The Journal of the New York State Nurses Association, Volume 52, Number 2

THE JOURNAL

of the

New York State Nurses Association

VOLUME 52, NUMBER 2

n Editorial: Systemic Improvements and Evidence-Based Nursing Practice in Healthcare Transformation by Simon Paul P. Navarro, MA, BSN, RN, CCRN, TCRN

n A Serendipitous Connection Between Nursing and Architecture: Innovative Model to Decrease Disparities in Children’s Health and Education by Bridget Maley, PhD, RN, CNE; Kathleen Falk, DNS, MS, RN, FNP; Eric Anderson, AIA; and Esteban Beita Solano, PhD

n Evidence-Based Strategies to Improve Door-to-Provider Times in the Emergency Department by Cynthia Diaz, DNP, MSN, RN, FNP-BC; Jasmine V. Hackett, DNP, MSN, RN, FNP-BC; and Reneé Lewis-DuQuesnay, DNP, MSN, RN, FNP-BC

n Ensuring Credibility and Trustworthiness in Qualitative Research by Alsacia L. Sepúlveda-Pacsi, PhD, DNS, RN, FNP, CCRN, CEN; and Cassandra Dobson, PhD, RN-BC, PHc

n Nurses Advocating for Safety: A Policy Review of New York’s Safe Staffing for Quality Care Law by Lorraine Cupelli, MS, RN

n Healthcare Literature Highlights

n CE Activity: Evidence-Based Strategies to Improve Door-to-Provider Times in the Emergency Department; Ensuring Credibility and Trustworthiness in Qualitative Research

THE JOURNAL

by Simon Paul P. Navarro, MA, BSN, RN, CCRN, TCRN n A Serendipitous

by Bridget Maley, PhD, RN, CNE; Kathleen Falk, DNS, MS, RN, FNP; Eric Anderson, AIA; and Esteban Beita Solano, PhD

by Cynthia Diaz, DNP, MSN, RN, FNP-BC; Jasmine V. Hackett, DNP, MSN, RN, FNP-BC; and Reneé Lewis-DuQuesnay, DNP, MSN, RN, FNP-BC n

by Alsacia L. Sepúlveda-Pacsi, PhD, DNS, RN, FNP, CCRN, CEN; and Cassandra Dobson, PhD, RN-BC, PHc n Nurses Advocating for Safety:

by Lorraine Cupelli, MS, RN

THE JOURNAL

of the New York State Nurses Association

n The Journal of the New York State Nurses Association Editorial Board

Anne Bové, MSN, RN-BC, CCRN, ANP Clinical Instructor New York, NY

Judith Cutchin, DNP, RN Registered Nurse

New York City Health + Hospitals/Woodhull New York, NY

Margaret Franks, BSN, RN, MED-SURG BC Med-Surge Nurse

Vassar Brothers Medical Center

Poughkeepsie, NY

Michelle Jones, MSN, RN, ANP-C Adult Nurse Practitioner Flushing Hospital Medical Center Flushing, NY

Alizia McMyers, MSN, MHA, BSN, RN Accountable Care Manager NYC Health + Hospitals—Harlem New York, NY

Simon Paul P. Navarro, MA, BSN, RN, CCRN, TCRN Clinical Nurse New York-Presbyterian/ Columbia University Irving Medical Center New York, NY

Alsacia SepÚlveda-Pacsi, PhD, DNS, RN, FNP, CCRN, CEN Registered Nurse III New York-Presbyterian Adult Emergency Department New York, NY

n Karen Broomes-James, DNP, RN, NPD-BC, CCRN-K, SCRN, PCCN, Co-Managing Editor

Rose Sona Bright Jibu, DNP, MSN, APRN, CPNP-PC, RNC-NIC, Co-Managing Editor

Nolan Webster, Editorial Assistant

The information, views, and opinions expressed in The Journal articles are those of the authors, and do not necessarily reflect the official policy or position of the New York State Nurses Association, its Board of Directors, or any of its employees. Neither the New York State Nurses Association, the authors, the editors, nor the publisher assumes any responsibility for any errors or omissions herein contained.

The Journal of the New York State Nurses Association is peer reviewed and published biannually by the New York State Nurses Association. ISSN# 0028-7644. Editorial and general offices are located at 131 West 33rd Street, 4th Floor, New York, NY, 10001; Telephone 212-785-0157; Fax 212-785-0429; email info@nysna.org. Annual subscription: no cost for NYSNA members; $17 for nonmembers

The Journal of the New York State Nurses Association is indexed in the Cumulative Index to Nursing, Allied Health Literature, and the International Nursing Index. It is searchable in CD-ROM and online versions of these databases available from a variety of vendors including SilverPlatter, BRS Information Services, DIALOG Services, and the National Library of Medicine’s MEDLINE system. It is available in microform from National Archive Publishing Company, Ann Arbor, Michigan.

n EDITORIAL

Systemic Improvements and Evidence-Based Nursing Practice in Healthcare Transformation

Simon Paul P. Navarro, MA, BSN, RN, CCRN, TCRN

This issue of The Journal of the New York State Nurses Association foregrounds the urgent need for systemic improvements and evidence-based strategies to confront the most pressing challenges currently shaping the healthcare landscape. Together with the editorial team of The Journal, we want to emphasize the position of the “nursing profession” as a pivotal force in driving meaningful transformation across healthcare systems. The featured articles in this issue collectively highlight targeted efforts to enhance patient outcomes, strengthen operational efficiency, promote research rigor, and drive necessary policy reform.

The opening article, “A Serendipitous Connection Between Nursing and Architecture: Innovative Model to Decrease Disparities in Children’s Health and Education,” illustrates the value of interdisciplinary collaboration in generating sustainable solutions through an unexpected yet productive partnership between nursing and architecture that led to an appreciative inquiry project aimed at reducing disparities in children’s health and educational experiences. This collaboration proposed an innovative healthcare design model and reinforced the importance of engaging nurses early in architectural planning processes to shape care environments that better support patient needs and clinical workflows.

In the following article, “Evidence-based Strategies to Improve Door-to-Provider Times in the Emergency Department,” operational efficiency is another key focus in mitigating overcrowding, which occurs when emergency services demand exceeds available resources. The authors emphasized the role of advanced practice providers (APPs) in triage and split-flow models as evidence-based strategies not only to mitigate overcrowding but also optimize outcomes in the emergency departments, like length of stay, door-to-provider times, patient satisfaction, and staff well-being.

Complementing these efforts, the article “Ensuring Credibility and Trustworthiness in Qualitative Research” emphasizes the importance of robust methodologies in qualitative research to advance nursing science and practice. The authors stress the role of trustworthiness frameworks, like Lincoln and Guba’s model, in strengthening the credibility and relevance of qualitative research. This focus captures complex patient experiences that quantitative approaches may overlook, enriching evidence-based clinical and organizational decision-making through qualitative inquiries.

Finally, the last article, “Nurses Advocating for Safety: A Policy Review of New York’s Safe Staffing for Quality Care Law,” presents the crucial intersection of policy and advocacy for workforce sustainability. A review of New York’s Safe Staffing for Quality Care Law reveals significant challenges in regulatory implementation, such as low hospital compliance and limited oversight from the NYS Department of Health. The article calls for stronger policy mechanisms to reduce nurse workload and burnout, address workforce shortages, and improve staffing practices that directly influence patient outcomes and professional well-being.

Taken together, these articles illuminate the intertwined challenges of operational strain and workforce sustainability facing healthcare systems today. Whether through innovative approaches to facility design, strategic deployment of APPs, strengthened research practices, or greater accountability in staffing policy, the collective insights point to a unified conclusion: Systemic improvements anchored in strong nursing leadership and evidence-based solutions ensure timely, high-quality care and reinforce the standing of healthcare organizations in communities.

On behalf of the new leadership of The Journal of the NSYNA, Karen Broomes-James, DNP, RN, NPD-BC, CCRN-K, SCRN, PCCN, and Rose Sona Bright Jibu, DNP, MSN, APRN, CPNP-PC, RNC-NIC, as well as the new members of the editorial board, I hope you enjoy and find these readings insightful!

A Serendipitous Connection Between Nursing and Architecture: Innovative Model to Decrease Disparities in Children’s Health and Education

Bridget Maley, PhD, RN, CNE

Kathleen Falk, DNS, MS, RN, FNP

Eric Anderson, AIA

Esteban Beita Solano, PhD

n Abstract

A serendipitous meeting of nursing and architecture revealed that both departments were working on similar areas of interest, which involved children’s disparities. An Appreciative Inquiry (AI) project was conducted with nursing faculty and students and architecture faculty and students. The aim of the inquiry was to examine the barriers to equitable outcomes for children and to develop a proposal for innovative approaches to decrease childhood disparities. Through this study method, participants discovered a collective vision of a novel model of healthcare design. An action plan was implemented, evaluated, and conclusions were drawn. Data from this inquiry imply that nurses should collaborate with other professional fields to develop new models of health care. It is beneficial for the architects and their design team to consult and seek advice from the nursing profession prior to initiating the design of buildings where health care is delivered.

Keywords: health, children, nursing, architecture, disparities, Appreciative Inquiry

Introduction

Serendipity, the idea of creating accidental and valuable inventions, plays an important role of innovation in organizations. An exemplar of leadership that fosters innovations is Edwin Catmull, cofounder of Pixar and president of Walt Disney Animation Studios. The physical workspace at Pixar represents a culture of collectiveness, which connects all departments, promoting communication fluidity. Busch’s (2022) systematic review investigated the essential aspects of serendipitous innovations. The researcher found that there are three necessary components to unplanned and valuable discoveries: (1) a surprise—that is a serendipity trigger; (2) agency—connects the dots to something meaningful; and (3) value—organizational content was materialized. Busch postulates that organizations that cultivate these essentials of serendipity make it possible for surprising and valuable discoveries to emerge. The use of Busch’s three essential aspects is used to describe the collaborative process between architecture and nursing.

A Surprise

Despite the fact that the nursing profession makes up 30% of hospitals healthcare workforce, there are few opportunities for nurses to contribute to the planning of the designs of structures where healthcare services take place (U.S. Bureau of Labor Statistics [U.S. BLS], 2020). The opportunity for input by the nursing profession on this project was the result of an accidental staircase meeting, which took place at a university’s research day poster presentation. A group of architect faculty noticed that the nursing faculty was addressing disparities in the Brownsville neighborhood of Brooklyn. In the previous month, the architects had been requested to develop renderings of buildings designed to target the same disparities in Brownsville. This came as a surprise to both parties. Neither department had any knowledge of the other’s involvement in this similar pursuit of inquiry. This unplanned connection was made possible by the university’s goal of promoting an environment in which collaboration occurred.

Bridget Maley, PhD, RN, CNE, New York City College of Technology, City University of New York, Brooklyn, New York

Kathleen Falk, DNS, MS, RN, FNP, New York City College of Technology, City University of New York, Brooklyn, New York Eric Anderson, AIA, Farmingdale State College, State University of New York, Farmingdale, New York

Esteban Beita Solano, PhD, New York City College of Technology, City University of New York, Brooklyn, New York

Agency

An introduction between the authors of the research posters was made. This coincidental meeting provided an opportunity for both professionals in the fields of nursing and architecture to learn from each other. This is where they began to connect the dots between what architecture and nursing was doing, thereby learning from each other. Both departments agreed to collectively focus on identifying barriers to equitable health in children, reducing chronic school absenteeism, and promoting architectural design for health and wellbeing. The following Appreciative Topic question was posed by participants: “What is the collective vision of health care and architecture for a wellness model that supports health in children and decreases chronic school absenteeism?”

Value

Both architecture and nursing departments’ leadership endorsed the collaboration. The president of the college also supported the endeavor. The integration of architectural science and nursing science through the Appreciative Inquiry (AI) framework fostered a collaborative approach to healthcare design that prioritized patient well-being. Architectural science contributed insights into how physical environments, such as lighting, spatial layout, and access to nature impact human health and behavior. Nursing science offered a profound understanding of patient care needs, emphasizing the importance of environments that support healing and comfort. By employing the AI framework, which focused on identifying and building upon existing strengths, nursing and architecture professionals were able to collaboratively envision healthcare spaces that addressed disparities in patient outcomes. This strengths-based approach encouraged the cocreation of innovative design solutions, such as incorporating natural light, communal areas for patient interaction, and therapeutic gardens, all aimed at enhancing patient engagement and promoting healing. Through this interdisciplinary collaboration guided by AI, the resulting healthcare environments were not only functionally efficient but also holistically supportive of patient health and recovery.

Background

Barriers to Achieving Equity in Children’s Health and Education

Social determinants of health, such as poverty, lack of health care, inadequate nutrition, and hardships of adverse childhood experiences (ACEs) impact the health, well-being, and educational outcomes of children. Youth who live in ZIP codes where they experience disparate rates of these inequities develop chronic diseases at an earlier age (Greenlund et al., 2022; Smith et al., 2022; & Rees et al., 2020). Chronic diseases in children are among the leading reasons for chronic school absenteeism, which is a strong predictor of high school incompletion (Throngseiratch & Chandeying, 2020). Historically, pediatric health care and education functioned in separate silos, when in reality they are interdependent—you can’t have one without the other. Therein lie policies that create barriers to equitable health and educational outcomes.

Nursing science offered a profound understanding of patient care needs, emphasizing the importance of environments that support healing and comfort. By employing the AI framework, which focused on identifying and building upon existing strengths, nursing and architecture professionals were able to collaboratively envision healthcare spaces that addressed disparities in patient outcomes.

The following is an example of policies in pediatric health care and education that perpetuate chronic illnesses in children: A child with uncontrolled asthma, living in a single-parent household with income 200% of the federal poverty level (FPL), spends 10 hours a day in school because they attend an after school program to facilitate childcare while their parent is working. Due to uncontrolled episodes of asthma, the child has frequent exacerbations that require emergency visits and admissions for acute hospitalizations and subsequent chronic school absenteeism. When the child returns to school after hospitalization, a new asthma action plan (APA) and medical treatment plan need to be furnished to the school. The responsibility to do this falls on the child’s parent, who may not be able to take time off from work to facilitate getting the documents from the pediatrician to the school. To complicate matters further, this also entails the parent needing to take additional time off from work to facilitate getting medications for the school from separate providers and pharmacies. The school nurse cannot administer the new medications and implement the updated APA unless the required documents are in place. Hence, the new APA does not get fully implemented and the child stays in the vicious cycle of uncontrolled asthma.

Centers for Disease Control and Prevention ([CDC], 2025) defines chronic absenteeism as 10% or more missed days from a school per year. (this includes excused and unexcused absences). People with less than a high school education also experience disparate rates of poverty, lack of employment opportunities, high rates of incarceration, and lower life expectancy (Institute for Health Metrics, 2024). The aim of this project is to examine the barriers to equitable outcomes in children and to develop a proposal for innovative approaches to decrease childhood disparities.

In this project, innovations are focused on three categories of health disparities that largely contribute to chronic school absenteeism: (a) uncontrolled asthma, (b) multisystem illnesses related to obesity, and (c) adverse childhood experiences. ACEs are events of neglect, abuse, and violence suffered by children. These experiences have deleterious effects

Figure 1

Appreciative Inquiry Process and Affirmative Topic

“What gives life?” The best of what is Discovery Appreciating

Destiny Sustaining

“How to empower, learn, and improvise?”

A irmative Topic

Appreciating

“What might be” Envisioning Dream Results/Impact

Design Co-constructing

“What should be — the ideal? ”

Note. Affirmative Topic is the same as Appreciative Topic. From “The Practice of Appreciative Inquiry,” by J. D. Ludema and R. E. Fry, 2011, in P. Reason & H. Bradbury (Eds.), The Sage Handbook of Action Research Participative Inquiry and Practice, 2nd ed. Copyright 2011 by SAGE.

on mental and physical health across their lifespan. By targeting treatment strategies in these three areas of chronic conditions, absenteeism from school can be decreased (Lomholt et al., 2022). Nursing and architecture collaborated on the design of a building that can facilitate developing (a) state-of-the-art specialty clinics that deliver evidence-based practice (EBP) interventions for asthma and that are designed to decrease the disparate rates of asthma-related emergencies and hospitalizations (Black & Elgaddal, 2024); (b) family-focused obesity treatment, an approach that decreases the risk of developing asthma, diabetes, and cardiovascular diseases within the entire family system (Toto et al., 2024); and (c) healthcare teams that will assess children for ACEs and make referrals to mental health services and resources (Felitti et al., 1998).

Appreciative Inquiry Model and Theory

AI is a generative form of action research (AR). AI process was employed in the collaboration of nursing and architecture. Cooperrider and Srivastva (1987) categorize AI as a philosophy in which inquiry and anticipatory learning take place. It is described as a “strength-based approach to transforming human systems toward a shared image and their most positive potential by discovering the very best in their shared experience” (Ludema & Fry, 2011, p. 281). As a branch of AR, AI seeks to create a positive revolution toward transformative changes. AI process is egalitarian in nature, valuing all participants’ input and expertise (Barrett & Fry, 2005; Ludema & Fry, 2011; Whitney & Trosten-Bloom, 2003). Participants in this project were (a) nursing faculty who were advance practice nurses

Table 1

Results of the Discovery Stage

Disparities Among Children

Nursing Asthma

Nursing

Nursing

Adverse childhood experiences (ACEs)

Building Design

Design of the Health and Wellness Center

• Asthma action plans (AAPs) provide an evidence-based practice (EBP) approach to fewer asthma exacerbations and subsequent missed days of school.

• School-based treatment provides evidence on the effectiveness of promoting management of asthma. This setting supports allergy testing for children with asthma.

• Reducing asthmatic allergens in the environment reduces the frequency and severity of asthma symptoms.

• EBP family approach to obesity prevention and treatment.

• Meta-analysis on the type of interventions that promote normal weight and assist in weight loss are interventional programs that offer a combination of nutritional and exercise/activity interventions.

• Promotion of plant-based nutrition to support optimal immune system and normal weight.

• Children who are traumatized by four or more ACEs are at significantly higher risk to develop mental health disorders, chronic physical illnesses, and health risk behaviors.

• Children who experience ACEs benefit from early identification and intervention.

• Identification of children affected by ACEs is made possible with the use of the 11-item ACE Scale.

• Space standards for youth centers, school health clinic standards, and school-based health standards for youth centers provide a comprehensive set of guidelines for the development of scalable community-based health delivery and counseling for K–12 youth. State departments of health and state agencies for child protection also offer guidelines for building standards for youth healthcare settings.

• These standards emphasize the importance of creating safe and welcoming environments for young people, while also promoting their health and well-being through accessible and high-quality healthcare services.

• Over-all design to promote population health include: (a) decreased carbon emissions; (b) sustainability; (c) indoor climate control and air filtration; and (d) construction from materials that lower the incidence of allergic asthma triggers.

and doctoral-prepared nurses; (b) architecture department faculty; and (c) registered nurses, bachelor of science nursing students, and undergraduate architecture students. The process of AI enabled participants to arrive at a shared vision of the preferred future and to be energized and inspired to take collective action. This project is an example of how the AI process can create synergistic energy that eventually yields a novel conceptual model (see Figure 1 and Tables 1 & 2).

Appreciative Inquiry Process: Appreciative Topic and Four-Stage Cycle

The AI process consists of arriving at an Appreciative Topic (AT) or a positively framed question focused on strengths and potential, followed by the Four-Stage Cycle, which includes the Discovery Stage, Dream Stage, Design Stage, and Destiny Stage. The first task for participants was to choose an AT of common interest in the context of urban public health for children living in ZIP codes with disparate rates of chronic illnesses and high rates of chronic school absenteeism. The following AT question was posed by participants: “What is the collective vision of health care and architecture for a wellness model that supports health in children and decreases chronic school absenteeism?”

Discovery Stage

After the AT was chosen, participants moved on to the Discovery Stage of the Four-Stage Cycle. The task of this stage is to “discover the best of what is.” In the context of health care and architecture, this required examining the “best” models of health care and architecture promoting healthy environmental structures and reducing illnesses in children (see Table 1).

Dream Stage

After identifying “the best of what is,” the focus moved onto the Dream Stage. The purpose of this stage is for participants to envision 2 to 3 years into the future. Participants imagined (a) a transformed practice for nurses working with children who bear a heavy burden of disparities in chronic illnesses and high rates of chronic school absenteeism, and (b) a transformed practice in architecture and design that incorporated sustainable spaces in buildings where evidence-based practice health care could be carried out.

Nurses met with a design team comprised of architecture faculty and architecture students to create a “wish list” of all the necessary

Table 2

Results of the Dream Stage

Disparities Among Children

Nursing

Uncontrolled asthma

Nursing

Obesity

Nursing

Adverse childhood experiences (ACEs)

Building Design

Uncontrolled asthma, rise in asthma rates, and global warming

Building Design

Obesity

Building Design

ACEs

Dream Stage “Wish List”

Envision 2-3 years in the future, a preferred practice

Design of the Health and Wellness Center

• Decrease asthma-related missed days from school with the services offered at the Center of Excellence in Asthma Treatment.

• Communication hot line: facilitate optimum recovery from asthma exacerbation and expedite resumption of school attendance. Interface with acute care facilities, community-based pediatric treatment facilities, families, and public schools and school nurses to coordinate care.

• Youth development program: vocational guidance, educational support/tutoring, fostering of civic engagement and leadership, and promotion of social and emotional skills. Support for emotional health and wellness: screening for ACEs, referral to mental health services, mentoring for children, and coaching for parents.

• Evidenced-based obesity and treatment for the entire family.

• Resources for boosting the immune system with plant-based focused, healthy meals and nutritional support.

• 60 minutes a day of recreational activities.

• Screening for ACEs.

• Referrals for mental health services.

• Mentoring for children and coaching for parents.

• Functional program: Model functional program analysis based upon current review of school-based health centers to educational outcomes.

 Science labs, media labs, learning spaces, technology resources, recreational facilities, and performance and arts facilities.

 Clinic spaces for examination and treatment.

 Inclusion of an indoor swimming pool for year-round access for children with asthma.

 Design that supports indoor gardens, plant-based nutrition, and an air quality-controlled environment.

• Building materials to be of low-allergen-producing products and a new technology air filtration system.

• Functional program: Build upon culinary interventions that model school-based programs that link home economics education in nutrition and food preparation.

 Clinic space and human resources devoted to the delivery of evidenced-based quality care.

 Commercial kitchen with cooking access.

 Hydroponic labs for fostering plant-based nutrition.

 Recreational facilities in a climate-controlled environment.

• Functional program: space that supports meditation and tranquility.

 Creation of a therapeutic milieu: a place for art therapy, role-playing, and music therapy.

 Private rooms for meeting with children and their parents.

resources that would be included in the design of the Wellness Center for Excellence in Health Care. The meeting with the design team was organized as a design charette, a structured process for project clients and stakeholders (nursing faculty and nursing students) to define their project vision, which comprised the following: (a) a definition of project goals, (b) strengths, (c) weaknesses, (d) opportunities, and (e) threats encountered in the project design. The development identified the vision used by the design team to develop the initial project concept. O’Hara et. al (2024) describe the collaboration of a design charrette conducted with architects Vincent Della Donna and Stephen Langston to develop goals and outcomes for “restorative spaces” that contributed to positive

Whether through collaborative design charrettes or evidence-based therapeutic design principles, recent work shows a clear trend: Involving stakeholders and applying health-focused design strategies lead to educational and healthcare spaces that better promote healing, well-being, and positive health behaviors.

health outcomes for both caregivers and patients. The charette team goal to “Apply architectural design features and elements to create a space and environment for well-being” (p. 19) presents the goals for analysis and synthesis of the facilities’ design and construction to support how the space is used. The charette process facilitated the development of a wish list, which was used to create a functional program statement to link therapeutic goals to architecture (see Table 2).

The design charette outcomes were used to measure and define the relationship between the functional program, educational activities, and treatment protocols of the proposed center (see Table 2). A concurrent review of space and operational standards for traditional school-based wellness centers is advisable to reduce duplication or redundancy in the definition of space quantity and attributes, as the new model is presented for funding and approval. Professional architectural organizations have long supported the use of architectural design as a critical tool for improving health and wellness. Whether through collaborative design charrettes or evidence-based therapeutic design principles, recent work shows a clear trend: Involving stakeholders and applying health-focused design strategies lead to educational and healthcare spaces that better promote healing, well-being, and positive health behaviors. The International Union of Architects (UIA) Public Health Group (Pentecost, 2025) established a “Year of Design for Health” initiative in 2022, a global professional call to action highlighting the integration of architectural design and health goals. In 2022 the UIA urged architects worldwide to apply evidencebased design to promote health in all building types. This initiative raised awareness that good design can foster safety, healing, and well-being beyond hospitals—extending into everyday environments like homes, schools, and public spaces. It reinforced at the highest level that design strategies (natural light, supportive layouts, community input, etc.) are instrumental to achieving health outcomes and echoed the same principles found in school-based health center design guidelines and therapeutic architecture research. Architects were encouraged to collaborate with the key stakeholders (healthcare professionals, educators, patients) in these projects to develop evidence-based design strategies to inform policymakers about their effectiveness. The strategies were based upon three goals:

• Design that Protects Health: Protecting human, animal, and environmental health.

• Design that Develops Health: Developing better Protecting human, animal, and environmental health.

• Design that Restores Health: Restoring Protecting human, animal, and environmental health.

An example of this strategy can be found in the current goals for the alignment of architectural and therapeutic goals of education, health, and building design embraced by the New York State Department of Health (NYSDOH) at their website (2025) (see Table 2).

Design Stage

The task of the Design Stage is to discuss concrete steps that individuals and groups can take to realize the vision of their future practice. One of the goals of student participants in AR is learning skills to become

agents of change that will endure beyond their academic years to become part of their future endeavors. In creating the action plan, participants were encouraged to focus on (a) “the smallest of change with the biggest impact to move toward the ideal practice,” and (b) “rat[ing] the issues according to degree of difficulty (it is often best to commence with simpler activities that are likely to be successful) and choos[ing] the issue(s) that [they] will work on first” (Stringer, 2020, p. 201; Oberschmidt et al., 2022).

For example, the funding to pay for the cost of the building proposed in this project was $40 million, which is the most difficult task to accomplish. Rather than participants focusing on the future goals of funding, they were asked to examine areas of change that required the least financial resources but had the largest potential for moving the innovation forward. These were (a) to develop grassroots support from the Office of the Brooklyn Borough President and present the model to the general public, (b) to present the model at national and international conferences, and (c) to create an immersive animated virtual reality (VR) video of the model that allowed for a virtual tour through the building’s design to showcase the various components of its novel innovation. An action plan was created to accomplish these tasks, which paved the way for the Destiny Stage.

Destiny Stage

During the Destiny Stage, the action plan was carried out, which provided local support. Information about the innovation was disseminated to international and national academic audiences. Stakeholders were able to virtually experience the “Wellness Model” and gain a sense of what it would be like to actually visit in person thanks to immersive technology that brought the designs to life in an interactive and engaging way. In this stage, participants engaged in discourse on next steps to take in order to sustain the gains made in the Design Stage and propel the innovation forward. The strategic Appreciative Topic for the next FourStage Cycle is: “What are the best strategies to establish partnerships with the following systems: (a) healthcare organizations, (b) youth development programs, (c) environmental development corporations, and (d) nursing and architect professional peer-reviewed journals (publication of the project)?” The next task of the new Four-Stage Cycle was to establish strong partnerships between these systems and create a shared vision for improving the health of children who experience health inequities and subsequent chronic absenteeism.

Methodology

This AI process was conducted at a large urban, public university in the Northeastern United States. The process of this inquiry took place over one academic semester (16 weeks). Faculty scholarly dissemination of this inquiry process at national and international conferences was completed after the semester. Participants in this inquiry process were as follows: (a) two nursing faculty members (one was credentialed as a family nurse practitioner and a doctor of nursing science and one with a PhD in nursing), (b) two architect faculty who were licensed architects (one with a PhD in architecture and one with a master’s degree in architecture),

(c) eight RN to BS students; and (d) nine senior undergraduate architecture students. The RN to BS students were enrolled in the clinical course Urban Health Issues and directly supervised by a nursing faculty member in this AI. Nursing students were assigned to a clinical setting in an urban community heavily burdened with poor childhood health and educational outcomes. The RN to BS students provided health promotion activities in a public school for pre-K through eighth-grade children, as well as asthma management health education seminars to parents. The architecture students were enrolled in an urban architecture course and were directly taught and supervised by the two architect faculty members who participated in this AI process.

All participants attended weekly focus groups for four weeks, in which the AI process was carried out (see Tables 1 & 2). Nursing faculty and architecture faculty facilitated the process and contributed their knowledge and expertise on the subject matter. At the end of each focus group, generated data was analyzed by nursing and architecture faculty and Construct Map charts were created. A visual depiction of how the various constructs were connected was done by drawing lines between constructs. This provided a visual depiction of how the various constructs were interconnected. Creating visual summaries of the data derived by participants assisted the nursing and architect students in understanding how addressing one construct could affect several areas.

In the Design Stage of the AI process, an action plan was created by participants. Nursing and architecture faculty guided the students through the activities that brought the action plan to fruition. These included but were not limited to the following: (a) developing grassroots support from the Office of the Brooklyn Borough President and presenting the model to the general public; (b) presenting the model at national and international conferences; and (c) creating an immersive animated virtual reality (VR) video of the model that allowed for virtual tours through the building’s design and showcased the various components of its novel innovation.

Discussion

In summary, this article depicts the “accidental” meeting between professionals in the fields of architecture and nursing. Serendipity was fostered not only by the opportunity to connect, but a willingness and eagerness to learn from each other’s area of expertise. Participants learned how to focus unconditionally on strengths and the role of the academic institution in preparing them to be future innovators and leaders in their respective fields. This is an important skill to master when dealing with the seemingly intractable conditions that contribute to disparities in children’s health and education. For example, all of the renderings of the models’ designs included indoor swimming pools. Architecture students initially pointed out that having an indoor swimming pool was a costly wish list component and that there were less expensive ways to design a space that incorporated exercise for children. Nursing students explained, however, that for some children with asthma, swimming is the only type of exercise or sports participation that they can tolerate—and swimming promotes lung functioning.

Participants learned how to focus unconditionally on strengths and the role of the academic institution in preparing them to be future innovators and leaders in their respective fields. This is an important skill to master when dealing with the seemingly intractable conditions that contribute to disparities in children’s health and education.

The innovative creative process, using AI methods, yielded a novel model of building design and health care. The focus of the model was to improve the outcomes of children who experience disparities in education and health. The collective vision of nurses and architects included: (a) developing communication systems between pediatric health care and schools to reduce institutional barriers that contribute to chronic school absenteeism; (b) encompassing a multipurpose Center for Excellence in Health Care; (c) developing a youth program (Alanazi, 2023); (d) building designs that reduce carbon emissions (Sadrizadeh et al., 2022); and (e) creating a plant-based nutritional program (Ahmad, 2022) (see Tables 1 and 2).

Implications of Findings

Implications of this AI process are in the domains of (a) healthcare and education policy development and (b) curriculum changes in nursing and architecture education. Stakeholders in children’s health, well-being, and education should advocate for policies that embrace innovative models that break down the existing silos of pediatric health care and children’s education. Removing barriers to effective communication can facilitate the delivery of optimal health care and promote school attendance. Leadership in academic institutions, businesses, and research organizations should develop policies on restructuring how departments interface with each other, helping to foster collaborative opportunities. Increasing the possibilities for serendipitous meetings also increases the chances of meaningful inventions.

Health care is one of the United States leading sectors of growth, with a 7.5% increase in spending, which outpaced the gross domestic product (GDP) of 6.6% (Fiore et al., 2024). As healthcare services expand, so does the need for new building designs in which health care is delivered. In order to meet the needs of healthcare expansion, nursing curriculum changes are needed to ensure inclusion of educational opportunities to experience the process of innovation. Working with professionals outside of health care can lead to developing new perspectives on health problems that seemingly are entrenched and intractable. Likewise, architecture students should have access to consultation with nursing professionals prior to developing plans for design.

There is a growing trend in the United States for healthcare providers to assess children and adolescents for ACEs during routine, urgent, and preventative visits. States such as California have already adopted this policy. Thirty-seven states have enacted some form of legislation to prevent or reduce ACEs (National Conference of State Legislators, 2022). Changes in nursing curriculum should reflect how to assess children for ACEs and use appropriate interventions when ACEs are detected. The New York State Education Department Office of the Professions has addressed this need by mandating new and one-time child abuse

training, which includes ACE training. Proof of this training is required when renewing a professional registered nurse license.

This article closes with the goals of the AI Destiny Stage. Publication of this project report will disseminate information about the model, which has the potential to change the trajectory of children experiencing chronic health conditions and subsequent chronic school absenteeism. The authors anticipate that serendipitous connections will be made and that the conceptual model will arrive to the right people at the right time. We encourage comments and questions.

n References

Ahmad, S. R. (2022). Plant-based diets for obesity treatment. Frontiers Sec. Clinical Nutrition Volume 9 –2022. https://doi.org/10.3389/ fnut.2022.952553

Alanazi, Y. (2023). Implications of lifestyle changes on the incidence of childhood obesity—a systematic review and meta-analysis. European Review for Medical and Pharmacological Sciences 27, 700–709.

Barrett, F. J., & Fry, R. E. (2005). Appreciative inquiry: A positive approach to building capacity. Taos Institute Publications.

Black, L. I., & Elgaddal, N. (2024). Chronic School Absenteeism for Health-related Reasons Among Children Ages 5–17 Years: United States, 2022 (NCHS Data Brief No. 498). National Center for Health Statistics. https://www.cdc.gov/nchs/data/databriefs/db498.pdf

Busch, C. (2022). Towards a theory of serendipity: A systematic review and conceptualization. Journal of Management Studies, 61(3), 1110–1151. https://doi.org/10.1111/joms.12890

Centers for Disease Control and Prevention (CDC). (2017). Chronic health conditions and academic achievement. https://archive. cdc.gov/www_cdc_gov/healthyschools/chronic_conditions/ pdfs/2017_02_15-CHC-and-Academic-Achievement_Final_508_1 .pdf

Cooperrider, D. L, & Srivastva, S. (1987). Appreciative Inquiry in organizational life. In W. A. Pasmore, & W. Woodman (Eds.), Research in organizational change and development, 1, 129–169. JAI Press. https://www.researchgate.net/publication/265225217_ Appreciative_Inquiry_in_Organizational_Life

Felitti, V. J., Anda, R. F., Norenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American Journal of Preventative Medicine, 14(4), 245–258. https:// doi.org/10.1016/s0749-3797(98)00017-8

Fiore, J. A., Madison, A. J., Poisal, J. A., Cuckler, G. A., Smith, S.D., Sisko, A. M., Keehan, S. P., Rennie, K. E., & Gross, A. C. (2024). National health expenditure projections, 2023–32: Payor trends diverge as pandemic-related policies fade. Health Affairs, 43(7), 910–921. https://doi.org/10.1377/hlthaff.2024.00469

Greenlund, K. J., Lu, H., Wang, Y., Matthews, K. A., LeClercq, J. M., Lee, B., & Carlson, A. C. (2022). PLACES: Local data for better health. Prevention of Chronic Disease, 19(210459). https://doi.org/10.5888/pcd19.210459

Institute for Health Metrics and Evaluation (IHME). (2024) U.S. Health Map. Institute for Health Metrics and Evaluation. http://vizhub.healthdata.org/subnational/usa Lomholt, J. J., Arendt, J. N., Bolvig, I., & Thastum, M. (2022). Children with school absenteeism: Comparing risk factors individually and in domains. Scandinavian Journal of Educational Research, 66(3), 411–426. https://doi.org/10.1080/00313831.2020.1869085

Ludema, J. D., & Fry, R. E. (2011). The practice of Appreciative Inquiry. In P. Reason, & H. Bradbury (Eds.), The SAGE handbook of action research participative inquiry and practice (2nd ed., pp. 280–296). SAGE.

National Conference of State Legislatures. (2022). Injury prevention legislation database. Opioid abuse prevention. https://www.ncsi .org/research/health/injury-prevention-legislation-database.aspx

New York State Department of Health (NYSDOH). (2025). School-Based Health Centers in New York State: Principles and Guidelines. https://www.health.ny.gov/facilities/school_based_health_centers/ docs/principles_and_guidelines.pdf

O’Hara, S., Langston, S., Della Donna, V., & Toft Klar, R. (2024). Implementing an innovative design charrette: Creating healing environments for clinicians and patients’ well-being. Building Healthy Academic Communities Journal, 8(2), 18–27. https://doi .org/10.18061/bhac.v8i2.9917

Pentecost, A. R. (2025, Feb). Momentum in design for Health. International Union of Architects (UIA). https://www.uiaarchitectes.org/en/mag/momentum-in-design-for-health/

Rees, C. A., Monuteaux, M. C., Raphael, J. L., & Michelson, K. A. (2020). Disparities in pediatric mortality by neighborhood income in United States Emergency Departments. Journal of Pediatrics, 219, 209–215.e3. https://doi.org/10.1016/j.jpeds.2019.09.016

Sadrizadeh, S., Yao, R., Yuan , F., Awbi, H., Bahnfleth, W., &; Bi, Y., (2022). Indoor air quality and health in schools: A critical review for developing the roadmap for the future school environment. Journal of Building Engineering, 57, 104908. https://doi.org/10.1016/ j.jobe.2022.104908

Smith, L. B., O’Brien, C., Kenny, G., Tabb, L. P., Verdeflor, A., Wei, K., Lynch, V., & Waidmann, T. (2022). Racialized economic segregation and potentially preventable hospitalizations among Medicaid/CHIPenrolled children. Health Service Research. 58(3): 599–611. https:// doi.org/10.1111/1475-6773.14120

Stringer, E. T., & Aragon, A. O. (2020). Action research (5th ed.). SAGE. Throngseiratch, T., & Chandeying, N. (2020). Chronic illness and student academic performance. Journal of Health Science and Medical Research 38(3). http://dx.doi.org/10.31584/jhsmr.2020738

Toto, H. I. G., Jaramillo, A. P., & Caceres, V. M. (2024) Family-based intervention for pediatric obesity: A comprehensive systemic review and meta-analysis of their effectiveness. Cureus, 16(8), e65919. https://doi.org/

U.S. Bureau of Labor Statistics (U.S. BLS). (2020, April). Registered nurses made up 30% of hospital employment in May 2019. The Economics Daily. https://www.bls.gov/opub/ted/2020/registered-nurses-madeup-30-percent-of-hospital-employment-in-may-2019.htm

Whitney, D., & Trosten-Bloom, A. (2003) . The power of appreciative inquiry: A practical guide to positive change Berrett-Koehler Publishers.

Evidence-Based Strategies to Improve Door-to-Provider Times in the Emergency Department

Cynthia Diaz, DNP, MSN, RN, FNP-BC

Jasmine V. Hackett, DNP, MSN, RN, FNP-BC

Reneé

Lewis-DuQuesnay, DNP, MSN, RN, FNP-BC

n Abstract

Background: Emergency department (ED) overcrowding remains a pervasive issue globally, compromising patient safety, satisfaction, and organizational efficiency. ED crowding is defined as when the demand for emergency services exceeds available resources, leading to inefficiencies that compromise patient safety and quality of care. The increasing patient volumes, coupled with higher acuity needs and strained ED resources, cause prolonged wait times, increased rates of patients leaving without being seen (LWBS), and delayed critical interventions. Evidence-based strategies, such as the use of mid-level providers in triage and split-flow models, have shown promise in addressing these challenges.

Purpose: To evaluate whether implementing evidence-based strategies, specifically incorporating advanced practice providers (APPs) in triage, improves door-to-physician times and patient satisfaction.

Design: This review examines the impact of ED crowding on patient outcomes, including delays in treatment, medication errors, and increased mortality risk. It explores the effectiveness of strategies like fast-track areas and early provider assessments in mitigating overcrowding and improving throughput times. Comparative data from organizations utilizing these strategies versus those that do not were analyzed to assess patient satisfaction and care quality metrics.

Participants: This quality improvement initiative involved ED staff, including registered nurses (RNs), APPs, and emergency physicians. Stakeholders from nursing leadership, hospital administration, and quality improvement teams also contributed to the planning and evaluation phases.

Setting: The project was initially approved to be conducted in a high-volume suburban ED.

Methods: A retrospective review of ED throughput data was conducted to identify delays in door-to-provider times. Based on these findings, a proposal to integrate an APP into the ED triage process was developed and presented to hospital leadership. Although initially approved by departmental administration, the proposal was ultimately not implemented following further review by upper hospital management. As the project did not undergo Institutional Review Board (IRB) review and was not implemented, outcome data is not available; however, findings informed the development of a theoretical intervention aimed at improving ED efficiency.

Findings: Incorporating mid-level providers in triage consistently demonstrated reduced length of stay (LOS), improved door-to-provider times, and decreased LWBS rates. Split-flow models further optimized patient throughput, particularly for Emergency Service Index 4 patients, significantly enhancing patient satisfaction and overall operational efficiency. The interventions also alleviated staff burnout and supported organizational compliance with regulatory benchmarks.

Conclusion: Evidence-based interventions, such as deploying mid-level providers in triage, are effective in mitigating ED overcrowding and improving patient satisfaction. These strategies ensure timely access to care, reduce adverse outcomes, and bolster organizational reputation within the community. Further research is warranted to explore long-term outcomes and scalability across diverse healthcare settings.

Keywords: emergency department (ED), overcrowding, mid-level providers, triage, patient satisfaction

Cynthia Diaz, DNP, MSN, RN, FNP-BC, Dominican University of New York, Orangeburg, New York

Jasmine V. Hackett, DNP, MSN, RN, FNP-BC, Dominican University of New York, Orangeburg, New York

Reneé Lewis-DuQuesnay, DNP, MSN, RN, FNP-BC, Dominican University of New York, Orangeburg, New York

Introduction

ED waiting times continue to increase due to overcrowding, leading to potential safety concerns, financial loss, and an inability to meet community needs satisfactorily (Franklin et al., 2021). As waiting times increase, organizations risk their professional reputation within the communities they serve and a potential loss of revenue from lost business or customer loyalty becomes a viable possibility (Agency for Healthcare Research and Quality [AHRQ], 2020). AHRQ’s resources on EDs’ data and analytics include ED boarding and crowding, infection prevention, and diagnostic safety. ED overcrowding and increased wait times are globally associated with detrimental consequences to patient care and safety, such as medical errors, increased mortality, and increased inpatient length of stay. Medical errors can include inappropriate diagnoses resulting in a return of patients to the ED for the same problems. Medication errors are another potential consequence of ED crowding and increased LOS. ED overcrowding also has negative effects on hospital staff and the system as an entity. Improving throughput times in the ED, particularly the time it takes for a patient to access a provider, is a critical aspect of ensuring quality patient care (Tsige et al., 2024). Improved door-to-physician times allows for an expedited decision for diagnosis, treatment, and disposition, improving stay length and reducing adverse outcomes such as increased mortality due to diagnosis delay.

This review explores the effectiveness of various strategies designed to alleviate crowding in EDs, with a focus on interventions including provider-in-triage models, split-flow methodologies, and Lean Six Sigma with the FOCUS-PDSA practices. By synthesizing the latest evidence, this review aims to provide actionable insights for optimizing ED throughput and improving patient care delivery. The purpose of this retrospective study is to evaluate whether implementing evidence-based strategies— specifically incorporating APPs in triage—improves door-to-physician times and overall patient satisfaction.

Objective

The objective of this research review is to evaluate whether integrating APPs in triage improves door-to-physician times. APPs, including emergency nurse practitioners (ENPs), nurse practitioners (NPs), and physician assistants (PAs), have become vital to ED operations. These licensed clinicians manage a wide range of patient conditions, allowing physicians to focus on critically ill patients, which improves departmental efficiency, reduces wait times, and enhances patient satisfaction. APPs can order and interpret diagnostic studies, prescribe treatments, perform procedures, participate in code response teams, and coordinate patient transfers, while also serving as educators and researchers in emergency nursing (Donelan et al., 2020).

The COVID-19 pandemic prompted temporary policy changes that expanded the roles of APPs and increased their autonomy, leading to discussions about permanent scope-of-practice reforms. Despite concerns regarding training variability, evidence shows that APPs can deliver highquality care. Their integration into ED teams helps address rising patient volumes and physician shortages, ensuring timely access to emergency services. As emergency health care evolves, APPs play a crucial role in maintaining patient throughput and care quality, making them essential members of today’s emergency care teams.

EDs in the U.S. have seen a steady increase in patient volume since World War II, with a brief decline during the COVID-19 pandemic (Augustine & Jouriles, 2023). Post-pandemic trends indicate a resurgence in ED visits with more complex cases, especially among the aging population. While alternatives like telehealth and urgent care centers have managed some low-acuity cases, EDs are increasingly handling higherseverity patients (Cairns & Kang, 2020). In 2022, there were approximately 150.7 million ED visits, leading to significant operational challenges, including a concerning LWBS rate of 4.9% linked to prolonged wait times (Augustine & Jouriles, 2023). The Emergency Severity Index (ESI) reflects this complexity: ESI Level 3 patients—those needing substantial resources but not immediate lifesaving care—rose from 49.0% in 2021 to 54.3% in 2022 (Augustine & Jouriles, 2023). Delays in treatment for highacuity patients can lead to increased morbidity and mortality (Dadeh et al., 2020). By involving mid-level providers in triage, the researchers explore a strategy to enhance patient flow, reduce wait times, and improve satisfaction. The findings will inform future policies on ED staffing and operational efficiencies to optimize patient outcomes in high-demand settings.

Search Strategies and Yield

To improve ER throughput, focusing on patient wait time from door to initial provider, a literature search was performed to assess effective and efficient strategies and evaluate search engines used, including CINAHL, EBSCOhost, PubMed, and Medline. Search criteria included articles published within the past five years, scholarly articles, peer-reviewed journals, articles in which the full text was available, and articles printed in the English language. Search terms included: improving ER wait times, immediate bedding, ED wait times, strategies to reduce ER wait times, emergency room wait time, improving emergency room throughput. This search yielded over 2,500 results. Exclusion criteria included articles and research older than five years and/or focusing on the pediatric population.

Inclusion/Exclusion Criteria

Inclusion criteria involved articles published between 2020 and 2024 that addressed ER wait times. Other inclusion criteria were research that analyzed the different steps in ER throughput. Systematic reviews, randomized control trials (RCTs), quasi-experimental studies, and peerBy involving mid-level providers in triage, the researchers explore a strategy to enhance patient flow, reduce wait times, and improve satisfaction. The findings will inform future policies on ED staffing and operational efficiencies to optimize patient outcomes in high-demand settings.

reviewed articles were included in the selection criteria. All studies, regardless of their methodological quality, underwent data extraction, analysis, and synthesis.

Exclusion criteria included studies focused only on the pediatric population, studies done among larger urban trauma hospitals, or studies that did not examine overall effects on patient satisfaction. Exclusion criteria also included editorials or opinions. Articles published prior to 2020 were excluded. After applying the inclusion and exclusion criteria, 69 relevant articles were selected, with 12 articles with high levels of evidence (I, II, and III) meeting criteria included in this scholarly quality improvement (QI) project.

Levels of Evidence

The articles selected for final retrieval for this project were analyzed and graded based on the Melnyk & Fineout-Overholt (2022) Levels of Evidence criteria. The data was evaluated using Oxford Centre level classification of Evidence-Based Medicine (CEBM) ranking. Level Ia consists of systematic reviews, Ib pertains to randomized controlled trials, level II is designated to cohort studies, level III involves case control studies, level IV examines case series, and level V is expert opinions. Out of the 12 included studies, two were level I (systematic review and meta-analysis), eight studies were level II (randomized control trials), and remaining two were level III (systematic review and meta-analysis of cross sectional and interventional studies, quasi-experimental, cohort and mixed methods).

Theoretical Framework

The integration of Lewin’s Change Theory with the FOCUS-PDSA quality improvement methodology, as discussed in the article by Abuzied et al. (2023), offers a comprehensive framework for enhancing health care delivery, particularly in streamlining ED throughput. Lewin’s threestage model—Unfreeze, Movement, and Refreeze—guides this capstone project aimed at reducing door-to-physician times by incorporating midlevel providers into the triage process.

In the Unfreeze stage, organizations must first recognize inefficiencies in current workflows, such as patients experiencing prolonged wait times after triage before being evaluated by an ED provider. This stage involves challenging existing norms and engaging stakeholders in a shared vision for improved patient outcomes. By applying the FOCUS component—Find, Organize, Clarify, Understand, and Select—organizations can critically assess their processes and identify key areas for improvement, such as modifying registration to occur at the point of care or through mobile technology.

In the Movement stage, changes are implemented through newly designed workflows, with mid-level providers serving as providers-intriage (PIT) to perform initial evaluations and assume some responsibilities traditionally managed by triage nurses. This aligns with the PDSA cycle— Plan, Do, Study, Act—as organizations pilot and refine these interventions, supported by staff training and open communication to address resistance.

Finally, the Refreeze stage ensures the sustainability of these improvements by embedding them into institutional policies and practices. Communication strategies, such as including PIT updates in daily staff huddles, reinforce these changes, while continuous quality monitoring

supports long-term adherence. This integration of Lewin’s theoretical model with the structured, iterative approach of FOCUS-PDSA ultimately fosters a culture of continuous improvement, resulting in enhanced patient satisfaction, reduced wait times, and improved overall safety.

Evaluation and Synthesis of Literature

Patient flow in the ED is a crucial concern for healthcare systems aiming to enhance patient outcomes and satisfaction. The challenges within the ED are primarily due to overcrowding, leading to delays in patient care and prolonged wait times to see medical providers. These extended waiting periods contribute to patients leaving the ED without being seen, potentially exacerbating their health issues, and creating more critical situations, further straining the healthcare system. It thus increases the risk of adverse events such as medication errors, delays in critical treatments like antibiotic administration, and patient falls. Addressing these interconnected problems is essential for improving patient outcomes and ED efficiency. Evaluating and synthesizing literature has identified strategies to streamline the throughput process and enhance overall care delivery.

Literature Review

Patient flow in the ED is critical in improving patient outcomes and satisfaction. Overcrowding leads to extended wait times and increases the likelihood of LWBS, which can result in worsened health conditions and heightened strain on healthcare resources. Delays in treatment are linked to adverse events, such as medication errors and increased mortality risks, underscoring the need for process improvements.

Research emphasizes the impact of overcrowding in EDs, with Darraj et al. (2023) and Morley et al. (2018) identifying prolonged wait times as a major cause of poor prognoses. Smalley et al. (2021) reported that 3.2% of ED patients leave before treatment completion, with over 33% returning within 30 days and higher admission rates upon return, reinforcing concerns about early departures.

Dadeh and Phunyanantakorn (2020) emphasized the role of wait times in ED efficiency. Use of the Lean process to improve throughput time demonstrated the effectiveness of targeted workflow improvements by reducing overall length of stay, arrival to the room, and ED attending to disposition (Kenny et al., 2024). Dadeh and Phunyanantakorn’s (2020) study on ED LOS for abdominal pain patients identified key factors— triage category, diagnostic testing, and consultation time—as primary determinants of prolonged stays.

Collectively, these studies provide a roadmap for improving patient throughput, reducing wait times, and enhancing care quality in emergency settings. Implementing evidence-based strategies—such as physicianled triage, APP integration, and optimized resource management—can significantly improve ED efficiency and patient satisfaction.

Method

Evaluating throughput optimization strategies in the ED reveals a pressing need for enhancements to align with Centers for Medicare &

Medicaid Services (CMS) benchmark times. The CMS has identified five critical metrics associated with ED overcrowding (Tsige et al., 2024), highlighting areas that require focused interventions. Major challenges include insufficient staffing, lengthy door-to-provider times, extended triage delays, setbacks in patient room placement, inefficient room turnover, and inconsistent two-provider triage coverage. Among these issues, prioritizing the reduction of door-to-provider time has emerged as the foremost area for improvement.

Methods for improving the triage process/ED throughput to subsequently improve the door-to-provider times were also discussed. Following a review of the data provided regarding turnaround times and evaluation of current literature from years 2021–2023 and recommended standard of practice set forth by national benchmarks such as CMS and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards, a protocol was developed to decrease door-to-provider times in the ED. Changes include a PIT (provider in triage), split flow, and a vertical. Emergency Service Index of three designations within the host hospital ED designated fast-track area. This change in process/throughput will in turn theoretically reduce/improve the metrics set forth by the CMS such as LWBS and overall LOS. The key stakeholders include the host hospital, ED leadership, ED providers, and ED nursing staff (including emergency department technicians). The proposal for this project did not undergo review by the Institutional Review Boards (IRBs). Due to circumstances beyond our control, this project has been redirected. Instead, the project was restructured to focus on publication after developing a protocol focused on evidence-based strategies to improve door-to-provider times in the ER by incorporating a mid-level PIT.

Preliminary data review at the study site identified significant gaps in ED throughput and service delivery, including extended wait times and bottlenecks in the triage process. Based on this needs assessment, a proposal was developed to integrate an APP into the triage workflow to improve operational efficiency. The initial proposal was well-received by departmental leadership and accepted at the administrative level. However, upon further review by upper management, the proposal was ultimately declined. As a result, the project did not move forward for IRB review or approval.

The proposed initiative did not progress beyond internal administrative consideration; therefore, no formal research activities were conducted, and no data were collected or analyzed under IRB oversight. Therefore, specific data related to ED performance metrics, outcomes, or proposed intervention effectiveness cannot be shared.

Interventions and Rationales

The first recommendation is the APP, which typically involves at a minimum, a physician or advanced care provider, conduct an initial screening exam and potentially initiate treatment and diagnostic testing at the time of triage (Tsige et al., 2024). Thus, providing a PIT reduces the time for a patient to go from door (arrival to the ED with initial registration) to being seen, to be initially evaluated by an ED provider, and to have ED interventions started. Two other major goals for implementing PIT are reducing LWBS and reducing ED LOS (Franklin et al., 2021).

The second recommendation is split flow, also called fast track, which has been associated with improved ED throughput and patient satisfaction (Tsige et al., 2024) and decreasing LOS in most patients in the ED. The split-flow process will be implemented when the host ED is the busiest.

The third recommendation is to move the vertical 3 patients into the fast-track area. A patient designated as a vertical 3/V3-patient with an ESI of three who can sit up (in a chair) and receive treatment, as those with abdominal pain, can be placed in fast track instead of the main ED where the horizontal (in a bed) V3 and ESI one and two patients would be placed in V3 (Dadeh et al., 2020; Hsieh et al., 2023). Placing patients from a horizontal position in the main ED and replacing them with multiple vertical chairs in the fast-track area allows examination in the upright position. These patients would have to meet specific clinical criteria resulting in a significant reduction in LOS (including admission), and a younger patient age group (Hsieh et al., 2023). The criteria to meet these standards would be discussed with ED leadership, including ED provider leadership. The criteria would then be posted in the designated areas, such as the triage area PIT and the fast-track area where these V3 patients would be received.

Findings and Rationale

ED overcrowding is a pervasive issue that has significant impacts on both patient care and hospital operations. The problem of overcrowding often results in prolonged waiting times, patient dissatisfaction, and delays in treatment that can lead to adverse health outcomes. To address and alleviate these challenges, several protocols have been designed to optimize patient flow and enhance the efficiency of care delivery. These protocols encompass strategies from both the medical and nursing standpoints, with an emphasis on multidisciplinary collaboration and continuous improvement.

I. Medical Standpoint

A. Provider in Triage: PIT is one of the most effective strategies for addressing ED overcrowding. The role of the provider in triage is critical, as it allows for rapid initial assessments and timely clinical decisions. A dedicated APP or EP is stationed in triage to conduct quick evaluations, order necessary diagnostic tests such as labs and radiology, and initiate appropriate treatments when necessary. This process is facilitated by implementing standardized triage protocols, such as the ESI, to ensure that high-acuity patients are promptly prioritized and treated. For highrisk conditions like sepsis, chest pain, or trauma, PIT providers are empowered to initiate treatment protocols immediately, which helps to reduce mortality rates, shorten lengths of stay, and minimize the number of patients leaving without being seen.

Additionally, the PIT model requires adjustments to the ED workflow to streamline diagnostic orders and ensure that the triage provider can initiate routine diagnostics without delay. Communication between triage and the main ED must be seamless, allowing for fast-tracking of patients to appropriate care areas, such as observation units or resuscitation rooms, to further improve patient flow.

B. Split-Flow Model: Another essential strategy for managing ED overcrowding is the implementation of split-flow models, which divide patients based on their acuity and resource needs. The fast-track model is used for low-acuity patients, often those classified as ESI levels 4 or 5, who can be treated quickly and discharged with minimal intervention. Conversely, moderate-to-high acuity patients (ESI levels 1–3) are directed to the main ED, where they receive more comprehensive care. This segmentation of patients allows for more efficient resource allocation and ensures that each patient receives the appropriate level of care based on their clinical presentation.

Real-time capacity management tools play an essential role in this model, allowing staff to track patient movement within the ED and monitor bed availability to minimize overcrowding in central ED areas. In parallel, specialized teams should be allocated to each flow segment, with NPs and PAs managing low-acuity cases and emergency physicians focusing on more critical patients. This division of labor helps streamline care and ensures that resources are used effectively, improving overall efficiency in the ED.

C. Monitoring and Analytics for Continuous Improvement: To ensure the ongoing success of the PIT and split-flow models, it is crucial to implement robust monitoring and analytics systems. Key performance indicators (KPIs) such as door-to-provider time, LWBS rate, LOS, antibiotic administration times, and mortality rates should be regularly monitored. The use of real-time dashboards allows ED leadership and staff to receive continuous feedback on these metrics, enabling them to identify potential bottlenecks or areas for improvement. In addition, clinical huddles— regular interdisciplinary meetings—should be held to review patient flow, identify challenges, and adjust staffing or resources as necessary to optimize efficiency and care quality.

II. Nursing Standpoint

A. Triage Optimization and Nurse-Provider Collaboration: Nurses play a crucial role in the management of ED overcrowding, particularly in the triage process. Enhancing the role of triage nurses can significantly improve the speed and accuracy of patient assessments. Nurses should be trained in rapid risk stratification using standardized ESI protocols to help them make quicker acuity-based decisions. In collaboration with PIT providers, triage nurses can expedite care by initiating diagnostic orders and care interventions for common conditions, such as chest pain or shortness of breath, before a provider’s involvement.

Furthermore, flexibility in nurse staffing is essential to cope with fluctuations in patient volume. By allowing for dynamic shift adjustments and the use of float pool nurses during peak times, hospitals can ensure that sufficient staffing is in place to manage surges in patient demand. These strategies improve the efficiency of care delivery while reducing delays caused by staff shortages.

B. Patient Education and Communication: Clear communication is essential for maintaining patient satisfaction during periods of overcrowding. Nurses should educate patients in the waiting room about expected wait times, the triage process, and the steps being taken to address their concerns. The use of digital boards or mobile apps that provide real-time updates on patient flow can help manage patient

expectations and reduce anxiety. Additionally, standardized discharge protocols for low-acuity cases should be developed to expedite the release of patients from fast-track areas, ensuring that discharged patients receive appropriate follow-up instructions and access to telehealth services if needed.

III. Cross-Disciplinary Recommendations

A. Resource Management: Effective coordination across different departments within the hospital is essential to alleviating ED overcrowding. Hospitals must ensure that inpatient beds are available and that patients are transferred swiftly from the ED to appropriate inpatient units when necessary. This frees up ED beds for incoming patients, helping to manage patient flow more efficiently. Additionally, creating surge areas—using underutilized hospital spaces such as conference rooms or waiting areas—can provide additional treatment areas during peak crowding situations, further alleviating pressure on the main ED.

B. Community and External Solutions: In addition to internal ED management strategies, external solutions can help reduce overcrowding. The promotion of urgent care clinics and retail health clinics for nonemergency cases can divert low-acuity patients away from the ED, ensuring that emergency departments are better equipped to handle more critical cases. Telehealth services, such as tele-triage, can also be introduced to allow patients to receive initial assessments from virtual providers, reducing the need for in-person visits, and alleviating physical congestion in the ED.

IV. Evaluation and Continuous Monitoring

A. Post-Implementation Review: After implementing these protocols, it is crucial to conduct a post-implementation review to assess their effectiveness. Data on door-to-provider times, patient satisfaction, LWBS rates, and adverse events should be collected over a six-month period. This data will help identify trends and areas that require further improvement. Patient feedback surveys should also be conducted to gauge satisfaction with the ED experience, providing valuable insights for refining protocols and improving care delivery.

B. Long-Term Sustainability: To ensure the long-term success and sustainability of these protocols, hospitals should establish ongoing quality improvement teams. These teams will monitor the effectiveness of implemented strategies, adjust protocols as needed, and ensure compliance with regulatory standards. By fostering a culture of continuous improvement, hospitals can maintain efficient ED operations and address future challenges as they arise.

Addressing ED overcrowding requires a multifaceted approach that integrates early intervention, streamlined workflows, and enhanced communication. By implementing evidence-based strategies such as early provider in triage, split-flow models, and improved nurse-provider collaboration, hospitals can significantly reduce overcrowding and enhance patient care. Through continuous monitoring and data-driven adjustments, these strategies can lead to sustained improvements in ED efficiency and patient satisfaction.

Limitations and Strengths

The project underscored several key advantages, including the organization’s recognition of issues with the triage and admission process. It also highlighted improvements in patient outcomes, enhanced hospital efficiency, ensured financial stability, and elevated the overall quality of health care. The benefits of enhanced patient outcomes through expedited access to care reduced door-to-provider time, ensured timely medical attention, and helped prevent the deterioration of conditions. This quick response is essential for effectively managing and stabilizing patients in critical situations. Early intervention is crucial in reducing mortality rates and complications. Swift medical attention significantly diminishes the risk of adverse outcomes, such as the progression of sepsis or complications related to strokes, improving patient survival, and recovery rates. Streamlining operations in the emergency department reduces the likelihood of overcrowding-related adverse events, including medication errors, patient falls, and delays in vital treatments. By optimizing workflows and resource allocation, healthcare providers can foster a safer environment for both patients and staff.

The project emphasized the potential for enhanced efficiency in the ED, characterized by reduced wait times, shorter door-to-provider intervals, and improved patient throughput. These improvements aim to minimize frustration and elevate satisfaction levels. Effective triage and streamlined workflows contribute to a decrease in unnecessary inpatient admissions and avoid delays in discharges. Proper patient flow management would ensure the ED staff, diagnostic services, and hospital bed availability are utilized to their fullest potential.

Enhancing the efficiency of the ED provides significant financial benefits for the hospital, primarily by improving reimbursement eligibility through compliance with CMS benchmarks and Joint Commission standards. This adherence would enable the organization to maximize funding opportunities and maintain financial stability. Reducing LWBS rates increases revenue and mitigates legal risks associated with delayed or missed care. The hospital can enhance its financial performance by ensuring more patients receive timely treatment while minimizing potential liabilities. Improving patient throughput generates cost savings by reducing the LOS, optimizing staff allocation, decreasing resource waste, and minimizing unnecessary hospital admissions. These efficiencies collectively reinforce the financial sustainability of the hospital and facilitate better resource management.

This project highlights the need for proactive nurse-led initiatives aimed at system-level improvements. Nurse practitioners are uniquely positioned to influence patient flow and care coordination due to their advanced clinical training, autonomy, and holistic approach to care.

This project encountered several challenges that impeded its successful completion, such as budgetary constraints, staffing limitations, and the capacity of administration to support new initiatives that impacted the IRB process. With a constrained budget, the community hospital faced difficulties allocating funds for hiring additional staff or redesigning workflows. Workforce shortages, including medical providers, nurses, and support staff, delayed project implementation, which affected efforts to reduce door-to-provider time and contributed to longer patient wait times.

Additionally, limited, or incomplete data posed a challenge in thoroughly assessing the project’s scope and potential impact. Administrators were cautious about approving initiatives requiring upfront investments without guaranteed financial returns. Furthermore, process improvement projects require dedicated time, effort, and leadership oversight, and when hospital leadership is managing multiple priorities, such a project may be perceived as challenging to implement rather than immediately essential. These unique challenges faced by the organization compounded the difficulty of completing the IBR process and achieving success in completing the capstone project.

Implications for Nursing Practice and Research

The issue of ED overcrowding presents critical implications for nursing practice, particularly for APPs, such as NPs, who are increasingly being integrated into acute care settings. The proposed implementation of an APP in the ED triage process, although not executed in this instance, aligns with growing evidence that supports the role of mid-level providers in improving operational efficiency, reducing patient wait times, and enhancing overall care delivery.

This project highlights the need for proactive nurse-led initiatives aimed at system-level improvements. Nurse practitioners are uniquely positioned to influence patient flow and care coordination due to their advanced clinical training, autonomy, and holistic approach to care. Integrating NPs into triage or split-flow models not only helps optimize throughput but also enables earlier patient engagement, timely interventions, and reduced burden on emergency physicians. It emphasizes the evolving leadership role of nurses in healthcare systems and the necessity of including nursing perspectives in decision-making processes related to workflow and staffing models.

Furthermore, the administrative decline of the proposal underscores the importance of advocacy and strategic communication skills among nurse leaders. To effect change, nurses must be prepared to present evidence-based interventions in a way that aligns with institutional goals, resource considerations, and interprofessional collaboration.

The project’s trajectory also illuminates critical areas for further nursing research. There is a need for robust, nurse-led studies that examine the outcomes of APP integration in emergency care settings, particularly with respect to quality indicators such as patient satisfaction, length of stay, LWBS rates, and cost-effectiveness. Additionally, more research is needed on the barriers to implementation of evidence-based interventions in hospital settings, including organizational culture, leadership engagement, and administrative decision-making processes.

Future research should also explore the development and validation of implementation frameworks that guide healthcare organizations

through the adoption of nurse-driven innovations. The lack of IRB approval and project execution in this case represents a missed opportunity for generating new knowledge, highlighting the importance of early and sustained stakeholder engagement to move research initiatives forward.

Conclusion

Emergency department overcrowding remains a critical challenge, impacting patient care, operational efficiency, and hospital finances. This research review highlights the effectiveness of targeted interventions—provider in triage (PIT), split-flow methodologies, and vertical patient management—in improving ED throughput and

reducing door-to-provider times. By integrating mid-level providers in triage, streamlining patient flow, and enhancing interdisciplinary collaboration, hospitals can significantly reduce wait times, decrease the rate of patients leaving without being seen (LWBS), and improve overall patient satisfaction.

The findings reinforce that structured triage enhancements, strategic staffing adjustments, and continuous performance monitoring are essential to optimizing emergency care. As healthcare demands continue to rise, these evidence-based interventions offer a sustainable framework for mitigating ED congestion while maintaining high standards of patient safety and quality care. Future research should explore long-term impacts on clinical outcomes, hospital costs, and staff workload to refine and expand these strategies across diverse healthcare settings.

n References

Abuzied, Y., Alshammary, S. A., Alhalahlah, T., & Somduth, S. (2023). Using FOCUS-PDSA quality improvement methodology model in healthcare: Process and outcomes. Global Journal on Quality and Safety in Healthcare, 6(2), 70–72. https://doi.org/10.36401/jqsh22-19

Agency for Healthcare Research and Quality (AHRQ). (2020, November 25). Some patients can’t wait: Improving timeliness of emergency department care. PSNet. https://psnet.ahrq.gov/ web-mm/some-patients-cant-wait-improving-timeliness-emergencydepartment-care#:~:text=to%20inpatient%20units.-,10,ED%20 bed%20placement%20was%20delayed

Augustine, J. J., & Jouriles, N. J. (2023). First look: Emergency operations in the pandemic Year 2021. ACEP Now. https://www.acepnow .com/article/first-look-emergency-department-operations-in-thepandemic-year-2021/

Cairns, C., & Kang, K. (2020). National Hospital Ambulatory Medical Care Survey: 2020 emergency department summary tables. CDC National Center for Health Statistics. https://dx.doi.org/10.15620/ cdc:12191

Campo, T. M., Carman, M. J., Evans, D., Hoyt, K. S., Kincaid, K., Ramirez, E. G., Roberts, E., Stackhouse, K., Wilbeck, J., & Weltge, A. (2016). Scope of practice for emergency nurse practitioners. Advanced Emergency Nursing Journal, 38(4), 252–254. https://doi.org/10.1097/ tme.0000000000000126

Chandrasekaran, R., Bapat, P., Venkata, P. J., & Moustakas, E. (2023). Face time with physicians: How do patients assess providers in videovisits? Heliyon, 9(6), e16883. https://doi.org/10.1016/j.heliyon.2023 .e16883

Darraj, A., Hudays, A., Hazazi, A., Hobani, A., & Alghamdi, A. (2023). The association between emergency department overcrowding and delay in treatment: A systematic review. Healthcare, 11(3), 385. https://doi.org/10.3390/healthcare11030385

Dadeh, A. A., & Phunyanantakorn, P. (2020). Factors affecting length of stay in the emergency department in patients who presented with abdominal pain. Emergency Medicine International, 2020. https:// doi.org/10.3390/healthcare11030385

Donelan, K., DesRoches, C. M., Guzikowski, S., Dittus, R. S., & Buerhaus, P. (2020b). Physician and nurse practitioner roles in emergency, trauma, critical, and intensive care. Nursing Outlook, 68(5), 591–600. https://doi.org/10.1155/2020/5406516

Endrejat, P. C., & Burnes, B. (2022). Draw it, check it, change it: Reviving Lewin’s Topology to facilitate organizational change theory and practice. The Journal of Applied Behavioral Science, 60 (1), 87–112. https://doi.org/10.1177/00218863221122875

Franklin, B. J., Li, K. Y., Somand, D. M., Kocher, K. E., Kronick, S. L., Parekh, V. I., Goralnick, E., Nix, A. T., & Haas, N. L. (2021). Emergency department provider in triage: Assessing site-specific rationale, operational feasibility, and financial impact. Journal of the American College of Emergency Physicians Open, 2(3), e12450. https://doi .org/10.1002/emp2.12450

Gilboy, N., Tanabe, P., Travers, D. A., & Rosenau, A. M., & Eitel, D. R. (2020, July). Emergency severity index, version 4: Implementation handbook. Agency for Healthcare Research and Quality Publication No. 12–0014. Agency for Healthcare Research and Quality. https:// www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/ hospital/esi/esihandbk.pdf

Hsieh, A., Arena, A., Oraha, A., Cotarelo, A., McLean, M., Hsieh, A., Hsieh, A., Hsieh, A., Chen, I., Mok, N., & Milizia, R. (2023). Implementation of vertical split flow model for patient throughput at a community hospital emergency department. Journal of Emergency Medicine, 64 (1), 77–82. https://doi.org/10.1016/ j.jemermed.2022.10.007

Ivanoff, A. (2022). Lean Six Sigma in healthcare improvement. MGMA Connexion/Medical Group Management Association, 28–35. Kenny, B., Rosania, A., & Lu, H. (2024). Lean-based approach to improve emergency department Throughput. Cureus, 16(9), e69591. https:// doi.org/10.7759/cureus.69591

Mataloni, F., Colais, P., Galassi, C., Davoli, M., & Fusco, D. (2018). Patients who leave emergency department without being seen or during treatment in the Lazio Region (Central Italy): Determinants and short- term outcomes. PLoS ONE, 13(12), e0208914. https:// doi.org/10.1371/journal.pone.0208914

Morley, C., Unwin, M., Peterson, G. M., Stankovich, J., & Kinsman, L. (2018). Emergency department crowding: A systematic review of causes, consequences, and solutions. PLoS ONE, 13(8), 1–42. https:// doi.org/10.1371/journal.pone.0203316

Ortíz-Barrios, M. A., & Alfaro-Saíz, J. J. (2020). Methodological approaches to support process improvement in emergency departments: A systematic review. International Journal of Environmental Research and Public Health, 17(8), 2664. https:// doi.org/10.3390/ijerph17082664

Pines, J. M., Zocchi, M. S., Ritsema, T. S., Bedolla, J., & Venkat, A. (2020). Emergency physician and advanced practice provider diagnostic testing and admission decisions in chest pain and abdominal pain. Academic Emergency Medicine, 28 (1), 36–45. https://doi .org/10.1111/acem.14161

Pines, J. M., Zocchi, M. S., De Maio, V. J., Carlson, J. N., Bedolla, J., Venkat, A., & U.S. Acute Care Solutions Research Group. (2020). The effect of operational stressors on emergency department clinician scheduling and patient throughput. Annals of Emergency Medicine, 76(5), 646–658. https://doi.org/10.1111/acem.14161

Smalley, C. M., Meldon, S. W., Simon, E. L., Muir, M. R., Delgado, F., & Fertel, B. S. (2021). Emergency department patients who leave before treatment is complete. The Western Journal of Emergency Medicine, 22(2), 148–155. https://doi.org/10.5811/ westjem.2020.11.48427

Tsige, T. T., Nasir, R., Puca, D., Charles, K., LoGalbo, S., Iyeke, L. O., ... & Richman, M. (2024). Does practice match protocol? A comparison of triage-to-provider time among more vs. less acute emergency department patients. Cureus, 16(8), e66079. https://doi.org/ Yancey, C.C., O’Rourke, M. C. Emergency Department Triage. (2025, Jan) [Updated 2022, Aug 31]. In: StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557583/

Ensuring Credibility and Trustworthiness in Qualitative Research

Alsacia L. Sepúlveda-Pacsi, PhD, DNS, RN, FNP, CCRN, CEN

Cassandra Dobson, PhD, RN-BC, PHc

n Abstract

Objective: This paper aims to highlight the importance of robust trustworthiness frameworks in enhancing the credibility and relevance of qualitative research in the health sciences. Utilizing the established framework of Lincoln and Guba (1985), it intends to offer practical strategies to improve the rigor and impact of qualitative studies in nursing and health research.

Methods: This section describes the methods established by Lincoln and Guba (1985) and Whittemore et al. (2001), which are centered on ensuring comprehensive, credible, and trustworthy research studies in conductive nursing qualitative and mixed-method research.

Conclusion: Qualitative research is vital in capturing the richness of patient experiences that quantitative data often overlooks. Researchers can enhance the rigor and trustworthiness of their studies by employing strategies to ensure credibility, dependability, confirmability, transferability, and authenticity.

Keywords: qualitative research, credibility, transferability, dependability, confirmability, authenticity, saturation, triangulation, prolonged engagement, audit trails

Background and Introduction

Credibility in qualitative studies is analogous to internal validity in quantitative research, as it aims to ensure that the findings accurately represent the perspectives and realities of the participants (Lincoln & Guba, 1985).

Lincoln and Guba delineate trustworthiness in qualitative research into four essential dimensions: transferability, dependability, confirmability, and authenticity. Transferability refers to the extent to which findings can be applied to other contexts or settings, emphasizing the importance of providing rich, thick descriptions that allow readers to determine applicability. Dependability involves the stability of the research findings over time, indicating that consistent methods and processes were used throughout the study to ensure replicability. Confirmability emphasizes the need for research findings to be grounded in the data collected, requiring a transparent audit trail that allows others to trace back the interpretations to the original data. Lastly, authenticity pertains to the

representation of diverse perspectives within the research, ensuring that the voices and experiences of participants are accurately portrayed.

Together, these dimensions help qualitative researchers produce reliable and meaningful findings that can withstand critical scrutiny. The frameworks established by Lincoln and Guba (1985) and further developed by Whittemore, Chase, and Mandle (2001) provide a solid foundation for evaluating the quality of qualitative research. They stress the importance of aligning researchers’ interpretations with participants’ lived experiences, fostering a deeper understanding of the studied subjects. This alignment not only bolsters the credibility of findings but also encourages a richer engagement with the complexities of the research context.

Quantitative research has traditionally highlighted the importance of rigor and validity, which are fundamental to maintaining methodological integrity. Rigor guarantees that research methods are precise and replicable, enabling consistent results across various studies. On the other hand, validity focuses on the alignment between the measurements

Alsacia L. Sepúlveda-Pacsi, PhD, DNS, RN, FNP, CCRN, CEN, Lehman College, City University of New York, New York, New York Cassandra Dobson, PhD, RN-BC, PHc, Lehman College, City University of New York, New York, New York

used and the constructs they aim to represent (Creswell, 2017). In sharp contrast, qualitative research prioritizes credibility and trustworthiness as its core values.

Quantitative research typically uses systematic surveys and experimental designs to gather numerical data. In contrast, qualitative research employs a more nuanced approach, utilizing in-depth interviews and observational studies to explore the complexities of human behavior and social interactions. This qualitative inquiry seeks to provide a comprehensive understanding of the frameworks proposed by Lincoln and Guba (1985) and Whittemore, Chase, and Mandle (2001), focusing specifically on how their criteria can enhance the credibility and trustworthiness of qualitative research in nursing and health studies.

Robust trustworthiness frameworks are crucial in bolstering the credibility and relevance of qualitative research within the health sciences. By applying the established framework of Lincoln and Guba (1985), this paper aims to present practical strategies for improving the rigor and impact of qualitative studies in nursing research.

Qualitative research plays a critical role in health care by capturing the nuanced experiences of patients that quantitative methods may overlook. While quantitative research focuses on statistical relationships and generalizability, qualitative research delves into the subjective experiences of individuals. To ensure the rigor of these studies, Lincoln and Guba’s (1985) framework for trustworthiness outlines five essential criteria: credibility, transferability, dependability, confirmability, and authenticity (Lincoln & Guba, 1994). These criteria are fundamental to enhancing the validity and reliability of qualitative research, ensuring that the insights derived genuinely reflect the participants’ perspectives. This paper aims to 1) explain the core criteria established by Lincoln and Guba (1985), 2) explore how these criteria ensure the integrity of qualitative research, and 3) highlight additional strategies for strengthening the credibility and trustworthiness of qualitative studies.

Credibility

Credibility is fundamental to qualitative research, ensuring that findings accurately represent participants’ experiences. It is closely aligned with internal validity in quantitative research and pertains to the truthfulness and accuracy of the data. Qualitative research often involves subjective interpretations and active engagement with participants, which makes establishing credibility a primary concern.

Lincoln and Guba (1985) propose several strategies to enhance credibility in qualitative research, with Prolonged Engagement being a cornerstone. Prolonged engagement enhances the depth of understanding and fosters trust between the researcher and participants, which is especially important in sensitive healthcare contexts. For example, in studies exploring chronic illness experiences, prolonged engagement helps ensure patients’ concerns are fully understood and accurately represented. Similarly, member checking ensures that researchers’ interpretations align with the participants’ lived experiences, thereby preventing misrepresentation of sensitive health data (Madsen et al., 2023; Sepúlveda-Pacsi et al., 2018; Pacsi, 2015). This allowed them to uncover layers of emotional and social dynamics crucial to understanding the participants’ experiences.

Another strategy to enhance credibility is persistent observation, which involves a focused effort to identify key features of the phenomenon under investigation (Ahmed, 2024). By paying close attention to these critical elements, researchers can uncover subtle patterns that enhance the depth and richness of the data. This focused attention to detail contributes to a more comprehensive understanding of the phenomenon and strengthens the credibility of the findings.

A third technique Lincoln and Guba (1985) recommend is member checking, which involves sharing interpretations and findings with participants to ensure that the research accurately reflects their perspectives. Member checking is an essential practice for validating the authenticity of the findings. By revisiting participants after data collection and confirming the accuracy of interpretations, researchers can enhance the trustworthiness of the research process. This process can be done through follow-up interviews and feedback between the researcher and the participants.

Credibility in qualitative research is vital for ensuring the findings are authentic and resonate with participants’ lived experiences (Ahmed, 2024; Holloway & Galvin, 2023). Prolonged engagement, persistent observation, and member checking help validate the accuracy of findings and increase confidence in the research’s authenticity.

Dependability

Dependability, closely related to reliability in quantitative research, refers to the consistency of findings over time and under similar conditions. It emphasizes the stability and trustworthiness of data across different contexts and populations. According to Polit and Beck (2022), dependability involves ensuring that data remains consistent when the research is repeated or replicated in similar settings. Ensuring dependability requires detailed documentation of research procedures and consistency across multiple interviews or observations, ensuring that similar findings emerge across varied contexts. Dependability emphasizes the need for consistent findings across similar contexts and over time. In nursing research, this consistency can be observed when similar patterns of health concerns emerge across different populations, such as the experiences of elderly patients with chronic pain or young mothers navigating postpartum care. Saturation is the point at which no new

Dependability emphasizes the need for consistent findings across similar contexts and over time. In nursing research, this consistency can be observed when similar patterns of health concerns emerge across different populations, such as the experiences of elderly patients with chronic pain or young mothers navigating postpartum care.

themes emerge from additional data collection and serves as a critical indicator of dependability, ensuring that the findings comprehensively reflect participants’ experiences.

A study is considered dependable when its findings remain stable and consistent across different situations, showing that the research process is well- organized and clearly documented. Dependability means that if the study were repeated with similar participants and conditions, it would likely produce comparable results. This can be seen in research exploring cancer-related concerns across different cultural groups, where dependability is demonstrated by recurring themes across diverse populations (Pentecost et al., 2020; Kim & Lee, 2023; Sepúlveda-Pacsi, 2018). In these studies, similar concerns, such as emotional challenges, information needs, or coping strategies, appear across groups, even when cultural backgrounds differ. These consistent patterns strengthen confidence in the reliability and trustworthiness of the research findings.

However, dependability differs from generalizability. While quantitative research seeks to generalize findings to larger populations, qualitative research focuses on saturation, the point at which no new insights emerge from additional data collection (Morse, 2015). Saturation is essential for dependability, ensuring the data comprehensively captures participants’ experiences. In mixed-methods designs, qualitative data collection methods (e.g., interviews and focus groups) are integrated into broader quantitative research to provide a more nuanced understanding of health phenomena (Meydan & Akkaş 2024). Several strategies that enhance credibility also contribute to dependability. For example, prolonged engagement and persistent observation help researchers develop a deeper understanding of the research context, ensuring that the findings reflect participants’ lived experiences (credibility) and that the data remains consistent and reliable over time (dependability). While credibility ensures the authenticity of findings, dependability ensures the stability and consistency of the research process across various contexts and periods. Thus, credibility and dependability are interdependent. Credibility ensures the accuracy and authenticity of findings, while dependability ensures consistency and reliability across different circumstances. By using overlapping strategies such as prolonged engagement and member

The goal of confirmability is to ensure that findings are shaped by participants’ voices, not the researchers’ preconceptions. This is particularly important in healthcare research when exploring deeply personal or culturally specific health experiences.

checking, researchers can simultaneously enhance both the credibility and dependability of their studies, reinforcing the overall trustworthiness of their qualitative research.

Confirmability

Confirmability refers to the extent to which others can corroborate a study’s findings and whether they reflect the participants’ perspectives rather than the researchers’ biases or preconceptions (Polit & Beck, 2022). This is achieved by maintaining transparency throughout the research process and providing an audit trail that documents researchers’ decisions and interpretations.

To enhance confirmability, researchers can use direct participant quotations to support the themes and findings that emerge from the data. These direct quotes provide concrete evidence that the findings are rooted in the participants’ voices and not the researchers’ assumptions. Additionally, documenting the data analysis process in detail allows for greater transparency and accountability, making it easier for others to assess the trustworthiness of the research. Additionally, an audit trail may include field notes, transcription records, decisions made during the analysis, and other data documenting the researchers’ thought processes throughout the study.

The goal of confirmability is to ensure that findings are shaped by participants’ voices, not the researchers’ preconceptions. This is particularly

Researchers recognize their personal biases and their impact on the research process, ensuring transparency. Polit & Beck, 2022

Ethical representation Participants are treated with respect, and their stories are shared with dignity and care, upholding ethical standards in the research process.

Polit & Beck, 2022

Understanding the cultural, social, and historical contexts of participants’ experiences makes the findings meaningful and representative. Khoa et al., 2023

important in healthcare research when exploring deeply personal or culturally specific health experiences. For instance, a researcher examining mental health in immigrant communities might have preconceived notions about healthcare access. By using member checking and maintaining an audit trail, the researcher ensures that these biases do not influence the interpretation of data and that the participants’ voices remain central.

Transferability

Transferability refers to the extent to which the findings of a qualitative study can be applied to other contexts, populations, or settings (Polit & Beck, 2022). Unlike quantitative research, which seeks to generalize findings to larger populations, qualitative research often focuses on providing rich, contextual insights that can inform similar settings.

To enhance transferability in qualitative research, particularly within the healthcare sector, researchers must provide detailed descriptions of the research context, including participant demographics, cultural settings, and methodologies employed. Such comprehensive accounts allow others to assess the applicability of findings to their contexts, recognizing the variability inherent in healthcare across diverse populations. For instance, findings from a study on urban breast cancer survivors may not readily generalize to rural populations due to differences in access to care. By offering detailed descriptions, researchers facilitate the evaluation of the relevance of their findings across various healthcare systems and cultural groups (Lincoln & Guba, 1985; Kim & Lee, 2023; Ahn & Lee, 2023).

Authenticity

Authenticity is vital for ensuring that qualitative research accurately represents participants’ experiences. It involves ethical considerations

Table 2

and the researchers’ commitments to capturing participants’ perspectives truthfully. Authenticity is achieved through rigorous data collection, ethical representation, and reflexivity, ensuring that participants’ voices are represented without distortion (Ide & Beddoe, 2024; Polit & Beck, 2022). It is not just about accurately representing participant experiences but also involves building strong, ethical relationships with participants that allow them to feel safe sharing their stories. Critical components of authenticity include truthfulness, where participants express their experiences honestly; reflexivity, where researchers acknowledge and reflect on their influence on the research process; ethical representation, which ensures that participants are treated with respect and their stories are portrayed ethically; and contextual accuracy, which involves capturing the cultural and historical contexts in which participants’ experiences occur (Khoa et al., 2023; Seale, 1999) (Table 1).

Enhancing Credibility and Trustworthiness

Several strategies can enhance the credibility and trustworthiness of qualitative research. These strategies include triangulation, prolonged engagement, reflexivity, fieldwork, and audit trails.

Triangulation

Triangulation, or using multiple data sources to cross-verify findings, is a valuable strategy for enhancing the credibility of healthcare research. For example, in a study on patient satisfaction, triangulation might involve combining patient interviews, healthcare provider surveys, and observational data to ensure a comprehensive understanding of the factors influencing satisfaction. This approach reduces bias and strengthens the interpretation of findings by corroborating insights from different sources (Morgan, 2024; Schlunegger et al., 2024; Meydan & Akka, 2023).

Criteria for Enhancing Credibility and Trustworthiness in Qualitative Research

Prolonged engagement: Building relationships and understanding the context by spending time in the research environment (Lincoln & Guba, 1985; Polit & Beck, 2022).

Persistent observation: Focusing on key parts of the research to identify important patterns (Lincoln & Guba, 1985).

Member checking: Participants receive their interpretations to confirm the results (Lincoln & Guba, 1985; Polit & Beck, 2022).

Peer debriefing: Having colleagues and experts review the research process helps identify biases and improve quality (Lincoln & Guba, 1985).

Thick description: Ensure descriptions are clear and detailed for better transferability and context relevance (Lincoln & Guba, 1985).

Authenticity: Ensure the findings accurately reflect what participants truly think. Be honest and represent them ethically (Seale, 1999; Lincoln & Guba, 2008).

Triangulation: Using different data sources, methods, researchers, or theories can make findings more reliable and thorough (Schlunegger et al., 2024).

Reflexivity: How a researcher’s viewpoint and biases affect gathering and analyzing data (Polit & Beck, 2022).

Fieldwork: Gathering information from real-life situations to learn how things work (Noble & Thorogood, 2018).

Audit trail: Maintain clear records of your research decisions, data collection methods, and analysis steps to ensure transparency (Polit & Beck, 2022).

Saturation: Gather all essential data until you stop discovering new information (Giorgi, 1970).

Contextual accuracy: It’s important to clearly describe the historical, cultural, and social contexts of the study (Khoa et al., 2023).

Prolonged engagement allows researchers to immerse themselves deeply in the research setting, building trust and understanding. At the same time, reflexivity encourages researchers to reflect on their biases and assumptions, ensuring that the researchers’ perspectives do not unduly influence the findings (Olmos-Vega et al., 2023; Karcher et al., 2024).

Maintaining audit trails provides transparency by documenting every step of the research process, making it easier for others to assess the trustworthiness of the findings (Polit & Beck, 2022; Holloway & Galvin, 2023). Additionally, peer debriefing occurs where colleagues review the research process and findings. This helps identify blind spots or biases, further validating the research process. The audit trail refers to a collection of notes and materials used by the researcher when conducting the conversations with the participants, which another researcher can then review, an expert in the study of the phenomenon, or check by the participants who participated in the study, to confirm the same study themes and conclusion that unfolded (Ahmed, 2024; Holloway & Galvin, 2023).

In the final step, the researcher provides supporting evidence of the study findings using quotes from the participants during the interview. The goal is for the participants to critique the study’s credibility and substantiate the interpretations personally (see Table 2).

Conclusion

Qualitative research is vital to nursing and health care. It offers rich insights into patient experiences that quantitative data often fails to capture. It explores the subjective dimensions of healthcare, such as beliefs, emotions, and personal narratives, which are essential for understanding the complexity of patient care.

Qualitative research can lay the foundations for future studies, particularly in emerging domains such as digital health, telemedicine, and health disparities. An interdisciplinary approach in these areas is crucial, as it facilitates collaboration and incorporates diverse perspectives and expertise. This collaborative framework is essential for tackling modern healthcare’s multifaceted challenges and working towards equitable access to care for all populations.

Researchers can enhance the rigor and trustworthiness of their studies by employing strategies to ensure credibility, dependability, confirmability, transferability, and authenticity. These strategies, such as triangulation, prolonged engagement, and reflexivity, help ensure that qualitative findings accurately represent participants’ experiences. As healthcare research evolves, these strategies will remain essential in improving patient care, informing policy, and advancing evidencebased practices.

n References

Ahn, J., & Lee, K-E. (2023). A hermeneutic phenomenological study on the disease experience among young women with breast cancer. Asia-Pacific Journal of Oncology Nursing, 10 (10), 100310. https:// doi.org/10.1016/j.apjon.2023.100310

Ahmed, S. K. (2024). The pillars of trustworthiness in qualitative research. Journal of Medicine, Surgery, and Public Health, 2, 100051. https:// doi.org/10.1016/j.glmedi.2024.100051

Creswell, J. W., & Creswell, J. D. (2017). Research design: Qualitative, quantitative, and mixed methods approaches. SAGE publications.

Dahal, N. (2023). Ensuring quality in qualitative research: A researcher’s reflections. The Qualitative Report, 28(8), 2298–2317. https://doi .org/10.46743/2160-3715/2023.6097

Fetters, M. D., Curry, L. A., & Creswell, J. W. (2013). Achieving integration in mixed methods designs—principles and practices. Health Services Research, 48 (6 pt 2), 2134–2156. https://doi .org/10.1111/1475-6773.12117

Giorgi, A. (1970). Toward a phenomenology of the human person. Journal of Phenomenological Psychology, 1(1), 3–12.

Green, J., & Thorogood, N. (2018). Qualitative methods for health research (4th ed.). SAGE Publications.

Holloway, I., & Galvin, K. (2023). Qualitative research in nursing and healthcare (5th ed.). Wiley-Blackwell.

Ide, Y., & Beddoe, L. (2024). Challenging perspectives: Reflexivity as a critical approach to qualitative social work research. Qualitative Social Work, 23(4), 725–740. https://doi.org/10.1177/1473325023117

Karcher, K., McCuaig, J., & King-Hill, S. (2024). (Self-) reflection/reflexivity in sensitive, qualitative research: A scoping review. International Journal of Qualitative Methods, 23, 16094069241261860. https:// doi.org/10.1177/16094069241261860

Khoa, B. T., Hung, B. P., & Hejsalem-Brahmi, M. (2023). Qualitative research in social sciences: Data collection, data analysis and report writing. International Journal of Public Sector Performance Management, 12 (1–2), 187–209. https://doi.org/10.1504/ IJPSPM.2023.132247

Kim, J., & Lee, K. (2023). Lived experiences of breast cancer in patients under the age of 40: A phenomenological study. European Journal of Oncology Nursing, 65, 102336.

Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry SAGE Publications.

Lincoln, Y. S., & Guba, E. G. (1994). The constructivist credo SAGE Publications.

Lincoln, Y. S., & Guba, E. G. (2008). The handbook of qualitative research (3rd ed.). SAGE Publications.

Madsen, R., Larsen, P., Carlsen, A. M. F., & Marcussen, J. (2023). Nursing care and nurses’ understandings of grief and bereavement among patients and families during cancer illness and death—a scoping review. European Journal of Oncology Nursing, 62, 102260. https:// doi.org/10.1016/j.ejon.2022.102260

Meydan, C. H., & Akkaş, H. (2024). The role of triangulation in qualitative research: Converging perspectives. In A. Elhami, A. Roshan, & H. Chandan (Eds.). Principles of Conducting Qualitative Research in Multicultural Settings (pp. 98–129). IGI Global.

Morgan, H. (2024). Using triangulation and crystallization to make qualitative studies trustworthy and rigorous. The Qualitative Report, 29(7), 1844–1856. https://doi.org/10.46743/2160-3715/2024.6071

Morse, J. M. (2015). Data were saturated.... Qualitative Health Research, 25(5), 587–588. https://doi.org/10.1177/1049732315576699

Noble, H., & Smith, J. (2015). Issues of validity and reliability in qualitative research. Evidence-Based Nursing, 18(2), 34–39. https:// doi.org/10.1136/eb-2015-102054

Olmos-Vega, F. M., Stalmeijer, R. E., Varpio, L., & Kahlke, R. (2023). A practical guide to reflexivity in qualitative research: AMEE Guide No. 149. Medical Teacher, 45(3), 241–251. https://doi.org/10.1080 /0142159X.2022.2057287

Pacsi, A. L. (2015). Understanding the experience of Dominican American women living with late-stage breast cancer: A qualitative study. Hispanic Health Care International, 13(2), 86–96. https:// doi.org/10.1891/1540-4153.13.2.86

Pentecost, C., Frost, J., Sugg, H. V. R., Hilli, A., Goodwin, V. A., & Richards, D. A. (2020). Patients’ and nurses’ experiences of fundamental nursing care: A systematic review and qualitative synthesis. Journal of Clinical Nursing, 29(11–12), 1858–1882. https://doi.org/10.1111/jocn.15082

Polit, D. F., & Beck, C. T. (2022). Nursing research: Generating and assessing evidence for nursing practice (11th ed.). Wolters Kluwer. Schlunegger, M. C., Zumstein-Shaha, M., & Palm, R. (2024). Methodologic and data-analysis triangulation in case studies: A scoping review. Western Journal of Nursing Research, 46(8), 611–622. https://doi .org/10.1177/01939459241263011

Seale, C. (1999). The quality of qualitative research: Introducing Qualitative Methods (1st ed.). SAGE Publications.

Sepúlveda-Pacsi, A. L., Hiraldo, G., & Frederickson, K. (2018). Cancer worry among urban Dominican women: A qualitative study. Journal of Transcultural Nursing, 29 (1), 30–37. https://doi .org/10.1177/1043659616672062

Whittemore, R., Chase, S. K., & Mandle, C. L. (2001). Validity in qualitative research. Qualitative Health Research, 11(3), 522–537.

Nurses Advocating for Safety: A Policy Review of New York’s Safe Staffing for Quality Care Law

Lorraine Cupelli, MS, RN

n Abstract

Healthcare has become increasingly complex, necessitating appropriate nurse-to-patient staffing levels to enhance positive patient outcomes and create healthy work environments that improve nursing sustainability and nurse well-being. The COVID-19 crisis unveiled the hidden issues in healthcare regarding chronic understaffing, acuity levels, and increased morbidity and mortality. The pandemic allowed policy stakeholders to gain legislative momentum for adequate staffing. New York State passed the Quality of Safe Nursing Act, requiring hospitals to submit staffing patterns, adhere to the critical care nurse-topatient ratio, and allocate nursing homes for registered nurses and certified nursing assistants. The New York State Nurses Association (NYSNA) investigated the law’s impact and found low hospital compliance, little oversight, and accountability from the NYS Department of Health (DOH). Only through multiple complaints from frontline nurses keeping track of staffing levels and submitting complaints to the DOH did the agency enforce the law. The article explores the need for policy regulation to improve patient care, reduce nurse workload and burnout, reduce work shortage, and enhance hospital staffing levels.

Keywords: nurse-to-patient ratios, staffing committees, policy implementation, stakeholder advocacy, safe staffing

Introduction

There are over four million nurses in the United States, the vast number of whom have worked through the COVID-19 crisis. Despite the fear, insufficient protective equipment, and unsafe, understaffed conditions, nurses stayed steadfast and remained at their patients’ bedsides. Nurses were displayed as “heroes” on the evening news and onlookers applauded them for their unyielding commitment to patient care. However, ethically and professionally, nurses have always stood by their patients and been their advocates despite the unsafe work conditions, which have historically compromised nursing practice. As the nurse workforce shrinks and our health outcomes worsen, nurses’ voices on staffing issues must be amplified and more clearly heard by our policymakers and healthcare institutions.

The United States healthcare system has grown increasingly complex, driven by rising patient acuity and the growing prevalence of chronic and acute conditions. In this evolving landscape, appropriate nurse staffing has emerged as a critical factor in ensuring safe, high-quality patient care. The burden of chronic diseases, coupled with the strain of

public health emergencies such as the COVID-19 pandemic, has highlighted the essential role of nursing in protecting the health and well-being of every patient entering the hospital.

This article highlights New York’s enactment of the Safe Staffing for Quality Care Act in 2021, emphasizing DOH oversight and enforcement. The law considers factors related to staffing, such as patient acuity, patient care models, nursing resources, and stakeholder advocacy, to enhance patient outcomes and reduce health expenditures.

Significance and Background

Research on nurse-to-patient ratios has shown that safe staffing provides quality care and positive patient outcomes (Griffiths et al., 2018). Despite the evidence supporting adequate nurse-to-patient ratios, uniform policy legislation has not been implemented to support safe staffing. Several states have policies requiring public disclosure of staffing plans, staffing committees, and mandated ratios. The staffing committee as legislated in eight states (CT, IL, NV, NY,

Lorraine Cupelli, MS, RN, Queensborough Community College, Queens, New York

OH, OR, TX, WA) is required to have at least 50% of direct-facing registered nurses (RNs) (ANA-n.d.-c; De Cordova et al., 2012019; N.Y. Health Law § 2805-T, McKinney 2025). Regulations vary among states, but literature has reported that oversight is necessary to determine if policies are being enforced. Staffing has remained inadequate across the United States, resulting in costly healthcare and poor patient outcomes. Compared with its peer countries, the United States spends the most per patient on health expenditures. Nevertheless, it attains the worst health outcomes, such as the lowest life expectancy (National Center for Health Statistics, 2022), and the highest rates of avoidable treatable deaths, multiple chronic conditions, obesity, and maternal and infant mortality (Gunja et al., 2023). Adequate staffing is a key determinant for optimizing the nation’s health. New York addressed staffing issues in 2021 when the Clinical Staffing Committees and Disclosure of Quality Indicators law was passed. The law, also known as the Safe Staffing for Quality Care Act, requires all New York hospitals to submit and publicly display minimum staffing standards for each unit, maintain a 1:2 nurse-topatient ratio in the critical care units, and designate minimum patient care hours for nursing home residents (American Nurses Association [ANA], n.d.-b; Rivera, 2021).

New York State Nurses Association (NYSNA) investigated the law’s impact and found that in 2023, hospital compliance with publicly posting staffing on units was 33%. Furthermore, NYSNA identified that the mandated intensive care unit (ICU) nurse-to-patient ratio was adhered to by only 50% from January 1 to October 31, 2024. Only one-third of the 387 staffing complaints submitted to the DOH had been investigated, and five violations had been issued. There has been a lack of transparency concerning DOH violations affecting frontline workers and minimal issuance of fines and civil penalties to noncompliant hospitals (NYSNA, 2024). The understaffing of New York hospitals remains a widespread problem that impacts the health of every New Yorker.

New York City Health + Hospitals, the most extensive public health system in the United States, reported a 7% decline in staffing between 2019 and 2023, with $589 million spent on travel nurses to temporarily Band-Aid the staffing issue (New York State Office of the State Comptroller, 2024). Similarly, Upstate New York hospitals face staffing hardships and have found it challenging to meet the 2021 NYS Clinical Staffing Committee Law requirements. There have been reports of chronic understaffing in 90% of all shifts, leading to a 14% increase in mortality (Lasater et al., 2024). This is further compounded by 70,000 nurses who do not practice in the nursing profession. Hospitals have the arduous task of recruiting and retaining nurses successfully; Eisner (2024) reports that 35,000 full-time equivalents will be needed to fill hospital and nursing home positions by 2030. All stakeholders, from the patients, communities, healthcare staff, and policymakers, should have a vested interest in healthcare; not only because, at one time or another, they will enter the system as patients, but also because adequate staffing will provide fewer sentinel events and will have reduced economic expenditures effects in healthcare institutions, insurance, and the gross national product (Gunja et al., 2023).

Several studies in Illinois, New York, and Australia compared hospitals with and without appropriate staffing and found differences related to care. Hospitals with mandated nurse-to-patient ratios reported statistical significance regarding reduced readmissions, morbidity, and

The primary reasons for nurse burnout are work overload and poor work environments. Work overload has been linked to higher urinary and surgical site infections. There are 7 million healthcare-acquired infections annually, and Cimiotti et al. (2012) indicate units with 30% less burnout had fewer than 6,300 HAIs and a cost savings of $68 million.

mortality (Aiken & Sloan, 2020; McHugh et al., 2021). Lasater et al. (2021a) indicated that 1,595 deaths could have been prevented with a four-patientto-one-nurse ratio for one year and created a cost savings of $117 million. It was also found that appropriate levels of nurses resulted in decreased health care-associated infections (HAIs) and shorter lengths of stay (Mitchell et al., 2018). Every patient added to a nurse’s workload (average 5.6 patients per nurse) increased the number of urinary tract and surgical site infections, costing anywhere from $749 to approximately $30,000 per treatment. The HAI went up significantly the more a nurse suffered from burnout. McHugh et al. (2021) evaluated the impact of staffing legislation in 27 intervention hospitals compared to nonintervention hospitals. The research (including Lasater’s study of 418,000 patients in 116 hospitals) found that hospitals with higher nurseto-patient ratios (range 4.3 to 10.5) or hospitals lacking nurse-to-patient ratio requirements had higher rates of illness, readmissions, extended hospital stays, and nurse burnout. The resulting outcomes were much more costly to health facilities than the cost to implement safe staffing. In another study, Lasater et al. (2021b) estimated that 4,370 lives would have been saved and that $720 million in costs would have been avoided over the 2-year study, had it not been for extended patient stays and readmissions (2021b).

Other issues related to nurse-to-patient ratios are patient and family satisfaction. The Centers for Medicare and Medicaid Services (CMS) measure patient satisfaction quarterly. Their scores determine whether hospitals will be provided with financial incentives or penalties. A low survey score harms a hospital’s reputation, resulting in fewer admissions and attracting fewer personnel (Centers for Medicare & Medicaid Services, 2021).

Staffing ratios directly impact nurse burnout, retirement, high turnover, and poor working conditions, which are the variables that perpetuate the vicious cycle of inadequate staffing. The primary reasons for nurse burnout are work overload and poor work environments. Work overload has been linked to higher urinary and surgical site infections. There are 7 million healthcare-acquired infections annually, and Cimiotti et al. (2012) indicate units with 30% less burnout had fewer than 6,300 HAIs and a cost savings of $68 million. Staffing legislation enhances hospital compliance for innovative staffing solutions and patient care models, positively affecting burnout, nurse retention, and satisfaction (Reynolds et al., 2021). The current national RN turnover of 18.4% costs health facilities $56,300 for each RN and a 9.9% vacancy (Gamble, 2024; NSI Nursing Solutions, 2024) to orient a nurse on

a medical-surgical floor. Additionally, 80,000 nurses retired in 2020, leaving the nursing workforce and exacerbating the staffing issue.

As of 2022, sixteen states have staffing regulations through mandated nurse-to-patient ratios, staffing committees, or public reporting of staffing levels by hospitals (de Cordova et al., 2019; ANA, n.d.-b). The states that have jurisdiction over ratios are California, Oregon, Massachusetts, and New York. However, they differ because California has staffing mandates in all units, while Oregon has limitations in the intensive care unit and medical-surgical areas. (NYSDOH, 2020). In contrast, New York and Massachusetts ratios are limited to the 1:2 nurse-to-patient ratio in critical care units. Several barriers exist to successfully attaining legislation. First, the cause and effect of ample local evidence are varied and not readily available. Secondly, the misconception surrounding the nursing shortage persists, despite the addition of approximately 102,000 RNs to the workforce in 2023. This shortage is further exacerbated by the demand for an estimated 194,500 new RN job openings annually, as proposed by the Bureau of Labor Statistics (2025). However, Lasater et al. (2021b) posits that New York has a higher RN-to-population ratio than California and is therefore capable of meeting the staffing requirements of a four-patient-toone-nurse ratio in medical-surgical units. Furthermore, Rotenstein et al.’s (2023) study highlights systemic barriers that hinder workforce expansion from effectively aligning with established staffing standards. Surveying over 40,000 individuals across more than 200 healthcare facilities, the study found that 59% of nurses reported experiencing burnout and 41% intended to leave their job within the next two years.

Lastly, the economic costs to the health facilities of adhering to staffing ratios are significant. The Healthcare Association of New York State (HANYS) and the Greater New York Hospital Association estimated that an additional $2 billion would be needed to fulfill New York staffing mandates for hospitals and nursing homes (NYSDOH, 2020). California is the only state to have mandated nurse-to-patient ratios in all hospital units, despite having fewer RNs than New York (Lasater et al., 2021b).

Since California’s implementation, a systematic review of 22 studies indicated positive outcomes of nurses’ intent to stay and job satisfaction. In contrast, mixed results were found with health care-associated infections, pressure ulcers, and falls, with difficulty in assessing causality and mortality (Lasater et al., 2024; NYSDOH, 2020; Twigg et al., 2021).

Problem Statement and Policy Analysis

Staffing New York hospitals remains an issue, due to a mass exodus of nurses from the hospital, poor nurse retention, high acuity, increased comorbidities of an aging population, and exorbitant healthcare spending despite unparalleled health outcomes. The primary reason nurses leave an organization is related to staffing. Maintaining appropriate staffing patterns in New York requires hospital administration to be accountable to the law and effectively recruit and retain RNs.

As of 2024, NYSNA revealed significant policy implementation gaps. The law stipulates that the clinical staffing committees comprise frontline nurses, other healthcare team members, and the administration. The committee oversees staffing pattern analysis, displays staff postings on all units, and reviews complaints. Many New York hospitals failed to submit and display staffing publicly despite legislation and repeated letters from the NYS DOH. Initially, the DOH, which was responsible

for executing the clinical committee law, lacked the empowerment to enforce the staffing policy. With inconsistent policy implementation, administrative staffing disclosure and liability were diminished, producing poor hospital compliance. NYSNA has been unable to measure the policy’s effectiveness accurately due to the lack of transparency (2024). Two hospitals, Albany Medical Center and Vassar Brothers Medical Center, Poughkeepsie, had repeatedly threatened patient safety with poor staffing, and it was only through nursing personnel submitting complaints to the DOH that this was addressed. Vassar eventually proposed a corrective action, collaborating closely with frontline nurses; however, the Albany Medical Chief Executive Officer refused to share the DOH report with the clinical staffing committee for a workable collaborative plan despite the agency’s directive. Additionally, the CEO retaliated against the committee members and understaffing has remained an issue. Furthermore, retrieving and reviewing violation investigations in nonunionized hospitals remained challenging, whereas hospital unions had an easier time reinforcing policy adherence (NYSNA, 2024).

Policy Analysis Framework

Kingdon’s Multiple Streams Framework provides the lens through which a policy develops when the problem, policy, and politics converge and create an opportunity for reform. New York’s Safe Staffing for Quality Care Act passed in 2021 when the COVID-19 pandemic magnified the ills in the healthcare system, combined with nursing lobbying for safe staffing for years. This framework was used because it outlines the key components underscoring staffing policy development in relation to the political, ethical, and societal pressures caused by the pandemic. The political path emerged quickly from these events, reinforced by the public support of nurses.

The media displayed chronic staffing issues, adverse patient outcomes, and mortality as a public health crisis necessitating the need for more staffing. Frontline nurses and nursing organizations continuously articulated safe staffing (ANA, n.d.-a; ANA, 2018). Displays of nurses having no equipment and staying steadfast to care for patients, often jeopardizing the nurses’ health, placed nurses in a favorable societal position and legislation was more easily promulgated. Kingdon’s framework highlights the strategic alignment of crisis, advocacy, and politics to transform staffing regulations (Giese, 2020).

Stakeholders

The stakeholders involved with nursing staffing at hospitals are the nurses, professional nursing organizations, hospital administrations, local and state legislators in New York, the insurance agencies, and the federal government. Furthermore, patients as stakeholders are at risk for poor care and are usually not involved in staffing legislation. Stakeholders are highly influential and have the potential to empower lawmakers to create and enforce the laws (Bartmess et al., 2021).

Frontline nurses have always stressed the importance of staffing for appropriate, safe patient care. However, historically, nursing management would have nurses devise strategies or “workarounds” to do more with less (Clark et al., 2025). Less equates with higher mortality, unavoidable deaths, and HAIs (Mitchell et al., 2018). Professional nurses’

Fixed nurse-to-patient staffing ratios are a critical policy tool for addressing the ongoing nursing shortage and ensure safe, equitable patient care; however, workforce pipelines will be insufficient to close the supply and demand gaps unless working conditions are improved.

associations and advocacy groups such as NYSNA have actively pushed forward the staffing agenda, contributing to the successful legislation of the Safe Staffing for Quality Care Act (2024). On the federal level, the ANA and National Nurses United (NNU) have advocated for safe staffing, although they are divided on staffing strategies (ANA, 2018; Bartmess et al., 2021). ANA proposes that nurses be autonomous in regularly assessing and planning staffing needs, which may include variable staffing levels, whereas NNU has enforced safer nurse-to-patient ratios. Differing perspectives weaken policymaking efforts, although nurses and their organizations look to policy to correct the situation (Bartmess et al., 2021).

Hospitals are another stakeholder group and are tasked with maintaining staffing ratios. Because hospitals spend over half their operating budget on staff wages, they may be reluctant economically to increase staff (Bartmess et al., 2021). However, they are confronted with penalties from the CMS that will not reimburse HAI, falls, or pressure ulcers arising from hospitalization (2024).

The last stakeholder group worth mentioning is the policymakers. Patient care is highly valued and staffing legislation is introduced more frequently in liberal-leaning states. However, there are different perspectives about a fixed nurse-to-patient ratio requiring institutions to have some flexibility with staffing levels based on acuity, nurses’ experience levels, and level of autonomy. Fixed nurse-to-patient staffing ratios are a critical policy tool for addressing the ongoing nursing shortage and ensure safe, equitable patient care; however, workforce pipelines will be insufficient to close the supply and demand gaps unless working conditions are improved.

Gaps and Barriers

Sixteen states have staffing committees and public disclosure of staffing, and one state, California, has mandated ratios. Ordinances and approaches to staffing corrections vary and are inconsistent state to state. Staffing measurements vary with the number of nurses, nursing hours per patient, and the number of patients to RN full-time equivalents in New York. Additional variables identified as impactful related to nursing practice are the nurses experience levels, expertise, autonomy, administrative

support, and patient trust. Even though quality care has been the focus nationally, 32 states have no legislation supporting nurse-to-patient ratios, and conservative states are less likely to participate in staffing legislation. The NYS DOH neglected to enforce the policy necessitating individual nurses to track and report staffing, and organizations such as NYSNA protested. Furthermore, the purpose of the NY staffing policy was to increase public transparency. However, the DOH will only disclose staffing levels to the consumer upon request. Unenforceable legislation often perpetuates the systemic issues it was designed to address, undermining the policy’s intent.

The nursing shortage is compounded by high turnover, older nurses retiring, many RNs not practicing as nurses, nurses’ emotional turmoil and need for well-being initiatives, and poor work environments. The number of nursing faculty vacancies has affected the workforce pipeline, making it challenging to maintain appropriate staff patterns. Furthermore, there is an aging general population with a chronic disease prevalence. Due to increased patient acuity, the proposed staffing ratio for medical-surgical units is one nurse to four patients (Lasater, 2021a). Hospitals are concerned about maintaining the mandates and the cost. Due to the disparities in staffing regarding health facilities in urban versus rural areas, facilities in rural New York can apply for an exemption since they have fewer nurses overall. However, national labor statistics indicate New York has more nurses than California, and the ratio mandates are logistically possible. The nursing-sensitive data varies in California, even though Aiken et al. (2020) report lower mortality and Flanagan et al. (2016) indicate significantly lower readmission rates for pneumonia after implementing the fixed ratio policy in California.

Recommendations and Implications for Practice

The DOH must consistently monitor New York’s healthcare facilities’ staffing ratios, reports, and complaints, and enforce Safe Staffing for Quality Care policy regulations. Research indicates reduced nurse burnout, improved working environments, and adequate staffing result in rates of 14% less patient mortality, 12% reduced inability to rescue patients, and 4% decreased lengths of stay (Bartmess et al., 2021) These long-term financial incentives may influence health care institutions to focus on nurse sustainability and well-being, resulting in improved job satisfaction, reduced turnover, and better stability of hospital staffing. Furthermore, as more research is conducted, the data will continue to inform policymaking efforts to enhance favorable patient outcomes with adequate staffing levels. Continued advocacy from nursing organizations, nurse leaders, and frontline nurses will be important in advancing quality patient care and nursing labor practices to the legislature. NYSNA (2024), which regularly supports the nursing profession, recommends that the DOH enhance public transparency, enforce current laws by imposing penalties for noncompliant hospitals, and improve nurse retention and working conditions to promote quality patient care.

n References

Aiken, L. H., & Sloane, D. M. (2020). Nurses matter: More evidence. BMJ Quality & Safety, 29(1), 1–3. https://doi.org/10.1136/bmjqs2019-009732

American Nurses Association (ANA). (n.d.-a). Nurse staffing crisis: The need for legislative action. https://www.nursingworld.org/practicepolicy/nurse-staffing/nurse-staffing-crisis

American Nurses Association (ANA). (n.d.-b). Staffing legislation landscape report. https://www.nursingworld.org/globalassets/ staffing-legislation-landscape-report-final.pdf

American Nurses Association (ANA). (n.d.-c). Advocating for safe staffing. https://www.nursingworld.org/practice-policy/nursestaffing/nurse-staffing-advocacy/

American Nurses Association (ANA). (2018, February). A NA applauds nurse staffing legislation. https://www.nursingworld.org/news/ news-releases/2018/ana-applauds-nurse-staffing-legislation/

Bartmess, M., Myers, C. R., & Thomas, S. P. (2021). Nurse staffing legislation: Empirical evidence and policy analysis. Nursing Forum, 56(3), 660–675. https://doi.org/10.1111/nuf.12594

Bureau of Labor Statistics, U.S. Department of Labor. (2025, April 18). Occupational outlook handbook: Registered nurses. https://www .bls.gov/ooh/healthcare/registered-nurses.htm

Centers for Medicare & Medicaid Services (CMS). (2024, April 22). Medicare and Medicaid programs: Minimum staffing standards for long-term care facilities and Medicaid institutional payment transparency reporting final rule (CMS 3442-F). https://www .cms.gov/newsroom/fact-sheets/medicare-and-medicaid-programsminimum-staffing-standards-long-term-care-facilities-and-medicaid Centers for Medicare & Medicaid Services (CMS). (2021, March). HCAHPS fact sheet (HCAHPS® hospital survey). https://hcahpsonline.org/ globalassets/hcahps/facts/hcahps_fact_sheet_march_2021.pdf

Cimiotti, J. P., Aiken, L. H., Sloane, D. M., & Wu, E. S. (2012). Nurse staffing, burnout, and health care–associated infection. American Journal of Infection Control, 40 (6), 486–490. https://doi .org/10.1016/j.ajic.2012.02.029

Clark, D., Lawton, R., Baxter, R., Sheard, L., & O’Hara, J. K. (2025). Do healthcare professionals work around safety standards, and should we be worried? A scoping review. BMJ Quality & Safety, 34(5), 317–329. https://doi.org/10.1136/bmjqs-2024-017546

de Cordova, P. B., Pogorzelska-Maziarz, M., Eckenhoff, M. E., & McHugh, M. D. (2019). Public reporting of nurse staffing in the United States. Journal of Nursing Regulation, 10 (3), 14–20. https://doi .org/10.1016/j.jnr.2019.07.001

Eisner, E. (2024, December). Upstate New York’s hospital staffing crisis. Fiscal Policy Institute. https://fiscalpolicy.org/wp-content/ uploads/2024/12/Upstate-New-Yorks-Hospital-Staffing-Crisis.pdf

Flanagan, J., Stamp, K. D., Gregas, M., & Shindul-Rothschild, J. (2016). Predictors of 30-day readmission for pneumonia. Journal of Nursing Administration, 46(2), 69–74. https://doi.org/10.1097/ NNA.0000000000000297

Gamble, M. (2024). The cost of nurse turnover is 24 numbers. Becker’s Hospital Review. https://www.beckershospitalreview.com/finance/ the-cost-of-nurse-turnover-in-24-numbers-2024.html

Giese, K. K. (2020). Coronavirus disease 2019’s shake-up of telehealth policy: Application of Kingdon’s multiple streams framework. The Journal for Nurse Practitioners, 16(10), 768–770. https://doi .org/10.1016/j.nurpra.2020.07.004

Griffiths, P., Recio-Saucedo, A., Dall’Ora, C., Briggs, J., Maruotti, A., Meredith, P., Smith, G. B., Ball, J., & Missed Care Study Group. (2018). The association between nurse staffing and omissions in nursing care: A systematic review. Journal of Advanced Nursing, 74(7), 1474–1487. https://doi.org/10.1111/jan.13564

Gunja, M. Z., Gumas, E. D., & Williams II, R. D. (2023, January). U.S. health care from a global perspective, 2022: Accelerating spending, worsening outcomes. The Commonwealth Fund. https://doi .org/10.26099/8ejy-yc74

Health Resources and Services Administration (HRSA). (2024, November). State of the U.S. health care workforce, 2024. U.S. Department of Health and Human Services. https://bhw.hrsa.gov/ sites/default/files/bureau-health-workforce/state-of-the-healthworkforce-report-2024.pdf

Lasater, K. B., Aiken, L. H., Sloane, D., French, R., Martin, B., Alexander, M., & McHugh, M. D. (2021a). Patient outcomes and cost savings associated with hospital safe nurse staffing legislation: An observational study. BMJ Open, 11(12), e052899. https://doi .org/10.1136/bmjopen-2021-052899

Lasater, K. B., Aiken, L. H., Sloane, D. M., French, R., Anusiewicz, C. V., Martin, B., Reneau, K., Alexander, M., & McHugh, M. D. (2021b). Is hospital nurse staffing legislation in the public’s interest? An observational study in New York State. Medical Care, 59(5), 444–450. https://doi.org/10.1097/MLR.0000000000001509

Lasater, K. B., Aiken, L. H., Sloane, D. M., French, R., Martin, B., Reneau, K., Alexander, M., & McHugh, M. D. (2024). Chronic hospital nurse understaffing meets COVID-19: An observational study. BMJ Quality & Safety, 30(8), 639–647. https://doi.org/10.1136/ bmjqs-2020-012538

McHugh, M. D., Aiken, L. H., Sloane, D. M., Windsor, C., Douglas, C., & Yates, P. (2021). Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: A prospective study in a panel of hospitals. The Lancet, 397(10288), 1905–1913. https://doi.org/10.1016/S0140-6736(21)00768-6

Mitchell, B. G., Gardner, A., Stone, P. W., Hall, L., & Pogorzelska-Maziarz, M. (2018). Hospital staffing and health care–associated infections: A systematic review of the literature. The Joint Commission Journal on Quality and Patient Safety, 44(10), 613–622. https://doi.org/10.1016/j.jcjq.2018.02.002

National Center for Health Statistics (NCHS). (2022, August). Life expectancy in the U.S. dropped for the second year in 2021 Centers for Disease Control and Prevention. https://www.cdc.gov/ nchs/pressroom/nchs_press_releases/2022/20220831.htm

New York Public Health Law § 2805-T (McKinney 2025). https://www .nysenate.gov/legislation/laws/PBH/2805-T

New York State Department of Health (NYSDOH). (2020, August). Study of nurse caregiver minimum staffing levels, other staffing enhancement strategies, and patient quality improvement initiatives. https://health.ny.gov/press/reports/docs/2020-08_ staffing_report.pdf

New York State Nurses Association (NYSNA). (2024). The state of safe staffing in New York: An analysis of nurse staffing since the hospital clinical staffing committee law was passed New York State Nurses Association. https://cf-simple-s3-origincloudfrontfors3-146697677730.s3.us-east1.amazonaws.com/safe StaffingResources/2024nysnaStaffingReport.pdf

New York State Office of the State Comptroller. (2024, November). NYC Health + Hospitals: Nurse staffing trends update (Report No. 182025). https://www.osc.ny.gov/files/reports/pdf/report18-2025.pdf

NSI Nursing Solutions, Inc. (2024). 2024 NSI National Health Care Retention & RN Staffing Report. https://www.scribd.com/ document/778510043/NSI-National-Health-Care-Retention-Report

Reynolds, H. V., Von Dohren, G., & Tabah, A. (2021). Mandated nursing ratios decrease mortality and hospital costs. What about the ICU? Anaesthesia, Critical Care & Pain Medicine, 40(6), 100977. https:// doi.org/10.1016/j.accpm.2021.100977

Rivera, G. (2021). Senate Bill S1168A: An act to amend the public health law concerning establishing clinical staffing committees. New York State Senate. https://www.nysenate.gov/legislation/bills/2021/S1168

Rotenstein, L. S., Brown, R., Sinsky, C., & Linzer, M. (2023). The association of work overload with burnout and intent to leave the job across the healthcare workforce during COVID-19. Journal of General Internal Medicine, 38 (8), 1920–1927. https://doi .org/10.1007/s11606-023-08153-z

Twigg, D. E., Whitehead, L., Doleman, G., & El-Zaemey, S. (2021). The impact of nurse staffing methodologies on nurse and patient outcomes: A systematic review. Journal of Advanced Nursing, 77(12), 4599–4611. https://doi. https://doi.org/10.1111/jan.14909

Upcoming NYSNA Nursing Education and Practice Workshops

NYSNA offers educational programs in person and online.

Scan the QR code above to view the 2026 Calendar of Events for the complete list of offerings.

Register for workshops on NYSNA E-LeaRN today at https://learning.nysna.org/topclass.

THE JOURNAL

of the New York State Nurses Association

Call for Papers

The Journal of the New York State Nurses Association is currently seeking papers.

Authors are invited to submit scholarly papers, research studies, brief reports on clinical or educational innovations, and articles of opinion on subjects important to registered nurses. Of particular interest are papers addressing direct care issues. New authors and student authors are encouraged to submit manuscripts for publication.

Additional Submission Opportunities Include the Following:

From Bedside to Stage

We are excited to invite NYSNA members to submit articles highlighting your successful execution of evidence-based practice (EBP) changes or future EBP implementation plans. We are particularly interested in projects that demonstrate how clinical practice improvements are being shared, implemented, and sustained across units or institutions. Even if your project has not yet been implemented, we welcome submissions outlining your plans and goals. In 350–500 words, please submit a summary including:

 Project outline

 Data and evidence supporting the change

 Implementation strategy (current or planned)

 Outcomes or anticipated outcomes

 Dissemination plan

We are proud to showcase your efforts and highlight the impact of your EBP initiatives.

Certification Spotlight

The Journal of the New York State Nurses Association is highlighting members who have completed a NYSNA Certification Review Course and have passed the respective certification exam. We would love to share your story of what this certification means to you, and how it will impact your career practice goals as a NYSNA nurse. In 50–100 words, tell

us your certification story. Please include a professional headshot along with the signed consent form to release your photograph for publication. Please also include your certificate and a short biography.

Letters to the Editor

The Journal of the New York State Nurses Association would like to publish your feedback. If you would like to draft a letter responding to an article published in our most recent publication, your insight and opinion would be welcome. Limit 300–500 words. Research experience is preferred.

Reflect & Resonate

The Journal of the New York State Nurses Association would like to publish your feedback. If you would like to draft a brief reading response to an article published in our most recent publication, your insight and opinion would be welcome. Limit 50–100 words. Research experience is not required.

Information for Authors

For authors’ guidelines and submission deadlines, go to the publications area of www.nysna.org or write to journal@nysna.org

2026 Secor Scholarship

The application window for the 2026 Secor Scholarship is now open. The Secor Scholarship Fund, established in 2007, was made possible by a generous bequest by long-time NYSNA member Jane Secor, PhD, RN. Dr. Secor stipulated that the endowment be used for furthering nursing education. Two Secor Scholarships will be awarded annually:

• $5,000 to a NYSNA member seeking a baccalaureate (or higher) degree in nursing.

• $5,000 to a family member of a NYSNA member seeking a first degree in nursing. The degree can be at any level, but it must be the first degree in nursing sought by the applicant.

Application deadline for the 2026 Secor Scholarship is July 10, 2026. Visit https://www.nysna.org/nursing-practice/nysna-secor-scholarship for full application instructions.

Correction to Volume 52, Number 1: The previous issue of the NYSNA Journal, Volume 52, Number 1, was printed with an error in the “Editorial” section. This section erroneously excluded Editorial Review Board Member Simon Paul P. Navarro as an author of this section and instead included former Board Member Meredith King-Jensen. Please excuse this oversight and accept this correction.

 HEALTHCARE LITERATURE HIGHLIGHTS

WHAT YOU NEED TO KNOW

Healthcare Literature Highlights provide concise summaries of relevant published studies or articles that may be of interest to registered nurses (RNs) and advanced practice

registered nurses (APRNs). We recommend that readers consult the original publications for further insights and comprehensive information.

 Variations in Job Turnover Factors Among Internationally Educated and U.S.-Trained Nurses: Insights from

the 2018 and

2022 National Sample Survey of Registered Nurses

 Zhang, J., Lin, B., Yang, Y., Jung, H. J., Navarro, S. P. P., & Norful, A. A. (2025). Variations in job turnover factors among internationally educated and U.S.-trained nurses: Insights from the 2018 and 2022 National Sample Survey of Registered Nurses. Nursing Outlook, 73(6), 102574. https://doi.org/10.1016/ j.outlook.2025.102574

Structured Abstract

Background: The United States relies on internationally educated nurses (IENs) to support and supplement its healthcare workforce. Although IENs play a vital role in mitigating the national nursing shortage, evidence describing variations in their sociodemographic and professional characteristics, turnover intentions, and retention factors remains limited and insufficiently explored within the U.S. nursing workforce.

Objective: To examine factors influencing retention and turnover intentions among IENs and to compare these variables with those locally trained nurses in the United States.

Methods: A secondary data analysis was conducted using the 2018 and 2022 National Sample Survey of Registered Nurses (NSSRN). Weighted descriptive and inferential statistics were applied to characterize the nursing workforce and compare IENs with U.S.-trained nurses. Both unadjusted and adjusted multiple regression models were used to evaluate predictors of intent-to-leave and to assess relationships between reasons for leaving and reasons for remaining across the two nurse subgroups.

Findings: Sociodemographic and professional characteristics differed significantly between IENs and U.S.-trained nurses. Burnout emerged as a consistent and significant predictor of turnover intentions across both groups. Organizational factors such as stressful work environments, inadequate staffing, and poor management or leaders were the most frequently identified drivers of turnover intentions among U.S.-trained nurses. In contrast, personal and role-related factors, including caregiving responsibilities, patient population, and professional autonomy were more often cited for IENs.

Key Takeaways

• Strengthening workforce stability requires addressing subgroupspecific organizational and personal determinants of turnover intention and retention.

• Tailored interventions are essential to support IEN integration, enhance professional role utilization, and mitigate challenges such as limited advancement opportunities.

• Broader institutional disparities may underlie restricted career progression for IENs and warrant targeted policy attention

• Future research should employ longitudinal designs and include variables such as leadership style, unionization, and coping mechanisms to advance understanding of workforce dynamics.

Keywords: nurses, retention, job turnover, workforce

Healthcare Literature Highlight summary by Simon Paul P. Navarro, MA, BSN, RN, CCRN, TCRN

 Education and Mammographic Breast Density

 Al Hasan, S. M., Matthew, K. A., & Toriola, A. T. (2025). Education and mammographic breast density. Breast Cancer Research and Treatment, 210 (2), 377384. https://doi.org/10.1007/s10549-02407575-5

Structured Abstract

Background: Mammographic breast density (MBD) is a significant risk factor for breast cancer, with higher density linked to increased risk. Both MBD and breast cancer share determinants such as age, adiposity, and reproductive history, which are also influenced by socioeconomic

status (SES). Education, a key SES indicator, affects health behaviors and access to care. However, evidence on the association between education and MBD is limited and inconsistent, varying by population, menopausal status, and measurement methods.

Objective: This study investigates the association between education and volumetric percent density (VPD), an automated measure of MBD, and quantifies the mediating roles of age and adiposity.

Methods: Data from 1,155 women undergoing screening mammography at the Joanne Knight Breast Health Center were analyzed.

Need to

 Education and Mammographic Breast Density (cont.)

VPD was assessed via automated volumetric methods. Generalized linear models estimated VPD differences by education, race, and menopausal status. Mediation analysis using the PROCESS macro evaluated indirect effects of age and adiposity. VPD values were log-transformed and backtransformed for reporting.

Results: Women with college (7.21%) and postgraduate education (7.18%) had higher VPD than those with below-college education (6.62%) after adjusting for age, BMI, and confounders (p = .051). This association attenuated and lost significance when body fat percentage replaced BMI (p = .156). Among premenopausal women, body fat percentage and BMI mediated 71% and 64% of the education–VPD association, respectively; no mediation was observed in postmenopausal women. Associations did not differ by race.

Conclusion: Adiposity, rather than education alone, largely explains differences in breast density, especially in premenopausal women. Breast cancer risk assessments should incorporate adiposity measures. Public health efforts must focus on adiposity reduction across educational levels.

Further longitudinal investigations are warranted to elucidate causal pathway, cultural factors, and social determinants influencing MBD.

Key Takeaways

• Higher education is associated with increased VPD; however, this association diminishes after accounting for body fat.

• Body fat percentage and BMI serve as mediators in the education-VPD relationship among premenopausal women, but not in postmenopausal women.

• There are no observed racial differences in the association between education and VPD.

• Adiposity is a significant mediator and should be considered in breast cancer risk assessments.

• Additional longitudinal and qualitative studies are necessary to investigate causal mechanisms and social determinants related to MBD.

Keywords: adiposity, mammographic breast density (MBD), volumetric percent density (VPD), social determinants, longitudinal studies

Healthcare Literature Highlight summary by Alsacia Sepúlveda-Pacsi, PhD, DNS, RN, FNP, CCRN, CEN

 Implementing Lifestyle Interventions for Adults with Mental Illness via Telemedicine

 Wright T., Fenton A., Ling C., & Tromba S. (2024). Implementing lifestyle interventions for adults with mental illness via telemedicine. The Journal for Nurse Practitioners, 21(3), 1–6. http://doi.org/10.1016/j.nurpra.2024.105302

Abstract

Adults with mental illnesses have significantly shorter life expectancies largely due to higher rates of comorbid chronic health conditions such as obesity, diabetes, hypertension, and other cardiometabolic conditions. Lifestyle factors (diet, physical activity, weight control) are modifiable and are underutilized in mental healthcare settings.

The project addresses health promoting factors and health indicators to determine whether the inclusion of these lifestyle education programs improved outcomes that can be adopted into standard practice.

A 9-week evidence-based quality improvement program in an integrated telemental health and primary care setting with pre- and posttest format was designed to assess participant’s self-care inventory scores (measuring confidence, ability in self-care behaviors), health indicators (weight, body mass index-BMI), and evaluate the feasibility of delivering the program in the telemedicine environment.

Participants showed significant improvements in weight, BMI, and reported increased self-care confidence and self-care behaviors following

the 9-week program. Investigators found telemedicine to be a viable tool for incorporating lifestyle interventions in this population. These outcomes align with existing literature underscoring the benefits of lifestyle interventions for individuals with mental health conditions.

Conclusion: Integrating tailored life-style education programs within virtual telemental health and primary care setting can yield positive outcomes among adults with mental health disorders who are at increased cardiometabolic risks and addresses solutions to accessibility barriers.

Key Takeaways

• Adults with mental health illnesses are at risk for cardiometabolic conditions, a telemedicine delivery education program showed improvements in self-care confidence, behavior and improved health outcomes.

• Telehealth is a viable platform for implementing customized lifestyle interventions into mental healthcare.

• The study highlights the significance of holistic approaches in fostering positive outcomes for individuals with mental illness.

Keywords: mental health, telehealth, cardiometabolic conditions, primary care

Healthcare Literature Highlight summary by Michelle Jones, MSN, RN, ANP-C

 CE Activity: Evidence-Based Strategies to Improve Door-to-Provider Times in the Emergency Department

Thank you for your participation in “Evidence-Based Strategies to Improve Door-to-Provider Times in the Emergency Department” a new continuing education (CE) activity offered by NYSNA. NYSNA members and nonmembers from any U.S. State are invited to take part in this activity.

INSTRUCTIONS

To receive the contact hour (CH) or continuing education unit (CEU) for this educational activity, participants are to read the article presented in this issue of The Journal, complete and return the post-test, evaluation form, and earn 80% or better on the post-test. This can be completed either by mail or online by registering for the CE Activity using NYSNA E-LeaRN. Access E-LeaRN learning.nysna.org/topclass or with the QR code displayed below:

This activity is free to NYSNA members and $10 for nonmembers. Participants can pay by check (made payable to NYSNA) or credit card. The completed answer sheet and evaluation form may be mailed or faxed back to NYSNA; see the evaluation form for more information.

The New York State Nurses Association is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.

This program has been awarded 1 CH through the New York State Nurses Association Accredited Provider Unit.

The New York State Nurses Association is accredited by the International Association for Continuing Education and Training (IACET) and is authorized to issue the IACET CEU.

The New York State Nurses Association is authorized by IACET to offer 0.1 CEU for this program.

To receive a CH/CEU, participants must read the entire article, fill out the evaluation, and get 80% or higher on the post-test.

Presenters disclose no conflict of interest.

NYSNA wishes to disclose that no commercial support was received for this educational activity.

All planners and authors involved with the development of this independent study have declared that they have no vested interest.

NYSNA program planners and authors declare that they have no conflict of interest in this program.

INTRODUCTION

Reducing overcrowding is an essential focus of emergency departments (EDs) seeking to improve organizational efficiency and patient safety and satisfaction. By remedying this pervasive issue, providers can ensure timely access to care, reduce adverse health outcomes, and bolster their organizational reputations in their communities. Identifying factors that contribute to issues including overcrowding, LWBS (leave without being seen) rates, and medication errors—coupled with the implementation of evidence-based strategies for streamlining operations—may help deliver these improvements. As research from this article indicates, evidencebased operational interventions may reduce staff burnout and support organizational compliance with regulatory benchmarks.

LEARNING OUTCOME

At the end of this CE activity, participants will be able to identify key factors contributing to ED overcrowding prolonged wait times to see providers, and analyze evidence-based strategies for improving patient flow and reducing door-to-provider times.

OBJECTIVES

At the completion of this learning activity, the learner will be able to:

1. Identify key factors contributing to ED overcrowding and prolonged wait times to see providers.

2. Analyze evidence-based strategies to improve patient flow and reduce length of stays.

3. Implement team-based care approaches to optimize throughput.

4. Apply patient communication and discharge strategies to minimize delays and unnecessary revisits.

Please answer either True or False to the questions below or select one of the multiple-choice options. Remember to complete the answer sheet by putting the letter of your corresponding answer next to the question number. Each question has only one correct answer.

The 1.0 CH and 0.1 CEU for this program will be offered until February 28, 2029.

QUESTIONS

1) Which of the following is a potential problem faced by organizations as ED waiting time increases?

a. Loss of customer loyalty and revenue

b. Increase in high-acuity patients

c. Improved professional reputation

d. Decreased overcrowding

2) True or False: ED overcrowding and increased wait times are globally associated with detrimental consequences to patient safety.

a. True

b. False

3) Improved door-to-physician time contributes to which of the following?

a. ED overcrowding

b. Increased lengths of stays

c. Early discharges home

d. Expediated decisions for diagnoses, treatments and dispositions

4) In 2022, approximately how many ED visits occurred in the United States?

a. 15 million

b. 220.8 million

c. 150.7 million

d. 200 million

5) True or False: Delays in treatment are NOT linked to adverse events, such as medication errors.

a. True

b. False

6) Patients who leave without being seen (LWBS) often have which characteristics?

a. They’re older females with low acuity scores.

b. They’re younger males with low acuity scores.

c. They’re older males with high acuity scores.

d. They’re younger females with moderate acuity scores.

7) Primary determinants of prolonged stays listed in the article include the following EXCEPT:

a. Consultation time

b. Diagnostic testing

c. Experience of the nursing staff

d. Triage category

8) Which of the following is a critical strategy for streamlining ED operations?

a. Rotating nursing staff weekly

b. Developing an ad-hoc triage process

c. Effective bed management and tailored triage processes

d. Creating an ED manual

9) How many levels are included in the Emergency Severity Index (ESI) system?

a. Three

b. Five

c. Two

d. Eight

10) Evidence-based strategies for the reduction of overcrowding in the ED include all of the following EXCEPT:

a. Early provider in triage

b. Split-flow models

c. Improved nurse-provider collaboration

d. Single-flow models

Answer Sheet

Evidence-Based Strategies to Improve Door-to-Provider Times in the Emergency Department

Please print legibly and verify that all information is correct.

First Name: MI:

Daytime Phone Number (Include area code):

Email:

Profession:

NYSNA Member # (if applicable):

Licensed in NY State? Y / N (Circle one)

ACTIVITY FEE: Free for NYSNA members/$10 nonmembers PAYMENT METHOD

 Check—payable to New York State Nurses Association (please include “Journal CE” on your check).

Credit Card:  Mastercard  Visa  Discover  American Express

Card Number:

Expiration Date: / CVV#

Name: Signature: Date: / /

Note: CH and CEU for this program will be offered until February 28, 2029.

Please print your answers in the spaces provided below. There is only one answer for each question.

Please complete the answer sheet above and course evaluation form on reverse. Submit both the answer sheet and course evaluation form along with the activity fee for processing. Email to: journal@nysna.org

Mail to: NYSNA, attn. Nursing Education and Practice Dept. 131 West 33rd Street, 4th Floor, New York, NY 10001 Or fax to: 212-785-0429

Learning Activity Evaluation

Evidence-Based Strategies to Improve Door-to-Provider Times in the Emergency Department

Please use the following scale to rate statements 1–7 below:

1. The content fulfills the overall purpose of the CE Activity.

2. The content fulfills each of the CE Activity objectives.

3. The CE Activity subject matter is current and accurate.

4. The material presented is clear and understandable.

5. The teaching/learning method is effective.

6. The test is clear and the answers are appropriately covered in the CE Activity.

7. How would you rate this CE Activity overall?

8. Time to complete the entire CE Activity and the test? ____ Hours (enter 0–99) _____ Minutes (enter 0–59)

9. Was this course fair, balanced, and free of commercial bias? Yes / No (Circle one)

10. Comments:

11. Do you have any suggestions about how we can improve this CE Activity?

Evidence-Based Strategies to Improve Door-to-Provider Times in the Emergency Department

Note: CH and CEU for this program will be offered until February 28, 2029.

 CE Activity: Ensuring Credibility and Trustworthiness in Qualitative Research

Thank you for your participation in “Ensuring Credibility and Trustworthiness in Qualitative Research,” a new continuing education (CE) activity offered by NYSNA. NYSNA members and nonmembers from any U.S. State are invited to take part in this activity.

INSTRUCTIONS

To receive the contact hour (CH) or continuing education unit (CEU) for this educational activity, participants are to read the article presented in this issue of The Journal, complete and return the post-test, evaluation form, and earn 80% or better on the post-test. This can be completed either by mail, or online by registering for the CE Activity using NYSNA E-LeaRN. Access E-LeaRN at learning.nysna.org/topclass/ or with the QR code displayed below:

This activity is free to NYSNA members and $10 for nonmembers. Participants can pay by check (made payable to NYSNA) or credit card. The completed answer sheet and evaluation form may be mailed or faxed back to NYSNA; see the evaluation form for more information.

The New York State Nurses Association is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.

This program has been awarded 1 CH through the New York State Nurses Association Accredited Provider Unit.

The New York State Nurses Association is accredited by the International Association for Continuing Education and Training (IACET) and is authorized to issue the IACET continuing education credit (CEU).

The New York State Nurses Association is authorized by IACET to offer 0.1 CEU for this program.

To receive a CH/CEU, participants must read the entire article, fill out the evaluation, and get 80% or higher on the post-test. Presenters disclose no conflict of interest.

NYSNA wishes to disclose that no commercial support was received for this educational activity.

All planners and authors involved with the development of this independent study have declared that they have no vested interest.

NYSNA program planners and authors declare that they have no conflict of interest in this program.

INTRODUCTION

Qualitative research plays a vital role in advancing nursing and health sciences by capturing the depth and complexity of patient and clinician experiences. However, the value of qualitative findings depends on their rigor, transparency, and ethical integrity. This learning activity explores established frameworks for trustworthiness—particularly the criteria outlined by Lincoln and Guba—to strengthen the credibility, dependability, confirmability, and authenticity of qualitative nursing research. Through this reading and assessment, learners will gain practical insight into strategies that enhance the rigor and impact of qualitative studies in healthcare settings.

LEARNING OUTCOME

Upon completion of this learning activity, participants will be able to apply trustworthiness frameworks to critically evaluate and strengthen the rigor of qualitative nursing and healthcare research.

OBJECTIVES

At the completion of this learning activity, the learner will be able to:

1. Identify and distinguish key criteria of trustworthiness—including credibility, dependability, confirmability, and authenticity—in qualitative nursing research.

2. Evaluate methodological strategies (such as audit trails, triangulation, and saturation) used to enhance trustworthiness and ethical representation of participants’ experiences in qualitative healthcare studies.

Please answer either True or False to the questions below, or select one of the multiple-choice options. Remember to complete the answer sheet by putting the letter of your corresponding answer next to the question number. Each question has only one correct answer.

The 1.0 CH and 0.1 CEU for this program will be offered until February 28, 2029.

QUESTIONS

1) Which criterion of trustworthiness is most directly concerned with ensuring that qualitative findings accurately reflect participants’ lived experiences rather than the researcher’s interpretations?

a. Transferability

b. Dependability

c. Confirmability

d. Credibility

2) Which methodological strategy is considered essential for establishing confirmability in qualitative nursing research?

a. Prolonged engagement

b. Thick description

c. Audit trail

d. Saturation

3) Why is authenticity considered a critical component of trustworthiness in qualitative healthcare research?

a. It ensures findings can be statistically replicated.

b. It guarantees methodological efficiency.

c. It ensures ethical and accurate representation of participants’ voices.

d. It prioritizes researcher interpretation over participant narratives.

4) In qualitative nursing research, saturation primarily supports which criterion of trustworthiness?

a. Transferability

b. Dependability

c. Confirmability

d. Authenticity

5) How does triangulation enhance the trustworthiness of qualitative research?

a. By eliminating the need for reflexivity

b. By increasing sample size

c. By verifying findings using multiple data sources or methods

d. By ensuring findings are universally generalizable

6) Which strategy best enhances the credibility of qualitative healthcare research by using multiple data sources to cross-verify findings?

a. Prolonged engagement

b. Reflexivity

c. Triangulation

d. Thick description

7) What is the primary purpose of maintaining an audit trail in qualitative research?

a. To ensure participant anonymity

b. To document researcher reflexivity only

c. To provide transparency and allow others to evaluate the trustworthiness of findings

d. To increase sample size and data saturation

8) Which method involves returning findings or interpretations to participants so they can confirm the accuracy of the results?

a. Peer debriefing

b. Persistent observation

c. Member checking

d. Contextual accuracy

9) The primary purpose of applying trustworthiness frameworks, such as those proposed by Lincoln and Guba (1985) and Whittemore, Chase, and Mandle (2001), in qualitative nursing and health research is to:

a. Increase the generalizability of findings to large populations.

b. Replace quantitative methods with qualitative approaches.

c. Enhance the rigor, credibility, and relevance of qualitative findings.

d. Eliminate researcher subjectivity entirely.

10) Which strategy best ensures confirmability in qualitative healthcare research, so findings reflect participants’ perspectives rather than the researcher’s bias?

a. Using standardized questionnaires to minimize participant variation

b. Allowing the researchers’ professional experiences to guide data interpretation

c. Applying member checking and maintaining an audit trail

d. Focusing primarily on statistical validity and reliability

Answer Sheet

Ensuring Credibility and Trustworthiness in Qualitative Research

Please print legibly and verify that all information is correct.

First Name: MI: Last Name:

Street Address: City:

Daytime Phone Number (Include area code):

Email: Profession:

NYSNA Member # (if applicable):

PAYMENT METHOD

ACTIVITY FEE: Free for NYSNA members/$10 nonmembers

 Check—payable to New York State Nurses Association (please include “Journal CE” on your check).

Credit Card:  Mastercard  Visa  Discover  American Express

Card Number:

Expiration Date: / CVV#

Name: Signature: Date: / /

Note: CH and CEU for this program will be offered until February 28, 2029

Please print your answers in the spaces provided below. There is only one answer for each question.

Please complete the answer sheet above and course evaluation form on reverse. Submit both the answer sheet and course evaluation form along with the activity fee for processing.

Email to: journal@nysna.org

Mail to: NYSNA, attn. Nursing Education and Practice Dept. 131 West 33rd Street, 4th Floor, New York, NY 10001 Or Fax to: 212-785-0429

Learning Activity Evaluation

Ensuring Credibility and Trustworthiness in Qualitative Research

Please use the following scale to rate statements 1–7 below:

1. The content fulfills the overall purpose of the CE Activity.

2. The content fulfills each of the CE Activity objectives.

3. The CE Activity subject matter is current and accurate.

4. The material presented is clear and understandable.

5. The teaching/learning method is effective.

6. The test is clear and the answers are appropriately covered in the CE Activity.

7. How would you rate this CE Activity overall?

8. Time to complete the entire CE Activity and the test? ____ Hours (enter 0–99) _____ Minutes (enter 0–59)

9. Was this course fair, balanced, and free of commercial bias? Yes / No (Circle one)

10. Comments:

11. Do you have any suggestions about how we can improve this CE Activity?

Ensuring Credibility and Trustworthiness in Qualitative Research

Note: CH and CEU for this program will be offered until February 28, 2029.