Kathleen Evanovich Zavotsky

“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.

Resuscitation team perceptions of family presence during CPR.

The literature supports family presence during cardiopulmonary resuscitation (CPR) and its many perceived benefits for patients and their families. It also suggests that, overall, health care professionals are supportive of this practice. There have not been any published studies to date that have looked at the perception of family presence from the multidisciplinary resuscitation or code teams perspective. The purpose of this study was to describe the multidisciplinary care providers understanding and perceived barriers of family presence during CPR in an academic medical center. This study is a quantitative, exploratory, descriptive study that utilized survey methodology. The sample included all members of an urban academic medical centers resuscitation response team. The study findings reveal that, overall, code team members feel that family members should be allowed to remain at the bedside during CPR but that challenges exist including education deficits and mixed feelings that may result from family presence; the study participants caring for neonates and children were more favorable to family presence during CPR than their adult counterparts. Barriers remain related to family presence during resuscitation. Education is needed for all members of the health care team to facilitate collaborative changes in resuscitation practices. Education should include information regarding institutional policies, methods for incorporating family members into the code process, and interventions to support the psychosocial needs of family members.

Early Pregnancy Loss and Bereavement in the Emergency Department: Staff and Patient Satisfaction With an Early Fetal Bereavement Program

Vaginal bleeding is a common complaint that brings women of childbearing age to the emergency department. One of the most common causes of bleeding during early pregnancy is spontaneous abortions. A spontaneous abortion is defined as loss of pregnancy before 20 weeks or loss of a fetus weighing <500 g. An estimate of pregnancies that abort spontaneously may range from 25% to 50%. Approximately 75% of spontaneous abortions occur before completion of the first trimester. The standard medical or surgical treatment for patients with a diagnosis of spontaneous abortion can vary from uterine evacuation with an admission or discharge home with specific instructions. Discharge instructions often are focused on identifying the physical symptoms of complications such as avoiding intercourse, bed rest, pain management, and appropriate follow-up with a gynecologist and inadvertently may overlook the psychological distress and grief that the patient and significant other can be feeling.

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.

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.

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.

Benefits to ED Nurses Participating in Interdisciplinary Research

Authors: Kathleen E. Zavotsky, MS, RN, CEN, ACNS-BC, CCRN, Lisa A. Wolf, PhD, RN, CEN, FAEN, Kathy M. Baker, PhD, RN, NE-BC, Margaret J. Carman, DNP, ACNP-BC, CEN, Paul R. Clark, PhD, MA, RN, Kevin Langkeit, MSN, RN, Gail Lenehan, EdD, MSN, FAEN, FAAN, and Michael Moon, PhD, MSN, RN, CEN, CNS-CC, FAEN, New Brunswick, NJ, Des Plaines, IL, Richmond, VA, Durham, NC, Louisville, KY, Bountiful, UT, Boston, MA, and San Antonio, TX Section Editors: Lisa A. Wolf, PhD, RN, CEN, FAEN