Situational Analysis.

Situational analysis is not commonly used in nursing research; however, its usefulness in examining complicated phenomena that are locally situated makes it an effective approach to emergency nursing problems. This paper describes the situational analysis approach as an extension of the grounded theory method and uses 3 studies to demonstrate the effectiveness of this qualitative approach.

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.

The perceived impact of legalized cannabis on nursing workload in adult and pediatric emergency department visits: A qualitative exploratory study.

OBJECTIVE: To investigate changes in emergency nursing workload related to cannabis ingestion or inhalation by adult and pediatric patients in states and bordering states where recreational cannabis is legal. DESIGN: Qualitative exploratory design using data collected from focus groups. SAMPLE: Twenty-four English-speaking emergency nurses over the age of 18 who provide direct care to patients and work in US emergency departments located in a state, or bordering state, where recreational cannabis use is legal. MEASUREMENTS: Qualitative data were gathered using a semi-structured interview format and analyzed using situational analysis. RESULTS: The legalization of recreational cannabis in some US states is reported as resulting in an increase in patients presenting with cyclic vomiting syndromes, and increased difficulty in managing both associated behaviors and repetitive ED presentations. New presentations also include unintentional intoxication in both pediatric and geriatric populations. An unexpected finding was the displacement of local homeless populations by younger, indigent "cannabis tourists"; social services agencies might consider this while planning for cannabis legalization in their state or territory. CONCLUSIONS: To protect public health and safety, regulatory efforts to standardize the formulation, dosing and labeling of cannabis products would be beneficial along with educational initiatives for both consumers and health care providers.

Emergency Nurses' Perception of Geriatric Readiness in the ED Setting: A Mixed-Methods Study.

INTRODUCTION: The Centers for Disease Control and Prevention (CDC) reports 136.9 million ED visits in 2015, of which 21.4 million (15.6%) were by patients who were 65 or older. This US population demographic is expected to grow by 112% over the next 40 years, becoming just below 25% of the total US population. Emergency nurses will play an increasingly important part in the development of nursing care for geriatric patients. The purpose of this study was to explore emergency nurses' perception of their ability to care for geriatric patients in the emergency setting. METHODS: This was a mixed-methods sequential design using quantitative survey data and qualitative focus group data, which were analyzed separately and then given equal priority during the data-interpretation phase. RESULTS: Less than 50% of survey respondents (N = 1,610) reported geriatric-specific screenings, accommodations, and communication with outside agencies as "always available" in their care settings. Qualitative analysis (N = 23) yielded the categories of Triage/Assessment, Care in the Emergency Environment, Discharge Planning, and Facilitators and Barriers, which generally reflected the trajectory of care for the older patient. The overarching concern was keeping patients safe in both the community and in the emergency department. DISCUSSION: Emergency departments should develop integrated systems to facilitate appropriate care of older patients. Identified barriers to improved care include a lack of integration between emergency care and community care, deficits in geriatric-specific education, inconsistent use of early screening for frailty, and lack of resources in the emergency care environment to intervene appropriately.

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.

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 Practice.

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 clinician's 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 patient's ED stay through an iterative process of assessment that included further probing and eliciting, evaluating, and reacting to the patient's response.

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.

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.

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

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.

"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.

Emergency Nurses' Perceptions of Discharge Processes for Patients Receiving Schedule II and III Medications for Pain Management in the Emergency Department.

INTRODUCTION: There is a lack of evidence-based criteria for the discharge of patients receiving Schedule II and III narcotic medications in the emergency department. The purpose of this study was to understand nurses' perceptions about common practices in the discharge of patients receiving Schedule II and III narcotics in the emergency department in terms of dosage, time, availability of care resources at home, and other discharge criteria. METHODS: A qualitative exploratory design was used. A sample of emergency nurses was recruited from the preregistered attendees of a national conference. Two focus group sessions were held, and audiotaped in their entirety. The audiotapes were transcribed and analyzed for emerging themes by the research team. RESULTS: Identified themes were Time, Physiologic Considerations, Cognitive Considerations, Safety Considerations, Policies, Evidence, Ethical/Legal Concerns, and Nursing Impact. Participants reported drug-to-discharge times of 0 minutes ("gulp and go") to 240 minutes after administration of Schedule II and III narcotics specifically, and "any medication" generally. The most common reason given for a wait of any kind was to assess patients for a reaction. DISCUSSION: It is the perception of our respondents that determination of readiness for discharge after a patient has received Schedule II or III narcotics in the emergency department is largely left up to nursing staff. Participants suggest that development of policies and checklists to assist in decision making related to discharge readiness would be useful for both nurses and patients.

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

INTRODUCTION: The 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. METHODS: A 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. RESULTS: High 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. DISCUSSION: Emergency 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.

Nothing changes, nobody cares: understanding the experience of emergency nurses physically or verbally assaulted while providing care.

INTRODUCTION: Workplace violence has been recognized as a violent crime that requires targeted responses from employers, law enforcement, and the community. According to data from the Bureau of Labor Statistics, the most common source of nonfatal injuries and illnesses requiring days away from work in the health care and social assistance industry was assault on the health care worker. What is not well understood are the precursors and sequelae of violence perpetrated against emergency nurses and other health care workers by patients and visitors. The purpose of this study was to better understand the experience of emergency nurses who have been physically or verbally assaulted while providing patient care in US emergency departments. METHODS: The study was conducted using a qualitative descriptive exploratory design. The sample consisted of 46 written narratives submitted by e-mail by emergency nurses describing the experience of violence while providing care at work. Narrative analysis and constant comparison were used to identify emerging themes in the narratives. RESULTS: "Environmental," "personal," and "cue recognition" were identified as the themes. Overall, nurses believed that violence was endemic to their workplace and that both limited recognition of cues indicating a high-risk person or environment and a culture of acceptance of violence were barriers to mitigation. DISCUSSION: These findings are consistent with the extant literature but with an added contribution of clearly identifying an underlying cultural acceptance of violence in the emergency department, as well as a distinct lack of cue recognition, in this sample of emergency nurses.

Frailty assessment tools in the emergency department: A geriatric emergency department guidelines 2.0 scoping review.

Objective: Given the aging population and growing burden of frailty, we conducted this scoping review to describe the available literature regarding the use and impact of frailty assessment tools in the assessment and care of emergency department (ED) patients older than 60 years. Methods: A search was made of the available literature using the Covidence system using various search terms. Inclusion criteria comprised peer-reviewed literature focusing on frailty screening tools used for a geriatric population (60+ years of age) presenting to EDs. An additional search of PubMed, EBSCO, and CINAHL for articles published in the last 5 years was conducted toward the end of the review process (January 2023) to search specifically for literature describing interventions for frailty, yielding additional articles for review. Exclusion criteria comprised articles focusing on an age category other than geriatric and care environments outside the emergency care setting. Results: A total of 135 articles were screened for inclusion and 48 duplicates were removed. Of the 87 remaining articles, 20 were deemed irrelevant, leaving 67 articles for full-text review. Twenty-eight were excluded for not meeting inclusion criteria, leaving 39 full-text studies. Use of frailty screening tools were reported in the triage, care, and discharge decision-making phases of the ED care trajectory, with varying reports of usefulness for clinical decision-making. Conclusion: The literature reports tools, scales, and instruments for identifying frailty in older patients at ED triage; multiple frailty scores or tools exist with varying levels of utilization. Interventions for frailty directed at the ED environment were scant. Further research is needed to determine the usefulness of frailty identification in the context of emergency care, the effects of care delivery interventions or educational initiatives for front-line medical professionals on patient-oriented outcomes, and to ensure these initiatives are acceptable for patients.