Paul R. Clark

Teamwork: building healthier workplaces and providing safer patient care.

A changing healthcare landscape requires nurses to care for more patients with higher acuity during their shift than ever before. These more austere working conditions are leading to increased burnout. In addition, patient safety is not of the quality or level that is required. To build healthier workplaces where safe care is provided, formal teamwork training is recommended. Formal teamwork training programs, such as that provided by the MedTeams group, TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety), or participatory action research programs such as the Healthy Workplace Intervention, have decreased errors in the workplace, increased nurse satisfaction and retention rates, and decreased staff turnover. This article includes necessary determinants of teamwork, brief overviews of team-building programs, and examples of research programs that demonstrate how teamwork brings about healthier workplaces that are safer for patients. Teamwork programs can bring about these positive results when implemented and supported by the hospital system.

“It’s a Burden You Carry”: Describing Moral Distress in Emergency Nursing

INTRODUCTIONnMoral 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.nnnMETHODSnA 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.nnnRESULTSnThemes 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.nnnDISCUSSIONnCauses 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.

Team behavioral norms: a shared vision for a healthy patient care workplace.

Leaders are bombarded with healthy workplace articles and advice. This article outlines a strategy for laying the foundation for healthy patient care workplaces at the pivotal unit level. This process facilitates the nursing unit staff to create and implement a shared vision for staff working relationships. Fourteen acute care hospital units, all participants in a healthy workplace intervention, were selected for this analysis because they chose team behavioral norms as a top priority to begin to implement their vision for a desired future for their units, a healthy workplace. These units developed specific team behavioral norms for their expectations of each other. The findings revealed 3 major norm themes and attributes: norms for effective communication, positive attitude, and accountability. Attributes of each norm are described to assist nurses to positively influence their core unit work culture.

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

INTRODUCTIONnThe 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.nnnMETHODSnA 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.nnnRESULTSnHigh 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.nnnDISCUSSIONnEmergency 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.

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.

Experiences of Nurses Who Care for Women After Fetal Loss.

OBJECTIVEnTo examine the experiences of, meaning for, and personal consequences for obstetric, emergency, and surgical nurses caring for women after fetal death and to determine how these nurses use Swansons caring processes in providing such care.nnnDESIGNnFour focus groups.nnnSETTINGnTwo hospitals within the same health care system.nnnPARTICIPANTSnRegistered nurses (Nxa0= 24) working in the obstetric, surgery, or emergency departments.nnnMETHODSnSwansons Theory of Caring guided focus group questions that were audiotaped and transcribed verbatim. Data were analyzed using a continuously emergent process of data collection, data reduction, data display, and interpretation.nnnRESULTSnAll participants demonstrated all of Swansons caring processes but used them preferentially according to situational exigencies and level of rapport with each woman. Nurses had positive and negative feelings associated with caring for women after fetal loss.nnnCONCLUSIONSnObstetric nurses provided relatively equal focus on all processes in the Theory of Caring except Maintaining Belief. Surgical and emergency department nurses focused primarily on the caring processes of Knowing and Doing For. The negative feelings reported by nurses mirror some emotions commonly associated with compassion fatigue. More research is needed to determine whether nurses caring for mothers experiencing fetal loss are at risk for compassion fatigue. Research is also needed to identify strategies and interventions to help nurses so they may continue to give the best care possible to these very vulnerable families without detriment to themselves.

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.