Being an experienced nurse I am used to my own thorough documentation. It feels as if we're being spoon-fed. l, more appropriate for entry level nurses” (Participant 169, Cluster 3)

▪ “Spending so much time complete this compulsory structure, takes time away from the patient, looking at the patient. Makes pt's care less direct and personal”. (Participant 63 Cluster 1)