Some healthcare professionals see blood, mangled bodies, and death every day, yet certain days are worse than others. As when, for instance, a dozen police officers are gunned down or 20 kids are killed in their elementary school in a mass shooting. Because public mass shootings happen nearly every 6 weeks in America, these tragedies are having a more frequent impact on the healthcare workforce.
Research data are sparse. One study surveyed 24 surgical residents working at Orlando Regional Medical Center in Florida in 2016. On June 12 that year, a gunman shot 49 people to death and wounded 53 others at the mass shooting at the Pulse nightclub. Three months later, rates of post-traumatic stress disorder (PTSD) and major depression were two and four times greater among the 10 residents on call that night versus the 14 off-duty residents. Though the differences didn’t reach statistical significance, assessments were revealing. A survey of the same residents 7 months after the mass shooting found that PTSD persisted in those affected in the on-call group but completely resolved in the off-call residents.
As part of an ongoing effort by MedPage Today to explore job stress and burnout among healthcare professionals, reporter Shannon Firth talked at length with physicians and nurses who shared personal experiences with mass shootings and how they affected their lives and careers.
On November 21, the US House of Representatives passed the Workplace Violence (WPV) Prevention for Health Care and Social Services Act of 2019 (the bill now moves to the Senate). Strongly supported by the Emergency Nurses Association, the bill now moves to the Senate for consideration.
In the U.S., the prevalence of workplace violence (WPV) in the healthcare industry is four times higher than in other private industries. According to surveys by the American College of Emergency Physicians (ACEP) and the Emergency Nurses Association (ENA), some 70 percent of emergency department (ED) nurses have been hit or kicked while at work. Because of ease of public access, crowding, long wait times, presence of weapons, and other factors, the emergency department is a highly vulnerable area, especially where triage occurs.
ED Health Providers Literally on the “Front Lines” for WPV
The shocking statistics on WPV in emergency departments are behind ACEP and ENA’s campaign, “No Silence on ED Violence.” This joint effort aims to educate, empower and protect doctors and nurses working in emergency departments. By raising awareness of the serious WPV dangers emergency health providers face every day, and promoting action among stakeholders and policymakers, the campaign seeks to ensure a violence-free workplace for emergency nurses and physicians.
Acts of workplace violence (WPV) can cause physical and/or
psychological harm to emergency nurses. WPV can lead to job dissatisfaction,
emotional exhaustion, burnout, secondary trauma stress, PTSD, absenteeism, and
intentions to leave the job or nursing profession, all of which have potential
impacts on patient care.
Workplace Violence Affects Majority of ED Doctors and Nurses
ACEP President William Jaquis, MD, FACEP, said, “If you asked the majority of our nurses and our physicians, they have all been impacted directly by violence—as have I. It goes everywhere from verbal violence, which happens frequently, to physical violence. Ultimately, we hope that in sharing our stories we will gain insight and share resources on how to prevent future harm to our medical teams and our patients.”
The “No Silence on ED Violence” website includes a variety of workplace violence resources for emergency healthcare providers, including guidelines for safety in and around the Emergency Department, and lists of warning signs indicative of potential violent events.
Inspired by the Raise Your Hand movement—which first encouraged emergency nurses in 2018 to share their workplace violence experiences — ACEP and ENA have collaborated on this effort to minimize the frequency of attacks, protect emergency department professionals and build a new level of awareness about this crisis.
Some Tips on Staying Safe
To increase program effectiveness, it is recommended that a workplace violence prevention program include education and training; formal incident reporting procedures; and administrative, environmental and consumer risk assessment, physical design, and security components to address all types of WPV.
Trust your feelings if you feel uncomfortable
around a patient.
Don’t isolate yourself.
Have security around.
Call security when you first become aware of a
Maintain safe distance.
Keep an open path for potential exit.
Present a calm, caring attitude.
Don’t match the threats.
Don’t give orders.
Acknowledge the person’s feelings.
Avoid any behavior that may be interpreted as
Limit eye contact.
Further, if you do become a victim of workplace violence, report it! Underreporting is a documented barrier to effective identification and mitigation of workplace violence. Although many nurses do report WPV incidents using both informal (e.g., telling a supervisor or colleague) and formal channels, the latter is only likely when an injury is sustained. Organizational commitment including workplace policies such as zero tolerance and the role of nursing leadership for establishing a just culture that discourages bullying and retaliation—is essential to mitigating all types and forms of WPV in emergency nursing and other healthcare environments.
Passed in the House, Now Advocate for the Bill With Your Senator
Among other features, the “Advocacy” page on StopEDViolence.org focuses on S. 851, the Workplace Violence Prevention for Health Care and Social Service Workers Act. Resources include an easy form for writing your Senator to support the act. In its current form, S.851 will require health care and social service employers to develop and implement comprehensive workplace violence prevention plans. These plans must include procedures to identify and respond to the common risks that make health care settings so vulnerable to WPV incidents. In addition, the bill is designed to help ensure that employees are appropriately trained in mitigating dangerous situations. For examples of action taken in State legislatures, see this PDF.
The nursing field is filled with various specialties. And
that’s a good thing, as while working in emergency would be too stressful for one
nurse, it is the perfect fit for another.
Cara J. Szeglin, BSN, RN, CPEN, a Clinical Ladder III Staff Nurse at NewYork-Presbyterian Morgan Stanley Children’s Hospital, is one of these nurses who thrives working with emergency patients. She took time from her schedule to answer our questions about what it’s like to work as a Certified Pediatric Emergency Nurse (CPEN).
How long have you been a CPEN? What drew you to
get that certification?
I became CPEN-certified in November 2014. By
this point, I had been an emergency nurse for about seven years. The first year
was with only adult patients, the next two years with adult and pediatric
patients, and the last four years were solely pediatric emergency
When I applied to sit for the CPEN, I had reached a point in my career where I felt like my education and pediatric emergency experience were enough for me to be ready. The Board of Certification for Emergency Nursing (BCEN) recommends nurses have two years of practice in their specialty. Passing BCEN’s Certified Pediatric Emergency Nurse (CPEN) examination proved to myself, my place of employment, and to my patients that I was indeed an expert in my field.
Why do you enjoy working as a CPEN?
I absolutely love working in pediatric emergency
care as a CPEN. I still cannot believe I get to do my job because it is just so
much fun. The pediatric patients are great, the parents and guardians are
grateful, and my co-workers are amazing.
Some of the greatest moments I have as a Certified Pediatric Emergency Nurse are when a patient comes in sick or injured, and their guardians and the patient can be confused, worried, upset, and experiencing a host of other emotions, and as a CPEN, I’m able to anticipate what the plan of care should be and I know how to tell them what’s happening and what to expect in a way they will understand. You know by their questions if they understand or if they need you try to explain it another way. I always tell them it is all right to ask questions — as many as they like — and as a CPEN, I feel confident I know the answers or know how to get them and explain them.
The biggest thing about being a CPEN is that you
have gained their trust because you are an expert professional who is going to
give their loved one the very best care.
What are some of
the biggest challenges to being a CPEN?
I have known some extraordinary pediatric
emergency nurses who just needed a motivating nudge to get their nerve up to
take the exam and get board certified. When I first started nursing and heard
about the CPEN, I thought “Those are the elite people. I want to be them one
day.” And then when I passed the exam, I said “What took me so long?”
What are some of
the greatest rewards?
As a CPEN, I’m part of the care plan for my
patients. Before I became a CPEN, fully understanding the rationale of why
providers were requesting what they were ordering and engaging with the whole
team had really been a challenge for me. Earning the CPEN has helped me
find my voice and offer suggestions instead of just accepting all orders as
they are. I love being able to constructively question the providers and asking
Being a CPEN has boosted my confidence — I am a valued member of the care team who needs to know what is going on and why and whose voice needs to be considered when the care plan is being discussed. This also means I’m better able to ensure that my patients and their families know what the plan is and understand why.
If nurses reading
this are interested in becoming CPENs, what would you say to them?
The CPEN is for nurses who want to demonstrate their expertise in treating infants and children in emergency settings. The exam covers the most common pediatric illnesses and clinical issues of all kinds, including trauma, respiratory and cardiac issues, plus less common things that you still need to know because you never know what might come through your doors. The BCEN website contains all the information you need to apply for the exam, how to schedule a test date (which you can do all over the country throughout the year), plus a lot of helpful resources.
I studied for the CPEN exam just as hard or probably even harder than I had for the nursing boards. A key part was scheduling a test date along with a pediatric emergency nursing friend of mine — so there was no backing out. We studied together, supported each other, and passed on the same day together! Each of us study and learn in different ways.
What else is important for readers to know?
There are so many good things, rewarding things about being a nurse, especially pediatric emergency care. There are days when everything seemed to go so smoothly and you excelled at everything you did. And then there are the days when something came through the doors totally unexpected, and you only hope you can hold it together until the end of your long shift so you can cry about it on the way home. The same can be said for all specialties of nursing. But you pull it together and show up for work the next shift, with the same level of care, dedication, and enthusiasm because being a nurse is the best career.
I love being a CPEN, and I hope that readers
can feel my passion and get motivated to become certified themselves, and if
they are already certified, I hope that this inspires them to seek out other
nurses and start being a mentor for them!
AACN Core Curriculum for Pediatric High Acuity, Progressive, and Critical Care Nursing
Ideal for pediatric critical care and acute care nurses, high acuity/critical care courses, and continuing education, AACN Core Curriculum for Pediatric High Acuity, Progressive, and Critical Care, Third Edition, contains core AACN guidelines for the highest quality nursing practice. The text covers anatomic, physiologic, cognitive, and psychosocial changes that occur throughout the pediatric lifespan.
When a patient is described as having “coded,” this generally refers to cardiac arrest. In such a case, urgent life-saving measures are indicated. This can happen within and outside of medical facilities. The benefit of the occurrence in a professional health care setting is that policies and guidelines are in place to address this life-threatening crisis. What follows is the perspective of responding to a code from an ER nurse.
Just as every patient is different, so is every code. The causes and outcomes of every code have to do with the characteristics of the patient in question: the history of present illness and, of course, their comorbidities. Timothy Wrede, RN, is a long-time emergency and critical care nurse in the suburbs of New York City, as well as a former EMT who has seen his fair share of codes. According to Wrede, nothing matters during a code so much as the team that responds to it. “It is imperative to ensure that a good team of doctors, nurses, and ancillary staff are working together efficiently in order to achieve resuscitation of spontaneous circulation (ROSC),” says Wrede.
According to Wrede, a veteran of level-I trauma care, when
it comes to staffing a code, less is more. Studies suggest
that thirteen is the maximum number of personnel participating in an effective
code. Included in this number are professionals that go beyond those
immediately at the bedside, such as pharmacy, lab, and spiritual services.
“There’s nothing worse than 25 people crammed into a patient room trying
to coordinate resuscitation,” according to Wrede. For him, the minimum is
five ‘in the box’, or in direct proximity to the patient, as well as one team
member ‘outside of the box’. “One doctor, three nurses, and two aides
are more than sufficient to obtain or sustain an airway while maintaining a
clear line of vision of the patient, the patient’s monitor, and other team
members,” he says. This consists of one nurse on either side of the
patient responsible for gaining peripheral IV access, administering IV
medication, and obtaining blood samples for lab work. The code
recorder, usually an RN, documents everything that occurs, including every
medication given, timing, team actions, compressions, defibrillation, and
Wrede’s description of the ideal code team is very similar
to the American Heart Association’s recommendation for high-quality CPR
teams. It includes a “triangle” of providers doing chest
compressions, defibrillating, breathing for the patient, and providing
medications, in addition to a code recorder and a physician outside of the
triangle. The physician acts as a team leader by making high-quality
treatment decisions, providing feedback, and overseeing team actions.
For Wrede, the most important times for a code are before and after it. Having a competent team with pre-assigned roles, as well as the opportunity to review and debrief afterward to improve the process continuously, and allow for best patient outcomes. Many hospitals address this by establishing a code team that arrives every time a code is called, with well-established roles, and protocols. Wrede’s experiences describe codes in the ED, although codes are generally run the same regardless of where they take place. The biggest difference is the patient context.
Fewer nurses on staff linked to increases in length of stay
Ask a nurse and they will tell you that staffing levels matter. Now a study in the Western Journal of Emergency Medicine supports that popular opinion, providing further evidence to make the case for nursing’s role in achieving healthcare outcomes and metrics.
“Our study provides additional data that may help providers further engage hospital administration to supply adequate nurse staffing that allows EDs [emergency departments] to better achieve performance goals and improve the patient experience,” the researchers wrote. “This analysis is a pivotal step in identifying and ensuring appropriate nurse staffing to optimize ED quality metrics.”
In the retrospective observational review of the electronic health record database from a high-volume, urban public hospital, researchers compared nursing hours per day with door-to-discharge length of stay, door-to-admission length of stay (LOS), and the percentage of patients who left without being seen.
From January to December 2015, more than 100,000 patients were seen in the ED at an average of 290 visits each day. During this time, the ED had an average of 465 nursing hours worked per day.
The researchers found that regardless of daily patient volume, occupancy, and ED admission rates, days in the lowest quartile of nursing hours experienced a 28-minute increase per patient door-to-discharge LOS when compared with the highest quartile of nursing hours.
However, door-to-admit LOS showed no significant change across quartiles.
There was an increase of nine patients per day that left without being seen by a provider from the lowest to highest quartile of nursing hours.
The authors concluded that lower staffing rates contribute to a statistically significant increase in wait time for patients, which then impacts how many patients receive treatment each day.
In addition to the clear patient safety and patient satisfaction issues around failing to receive timely treatment, the decrease in patients seen can also impact throughput metrics and decrease the overall revenue of facilities.
Two reports find that RNs are both personally and professionally affected by natural disasters
As communities hit by natural disasters go down the long path to recovery, it’s important to remember that disasters leave more in their wake than physical damage to homes and property. They also leave marks on victims’ psyches.
She, along with colleagues at NYU Rory Meyers College of Nursing and NYU Dentistry, recently published two reports in the Journal of Nursing Scholarship that offer insights on emergency preparedness, recovery, and resilience. The studies were centered on nurses working at NYU Langone Health’s main hospital during Superstorm Sandy in 2012. Key themes that emerged were communication — both improving channels and the importance of connecting nurses with others during a crisis — and social support.
Preparedness Training Needed
To understand how nurses at NYU Langone were impacted before, during, and after the storm, the researchers conducted interviews and surveys with 16 nurses who participated in the mid-storm evacuation of more than 300 patients at the institution’s 725-bed Tisch Hospital due to high water levels.
Raveis and her team explored nurses’ experiences in disasters, assessed the nurses’ challenges and resources for carrying out responsibilities, and uncovered some lessons.
After the interviews, an online survey was sent to all RNs assigned to inpatient units at NYU Langone on the day of the storm. The researchers received 528 anonymous responses, including responses from 173 nurses who were part of the evacuation.
While some nurses had previous disaster training and experience, and a few of them reported feeling prepared during the storm and the resulting evacuation, many working the night of the storm lacked prior hands-on experience or deep knowledge of emergency preparedness.
This lack of comfort with emergency preparedness is not uncommon, noted Eric Alberts, corporate manager for emergency preparedness at Orlando Health in Florida.
“Or if they do, they don’t practice it. And if they do practice it, they’re not really practicing it — they’re just doing a flu shot campaign and calling it an exercise.”
Alberts recommended that hospital and health system leaders do a thorough evaluation of their disaster readiness: “Really look at your processes and your people and see what is available during emergencies. Emergency preparedness and healthcare looks and feels different everywhere you go. And then from that, look at what resources and people are able to help those individuals have a good, efficient, and effective plan.”
The researchers also called for more education and planning for future disasters and they recommend FEMA’s all hazards approach to disaster planning.
RNs reported unlocking medication carts in anticipation of the power outage and handwriting medical summaries for patients being evacuated to other hospitals. Of the nurses surveyed, 72% reported that their primary mode of communication was talking face-to-face and 24% used personal cell phones.
The researchers also found that nurses had their own personal concerns during the storm, worrying about their families’ welfare and personal loss. And while many arranged for extended stays at the hospital before the storm, they reported feeling uncertain about leaving their families and later had trouble contacting loved ones.
The survey found that 25% of nurses suffered property damage or loss, and 22% needed to relocate after the storm. Some respondents reported psychological problems after the storm, including having disturbing thoughts (5%) and difficulty sleeping (4%).
Social support from co-workers, hospital leadership, and loved ones was cited as an important resource in helping nurses cope with the stress of the disaster.
“Our research also shows that maintaining good communication with peers and hospital leaders after the hurricane helped the nursing staff feel more connected and less stressed,” said another of the study coauthors, Christine T. Kovner, RN, PhD, professor of geriatric nursing at NYU Meyers.