The everyday work at a Swedish emergency department – The practitioners’ perspective

International Emergency Nursing (2012) 20, 58– 68

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The everyday work at a Swedish emergency department – The practitioners’ perspective Henrik Andersson RN, MSc (Lecturer, PhD student) a,b,*, Eva Jakobsson RN, PhD (Senior Lecturer) a, ˚ker RN, PhD (Associate Professor, Senior Lecturer) a, Carina Fura Kerstin Nilsson RN, PhD (Associate Professor, Senior Lecturer) a a b

¨teborg, Sweden University of Gothenburg, The Sahlgrenska Academy, Institute of Health and Care Sciences, Go ˚s, School of Health Sciences, Bora ˚s, Sweden University of Bora

Received 14 March 2011; received in revised form 22 June 2011; accepted 23 June 2011

KEYWORDS Everyday work; Practitioners; Emergency care; Content analysis

Abstract In the everyday work at emergency departments (EDs), the patients being cared for have different needs and perceived symptoms. To meet their need for emergency care, knowledge of the work is important. The aim of this study is to explore the everyday work at a Swedish ED from a practitioner’s perspective. Method: This study has a qualitative, exploratory design with observations and interviews at two EDs. Data were analysed by content analysis. Findings: The everyday work is characterised by a rapid, short and standardised encounter with limited scope to provide individualised care, which leads to a mechanical approach. It is also characterised by an adaptive approach in which practitioners strive to be adaptable by structuring everyday work and cooperation to achieve a good workflow. Conclusions: The study shows that the practitioners’ encounter with patients and relatives is rapid and of limited duration. The care activities that practitioners mainly perform comprise standard medical management and are performed more mechanically than in a caring way. The practitioners strive to balance the requirements and the realisation of the everyday work through structures and in cooperation with other practitioners, although they work more in parallel than in integrated teams.

ª 2011 Elsevier Ltd. All rights reserved.

Introduction Corresponding author. Address: University of Bora ˚s, School of Health Sciences, Department of Emergency Care, SE-501 90 Bora ˚s, Sweden. Tel.: +46 33 435 47 79; fax: +46 33 435 44 46. E-mail address: [email protected] (H. Andersson).

In the everyday work at emergency departments (EDs), the patients being cared for have different needs and perceived symptoms of illness or injury and the condition of these

1755-599X/$ - see front matter ª 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.ienj.2011.06.007

The everyday work at a Swedish emergency department – The practitioners’ perspective patients can change rapidly (Nystro ¨m et al., 2002; Wiman and Wikblad, 2004). This everyday work is an essential part of the ED and its practitioners. It is routine and is characterised by numerous short encounters and a constant need to re-prioritize the care provided (Larsson Kihlgren et al., 2005). The care system at EDs in Sweden is based mainly on team nursing (Finkelman, 2006), which means that assistant nurses (ANs) and registered nurses (RNs) work together to provide care for a group of patients, such as surgery patients. The proportion of ANs and RNs in Sweden varies according to the time of day but in general staffing comprises about 40% ANs and 60% RNs (Andersson and Nilsson, 2009) with 1–4 medical doctors (MDs) depending on the specialisation. The team-nursing model thus includes ANs, RNs and MDs, who in this study are designated ‘practitioners’. In the everyday work, the above practitioners perform specific tasks and activities, individually or together. National descriptions of required competences are available for RNs (The Swedish Emergency Nurses Association, 2010) and MDs (The National Board of Health and Welfare, 2008), but not for ANs (Nilsson et al., 2008). Ultimately, it is the manager who determines the necessary competences at an ED (The National Board of Health and Welfare, 2005). ANs and RNs normally work close to the patient but with different tasks. The ANs mainly check vital signs, attend to dressings and basic hygiene tasks and generally ensure the patient is comfortable. The RNs are responsible for triage assessment, administering medication and assuming overall responsibility for patient care (The Swedish Emergency Nurses Association, 2010). Finally, the main tasks of MDs are to assess, diagnose and treat the patient (The National Board of Health and Welfare, 2008). The practitioners’ level of autonomy is socially constructed and determines the practitioners’ independence in their everyday work, although the everyday work is also influenced by society – political decisions for example – and guidelines as well as the ED itself through the work organisation, managers, other practitioners or the practitioners themselves (Ellstro ¨m, 1997). An ED can be viewed as a system which means that the ability of an ED to perform its task is based on interaction between the totality (the ED and its environment) and its parts (structures, functions and practitioner relationships) as well as communication and an interconnection between the parts (Senge, 1995). In this system the everyday work can be seen from the point of view of the practitioners-‘ relationship to the organisation, its managers, and other practitioners (Møller, 1994) as well as the patients seeking care at the EDs. In recent years, work at EDs has undergone a significant change. Nowadays, diagnosis and treatment are initiated at the EDs more often than in the past and the structure of society has led to more patients with specific health needs. This change took place subsequent to the hospitals reducing the length of stay for inpatients and the number of hospital beds (The National Board of Health and Welfare, 2006, 2009a,b; Sa ¨fwenberg, 2008). Finally, people increasingly expect to be diagnosed and treated at the ED (Russ et al., 2010). The logistics and the working environment at the EDs are influenced by all these changes (Henneman et al., 2010; Moskop et al., 2009). Displeasure has been ex-

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pressed by patients regarding the long wait to be examined by an MD, as well as the lack of treatment and inadequate information from the ANs and RNs (Bridges et al., 2010; Muntlin, 2009). The dilemma is that the practitioners are expected to satisfy all the patients’ needs (Asplin et al., 2003; Wiler et al., 2010), and at the same time provide a fast, safe and effective care (ACEP, 2005) and fulfill political demands, e.g. a maximum of 4 h waiting time at the ED (Larsson, 2010). Everyday work at an ED is complex, routine and with few dramatic situations. Practitioners sometimes lack efficient strategies for performing their work (Andersson and Nilsson, 2009; Frank, 2010). Knowledge of the work at an ED from the practitioners’ perspective is important. However, this also requires knowledge of what support practitioners need in order to develop their work (Fetzer, 2005). No Swedish studies of everyday work at EDs from the point of view of the practitioners have yet been performed. International studies are conducted in ED contexts that are different from the Swedish context, e.g. by providing access to specially trained RNs or MDs and the development of health systems (Arnold and Corte, 2003; Cooke et al., 2004; Schneider, 2010; Turris et al., 2007; Uranu ¨s and Lennqvist, 2002). There is thus a knowledge gap with regard to Swedish EDs that the present study aims to address. The purpose of this study is to explore the everyday work of the ANs, RNs and MDs and their care and treatment of patients with urgent and non-urgent conditions at Swedish EDs. Specific issues are; – What does the practitioners’ everyday work consist of? – How do the practitioners describe their everyday work?

Methods Design To facilitate a description of the practitioners’ everyday work, a qualitative exploratory study design, was chosen based on data from observations and interviews (Patton, 2002).

Setting Data was collected at two EDs in western Sweden. They were chosen based on differences in size, the presence of emergency MDs and access to basic specialties, in this case medicine, surgery and orthopaedics. The main functions of these EDs are to provide 24-h care for patients with medical, surgical or orthopaedic diseases and injuries and ensure they are triaged as requiring immediate, urgent or non-urgent attention. Immediate means a life-threatening condition that requires instant attention. Urgent means a condition that is not life-threatening, but requires instant attention (time to MD 10–15 min). Non-urgent is a condition that is not life-threatening and does not call for instant attention (time to MD 120–240 min). The triage system used is a local system, based on the Manchester Triage System (MTS) and Medical Emergency Triage and Treatment System (METTS). METTS is a Swedish-designed triage decision system inspired

60 by MTS and supplemented by additional assessments (e.g. vital signs) and measurement processes (e.g. blood sampling) (Olofsson et al., 2009; Widgren and Jourak, in press). The work at the two EDs is co-ordinated by either RNs or MDs. This means they lead the operational work-assigning tasks, supervising, monitoring of patients, answering incoming telephone calls and as necessary directing patients to the reception department. The two EDs differ in terms of the number of patient visits per year (43,000 and 29,000), the number of beds (360 and 200) and the number of practitioners at hospital. The first ED was staffed during the daytime with special emergency MDs whilst the second ED was staffed with MDs from other clinics at the hospital.

Sample The sample consisted of ANs, RNs and MDs, who work permanently at the ED. The criterion for participation was the willingness to share their everyday work, which was important to ensure a broad, varied and rich body of data. Participation was voluntary and a request for participation in the observation was made either by the main author in conjunction with the observation or by the practitioners manager a few days before. The main author observed one employee at a time during a full session and observed all the situations in which the employee was involved. A request for volunteers to participate in the interviews conducted by the main author was made via posters in the staff room and in the MDs office. The practitioners agreed to participate by writing their name on a list on a poster containing information about the study. All participants who were asked or who signed up for the study participated fully with the exception of one RN who chose to suspend participation during an observation session. Since the participants were given the right to withdraw at any time without explanation, the reason for withdrawal was not requested. All data collected related to this participant has been excluded from the study. For further information about the participants, see Table 1.

Data collection Data collection was conducted in spring and autumn 2009 and produced both observation and interview data (Table 1). The observations were carried out for 24 weeks, 12 weeks at each ED. There were two observation days each week and observations took place either between 7 am and 3 pm or 2 pm and 10 pm. No data was collected at weekends or during night shifts. Observations were recorded continuously as field notes and the conversations that took place before and after observations were recorded as memos and have been used to support the analysis of field notes. The observed activities are described in Table 2. To gain a deeper understanding of the participants’ perceptions of everyday work, semi-structured group interviews were carried out (Kvale, 1997; Polit and Beck, 2004). The following questions guided the group interviews: ‘‘What form does the everyday work and co-operation take at the ED? Are there similarities and differences between the work of the ANs, RNs and MDs in terms of content and function? What opportunities and obstacles are there

H. Andersson et al. regarding the development of everyday work and co-operation?’’ Group interviews were supplemented by two individual interviews due to the low number of MDs in the group interviews and the interview questions were the same as for the group interviews (Table 1).

Data analysis Data were analysed using content analysis (Elo and Kynga ¨s, 2008; Graneheim and Lundman, 2004). Initially, field notes and the transcribed interview texts (units of analysis) were read several times to ensure data familiarisation. The analysis process started with observational data and was initiated by identifying the units of meaning and these were then coded based on the purpose and the question: ‘‘What does the everyday work consist of’’. The codes were compared and grouped according to different content aspects (sub-categories). Sub-categories were reviewed and accepted, removed or rewritten during the analysis process. Sub-categories were then grouped into categories based on similarity. The categories that emerged were Patient relationship, Care activity, Structuring and Co-operation. The analysis then continued with interview data (Elo and Kynga ¨s, 2008). The analysis of interview data had its point of departure in the categories that emerged from analysing observational data. This means that the categories were used as a template for the analysis (Crabtree and Miller, 1999). Units of meaning related to the categories (from the observation data) were searched for in the interview data and then grouped in to sub categories (Elo and Kynga ¨s, 2008). Categories with additional subcategories from both data sources were then scrutinised to perform an abstraction of the analysis and to formulate a general description, i.e. main categories. For an example of the analysis process, see Table 3. The analysis of this data is a combination of both observations and interviews and the combination will enable the creation of a broad, comprehensive and verified data set. By describing the EDs, participants, data collection and the analysis process and by providing descriptions of situations and quotes the reader is given the opportunity to assess the study’s credibility and trustworthiness of the study (Graneheim and Lundman, 2004). The results are supported by quotations from field notes and interviews. The codes given to the quotations are as follows: ‘‘OL’’ – observation by an MDs, ‘‘OS’’ – observation by an RNs and ‘‘OU’’ – the observation by an ANs. The number relates to the participant. ‘‘G’’ is the code for group interviews and the numbers indicate the groups interviewed and the participant.

Ethical considerations The study was approved by the Regional Ethics Committee in Gothenburg (Ref. 639-08). All the participants gave their informed consent.

Results The results show that the everyday work can be broken down into four categories: Patient relations, Care activities,

The everyday work at a Swedish emergency department – The practitioners’ perspective Table 1

61

Overview of participants and data collection. Total

ANs

RNs

MDs

10

10

8

46

42

28

10 0

6 4

2 6

13

14

2

Gender Women Men

12 1

10 4

2 0

Age (yrs) Range Mean

27–63 45.6

25–61 36.2

28–35 31.2

Work experience in the profession (yrs) (range) 0–1 2–5 6–10 11–15 16–20 21–30 >31

– – 2 1 1 6 3

2 3 6 – 2 1 –

3 1 – – – – –

Work experience at the ED (yrs) (range) 0–1 2–5 6–10 11–15 16–20 21–30 >31

– 1 5 2 1 3 –

5 4 3 2 1 – –

3 1 – – – – –

Participation observations Number (shift observed) Participants divided according to profession Observation time (h) Time-divided profession (h)

28 116

Gender Women Men Group interviews Number Participants divided according to profession Interview time (h)

Individual interviews Number Participants divided according to profession Interview time (h)

7 8

2 2 1.5

Gender Women Men

1 1

Age (yrs) Range Mean

38–35 31.5

ANs – Assistant Nurses, RNs – Registered Nurses, MDs – Medical Doctors

Structuring of everyday work and Co-operation. The everyday work is grouped into two main categories; Mechanical approach in the encounter and Adaptive approach to the

everyday workflow. An overview of the results from the observation data and the interview data is presented in Table 4.

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Table 2

Type of observed activities distributed among the different professions.

ANs

RNs

MDs

Triage Assessment Examination Assisting in treatment Plaster treatment Investigation Dressing Nursing round Work planning Transport

Triage Trauma alert Assessment Investigation Reporting Arranging transportation home Co-ordination of work Nursing round

Medical alert (intoxication) Assessment Examination Consultation Co-ordination of work

ANs – Assistant Nurses, RNs – Registered Nurses, MDs – Medical Doctors.

Table 3

Examples of analysis process.

Transcription

Codes

Sub-categories

Categories

MD enters the examination room and says ‘‘Hi, my name is [name] and I’m the MD here ... how are you?’’ AN says ‘‘are you okay?’’ The patient replies that it’s OK. AN says ‘‘Is there something you want to know?’’ RN asks the patient to sit down on a chair and says ‘‘We will take some blood samples from you’’ RN says ‘‘Short encounters require more ... in a short time to create a confidence’’

Creating rapid contact

Creating rapid contact during a short encounter (Observation)

Patient relations

Be accessible to patient

Inform the patient what will happen

Create confidence in a short time

Mechanical approach in the encounter The results show that the everyday work consists of patient relations and care activities and that the work is characterised by a rapid, short and standardised encounter in which care and treatments are provided to many patients and with limited space to provide individualised care (Table 4). Patient relations Creating rapid contact during short encounter. During the short encounter at the ED, practitioners attempt to rapidly establish contact with patients and their relatives (Table 4). At the same time, practitioners are trying to involve patients and their relatives in the care process and make it possible for them to influence the care being provided. The practitioners rapidly introduce themselves and their function as the first step. However, this rapid contact quickly switches to care activities. The example below illustrates a situation where the MD rapidly creates contact and quickly turns to assessing the patient’s need for care and treatment: MD goes into the examination room and says ‘‘Hi, my name is [name] and I’m MD here ... how are you? ‘‘The

Rapidly establishing confidence (Interview)

patient says: ‘‘Sat and talked about work ... felt weird in my stomach ... fell off the chair and hit my head’’ (OL 1:3) Rapidly establishing confidence. Practitioners want to rapidly establish confidence (Table 4) using non-verbal and verbal communication. Touch and placing oneself next to the patient are stated as being ways to creating confidence through non-verbal communication. Changes in the patient’s status, for example, are more easily recognised, when the practitioners are able to establish a feeling of closeness. Establishing confidence through verbal communication with the practitioners is exemplified by trying to involve the patients and their relatives in the care process. The MDs desire to discuss the diagnostic tests to be performed on the patient is another example of creating confidence. A further example is when the RNs obtain consent to release information about the patient. Establishing relationships between practitioners and patients and their relatives is the basis for establishing trust. According to the practitioners this is a challenge. Practitioners highlight the problem of being able to create many individual and trusting encounters during a limited period of time and one RN said:

The everyday work at a Swedish emergency department – The practitioners’ perspective Table 4

63

An overview of what the everyday work consists of.

Sub-categories

Categories

Main categories

Creating rapid contact during a short encounter (O) Rapidly establishing confidence (I) Providing information to reduce frustration related to waiting times (I) Assessment, examination, treatment, caring and documentation of care provided (O) Standardised vs. individualisedcareactivities (I) Organising material and human resources (O)

Patient relations

Mechanical approach in the encounter

Monitoring and evaluating the work flow (I) Adaption to constant changes (I) Communication and collaboration (O) Promoting co-operation in the work process (I) Promoting team-spirit at work (I)

Care activities

Structuring of every day work

Adaptive approach to the everyday work flow

Co-operation

(O) = Observational data, (I) = Interview data.

‘‘...you must be able to talk to a person quickly and form an opinion ... encounter... to know what she or he says ... you have so little time ...’’ (G1: 3) Providing information to reduce frustration related to waiting times. The patients’ symptoms and complaints actually cause uncertainty. To minimise the uncertainty the practitioners state the importance of informing patients and their relatives about what they can expect during their waiting time at the EDs (Table 4) and about the expected waiting time. They say that information will reduce the patients’ and the relatives’ frustration. Providing adequate information, however, is perceived as difficult and one AN said: ‘‘Reaching out with what you want to say ... it makes great demands ... and providing information about how and why ... that’s an enormous requirement and very difficult ‘‘(G4: 3) Care activities Assessment, examination, treatment, caring and documentation of the care provided. Practitioners rapidly assess the patient on arrival at the EDs and they do so continuously during the patients stay (Table 4). Assessment takes place through observation and specific questions to patients and relatives about the patient perceived symptoms, their prevalence and the patient’s needs. These questions are important to the RNs assessment of a patient’s medical care needs and priorities as well as decisions regarding a reasonable waiting period for an assessment by an MD. The following situation illustrates an assessment of a 10-year-old schoolgirl who an hour earlier had cut herself on a knife: AN takes the patient and her parent from the waiting room into the triage room. AN: ‘‘What happened?’’ Patient: ‘‘I cut myself on a knife in woodwork.’’ AN: ‘‘I will remove the bandage from the finger?’’ RN enters the triage room, greets and asks: ‘‘When did the injury

occur?’’ Patient: ‘‘It happened at 1.30.’’ RN: ‘‘Can you stand a local anaesthetic?’’ Patient: ‘‘Yes’’. RN: ‘‘Do you have any blood contamination, jaundice?’’ Patient: ‘‘No’’, RN: ‘‘You have a deep wound that needs to be sewn’’ (OS 3:6) To obtain in-depth knowledge of the patient’s actual condition the practitioners carry out an examination in order for the MDs to make a medical diagnosis. What kind of examination ANs and RNs carry out is governed by departmental protocol, i.e. triage-guidelines. The protocol points out what is a general examination, e.g. monitoring of vital signs, and what is a specific examination, e.g. urine tests on patients with abdominal pain. There is a division of labour in examinations, which involves the ANs making noninvasive checks, such as blood pressure measurement, the RNs performing invasive examinations such as blood sampling and the MDs examining the patient by means of inspection and palpation. The following situation illustrates a division of labour in examinations: The AN says to the patient: ‘‘Hi, I’ll carry out some checks on you.’’ The AN connects the equipment to measure vital signs. The temperature is then measured in the ear of the patient and after a while the AN says aloud: ‘‘37.4’’. The MD greets the patient and says: ‘‘Hi I’m the MD here and I’ll check you out’’ MD: ‘‘You can open, and then close your eyes’’. The patient complies with the request. MD: ‘‘Can you lift up your arms and legs’’ When this is done the RN says: ‘‘I’ll insert a needle in your arm’’ and she then asks the patient: ‘‘Do you know where you are?’’ The patient answers: ‘‘No’’ (OS 10:1) The practitioners also carry out various other activities such as treatment and care of the patients. Treatment for example, could take the form of the ANs putting on the plaster, the RN administering the medication and the MD prescribe medicine. Caring activities, mainly performed by the ANs, consist of activities to meet the patients’ basic care needs, e.g. food, drink, toilet and comfort require-

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ments. MDs and RNs also meet basic care needs, e.g. the MDs could give the patient a drink after completing the examination and the RNs could help the patient to change position. Finally, practitioners document the assessments, examinations, treatments and caring in the medical records although there is a substantial variation in how activities related to caring are recorded, ranging from none to detailed documentation. Standardised vs. individualised care activities The care activities are described as standardised care and treatment with a clear guidance on what to do when a patient presents with different signs and symptoms (Table 4). Certain activities are carried out if the patient has a headache or abdominal pain and others are carried out if the patient has ECG changes. At the same time, the practitioners describe the need to provide individualised care based on the patient’s current situation. RNs in particular find it difficult to provide individualised care; particularly satisfying the patient basic needs. RNs attribute the difficulties to all the other activities they need to performed, such as administration of medication. According to one RN meeting the patients’ basic needs mostly become a task for the ANs; ‘‘... The caring bit we try ... even if we (do) not always manage as much ... ‘‘(G1: 3)

Adaptive approach to the everyday workflow The results also show how the practitioners strive to be adaptable to changing working conditions in order to achieve efficient workflow. Structuring everyday work and co-operation are key elements. Adaptation to changes in the work environment takes place in co-operation with other practitioners (Table 4). Structuring of everyday work Organising material and human resources. Practitioners organise material and human resources to achieve flow in the everyday work (Table 4). As a result, there is a constant evaluation of the EDs activities, and readiness to switch from the current situation. The co-ordinators are mostly RNs; they could be MDs, but they are never ANs and sometimes no particular practitioner is designated as co-ordinator. The co-ordinator has a crucial role to play when structuring everyday work and is the one who ultimately leads and continually prioritises what should be done and in what order. The co-ordinator constantly checks the work situation and organises resources based on the workload. The work situation is also controlled by others; the MDs and RNs check the number of patients admitted and the ANs check to ensure that the examination rooms are prepared for new patients. The co-ordinators ability to lead the everyday work can be viewed in terms of how they manage the work situation and how they allocate resources. This is illustrated by the following situation; Co-ordinator: ‘‘I wonder if we should take the next patient into the room?’’ RN: ‘‘Yes, what is it?’’ Co-ordinator: ‘‘There’s a patient with an infected arm, it’s sore and swollen.’’ RN: ‘‘Place?’’ Co-ordinator: ‘‘9’’. The RN goes to the patient in the examination room (OS6: 3)

In order to use available resources optimally, the practitioners ensure the logistics at the ED function as efficiently as possible. There is a constant movement of patients in the ED and the ANs and the RNs move patients in and out of the examination rooms preparing the way for MDs to assess new patients’. Practitioners are also constantly on the move: in and out of different areas. One example is the MD, who moves between different examination rooms and the MDs office depending on the activity that has highest priority at that particular moment. In addition to checking and creating logistical flows, practitioners work on patient safety by preventing errors and injuries. This can be seen, for example, when the AN gives the patient a bell to call for help or when the RN checks the patients ID when the ID label is made out. Monitoring and evaluating the work flow. When practitioners talk about structuring everyday work, it is mean continuously monitoring and evaluating the work situation at the ED (Table 4). Structuring the workflow could be problematic because of an imbalance between inflows and outflows. This in turn might lead to more tests and treatment and it would be necessary to perform these at the ED. An inadequate workflow influences the work environment and one RN said; ‘‘Some days I think it’s been brilliant ... everything has gone so well ... other days it can be ... you think what am I doing here ... you don’t get anything out of it ... nothing happens ... you may not get what you want ... ‘‘(G4: 1) Adaption to on-going changes. Practitioners describe the readiness to rapidly switch from a low-intensity situation to a high-intensity situation (Table 4). This adaptive ability is important in order to meet changing conditions in the ED and to satisfy patients’ care needs. This means that practitioners must be prepared to respond to on-going change, e.g. patients who become worse while they are at the ED. To be in a state of readiness for change is stressful and one MD said: ‘‘... High work rate, a lot of decisions ... there’s a lot happening ... it’s pretty hard work ... So many people, both practitioners and patients ...’’ (G4: 2) Co-operation Co-operation in everyday work involves planning, discussing and helping each other as well as promoting co-operation and team-spirit between practitioners (Table 4). The ANs and the RNs together plan what to do regarding different care activities, such as dressing wounds. The RNs collaborate with other RNs, planning administration of prescribed medication and the MDs collaborate with a AN for example how plaster treatment is best carried out. Communication and collaboration. There is an on-going discussion between the ANs and the RNs in order to co-ordinate the work optimally. This could include how to perform oxygen treatment or who would be suitable to provide food and drinks to waiting patients. The RNs and the MDs talk about assessing priorities and medical prescriptions. It is either RNs or MDs who initiate these discussions. Other practitio-

The everyday work at a Swedish emergency department – The practitioners’ perspective ners can also initiate discussions, e.g. MDs could speak to ANs about logistics, such as the rotation of patients between examination rooms. The practitioners speak to others in the same profession, e.g. MDs talk to other MDs on how to interpret the examination tests. The practitioners work mainly in parallel. The ANs help other practitioners such as assisting the RNs with taking blood samples and the MDs with suturing. However, the ANs may also receive help, the RNs helps with ECG connection and the MDs help to dress wounds. There are no clear boundaries regarding who help who. The practitioners discuss while they are working together as illustrated by the following situation; a boy has played soccer and has broken his wrist, which needed a plaster; MD to AN: ‘‘The patient is in the plaster room ... we first need to place the arm in traction and collect a local anaesthetic’’. The AN picks up the equipment, goes into the plaster room. AN to MD: ‘‘What size of gloves do you have?’’ MD: ‘‘Medium’’. MD to the patient: ‘‘You’ll feel a little prick when we give you a local anaesthetic, we will then pull your fingers and put the plaster on’’. Patient: ‘‘Yes.’’ The MD administers a local anaesthetic. AN to the patient: ‘‘Can I borrow your arm so I can measure the length?’’ The AN measures the plaster and cuts into it. The MD to the patient: ‘‘Now I’m going to pull your fingers.’’ The AN pulls the other way and the MD continues pulling and squeezing the fracture area. MD to AN:’’I think that’s enough.’’ AN: ‘‘Can I let it go?’’ MD: ‘‘Yes’’. AN stop pulling and puts the plaster in the water. AN takes up the plaster, squeezes out the water, goes to the patient and puts the plaster on. AN to MD: ‘‘Maybe it´s a bit thick?’’ MD: ‘‘No, it’s probably fine.’’ The AN wraps an elastic bandage around the cast and asks the MD ‘‘What do you think?’’ MD: ‘‘It looks good’’ (OU3: 3) Promoting co-operation in the work process. Practitioners describe their wish to promote co-operation in the work process, which means that they strive to help each other. The situation and the function of the practitioners determine what kind of help they give each other but this also means that there are situations when they cannot help each other. Practitioners also describe the importance of feedback, especially rapid feedback on completed or planned activities. The ANs sometimes feel excluded by the RNs and this complicates co-operation between ANs and RNs. ANs state that they are not always permitted to participate in patient reporting which limits the ANs ability to receive feedback on their work. Promoting team-spirit at work. Practitioners also state that they strive to establish team-spirit in their everyday work but this feeling is complicated by specialisation, such as patients being treated by MDs with either a medical or surgical speciality. Speciality division also reinforces the hierarchical border between the ANs/RNs and the MDs. This combined with a lack of MDs with an interest in working at an ED leads to problems recruiting MDs who are interested in working at an ED. According to one MD, this means that the practitioners do not know each other and a MD who is a temporary ED practitioner feels like a guest, thus affect-

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ing the continuity in the work of the MDs and the teamspirit; ‘‘I can see a problem ... that there is no continuity with the doctor ... that there are new people all the time ... so you should adapt ‘‘(G4: 2) In conclusion, the mechanical and adaptive approaches are a totality and mutually dependent, since they constitute the everyday work.

Discussion This study shows that the efforts made by the practitioners’ to achieve a work flow can cause the everyday work to become mechanical where the interpersonal encounter with patients and their relatives is reduced to a technical meeting preventing the establishment of a patient relationship on an individual level. In line with findings by Berg (2006) and Frank et al. (2009), this study shows that the relationship with the patient is essential to provide security and patient participation in the care provided. However, this study also indicates that holism and the creation of individual therapeutic relationships with the patient might be difficult, especially when establishing confidence is linked to a rapid succession of contacts during a series of short encounters. Our results can be compared to those of Frank (2010) who addresses the problem with short rapid encounters and the risk that interaction with the patient becomes superficial and that satisfying the general needs of the patient might not take place or be weakened. This study also indicates that providing information is an important factor in reducing frustration related to waiting times and the patients’ condition. These results are supported by the studies of Meade et al. (2010) which show that individualised information increases patient satisfaction and reduces frustration related to waiting time. Finally, this study emphasises in line with Nystro ¨m (2003) the practitioners’ task of establishing relationship with the patient relations. It is therefore important to develop the encounter and interaction with the patient. If this is not done, there is a risk that the encounter is simply a scan of the signs and symptoms and not an encounter between people thus contributing to the mechanical approach in the encounter. The findings in this study show in line with Larsson Kihlgren et al. (2005) that care activities are an essential part of the work at EDs although the care activities are focused mainly on meeting the patients’ medical care needs. This is problematic as inadequate care activities could impact on the patient’s total health needs. At the same time, our study shows that care activities are linked to standardised care, mainly guidance in medical procedures, and that there are difficulties providing individualised care activities. Even this is problematic. Studies have shown that standardised rounds by staffs might be one way of addressing the individual needs of the patients (Meade et al., 2010). It is therefore important to ensure that appropriate care activities are created, implemented and evaluated (The National Board of Health and Welfare, 2005) to enable good and careful handling of the patient (Bondas, 2003) as a way of preventing a mechanical approach to the patient.

66 In the light of our findings, structuring everyday work is important to the working conditions at EDs and the outcome of the everyday work. This is in line with the findings of Lovgren et al. (2002), who demonstrated that working conditions are essential to providing good care. This emphasises the co-ordinators’ position as the one leading this work; leading in terms of influencing the other practitioners to grasp and agree on what needs to be done (Yukl, 2009). The study also underlines the importance of the co-ordinator’s ability to exercise leadership (Yukl, 2009) and strike a balance between the workflow and the potential to provide good care (Csikszentmihalyi, 2004). This is essential as an imbalance between demands and opportunities to meet requirements impacts negatively on practitioner job satisfaction and work performance (Lovgren et al., 2002). Our study indicates the value of the co-ordinator being familiar with the day-to-day work content and having the knowledge and skills to lead that work. Previous studies show that leadership affects the everyday work and it is through leadership that practitioners can become involved and committed and have the desire to develop their work (Nilsson, 2003). As a result, it is important that the co-ordinator can alternate between being a leader and being led in their everyday work and has the ability to reflect on their role as a leader. This is in line with Bondas (2006), who showed that reflection in leadership is essential because it influences the care provided and the organisational culture. It is therefore necessary to support and facilitate practitioners’ leadership in order to improve the outcome of the everyday work (Gullo and Gerstle, 2004) and thus practitioners’ adaption to the everyday workflow. The present study highlights the practitioners’ co-operation and shows that they communicate regularly to solve various tasks. Communication, in line with Mercer et al. (2008), is an important part of patient care and at the same time facilitates co-operation. Communication at the ED is not always easy (Xiao et al., 2007) as the everyday work is carried out in a noisy environment and with constant interruptions. This underlines the importance of optimal conditions for both oral and written communication to reduce the risk of mishaps influencing patient care. Using a structured means of providing and receiving information minimises the risk of mishaps (Wallin and Thor, 2008). The practitioners in the study promote co-operation and teamspirit – although it is not apparent that interdisciplinary work is seen as an important factor in developing the everyday work. This is surprising. According to Rafferty et al. (2001) interdisciplinary work can have a positive impact on job satisfaction, plans to remain at the ED, and lower levels of burnout. Hence, although interdisciplinary work can promote development of the work environment, consensus is required among practitioners on the use of knowhow and skills in the everyday work (Miller et al., 2001; Øvretveit et al., 1997). At the same time the prerequisites for achieving consensus are problematic and may be due to differences in the features of the various professional groups. Our results show that there are difficulties co-operating with others, e.g. when the ANs are excluded from collaborative activities, or when the MDs are forced to work at the ED. These difficulties are likely to strengthen territorial thinking and hierarchical boundaries between the different practitioners (Abbot, 1988), which in turn would impede co-

H. Andersson et al. operation. It is therefore important to support practitioners to develop cooperation in their everyday work and this could be done through supportive leadership (Nilsson et al., 2005).

Study limitations One study limitation is that few MDs participated. The observation time was reduced compared to the other practitioner groups and fewer MDs attended the interviews. On the other hand, this is a reflection of the proportion of MDs at the EDs, which is lower than the other two practitioner groups. This means that the MDs everyday work could be lacking in variation. Another limitation is that there were few observed female MDs and there were few interviewed male MDs. There were also few male ANs involved in both observations and interviews. These limitations concerning participation might result in the everyday work of the MDs and ANs from a gender perspective being highlighted unilaterally. Finally, the lack of data collection on night shifts means that a description of the everyday work at night shifts compared with day and evening shifts may include content that differs from the content in this study.

Implication This study reveals the need to develop the best practice in the approach to encounters with patients and relatives. Activities and care processes that ensure precise and appropriate care provision to patients seeking care and treatment at the ED need to be established as a way of preventing the onset of a mechanical approach. Reflection and discussion about care provision at various levels in the organisation as well as in education might contribute to minimising the mechanical approach. However, further research questions need to be raised in this area. It is also essential to highlight the conditions of structure and balance between everyday work requirements and the potential to meet those requirements. Support in the practitioners’ development of operative leadership is therefore required as part of in-service training and higher education courses. Finally, it is necessary to emphasise the value of creating conditions and prerequisites for a working environment that facilitates co-operation and interdisciplinary work between different practitioner groups through for example team training.

Conclusions The practitioners’ encounter and interaction with patients and relatives are rapid and of limited duration and the care activities that practitioners mainly perform take the form of medical management of the patient. The practitioners’ strive to structure and balance the requirements and the realisation of the everyday work in collaboration with other practitioners, but they work more in parallel than as part of an integrated team. It is important to draw attention to practitioners’ adaption and efforts to achieve flow in the everyday work and at the same time being aware of the risk of a mechanical approach in the encounter. The study adds

The everyday work at a Swedish emergency department – The practitioners’ perspective knowledge about the everyday work, which could lead to new research questions; questions that can help clarify and develop everyday work and the management of patients with urgent and non-urgent conditions.

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