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.


CONCLUSIONS
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.
Des Plaines, IL, Louisville, KY, and San Antonio, TX. Electronic address: lwolf@ena.org.
Lisa A
LA
Wolf
Des Plaines, IL, Louisville, KY, and San Antonio, TX.
Cydne
C
Perhats
Des Plaines, IL, Louisville, KY, and San Antonio, TX.
Altair M
AM
Delao
Des Plaines, IL, Louisville, KY, and San Antonio, TX.
Paul R
PR
Clark
Des Plaines, IL, Louisville, KY, and San Antonio, TX.
Michael D
MD
Moon
D000328:Adult; D001291:Attitude of Health Personnel; D016529:Emergency Nursing / Q000706:statistics & numerical data*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005069:Evaluation Studies as Topic; D005260:Female; D017144:Focus Groups; D006801:Humans; D008297:Male; D008875:Middle Aged; D009741:Nursing Staff, Hospital / Q000523:psychology* / Q000706:statistics & numerical data; D016272:Occupational Health / Q000706:statistics & numerical data*; D010561:Personnel Staffing and Scheduling / Q000706:statistics & numerical data*
Emergency care; Emergency department staffing; Nurse retention; Nursing workload; Workplace safety