Introduction
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.
Methods
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.
Results
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.
Discussion
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.
Key words
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of Emergency NursingAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- The effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments.Med Care. 2012; 49: 1047-1053
- Implications of the California Nurse Staffing Mandate for other states.Health Serv Res. 2010; 45: 904-921
- Do staffing levels predict missed nursing care?.Int J Qual Health Care. 2011; 23: 302-308
- The association of registered nurse staffing levels and patient outcomes: systematic review and meta-analysis.Med Care. 2007; 45: 1195-1204
- Baccalaureate nurses and hospital outcomes: more evidence.Med Care. 2014; 52: 861-863
- Baccalaureate education in nursing and patient outcomes.J Nurs Adm. 2014; 43: 89-94
- Lower mortality in Magnet hospitals.Med Care. 2013; 51: 382-388
- An increase in the number of nurses with baccalaureate degrees is linked to lower rates of postsurgery mortality.Health Aff. 2013; 32: 579-586
- Economic evaluation of the 80% baccalaureate nurse workforce recommendation: a patient-level analysis.Med Care. 2014; 52: 864-869
- Designing a data-driven decision support tool for nurse scheduling in the emergency department: a case study of a southern New Jersey emergency department.J Emerg Nurs. 2015; 41: 30-35
- ENA Staffing Guidelines Online Module.Emergency Nurses Association, Des Plaines, IL2013
- Nurse staffing calculation in the emergency department—performance-oriented calculation based on the Manchester Triage System at the University Hospital Bonn.PLoS One. 2016; 11: e0154344
- Emergency capacity in California: a look at more recent trends.Health Aff. 2004; (Suppl Web Exclusives:W4-152-4)
- Nursing workload and patient safety—a human factors engineering perspective.in: Hughes RG Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Volume 2. Agency for Healthcare Research and Quality, Rockville, MD2008
- Safe staffing for nursing in emergency departments: evidence review.Emerg Med J. 2015; 32: 888-894
- Basics of Qualitative Research: Grounded Theory Procedures and Techniques.Sage Publications, Newbury Park, CA1990
- Standards for reporting qualitative research: a synthesis of recommendations.Acad Med. 2014; 89: 1245-1251
- Research Design: Qualitative, Quantitative, and Mixed Methods Approaches.4th ed. Sage Publications, Thousand Oaks, CA1990
- et. al. A human factors framework and study of the effect of nursing workload on patient safety and employee quality of working life.BMJ Qual Saf. 2011; 20: 15-24
- Improving nurse-to-patient staffing ratios as a cost-effective safety intervention.Med Care. 2005; 43: 785-791
- The effect of mandatory nurse ratios on patient care in an emergency department.J Emerg Med. 2011; 40: 76-81
Biography
Lisa A. Wolf, Member, Pioneer Valley Chapter, is Director, Institute of Emergency Nursing, Emergency Nurses Association, Des Plaines, IL.
Biography
Cydne Perhats is Senior Associate, Institute for Emergency Nursing Research, Emergency Nurses Association, Des Plaines, IL.
Biography
Altair M. Delao is Senior Associate, Institute for Emergency Nursing Research, Emergency Nurses Association, Des Plaines, IL.
Biography
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.
Biography
Michael D. Moon, Member, San Antonio Chapter, is Associate Professor, University of the Incarnate Word, San Antonio, TX.
Article info
Publication history
Published online: November 08, 2016
Footnotes
Earn Up to 6.5 CE Hours. See page 189.
Identification
Copyright
© 2017 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved.
