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You’ll need to look outside your own ED to spot trends that will affect your department, urges Diana Contino, RN, MBA, CEN, CCRN, president of Emergency Management Systems, a Monarch Beach, CA-based consulting firm that specializes in staffing issues. "It’s critical for nurses to be proactive and benchmark," she says. "Treatments and technology are changing rapidly. If you don’t monitor the trends, you can’t adapt your practice and education to address these changes."
Financial margins will be tight in the foreseeable future, says Contino. "Identifying and monitoring trends will help you use funds to set up programs to counteract any negative trends," she says.
If you don’t keep abreast of trends in the ED, you won’t be able to come up with effective solutions, says Kathy Robinson, RN, CEN, ED case manager at Geisinger Medical Center in Danville, PA. "This opens the door for persons who are less informed to implement policies that nurses will have to live with," she warns.
Here are short- and long-term trends and methods to address them:
1. New opportunities for nurses. Due to the nursing shortage, nurses are finding unprecedented opportunities, says Robinson. "In recruitment ads I receive, I am seeing an increase in sign-on bonuses, tuition reimbursement, flexible scheduling options, and even relocation assistance," she says. "This was formerly only available to management level positions."
Take advantage of enhanced education and skill-building opportunities that can make you more attractive to employers, she urges. More facilities are offering tuition reimbursement so nurses can pursue advanced degrees, says Contino. "Nurses should consider obtaining advanced clinical and managerial degrees, especially managers who need advanced training in financial management, human resource management, and marketing," she advises. "These skills are critical for improving work environments."
2. The use of mandatory overtime. Using mandatory overtime as a staffing "solution" is a dangerous practice, warns Robinson. "In Michigan, the state nursing board has taken the initiative to pass a resolution protecting nurses from charges of abandonment when they refuse an additional shift because they feel unsafe from fatigue or stress," she reports.
Mandatory overtime should be the exception rather than the norm, says Mary Jagim, RN, BSN, CEN, manager of the emergency center and walk-in clinics at MeritCare Health System in Fargo, ND, and current president of the Emergency Nurses Association in Des Plaines, IL. She notes that a bill was recently introduced in the House of Representatives by Tom Lanto (D-CA), James McGovern (D-MA), and Hilda Solis (D-CA) to prohibit mandatory overtime after a licensed health care employee (other than a doctor) has worked 80 hours in a 14-day workweek.
3. Increased potential for violence. ED overcrowding is becoming an epidemic, resulting in significant delays, reports Robinson. "Nurses need to be vigilant and observant of the potential for violence from frustrated patients and families," she says. (For more information on reporting of assaults in the ED, see ED Nursing, March 2001; To learn how to prevent assaults, see ED Nursing, April 2001.)
4. Shortage of qualified nurses. Congress is starting to take notice of the nursing shortage, and the U.S. Senate has formed a subcommittee to find solutions, says Robinson. "This is a good first step in fixing the problem," she adds. However, the nursing shortage is expected to continue for some time. "You’ll need to do everything in your power to develop a positive work environment for staff," underscores Jagim. "We need to keep nurses in the profession. This requires support, caring, recognition, and attention to their issues." Offer competitive wages and benefits, flexible scheduling, and a safe and supportive work environment, Jagim advises.
5. Holding ICU patients. An ED that never held patients now frequently holds ICU patients for one to three days, says Contino. "On average, about 10% of the ED volume is admitted to the ICU," she says. "We can’t expect ED nurses to be experts managing ICU patients beyond the initial crisis management without additional training." To address this trend, Contino suggests providing additional training for staff. "Or cross-train a group of ED and ICU staff to better meet the needs of both units," she says.
6. Continued high diversion rates. You must obtain support from administrators so diversion is not viewed as simply an "ED problem," warns Robinson. "Don’t wait until you have time’ to explain the situation. Call them during times of crisis," she advises. "Have them come down and see firsthand what you’re dealing with, especially when there are dissatisfied patents in the hall and providers waiting for an ED stretcher to open up."
Show data to point to the reasons that you can’t get patients out of the ED, says Robinson. "See if you can identify a cause: slow consultants, complicated processes [including admitting], or lack of nurses on the floor to open beds," she says. "Maybe you can document that unnecessary tests are ordered when patients are boarding in the ED," she suggests. Length-of-stay data are particularly important, says Robinson. "Use tracking programs to show exactly where the delays are," she says. "Include logs with the frequency of diversion. Missed patients may translate to lost revenue."
For more information about trends in ED nursing, contact:
• Diana Contino, RN, MBA, CEN, CCRN, Emergency Management Systems, 24040 Camino Del Avion, Suite 123, Monarch Beach, CA 92629. Telephone: (949) 493-0039. Fax: (949) 493-7568. E-mail: firstname.lastname@example.org.
• Mary Jagim, RN, BSN, CEN, Emergency Center and Walk-In Clinics, MeritCare Health System, 720 N. Fourth St., Fargo, ND 58122. Telephone: (701) 234-6732. Fax: (701) 234-3336. E-mail: MaryJagim@meritcare.com.
• Kathy Robinson, RN, CEN, Emergency Department, Geisinger Medical Center, 100 N. Academy Ave., Danville, PA 17822. Telephone: (570) 271-7956. Fax: (570) 271-6507. E-mail: email@example.com.