Emergency Nurse Efficiency as a Measure of Emergency Nurse Performance

Abstract

Background: Emergency department crowding (EDC) is a major issue affecting hospitals in the United States and has devastating consequences, including an increased risk of patient mortality. Solutions to address EDC are traditionally focused on adding resources, including increased nurse staffing ratios. However, these solutions largely ignore the value of the experience and expertise that each nurse possesses and how those attributes can impact patient outcomes. This dissertation uses Benner’s Novice to Expert theory of professional development to describe how individual emergency nurse expertise influences patient length of stay in the emergency department and how it can be part of the strategy in addressing EDC.Purpose: The purpose of this program of research was to identify, articulate, and demonstrate a new approach to emergency nurse performance evaluation that integrates patient outcome data and emergency nurse characteristics. Methods: First, in a scoping review, we explored the different approaches to measuring nurse performance using patient outcome data and identified common themes. Second, a concept analysis introduced Emergency Nurse Efficiency as a novel framework to understand how emergency nurses can be evaluated using patient outcome data. Finally, a retrospective correlational study established the association between nurse expertise and emergency patient length of stay. Results: In Chapter Two of this dissertation, the researchers conducted a scoping review of nurse performance metrics and identified twelve articles for inclusion. We identified three themes: the emerging nature of these metrics in the literature, variability in their applications, and performance implications. We further described an opportunity for future researchers to work with nurse leaders and staff nurses to optimize these metrics. In Chapter Three, we performed a concept analysis to introduce a novel metric, called Emergency Nurse Efficiency, that is a measurable attribute that changes as experience is gained and incorporates the positive impact of an individual nurse during a given time while subtracting the negative. Using this measurement to evaluate ED nurse performance could guide staff development, education, and performance improvement initiatives. In Chapter Four, we performed a retrospective correlational analysis and administered an online survey to describe the relationship between individual emergency nurses, and their respective level of expertise, and their patients’ ED LOS. We found that, when accounting for patient-level variables and the influence of the ED physicians, emergency nurses are a statistically significant predictor of their patients’ ED LOS. A higher level of clinical expertise among emergency likely produces a lower ED LOS for their patients, and nurse leaders should seek to better understand these metrics for professional development and quality improvement activities. Conclusions: This dissertation made substantial knowledge contributions to the literature regarding the evaluation of individual emergency nurses and the influence that they have on patient outcomes. It established, first, that the measurement of individual nurse performance is varied and inconsistent; second, that considering emergency nursing as a team activity similar to professional sports results in a conceptual framework that can evaluate individual performance within a group context; and, third, that there is a relationship between the individual emergency nurse and their patients’ ED LOS, and that relationship can be further understood within Benner’s Novice to Expert theoretical model. We recommend that nurse leaders use these data as part of their strategy to decrease EDC.