Optimal Nurse Staffing in the Emergency Department: From Problems to Best Practices

1. Framing the problem, finding solutions

The National Science Foundation (NSF) recognizes the need to ensure timely access to healthcare services while improving the care experience for patients and the effectiveness of healthcare staff. NSF awards funding to researchers and organizations to investigate the problems and apply rigorous scientific methods to develop and apply solutions. Medecipher, a healthcare technology company founded to help hospitals optimize operational decision making, has been awarded a National Science Foundation (NSF) Small Business Innovation Research (SBIR) grant for $225,000 to conduct research and development (R&D) work on optimizing staffing decisions in emergency departments[i]. As a part of this research, Medecipher has conducted extensive interviews and surveys with Emergency Department (ED) nurses and nursing leaders.

This article serves a connecting function: sharing what we’ve learned first-hand from front-line nurses and leaders about their top staffing challenges – including solutions they’ve tried and lessons learned, showing how we apply this knowledge to improve staffing decisions in hospital EDs — and revealing opportunities for ED nurses and leaders to collaborate in developing solutions. First, we provide some background on the problems.

2. Current hospital pressures: striving for efficiency under resource constraints

Hospitals are under tremendous pressure to increase efficiency, improve revenue margins and enhance the patient experience, all while reducing the burden on frontline patient care teams. However, hospitals currently lack adequate tools to use data to achieve operational productivity gains. Barriers to effective patient flow create major problems for hospitals including queues and delays, under- and over-capacity utilization, patient acceptance in inappropriate settings, variability of workload and additional stress for hospital staff, which leads to their severe dissatisfaction, and may result in clinical errors.

Adding to these challenges, the United States currently faces a worsening nurse staffing shortage expected to exceed half a million nurses by 2025, in large part due to retirement of the aging nursing workforce and influx of new patients into our health system. Over the last two decades, there has been a 20% increase in the number of patients seeking care in EDs, while at the same time, 15% of the nation’s EDs have closed. The burden of a growing resource shortage impacts nurses working in the profession as they mitigate the additional workload. The additional patient volume and rising shortage creates increased wait time for patients, higher risks of mistakes, and insufficient personal attention to patients in the hospitals.

As healthcare delivery and treatment of patients becomes progressively more complex, effective decision making and allocation of nurse staffing resources is increasingly difficult. Current strategies and practices for determining nurse staffing levels have proven inadequate to meet existing needs, and the problem continues to worsen as time goes on. Across the country, nurses are striking against unsafe nursing staffing practices that impact patient care[ii], and are leaving their organizations in record numbers, with turnover rates as high as 40% in some areas.

3. The Emergency Department: clinical area of greatest need

While optimizing nurse staffing allocation is important across all clinical settings, the ED is especially sensitive to efficiency pressures, variability in patient flow dynamics, and shortages in nurse staffing. Jennifer Noble, charge nurse at Michael E. Debakey Medical Center in Houston, explains:

“The biggest challenge in the emergency department for nursing staffing is the nurse-to-patient ratio. Usually we go one-to-four but, as the influx of patient comes in, it goes to one-to-six, which is not safe. So, a lot of the nurses become burned out and they cannot really do their job well, as they are not able to give patients the care they need; patient outcomes are also affected.” [iii]

Top Challenges facing Emergency Departments:

Nurse staffing models in the ED must adapt to variability in hospital inflow conditions (variability in patient arrival volume and acuity) in addition to hospital outflow conditions (inpatient boarding, behavioral health boarding, and surgical case volume) which cause problems when hospital patient flow is not well understood and becomes unbalanced. Traditional ED staffing models have not evolved to adapt to these factors, and our customer discovery research shows there is difficulty in predicting and matching nursing resources with patient clinical demand, especially when hospital patient flow is laden with barriers, not well understood or actively managed.

Figure 1 Our discovery interviews pointed to opportunities to boost effectiveness in managing three main challenges relating to hospital inflow and outflow.

Boarding is the practice of keeping inpatient admissions in the ED until an inpatient bed becomes available. Patients boarding in the ED present safety issues and create nurse staffing challenges. In 2016, there were over 11 million inpatient admissions from EDs in the United States. Of those, more than two million patients—one in five—boarded in the ED, waiting six or more hours for an inpatient bed. [iv] Boarding has been shown to increase morbidity and mortality, inpatient length of stay (LOS), and healthcare costs.[v]  When admitted patients board in the ED, staff must manage the usual variability of ED inflow while simultaneously addressing this ED outflow problem.

Behavioral health patients boarding in the emergency department further complicate staffing demands. Many psychiatric conditions requiring admission call for surroundings with reduced stimuli, the need for 1:1 care, and de-escalation of acute symptoms. Inadequate psychiatric beds in many hospitals and limited options for external transfers contribute to the burden of nurse staffing. Additionally, many ED nursing staff have limited experience caring for behavioral health patients for extended periods of time.

Ron Woita, Director of Emergency Services, Sky Lakes Medical Center in southern Oregon, summarizes these biproducts of inflow and outflow challenges that he encountered in his nursing career:

“The single biggest challenge to nurse staffing is ensuring that you have experienced, high quality nurses at the bedside when you actually need them. An example of this would be we have seven mental health boarders, meaning psychiatric patients who are boarding in the emergency department. And I need to up my staffing by two RNs, actually four, over a 24-hour period and not have anybody to call or to bring in outside of our core staffing.[vi]

Ouida Lester, an emergency nurse at Baptist Memorial Healthcare Corporation in Memphis, TN, discussed the quality and safety implications of boarding patients in the emergency department, and relying on emergency department nurses to stretch their clinical skills beyond the ambulatory setting:

“The biggest challenge that I see in emergency nursing today, and has been for the past 15 years, and will be in the foreseeable future is boarders. How do you take care of boarders? The Joint Commission requires that you provide the same level of care that they would receive if they were actually in the appropriate bed, whether it be a general med/surg or an intensive care bed, and try to juggle that patient’s care with an ER nurse who is not a med/surg or an ICU nurse. We’re used to taking care of the acute part of it and then moving them on”.[vii] There is also the problem of lack of capacity, and an ED physical space that is not suitably designed for extended care. “How do you take care of all these people when you increase your volume by 20-30 more patients, but you don’t have 20-30 more beds?” She highlighted several challenges of the physical emergency department in providing boarding care: “Simple things like they don’t have a bathroom, a tray table to eat their meal on. Very simple things like that can be a very big challenge.” [viii]

And finally, the day-to-day variability in arrivals causes challenges planning for nurse staffing resource allocation. As we heard from Krystle Davis, ED nurse at Marin General Hospital:

“Some of the biggest challenges with staffing in the emergency department definitely has to be that it’s not the same every day…So I think when we are just going with our regular staffing model that we end up just being short. And if the acuity is high, which means the patient comes in very sick and needs to be treated one-to-one, that nurse gets pulled. We’re a trauma hospital so when we have major traumas come in, we have to pull staff as well. We lack, I think, that flexibility.” [ix]

4. Additional ED-specific concerns

While challenges around patient flow management are the most systemic for managing staffing in the emergency department, our interviews revealed additional ED-specific concerns. As part of our research, we conducted 30 phone interviews with chief nursing officers, nursing directors, and nurse managers. We surveyed 81 emergency department clinical and leadership staff, including front-line ED nurses, nurse leaders, and providers, and conducted 22 video interviews of nurses attending the Emergency Nurses Association conference, ENA 2019. In all these contexts, nurse staff turnover was cited as the greatest pain point, as shown in the following list. 

1. Nurse staff turnover

Nurses across the country say they not only feel overworked, but deeply worried that they can’t adequately care for the number of patients they’re responsible for in each shift. If not addressed, these deep underlying concerns lead to burnout, which costs hospitals over $9 Billion annually, in part because of turnover[x].

2. Staffing-related activities are a significant drain on nursing leadership.

Approximately 20-25% of work time is consumed with scheduling-related tasks. Additionally, when shifts are unfilled or there are gaps in the schedule, leadership often needs to step in to fill shifts at the last minute.  This results in lost opportunity to serve as leaders on the unit, and to provide nurse development.

3. Politics/interpersonal dynamics and bias leading to dissatisfaction

There is pressure to give the best shifts to nurses with the most tenure. Nurse staffing managers expend significant energy accounting for politics and hierarchy. Successful models either define very clear guidelines around merit or seniority and enforce them consistently or implement a flat system where all staff members are staffed with the same priority.

4. Inpatient solutions to nurse staffing do not meet the needs of Emergency Departments

EDs rely on more staggered shifts to match capacity with demand, thus introducing complications in the scheduling process. The inpatient model of “heads in beds” doesn’t apply.

5. Current approaches and their shortcomings

Nurse leaders manage their pools of emergency department nurses through annual forecasting, schedule planning, balancing, staff deployment with (or without) automated scheduling systems, open shift filling (at times via self-scheduling), “day-of” flexing, and daily reconciliation of time scheduled to time worked. These staffing activities are often performed within the hospital’s integrated business management Enterprise Resource Planning (ERP) software, spreadsheets, or other data management tools.

Through our research, we discovered that EDs are frequently challenged to supplement their staff in real-time to address these issues. The most common strategies included use of contract staff and flexing (adding staff or shift cancellation). Contract staff, overtime and incentive pay are expensive, and may result in decreased quality of care. The cost of a contracted agency nurse is 1.5 to 2 times higher than the rate of other acute care nurses. Conversely, shift cancellation can lead to dissatisfaction among staff.[xi]

Figure 2 Premium services such as use of contract labor and flex staffing are common solutions to staffing challenges

Ouida Lester, an emergency nurse at Baptist Memorial Healthcare Corporation in Memphis, TN describes the advantages and challenges of using this strategy to care for boarding patients in the emergency department: “We address that by hiring seasonal nurses because our typical hold pattern for boarders was from late fall to early spring. So, hire seasonal nurses for that time so they’re here when you need them and not when you don’t. However, that has not worked this spring and summer because we’ve continued to hold boarders.  So now, we’re working with the resources we have, and while we do try to pay lots of overtime, the nurses quickly get burnt out of that as well. The hospital pays “star pay,” which means that they offer you time and a half, even if you haven’t worked you know your 40 hours (which generally qualifies you to receive overtime). But it’s just a challenge because the nurses quickly burn out from that.[xii]

Some EDs have begun cross training their existing float pool workforce in order to increase the flexibility and availability of resources to cover the emergency department. Ron Woita, Director of Emergency Services, Sky Lakes Medical Center in southern Oregon relayed:

“[My hospital] is working as an organization to ensure that we have flexible staff who can move to where they’re needed. So, through pay and through bonuses we have enticed staff to become certified in four or more areas within the organization. So that we can call them in when our ED population demands that.”[xiii]

Many EDs, however, do not currently utilize alternative staffing strategies to address volume, acuity or staffing fluctuations. Opportunity exists to improve how such fluctuation and variability is managed. If the current problems could be fixed, how valuable would that be to patients and staff? Let’s look at what the nurses and other staff told us.

6.    What would happen if we could solve these problems?

Emergency nurses today can identify the impact that solving nurse staffing challenges would have on their day-to-day work and can envision better ways to do things.

Several important themes emerged in the observations. Optimal nurse staffing would lead to a better patient experience – less waiting, and better quality and outcomes. It would also lead to a better staff experience as nurses would be able to focus on patient care for emergency patients and would be empowered to make timely and appropriate decisions. And finally, it would impact efficiency and performance metrics such as throughput and patient satisfaction.

Yvette Gulinao, ED nurse at Sibley Memorial Hospital in Washington, DC, describes how her solving nurse staffing challenges at her hospital would lead to patients receiving faster care:

“If we weren’t having such a clog in the ER, triage patients would be getting care faster. They’d be getting the care that they needed and getting through the process faster and they’d be saved and not waiting for care.” [xiv]

Samantha Hoyler, an emergency staff nurse at a community hospital part of Northwell Health in New York, stated that nurses could better focus their attention to providing emergency care:

“If that was resolved, it would be so much easier for me to focus my time on the patients that are coming into the emergency room for emergency cases. I’m not saying that the inpatients aren’t important. They need their care, but they require so much more than just a quick assessment of what I can do for an ER patient. It takes away my time from my emergencies when I have to give a lot of medications and bed care; my time would be more devoted to my ER patients.”[xv] 

Emergency nurse managers told us how optimized staff would impact their day-to-day lives, both on-the-job, and at home.

Ron Woita stated: “If this problem were solved, it would actually be a huge staff satisfier and give us the ability to act as a manager, and take away some of the fear of the mid-afternoon when sick calls are coming or when psychiatric patients are boarding or even backed up from an admission standpoint.” [xvi]

Karima Durazzai, a charge nurse at Memorial Hermann in Houston commented on the potential impact to her personal life: If staff scheduling challenges were resolved, “Personally, my life would be changed, because I love the weekend and would love to enjoy it without being bombarded with text messages and last-minute preparation or getting called in to go to work.” She would never again have to rearrange her weekend plans, explaining to her family, “Oh sorry I have to drop this because I have to report to work because of the shortage on this job and helping my partner in crime.”[xvii]

Clearly, solving these troubling and persistent staffing issues is good for the health of patients, the hospital, and the work life of the staff who are trying to work around these problems.

7.    The Value of Rigorous Optimizing Solutions

What if better solutions were available to resolve the problems rather than just cope with them? The good news is that there are! The use of predictive analytics, in conjunction with technology, to address staffing based on actual data has been found to be useful in managing staffing issues associated with volume, acuity or other factors that impact ED nurse staffing. Now we’ll look at how Medecipher has developed solutions that are recognized as valuable and practical by emergency staff.[xviii]

Medecipher helps emergency departments improve the quality of care for patients, improve the quality of the work environment for staff, and reduce operating costs with a suite of proactive planning and real-time decision support tools. Our flagship product, Flo, combines proactive planning with real-time decision support to enhance a nurse manager’s decision making across the entire staff scheduling horizon – from the annual forecasting budgeting process through same-day flexing.

Figure 3 Medecipher supports the staffing & scheduling continuum

The tool works by learning a hospital’s unique patient demand, throughput and workflow to predict in real time the outlook for scheduling horizon and prescribe a staffing scheduling course of action. The nurse manager then adapts the recommendation based on her clinical judgement, and that feedback is reincorporated into the model to improve future predictions and recommendations.

Figure 4 Medecipher Predict-Prescribe-Adapt Methodology

8.    Opportunities and Optimism

Staffing problems are visible and persistent in hospital EDs. The nurses and other staff are aware of them, have learned to work around them, and have valuable ideas for solving them. As patients suffer the consequences of delayed or inadequate care and hospitals operate at suboptimal levels of efficiency, the call for improvement is urgent.  Medecipher’s multidisciplinary collaboration with hospitals, staff, and analytical experts is already yielding impactful improvement in operational decision-making and noticeable boosts to efficiency. As our collaborative community of learners and implementers continues to grow, the benefits will accelerate.  What opportunities would you like to seize to be part of these essential innovations? Contact us to participate.

[i] See “Medecipher Awarded Competitive Grant from the National Science Foundation” at
[ii] source: California, and University of Chicago
[iii] Jennifer Noble, Charge Nurse, Michael E. Debakey Medical Center in Houston.
[iv] AHRQ, 2014; TeleTracking, 2017
[v] Sun, 2013; Carter et al, 2014; Sayah et al., 2014; Stang, 2015
[vi] Ron Woita, Director of Emergency Services, Sky Lakes Medical Center in southern Oregon, September 30, 2019, Emergency Nursing Association Annual conference
[vii] Ouida Lester, emergency department nurse, Baptist Memorial Healthcare Corporation, Memphis Tennessee.
[viii] Ouida Lester, emergency department nurse, Baptist Memorial Healthcare Corporation, Memphis Tennessee.
[ix] Krystle Davis, ED Nurse, Marin General Hospital
[xi] Source: Medecipher – customer discovery interviews & surveys, conducted in September 2019
[xii] Ouida Lester, emergency department nurse, Baptist Memorial Healthcare Corporation, Memphis Tennessee.
[xiii] Ron Woita, Director of the Emergency Department for nursing at Sky Lakes Medical Center in Southern Oregon, September 30, 2019, Emergency Nursing Association Annual conference.
[xiv] Yvette Gulinao, ED nurse, September 30, 2019, Emergency Nursing Association Annual conference.
[xv] Samantha Hoyler, Northwell, Long Island, NY, September 30, 2019, Emergency Nursing Association Annual conference.
[xvi] Ron Woita, Director of Emergency Services, Sky Lakes Medical Center in Southern Oregon, September 30, 2019, Emergency Nursing Association Annual conference.
[xvii] Karima Durazzai, Emergency Department charge nurse, Memorial Hermann
[xviii] See “Medecipher awarded #BestValue for Emergency Medicine at ACEP’s section for Informatics” at