CUTTING-EDGE DISCUSSIONS OF MANAGEMENT,POLICY, AND PROGRAM ISSUES IN

EMERGENCY CARE

Authors: Jeff Solheim, RN, CEN, CFRN, FAEN, and AnnMarie Papa, DNP, RN, CEN, NE-BC, FAEN,Doylestown, PA, and Keizer, OR

Burnout is an epidemic within nursing and is widelyconsidered to be a leading contributor to the nur-sing shortage.1-9 Although a plethora of research

has been published about burnout in psychiatric, onco-logy, and intensive care nursing, research examining theeffects of burnout in the emergency care setting is scarce.Therefore a broader investigation encompassing criticalcare nursing was necessary to establish the current stateof the science.

WHAT IS BURNOUT?

Nursing burnout is a psychological syndrome of emotionalexhaustion, depersonalization, and reduced personalaccomplishment.10 The major symptoms of burnoutinclude exhaustion, cynicism, and dehumanization ofothers, which affects individuals not only psychologicallyand socially but physically as well.2,5,6,10 Burnout andwork-related stress contribute to mental and physical illnesssuch as depression, insomnia, and gastrointestinal distur-bances.3,11 High turnover rates, low job satisfaction, drugand alcohol abuse, and high absenteeism further contributeto the growing shortage of nurses as a direct consequence ofburnout.3 Most significantly, burnout can lead to nursingapathy and poor patient outcomes.

Factors that contribute to nursing burnout includestress, role conflict, lack of workplace support, increasedworkload, and incompatible personality types.1,2,5-7,11-13

The majority of these factors are environmental and thuscontrollable. It is the nurse manager’s responsibility to pro-vide a safe, supportive workplace environment that promotesjob satisfaction and patient safety. However, nursing burn-out and attrition continue to rise; research shows that onethird of nurses leave within the first 6months, andmore thanhalf leave within the first year.14 On average, it costs 1 year ofa registered nurse’s (RN’s) salary to train each new nurse,meaning that high attrition rates are affecting the nursingshortage, the financial status of hospitals, and the qualityof patient care.14

EFFECTS OF BURNOUT

Of the 2.4 million RNs in the United States, almost 60%work in the acute care setting, the ICU, and the emergencydepartment.14,15 With a projected shortage of 800,000nurses by 2020, the double impact of the shortage and nur-sing burnout will have a devastating effect on the profes-sion of nursing.16 Nursing recruitment and retention hasbecome a crucial focus of nurse managers to minimizethe damage caused by this shortage.

The emergency department serves as the only guaran-teed source of health care for the uninsured. The majorityof ED patients are uninsured or Medicaid/Medicare bene-ficiaries, limiting the financial reimbursement to hospi-tals.17-18 Compounded by the fact that ED costs are 2 to3 times higher than the costs of other settings, the over-whelming financial burden has caused a 12% reductionin total operating California emergency departments.17

Within the past 10 years, ED use has increased 600%,causing the remaining emergency departments to be over-whelmed and overcrowded.19 In turn, the overcrowdinghas caused an increase in medical errors, patient wait times,treatment delays, and increased nurse workload.19-21

The high-stress environment of the emergency depart-ment places emergency nurses at particular risk for burn-out. Additionally, emergency nurses face the constantthreat of violence. Recent evidence suggests that almost50% of emergency nurses experience physical violence

The opinions expressed are those of the respondents and should not be con-strued as the official position of the institution, ENA, or the Journal.

Editors’ note: The following article, “The Changing Emergency Department:Are Emergency Nurses Suffering More Burnout?” was written by S Kate Bay-han, MSN, RN, who is an Emergency Nurse at California State University inFullerton, California. She can be reached via E-mail at skatebay@gmail.com.

J Emerg Nurs 2011;37:90-5.

0099-1767/$36.00

Copyright © 2011 Emergency Nurses Association. Published by Elsevier Inc.All rights reserved.

doi: 10.1016/j.jen.2010.10.006

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at the hands of altered patients, psychiatric patients, med-ical clearance patients from jails and institutions, andeven fellow nurses.22

IMPLICATIONS FOR MANAGEMENT

Burnout is largely attributed to the environment in whichthe individual works10; therefore, it is the manager’sresponsibility to create a constructive, nurturing environ-ment that minimizes burnout and promotes higher jobsatisfaction and nurse retention. Recommendations tominimize burnout include establishing a mentorship pro-gram for all new hires,14 maintaining appropriate staffingratios so that existing staff members are not overloaded,and creating a program to recognize and reward excep-tional nurses.1,7 The literature also recommends that anethics committee and anonymous abuse hotline be estab-lished to provide support to the staff while creating ameans to track abuse prevalence and ethical issues withinthe facility.8,22 Finally, management should maintain anopen-door policy and provide opportunities for staff togrow both academically and professionally.7 RN engage-ment is a powerful tool to combat feelings of stress, worth-lessness, and job dissatisfaction.

RECOMMENDATIONS

The combination of the nursing shortage, health carereform, burnout, and violence is creating an alarmingtrend in emergency nursing. To date the informationand research specific to these issues as they pertain tothe emergency setting are surprisingly scarce. Looking for-ward, nursing researchers and leaders must begin to focusefforts and resources to address the needs of this vulnerablenursing population.

JOURNAL CLUBS

Have you started a journal club in your department? If

so, what has the response been?

Answer 1:At Robert Wood Johnson University Hospital (RWJUH),we instituted an Evidence-Based Practice (EBP) Commit-tee in a response to the desire of the staff to have moreexposure to EBP and as a mechanism to help them meetthe requirements for the clinical ladder/professional

advancement system. The EBP Committee met monthlyduring the day shift. The Committee began with the EDclinical nurse specialist (CNS) as the chairperson, butbecause staff showed a high level of commitment withinthe first year, 2 staff nurse co-chairs were selected. Theirduties included developing bylaws as well as a standingagenda. The standing agenda consists of best practices, cur-rent research at RWJUH, a review of a nursing researcharticle, and a report from a librarian who is affilitated withthe Robert Wood Johnson Medical School, which is closelyaffilitated with RWJUH. The librarian helps perform litera-ture reviews and helps ensure that technology is being uti-lized. She also maintains an EBP blog that can be accessedby all staff; this blog provides a venue for discussing the arti-cle and posting EBP-related questions. All articles, minutes,and agendas are maintained on the RWJUH Intranet,where the staff can have access to the information 24 hoursa day, 7 days a week.

The EBP Committee goes from unit to unit, and thetopic is selected by the unit where the Committee meet-ing is being held. The discussion is lead by the ED CNS.The discussion includes a review of the methodology,review of the data, and the implications for practice.RWJUH has a nursing conceptual model to guide prac-tice, and this model is used when discussing the implica-tions for practice. This Committee is also charged withproviding mentorship to staff nurses who would like toget more involved in research. Staff who are unable toattend the meeting but would like to receive contact hoursfor the review of the article can access the article on theRWJUH Intranet and are able to complete an online testand receive contact hours.

Within 2 years, the staff requested that this Commit-tee be duplicated for the night shift, so the ED CNSreplicated the monthly Committee at 1 AM. Two addi-tional co-chairs were selected, and this second Committeehas been very successful.

The Committee set goals for 2010. The first goal wasto develop an RWJUH Evidence-Based Practice Facebookaccount as a way to increase communication. The secondgoal was to place an “Academic Accolades” page on theRWJUH EBP site where all staff who have either publishedan article or presented a poster can post their informationelectronically. The last goal is to create a “STAT” Chat pro-gram that will enable the librarian to have remote access tothe staff on the clinical units through use of a camera. Thisservice would be available 24 hours a day, 7 days a week.—Kathleen Evanovich Zavotsky, CNS, RN, CCRN, CEN,ACNS-BC, Clinical Nurse Specialist, Emergency Department,Robert Wood Johnson University Hospital, New Brunswick,NJ; E-mail: kathy.zavotsky@rwjuh.edu

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Answer 2:We are on the journey of becoming a Magnet designatedhospital, and journal clubs are seen as a way of promotingnursing research and evidence-based practice.

Saint Joseph Hospital (SJH), a 300-bed hospital, is amember of Resurrection Health Care (RHC). Four otherhospitals and a long-term acute care hospital are currentlyin the RHC system.

In 2008 SJH made a 0.5 contact hour application forjournal clubs that would become the template to be usedby all the hospitals in the system. The template allowed fora rapid application process with the Illinois Nursing Asso-ciation. The ability to grant 0.5 contact hour was seen as apositive benefit by nursing staff.

Currently SJH averages approximately 10 journalclubs per month throughout the different clinical unitsand areas. From March 1 to June 1 this year, we had 34journal club activities at SJH.

Our Maternal Child Unit was a pioneer in the success-ful use of the journal clubs. Maternal Child Educator Eliza-beth Stapleton reports that the success of the journal clubswas a gradual process that started with articles simply beingposted in the nursing break area. She then started markingarticle highlights with a yellow highlighter. Eventually thearticles started disappearing from the bulletin board andwere obviously being read. With the encouragement andsupport of Nurse Manager Mary Ann Harper, journal clubshave been embraced by the Maternal Child Unit.

Educators and clinical nurse specialists from differentareas are the cheerleaders and help with the paperwork.Nurses are becoming more and more comfortable withfacilitating the journal clubs. Working with the staff onhow to facilitate a journal club and not be intimidatedhas been the key. Members of our Research Council attendjournal clubs to provide support and answer any questionsas it relates to research and evidence-based practice.

Our clinical ladder, which is shared with RHC, has aperformance standard as follows: “reads, critiques, utilizes,or participates in nursing research.” Because we are not auniversity-based hospital, research is still a rather new con-cept to many staff nurses. The journal clubs have proved tobe a valuable tool to educate staff on evidence-based prac-tice and research. It is gratifying to hear staff nurses discusscurrent evidence-based standards of care and actively colla-borate with other members of the health care team.

The RHC system also implemented a “DemystifyingNursing Research” class that also serves as an introductionto evidence-based practice. In the class, participants learnhow to critique a nursing research article. At SJH we offeran introductory course on “Evidence Based Practice” thatfocuses on the importance of evidence-based practice to

nursing.—Elizabeth Stapleton, MSN, RN, Maternal ChildEducator, Saint Joseph Hospital, Chicago, IL; E-mail:estapleton@reshealthcare.org and Laura McAnally, MA,BSN, RN, MJ, CCRN, Manager of Staff Education, SaintJoseph Hospital, Chicago, IL; E-mail: lmcanally@reshealth-care.org

CROSS-TRAINING

Do you have a program that allows cross-training or

shared experiences between the emergency

department and other areas of the hospital?

Answer 1:As a critical access hospital, our resources can be quite lim-ited at times, and thus all qualified nursing staff, includingcertified nursing assistants (CNAs) and unit secretaries(USs), have the opportunity to cross-train to other depart-ments if they have an interest in doing so. Nursing admin-istrators continuously collaborate to share and train ourstaff across departments. All of my night RNs are trainedto work in both the ICU and the emergency department,and they work shifts in both departments. Most of myother staff are cross-trained to work in other departments,including the CNAs and USs. I even have per-diem staffwho work part time for another department. Recently,we started a departmental float position as part of theorientation for new graduates and plan to expand it toinclude new-hire RNs.

The new graduate orientation is structured so the newgraduate floats one shift a week to another department forup to a month per department. All nursing departments areincluded: medical/surgical, the emergency department,obstetrics, ICU, oncology, care management, perioperativeservices, and nursing supervisors, as well as our health cen-ters. We also have included radiology (computerized tomo-graphy, nuclear medicine, ultrasound, magnetic resonanceimaging, and the breast center), the laboratory (where thenurses go on rounds with a phlebotomist to collect speci-mens and learn techniques for drawing blood from patientsof all ages, appropriate labeling, and proper handling ofspecimens) and integrated involvement in shared govern-ance as part of the orientation. The amount of time spentin each department depends upon the new graduate’s inter-est, previous employment and clinical experience, and thevalue of additional time spent in the other department.

The extensiveness of this program has a multifacetedrationale. First, I recalled my own experience as a new grad-uate in the emergency department, with the limited scopeand duration of my time in orientation before I was “out of

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the frying pan into the fire.” At the time, new nurses had avery limited and unstructured orientation that was limitedto the emergency department only. Later, when I was apreceptor of new graduates and new hires who were sentto oncology to learn how to manage port-a-caths, I couldsee the value of learning other skills and information inaddition to port-a-cath management. Staff learned aboutthe different roles and responsibilities of the oncologyRNs and developed a mutual respect for their differingroles; this experience contributed to greater rapport. As apreceptor, I also could see how frustrating it was for staffto be unfamiliar with out-of-department processes andpatient flow. Understanding the process of patient flowwithin a hospital system, ancillary departments, and theinpatient setting is a tremendous benefit. By expandingtraining to include all nursing and pertinent ancillary depart-ments, this greater understanding contributes to increasedrespect and better rapport in addition to better collabora-tion. In addition, opportunities for new graduates from acommunity college or university in rural America to seeand learn often are limited by the distances they would haveto travel to experience clinical rotations in an urban area.

A comprehensive multi-departmental orientation is atremendous complement to departmental orientation.The value is demonstrated by greater confidence of selfand a “belongingness” not only to the department but tonursing and the organization.—Chris Costello, RN, CEN,Mount Desert Island Hospital, Bar Harbor, ME; E-mail:chris.costello@mdihospital.org

Answer 2:Greater Baltimore Medical Center has a combined pedia-tric ED and pediatric inpatient unit. One side of the unitis for inpatients and the opposite side is the emergencydepartment, with a shared nurse’s station in the middle.We opened 6 years ago and initially hired staff for eachunit separately. However, it didn’t take long to realizethat we needed to cross-train everybody in both areas.Now the entire staff is skilled in both areas.—ValerieTighe, BSN, RNC, Nurse Manager, Pediatric ED andPediatric Inpatient Unit, Greater Baltimore Medical Center,Towson, MD; E-mail: vtighe@gbmc.org

Answer 3:My last emergency department had an exchange programwith the intensive care and cardiac care areas. It permitted“share time.” The structure was loose. It took advantage oftimes when cancellation was considered for inpatient staff.It provided a safety valve, because nurses could return totheir unit with admission influx. Likewise, with the EDstaff members, a lax time was used. They could alwaysreturn if the “what if” event occurred. The exchange pro-

gram was offered to all staff, but it was not required. Wedid not want mandatory elements to dampen attitudes.The role was to observe.

This program renewed respect between the areas. Stafffrom critical care units saw how their patients arrived in theemergency department (ie, before they were stabilized).They also observed that the critical patient was not theED staff’s only concern or knowledge base and saw allthe patients who were sent upstairs. ED staff, on the otherhand, observed trends in laboratory values, electrocardio-grams, and other assessment parameters being tracked overtime in the critical care units. They came to understand thereasons for questions that can be annoying during patienthand-off. By becoming familiar with the operations of theother area, staff came to understand what was wanted andwhat could be easily provided.

The two practice areas have very different mindsets.After participating in the exchange program, critical carenurses said they wouldn’t be able to keep track of all the spe-cialties in one ED shift, and ED nurses were glad to be backin their chaotic environment and freed from the detailedtracking performed in the critical care environment.—Martha Underwood, MS, RN, CEN, Clinical Nurse Specia-list, Baltimore Washington Medical Center, Glen Burnie,MD; E-mail: munderwood@bwmc.umms.org

Answer 4:We have a cross-training program in our hospital betweenthe emergency department and other integral patient caredepartments for our fellowship nurses: two ICUs of differ-ent specialties, the cardiac monitoring floor, and respiratorytherapy. Nurses also can observe the patient in the cardiaccatheterization laboratory and the gastrointestinal labora-tory. The outpatient intravenous (IV) therapy and pedia-trics departments also have made themselves available ifwe believe we need them. The direct benefits of cross-train-ing are specialty-focused learning, expansion of the nurse’spatient education knowledge, exposure to high-risk/low-volume skills, interdepartmental technical continuity (suchas how different departments prepare IV lines), and build-ing relationships, which is always important. The indirectbenefit is a broader health system perspective for both thepatient’s benefit and the nurse’s professional awareness.

I contact a department’s nursing supervisor and askpermission for a nurse to cross-train in his or her depart-ment. I provide the nurse’s name and suggest a date andtime frame. I have limited the training time to 4 to 6 hoursbut instruct the nurse to stay longer if the activities in thedepartment are informative. The supervisor gives me a con-tact person for the new nurse to work with, and the floormakes a note on their schedule. I have created a form so the

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preceptor can indicate the experiences the trainee had andso the trainee can comment on what he or she learned. Toacknowledge the preceptor’s time, I give him or her a cer-tificate to the cafeteria.

We cross-train with the departments that receive mostof our admissions. Respiratory therapy, for example, has alarge presence in our department. Activities such as ventilatorand tracheostomy care are high-risk/low-volume interven-tions. Without an airway you don’t have the rest, so I believethis training is valuable. We are not a large institution.

When I first became an ED nurse, part of my orienta-tion was a ride-along shift with the paramedics. Thisexperience impressed on me how unclear and chaotic thefield situation can be, and I realized how well-packagedpatients are when we receive them in the emergencydepartment. This experience was invaluable in developingmy perspective of and relationship with the EMS system asan ED nurse. One complication of offering this opportu-nity in all hospitals is liability coverage for potential injuryto the ED nurse while he or she is on duty in this setting.Contracts and coverage must be verified before the nurseand the hospital is put at risk.

Offering my new nurses exposure to all ED nursingsituations within the department would be the ideal. Somehospitals have access to a simulation laboratory, which is awonderful learning tool, but it does not expose the newnurse to the integration of overall hospital processes or buildrelationships with other nurses within the institution. Cross-training provides hands-on live patient care with supervi-sion, and even though it is not in an ED context, it hasoverall professional benefits. I would like to see morecross-training of floor nurses in the emergency department—maybe then they would understood how well the ED staffpackages patients for them considering the initial chaos.—Laura Kleeman, BSN, RN, Emergency Department ClinicalEducator, St. Luke’s Hospital, Chesterfield, MO; E-mail:laura.kleeman@stlukes-stl.com

Answer 5:We do not have a “formal” program for cross-training withnew graduate nurses or experienced RNs. However, weallow anyone who thinks he or she may be interested inworking in the emergency department to shadow a nurse(usually for at least 4 hours). This experience is arrangedthrough the manager.

I speak as a nurse whose first job was in the float pool atour hospital for 10 years. I loved working in different depart-ments and was disappointed when the hospital dissolved thefloat pool. My experiences in floating to all the departmentsgave me an appreciation for the different types of nursingthat exist. What I often see is ignorance (which I don’t mean

in an offensive way) on the part of many nurses regardingwhat their counterparts do on different units and in differentspecialties. All types of nursing take a “special” person tocome in day after day and do what we do. Until you walkin another person’s shoes, you cannot fully understand orappreciate the complexities of their job.

I believe a lot can be gained by cross-training. Under-standing nursing from a perspective other than one’s ownenhances teamwork in the entire health system. Thisenhanced teamwork should, in turn, result in better careand satisfaction for patients.—Lynette Wryk, RN-SANE,Staff Nurse, Sisters of Charity Hospital, Buffalo, NY; E-mail:l9795@hotmail.com

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