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Redrawing the Boundaries: Conceptualizing Emergency Medicine as a Complex Communication System
Unformatted Document Text:  4 Like we’ve seen in other kinds of businesses, you can only invest selectively to a degree. At some point, sub-par service in one area begins to hurt the overall reputation of the institution. If we had to rank-order our challenges in the ED, we would start with staffing, both ours and of the hospital overall. We know that every hospital is challenged to attract and retain staff, but we sometimes seem to struggle more than most. Is our compensation really competitive with other hospitals in the area? Are we being sufficiently strategic with our pay and benefits? It’s so hard to say. It seems to us that our competitors offer more attractive packages in many respects, including critical pay, signing bonuses, weekend bonuses, etc. In addition, so many nurses moving from regular staff to the flex pool has been a mixed bag for the department. In a perfect world, most of us would prefer to be permanent staff members, but the schedules and pay scales are different enough to make us reconsider. These days, you have to look out for yourself, so why not join the pool? But we know the managers struggle with staffing and the pay inequities this arrangement creates. Another thing we are learning lately about staffing is that as much as we need people, hiring folks who truly aren’t qualified to do emergency work is worse than being short-staffed. While we appreciate the efforts on the part of HR and administration to get us some help, the answer—at least in our area-- won’t be found in hiring less qualified employees. Friends in other industries say that loyalty is dead, that everyone is an independent contractor these days, only out for him or herself. Health care professionals have felt something like this for a long time, but it’s getting more pronounced these days. Some of this diminished loyalty has led to tensions among the nursing staff, mostly due to perceived inequities between permanent and flex-pool employees. But any tensions within the department pale in comparison to the isolation we often feel from the rest of the hospital. The ED staff is a different breed, we feel, and we would never willingly learn about the social world of another department. We expect them to serve us better, but in truth we don’t know very much about what they do and why they do it. When a patient is scheduled to be admitted to the hospital, they can remain in the ER for hours or days either because there’s no room upstairs and/or because our supporting departments—e.g., radiology, phlebotomy, and pharmacy—either won’t, or more likely can’t respond quickly. The support that they do provide doesn’t approach our cases with the same sense of urgency that we feel they deserve. Most recently, the changes in radiology have been a serious challenge, jamming up the system and causing long delays. Worse yet, we’re at the bottom of the bed list--available bed space upstairs isn’t offered to our patients until other departments have had their bed demands met. These other departments get irritated with our demeanor and demands, but maybe if they understood our world, they would better understand why we react the way we do. Perhaps other departments don’t get us because we tend to wear our emotions on our sleeves. The ED is an emotional place, our patients (and their families) show up here on one of the worst days of their lives, and we have to take the heat. Truth be told, the kind of person who picks a career in the ED is pretty emotional too, willing and capable of dealing with other people’s problems. So even more than most health professionals, we have created a climate that is emotionally high-pitched, and we tend to respond strongly to the feelings and actions of patients, their families, and our co-workers. Perhaps for this reason (and others), all too often we are seen as “bad guys” by the rest of the hospital, and it really hurts. Over the years, the ED has become a kind of “whipping boy” for CHC as a whole, as many of the hospital’s employees lack the awareness that most of what become the hospital’s problems ultimately begin here, on the front lines of emergent care. But we must take some

Authors: Eisenberg, Eric., Pynes, Joan. and Baglia, Jay.
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4
Like we’ve seen in other kinds of businesses, you can only invest selectively to a degree. At some
point, sub-par service in one area begins to hurt the overall reputation of the institution.
If we had to rank-order our challenges in the ED, we would start with staffing, both ours and of the
hospital overall. We know that every hospital is challenged to attract and retain staff, but we
sometimes seem to struggle more than most. Is our compensation really competitive with other
hospitals in the area? Are we being sufficiently strategic with our pay and benefits? It’s so hard to
say. It seems to us that our competitors offer more attractive packages in many respects, including
critical pay, signing bonuses, weekend bonuses, etc. In addition, so many nurses moving from regular
staff to the flex pool has been a mixed bag for the department. In a perfect world, most of us would
prefer to be permanent staff members, but the schedules and pay scales are different enough to make
us reconsider. These days, you have to look out for yourself, so why not join the pool? But we know
the managers struggle with staffing and the pay inequities this arrangement creates.

Another thing we are learning lately about staffing is that as much as we need people, hiring folks
who truly aren’t qualified to do emergency work is worse than being short-staffed. While we
appreciate the efforts on the part of HR and administration to get us some help, the answer—at least
in our area-- won’t be found in hiring less qualified employees.

Friends in other industries say that loyalty is dead, that everyone is an independent contractor these
days, only out for him or herself. Health care professionals have felt something like this for a long
time, but it’s getting more pronounced these days. Some of this diminished loyalty has led to tensions
among the nursing staff, mostly due to perceived inequities between permanent and flex-pool
employees. But any tensions within the department pale in comparison to the isolation we often feel
from the rest of the hospital. The ED staff is a different breed, we feel, and we would never willingly
learn about the social world of another department. We expect them to serve us better, but in truth we
don’t know very much about what they do and why they do it.

When a patient is scheduled to be admitted to the hospital, they can remain in the ER for hours or
days either because there’s no room upstairs and/or because our supporting departments—e.g.,
radiology, phlebotomy, and pharmacy—either won’t, or more likely can’t respond quickly. The
support that they do provide doesn’t approach our cases with the same sense of urgency that we feel
they deserve. Most recently, the changes in radiology have been a serious challenge, jamming up the
system and causing long delays. Worse yet, we’re at the bottom of the bed list--available bed space
upstairs isn’t offered to our patients until other departments have had their bed demands met. These
other departments get irritated with our demeanor and demands, but maybe if they understood our
world, they would better understand why we react the way we do.

Perhaps other departments don’t get us because we tend to wear our emotions on our sleeves. The
ED is an emotional place, our patients (and their families) show up here on one of the worst days of
their lives, and we have to take the heat. Truth be told, the kind of person who picks a career in the
ED is pretty emotional too, willing and capable of dealing with other people’s problems. So even
more than most health professionals, we have created a climate that is emotionally high-pitched, and
we tend to respond strongly to the feelings and actions of patients, their families, and our co-workers.
Perhaps for this reason (and others), all too often we are seen as “bad guys” by the rest of the
hospital, and it really hurts. Over the years, the ED has become a kind of “whipping boy” for CHC
as a whole, as many of the hospital’s employees lack the awareness that most of what become the
hospital’s problems ultimately begin here, on the front lines of emergent care. But we must take some


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