Lisa A. Wolf

“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.

Does Your Staff Really “Get” Initial Patient Assessment? Assessing Competency in Triage Using Simulated Patient Encounters

I n an ideal world, sufficient resources and staff would be available to care for every person who arrives at the emergency department, but because that is rarely the case, both formal and informal triage is necessary. In the high-acuity, high-uncertainty environment of the emergency department, where multiple distractions, constant interruptions, innumerable high-priority tasks, and limited staff are the norm, the ability of the nurse to assess critical patient factors is central to maintaining both safety and efficiency. The work of the ED triage nurse perhaps best exemplifies the need for rapid accurate assessments that are likely to facilitate recognition of and attention to patients’ needs. The problem that presents itself, then, is how to understand the components of good decision making in environments in which patients are essentially unknown (high uncertainty) and potentially very ill (high acuity). Good decision making is essential because patient outcome is highly dependent on the initial assessment of the triage nurse. For example, a nurse who makes effective clinical decisions can potentially differentiate a “well-looking ill” patient from an “ill-appearing well” patient, sending the first to a high-acuity area and the second to a lower acuity area for further evaluation and treatment, maintaining both safety (appropriate direction to resources) in the first case and efficiency (getting the right patient to the right place) in the second case. A less-skilled nurse may send the well-looking patient to a lower acuity area, where appropriate care could be delayed with potentially serious consequences, and send the ill-appearing patient to a high-acuity area, where resources more appropriate to a sicker patient may be used unnecessarily. The question becomes: What “critical cues” do effective nurses consider that are overlooked or ignored by ineffective nurses, and how can educators assess for the ability to recognize them? Commonly, triage accuracy is established via chart review, but a chart review gives only the “what” of deficiencies, not the “why.” In this article I will describe the development and use of simulated triage “patients” to evaluate the triage skills of ED nurses and develop educational interventions.

Ethical issues in the response to Ebola virus disease in United States emergency departments: a position paper of the American College of Emergency Physicians, the Emergency Nurses Association, and the Society for Academic Emergency Medicine.

The 2014 outbreak of Ebola virus disease (EVD) in West Africa has presented a significant public health crisis to the international health community and challenged U.S. emergency departments (EDs) to prepare for patients with a disease of exceeding rarity in developed nations. With the presentation of patients with Ebola to U.S. acute care facilities, ethical questions have been raised in both the press and medical literature as to how U.S. EDs, emergency physicians (EPs), emergency nurses, and other stakeholders in the health care system should approach the current epidemic and its potential for spread in the domestic environment. To address these concerns, the American College of Emergency Physicians, the Emergency Nurses Association, and the Society for Academic Emergency Medicine developed this joint position paper to provide guidance to U.S. EPs, emergency nurses, and other stakeholders in the health care system on how to approach the ethical dilemmas posed by the outbreak of EVD. This paper will address areas of immediate and potential ethical concern to U.S. EDs in how they approach preparation for and management of potential patients with EVD.

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.

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.

To Foley or Not To Foley: Emergency Nurses' Perceptions of Clinical Decision Making in the Use of Urinary Catheters in the Emergency Department

INTRODUCTION The purpose of this study was to obtain information about individual and environmental factors that affect clinical decision making regarding urinary catheter placement and maintenance as reported by a sample of emergency nurses in the United States. METHODS A qualitative exploratory design featuring focus group data collection and analysis methods was used in this study. RESULTS The following themes were identified: frequency, ownership, education and competencies, negotiation with families, communication, and barriers and facilitators. DISCUSSION Decision making with regard to catheter placement is reported as being under the purview of nursing, with little collaborative discussion. It may be important to reformat education and competency to include observational evaluations of decision making with regard to appropriate indications for insertion; validation of insertion techniques may be important as well.

Ethical Issues in the Response to Ebola Virus Disease in US Emergency Departments: A Position Paper of the American College of Emergency Physicians, the Emergency Nurses Association and the Society for Academic Emergency Medicine

The 2014 outbreak of Ebola Virus Disease (EVD) in West Africa has presented a significant public health crisis to the international health community and challenged US emergency departments to prepare for patients with a disease of exceeding rarity in developed nations. With the presentation of patients with Ebola to US acute care facilities, ethical questions have been raised in both the press and medical literature as to how US emergency departments, emergency physicians, emergency nurses and other stakeholders in the healthcare system should approach the current epidemic and its potential for spread in the domestic environment. To address these concerns, the American College of Emergency Physicians, the Emergency Nurses Association and the Society for Academic Emergency Medicine developed this joint position paper to provide guidance to US emergency physicians, emergency nurses and other stakeholders in the healthcare system on how to approach the ethical dilemmas posed by the outbreak of EVD. This paper will address areas of immediate and potential ethical concern to US emergency departments in how they approach preparation for and management of potential patients with EVD.

Searching the literature: what is known (and not known) about your topic?

n the previous articles in this series (appearing in the November 2012, March 2013, and May 2013 1–3 I issues), we have discussed how evidence can change practice, how to evaluate evidence, and how to develop a clinical question. At this point in the process, you need to find out more about your problem to create workable interventions. For example, who is the best health care professional to perform triage? This is a good question; however, what do you know about this problem and possible solutions that are already in use? Before you can begin to plan to address a clinical problem, you must know what is known and not known about your particular problem. A literature search will familiarize you with the work that has already been done in your area of interest or inquiry. It should be a comprehensive survey of all publications and other information about a specific topic. The search will produce a list of references on the topic of interest.