Validation of a grounded theory of nurse bullying in emergency department settings.

BACKGROUND: Workplace bullying in health care settings, including emergency departments (EDs), is a significant and negative factor in the dynamics of patient care, nursing work culture, and nurse retention. Specifically, workplace bullying has a significant and negative effect on patient care, with both direct (errors and substandard care) and indirect sequelae (high turnover and inexperienced nursing staff hired to replace those nurses who have left to escape bullying behavior). The purpose of this study was to determine the theoretical coherence of the ENA model of nurse bullying in emergency department and its impact on emergency nurses' intent to leave their job. METHODS: Correlational study using the Practice Environment Scale of the Nursing Work Index (PES-NWI), the Secondary Traumatic Stress Scale (STSS), and the Short Negative Acts Questionnaire (SNAQ) in a cross-sectional sample of emergency nurses working in the United States. RESULTS: Extremely high intent to leave the current ED (PD1) rates were associated with nurses' reported exposure to daily bullying (PD1 rate = 67.6%, zero-order OR = 4.77, Nr2 = 3.2%, p < .001) and bullying multiple times per week (49.1%, zero-order OR = 2.31, Nr2 = 2.6%, p < .001). Nurses who reported no exposure to bullying at work had a distinctly below average PD1 rate (22.9%, OR = 0.47, Nr2 = 3.9%, p < .001). CONCLUSIONS: The relationships between the tested elements of the model (specifically, the influence of bullying on nurse intent to leave) as constructed appear to adequately reflect the phenomenon of workplace bullying and its effects on nurse retention in emergency care settings.

Establishing Research Priorities for the Emergency Severity Index Using a Modified Delphi Approach.

INTRODUCTION: The accuracy of an initial ED triage decision has been reported to drive the clinical trajectory for ED patients, and, therefore, this assessment is critical to patient safety. The Emergency Severity Index-a 5-point score assigned by a triage nurse and based on disease acuity, patient potential for decompensation, and anticipated resource use-is used both in the United States and internationally. In the US, the Emergency Severity Index is used by up to 94% of the academic medical center emergency departments. In 2020, the Emergency Nurses Association acquired the intellectual property rights to the Emergency Severity Index and is responsible for its maintenance and improvement. OBJECTIVE: The purpose of this study was to establish a research agenda for the improvement of individual and institutional understanding and use of the Emergency Severity Index. METHODS: Modified Delphi process was used with 3 rounds of data collection. RESULTS: Round 1 yielded 112 issues, which were collapsed into 18 potential research questions in 4 general categories: education and training (6 questions), workplace environment (3 questions), emergency care services (7 questions), and special populations (2 questions). These questions were used in round 2 to establish importance. Round 3 yielded a rank ordering of both categories and research questions. DISCUSSION: The research priorities as set through the use of this modified Delphi process align well with current gaps in the literature. Research in these areas should be encouraged to improve the understanding of educational, environmental, and process challenges to emergency nurses' triage decisions and accuracy of Emergency Severity Index assignments.

Triage Decisions Involving Pregnancy-Capable Patients: Educational Deficits and Emergency Nurses' Perceptions of Risk.

BACKGROUND: In areas where obstetric services are not available, emergency departments often become the default for unplanned obstetric care, yet emergency nurses are not universally trained in the identification and treatment of obstetric emergencies. The purpose of this study was to explore emergency nurses' perception of acuity in the triage of pregnant or postpartum patients presenting to the emergency department with high-risk complaints and to identify facilitators and challenges to the accurate identification and treatment of these patients. METHOD: A mixed-methods study was conducted using chart review data (N = 12,766) and focus group data (N = 39) from five emergency departments in the eastern United States. RESULTS: In 86.5% of cases, pregnancy status was not documented. Ninety-four percent of pregnant patients with a systolic blood pressure over 140 mmHg were under-triaged. The overall theme of the qualitative data was acuity blindness, with identified barriers to assessment that included educational needs and triage processes and workflow issues. CONCLUSION: There are significant knowledge deficits in the care of patients presenting with high-risk conditions associated with pregnancy. [J Contin Educ Nurs. 2021;52(1):21-29.].

Traumatic stress in emergency nurses: Does your work environment feel like a war zone?

INTRODUCTION: Emergency nurses are exposed to both primary and secondary trauma with attendant sequelae in both work and personal spheres. The purpose of the study was to investigate the prevalence of traumatic stress, measured by the secondary traumatic stress scale (STSS) in a sample of emergency nurses and describe the impact of traumatic stress on nursing practice and workplace environment. METHODS: Mixed methods approach using survey instrument data from the Secondary Traumatic Stress Scale (STSS) (N = 125) and focus group data (N = 53). RESULTS: The average total score on the STSS was 51.83 for nurses who attended one of the focus groups 48.42 for nurses who did not attend (clinical cutoff for STS = 39). Focus group data aligned with elements of the STSS; thematic categories of cumulative trauma, mental health sequelae, bullying and organizational violence, coping mechanisms, relationship damage, and solutions were described. Although we measured only STS, participants often used the terms "PTSD" and "STS" interchangeably. CONCLUSIONS: The nurses in this study demonstrated high levels of STS and described in detail how chronic, cumulative trauma affected relational nursing care and social connections. Participants discussed high levels of suicidality in the profession, and the compounding trauma of relational and organizational violence. The pervasiveness of traumatic stress and the extent to which it affects all areas of nurses' lives is a cause for great concern.

Emergency Nurses' Perception of Geriatric Readiness in the ED Setting: A Mixed-Methods Study.

INTRODUCTION: The Centers for Disease Control and Prevention (CDC) reports 136.9 million ED visits in 2015, of which 21.4 million (15.6%) were by patients who were 65 or older. This US population demographic is expected to grow by 112% over the next 40 years, becoming just below 25% of the total US population. Emergency nurses will play an increasingly important part in the development of nursing care for geriatric patients. The purpose of this study was to explore emergency nurses' perception of their ability to care for geriatric patients in the emergency setting. METHODS: This was a mixed-methods sequential design using quantitative survey data and qualitative focus group data, which were analyzed separately and then given equal priority during the data-interpretation phase. RESULTS: Less than 50% of survey respondents (N = 1,610) reported geriatric-specific screenings, accommodations, and communication with outside agencies as "always available" in their care settings. Qualitative analysis (N = 23) yielded the categories of Triage/Assessment, Care in the Emergency Environment, Discharge Planning, and Facilitators and Barriers, which generally reflected the trajectory of care for the older patient. The overarching concern was keeping patients safe in both the community and in the emergency department. DISCUSSION: Emergency departments should develop integrated systems to facilitate appropriate care of older patients. Identified barriers to improved care include a lack of integration between emergency care and community care, deficits in geriatric-specific education, inconsistent use of early screening for frailty, and lack of resources in the emergency care environment to intervene appropriately.

Emergency Nurses' Perceptions of Risk for Firearm Injury and its Effect on Assessment Practices: A Mixed Methods Study.

INTRODUCTION: Injury from firearms is a significant problem in the United States, accounting for 73% of all homicides and 50% of all suicides that occurred among US residents. What is not known are the perceptions of emergency nurses regarding the impact of in-home access on the risk for firearm-related injury and death in their patient populations. The purpose of this study was to explore emergency nurses' perception of patient risk for firearm injury and in which ways that perception affected the process of ED patient screening, assessment, counseling, and discharge education. METHODS: We employed a mixed methods, sequential, explanatory design using quantitative survey data and qualitative focus-group data. RESULTS: Between 21.8 and 43.5% of respondents reported asking patients about access to in-home firearms, depending on presentation. Statistical analyses showed the single most significant factor correlated with nurses asking about the availability of a staff person who could further assess risk and offer assistance and safety counseling to patients. Another important influence was identified from focus-group discussions in which nurses reported that they felt challenged to bring up the topic of firearms in a way that did not seem confrontational. DISCUSSION: Access to firearms poses risk to patients, and patient safety and the continuum of care depends upon the emergency nurse assessing patient firearms risk and taking appropriate action. The findings from this study suggest that emergency departments (1) normalize and standardize the assessment of firearms, (2) designate an ED staff member on each shift to further assess risk if a positive response is elicited, and (3) continue to improve workplace safety.

Assessing for Occult Suicidality at Triage: Experiences of Emergency Nurses.

INTRODUCTION: Screening for suicidality is a critical nursing function at the initial ED encounter. Suicide is the tenth leading cause of death in the United States, and a substantial percentage of people who die by suicide present for health care in the year before their deaths. The emergency department provides health care professionals with a critical opportunity to identify patients at risk for suicide and intervene appropriately. METHODS: Qualitative exploratory study using focus-group data. FINDINGS: Effective and accurate suicidality assessment occurs not by asking a single question but also with the assessment of patient behaviors and presentation (appearance, hygiene, etc). When emergency nurses suspected occult suicidality, additional actions (finding private space, keeping patients safe, and passing on information), took priority. DISCUSSION: The Joint Commission recommends using clinical judgment tools for the final determination of safety for a patient at suspected risk of suicide, as research findings suggest that a screening tool can identify persons at risk for suicide more reliably than a clinician's personal judgment. Our participants report that when they assessed suicide risk at triage, it was usually by asking a single question such as "Do you have thoughts or plans to harm yourself?" and they expressed concern about the effectiveness of doing so. Participants described their efforts to improve suicide screening across the duration of the patient's ED stay through an iterative process of assessment that included further probing and eliciting, evaluating, and reacting to the patient's response.

Triaging the Emergency Department, Not the Patient: United States Emergency Nurses' Experience of the Triage Process.

INTRODUCTION: Triage, as it is understood in the context of the emergency department, is the first and perhaps the most formal stage of the initial patient encounter. Bottlenecks during intake and long waiting room times have been linked to higher rates of patients leaving without being seen. The solution in many emergency departments has been to collect less information at triage or use an "immediate bedding" or "pull until full" approach, in which patients are placed in treatment areas as they become available without previous screening. The purpose of this study was to explore emergency nurses' understanding of-and experience with-the triage process, and to identify facilitators and barriers to accurate acuity assignation. METHODS: An exploratory qualitative study using focus-group interviews (N = 26). RESULTS: Five themes were identified: (1) "Sick or not sick," (2) "Competency/qualifications," (3) "Triaging the emergency department, not the patient," (4) "The unexpected," and (5) "Barriers and facilitators." DISCUSSION: Our participants described processes that were unit- and/or nurse-dependent and were manipulations of the triage system to "fix" problems in ED flow, rather than a standard application of a triage system. Our participants reported that, in practice, the use of triage scales to determine acuity and route patients to appropriate resources varies in accuracy and application among emergency nurses and in their respective emergency departments. Nurses in this sample reported a prevalence of "quick look" triage approaches that do not rely on physiologic data to make acuity decisions. Future research should focus on intervention and comparison studies examining the effect of staffing, nurse experience, hospital policies, and length of shift on the accuracy of triage decision making. Contribution to Emergency Nursing Practice.

The Experience of Advanced Practice Nurses in US Emergency Care Settings.

INTRODUCTION: Little information has been published regarding the actual practice, training, and validation of basic skills and competencies needed by the advanced practice registered nurse (APRN) in the emergency care setting. The purpose of this study was to (1) identify skills being performed by APRNs practicing in emergency care settings (2); explore types of training; and (3) describe competency validation. Additionally, we explored frequency of skill use and facilitators and barriers to performing a skill to the full extent of training and education. METHODS: An exploratory mixed-methods study was performed incorporating a self-report survey and focus group interviews. RESULTS: The educational path to advanced practice nursing in emergency care settings is not standardized. Few programs incorporate or address the need for APRNs to receive acute care training across the life span, which is the hallmark of emergency nursing practice. Similarly, training is reported as fragmented, and validation of skills for both nurse practitioners and clinical nurse specialists can vary. APRN practice autonomy is affected by the presence of other providers (specifically physicians), institutional culture, and state boards of nursing that regulate practice. DISCUSSION: Integrated educational and orientation programs are needed that address high-acuity patients across the life span. Additionally, a more nuanced approach to assessing APRN capabilities as a combination of hard (clinical emergency) and soft (communication and organizational) skills may be an appropriate framework within which to examine the advanced practice role. Future research should continue to evaluate training, competency assessment, and outcomes for APRNs in the emergency care setting.

Workplace aggression as cause and effect: Emergency nurses' experiences of working fatigued.

INTRODUCTION: Emergency nursing requires acute attention to detail to provide safe and effective care to potentially unstable or critically ill patients; this requirement may be significantly impaired by physical and mental fatigue. There is a lack of evidence regarding the effects of fatigue caused by factors other than a sleep deficit (e.g., emotional exhaustion). Fatigue affects nurses' ability to work safely in the emergency care setting and potentially impacts their health and quality of life outside of work. METHODS: This was the qualitative arm of a mixed methods study; we used a qualitative exploratory design with focus group data from a sample of 16 emergency nurses. Themes were identified using an inductive approach to content analysis. RESULTS/DISCUSSION: The following themes were identified: "It's a weight on your back;" "Competitive nursing;" "It's never enough;" "You have to get away;" and "Engagement as a solution." CONCLUSIONS: Our participants reported high levels of fatigue, which compromised patient care, had a negative effect on their personal lives, and created a toxic unit environment. They reported lateral violence as both the cause and effect of mental and emotional fatigue, suggesting that unit culture affects nurses and the patients they care for.

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

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.

"It's a Burden You Carry": Describing Moral Distress in Emergency Nursing.

INTRODUCTION: Moral distress in nursing has been studied in many settings, but there is a paucity of research on moral distress as it manifests in the emergency department. One study suggests a correlation between moral distress and aspects of burnout, and other researchers report that nurses have considered leaving their position or even their profession because of moral distress. Further exploration of these issues may provide insight into their effects on ED patient care and the emergency nursing profession. The purpose of this study was to explore the nature of moral distress as it is experienced and described by emergency nurses. METHODS: A qualitative, exploratory design was employed using semi-structured focus groups for data collection. Using an iterative process, transcripts were analyzed for emerging themes by the research team. Six researchers analyzed the transcripts using a thematic analysis approach. RESULTS: Themes from the data included dysfunctional practice arena, being overwhelmed, and adaptive/maladaptive coping. Participants described, overall, a profound feeling of not being able to provide patient care as they wanted to. DISCUSSION: Causes of moral distress in emergency nurses are environment driven, not incident driven, as is described in other settings, and include a high-acuity, high-demand, technical environment with insufficient resources. Interventions should be targeted to improve environmental factors that contribute to the moral distress of emergency nurses. Future research should focus on the development and validation of an instrument to measure moral distress in this setting.

Exploring the Management of Death: Emergency Nurses' Perceptions of Challenges and Facilitators in the Provision of End-of-Life Care in the Emergency Department.

INTRODUCTION: The importance of end-of-life (EOL) care for dying patients and their families is well described; however, little research has been performed in emergency settings. The purpose of this study was to explore emergency nurses' perceptions of challenges and facilitators in the care of patients at the EOL. METHODS: A mixed-methods design using survey data (N = 1,879) and focus group data (N = 17). Data were collected on questions regarding care of the EOL patient in the emergency department, specifically nurses' perceptions of the care of these patients; educational content needs; barriers to safe and effective care; and the availability of resources. RESULTS: High scores on the quantitative survey showed a high mean level of consistently positive attitudes and beliefs toward caring for dying patients and their families and loved ones (131.26 ± 10.88). Analysis of the focus group transcripts uncovered 9 themes, reflecting concerns around comfort and challenges with EOL care, appropriate training for nurses, and the availability of resources to provide this type of care in the emergency setting. Also noted was dissonance between the nature of emergency care and the nature of EOL care. DISCUSSION: Emergency nurses are comfortable providing EOL care in the emergency setting but note that challenges to providing good care include lack of space, time, and staff. Other challenges involve the mismatch between the goals of emergency care and those of EOL care, as well as the emotional burden of caring for the dying, especially when the appropriate resources are lacking.

US emergency nurses' perceptions of challenges and facilitators in the management of behavioural health patients in the emergency department: A mixed-methods study.

BACKGROUND: Behavioural health patients often have longer lengths of stay in the emergency department compared with general medical patients, and their modalities of care are not well documented. This study's purpose is to describe US emergency nurses' estimates of lengths of stay for behavioural health patients, explore factors affecting length of stay, and assess nurses' perceptions of their skills, beliefs/attitudes, and confidence in caring for this population. METHODS: Using a mixed-methods design with demographically-diverse samples of emergency nurses, survey data (N=1229) were analysed using descriptive statistics, correlation coefficients, and linear regression. Focus group participant data (N=20) were analysed for themes using constant comparison. RESULTS: Findings suggest that shorter lengths of stay are associated with higher levels of perceived nursing confidence/preparation to care for this population, along with the availability of appropriate resources and protocols/standards of care (p=0.01). Longer lengths of stay are associated with an absence of dedicated inpatient space for managing the care of these patients. CONCLUSIONS: Participants note a lack of education, resources, and treatment options tailored to the delivery of safe, effective care for behavioural health patients. The use of trained specialists and additional guidelines/protocols may help move patients through the emergency department faster and with greater surety.

Emergency Nurses' Perceptions of Discharge Processes for Patients Receiving Schedule II and III Medications for Pain Management in the Emergency Department.

INTRODUCTION: There is a lack of evidence-based criteria for the discharge of patients receiving Schedule II and III narcotic medications in the emergency department. The purpose of this study was to understand nurses' perceptions about common practices in the discharge of patients receiving Schedule II and III narcotics in the emergency department in terms of dosage, time, availability of care resources at home, and other discharge criteria. METHODS: A qualitative exploratory design was used. A sample of emergency nurses was recruited from the preregistered attendees of a national conference. Two focus group sessions were held, and audiotaped in their entirety. The audiotapes were transcribed and analyzed for emerging themes by the research team. RESULTS: Identified themes were Time, Physiologic Considerations, Cognitive Considerations, Safety Considerations, Policies, Evidence, Ethical/Legal Concerns, and Nursing Impact. Participants reported drug-to-discharge times of 0 minutes ("gulp and go") to 240 minutes after administration of Schedule II and III narcotics specifically, and "any medication" generally. The most common reason given for a wait of any kind was to assess patients for a reaction. DISCUSSION: It is the perception of our respondents that determination of readiness for discharge after a patient has received Schedule II or III narcotics in the emergency department is largely left up to nursing staff. Participants suggest that development of policies and checklists to assist in decision making related to discharge readiness would be useful for both nurses and patients.