Study: Emergency department staffing needs to account for required level of care, patient volume; not just number of beds

November 11, 2016 News Research
DES PLAINES, Ill., - An article just published in the Journal of Emergency Nursing, the Emergency Nurses Association’s peer-reviewed publication, offers insights into what emergency nurses believe are the necessary components to achieve safe staffing levels in emergency departments. Twenty-six emergency nurses took part in a qualitative research focus group.

Unsafe staffing negatively impacts patient care and contributes to nurse burnout and retention, wrote the authors of “On the Threshold of Safety: A Qualitative Exploration of Nurses' Perceptions of Factors Involved in Safe Staffing Levels in Emergency Departments.” Patient care is the primary factor motivating participants to find safe staffing solutions, researchers found.

Hospitals primarily rely on nurse-to-patient ratios to achieve safe staffing, a method which is inadequate in an emergency department. ENA’s position paper, Staffing and Productivity in the Emergency Department, notes California was the first state to mandate nurse-to-patient ratios. Yet researchers note there is a dearth of research specific to the emergency care environment.

“Despite improved nurse-patient ratios in California, the failure to rescue (deaths in patients who developed serious complications) rate has not improved” in emergency departments, the paper states.

Researchers concur.

Inpatient and emergency departments are different environments. An emergency department’s caseload is unpredictable and, by law, emergency departments do not choose what patients they will accept and cannot limit the number of patients seen.

“This requirement that all patients be examined effectively precludes patient volume control; as a result, staffing needs are difficult to anticipate and are therefore fluid and unpredictable,” researchers wrote. Achieving safe staffing “involves more than just the number of nurses on a given shift but also includes skill and experience mix (e.g., experienced versus inexperienced nurses, level of education, and professional training) and educational and administrative support (e.g., safe staffing policies and flexible scheduling).”

Emergency nurses report that the intensity of nursing care required, or patient acuity, along with patient volume, and nurse skill and experience mix, should inform safe staffing decisions.

Other possible solutions discussed included “having huddles throughout the day to reorganize care, establishing processes for other nurses in the hospital to provide patient care in the emergency department during surges, and engaging staff and administration in understanding the complex interplay between adequate staffing and the provision of high quality, safe, emergency care.”

The authors suggest further research be conducted on a quantitative level to better determine safe staffing levels for patients and nurses.

The journal article was researched and written by Lisa A. Wolf, PhD, RN, CEN, FAEN, director of ENA's Institute of Emergency Nursing Research; Cydne Perhats, MPH, and Altair M. Delao, MPH, IENR senior associates; Paul R. Clark, PhD, MA, RN, assistant professor at the University of Louisville School of Nursing and system educator at Norton Healthcare Institute for Nursing, Louisville, Ky.; and Michael D. Moon, PhD, RN, CNS-CC, FAEN, associate professor at the University of the Incarnate Word, San Antonio, Texas.

About the Emergency Nurses Association

The Emergency Nurses Association is the premier professional nursing association dedicated to defining the future of emergency nursing through advocacy, education, research, innovation, and leadership. Founded in 1970, ENA has proven to be an indispensable resource to the global emergency nursing community. With more than 50,000 members worldwide, ENA advocates for patient safety, develops industry-leading practice standards and guidelines, and guides emergency healthcare public policy. ENA members have expertise in triage, patient care, disaster preparedness, and all aspects of emergency care. Additional information is available at

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