Nursing staff factors influencing pain management in the emergency department: Both quantity and quality matter

The Role of Structural Empowerment in Mediating the Relationship Between Practice Environment and Quality of Care Among Emergency Nurses: A Multilevel Modeling Approach

INTRODUCTION

Strong evidence demonstrated that working in a healthy environment has been associated with high-quality patient care. However, the mechanism underlying this relationship requires further investigation. This study aimed to examine the role of structural empowerment in mediating the relationship between nursing practice environment and quality of care among emergency nurses.

METHODS

A proportional stratified clustered sampling technique was used to recruit staff nurses working in acute care hospitals in Oman. Four standardized instruments were used to assess nurses' sociodemographic characteristics, perception of the practice environment, structural empowerment, and perceived quality of care. Hayes' process for mediation analysis was used to examine whether empowerment mediates the relationship between the practice environment and quality of care.

RESULTS

A total of 160 emergency nurses participated. The majority (78.8%) perceived the quality of care as good/excellent. Having an adequate foundation for quality of care, sufficient staffing, and managerial support were significant predictors of perceived quality of care. Practice environment was directly and indirectly related to the perceived quality of care through structural empowerment.

DISCUSSION

Nurse leaders can enhance care quality in emergency departments by improving the work environment through engaging nurses in quality activities, ensuring adequate staffing and resources, and providing robust leadership support, which collectively empower nurses and improve patient outcomes.

Simplified Pain Management Including Fentanyl TTS in PACU Patients With Hip Fracture Surgery to Improve Patients' Well-Being: A Double-Blind Randomized Trial

PURPOSE

Adequate pain management is eminently relevant for elderly and more vulnerable patients with hip fractures in the setting of pre and postoperative pain. This study compares postoperative hip fracture patients treated with standard pain management with a variety of medications or an approach with only one option in each medication category (nonopioid: acetaminophen; opioid: fentanyl TTS 12,5 mcg/hour; rescue medication: piritramide) to simplify the treatment algorithm for nurses and improve patient well-being.

DESIGN

Double-blind randomized controlled trial.

METHODS

The sample was cognitively intact patients (N = 141) with hip fractures in a tertiary university hospital. Administration of fentanyl 12 mcg/hour transdermal therapeutic system was administered by the nurses in the postanesthesia care unit (PACU) to address basal wound pain to improve patient well-being and patient treatment in the PACU for 24 hours to better control for early complications.

FINDINGS

Well-being was equally increased in both groups in comparison to our preintervention data from 35.7% to over 60% and did not differ significantly between the intervention and control group. No statistically significant differences in numeric rating scale scores, rescue opioid dosage (piritramide i.v.) or in complications were present.

CONCLUSIONS

This one-size-fits-all simplified pain management approach did not improve patient well-being or any other outcome but highlighted the importance of adequate pain management and a sufficient nurse-to-patient ratio.

The association between nurse staffing and quality of care in emergency departments: A systematic review

BACKGROUND

The relationship between nurse staffing, skill-mix and quality of care has been well-established in medical and surgical settings, however, there is relatively limited evidence of this relationship in emergency departments. Those that have been published identified that lower nurse staffing levels in emergency departments are generally associated with worse outcomes with the conclusion that the evidence in emergency settings was, at best, weak.

METHODS

We searched thirteen electronic databases for potentially eligible papers published in English up to December 2023. Studies were included if they reported on patient outcomes associated with nurse staffing within emergency departments. Observational, cross-sectional, prospective, retrospective, interrupted time-series designs, difference-in-difference, randomised control trials or quasi-experimental studies and controlled before and after studies study designs were considered for inclusion. Team members independently screened titles and abstracts. Data was synthesised using a narrative approach.

RESULTS

We identified 16 papers for inclusion; the majority of the studies (n = 10/16) were observational. The evidence reviewed identified that poorer staffing levels within emergency departments are associated with increased patient wait times, a higher proportion of patients who leave without being seen and an increased length of stay. Lower levels of nurse staffing are also associated with an increase in time to medications and therapeutic interventions, and increased risk of cardiac arrest within the emergency department.

CONCLUSION

Overall, there remains limited high-quality empirical evidence addressing the association between emergency department nurse staffing and patient outcomes. However, it is evident that lower levels of nurse staffing are associated with adverse events that can result in delays to the provision of care and serious outcomes for patients. There is a need for longitudinal studies coupled with research that considers the relationship with skill-mix, other staffing grades and patient outcomes as well as a wider range of geographical settings.

TWEETABLE ABSTRACT

Lower levels of nurse staffing in emergency departments are associated with delays in patients receiving treatments and poor quality care including an increase in leaving without being seen, delay in accessing treatments and medications and cardiac arrest.