Short-Staffed Nursing Effects on Emergency Room Care

Introduction

The emergency department's efficiency is a critical component of delivering quality and safe care within the health sector. The utilization of emergency departments has significantly increased without a corresponding increase in available emergency services (Ramsey et al., 2018). To attend to this increased demand, it is important to evaluate the various factors contributing to care delays (Schull et al., 2003). Scholars have identified multiple hospital characteristics associated with worse emergency room outcomes, including time on ambulance diversion, emergency room crowding, hospital occupancy, the proportion of emergency department patients admitted, the treating physician's level of training, elective surgical admission numbers, the socioeconomic status of the neighborhood, decreased nurse staffing, access to expedited diagnostic testing, and overall hospital occupancy.

However, there is a lack of relevant data to connect hospital occupancy to overcrowding. According to Schull et al., hospital bed closures in Canada correlated with the rise in emergency room overcrowding within Toronto (Polevoi et al., 2005). Nevertheless, that finding was made in the context of concurrent changes within Toronto's health services, including the closure of multiple emergency rooms (Ramsey et al., 2018). Some research studies also appear to support the theory that hospital overcrowding influences the decision to admit.

It is also critical to understand whether bed availability impacts the disposition and length of stay within emergency rooms. Data regarding such relationships could assist in developing mechanisms for reducing overcrowding (Lucas et al., 2009). Moreover, if hospital occupancy varied with patient disposition, this would serve as a clear indicator that hospital overcrowding results in lower-quality emergency room care.

Research Hypotheses

1. Short-staffed nursing in emergency rooms increases patients' wait times.

2. Short-staffed nursing prolongs patient treatment times in emergency rooms.

3. Increased wait times due to nurse shortage do not lower patient satisfaction.

Central Research Question

What are the effects of short-staffed nursing in emergency rooms?

Specific Questions

How does short-staffed nursing in emergency rooms affect patients' wait time? Does short-staffed nursing in emergency rooms impact patients' treatment time? How is patient satisfaction affected when wait times increase due to nurse staffing shortages?

Statement of the Problem

When healthcare facilities and emergency rooms have inadequate staff, patients' welfare is compromised. Overwhelmed staff may overlook important details or may not be fully attentive and engaged with patients. As a result, patients may be dissatisfied with providers' performance (Ramsey et al., 2018). Emergency rooms face multiple critical problems within the modern healthcare environment (Lucas et al., 2009). Simultaneously confronted with growing public demand and decreasing hospital resources, emergency rooms frequently experience prolonged overcrowding and extended waiting times. Reducing the delay between the onset of symptoms and the initiation of therapy is vital for enhancing outcomes for critically ill patients (Ramsey et al., 2018). Overcrowding pushes emergency rooms to work beyond their staff capacity, leading to delays in diagnosis and treatment and adversely affecting the quality of patient care (Lambe et al., 2003). The effect of overcrowding on emergency room quality and public health has recently received global attention, prompting urgent calls for reform (Schull et al., 2003). Consequently, there is a critical need for mechanisms to improve patient flow, minimize the overcrowding burden within emergency rooms, and enhance the overall quality of emergency care.

Those supporting the enactment of minimum nurse-to-patient ratios in emergency rooms argue that doing so would reduce nurse workloads to a manageable level, allowing patient care, disposition, and evaluation activities to be completed within an appropriate timeframe, thereby improving patient flow and throughput within emergency rooms (Wiler et al., 2012). This paper discusses the effects of short-staffed nursing in emergency departments (Schull et al., 2003), including how patient wait times are affected, how patient treatment times are affected, and how patient satisfaction is affected when wait times increase due to nurse staffing shortages.

Literature Review

Health researchers have reported connections between nurse staffing and patient care outcomes and satisfaction (Polevoi et al., 2005). Nevertheless, nursing staffing and care have been background variables in many such studies rather than the primary focus (Ramsey et al., 2018). Nurses constitute the largest group of hospital workers responsible for most patient care, making it essential to investigate their work's effect on both patient safety and healthcare quality (Schull et al., 2003). A growing body of evidence suggests that insufficient nurse staffing within emergency rooms and hospitals can lead to adverse events such as healthcare-associated infections, patient falls, in-hospital mortality, and medication errors (Ramsey et al., 2018). According to Aiken et al., an increased proportion of nurses with bachelor's degrees and enhanced nurse staffing reduced the likelihood of patient death within thirty days of admission (Lucas et al., 2009). Scholars have argued that adequate nurse staffing determines surveillance quality by enabling nurses to spend more time on direct and indirect care.

The lack of an adequate number of nurses also impacts patient satisfaction. According to scholars, whenever a patient has a negative perception of nursing care, it is equivalent to missed care attributable to a shortage of nursing staff (Polevoi et al., 2005). As a result, patients lose confidence when they leave before being seen (Rathlev et al., 2007). Patient satisfaction data are used by emergency room administrators to track aggregate information over time, assess individual practitioner performance, establish financial incentive plans, and evaluate interventions (Ramsey et al., 2018). According to the literature, six aspects of emergency care are most likely to result in patient dissatisfaction (Schull et al., 2003): failure to receive help when needed; not being informed when normal activities can be resumed; lack of information about waiting times; not knowing when to return to the emergency room; failure to receive an explanation of test results; and a poorly explained diagnosis or problem.

Earlier studies have shown that an increased nurse-to-patient ratio directly improves patient outcomes, while understaffing is associated with a rise in the rate of patients who leave without being seen and longer emergency room care times (Schull et al., 2003). Several teaching hospitals, safety-net hospitals, and tertiary care facilities have experienced nursing shortages due to administrative initiatives aimed at reducing costs by cutting nurse overtime hours (Ramsey et al., 2018). Without a corresponding increase in hiring, this shift has resulted in substantial emergency department nurse staffing gaps (Polevoi et al., 2005). These gaps have led to unpredictable closure of parts of emergency departments in several hospitals and a rise in average nurse-to-patient ratios (Rathlev et al., 2007). Scholars have identified multiple hospital features associated with worse emergency room outcomes, including ambulance diversion time, emergency room crowding, hospital occupancy, the proportion of admitted emergency department patients, the treating physician's level of training, elective surgical admission numbers, neighborhood socioeconomic status, decreased nurse staffing, and access to expedited diagnostic testing (Lucas et al., 2009).

Overcrowding within emergency rooms is a critical global challenge that can decrease the quality of care (Schull et al., 2003). North America, Australia, and Europe have all reported overcrowding in most emergency rooms (Polevoi et al., 2005). According to multiple editorials and surveys, increased emergency department congestion within hospitals constitutes a national crisis because it hinders the timely and effective delivery of emergency medical care (Ramsey et al., 2018). Within understaffed emergency rooms or healthcare facilities, the same volume of work falls to fewer nurses, forcing them to work longer hours (Forster et al., 2003). This can result in mental breakdown and physical and emotional health challenges (Chang et al., 2018). Consequently, nurses who become ill may not report for duty, further worsening the staffing deficiency.

Additionally, nurses constantly exposed to work-related stress can develop health complications such as hypertension, musculoskeletal disorders, heart disease, depression, anxiety, and exhaustion (Schull et al., 2003). Further research should be conducted on the cost-effectiveness of increasing nursing hours relative to lost revenues from patients who leave without being seen (Lambe et al., 2003). Understanding the effect of nurse staffing on patient satisfaction remains an important area for future investigation.

In recent decades, growing concern about nurse staffing deficiencies and escalating patient workloads has threatened the quality of patient care in emergency rooms (Polevoi et al., 2005). Some studies have proposed increasing nurse-to-patient ratios to address these deficiencies (Recio-Saucedo et al., 2015). For instance, in 2004, California implemented minimum nurse-to-patient ratios under Assembly Bill 394, the safe staffing law (Lambe et al., 2003). This law established minimum staffing ratios in all hospitals, including emergency rooms (Ramsey et al., 2018). Emergency rooms simultaneously face growing public demand and decreasing hospital resources, resulting in prolonged overcrowding and extended waiting times (Chan et al., 2010).

Beyond direct patient care, nurse staffing is critical to emergency room patient flow, operations, and efficiency (Polevoi et al., 2005). Minimum staffing regulations may be particularly challenging for emergency rooms due to potential minute-by-minute fluctuations in patient load, census, and acuity (Schull et al., 2003). As a result, many emergency rooms have established timeout periods for compliance with nurse-to-patient ratio requirements (Ramsey et al., 2018). Conversely, some scholars have argued that minimum nurse-to-patient ratios in emergency rooms could negatively affect patients by reducing the number of available patient care areas that cannot be staffed to meet ratio requirements.

References

Chan, T. C., Killeen, J. P., Vilke, G. M., Marshall, J. B., & Castillo, E. M. (2010). Effect of mandated nurse-patient ratios on patient wait time and care time in the emergency department. Academic Emergency Medicine, 17(5), 545–552.

Chang, A. M., Cohen, D. J., Lin, A., Augustine, J., Handel, D. A., Howell, E., & Sun, B. C. (2018). Hospital strategies for reducing emergency department crowding: a mixed-methods study. Annals of Emergency Medicine, 71(4), 497–505.

Forster, A. J., Stiell, I., Wells, G., Lee, A. J., & Van Walraven, C. (2003). The effect of hospital occupancy on emergency department length of stay and patient disposition. Academic Emergency Medicine, 10(2), 127–133.

Lambe, S., Washington, D. L., Fink, A., Laouri, M., Liu, H., Fosse, J. S., & Asch, S. M. (2003). Waiting times in California's emergency departments. Annals of Emergency Medicine, 41(1), 35–44.

Lucas, R., Farley, H., Twanmoh, J., Urumov, A., Olsen, N., Evans, B., & Kabiri, H. (2009). Emergency department patient flow: the influence of hospital census variables on emergency department length of stay. Academic Emergency Medicine, 16(7), 597–602.

Polevoi, S. K., Quinn, J. V., & Kramer, N. R. (2005). Factors associated with patients who leave without being seen. Academic Emergency Medicine, 12(3), 232–236.

Ramsey, Z., Palter, J. S., Hardwick, J., Moskoff, J., Christian, E. L., & Bailitz, J. (2018). Decreased nursing staffing adversely affects emergency department throughput metrics. Western Journal of Emergency Medicine, 19(3), 496.

Rathlev, N. K., Chessare, J., Olshaker, J., Obendorfer, D., Mehta, S. D., Rothenhaus, T., & Litvak, E. (2007). Time series analysis of variables associated with daily mean emergency department length of stay. Annals of Emergency Medicine, 49(3), 265–271.

Recio-Saucedo, A., Pope, C., Dall'Ora, C., Griffiths, P., Jones, J., Crouch, R., & Drennan, J. (2015). Safe staffing for nursing in emergency departments: evidence review. Emergency Medicine Journal, 32(11), 888–894.

Schull, M. J., Lazier, K., Vermeulen, M., Mawhinney, S., & Morrison, L. J. (2003). Emergency department contributors to ambulance diversion: a quantitative analysis. Annals of Emergency Medicine, 41(4), 467–476.

Wiler, J. L., Handel, D. A., Ginde, A. A., Aronsky, D., Genes, N. G., Hackman, J. L., & Fu, R. (2012). Predictors of patient length of stay in 9 emergency departments. The American Journal of Emergency Medicine, 30(9), 1860–1864.