Access provided by
London Metropolitan University
• To understand the various factors that influence crowding (overcrowding) in emergency departments
• To be aware of the limited literature on the effects of crowding on emergency nurses
• To recognise the effects of crowding on nurses' workload and mental health and well-being
Although the phenomenon of crowding in emergency departments (EDs) is not new, it remains a significant problem for patients, ED staff and the wider healthcare system. Crowding in EDs, which is also called overcrowding, has been widely explored in the literature, but there are relatively few studies of the subject from an emergency nurse perspective. This article reports the findings of a literature review that aimed to explore the effects of crowding on nurses working in EDs. Four key themes were identified from a synthesis of 16 articles included in the review: staffing and skill mix; inadequate care and the effect on nurses’ well-being and stress levels; violence in the ED; and hospital metrics and patient flow. Further research is required to explore in more depth the effects of ED crowding on emergency nurses and to address the multiple factors that perpetuate the phenomenon.
Emergency Nurse. doi: 10.7748/en.2024.e2211
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Webster A, McGarry J (2024) Exploring the effect of emergency department crowding on emergency nurses. Emergency Nurse. doi: 10.7748/en.2024.e2211
Published online: 26 September 2024
An increase in crowding in emergency departments (EDs) in the UK is causing significant problems for hospitals, patients and staff. Crowding has been defined as occurring ‘when the demands on an ED exceed the capacity of the department, and hospital or health system, to meet them’ (Royal College of Emergency Medicine (RCEM) 2024a). It is also referred to as overcrowding, but the authors have used the term crowding throughout the article for consistency.
The effects of crowding are felt across all areas of the healthcare system, including delays in patient transfers from ambulances to the ED, delays in ED assessment, long waiting times for inpatient admissions and, ultimately, an increase in patient morbidity and mortality (Sartini et al 2022). The RCEM has reported that ED staff are becoming increasingly frustrated that crowding is seen as a problem for EDs rather than a problem for the wider hospital and has issued guidance on how to tackle crowding (RCEM 2024a).
In its guidance on the management of ED crowding, the RCEM (2024a) recommends implementation of policies focused on system-wide improvements, such as improving capacity in the hospital and increasing staffing levels across all urgent care services, to ensure patients receive treatment in a setting appropriate to their care needs. Moreover, the RCEM suggests that additional investment is required in social and community care to help relieve the pressures on EDs by having the appropriate resources in place for patients who require care but who do not require acute admission and to enable timely and safe patient discharges (RCEM 2024a).
The RCEM (2024a) points out that crowding affects ED staff as well as patients and the healthcare system, and highlights the incidence of moral injury and burnout among ED staff due to crowding. This has implications for retention and recruitment within EDs (Roy and Chatha 2023). It is evident from a scoping of the literature that there are numerous references to crowding in the ED, but few references to the effects of crowding on ED staff, particularly emergency nurses.
To explore the effects of crowding on nurses working in EDs, to identify areas for future research and service development.
A systematic approach (Aveyard 2007) was used to identify relevant literature. A database search was conducted in March 2024 using MEDLINE, the Cumulated Index to Nursing and Allied Health Literature (CINAHL), PubMed and Scopus, using the keywords ‘Crowd* and Nurs* and Impact*. The search was limited to peer-reviewed articles published in English between 2019 and 2024. A search of the ‘grey literature’, such as national and international policy documents and commissioned reports, was also carried out and the references of articles published in relevant journals and websites were hand searched.
The search initially generated 1,630 articles. The authors used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (Page et al 2021) to identify, select, appraise and synthesise the articles. Following this process, 16 articles were selected for inclusion in the review (Table 1).
The articles reviewed involved settings across the globe, including in Asia, North America, Europe, Australasia and Africa, which illustrates that ED crowding is not limited to the UK. This suggests that an international and collaborative response is required to assess and manage the concerns of the medical and nursing ED communities regarding crowding.
Different methodologies were used in the articles; eight were systematic reviews (Son et al 2019, Zodda and Underwood 2019, Jeyaraman et al 2021, Stafford et al 2022, Maninchedda et al 2023, Pearce et al 2023, 2024, Drennan et al 2024), one was a narrative review (Sartini et al 2022) and seven involved empirical studies (Chen et al 2018, van der Linden et al 2019, Afaya et al 2021, Saaiman et al 2021, Payne et al 2023, Gillespie et al 2024, Parvaresh-Masoud et al 2024).
A synthesis of the 16 articles identified key themes (Table 1), which were then refined into four main themes: staffing and skill mix; inadequate care and the effect on nurses’ well-being and stress levels; violence in the ED; and hospital metrics and patient flow. The following sections report some of the findings within each of these themes.
• Crowding affects emergency department (ED) staff, as well as patients and the healthcare system, which has implications for recruitment and retention
• Various factors contribute to an increased number of patients in the ED at one time, resulting in a greater workload for already stretched nursing staff
• Excessive workload can adversely affect nurses’ mental health and well-being
• Crowding can significantly affect patient morbidity and mortality, which can cause moral distress and moral injury to all members of the multidisciplinary team
Inadequate staffing levels in the ED was a key theme in six of the articles reviewed (Chen et al 2018, Son et al 2019, Afaya et al 2021, Saaiman et al 2021, Pearce et al 2023, Drennan et al 2024) and was identified by nurses as a significant problem and a factor that contributes to crowding. In the authors’ experience, and informed by the findings of the review, inadequate staffing levels means there are fewer available staff to administer medicines, take patients for radiological investigations and provide care; this can result in patients being unable to leave the ED, either to be admitted to a ward or to be discharged home, as they have not had the appropriate investigations to facilitate care decisions. In addition, this can cause friction within the wider multidisciplinary team as each discipline attempts to transition patients through the healthcare system in a safe and timely manner.
Some of the articles reviewed referred to the effect of crowding on quality-of-care provision and nurses’ well-being. For example, Zodda and Underwood (2019) noted that crowding affected the quality of care that nurses felt able to provide, while nurse participants in Afaya et al’s (2021) study described feeling exhausted and frustrated by crowding and how these feelings adversely affected the care they provided.
Saaiman et al (2021), Pearce (2023) and Parvaresh-Masoud et al (2024) suggested that suboptimal care delivery within the ED can lead to deterioration in nurses’ mental well-being and burnout, while Sartini et al (2022) noted that provision of suboptimal care was associated with reduced job satisfaction and increased stress levels in ED nurses.
Violence in the ED emerged as a theme in Stafford et al (2022) and Gillespie et al (2024). Stafford et al (2022), who explored the effect of patient violence on ED nurses’ intention to leave, explained that violence in the ED increases with increasing crowding pressures. With violence causing further delays to patient care, and therefore an increase in crowding, this is a cyclical problem which needs to be addressed to enable patients to receive appropriate and timely care.
The most common reason identified by Stafford et al (2022) for patient violence was long waits and no communication from the medical and nursing teams; in addition, the researchers noted that nurses were disproportionately affected due to the amount of patient contact they have.
Seven of the articles reviewed noted that hospital metrics (for example, radiology turnaround times, patient length of stay, number of unscheduled return visits or four hour targets) and flow out of the ED have a significant effect on ED crowding (Chen et a 2018, Son et al 2019, van Der Linden et al 2019, Maninchedda et al 2023, Pearce et al 2024, Payne et al 2023, Saaiman et al 2021). Pearce et al (2024) noted that input and output interventions showed the best outcomes with regards to ED crowding metrics and suggested that solutions to crowding should be matched to specific, local problems.
Inadequate management of patient flow can directly affect nurses’ workload as they provide care for patients newly arrived at the ED as well as ongoing care for those who cannot be transferred to other areas or discharged. This increase in workload can result in them feeling unable to provide optimal patient care, as noted by Chen et al (2018) and Afaya et al (2021), which is linked to moral injury and distress.
The findings of this literature review emphasise that causes and effects of ED crowding are multi-factorial and have negative effects on nurses’ workload and mental health and well-being. Crowding in the ED can be caused by inadequate patient flow out of the department (McKenna et al 2019), which can be due to lack of available hospital beds for patient admissions (RCEM 2024b), or because patients have not yet been assessed or are waiting for results of blood tests or radiological examinations before care decisions are made (Darraj et al 2023). These factors all contribute to an increased number of patients in the ED at one time, resulting in a greater workload for already stretched nursing staff.
It has been reported that, in the UK, many senior and experienced emergency department nurses are leaving the profession due, in part, to workload pressures (Mitchell 2023). Moreover, in a blog on the reality of nursing in an ED, Heather Wilson (2023) described how staff to patient ratios have increased in recent years due to chronic staff shortages and staff sickness. A US study of contributing factors to experienced nurses leaving healthcare employment reported that 21% of 7,887 nurses cited insufficient staffing as a reason for leaving the profession (Muir et al 2024). The loss of experienced ED nurses, and reduced staffing levels, increases the pressure on the existing nursing team. This in turn can adversely affect nurses’ stress levels and job satisfaction which may lead to them seeking other job opportunities or taking time off work due to burnout and stress (Muir et al 2024).
The RCEM (2024a) suggests that having adequate numbers of medical, nursing and allied healthcare professionals is the primary intervention required to reduce crowding. In addition, the RCEM suggests that the design and physical space of EDs should be considered, in terms of enabling the department to run as effectively as possible, and that having a senior decision-maker involved at an earlier stage in a patient’s potential admission to the ED would help reduce crowding (RCEM 2024a). Other potential solutions include interdisciplinary working. For example, in their literature review, Jeyaraman et al (2021) identified various ‘within’ ED and ‘without’ ED interventions or strategies involving primary health care professionals, including nurses, that had a positive effect on patient flow and on patient length of stay. Examples included an area in the ED staffed by primary health care professionals to manage lower acuity patients streamlined at triage and integrating hospital and GP care.
The findings of the review suggest that when the ED is crowded it can significantly affect patient morbidity and mortality, which can cause moral distress and moral injury to all members of the multidisciplinary team. Even after the patient has left the ED the consequences of crowding can be significant. For example, Jones et al (2022), who conducted a study to assess and quantify the increased risk of death resulting from delays to inpatient admission from EDs, reported that the greatest change in the 30-day standardised mortality ratio was an 8% increase in the patient cohort that waited in the ED for more than six to eight hours from time of arrival.
Excessive workload can adversely affect nurses’ mental health and well-being, as noted in the articles reviewed. In addition, as levels of ED crowding increase, so too do levels of violence which may increase the likelihood of nurses experiencing deteriorating mental health and/or leaving their job (RCEM 2021). It could be argued that if patients were seen, assessed and admitted with no delays there may be a consequent reduction in violence in the ED.
NHS Digital (2024) figures for April 2024 show that mental health issues were the most reported reasons for sickness absence among NHS staff, accounting for over 542,600 full time equivalent days lost and 27% of all sickness absence.
According to NHS Employers (2024), staff must understand the factors that affect their mental health and should be able to have regular well-being conversations with their managers. To support such conversations and respond to individual’s needs, managers require the right skills which may require them to undertake training.
Finally, crowding was identified by Gillespie et al (2024) as an area requiring further research in the context of nursing. The Royal College of Nursing (RCN) Institute of Excellence and Workforce Academy was launched in 2024 to drive innovation and improvements within the nursing profession (RCN 2024); this may provide the impetus for further research of the effects of ED crowding on nurses.
A limitation of this literature review is that none of the included articles were UK based, which may restrict the applicability of the findings to UK healthcare systems. However, this also emphasises the fact that crowding, and the consequent effects on nurses, is a global issue and that there is a need for further research in UK settings.
ED crowding can have significant adverse effects on nurses, including in relation to their workload and mental health and well-being. Various ED specific and system-wide factors must be addressed to reduce the effects of crowding on nurses, including staffing levels and skill mix, hospital metrics and patient flow. Further research of this topic is required to explore in more depth the effects of crowding on nurses and on the wider healthcare system, and to address the factors that perpetuate this phenomenon.
Views of specialist head and neck nurses about changes in their role
The Cancer Reform Strategy (Department of Health 2007)...
Emergency assessment bay for cancer patients
The annual Quality in Care (QiC) Excellence in Oncology...
An evaluation of the role of support workers in lung cancer
Aim To map the prevalence and type of unregistered roles...
The role of lung cancer nurse specialists
A report published by the National Lung Cancer Forum for...
Role of lung cancer nurse specialists in recruiting patients to clinical trials
Facilitating access to anti-cancer treatment is an important...