Stress in the emergency department clerical staff

The Journal of Emergency Medicine, Vol 14, No 2, pp 247-249, 1996 Copyright 0 1996 Elsevier Science Inc. Printed in the USA. All rights reserved 0736~4679/96 $15.00 + .I0 ELSEVIER

SSDI 07364679( 95) 02109-4

Administration of Emergency Medicine

STRESS

IN THE EMERGENCY

John L. Zautcke,

MD, FACEP,

DEPARTMENT

Valerie D. Neylan,

MD, FACEP,

CLERICAL

STAFF

and Raymond G. Hart,

MD, FACEP

Department of Emergency Medicine, University of Illinois at Chicago, Chicago, Illinois Reprint Address: John L. Zautcke, MD, FACEP, Department of Emergency Medicine, University of Illinois at Chicago, 1740 West Taylor Street, Suite 1600, M/C 722, Chicago, IL 60612

0 Abstract-Clerical staff are vital for the effective management of the emergency department. A survey of emergency department clerks was conducted to determine the prevalence and types of stress in their jobs. Forty-six of fifty surveys were completed and returned. Seventy-six percent of the respondents rated their job in the “extremely stressful” range. Stress was a factor responsible for job absenteeism in 24% of the respondents. Most agreed that physician education is necessary. 0 Keywords-stress; partment clerks

position a potential reservoir for stressand job dissatisfaction ( 1) . Stresshas been well described in physicians, nurses, and EMTs, but little is reported on clerical staff (212). Job stress is believed to cause high levels of anxiety, depression, job dissatisfaction, absenteeism, and “burn out.” Many employers are taking measures to address and counteract the ill effects that stresshas on job satisfaction and performance. The objective of this study is to identify the prevalence and types of stress experienced by EDCs. Stressors should be identified to prepare and retain the clerical staff. Job performance and satisfaction also may be positively influenced by addressing these concerns. We believe that physicians may contribute to this stressby having a poor understanding of clerical capabilities and limitations. Emergency medicine residents, in particular, may lack awarenessin this area and may be more at fault than their attending counterparts. In addition, unprofessional and discourteous treatment of EDCs by resident and attending physicians may be factors contributing to this stress.

job absenteeism; emergency de-

INTRODUCTION Emergency department clerks (EDCs) provide a vital function in the effective management of a busy emergency department (ED). They play a central role by facilitating and organizing a wide spectrum of ongoing activities crucial to the smooth operations of the department. Despite their integral role, little is known about their level of satisfaction and stress on the job. Difficulties experienced by the EDCs may negatively affect the quality of patient care. In most emergency departments, the clerks must be responsive to the physicians, nurses, managers,administrators, and often the patients themselves. One clerk often is responsible for an entire department or specific care area and has no peers available to him or her. This organizational structure makes the clerical staff Administration RECEIVED: ACCEPTED

MATERIALS

A 19-question survey was developed by the authors and distributed to all EDCs at four metropolitan emergency departments. All facilities are teaching hospitals and each is associated with one of two emergency

of Emergency Medicine is coordinatedby Eugene Kercher,

field, California, and Richard Salluuo, 3 August 1995; : 16 October 1995

MD,

AND METHODS

MD, of Kern Medical Center,Bakersof Albany Medical Center,Albany, New York

247

L: i. Zamke

248

medicine residency programs. Two of the hospitals are Level 1 trauma centers; all have an annual census of 38,000 to 42,000. The questionnaire requests demographic data, job descriptors, level of job stress and satisfaction, and perceived treatment by physicians. Questions rated the amount and type of stress experienced by the EDCs as well as how they felt residents and attendings understood their job capabilities and limitations. Finally, the need for physician education was addressed. The data were analyzed using the Student’s f-test, Chi-square, and Fisher’s exact test (2tail) analysis.

RESULTS Forty-six of 50 (92%) surveys were completed. Ninety-one percent of the respondents were female, with a mean age of 29.4 years and 5.1 years in their present position. Eleven (25.6%) of the respondents work only in the patient-care area, seven ( 16.3%) work only in registration, and 25 (58.1%) work in both areas (three clerks did not respond to this question). They work a mean of 34.4 hours per week with a typical shift being eight hours. Fifteen (32.6%) work days, 16 (34.8%) work afternoons/evenings, and eight ( 17.4%) work nights. The remaining seven (15.2%) work variable shifts. The EDCs rated their overall job stress on a scale of 1 to 10, 1 meaning “no stress” and 10 meaning “extremely stressful.” The mean overall stress rating was 6.7~2.2, with 76% of the respondents rating their stress as 6 or greater. They also rated the percentage of time they felt their job was extremely stressful. The mean was 51.4%, with 58% of the respondents rating their job as extremely stressful at least 50% of the time. Eleven (24%) reported that job stress has caused them to miss work. Finally, they rated overall job satisfaction on a 1 to 10 scale, 1 meaning “extremely dissatisfied” and 10 meaning “extremely satisfied.” The mean response was 5.922.1, with 67% of the respondents rating their job satisfaction as 6 or greater. The EDCs were asked to comment on the percentage of time spent performing various activities and to rate the degree of stress related to each. They rated phone and chart activities and nurse and physician interactions as their most frequent activities. No single activity, however, was found to be extremely stressful. The EDCs rated the frequency of courteous and professional treatment by both attending and resident emergency physicians. They also rated the frequency that these physicians understood their job capabilities and limitations. For both, we used a 1 to 10 scale, 1 meaning “never” and 10 meaning “always.” The

et a.

mean rating for courteous and professional treatment was higher for attending physicians (7.6?12.4) than for residents (6.6~2.1 ) (I? SC:0.05 ). The mean rating I’br understanding of job capabilities and limitations was also higher for attendings (7.022.3 ) than for residents (5.6k2.1) (p < 0.05). Finally, the EDCs rated the need for education ot attendings and residents regarding their job capabilities and limitations. The scale was 1 to 4. I meaning “strongly disagree” and 4 meaning “strongly agree.“ The mean rating for attendings (3.310.8) was not different than that for residents (3.520.6).

DISCUSSION EDCs’ responsibilities are numerous and vital to the smooth functioning of an emergency department. The emergency department is an unpredictable and volatile environment conducive to high levels of stress. Unfortunately, little has been published about stress and its effect on ED clerical staff. Hall et al. surveyed 46 female clerical workers employed in patient-care areas ( 1). Twenty-three were clerks in hospital units and 23 were in ambulatory clinics. The women perceived themselves to be at the lowest strata of the job hierarchy. Often, they felt they were blamed for mishaps because of their subordinate position, and that they were called upon to do things not in their job description. Other sources of stress they encountered were racial tension, thwarted aspirations, discourteous and hostile treatment by coworkers, and frustration by irritable and demanding patients. Our survey was conducted for emergency medicine clerical staff only, the majority of whom were women with a mean age of 29 years and 5 years of job experience. We confirmed the EDCs feel significant amounts of stress like other members of the ED team. We attempted to identify the activities most frequently performed and the degree of associated stress. The EDCs felt that the majority of their time was spent on phone-related activities, charting activities, and interactions with nurses and physicians. We were unable to identify any specific activity that accounted for the majority of their stress. The EDCs perceived significant differences between attendings and residents in two areas. They felt they were treated courteously and professionally more often by attendings than residents. However, the overall high rate of discourteous and unprofessional treatment by both groups is disturbing and needs to be addressed. The residents’ understanding of the job capabilities and limitations of the clerks was signifi-

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Clerical Staff Stress

cantly less than the attendings’ and reveals that there is a lack of resident education in this regard. At each of the four hospitals surveyed, residents rotate through the emergency department on a monthly basis and often do not return for up to 6 months. This makes it very difficult for residents to become integrated into the unique infrastructure of the emergency department. In our current system, the residents are orientated only once, by the chief resident, to the policies of the emergency department, but are not given a specific job description for the clerical staff. They learn to function with the clerical staff primarily by observation of the attending and nursing staff and by trial and error. Due to their sporadic and infrequent contact, the residents have a more difficult time establishing strong interpersonal relationships with the EDCs. All of these factors may play a role in the perceived differences between residents and attendings. One solution is to include information about EDCs as part of the residents’ orientation. Job descriptions of all the ancillary personnel, in particular the EDCs

and their importance to the smooth operations of the ED, would be included. A similar orientation could also be used for new attending faculty. The limitations of this study were primarily its small sample size and the fact that all facilities were teaching hospitals using rotating emergency medicine residents. The identification of stressful activities may have been missed by listing activities and not allowing alternative responses.

CONCLUSION Stress and job satisfaction have been well documented for various medical personnel, but not for the EDCs. We established that EDCs feel a significant amount of stress in their job, which contributes to job absenteeism. Specific stressful activities could not be identified. Discourteous and unprofessional behavior and a lack of understanding of the EDCs’ job capabilities by physicians is one component of this stress. Educational initiatives might be beneficial.

REFERENCES I. Hall JM, Stevens PE, Melis Al. Experiences of women clerical workers in patient care areas. J Nurs Adm. 1992;22:1 l-17. 2. Schiedermayer DL, Tesch BJ. Primary care physician burnout: definitions, self-assessment and treatment. Wis Med J. 1992; 91:179-82. 3. Saunders DE. Medical burnout. JSC Med Assoc. 1992;88:312-4. 4. Neale AV. Work stress in emergency medical technicians. J Occ Med. 1991;33:991-7. 5. Keller KL. The management of stress and prevention of burnout in emergency nurses. J Emerg Nurs. 1990; 16:90-5. 6. Harrison P. Life in the ER: wild nights, mounting stress and mid-40’s burnout. Can Med Assoc J. 1993; 148: 1598-1600. 7. Lloyd S, Streiner D, Shannon S. Burnout, depression, life and job satisfaction among Canadian emergency physicians. J Emerg Med. 1994: 12:559-65.

8. Whitley TW, Allison EJ, Gallery ME, et al. Work-related stress and depression among practicing emergency physicians: an international studv. Ann Emerg Med. 1994: 23: 1068-7 I. 9. Hall KN, Wakemann MA, Khoury J. Factors associated with career longevity in residency-trained emergency physicians. Ann Emerg Med. 1992;21:291-7. 10. Whitley TW, Allison EJ, Gallery ME, et al. Work-related stress and depression among physicians pursuing postgraduate training in emergency medicine: an international study. Ann Emerg Med. 1991;20:992-6. 11. Lloyd S, Streiner D, Hahn E, et al. Development of the emergency physician job satisfaction measurement instrument. Am J Emerg Med. 1994;12:1-10. 12. Duquette A, Sandhu BK, Buaudet L. Factors related to nursing burnout: a review of empirical knowledge. lssues Men H Nurs. 1994; 15:337-58.