What is your first thought?
Mine was a sinking feeling, believing they were going to tell me that the wait times were too high or that there had been too many breaches. The perceived doctor/manager divide is a challenge in all healthcare settings but a few things have changed my outlook on these interactions.
When we are leading an ED we need to be aware of the clinical load in the department, the staffing levels (including skill mix) and predicted outflow. This helps gain situational awareness so we can recognise current problems but also, most critically, predict potential future ones within the different areas of the ED.
Managers may have a slightly different perspective. They are aware of what actions they have taken to mitigate the potential problems that they see and act in real-time to attempt to keep flow going through the ED. While these perspectives are slightly arbitrary and clearly the doctor in charge acts in the here and now and managers do plan for future eventualities they are seeing the same problem through a different lens. Having recognised these potential differences do potentially exist, our ED has circulated a document to managers about how they can assist the doctor/nurse in charge. It was designed to help both managers and clinicians work together more effectively.
The first element was about exploring situational awareness. A manager’s situational awareness may not be completely focussed on the ED. It is easy for Emergency Clinicians to believe the most important and challenging issues are occurring in the ED but from a manager's perspective, this may not be the case. The action of looking at the ED patient screen can begin to give them an insight into the current state of the ED and will help them understand things from the point of view of the ED staff.
Stick to the basics
- How many patients are in the department? It’s always worth a reminder that the staffing levels of ED are static, but the patient numbers can carry on increasing, unlike on a ward. The more patients there are, the more responsibility each of the nurses and doctors is carrying. It will also mean the team will be more strained – the nurses will be giving more treatments, more sets of observations will need to be done and the doctors will have a growing list of patients waiting to be seen.
- Acuity of patients in Assessment and/or treatment areas (e.g. Majors). Priority patients will be more labour intensive for both the nursing and medical teams, and the more priority patients there are, the wait time for the non-priority patients will increase.
- What's the situation in Resus? How many patients are in there? If it’s full and there hasn't been any flow to the wards then the likelihood is some will be moved to Major, which increases the acuity in Majors and has an impact on patient safety. Some scenarios will involve more team members e.g. cardiac arrest, leaving fewer doctors to see the other patients.
- Situational awareness of other areas. How long is the wait time? Remember if the wait time is long there is likely to be low morale already, so tread carefully. Patients will often be complaining, further increasing the strain on the staff. In Paediatrics – remember that some staff will not be able to work in paediatrics, both medical and nursing, so if it is busy how are the staff there coping?
The doctor/nurse in charge will, or should have, a handle on this and so the manager needs to grasp this too, from the perspective of the ED. It may be the manager needs to be informed, you have lost situational awareness and need some time to regain this. Managers can aid the situation if they feel the clinician has lost awareness and should approach this in a sensitive manner – ‘have you done a walk around the department recently?'
The second element is for the manager to understand and assess what role the doctor/nurse in charge is primarily acting as at the current time. Is it as a clinical specialist, where they are providing senior level care? Is it as a clinical supervisor, where they are overseeing the care provided by other team members? Is it as a clinical educator, where they are providing teaching or training? Or is it as a clinical manager, where they are troubleshooting and trying to aid flow?
Understanding this will allow the manager to understand the current pressures on that individual and allow them to start a conversation in the right way. Ideally, others can fulfil some of these roles but especially during night shifts, this is not always possible.
The third element is for the manager to give a brief on how things are from their perspective, which may help those in the in-charge role. They should outline the plan outside the ED and the expected outcomes of these plans. This reduces the cognitive workload of the doctor in charge. Also, a timeline of expected changes affecting inflow/outflow can be helpful, allowing better preparation e.g. timings of breaks.
What should managers keep in mind?
- Language: this is really important and can, especially in stressful situations, make or break the effectiveness of an interaction or communication. Phrases like ‘what can I do to help you’ are really useful.
- Cognitive load: there is a known relationship between stress (or cognitive load) and performance. Very low or very high cognitive load will give a poor performance, so the busier the ED, the more stressful it will be. Approach these situations in an empathetic manner with that in mind.
- Take a break: when in charge of the ED it can be difficult to take a break. Sometimes skill mix won’t allow it, or sometimes other priorities get in the way. Being hungry and thirsty is not helpful when decision-making, so managers can help by reminding those in charge that they should get a break if they can.
- Low morale: an offensive stance (both verbally and physically) will often prompt a defensive reaction and undermine working well as a team between those in charge and management. Be aware that the ED team is usually working as fast as they can in challenging circumstances.
- Changes/interventions: even outside the ED should always be reported back to the doctor/nurse in charge so that everyone is on the same page.
Giving this framework to your managers may help often fraught interactions. If you both understand each other’s perspective, pressures and limitations then more effective communication is much more likely, and you won’t dread those night shift meetings. Having discussed this blog post with an Emergency Department service manager, the anxieties about communication work both ways – something I think doctors can easily forget.