FormalPara Clinician’s capsule

What is known about the topic?

Professional culture is important to the practice of emergency medicine (EM) but incompletely understood. Disasters are a time when culture can be easily studied, as such COVID-19 presented an opportunity to learn more about the culture of EM.

What did this study ask?

How does COVID-19 expose and challenge our collective EM values and beliefs?

What did this study find?

There are tensions between, and threats to the values central to EM that were exposed by COVID-19. The values and beliefs that clinicians hold do not always align with the realities of the practice.

Why does this study matter to clinicians?

The tensions between values and practice provides an explanation for understanding the challenges emergency clinicians face and provides impetus for organizations to align operations with what matters most to clinicians.

Introduction

Professional culture—the values, beliefs and practices that underpin a group—is a powerful influence in emergency departments (EDs), but incompletely understood [1,2,3,4,5]. Although emergency clinicians often draw strength from their professional culture, they can also become distressed when workplace realities conflict with their emergency medicine (EM) values and beliefs [6,7,8]. A deeper understanding of EM culture might help clinicians recognize values and beliefs as a source of support in their work, and also to help understand growing unease in the face of escalation of challenging workplace realities.

Disasters efficiently magnify existing culture through several mechanisms (i.e., clear showcasing of value-based decisions, trade-offs, and priorities; more deliberate and open reflection on what is important; and a regression to intuitive behaviors) [9]. As such, the COVID-19 pandemic presented a unique opportunity to explore the values of EM in Canada. Increasingly, anthropologists, experts in the study of culture, are called upon to study hospital behavior to inform healthcare strategy [10,11,12,13]. Recently, they have sought to better understand the culture of EM and Purdy et al. has developed a framework that highlights seven core values as foundational to the beliefs and practices of the speciality (Fig. 1) [1,2,3,4,5]. This framework, serves as a tangible starting point for reflection around the EM community’s professional cultural experiences and challenges as magnified in the early phases of the COVID-19 pandemic.

Fig. 1
figure 1

Emergency medicine value framework

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Using data from an ethnography that informed the early departmental response to COVID-19, we sought to understand the impact of the pandemic on the manifestation of ED values in a Canadian tertiary care emergency department.

Methods

We conducted a collaborative ethnography during the first 12 weeks of the COVID-19 pandemic. Collaborative ethnography is a method that partners directly with communities during design, data gathering, and analysis to study local culture in a way that is useful for those groups [14]. Our pragmatic approach was designed to provide local ED leadership with a weekly “pulse” from the floor to support real-time decision-making, while also being robust enough to provide in-depth insight into EM culture.

Setting

Two sites associated with the Kingston Health Sciences Centre—Kingston General Hospital (KGH) ED and Hotel Dieu Hospital (HDH) Urgent Care were included. Kingston, ON, Canada has a population of approximately 136,000 and visits to both sites combined average ~ 100,000 per year. The study took place from March 15, 2020 to May 31, 2020.

Creating the research team

A critical phase of collaborative ethnographies is engaging a local community in the design and conduct of the study. After consultation with department leadership by EP (EM resident and MSc in Applied Anthropology), the project was advertised. Any individuals in the department wishing to participate were included in the core research team. They assisted in design and had primary roles as data collectors in the collaborative ethnography process. Then, they were partners in the interpretation and distribution of results. The local individuals and roles at the time were EP (resident physician), SD (ED physician and quality improvement lead), LM (Nurse Educator), MP (Registered Nurse), KW (Registered Nurse and charge nurse), LR (ED physician and wellness lead), and DD (emergency physician and competency-based medical education lead). The external team members included DH (PhD Applied Anthropologist, specializing in disaster anthropology), RB (retired ED physician), GF (medical student), and HM (medical student).

Participants

All staff (~ 300) working in the ED were included in participant observation and eligible for interviews. This included nurses, physicians, residents, unit clerks, respiratory therapists, environmental services experts, porters, administrators, and hospital leaders. Purposive sampling [15] of this group and open self-referral was used to identify participants for informal and formal interviews across the study period.

Data collection

Field notes: All local research team members (EP, LM, MP, KW, LR, DD, and SD) recorded field notes during a convenience sampling of their shifts and from informal interviews using a template (Supplementary file 1). Observations occurred while on shift to minimize COVID exposures.

Interviews: EP conducted semi-structured interviews with participants (Supplementary file 2). The interviews were conducted by telephone, audio recorded, and transcribed. Participants had the opportunity to check transcripts.

Document review: Official documents including department daily/weekly updates, and clinical updates, and reports provided to ED leadership (Supplementary file 3) were archived and reviewed.

Data analysis

Data were analyzed using theoretical thematic analysis in Nvivo 12.0 [16, 17]. Data were coded deductively by both EP and GF using the framework for EM culture (Fig. 1) weekly [1]. During the coding process they met regularly to discuss key findings, interactions, and additional reflections on the data and their positioning. These results were shared with the local study team and further interpretation discussed. The real-time analysis informed reports to ED leadership (Supplementary file 2) and shaped further data gathering.

Member checking

At the end of the study period, collated results were summarized in a report and shared with the entire ED staff and leadership via email and placement around the department (Supplementary file 4). Informal verbal feedback was sought and two online town halls were hosted to solicit community perspective.

Ethics

Queen’s University Health Sciences and Affiliated Teaching Hospital Research Ethics Board approval #6029355.

Results

We conducted over 300 hrs of participant observation and informal interviews which informed over 47,000 words of field notes. EP conducted 42 semi-structured interviews including 9 attending physicians, 11 residents, 12 nurses, 6 core leadership team members, 1 paramedic, 2 porters, and 1 environmental services expert. Interviews ranged from 20 to 50 min. 57 departmental documents were archived and reviewed.

We readily identified aspects related to each of the values and beliefs from the EM values framework (Table 1). “The team approach” (Value 4) seemed protective and was even strengthened during the acute phase (Table 1). “Managing uncertainty” (Value 2) supported EM teams’ ability to navigate this tumultuous time. Most striking, however, were the threats to each of the other core values (Table 1) and the magnified tension between values. Below we outline how a system-wide response in the early weeks of COVID-19 exposed a problematic status quo, how unavoidable tensions become unmanageable, and how threats to values impact self-identity. During member checking, results resonated with colleagues and no significant changes were made to the interpretation of findings.

Table 1 Impact of COVID-19 on Values
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The honeymoon period exposed a broken system

During the first few weeks of the COVID-19 crisis, the emergency department benefited significantly from system re-organization and increased resource allocation alleviating usual threats to ED values (i.e., boarding, overcrowding, lack of resources). This contrast allowed participants to recognize and describe many longstanding distressing daily realities that predated the pandemic. For example, they were troubled by the normalized practice of hallway medicine. As one nurse said,

“You should have a room for everybody. The hallway thing, I've seen it develop over the years and it's distressing because it's not a good thing and I know we're not the only place that does it, that's for sure, but how did we get to that?” – Nurse (int 23)

In the early phase of the crisis, stretchers in hallways were notably missing as system-wide resources relieved pressure. A glimpse of a system that was better functioning made going back to the disheartening realities of the usual system’s shortcomings more troublesome once misbalance returned.

“I have lived…in a medical system that has normalized emergency care for patients in what now, I'm actually realizing is a very problematic way [hallway medicine].”- EP Field notes

As time went on these gains, and the constructive system orientation towards the situation, disappeared. Not long after our study started, the brief COVID-19 honeymoon period ended. When that happened, emergency staff were left with significant challenges in negotiating a rapidly escalating and increasingly impossible balance of needs and resources to care for patients—a situation that simultaneously threatened multiple core values. The appetite to creatively optimize clinical environments and processes faded, further magnifying the misbalance for clinicians on the ground.

“[there is now] some strain around where to put patients now that volume has increased. There is limited acute/resuscitation hallway space, no offload, and now the subacute zones have the “long stay” patients back...” – LR Field notes

Unavoidable tensions become unmanageable

Participants identified classic tensions between core values that are central to the practice of EM. For example, “patients and families at the center of care” (Value 3) often conflicts with the ability to “balance needs and resources at a system level”(Value 4). Participants suggested that the line differentiating expected tensions between these values and unacceptable stress from unmanageable conflicts between values was precarious and often crossed even before the pandemic. COVID-19 increased the likelihood of predictable tensions between values becoming demoralizingly unmanageable.

Visitor restrictions were one example. In the early days staff were bothered by, but could make sense of, the need for restrictions. The need to protect the system from uncertainty and disease was acceptable, despite potential harm to individual patients. But as time went on the threat to the value of patient and family centered care became more problematic. Distress ultimately came when providers felt that the potential benefit to the system no longer seemed to justify the individual harm.

“ …It’s just so against everything that we’ve always done and really believe in. …just putting yourself in their position and not being able to see a loved one in such a time of need.” – Nurse (int 3)

The requirement to put the system above individual patients, and the distress that caused staff, mirrored many of the more usual problematic challenges EM providers face when attempting to access care for patients in a system with limited resources—such as wanting to schedule an outpatient follow-up for a patient (to satisfy values 1, 2 and 3) but not having access to the appropriate clinic (Value 4).

The threat to identity

Emergency providers value being good at their job and experience a profound heaviness, sometimes even manifesting as tears in our interviews, when that identity was threatened. This was most obvious when providers felt the work they were doing did not, or could not, align with their core values.

For example, though emergency providers pride themselves in “managing uncertainty” (Value 2), they were pushed to the limit as ever evolving infection control protocols required re-organization of resuscitation rooms, a change in triage protocols, and department layout. Staff found these environmental and process changes a direct obstacle to effectively “identifying and treating dangerous pathology”(Value 1).

“…everything got changed … even though I've been in there for weeks on end, I still don't know where stuff is…I think it also has affected some of the cases that I've been involved in.” – Attending (int 15)

On a more abstract level, underlying tension exists between “identifying and treating dangerous pathology” (Value 1), “managing uncertainty” (Value 2) and “EM is part of self-identity” (Value 7). COVID-19 highlighted how interconnected these values are. The threat of a new disease overtly challenged the traditional cognitive schema and systems that allow the care team to manage the uncertainty around critical illness effectively and this in turn impacted the confidence and self-worth of participants. The constant vigilance required to simultaneously manage uncertainty and expertly make critical diagnoses is not new in the COVID era but the increasing challenge in doing so emphasized how closely tied these capabilities are to self-identity and self-worth.

"You know, the two obvious things [that I worry about] are that I'm going to over-Covidize everything [think every presentation is COVID related]and just downplay something else and someone is going to have a bad outcome as a result of that..." – Attending (int 2)

Discussion

Interpretation of findings

The acute phase of the COVID-19 crisis offered a powerful lens for understanding the values and beliefs that underpin EM culture. We uncovered critical threats to EM values then saw the negative impact of holding a certain set of values but being unable to practice them. The readily identified threats to and tensions between core values can be used to contextualize current challenges facing the broader EM community. The results of this ethnography offer a helpful voice in merging the conversations related to EM systems and the rising levels of burnout.

Comparison to previous studies

A recent Canadian Journal of Emergency Medicine editorial by Atkinson et al. outlined systems-based challenges threatening the current paradigm of EM including disproportionately high usage, lack of access to primary care, access block, and lack of long-term care funding [18]. The searing commentary resonated with emergency physicians across the country, as evidenced by robust online discussion and the second highest Altmetric Attention Score of all time for any CJEM article [19]. Meanwhile news outlets and researchers have identified alarming levels of discontent manifesting as burnout, exodus, and depression in up to 60% of the Canadian EM community—with obvious and dramatic implications for the national workforce [20,21,22,23,24]. The ethnography we present acts as a direct link between these systems frustrations and a looming workforce catastrophe.

The opportunity to have values and work align is a concept known as “value congruence”. It is essential to an effective and sustainable workforce. Across industries it is critical to longevity and operational success [6,7,8,9]. Unfortunately, our analysis spotlights a troubling degree of value incongruence in the current practice of EM that has been further magnified by COVID-19. Our study provides empirical data that supports the desperate need for realignment of the EM community’s values with actual work in EDs.

Strengths and limitations

This was a single-site study in the early phases of the pandemic response in a geographic area with low COVID-19 case numbers at the time of the study. While many of our findings will be universal, some issues identified will be unique to our specific context. Some degree of turmoil may be explained by the unique stresses of COVID-19, which other studies have also identified [20, 26]. Undoubtedly, as the pandemic has evolved, the nature of the threat to values has changed. From collective experience, we speculate that that our findings related to value incongruences for our EM community are even more stark now than the acute phase that was the focus of this report.

We focused on areas of tension between and the threats to values in the ED but recognize that some aspects of EM work, mostly as they relate to teams, remain well aligned and even strengthened. We witnessed committed groups of people doing excellent work despite the profound challenges faced. These teams currently act as a buffer to the negative realities of value incongruence. Such team resilience is a phenomenon that should be further studied and organizationally harnessed.

Clinical implications

Unfortunately, there are no simple fixes. We cannot offer a clear table of actions or easy to implement suggestions based on our findings. Issues that are as seemingly inconsequential as a poorly timed electronic medical record downtime to as significant as hospital funding models will impact whether EM values and practice align for clinicians on the ground. We do, however, hope that raising awareness about the concept of value congruence and providing the pragmatic structure of the EM values framework will be useful in several ways. For individuals in the face of ongoing threats, it can be a tool to cognitively frame experiences—admittedly a strategy that has limited impact and is only helpful in the short term. For leaders, it may provide practical scaffolding for unwavering defence of EM values for decisions at every management level. For hospitals and systems, it should provide urgency and direction for aligning funding, processes, and procedures with core values of those on the ground. Each of these requires a recognition of and conversation about the values and beliefs we hold, the importance of reconciling tensions that exist, and a brighter vision for our future. The alternate reality must also be faced. Under sustained threat, clinicians are likely to reconcile the incongruence experienced by shifting their values. If the system cannot match the current values of emergency providers, providers will match their values to the system. The culture of EM—the values, beliefs and practices that make us who we are—will change.

Research implications

Our single-site study should serve as a starting point for research related to value congruence, staff retention, and identifying health system policies that support alignment of work as experienced with the embodied core values of EM staff. Methodologically, we are the first group to apply the framework for EM culture (Fig. 1) by Purdy et al. in a clinical and Canadian context [1]. We did identify the need for changes to the framework as it related to teams (Fig. 2). This evolution highlights how understanding of culture is fluid and everchanging. There are likely to be local variations when applied in other sites. The framework is not meant to be a fundamental truth, rather a useful tool for exploring the culture of EM.

Fig. 2
figure 2

Refined emergency medicine value framework

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Conclusion

COVID-19 has highlighted and compounded existing tensions and threats to the core values of EM. Realignment of the realities of ED work with staff values is needed to sustain the culture of EM in Canada.