About a year ago, a registered nurse in Washington state called 911 from an overfilled emergency department to make a plea for help. Her problem? The hospital lacked enough nursing staff for the crush of patients that had overwhelmed its emergency services. 

In a setting that offers 24/7 care for patients with life-threatening conditions, the nurse had already reached out to more typical sources of support, like off-duty staffers and first-responders from an ambulance firm that serves the hospital, but when no one was available, she felt 911 was her only choice.

Our investigative team, including LDI Associate Fellow K. Jane Muir and Senior Fellows Linda Aiken and Matthew McHugh, recently published a study focusing on the quality of emergency nurse work environments at U.S. hospitals and the implications for patient care and nurse well being.

Nurses are often the first contact point for patients entering emergency departments, where providing care can be unpredictable and fast-paced. When we surveyed 746 emergency nurses working in 221 hospitals in New York and Illinois in 2021, we found that more than half of nurses reported high burnout, more than a third were dissatisfied with their jobs, and more than a quarter intended to leave in the next year.

Emergency nurses in hospitals with lower -quality work environments experienced higher rates of burnout, job dissatisfaction, and turnover intention.

The quality of emergency department workplaces varied widely across hospitals according to the results of our survey. Low nurse-reported scores on measures of adequate staffing, effective nurse-physician collaboration, involvement in decision-making, and supportive nursing leaders were linked to poor nurse-reported patient care quality and safety, and worse nurse job outcomes.

Likewise, emergency nurses in better work environments were significantly less likely to report poor patient care quality outcomes or give their hospital a poor patient safety grade. These nurses were also less likely to report high burnout, job dissatisfaction, and turnover intentions.

In light of indications that physicians also are dissatisfied with the quality of emergency department workplaces—for instance, nearly half of emergency residency positions had an unfilled position in the U.S. Match in 2023 our findings signal problems for the future of the emergency care workforce. As employers struggle to recruit and retain clinicians to emergency departments, efforts must shift toward investing in high-quality work environments.

To achieve this, administrators can look to the top interventions endorsed by emergency nurses. A recent study of 794 emergency nurses in Magnet hospitals, led by clinical nurse researchers from Penn Medicine’s Pennsylvania Hospital, found that an overwhelming majority of emergency nurses recommend improved nurse staffing to improve their work environment.

Indeed, hospital CEOs increasingly are supporting policy efforts to improve safe staffing in U.S. hospitals, and these solutions must extend to emergency departments where most hospital care begins.

A 911 call for staffing help from the emergency department is an avoidable event. It is also a red flag that our health care leaders have chronically underinvested in high-quality work environments and safe nurse staffing.

Action to remediate this underinvestment is critical to ensure that patients receive the highest-quality care in our nation’s hospitals.

The study, The Association of the Emergency Department Work Environment on Patient Care and Nurse Job Outcomes, was published September 28, 2023, in  JACEP Open. Authors included K. Jane Muir,  Douglas M. Sloane,  Linda H. Aiken,  Vaneh Hovsepian, and Matthew D. McHugh.


Jane Muir

K. Jane Muir, PhD, APRN

Postdoctoral Fellow, National Clinician Scholars Program, Center for Health Outcomes and Policy Research.

Linda Aiken, PhD, RN

Claire Fagin Leadership Professor, Penn Nursing; Professor, Sociology, School of Arts and Sciences; Founding Director, Center for Health Outcomes and Policy Research.

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