From "Advance for Nurses" May 7, 2007 edition as submitted by Christine Connor, MSN, MPH, APRN with contributions from Tina Tolson, MSN, RN, nurse manager, and Jessica Fischer, RN

    Four years ago, I set out to work as an emergency department nurse and looked at several area hospitals. Though I had received a job offer for one area hospital, a friend advised me that the ED at The Johns Hopkins Hospital would be a better choice. I followed my friend's advice, and waited for a position in the Adult Emergency Department (AED) at Johns Hopkins Hospital. I'm so glad I did.

   The AED is divided into four treatment areas, plus a staging area to initiate care to acutely ill patients, and a critical care area for priority 1 trauma and medical patients. In addition to the AED, the department has an Urgent Care Center for quick turnover of low acuity patients, and an Emergency Acute Care Unit for those patients requiring a more lengthy observation and continued care.

   The AED staff is an integrated team of providers, nurses, technicians and support staff that provides excellent care in their areas. There is open communication among the team members, who build upon each other's knowledge to assess and diagnose the patients. Together we determine the most effective plan of care.

Covering One Another

   In the past few years, we have gained several new staff members and made several improvements, but the function of the team has not changed. I'm still amazed how nurses are always available when you need them, even when we become very busy. In the charge nurse role, I rarely need to ask someone to help out another team member. They automatically do it.

   When a critically sick or injured patient arrives in the ED, everyone recognizes the need for help at the bedside. Nurses will fall into the role of either assisting with the more complicated patient, or caring for the other patients while the primary nurse stabilizes the critical one.

Proactive Staff

   The department leadership encourages a shared governance approach to quality improvement, and most nurses participate in at least one committee or departmental project. The majority of these committees are led by clinical nurses, as opposed to administration or management, demonstrating characteristics of our shared governance and professional practice model.

   By functioning as a member of these committees, the staff members are encouraged to promote improvement in the department. This creates staff autonomy and increases satisfaction. Nurses feel that their voices are heard and that they can lead the department in a positive direction. This abundance of staff participation and support has contributed to an 18 percent decrease in staff turnover in the past year.

   One example of our shared governance in action is the department scheduling committee. Our nursing leadership gave this committee the autonomy to manage this important responsibility. The committee brainstormed the needs of the department and created improvement strategies for scheduling. One such improvement was to share the responsibility of the staff schedule, so that it no longer fell on one person, but on the committee members. In addition, the committee, in conjunction with the nursing leadership, created ways to recognize seniority within the department and be flexible and accommodating with the staffing assignments.

'Best of the Best'

   The Johns Hopkins Hospital has been named "Best of the Best" for many years, and our ED team strives to live up to that daily. Our leadership has raised the bar for what is expected of us as a "Hopkins nurse." The majority of our staff members are BSN-trained, and nearly 60 percent of our nurses are enrolled in graduate education or other continuing education courses to enhance their knowledge.

   Our clinical specialist also offers many classes each year for RNs and clinical technicians including trauma education, advanced triage and advanced assessment. We also have added CEN certification as a criterion for advancement within our nursing clinical ladder system.

In the past 2 years, we have experienced a dramatic change in leadership, and a shift in responsibilities with the implementation of new roles. Despite these changes, the nursing staff has adapted and excelled.

   As we work closely together as a team, we learn the strengths of our colleagues and build upon them, and we support each other's weaknesses. We trust each other.