Boarding inpatients has become an all-too-frequent occurrence in emergency departments (EDs) across the country. Twenty years ago, boarding inpatients in an ED was not common and usually occurred only in large, inner-city departments. Now, 25-bed critical access hospitals and large academic medical centers alike share this burden. And, although The Joint Commission mandates that hospitals make efforts to decrease ED overcrowding, most of us at the stretcher-side would agree that we've seen little to no progress in the past 5-10 years. In fact, it's getting worse.

Aside from the well-known risks of boarding for the patients (e.g., longer hospital lengths of stay, increased morbidity and mortality, delays in receiving treatment; Chalfin, Trzeciak, Likourezos, Baumann, & Dellinger, 2007; Johnson & Winkelman, 2011), boarding inpatients also exacts a toll on the emergency nursing staff. We specify nursing staff here because ED physicians are less likely to be affected because the medical care of these patients has been handed off to an admitting service. Not only are we frequently short-staffed and overworked but also caring for inpatients is not what emergency nurses want to do. Any of us could have a job as an inpatient nurse if we wanted it. This is not to say that these are less stressful or less difficult nursing jobs. On the contrary, we all realize that the medical-surgical and intensive care unit nurses are also working hard. However, it's a different type of work. Emergency nurses are wired differently and that's what allows us to be successful in our environment. We have our own brand of attention deficit disorder. We like the variety in patient type, acuity, and disease condition. We want fast results (instant gratification). We want to "disposition" of our patients as quickly as possible to clear out the stretcher for the patient in cardiac arrest who we know may arrive at any time. We don't want to care for the same four to six patients for an entire shift.

Emergency nurses don't think in terms of a plan of care for the shift, 9:00 a.m. medications, or getting patients out of bed to walk twice today. We think in terms of the next priority, "What is the worst thing this could be and how do we rule that out or manage it if it is indeed life-, limb-, or vision-threatening?" Once the dust is settled, we're on to the next patient who comes through our doors and those 9:00 a.m. medications are forgotten. Or, if we remember them, the 9:00 a.m. medications aren't stocked in the ED and they haven't come up from the pharmacy, so by the time we track them down, it's noon. And, forget basic hygiene, most EDs do not have ready access to showers or even bathrooms en suite for patients. We know in our heart of hearts that we are not providing the same standard of care that patients would receive on an inpatient unit, so that's an additional stressor.

"Nurses' satisfaction" is not a typical element in the all-important satisfaction scores followed by hospital administration. Perhaps, it should be. We know that there is a shortage of experienced emergency nurses, and we know it is expensive to train a new or inexperienced nurse to the point of competence in the ED. This expense is not just monetary, and it is not just related to education and nonproductive time. A little appreciated expense is the burden on clinical nurse specialists, educators, and current emergency nurses to train and precept these new nurses and to watch out for them and their patients until true competence is attained (2-3 years according to Benner, 1984). Yes, we will always need to train new emergency nurses, but the constant cycle of new hires/new resignations creates more stress on the current staff. Add that to job, dissatisfaction related to caring for boarders, and some emergency nurses will decide that the grass has to be greener elsewhere. Right now, the economy may be decreasing turnover as nurses choose to work more hours and put off retirement, but when the economy turns around, we may find ourselves with an even greater shortage of emergency nurses.

Several years ago, an article authored by emergency nurses and physicians addressed the shortage of emergency nurses. In that article, several recommendations were made to help improve the workforce in the future. The first recommendation was to "improve the workplace environment" (Schriver, Talmadge, Chuong, & Hedges, 2003). The two key strategies identified to improve the workplace environment were to improve nurse-to-patient ratios and to stop boarding inpatients. Now, 10 years later, we find that these situations have not improved; they have indeed deteriorated. So, we beg the question, "What are you doing in your ED to address inpatient boarding and the nurses' satisfaction?"

-Jean A. Proehl, RN, MN, CEN, CPEN, FAEN

Emergency Clinical Nurse Specialist

Proehl PRN, LLC

Cornish, NH

-K. Sue Hoyt, PhD, RN, FNP-BC, CEN, FAEN, FAANP, FAAN

Emergency Nurse Practitioner

St. Mary Medical Center

Long Beach, CA

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