Proper selection of caregivers is critical. Emergency physicians in one Australian study were found to have Meyers Briggs Type personality profiling that significantly differed from the general population with ENTJ (extraversion, intuition, thinking, judgment) being the most frequent profile for emergency medicine physicians.11 Generally, people with these characteristics are “natural born leaders… career focused… dislike mistakes and inefficiencies… may hold onto submerged emotions….” These findings underscore the degree of self-selection that may occur among individuals seeking the EM career,12 since the ability to tolerate and thrive in the high-pressure career of emergency medicine is a determinant of career satisfaction. It is important to ensure that emergency medicine residency candidates are a good match for the inherent demands of the profession and the specific demands of a particular practice.
Identifying Stress and Burnout
ED nursing and medical leaders have an important role to play in identifying stress and burnout among their colleagues, employees, and associates. Direct observation, reports from work associates, quality reviews, and compliments and complaints from physicians, staff, and patients continually inform the department leaders. Certain verbal expressions and nonverbal signs may signal a problem. Clinical problems, decreasing patient satisfaction (as noted by trends in surveys or complaints), tardiness, absenteeism, avoidance by other employees, and changes in behavior and personality are harbingers of burnout.
The most stressful roles in the ED may be those of the medical and nurse director. Unlike staff physicians and nurses who work their shifts and then go home and decompress, the jobs of the clinical directors never stop.
Emergency Medicine's Longitudinal Study
Between 1994 and 2008, a longitudinal study comprising 5 intervals examined career satisfaction and burnout among emergency physicians.13 Approximately two-thirds of respondents reported high career satisfaction, with over three-quarters reporting that emergency medicine had met or exceeded career expectations. Despite these encouraging numbers, nearly one-third of respondents reported that burnout was a significant problem.
This survey noted high correlation of certain career characteristics with high satisfaction. For example, EM physicians involved in teaching, consulting, institution leadership roles, or organized medicine leadership roles were twice as likely to report high career satisfaction. Job security and job excitement were also positive correlates.
Conversely, factors associated with respondents reporting low career satisfaction included
- Insufficient time for their personal lives
- Long shift length
- High census
- Lack of subspecialty support
- Unsupportive hospital administration
- Self-reporting of burnout
Major contributors to burnout included
- Poor control over the workday environment
- Poor sense of personal reward
- Lack of control over shift length, night shifts, patient acuity
- Lack of resources for patient needs
- Lack of time to attend educational conferences
The longitudinal study noted that physicians who felt dissatisfied with professional autonomy or compensation were more likely to seek new positions. In fact, dissatisfied physicians were found to be 3 times as likely to leave the practice of medicine. These studies strongly indicate that emergency medicine providers, and by extrapolation all ED workers, can benefit from an environment that supports wellness, work/life balance and career longevity. Such a positive environment supports patient satisfaction and practitioner wellness, long-term employment, and quality care.
Solutions to Enhance Wellness and Prevent Burnout
Burnout has significant effects on the functioning of an ED. An ED leader who fails to consider and plan to reduce burnout and its causes may find that nurses and physicians deliver lower quality care, have greater absenteeism, and lower morale, and experience higher than average job turnover.6 Physician quality measures and peer satisfaction surveys, such as the Press Ganey surveys, provide a window into employee functioning. Patients treated by physicians with low job satisfaction and high stress have lower satisfaction and lower compliance with care instructions.6
Hospital and departmental leadership can take steps to enhance wellness and prevent burnout. These steps are applicable to all group practice arrangements. Offline preventative measures, real time interventions, and planning practice characteristics can have a constructive impact.
Methods of preventing stress and enhancing wellness include schedule adjustments that provide opportunities for physiological sleep, ensure personal time prior to and after shifts, and optimize circadian rhythms. Examples of strategies that are helpful to the entire group of workers include
- 8- and 9-hour shifts (rather than traditional 12-hour shifts)
- 1-hour shift overlaps
- Rewards for those who commit to full time nightshift work on increased hourly rate and a reduced weekly hour commitment (helpful to entire group)
These strategies also partially address the frequently noted difficulties associated with the aging caregiver.
It is helpful to provide staff support following unexpected clinical outcomes, disasters, death of a young patient, or particularly disturbing emotional trauma. Involving the at-risk staff in a CISD can provide immediate support as well as determine how the physicians, nurses, and other staff members are reacting. CISD can therefore help to gauge when further counseling is needed.
Improving the Environment of Care
Environmental strategies to improve physician wellness are predicated on the belief that there is a direct correlation between the wellness of the workforce and the delivery of care to the patients. To accomplish this goal, some institutions provide incentive programs that include smoking cessation, a monetary dollar credit for participating in a well-equipped health club gym with proof of regular usage, weight loss programs, and lifestyle education.
Creating Standards for Effective Communication
The successful ED practice demands teamwork among a variety of professionals and auxiliary personnel. An ED practice environment requires workers who effectively communicate, have procedural competency, and are able to focus in the face of frequent interruptions. Language and communication processes are helpful in creating an environment conducive to wellness. They enhance patient safety while creating a culture of respect and teamwork. Scripted methods of communication bring a sense of control to the emergency physician, helping to prevent burnout. Specific examples include
- ICARE: An acronym used to effectively communicate with patients and families. This program has been adopted by EDs to facilitate communication with patients (Figure 13-1).
- SBAR: It standardizes communication, especially during patient handoff transitions and specialty backup consultation requests (Figure 13-2). It helps to ensure patient safety. SBAR stands for Situation-Background-Assessment-Recommendation.14
- The 4 Cs: Civility, collegiality, collaboration, and community—guide relationships among emergency care providers and their many audiences including specialists, ancillary departments, and others. The 4 Cs employ relationship rules to build teams and ensure a culture of respect.
- EI (emotional intelligence): Effective emotional intelligence depends on self-awareness, managing one's emotions, having social awareness, and ultimately addressing other's emotions.15
- Crucial conversations: A crucial conversation occurs when people are discussing difficult issues with high stakes, different points of view, and high emotions, ie, addressing unmet commitments. The book Crucial Conversations describes techniques designed to master communications involving these difficult discussions.16
CEPs ICARE communication strategy.
SBAR patient handoff program.
The systems described here emphasize that effective communication is the most important competency required for optimum team interaction in order to adequately and safely treat patients, make appropriate dispositions while satisfying patients, and decreasing stress in both the clinical and administrative practice of emergency medicine.
In addition to workplace and family stress, emergency care workers are subject to the same types of impairments that affect the general population. ED leaders must be familiar with their institution's (HR/Medical Staff Bylaws) guidelines regarding identification, treatment, and work continuation rules of the addicted or impaired professional.
Employee Assistance Programs (EAP) and, in certain situations, state impaired physician/nurse programs have a role in helping an ED worker salvage a career threatened by the impairment of addiction. Referral to EAP may allow for addressing the impairment. Absolute privacy and confidentiality are necessary for the protection of the employee and to avoid legal implications and grievance filing.