Research| Volume 43, ISSUE 2, P150-157, March 2017

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On the Threshold of Safety: A Qualitative Exploration of Nurses’ Perceptions of Factors Involved in Safe Staffing Levels in Emergency Departments

Published:November 08, 2016DOI:


      The emergency department is a unique practice environment in that the Emergency Medical Treatment and Active Labor Act (EMTALA), which mandates a medical screening examination for all presenting patients, effectively precludes any sort of patient volume control; staffing needs are therefore fluid and unpredictable. The purpose of this study is to explore emergency nurses’ perceptions of factors involved in safe staffing levels and to identify factors that negatively and positively influence staffing levels and might lend themselves to more effective interventions and evaluations.


      We used a qualitative exploratory design with focus group data from a sample of 26 emergency nurses. Themes were identified using a constructivist perspective and an inductive approach to content analysis.


      Five themes were identified: (1) unsafe environment of care, (2) components of safety, (3) patient outcomes: risky care, (4) nursing outcomes: leaving the profession, and (5) possible solutions. Participants reported that staffing levels are determined by the number of beds in the department (as in inpatient units) but not by patient acuity or the number of patients waiting for treatment. Participants identified both absolute numbers of staff, as well as experience mix, as components of safe staffing. Inability to predict the acuity of patients waiting to be seen was a major component of nurses’ perceptions of unsafe staffing.


      Emergency nurses perceive staffing to be inadequate, and therefore unsafe, because of the potential for poor patient outcomes, including missed or delayed care, missed deterioration (failure to rescue), and additional ED visits resulting from ineffective discharge teaching. Both absolute numbers of staff, as well as skill and experience mix, should be considered to provide staffing levels that promote optimal patient and nurse outcomes.

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      Lisa A. Wolf, Member, Pioneer Valley Chapter, is Director, Institute of Emergency Nursing, Emergency Nurses Association, Des Plaines, IL.


      Cydne Perhats is Senior Associate, Institute for Emergency Nursing Research, Emergency Nurses Association, Des Plaines, IL.


      Altair M. Delao is Senior Associate, Institute for Emergency Nursing Research, Emergency Nurses Association, Des Plaines, IL.


      Paul R. Clark, Member, Kentuckiana Chapter, is Assistant Professor, University of Louisville School of Nursing, and System Educator, Norton Healthcare Institute for Nursing, Louisville, KY.


      Michael D. Moon, Member, San Antonio Chapter, is Associate Professor, University of the Incarnate Word, San Antonio, TX.