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The nurse workforce consists of people with varying levels of education and experience in specialty areas.1 Nurses often seek to distinguish clinical and professional expertise through specialty certification.2,3 As the healthcare environment is becoming more complex, some healthcare leaders are advocating for specialty certification as a national standard to increase nurses' professional standing and prepare nurses to better meet the specific needs of the patient populations they serve.4 Board certification demonstrates excellence and recognition of the specialized knowledge, skills, and clinical judgement validated by the achievement of standards identified by nursing specialty to promote optimal health outcomes.5 The first large-scale, rigorous study examining the value of emergency nursing certification to nurses, their patients, and their employers, “The Value of Certification Study,” was conducted by the Human Resources Research Organization and commissioned by the Board of Certification for Emergency Nursing (BCEN).6 Study results were based on survey data from over 8,800 certified and non-certified emergency nurses and over 1,000 emergency supervisors. Previously, ENA has collaborated with stakeholders, including the American Academy of Emergency Nurse Practitioners (AAENP) and the National Association of Clinical Nurse Specialists, to further establish core competencies and expand opportunities for APRNs in the emergency setting.20,21 In 2019, the ENA Position Statement, Advance Practice Registered Nurses in the Emergency Setting, established the importance of APRNs in the ED setting and outlined gaps in national certifications.22 AAENP developed a strategic partnership with ENA to establish the emergency nurse practitioner (ENP) specialty scope and standards, thereby paving the way for professional certification mechanisms.17,23 Emergency nurse practitioners may attain an Emergency Nurse Practitioner Certification (ENP-C) through a program offered by the American Academy of Nurse Practitioners in collaboration with AAENP.24 For clinical nurse specialists (CNSs) who practice in the emergency setting, there is currently no emergency certification method for the CNS APRN role. [...]variations in practice, which take into account the needs of the individual patient and the resources and limitations unique to the institution, may warrant approaches, treatments and/or procedures that differ from the recommendations outlined in this position statement. [...]this position statement should not be construed as dictating an exclusive course of management, treatment or care, nor does adherence to this position statement guarantee a particular outcome.

Description In 2002, the World Health Organization declared workplace violence to be a global epidemic with a negative impact on the retention of health personnel and delivery of health care.1 The violence also results in significant economic, personal, and professional costs.1-3 In the United States, the prevalence of workplace violence in the health care industry is 4 times higher than in other private industries.4 Ease of public access, crowding, long wait times, presence of weapons, and other factors make the emergency department a highly vulnerable area,5-9 especially where triage occurs.10,11 Emergency nurses and other ED staff are at serious occupational risk of experiencing workplace violence, including verbal and physical assaults.5-7 For these reasons, workplace violence has been recognized in many states as a violent crime.12 Yet, at the time of this publication, only about 30 states have adopted laws that make it a felony to assault a registered nurse.13 Other ongoing legislative initiatives include the introduction of the “HR 1309: 1 Both definitions demonstrate that workplace violence manifests in myriad ways as emotional or verbal abuse, coercive or threatening behavior, or physical and sexual assault,4 and can involve consumers, providers, and organizations.15 The patient population (eg, active substance use), along with work schedule (ie, night shift) experience level, and younger age of the health care provider, are consistent risk factors for WPV.8-10,16-18 Acts of workplace violence can cause physical and/or psychological harm to emergency nurses leading to job dissatisfaction, emotional exhaustion, burnout, secondary trauma stress, posttraumatic stress disorder, absenteeism, and intention to leave the job or the nursing profession,4,9,16-25 all of which have potential impacts on patient care due to nurses' decreased productivity, organizational commitment, and engagement.9,18,25-27 Workplace violence is seen as a contributing driver of poor nurse retention and recruitment, further exacerbating the nursing shortage and its costly consequences for health care organizations and their patients.4,18,20,25,27-29 Despite continued education, legislation, and research to increase awareness and understanding of the issue, emergency nurses are reluctant to report incidents of WPV because they believe it is not violence if they did not sustain an injury, reporting can be laborious and futile, patients are not seen as responsible because of their age or illness, and WPV is an expected part of the job.23,28 Different types of violence exist independently, overlap, and enable each other. Background To increase program effectiveness, it is recommended that a workplace violence prevention program include training; formal incident reporting procedures; administrative, environmental, and consumer risk assessment; physical design; and security components to address all types of violence.3,4,6,28,31-38 When establishing a WPV prevention program, WPV experts recommend health care organizations adopt a multi-faceted, collaborative, interdisciplinary approach that includes a variety of stakeholders, such as health care administrators, ED managers, clinicians and staff, law enforcement and security personnel, and specialty providers such as mental health practitioners.28-30,32,33,35,38 Given the crucial focus on prevention of workplace violence by patients, visitors, coworkers, and intimate partners, coordination and advocacy among employees, health care employers, managers, and nursing leadership is considered necessary for effective implementation of educational, administrative, behavioral, legislative, and engineering approaches necessary for mitigating workplace violence.3,4,33-35,37,38 Emergency nurses, with their high risk for experiencing WPV, can serve an integral role in all aspects of violence prevention, planning, monitoring, and reporting.

Homelessness is a growing public health crisis across the United States. Emergency physicians are uniquely positioned to address immediate medical concerns and the underlying social drivers of health for patients experiencing homelessness. Initiating coordination of care in the emergency department addresses their hierarchy of needs and can help support patient movement through the department. Practice adaptations described include early engagement; trauma-informed care approach; addressing unmet nonmedical needs; establishing safe dispositions; documenting homelessness, substance use disorder, and linkages to care; clinical practice adaptations; and palliative care approaches. Programs and initiatives outside of the emergency department described include street medicine and government initiatives. Sustainable solutions offered ideally use programs and incentives already available.

The council took an active role in updating ENA’s Emergency Nursing Scope and Standards,2 which includes the advanced practice role as well as reviewing the recently published Scope and Standards for emergency nurse practitioners (ENPs).3,4 The IENAP AC continues to partner with the ENA Position Statement Committee and outside organizations, including the American College of Emergency Physicians (ACEP) and the American Academy of Emergency Nurse Practitioners (AAENP), to review and update position statements affecting APRN practice.Advocacy Advocacy for issues important to emergency nursing practice is a pillar of ENA’s mission and aligns with the 2010 Institute of Medicine’s call to action in the Future of Nursing report.1 In a rapidly evolving health care climate, IENAP has been very active in advancing APRN practice through ENA’s Government Affairs and other organizations, monitoring and responding to key issues including full practice authority and barriers to practice.APRNs interested in learning more about the Institute for Emergency Nursing Advanced Practice are encouraged to get involved by contacting IENAP@ena.org.

APRNs have existed for more than 50 years and are established members of emergency care teams throughout the United States (US) and in many countries worldwide.2-6 Nearly a decade ago, the Institute of Medicine identified APRNs as necessary for the future of health care delivery in the US.7,8 Since then emergency departments (EDs) in the US and abroad have become increasingly overcrowded, in part due to their status as a health care safety net for those who cannot access a primary care provider.9,10 It is estimated that EDs provide more than 47% of all hospital-associated health care in the US.9 As a result, there is currently a substantial mismatch between the need for emergency services and the available resources to provide that care.10 APRNs have been identified as particularly important for bridging this gap in both urban and rural settings.11-14 The regulatory landscape for APRNs in the US continues to evolve, and APRNs who work in the emergency care setting face a few unique licensing and certification challenges. The Consensus Model’s licensing paradigm could create barriers to APRN practice in the emergency care setting because it would require APRNs who treat the full population of the emergency care setting to complete three courses of graduate study and to obtain and maintain three certifications (eg, Family Nurse Practitioner, Adult-Gerontological Acute Care Nurse Practitioner, and Pediatric Acute Care Nurse Practitioner).1,17 CNSs, for whom there are fewer courses of study than for NPs, would be required to have and maintain 2 licenses (Adult-Gerontology CNS and Pediatric CNS), but they would be restricted to either primary or acute care.18ENA Position The following are the positions of the Emergency Nurses Association (ENA): APRNs are established members of the emergency care team and are critical to the future of quality health care across the US and worldwide. Background The emergency care setting is unique when compared to most other practice settings in that its patient population consists of all ages and all combinations of medical history and chief complaint, rather than a narrow subset of them, as is the case with most other specialties (eg, pediatric oncology, adult cardiology, etc).19 Although some APRNs only treat a subset of the patients in the emergency care setting, for example, only pediatric patients or only adults with urgent or chronic needs, other APRNs are called upon to treat all patients and conditions, from nonemergent, episodic chronic care to acute, complex, life-threatening traumatic and medical conditions.2,20-23 APRNs are licensed and regulated by state law, and reciprocity across state lines is determined by each state. The Consensus Model’s proposal that US states license APRNs as “primary care” or “acute care” APRNs, along with its stipulation that an APRN only be allowed to expand his or her scope of practice by completing another graduate program of study, stands in contrast to how APRNs are currently licensed and regulated today.24-29 In nearly all states, APRNs are licensed at the role level, and the scope of practice is determined not only by formal education and national certification but by clinical experience as well.30 Degree-granting programs are designed to prepare APRNs for entry-level competency, and postgraduate training after one’s formal course of education confers clinical expertise.6,29,31-34 It is, therefore, no surprise that APRNs who are currently providing safe and effective primary and acute care across the country are certified as family nurse practitioners (FNPs), acute care nurse practitioners (ACNPs), Adult NPs, Pediatric NPs, Adult-Gerontological NPs, Adult-Gerontological CNSs, and Pediatric CNSs, among others.15,21,35,36 The Consensus Model has been a powerful force for raising the quality of APRN education and training in the US and has successfully championed full practice authority for APRNs in all states.15 Regardless of the outcome of these and future discussions over whether and how to implement the Consensus Model’s definitions of primary care, acute care, and scope of practice, APRNs will continue their long tradition of providing safe, effective care in the emergency care setting, and ENA will remain committed to interprofessional collaboration and advocacy on their behalf.Resources Advanced Practice Registered Nursing Consensus Work Group, The National Council of State Boards of Nursing APRN Advisory Committee.

Organizational leaders turned to their System Nurse Practice Council (SNPC), a team comprised of nursing administrators, Clinical Nurse Specialists, nurse educators and front line nursing from multiple facilities and departments across the organization, requesting that nursing documentation be standardized across the system. [...]readiness for change was measured by willingness to support the redesign process.

Health care is incredibly complex. Now, more than ever, health care providers are being called on to deliver care that is based on evidence and is consistent with current professional knowledge. Educators often struggle to find time when staff are available to participate in scheduled education. The work of nursing staff is to provide patient care. This article describes the journey of neophyte researchers who conducted a clinical trial as a strategy to implement evidence-based practice. Although educational opportunities for the staff were included as part of the trial, there were also many challenges applicable to the neophyte researcher role. Those challenges included the participants' neophyte knowledge and perception of the research process, vendor relationships, data collection methods, staff perceptions, and the culture of the institution itself. J Contin Educ Nurs 2009;40(8):380–384.

The three phases of the reconciliation process are imperative to ensure effective medication management and obtaining an as complete and accurate medication history is the first step.2 Medication management and reconciliation in the emergency setting is a collaborative effort between nurses, physicians, pharmacists, and patients to reduce risk for patients in health care settings and at home.1,2,4,8,9,13–15 This process requires that health care providers, including emergency nurses, communicate clearly with patients and their caregivers about the importance of maintaining an accurate medication list.4,13,16 An accurate medication list includes all medications including prescriptions, over-the-counter medications, supplements, herbals, medicinal marijuana, known allergies and last dose. Emergency nurses play an important role in empowering patients to understand the role they play in the medication management process as well as helping them to understanding the potential risks of drug/drug or drug/food interactions.3,13,16,20,36 Emergency nurses can educate patients and/or their caregivers on the importance of maintaining and keeping with them an accurate medication history including, dosage and frequency of all prescriptions, over-the-counter drugs, supplements, medicinal herbs, and other substances.16,20,36 Additionally, emergency nurses are in a position to advocate for best practices in the medication management process to ensure patient safety.ENA Position It is the position of the Emergency Nurses Association that: Triage is intended to rapidly identify life-threatening or high-risk situations. [...]collection of comprehensive medication history can be delayed and performed after the patient is stable. When first announced, there was little direction as to the who, what, when, where, and how to complete the process, which led to, and continues to create, confusion among emergency nurses and other health care providers.18,37 As initially defined by TJC, the process of medication reconciliation was intended to reduce discrepancies and prevent medication errors but was complex, laborious, and did not necessarily result in accurate information.18,19 Because of difficulty in implementation the lack of proven strategies for success TJC, in 2011, suspended the original NPSG and incorporated medication reconciliation into NPSG number 3.1 This safety goal acknowledges the challenges of reconciliation yet still requires a “good faith effort” to obtain a medication history (the first step) on arrival and then comparing it with those medications that are prescribed (the reconciliation stage).