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When asked to identify the single biggest challenge facing emergency nursing, emergency department (ED) managers, staffing experts, and staff nurses answered in unison: The growing nursing shortage. "As government asks us to do more, pays us less — with fewer people to do it — emergency nursing will be required to redefine its roles and responsibilities," says Barbara Weintraub, RN, MSN, MPH, CEN, coordinator for pediatric emergency services at Northwest Community Hospital in Arlington Heights, IL.
The current shortage was predicted in the early 1980s by the Washington, DC-based Institute of Medicine (IOM), according to Ann Kobs, MS, RN, president and CEO of Ann Kobs & Associates, a Goodyear, AZ-based consulting firm specializing in accreditation compliance.1 "However, economic times became tight, CEOs had to cut spending to save their jobs, and nursing was sacrificed, being the biggest line item in the health care budget," she says.
These staffing cuts discouraged experienced nurses from staying, and nothing was done to attract men and women to the profession, Kobs says. The nursing shortage will only improve if dramatic steps are taken to reduce the growing frustration of nurses, she says. Kobs points to a 2001 report from the IOM that called for a complete overhaul of the health care system.2 "The IOM should be congratulated for their fine work," Kobs says. "However, if it results in no action, another, even worse shortage will ensue."
Here are current developments and predictions for the future:
• Concerns about patient care are growing. Patients potentially could be given unsafe care due to the shortage, stresses Darlene Bradley, RN, MSN, MAOM, CCRN, CEN, director of emergency and trauma services at University of California-Irvine Medical Center in Orange. "As the shortage persists, waits definitely will increase," she says.
If your staffing consists largely of new graduates or inexperienced ED nurses, your liability risks are increased, she warns. It’s more important than ever for ED nurses to initiate treatment prior to a physician’s involvement and to recognize when a patient needs immediate attention, Bradley adds.
She suggests giving every patient a handout with information about what to expect from the ED visit. She also advises investing in information systems that track wait times, so staffing can be adjusted to provide the best care when the need is greatest. "Use of unlicensed assistive personnel may be another necessary option," she adds.
Kobs points to data from the Joint Commission showing that lack of adequate orientation and training is one of the primary root causes for sentinel events.3 However, she says it’s disturbing that there has been little action on the part of hospital senior leadership to invest in such activities. She reports a recent discussion with an experienced ED nurse at a well-respected teaching hospital who reported that all in-house education was being cut, including orientation. "This is still seen by many as fluff," Kobs says. "There seems to be an epidemic of denial on the part of leadership."
• Adequate staffing must be addressed.
The new Joint Commission staffing standards are disappointing because they don’t go far enough, according to Kobs. "The scoring merely looks at whether an organization is using data from its administrative and clinical indicators to make staffing decisions," she says.
Kobs says it’s doubtful that an accredited organization hasn’t done what the standards require: tracking sick time, overtime, and hours per patient day, or that if clinical outcomes deteriorated, staffing would not be considered, she explains. "This has always been part of the annual budgeting process."
Weintraub says she expects the trend of increased use of nurse practitioners in the ED will continue. She says the biggest advancement for emergency nursing in the last five years has been the emergence of this role. "This is one way of handling increasing volumes of patients, when the government is funding fewer residency programs," she says. ED nurse practitioners are ideally suited to see large numbers of patients, critical and routine, and diagnose, treat, and educate the patients and their families, she explains.
Robin Gilbert, RN, BSN, CEN, ED manager at Central Maine Medical Center in Lewiston, stresses the need to maintain a staffing and skill mix that meets the needs of an individual ED. "For EDs, staffing ratios may not be the best option," she says. "Nurse-to-patient ratios do not take into account admitted patients being held in the ED, the design of the department, or the current reimbursement methods that are based on hours per patient visit."
She says that a better solution is to rely on staffing formulas specifically for EDs, such as a new tool developed by the Emergency Nurses Association’s (ENA) Staffing Best Practice Work Group. "This formula determines staffing based on volumes, mix, length of stay, acuity levels, and other variables," she says. (For more information on the ENA’s staffing tool, go to www.ena.org).
Gilbert says that using this type of staffing formula is crucial to keep nurses satisfied in the coming years.
• New legislation may help the shortage. The Nurse Reinvestment Act recently was passed and promises to fund scholarships, student loan repayment, nurse training programs such as career ladders and geriatric care, and public service announcements. (For more information, see "Update on new law to combat nursing shortage," ED Nursing, October 2002, p. 166.)
However, none of these programs have been funded yet by Congress, cautions Kathleen A. Ream, director of government affairs for the Des Plaines, IL-based Emergency Nurses Association. "This law can have a significant impact, but only if we can get the funding behind it. The bill signed into law was only an authorization," says Ream. "The nursing community is working diligently to bring this to reality." (Editor’s note: To check the status of the law, go to http://thomas.loc.gov and search for bill S. 1864.)
• EDs with "magnet" status are attracting nurses. Hospitals designated with "Magnet Recognition Program" status by the Washington, DC-based American Nurses Credentialing Center are recognized as promoting professional nursing practice, with characteristics such as influential nurse executives and investment in nurse education. A study has shown that facilities that met the magnet criteria have lower nurse burnout rates and higher levels of job satisfaction.4
"Magnet status is the new and upcoming thing," says Bradley. "There are very few hospitals that have received that status as yet, but I do foresee that experienced nurses who want their professional practice recognized will seek hospitals that have this status."
The magnet status implies that an organization respects and values nursing, says Gilbert. "This program may be our road for opportunity. It will help remove the them vs. us’ between administration and nursing," she says. The only true way to solve the nursing shortage is to make nurses must feel valued, respected, and supported, Gilbert says. "This allows for nurses to achieve professional goals and deliver quality care that will produce evidence-based outcomes," she says.
1. Institute of Medicine Division of Health Care Services. Nursing and Nursing Education: Public Policies and Private Actions. Washington, DC: National Academy Press; 1983.
2. Institute of Medicine Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.
3. Joint Commission on Accreditation of Health Care Organizations. Sentinel Event Statistics. Root Causes of Sentinel Events (All Categories). May 1, 2002. (www.jcaho.org/accredited+organizations/ambulatory+care/sentinel+events/root+causes+of+sentinel+events.htm).
4. Aiken LH, Havens DS, Sloane DM. The Magnet nursing services recognition program: A comparison of two groups of magnet hospitals. Am J Nurs 2000; 100:26.
For more information on trends in the nursing shortage, contact:
• Darlene Bradley, RN, MSN, MAOM, CCRN, CEN, Director Emergency/Trauma Services, UCI Medical Center, University of California, Irvine, 101 The City Drive S., Route 128, Orange, CA 92868-3298. Telephone: (714) 456-5248. Fax: (714) 456-5390. E-mail: firstname.lastname@example.org.
• Robin Gilbert, RN, BSN, CEN, Emergency Department, Central Maine Medical Center, 300 Main St., Lewiston, ME 04240. Telephone: (207) 795-2219. E-mail: email@example.com.
• Ann Kobs, MS, RN, President and CEO, Ann Kobs & Associates, 3025 N. 152nd Lane, Good-year, AZ 85338. Telephone: (623) 536-9904. Fax: (623) 536-9905. E-mail: AEJBBK@aol.com.
• Kathleen A. Ream, Director, Government Affairs, Emergency Nurses Association, 6534 Marlo Drive, Falls Church, VA 22042. Telephone: (703) 241-3947. Fax: (703) 534-9036. E-mail: firstname.lastname@example.org.
• Barbara Weintraub, RN, MPH, MSN, Northwest Community Hospital, 800 W. Central Road, Arlington Heights, IL 60005. Telephone: (847) 618-5432. Fax: (847) 618-4169. E-mail: email@example.com.