Frailty means falling between the cracks: A qualitative study exploring emergency nurses' understanding of frailty and its use in informing clinical decision-making related to acuity, care, and disposition.

THE PURPOSE: Of this study was to understand emergency nurses' use of frailty to inform care, disposition decision-making, and further assessment. METHODS: A qualitative, descriptive, exploratory approach was used. Field notes from group discussions held during a conference presession on frailty and post-session evaluation data were analyzed. RESULTS: Two common ideas threaded these discussions: frailty as vulnerability to "falling through the cracks" and that of an iceberg. Participants stressed the broad and expansive ramifications of frailty, and lack of structure/process to accurately describe, quantify, and utilize the concept. Participants described issues of physical and emotional/social fragility, including being unable to complete activities of daily living independently; also of concern were the patients' social determinants of health and financial challenges. CONCLUSION: The conceptual understanding of frailty encompassed physical, social, cognitive, and access deficits. Emergency nurses are aware of this concept and would conduct formal frailty screening if provided with training, time, and resources.

Elements of an Advanced Trauma Education Program for Emergency Nurses: A Modified Delphi Approach.

BACKGROUND: Basic trauma education for emergency department (ED) staff is available, but there are currently no advanced trauma nursing practice standards for ED nurses. OBJECTIVE: The purpose of this study was to identify consensus-based elements of an advanced trauma nursing program for ED nurses. METHODS: We used a modified Delphi process with three rounds of online survey data collection to ensure a large group of geographically diverse experts. Data were collected from February 2023 to May 2023. The sample for Round 1 was recruited from members of the Emergency Nurses Association reporting job titles, including trauma coordinator, trauma nursing core course instructor, and vice president of trauma services (n = 829). Participants in subsequent rounds were drawn from respondents to the initial invitation to participate (n = 131). Members of an emergency nursing research council with clinical and research expertise reviewed the results and provided expert input. RESULTS: An initial sample of 131 experts identified 17 elements that were assigned a median score equivalent to "agree/strongly agree" (i.e., median 4/5 or 5/5) in Round 2 (n = 69). These elements were presented in Round 3 (n = 43) to determine a rank order. Critical thinking/clinical judgment was the overall priority, followed by assessment/reassessment and early recognition of trauma. CONCLUSIONS: Emergency department trauma care experts identified priority content for advanced trauma education. Heterogeneity in the final ranking of components for this advanced trauma course, specifically differences by facility, regional, or demographic characteristics, suggests that training and education may not conform to a one-size-fits-all model.

Ensuring Throughput: Development and Validation of Charge Nurse Competencies for United States Emergency Care Settings.

INTRODUCTION: Charge nurses are shift leaders whose role includes managing nursing resources and facilitating appropriate patient care; in emergency departments, the charge nurse role requires both clinical and leadership skills to facilitate the flow of patients, while ensuring patient and staff safety. Literature on orientation and specific training is notably sparse. This study aimed to evaluate the content and process of core competency training and identify evaluation and implementation strategies necessary to improve charge nurse performance in United States emergency departments. METHODS: A modified Delphi technique was used in phase 1 and a qualitative content analysis method was used in phase 2 to address specific aims of the study. RESULTS: In total, 427 emergency nurse managers, directors, educators, and charge nurses responded to the initial survey to identify elements, teaching modalities, and evaluative processes; 22 participated in 1 of 2 focus groups to provide further information about the pedagogical approaches to teaching emergency charge nurse competencies. The top 5 competencies were identified as patient flow management, communication, situational awareness, clinical decision making, and nurse-patient assignment, with understanding that each competency overlapped significantly with the others. Low-fidelity simulation and gamification were identified as a preferred method of both training and evaluation. DISCUSSION: These findings have the potential to support a standardized approach to emergency charge nurse training and evaluation focusing on communication skills, clinical decision making, and situational awareness to facilitate safe and effective nurse-patient assignment and emergency department throughput.

Individual Attributes and Environmental Conditions of Registered Nurses Working in Freestanding Emergency Departments in the United States: A Descriptive Exploratory Study.

INTRODUCTION: Freestanding emergency departments (FSEDs) are emergency facilities not connected to inpatient services. The percentage of FSEDs of all EDs grew from 1% in 2001 to 12% in 2017, making FSEDs a substantial subset of US emergency care. The purpose of this study was to describe the individual attributes and environmental conditions of registered nurses working in FSEDs in the US. METHODS: A quantitative descriptive exploratory design with cross-sectional survey methodology. RESULTS: A total of 364 emergency nurses responded to the survey. Most reported their FSED was open 24 hours/day (99.5%), with board-certified emergency physicians onsite (91.5%) and a mean of 3.6 RNs working per shift. Resources immediately available in more than 50% of FSEDs included laboratory and imaging services, and in fewer than 30% of FSEDs included behavioral health care, MRI, obstetric care, orthopedic care, neurologic care, and surgical consult care. Respiratory therapy was reported by 39.6% of respondents as being immediately available. A significant minority of respondents expressed concerns about adequacy of resources and training and the effect on patient care in both survey (30% of respondents) and open-ended questions (42.5% of respondents). DISCUSSION: The practice environment of emergency nurses in FSEDs was reported as having positive elements; however, a substantial subpopulation reported serious concerns. FSEDs adhere to some of the standards put forward by the American College of Emergency Physicians, with notable exceptions in the areas of staffing RNs, staffing ancillary staff, and availability of some resources.

The Effect of Mandatory Triage Questions on Triage Processes: A Qualitative Exploratory Study.

INTRODUCTION: The study purpose was to obtain an understanding of both the types of questions mandated for the triage encounter in emergency departments across the United States and how emergency nurses perceive the relevance of these questions to the triage process. METHODS: A qualitative descriptive exploratory study using focus group data was used. Data were collected at an in-person emergency nursing conference held in September 2022. Data were analyzed using Mayring's 8-step process. RESULTS: Participants (n = 35) voiced concerns about a lack of expertise at all points in the triage process. The overarching problem is reported as data required by regulatory agencies are conflated with triage assessment information. Participants in this study reported that the conflation of the triage assessment with regulatory compliance is causing significant issues in the ability of emergency nurses to appropriately evaluate patient presentations. Thematic categories were identified as who's assessing the patients? assessment or compliance? important questions, situationally important questions, questions asked before discharge, and the lack of emergency nurse input. DISCUSSION: The conflation of regulatory data collection with patient assessment at the initial triage encounter challenges the ability of the emergency nurse to rapidly and accurately identify patients at risk of deterioration. We recommend that initial triage processes encompass questions that focus on establishing the stability of the patient and the safety of the waiting room and include inquiry relevant to the patient presentation.

Emergency nurses' perceptions of the utility, adaptability and feasibility of the emergency nursing framework HIRAIDTM for practice change in US: An exploratory study.

BACKGROUND: Patient assessment is a core component of nursing practice and underpins safe, high-quality patient care. HIRAIDTM, an evidence-informed emergency nursing framework, provides nurses with a structured approach to patient assessment and management post triage. In Australia, HIRAIDTM resulted in significant improvements to nurse-led communication and reduced adverse patient events. OBJECTIVES: First, to explore United States (US) emergency nurses' perceptions of the evidence-informed emergency nursing framework, HIRAIDTM; second, to determine factors that would influence the feasibility and adaptability of HIRAIDTM into nursing clinical practice in EDs within the US. METHODS: A cross-sectional cohort study using a survey method with a convenience sample was conducted. A 4-hour workshop introduced the HIRAIDTM framework and supporting evidence at the Emergency Nurses Association's (ENA) conference, Emergency Nursing 2022. Surveys were tested for face validity and collected information on nurse-nurse communication, self-efficacy, the practice environment and feedback on the HIRAIDTM framework. RESULTS: The workshop was attended by 48 emergency nurses from 17 US States and four countries. Most respondents reported that all emergency nurses should use the same standardised approach in the assessment of patients. However, the greatest barriers to change were a lack of staff and support from management. The most likely interventions reported to enable change were face-to-face education, the opportunity to ask questions and support in the clinical environment. CONCLUSION: HIRAIDTM is an acceptable and suitable emergency nursing framework for consideration in the US. Successful uptake will depend on training methods and organizational support. HIRAIDTM training should incorporate face-to-face interactive workshops.

Current Practice and Practice Competencies of Clinical Nurse Specialists Working in US Emergency Care Settings: A Survey Study.

PURPOSE/AIMS: The aim of this study was to investigate the current practice of clinical nurse specialists working in US emergency care settings to (1) explicate the application of the Emergency Nurses Association core competencies and define the specialized clinical nurse specialist role in emergency care and (2) align current clinical nurse specialist practice in emergency settings with the National Association of Clinical Nurse Specialists core competencies and the identified substantive areas of clinical nurse specialist practice. DESIGN: This study used a quantitative exploratory descriptive approach using survey data. METHODS: A purposive convenience sample was recruited from the Emergency Nurses Association and the National Association of Clinical Nurse Specialists. Participants completed a 39-item survey based on a consensus process to develop competencies for emergency department (ED)-situated clinical nurse specialists. RESULTS: Respondents (n = 285) reported spending more than 50% of their work time in a primary clinical nurse specialist role. Significant differences in practice were found between geographic location, setting, educational preparation, title protection status, and type of institution. CONCLUSIONS: Our findings suggest that that the competencies ascribed to ED-situated clinical nurse specialists are valid in both frequency and importance. However, ED-situated clinical nurse specialists are not fully credentialed or practicing to the full extent of their education and licenses, because of professional, legislative, and environmental limitations.

The Experiences of United States Emergency Nurses Related to Witnessed and Experienced Bias: A Mixed-Methods Study.

INTRODUCTION: The purpose of this study was to obtain a broad view of the knowledge, attitudes, beliefs, and lived experiences of emergency nurses regarding implicit and explicit bias. METHODS: An exploratory, descriptive, sequential mixed-methods approach using online surveys and focus groups to generate study data. Two validated instruments were incorporated into the survey to evaluate experiences of microaggression in the workplace and ethnocultural empathy. Focus group data were collected using Zoom meetings. RESULTS: The final sample comprised 1140 participants in the survey arm and 23 focus group participants. Significant differences were found in reported experiences of institutional, structural, and personal microaggressions for non-white vs white participants. Respondents who identified Christianity as their religious group had lower mean scores on items representing empathetic awareness. Respondents who identified as nonheterosexual had significantly higher mean total Scale of Ethnocultural Empathy scores, empathetic awareness subscale scores, and empathetic feeling and expression subscale scores. Thematic categories that arose from the focus group data included witnessed bias, experienced bias, responses to bias, impact of bias on care, and solutions. DISCUSSION: In both our survey and focus group data, we see evidence that racism and other forms of bias are threats to safe patient care. We challenge all emergency nurses and institutions to reflect on the implicit and explicit biases they hold and to engage in purposeful learning about the effects of individual and structural bias on patients and colleagues. We suggest an approach that favors structural analysis, intervention, and accountability.

Role and Training of Emergency Department Charge Nurses: A Mixed Methods Analysis of Processes, Needs, and Expectations.

INTRODUCTION: Charge nurses (CNs) are shift leaders who manage resources and facilitate patient care, yet CNs in EDs receive minimal training, with implications for patient safety and emergency nursing practice. The purpose of the study was to describe the experiences of emergency nurses related to training, preparation, and function of the CN role. METHODS: An explanatory sequential mixed methods design using survey data (n = 2579) and focus group data (n = 49) from both CN and staff nurse perspectives. RESULTS: Participants reported minimal training for the CN role, with divergent understandings of role, required education and experience, the need for situational awareness, and the acceptability of the CN taking on other duties. CONCLUSIONS: The ED CN is critical to the safety of both nursing environment and patient care. Nurses in this pivotal role do not receive adequate leadership orientation or formal training in the key areas of nurse patient assignment, communication, and situational awareness. Formal training in nurse-patient assignment, communication, and situational awareness are critical to appropriate patient care and maintenance of interprofessional trust necessary for successful execution of the CN role. ED nurse managers should advocate for this training.

Development of Nurse-Sensitive, Emergency Department-Specific Quality Indicators Using a Modified Delphi Technique.

BACKGROUND: There is no identified set of nursing-sensitive, emergency department (ED)-specific quality indicators. PURPOSE: The purpose of this study was to address the gap in quality indicators specific to the emergency care environment and identify a list of nursing-sensitive, ED-specific quality indicators across ED populations and phases of the ED visit for further development and testing. METHODS: A modified Delphi technique was used to reach initial consensus. RESULTS: Four thematic groups were identified, and quality indicators within each were rank ordered. Of the 4 groups, 21 quality indicators were identified: triage (6) was ranked highest, followed by special populations (4), transitions of care (4), and medical/surgical (7). CONCLUSIONS: Many of the recommended metrics were questionable because they are nonspecific to the ED setting or subject to influences in the emergency care environment. Some identified priorities for quality indicator development were unsupported; we recommend that alternate methodologies be used to identify critical areas of quality measurement.

Educational Needs of U.S. Emergency Nurses Related to Forensic Nursing Processes.

BACKGROUND: Forensic nursing is a specialty deployed in patient care areas, including emergency departments, intensive care units, labor and delivery suites, and psychiatric units treating persons who have suffered trauma from a violent or criminal act. The recognition of violence-related injuries in patients presenting to health care facilities is critical to an appropriate care trajectory. These patients require specialized resources beyond the treatment of physical injuries to include psychosocial and legal care that supports patient recovery and pursuit of criminal justice. OBJECTIVE: The purpose of this study is to obtain a broad view of current forensic knowledge and training for emergency nurses working in U.S. emergency departments and to identify gaps in nursing skills and practice such that appropriate education can be developed for this nursing specialty. METHODS: The study was conducted using a quantitative exploratory, descriptive approach via an emailed cross-sectional survey sent to a convenience sample of U.S. emergency nurses. RESULTS: A total of 43,775 emails were sent out to members of the Emergency Nurses Association. Of that group, 2,493 recipients opened the email, and 1,824 completed the survey, resulting in a total response rate of 4% and a 73% response rate from those who opened the email. Few respondents self-reported competence in the care of patients who experienced child abuse (13.1%), elder abuse (12.4%), interpersonal violence (17.6%), sexual assault (19.2%), human trafficking (7.4%), developmental challenges (7.2%), strangulation (12.5%), or who were suspected of committing a violent crime (11.4%). CONCLUSIONS: There is a compelling need to expand forensic education to advance knowledge and skill acquisition in emergency nursing practice and provide staff with additional resources that support a holistic trauma-informed approach to patient care.

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.