Cydne Perhats

Alcohol screening, brief intervention, and referral in the emergency department: an implementation study.

INTRODUCTION Alcohol is the single greatest contributor to injury in the United States. Numerous studies have reported that a standardized screening, brief intervention, and referral to treatment (SBIRT) intervention can effectively minimize future alcohol consumption, reduce injury recurrence, and decrease the number of repeat ED visits. To date, SBIRT studies have been conducted in settings in which physicians or research assistants carried out SBIRT. Little is known about ED nurses carrying out SBIRT. The purpose of this study was to examine ED nurse training needs and identify both barriers to, and enablers of, SBIRT implementation in the emergency department. METHODS Two coordinators from each of the 5 ED sites selected for the study attended a 1-day SBIRT educational session. Site coordinators then trained their staff nurses to conduct SBIRT. Site coordinators were surveyed at the midpoint and end of the 6-month implementation study period. Patient data from each facility was collected. RESULTS Ten site coordinators were trained and held subsequent training sessions with nursing staff in their respective emergency departments. All sites encountered barriers to implementation, but 2 of 5 sites were able to implement the SBIRT process fully by the end of the evaluation period. A total of 3265 patients were screened for alcohol use problems. Of those screened, 678 (21%) were classified as hazardous drinkers. Overall, 56% of the positive-screened patients received 3 to 5 minutes of a brief intervention. After the brief intervention, between 9% and 82% of patients were referred for further care. DISCUSSION The SBIRT process can be conducted successfully by emergency nurses. However, substantial operational barriers to widespread routine implementation exist. These barriers need to be addressed before emergency nurses incorporate SBIRT as routine part of ED care.

“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.

Suicide Prevention in the Emergency Department

Every year, over 30,000 persons in the United States and 1 million worldwide die by suicide. Suicide is the third leading cause of death for young persons aged 15 to 24 years and the eleventh for persons of all ages in the United States. Over the past 100 years, suicides have outnumbered homicides by at least 3 to 2. Annually, an estimated 650,000 persons in the United States receive emergency care after attempting suicide. Suicidal behavior is a complex phenomenon—one that includes biological, social, and psychological risk factors. Many persons who have 1 or more risk factors, however, are not suicidal. Generally, adverse life events such as job loss or death of a loved one are considered to be precipitators of suicide attempts when they occur in combination with other risk factors such as depression. Research indicates that 90% of persons who kill themselves have depression or another diagnosable mental illness and/or substance abuse disorder. Other risk factors include a prior suicide attempt, previous episodes of deliberate self-harm, family history of suicide, family violence, easy access to lethal methods including firearms in the home, incarceration, exposure to suicidal behavior in others, physical illness, isolation or lack of social support, barriers to mental health treatment, some cultural and religious beliefs, and an unwillingness to seek help because of stigma.3,4 Hopelessness and previous suicide attempts are especially strong and independent predictors of suicide risk. The majority of suicide deaths among both men and women are caused by the use of a firearm. Men are 4 times more likely to die by suicide than women, but women report attempting suicide about 3 times more often than men. In 2002, suicide ranked fourth as a leading cause of death among men in the middle years of life, and as such, they represent the highest public health burden for suicide in terms of years of potential life lost. Adults aged 65 years or over are at highest risk for completed suicide; in particular, white men aged over 85 years have the highest rate of suicide completion. The public health significance of suicide has been emphasized in several national appeals from the Surgeon General, Institute of Medicine’s reports, and Healthy People 2010, which establish national priorities for preventing suicide-related morbidity and death. Patient suicide also ranked at the top of the sentinel events reported to the Joint Commission on Accreditation of Healthcare Organizations from January 1995 through June 30, 2005. As a result, the Joint Commission on Accreditation of Healthcare Organizations’ 2007 patient safety goals include the identification of patients at risk for suicide, and accredited organizations are thus required to conduct a risk assessment of specific factors that may increase or decrease suicide risk, address immediate safety and treatment needs, and provide a crisis hotline.

The Effect of Reported Sleep, Perceived Fatigue, and Sleepiness on Cognitive Performance in a Sample of Emergency Nurses.

OBJECTIVE: The aim of this study is to explore the relationship between reported sleep, perceived fatigue and sleepiness, and cognitive performance. BACKGROUND: Although evidence suggests that fatigue and sleepiness affect the provision of care in inpatient units, there is a lack of research on the sleep patterns of emergency nurses and the effects of disturbed sleep and fatigue on their cognitive abilities and susceptibility to medical errors. METHODS: A quantitative correlational design was used in this study; in each of 7 different statistical models, zero-order relationships between predictors and the dependent variable were examined with appropriate inferential tests. RESULTS: Participants reported high levels of sleepiness and chronic fatigue that impeded full functioning both at work and at home. CONCLUSIONS: Although high levels of self-reported fatigue did not show any effects on cognitive function, other factors in the environment may contribute to delayed, missed, or inappropriate care. Further research is indicated.

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

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.

Workplace bullying in emergency nursing: Development of a grounded theory using situational analysis

BACKGROUND The Institute of Medicine recognizes that the workplace environment is a crucial factor in the ability of nurses to provide safe and effective care, and thus interactions that affect the quality and safety of the work environment require exploration. OBJECTIVES The purpose of this study was to use situational analysis to develop a grounded theory of workplace bullying as it manifests specifically in the emergency care setting. METHODS This study used a grounded theory methodology called situational analysis. 44 emergency RNs were recruited to participate in one of 4 focus group sessions, which were transcribed in their entirety, and, along with field notes, served as the dataset. RESULTS This grounded theory describes the characteristics of human actors and their reactions to conditions in the practice environment that lead to greater or lesser levels of bullying, and the responses to bullying as it occurs in U.S. emergency departments. DISCUSSION Workplace bullying is a significant factor in the dynamics of patient care, nursing work culture, and nursing retention. The impact on patient care cannot be overestimated, both in terms of errors, substandard care, and the negative effects of high turnover of experienced RNs who leave, compounded by the inexperience of newly hired RNs. An assessment of hospital work environments should include nurse perceptions of workplace bullying, and interventions should focus on effective managerial processes for handling workplace bullying. Future research should include testing of the theoretical coherence of the model, and the testing of bullying interventions to determine the effect on workplace environment, nursing intent to leave/retention, and patient outcomes.

Promoting Safer Medication Use Among Older Adults

Still struggling with medication reconciliation? In July 2004, the Joint Commission on Accreditation of Healthcare Organizations announced 2005 National Patient Safety Goals that included this goal: “accurately and completely reconcile medications across the continuum of care.” While implementation of medication reconciliation can be challenging in the emergency setting, increasing emergency nursing understanding of medication safety can improve patient outcomes and decrease the risk of adverse drug events (ADEs). The older adult population is the most affected by adverse drug events. Adults aged 65 years and older consume more prescription and over-the-counter (OTC) medicines than any other age group. While they make up only 14% of the U.S. population, they consume more than 30% of all prescription drugs and 40% of all OTC drugs.

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.

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 PracticeThis study explored the experience and understanding of triage as a nursing process in emergency settings.Application of these findings may include the following:A better understanding of how environmental constraints affect the decision‐making capabilities of emergency nursesClear metrics and assessment mechanisms for triage competencies

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 clinicians 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 patients ED stay through an iterative process of assessment that included further probing and eliciting, evaluating, and reacting to the patients response.