Pediatric Denver II Assessment Assignment

The emergency, trauma, and transport nursing workforce:

Nurses working across the emergency spectrum—in adult, mixed, and pediatric EDs, in trauma centers, on scene, and during transport—deliver critical care in dynamic, high-stakes, and high-stress environments. Because emergency/trauma/transport nurses serve on the frontline of healthcare, they must respond expertly and confidently with no room for error, often when seconds count and detecting subtle signs or changes can have major implications. Ensuring that these nurses possess the highest levels of clinical knowledge and expertise and supporting their continued competence, preparedness, well-being, and ability to be compassionate as they respond to the unique needs of every emergent patient and situation are vital concerns of the healthcare community and consumers.

Previous studies have described the characteristics of the entire US nursing workforce, and researchers and professional nursing organizations have examined specific emergency nursing issues and trends.1-3 However, to our knowledge, no research had been conducted to describe the characteristics of the emergency nursing workforce across the spectrum of emergency care. In 2018, the Board of Certification for Emergency Nursing (BCEN) formed a research partnership with the MedEvac Foundation International, Emergency Nurses Association (ENA), Society of Trauma Nurses (STN), and Air & Surface Transport Nurses Association (ASTNA). The partnership commissioned the Human Resources Research Organization (HumRRO) to conduct a comprehensive study of the emergency nursing workforce, including an in-depth look at the emergency, trauma, and transport specialties.

In this article, we highlight major findings from the 2019 Emergency/Trauma/Transport Nursing Workforce Survey (ETTS), which was developed to profile today’s emergency nursing workforce and help identify specific resources necessary to ensure a sufficient, well-prepared, and well-supported future workforce.

We conducted a descriptive study of the emergency/trauma/transport nursing workforce using two data sources: an extract of data for emergency/trauma nurses from the 2017 National Nursing Workforce Survey (NNWS)4 provided by the National Council of State Boards of Nursing and the custom-designed ETTS, which included items developed specifically for this study and items from the NNWS. (View the survey instrument and other bonus content by visiting and clicking on the Online Exclusives tab.) The inclusion of NNWS items in the ETTS allowed us to evaluate the representativeness of our sample of respondents and directly compare ETTS results with those for the entire nursing workforce. NNWS data provide population-level estimates.

The ETTS included 60 questions that had either been previously developed or were developed to address the research questions.1,5 The study was reviewed and approved by the Institutional Review Board at HumRRO. Following publicity about the survey by the research sponsors, HumRRO emailed the custom survey to 157,608 individuals identified in the BCEN, ENA, STN, and ASTNA databases. Because some of the organizational databases didn’t include RN status for every individual, selection for RN status occurred via the survey instrument. Participants took the survey between January 25 and February 18, 2019, and completed a consent statement before taking the survey. Responses were stored on a secure server. A total of 7,089 individuals began the survey. Before calculating descriptive statistics and correlations, we cleaned the data to include only responses from actively employed RNs working in emergency, trauma, or transport nursing settings. In total, 4,702 individuals met the inclusion criteria. Where NNWS and ETTS shared common questions, we compared the results across surveys.

Workforce profile
Based on self-reported specialty and work setting, 73.8% of ETTS respondents identify as emergency nurses, 11.5% as trauma nurses, and 14.7% as transport nurses. Overall, workforce profile demographics are similar across the three specialties. Based on survey responses for those answering the demographics questions, the largest proportions of the emergency/trauma/transport nursing workforce are 30 to 39 years old (33.5%), female (78.8%), and White (87.4%). Survey results suggest that emergency/trauma/transport nurses are younger than the general nursing population. Specifically, ETTS data indicate that the average age is 43.6, the median age is 42, and 31.7% of emergency/trauma/transport nurses are 50+ years old. Similarly, the NNWS data for emergency/trauma nurses suggest that the mean age is 41.6, the median age is 40, and 37.9% of emergency/trauma nurses are 50+ years old. However, the NNWS data for the general nursing population suggest that the average age is 50, the median age is 53, and 50.9% of nurses are 50+ years old. (See online bonus content.)

The gender of ETTS respondents is 78.8% female and 21.1% male compared with 90.9% female and 9.1% male in the overall NNWS data. Notably, ETTS data indicate that the female-to-male ratio for transport nurses is approximately 3:2 versus 4:1 for trauma nurses and nearly 5:1 for emergency nurses. The racial and ethnic diversity of ETTS respondents generally mirrors the NNWS data. Nurses responding to the ETTS represent all 50 states, as well as Washington, D.C., American Samoa, Puerto Rico, and the US Virgin Islands, with 42.6% reporting their main work setting as urban, 31.7% suburban, and 22.8% rural. The geographic distribution of ETTS respondents is generally representative of the NNWS data for emergency/trauma nurses.

Workforce qualifications
Licensure, education, tenure, and professional credentials. Of the ETTS respondents, 6.4% indicate that they’re advanced practice registered nurses (APRNs). Similarly, 5.9% of respondents from the NNWS emergency/trauma nurse data are APRNs, whereas 9.9% of nurses in the full NNWS data set are APRNs. Among emergency/trauma/transport nurses, 60.4% report having a bachelor’s degree as their highest level of nursing education versus 51.0% for NNWS emergency/trauma nurses and 45.2% for all nurses. (See Figure 1.) For 16.3% of emergency/trauma/transport nurses, a master’s degree is the highest level of nursing education as compared with 12.9% for NNWS emergency/trauma nurses and 17.1% for all nurses. Considering emergency/trauma/transport nursing tenure by specialty, emergency nurses obtained their RN more recently (14.7 years) on average than trauma nurses (17.0 years) or transport nurses (17.2 years) but also report the longest tenure within their specialty (11.6 years) as compared with trauma nurses (10.6 years) and transport nurses (9.9 years).

Figure 1:: Highest nursing education degree held by ETTS RNs vs. NNWS RNs
National board certification validates specialty knowledge, clinical judgment, and expertise, and is the highest professional credential a nurse can hold. Over three-quarters of ETTS respondents (77.0%) indicate that they hold one or more board certifications, 28.5% hold two or more, and 8.0% hold three or more, with the Certified Emergency Nurse being the most commonly held certification (55.4%). The most-held emergency nursing board credentials by specialty are shown in Table 1.

Table 1:: Most commonly held board certifications for emergency/trauma/transport nurses by specialty
Self-reported preparedness/competency. ETTS respondents rated the extent to which they agree that they have the knowledge/clinical expertise/skills needed to excel at their job, feel prepared to handle all cases they may deal with on their next shift, and have access to all the equipment they need to perform their job well. We averaged responses to these questions to create an overall preparedness/competency score. Most respondents (69%) report feeling prepared/competent overall, although nearly 10% don’t. Looking at the individual components of preparedness/competency, most in each age cohort agree or strongly agree that they have the knowledge/clinical expertise/skills to excel and are prepared to handle all cases on their next shift. However, one-third (32%) of the age 29 and younger group and at least one-quarter (25% to 27%) of all other ages report that they don’t have access to all the equipment they need to perform their job well. (See Table 2.)

Table 2:: Preparedness/competency ratings for all emergency/trauma/transport nurses by age
Perceived skill/ability shortages and need for training. ETTS respondents were asked which skill/ability shortages and training needs exist among nurses in their respective specialties. The overall magnitude of the perceived shortages is generally similar across the three specialties, with fewer skill/ability gaps indicated by transport nurses. The skill/ability shortages that the highest proportion of emergency/trauma/transport nurses indicate as existing among their peers are stress management (63.7%), critical-thinking skills (52.1%), clinical knowledge and skills (43.7%), decision-making under pressure (43.0%), time management (40.5%), leadership (39.8%), and mentorship (39.5%). Training on specific equipment (39.2%), leadership/management training (38.5%), crisis management training (33.1%), stress management (32.3%), and workplace violence/incivility/bullying education (30.1%) are the types of training most needed.

The skill/ability gaps most perceived in new nurses include critical-thinking skills (75.2%), decision-making under pressure (71.7%), time management (65.1%), unrealistic job expectations (64.1%), and clinical knowledge/skills (61.5%). Respondents’ top recommended changes to new nurse training include more hands-on training (87.1%), better simulations (61.1%), pharmacologic training (40.1%), and training on interpersonal skills (38.1%). (See online bonus content.)

Occupational profile
In the ETTS, the top three work settings overall are ED (59.2%), trauma center (15.5%), and air (rotor wing) transport (6%). Whereas 65.3% of all nurses work full time according to NNWS data, 85.4% of emergency/trauma/transport nurses work full time, with 13.7% working per diem and 11.5% working part time, according to ETTS data. Most emergency/trauma/transport nurses work 12-hour shifts (65.1%), whereas 15.2% work 8-hour shifts and 7.2% work 24-hour shifts.

Approximately two-thirds (69.3%) of emergency/trauma/transport nurses hold one nursing job, 24.1% hold two, and 6.5% hold three or more. By comparison, 83.3% of all NNWS respondents hold one position, 13.9% have two, and 2.8% have three or more. Just under half of ETTS respondents (49.4%) report working about the same number of hours as they were hired to work, whereas 39.4% report working more hours than they were hired to work and 8.3% report working far more hours. However, when asked how often mandatory overtime is assigned, 82.3% indicate that they’re never or almost never assigned mandatory overtime.

When asked to evaluate their workload, 5.5% of all ETTS respondents report their workload is overwhelming, 33.0% say it’s too heavy, and 57.4% indicate that it’s about right. (See Figure 2.) By specialty, 42.9% of emergency nurses and 41.6% of trauma nurses report that their workload is overwhelming or too heavy versus 15.3% of transport nurses. Regarding staffing levels, few participants (1.8%) overall describe their organization as overstaffed, 42.6% describe staffing levels as about right, and over half (55.6%) indicate that their organization is understaffed.

Figure 2:: Perceptions of workload across all emergency/trauma/transport nurses
Most ETTS respondents (97%) report that their role involves direct patient care. Across emergency/trauma/transport nurses serving in a role focused primarily on direct patient care (as indicated by their job title), direct patient care accounts for 59.4% of their time, with 27.7% spent on documentation and 9.1% on administrative responsibilities. Across all nurses working directly with patients, of the time spent on direct patient care, 50.8% is medical; 27.3%, injury-related; and 14.6%, behavioral. Also, of that time, 40.3% of participants’ time is spent on treating adults, 32.1% on older adults, 14.7% on infants and children, and 12.9% on adolescents.

ETTS respondents indicate high degrees of professional development offerings at their organizations, including training by staff, onsite continuing education, tuition assistance for advanced degrees, funding for advanced certifications and continuing education, and company-provided time for continuing education. The three most desired types of professional development resources are funding for professional organization membership fees (41%), funding for conferences (31.6%), and funding for advanced certification (24.1%.). Utilization rates for many of the resources offered by organizations tend to increase with age. For example, among the age 29 and younger group, 45.9% say they take advantage of funding for advanced certification and 33.3% take advantage of the membership fees for professional organizations, whereas 60% and 58.5% of the age 30 and older group, respectively, take advantage of those opportunities.

According to ETTS data, the median annual salary for emergency/trauma/transport nurses is $77,500, whereas the median annual salary is $68,000 for emergency/trauma nurses and $63,000 for all nurses, according to NNWS data. When only considering nurses working full time in the ETTS data, the median salary is $77,500 (with the 25th and 75th percentiles being $67,500 and $97,500) versus $69,000 in the NNWS emergency/trauma data. (See Figure 3.) Based on ETTS data by specialty for nurses working full time, the median annual salary is $77,500 for emergency nurses and $82,500 for both trauma and transport nurses. (See online bonus content.)

Figure 3:: Salary distribution across emergency/trauma/transport nurses working full time vs. NNWS emergency/trauma nurses working full time
Well-being profile
ETTS respondents indicated their job satisfaction by rating the extent to which they’re satisfied with their job and the kind of work they do, and the extent to which they think about quitting. The majority of emergency/trauma/transport nurses are satisfied with their job (67.0% agree or strongly agree) and with the work they do (86.7% agree or strongly agree). Nearly one-quarter (24.4%) say they frequently think about quitting, whereas over half (54.5%) report they don’t. (See Figure 4.) Satisfaction scores are somewhat higher for transport nurses than for emergency and trauma nurses.

Figure 4:: Job satisfaction components across all emergency/trauma/transport nurses
Perceived organizational support is measured by employees’ belief that their employer values their contribution and cares about their well-being.6 High levels of perceived organizational support lead to increased job satisfaction, commitment, and employee performance.7 ETTS respondents rated the extent to which their employer values their contributions, considers their goals and values, cares about their well-being, cares about their opinions, and takes pride in their accomplishments at work. Responses were averaged to create an overall perceived organizational support score. Across all emergency/trauma/transport nurses, 41.9% have high or very high perceived organizational support scores and 25.7% have low or very low perceived organizational support scores. (See Figure 5.)

Figure 5:: Overall perceived organizational support score across all emergency/trauma/transport nurses
ETTS respondents rated their level of burnout, such as feeling work-related stress, reduced motivation, fatigue, and exhaustion. Whereas 12.9% report no burnout symptoms, 50% report occasional stress, 26.7% indicate that they’re definitely burning out, 8% report persistent symptoms, and 2.5% feel completely burned out. Burnout symptoms decrease slightly by age, and transport nurses report the lowest levels of burnout. When asked what resources are most commonly provided by employers to address burnout, the most frequent response is access to counselors (50%). Notably, the second most common response is that their employer provides no resources (35.7%). (See Figure 6.)

Figure 6:: Burnout resources offered to emergency/trauma/transport nurses by their employers, as reported by respondents
We also examined the relationships between certain nurse well-being variables, and our findings support the importance of nurse well-being to nursing outcomes. Specifically, our analyses show that perceived organizational support and job satisfaction are related to feelings of preparedness/competency and burnout. (See Table 3.) We compared perceived organizational support with the likelihood of quitting. Of ETTS respondents who report high levels of organizational support, 76.1% are unlikely to quit, whereas 52.7% of emergency/trauma/transport nurses reporting low perceived organizational support indicate being likely to quit.

Table 3:: Relationships between well-being variables for all emergency/trauma/transport nurses
Workforce pipeline
ETTS respondents were asked to comment on the future of the emergency/trauma/transport nursing workforce, including their own career plans. Most (79.6%) expect a shortage or extreme shortage of nurses across the emergency spectrum in the next 5 to 10 years, with transport nurses predicting a less pronounced trend for their specialty.

Across all ETTS respondents, 34.1% of nurses age 29 and younger and 25.8% of nurses ages 30 to 39 expect to leave the field of emergency nursing within the next 4 years, which may erode the pipeline of experienced nurses. (See Figure 7.) This pattern of planned exodus by early-career nurses holds when considering the recency of receiving an RN license, indicating that age, not tenure, is related to plans to leave the field. (See online bonus content.) Similarly, 64% of emergency/trauma/transport nurses age 29 and younger and 46.7% of those ages 30 to 39 plan to stay with their current employer for 4 years or less. Likewise, 69.3% of emergency/trauma/transport nurses age 29 and younger and 55.4% of those ages 30 to 39 plan to leave their current primary nursing position within the next 4 years.

Figure 7:: Anticipated number of years emergency/trauma/transport nurses indicate they’re planning to remain in their specialty by age group
Most ETTS respondents indicate that when they entered the field of emergency nursing, they planned to continue in their specialty, either in their current role (50.1%) or by advancing into a supervisory position (20.5%), whereas 24.3% planned to become an APRN. Regarding their current career plans, 46.6% expect to continue in their current role, 35.1% plan to earn a specialty certification, 21.2% plan to become an APRN, 18.1% plan to take on a nursing education role, and 14.5% aspire to a supervisory role in their specialty. (See Figure 8.) Among respondents under age 40 who intend to leave the field in the next 5 to 10 years, their career plans include becoming an APRN (42.8%), earning a specialty certification (35.7%), continuing in their current role (28.8%), becoming a nurse in another specialty (23.8%), and taking on a nursing education role (22.4%). (See Figure 9.)

Figure 8:: Current career plans for the next 5 to 10 years for all emergency/trauma/transport nurses
Figure 9:: Career paths for emergency/trauma/transport nurses younger than age 40 planning to leave their specialty in the next 5 to 10 years
When asked which approaches to maintaining and building the pipeline of nurses would be most helpful, respondents overall indicate better pay (75.9%), better nurse-patient ratios (57.2%), and employer support (53.2%).

Nursing challenges and impact
The ETTS included two open-ended questions. When asked to indicate the biggest challenges emergency/trauma/transport nurses face, responses from 2,777 participants frequently cite burnout, ineffective leadership, insufficient staffing, lack of support and appreciation, underprepared new recruits, inadequate nurse-patient ratios, and workplace incivility/violence.

Respondents were also asked to describe a critical incident(n = 1,984) where they or a nursing colleague had an impact on clinical or operational outcomes. Emergency/trauma/transport nurses positively impact outcomes as they assess, intervene, evaluate, and communicate regarding patients’ clinical conditions; increase patient safety or prevent errors; advocate for patients with physicians and management; provide counsel and support to patients and their families; and increase the quality, speed, and effectiveness of operations.

Key observations
The 2019 ETTS provides the first comprehensive and detailed description of the emergency nursing workforce, including core demographics (age, gender, diversity, education, and professional credentials), occupational profile (work setting, workload, time spent across duties, professional development, and salary), nurse well-being (job satisfaction, perceived organizational support, and burnout), pipeline prospects (nursing shortage and career plans), top challenges, and impact on outcomes. One limitation of our study was its sampling strategy, which was limited to the membership databases of relevant professional organizations that include board-certified nurses, certification candidates, and other stakeholders. Our sample may be more professionally involved than emergency/trauma/transport nurses as a whole, which may, in turn, affect at least some of our findings (such as board certification rate).

However, findings from ETTS and NNWS data on identical questions are similar, suggesting that the ETTS sample is likely representative of the emergency/trauma/transport nursing workforce overall. As such, this research offers important information and insights for nurse leaders, healthcare administrators, and other stakeholders to consider as they work collaboratively and organizationally to solve the challenges that are unique to emergency/trauma/transport nursing. This survey may also serve as a benchmark for future research.

As the findings from this expansive study continue to be unpacked and analyzed, we offer the following high-level observations. First, emergency/trauma/transport nurses need more support in the form of critical resources, including staffing, equipment, and professional development, to meet the demands for their services. These demands include staying current and competent on a wide, ever-changing range of clinical knowledge, procedures, protocols, best practices, technology, and equipment so they’re prepared to respond to every patient and scenario, from the more commonplace, low-risk cases to the low-volume, high-risk ones. Emergency/trauma/transport nurses demonstrate a high level of commitment to education and want comprehensive, continuous professional development to attain and maintain the mastery that emergent care warrants. Yet our findings suggest more can be done to ensure that all emergency/trauma/transport nurses, particularly younger nurses, leverage the training and developmental resources their organizations offer.

Second, our research indicates that emergency/trauma/transport nurses demonstrate an exceptional level of dedication to their jobs. Over 85% work full time (versus 65% of all NNWS nurses), nearly one-third hold more than one position (versus 17% of all NNWS nurses), many work 12-hour or longer shifts, and nearly half (47%) work more hours than they were hired to despite mandatory overtime rarely being assigned. Although emergency/trauma/transport nurses report facing formidable on-the-job challenges, their impact on clinical, human, and operational outcomes is significant. Emergency/trauma/transport nurses are explicitly asking for effective, competent leaders who’ll work to ensure that their dedication is matched with reasonable workloads, a supportive and safe work environment, and meaningful concern for their well-being, including knowing they’re genuinely valued team members.

Third, our research indicates that substantial proportions of early-career nurses intend to leave the emergency/trauma/transport specialty in less than 5 years. Given that 45% of emergency nurses are younger than age 40 and nearly 70% are younger than age 50, and with more than half of trauma nurses (55%) and over two-thirds (67%) of transport nurses in the ages 30 to 49 group, the emergency/trauma/transport nursing profession must be attractive to new recruits and remain so for all ages. Once new recruits are hired, our findings point to onboarding considerations, such as more hands-on training and better simulations, along with the development of critical-thinking and decision-making skills so novices may move up the clinical and professional learning curves thoughtfully, completely, and expeditiously. Our findings also suggest that the confidence, competence, and knowledge transfer that come with experienced nurses are hard to replace.

Finally, our findings suggest that increased organizational support across all age groups may increase preparedness/ competency measures and overall job satisfaction, reduce burnout, and limit attrition, which may help sustain and hopefully expand an engaged, high-performing workforce eager to deliver expert and compassionate care when patients need it the most.

Our nurses have spoken
The ETTS offers rich data for emergency/trauma/transport nurse leaders and the C-suite to assess, address, and improve a wide range of emergency nursing workforce measures and issues, including important specialty-specific benchmarks. The study also underscores the need for and urgency of addressing systemic organizational issues impacting nursing and patient care across the emergency spectrum, such as patient boarding in the ED. Perhaps most significantly, the findings make a powerful case for nurse leaders to prioritize regular one-on-one communication with each of their team members.

Emergency/trauma/transport nurses have spoken. They’re dedicated professionals who want to be heard, want to be part of the decision-making process and help problem solve, want to grow and develop, and want to be recognized. No matter their age or tenure, they’re looking for effective leadership and support. Their stated career plans mandate making nursing across the emergency spectrum attractive, particularly for newer and younger nurses. Leaders who prioritize connection and engagement on each of these fronts will find that their investment pays dividends for nurses and patients alike.

Bonus content
Head to and click on “Results from the 2019 Emergency/Trauma/Transport Nursing Workforce Survey” in the Online Exclusives tab for more ETTS results and the survey instrument.

INSTRUCTIONS The emergency, trauma, and transport nursing workforce: Highlights of a benchmark 2019 survey
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